Practice Questions

Front 1

The use of EFM

Back 1

increased the overall cesarean delivery rate

The use of EFM increased the use of vacuum and forceps

did not reduce overall perinatal mortality

Front 2

What % of cases of CP occur before the onset of labor

Back 2

70%

Front 3

Decrease in FHR variability with betamethasone but not

Back 3

dexamethasone

Front 4

Normal FHR _____ provides reassurance about fetal status.

Back 4

variability

Front 5

scalp pH not very predictive

Back 5

hmmmmm.

Front 6

hypertonus

Back 6

(single contraction lasting more than 2 minutes)

Front 7

Any conditions in which the risks of emergency contraception use outweigh the benefits?

Back 7

No.
Women with previous ectopic pregnancy, cardiovascular disease, migraines, or liver disease and women who are breastfeeding may use emergency contraception.

Front 8

women who are breastfeeding may use emergency contraception?

Back 8

Yes

Front 9

emergency contraception to women with undiagnosed genital bleeding?

Back 9

Yes.
Don't deny anyone emergency contraception.

Front 10

• What screening procedures are needed before provision of emergency contraception?

Back 10

No clinical examination or testing is required

Should not be withheld or delayed in order to test for pregnancy, nor should it be denied because the unprotected coital act may not have occurred on a fertile day of the menstrual cycle.

Front 11

• When should emergency contraception be initiated?

Back 11

up to 120 hours after intercourse

Front 12

which is more effective for Emergency contraception - levonorgestrel or combined estrogen-progesterone?

Back 12

The levonorgestrel-only regimen is preferred to the combined estrogen–progestin regimen,
PLAN B is Best TT

Front 13

Are antiemetics useful as an adjunct to treatment with the levonorgestrel-only regimen?

Back 13

not necessary

Front 14

Are antiemetics useful as an adjunct to treatment with the combined regimen?

Back 14

may be beneficial because the incidence of nausea

Front 15

Antiemetic taken _____ before the first dose of emergency contraception has been shown to decrease the incidence or severity of nausea

Back 15

1 hour

Front 16

Emergency contrception dose should be repeated if vomiting occurs within ____ of taking a dose.

Back 16

2 hours

Front 17

If severe vomiting occurs, emergency contraception may be administered how?

Back 17

vaginally

Front 18

Is emergency contraception safe if used repeatedly?

Back 18

May be used even if the woman has used it before, even within the same menstrual cycle

Front 19

What clinical follow-up is needed after use of emergency contraception?

Back 19

No scheduled follow-up is required after use of emergency contraception

Front 20

For what reasons should patient f/u after emergency contraception?

Back 20

menstrual period is delayed by a week or more


persistent irregular bleeding

lower abdominal pain

Front 21

When should regular contraception be initiated or resumed after use of emergency contraception?

barrier
short term contraception
longterm contraception

Back 21

barrier contraceptives immediately

Short-term hormonal contraceptives (eg, pills, patches, and rings) may be started either immediately (with a backup barrier method) or after the next menstrual period.

Long-term hormonal methods should be started after the next menstrual period, when it is clear that the patient is not pregnant.

Front 22

• How can access to emergency contraception be facilitated?

Back 22

Providing an advance prescription or supply


prescribing it by phone without requiring an office visit

Front 23

copper IUD for emergency contraception - pregnancy rate of

Back 23

0.2%

Front 24

When is an intrauterine device appropriate for emergency contraception?

Back 24

women who desire long-term contraception and who are otherwise appropriate candidates for IUD use.

Front 25

copper IUD for emergency contraception most effective if inserted within ____ after unprotected intercourse

Back 25

5 days

Front 26

Emergency contraception progestin-only regimen, which consists of

Back 26

a total of 1.5 mg levonorgestrel

one 0.75-mg levonorgestrel pill ASAP after unprotected intercourse and to take the second 0.75-mg pill 12 hours after the first dose.


taking both pills at the same time or taking each 0.75-mg pill 24 hours apart is as effective as taking them 12 hours apart and does not increase the risk of side effects.

Front 27

Emergency contraception combined estrogen–progestin regimen, which consists of

Back 27

two doses—each containing 100 µg of ethinyl estradiol plus 0.50 mg of levonorgestrel—taken 12 hours apart.

Front 28

Preliminary Classification Criteria for Antiphospholipid Syndrome in PREGNANCY
Criteria Definition

Clinical
Obstetric

Back 28

1) Three or more consecutive spontaneous abortions before the 10th week of gestation
2) One or more unexplained fetal deaths at or beyond the 10th week of gestation

3) Severe preeclampsia or placental insufficiency necessitating birth before the 34th week of gestation

Front 29

Preliminary Classification Criteria for Antiphospholipid Syndrome*
Criteria Definition
Vascular
thrombosis

Back 29

1) Unexplained venous thrombosis
2) Unexplained arterial thrombosis

3) Small-vessel thrombosis in any tissue or organ, without significant evidence of inflammation of the vessel wall

Front 30

Preliminary Classification Criteria for Antiphospholipid Syndrome*
Criteria Definition

Laboratory

Back 30

ACA IgG or IgM isotype in medium to high titers, on TWO or more occasions at least 6 weeks apart, measured by standardized ELISA

LA
LA present in plasma, on TWO or more occasions at least 6 weeks apart.

Front 31

*Definite antiphospholipid syndrome is considered to be present if at least one of the clinical criteria and one of the laboratory criteria are met.

Back 31

Hmmmmm.

Front 32

How should antiphospholipid syndrome be managed during pregnancy and the postpartum period? Treatment of women with antiphospholipid syndrome without a thrombotic event

Back 32

prophylactic heparin and aspirin

6–8 weeks of postpartum thromboprophylaxis

referred to an internist or hematologist

Front 33

How should antiphospholipid syndrome be managed during pregnancy and the postpartum period? antiphospholipid syndrome who have had a thrombotic event

Back 33

full/adjusted dose heparin anticoagulation
benefit of adding aspirin is unknown.

continued for a minimum of 6 weeks postpartum to minimize the risk of maternal thromboembolism
can be safely accomplished with coumarin.

referred to an internist or hematologist

Front 34

Should women with antiphospholipid syndrome have antepartum surveillance?

Back 34

detection of preeclampsia or IUGR

serial ultrasonographic assessment.

Antepartum testing should be considered after 32 weeks of gestation, or earlier if there are signs of IUGR

Front 35

Are estrogen-containing oral contraceptives in women with well-characterized antiphospholipid syndrome okay?

Back 35

No.
Estrogen-containing oral contraceptives in women with well-characterized antiphospholipid syndrome should be avoided.

Front 36

which mode of misoprostol in regimens with mifepristone results in complete abortion in higher success rates for these gestational ages 50-63 days? vaginal v. oral

Back 36

vaginal

better than oral

Front 37

Medical contraindications to abortion with mifepristone regimens include:

Back 37

confirmed or suspected ectopic pregnancy or undiagnosed adnexal mass,
intrauterine device in place,
current long-term systemic corticosteroid therapy,
chronic adrenal failure, severe anemia,
known coagulopathy or anticoagulant therapy, and
mifepristone intolerance or allergy.

Front 38

Misoprostol contraindications:

Back 38

uncontrolled seizure disorder
allergy or intolerance to misoprostol or other prostaglandins.
Asthma is not a contraindication because misoprostol is a weak bronchodilator.

Front 39

• Do nonsteroidal antiinflammatory drugs affect the success rates for medical abortion?

Back 39

No

Front 40

• How should a patient be counseled about potential teratogenicity if a medical method fails to lead to abortion?

Back 40

No conclusions regarding teratogenicity can be drawn
Patients must be informed of the need for a surgical abortion in the event of a continuing pregnancy.

Front 41

High-risk HPV testing as an adjunct to cervical cytology in women aged 30 years and older
If both test results are negative, combined testing should not be repeated more often than every

Back 41

3 years

Front 42

• Normal Pap but HPV positive, what is the appropriate follow-up?

Back 42

Repeat cytology and HPV test in 6–12 months


Colposcopy is not recommended as further testing after a single HPV-positive, Pap-negative result.

Front 43

• ASCUS Pap, how should the patient be treated?

Back 43

Immediate colposcopy
Triage to colposcopy by HPV DNA testing (except adolescents)
Repeat cytology tests at 6 and 12 months.

Front 44

If HPV testing is elected, those women whose test results are HPV positive should

Back 44

be referred for colposcopy.

Front 45

Those women who test negative for HPV can be scheduled for

Back 45

repeat cytology testing in 1 year.

HPV neg expires in 1 year

Front 46

As an alternative to immediate colposcopy, adolescents with ASC HPV-positive test results may be monitored with

Back 46

Pap at 6 and 12 months or with a single HPV test at 12 months

with colposcopy for any abnormal cytology result or positive HPV test result.

Front 47

follow-up of LSIL in adolescents.

think of ASC HPV+ = LSIL

Back 47

Pap at 6 and 12 months or with a single HPV test at 12 months

That said, although follow-up cytology tests may allow some women to avoid colposcopy, waiting 6–12 months for a definitive diagnosis can create anxiety and will delay the possible diagnosis of cancer.
In addition, the rate of loss to follow-up is substantial

Front 48

Pap LSIL how should the patient be treated?

Back 48

colposcopy is recommended for evaluation of LSIL, except in adolescents

Front 49

Pap ASCUS-H, how should the patient be treated?

Back 49

colposcopy is recommended for evaluation of ASCUS –H, or triage with HPV for >30yo

Front 50

Follow-up of a colposcopy result of CIN 1 or normal

ASC + HPV+ = LSIL = CIN I

Back 50

Either cytology tests at 6 and 12 months or an HPV DNA test at 12 months,

No excision necessary

Front 51

• When the results of colposcopy performed for the evaluation of ASCUS, ASCUS-H, or LSIL reveal no dysplasia or CIN 1, how should the patient be treated?

Back 51

Repeat cervical cytology screening tests at 6 and 12 months or an HPV test at 12 months.

Front 52

If the follow-up cytology result is ASC or higher-grade cytology or a positive HPV test, what should be done?

Back 52

colposcopy should be repeated.

Front 53

Pap HSIL, how should the patient be treated?

Back 53

Colposcopy and biopsy of visible lesions

ECC should be performed in the nonpregnant patient

entire vagina should be examined, especially when a lesion corresponding to the cytology result is not found.

Front 54

Pap HSIL, what is an alternative to how this patient should be treated?

Back 54

An alternative "see and treat" management plan may be used in this patient population in the event that a lesion consistent with CIN 2 or CIN 3 is seen.

In these cases, the cervical biopsy is omitted and an ECC after the LEEP may be considered.

Front 55

• When the initial evaluation of an HSIL Pap result is Colpo CIN 1 or less, how should the patient be treated?

Back 55

Review of the cytology/Pap and histology/Colpo results

If review is not undertaken or colposcopy results are not satisfactory, excision is recommended.

Front 56

For HSIL Pap result is Colpo CIN 1 or less. Who is an exception to excision?

Back 56

HGSIL Adolescents, follow-up with colposcopy and cytology tests at 4–6 months may be undertaken, as long as the colposcopy results are adequate and the endocervical curettage is negative.

Front 57

• When the results of Pap AGC or AIS, how should the patient be treated?

Back 57

Colposcopy and endocervical sampling should be included in the initial evaluation of all women with AGC results, except for those with results that specify “atypical endometrial cells.”

Front 58

The most common significant lesions associated with AGC are

Back 58

squamous

At least half of AIS and adenocarcinoma results will be accompanied by squamous CIN.

Front 59

Women with atypical endometrial cells and a normal endometrial sampling should undergo

Back 59

colposcopy and endocervical sampling

Front 60

Endometrial sampling is indicated in women with atypical endometrial cells and all women with AGC results who are aged 35 years or older, as well as those younger than 35 years with

Back 60

abnormal bleeding, morbid obesity, oligomenorrhea, or clinical evaluation suggesting endometrial cancer.

Front 61

• When the results of the initial evaluation of AGC reveal no neoplasia, how should the patient be treated if original pap was AGC-NOS?

Back 61

repeat cytology testing and ECC FOUR times at 6-month intervals

Front 62

Like squamous CIN, HPV is found in more than 95% of AIS and 90–100% of invasive adenocarcinomas of the cervix.

Back 62

Hmmmm.

Similar reports suggest that it is reasonable to monitor women with AGC cytology test results, a negative initial evaluation, and a negative HPV test result with a repeat cytology and endocervical sampling in 1 year rather than requiring four visits at 6-month intervals.

Front 63

For women with reports of
1) AGC favor neoplasia or an AIS cytology result and a negative initial evaluation by colpo, or
2) a SECOND AGC-NOS result and a SECOND negative evaluation what should be done?

Back 63

excision is warranted

Cold-knife conization is a good choice in this situation because of the prognostic importance in AIS of the pathologic evaluation of margins, which may be obscured by thermal artifact in some LEEP specimens.

complexity may require consultation with gynecologic oncologist.

Front 64

• When should endocervical curettage be used in the colposcopic examination?

Back 64

ECC should be performed if colposcopy results are unsatisfactory or if ablative treatment, such as cryotherapy or laser ablation, is contemplated

Front 65

In women with ASC-H, HSIL, AGC, or AIS cytology results, ECC should be considered as part of the initial colposcopic evaluation, unless

Back 65

excision is planned.
***If an excision is planned, endocervical sampling may be omitted, although it may be performed at the time of the procedure following the excision to assess the completeness of the procedure.

Front 66

• How should CIN 1 be managed?

Back 66

Individualized
Younger women, observation provides the best balance between risk and benefit and should be encouraged

Front 67

If observation of CIN I, then how should it be done

Back 67

two cytology screening tests 6 months apart with colposcopy for an ASC or higher-grade result,

or a single HPV test at 12 months, with colposcopy if the test result is positive.

Front 68

• How should CIN 2 and CIN 3 be managed?

Back 68

immediate treatment of CIN 2 and CIN 3 with excision or ablation in the nonpregnant patient is recommended.

The only exception to this recommendation is that follow-up similar to CIN 1 may be considered in the adolescent with CIN 2

Front 69

• Does management of CIN 2 or CIN 3 differ for women who are HIV positive?

Back 69

Standard ablative or excisional treatment is recommended for women who are HIV positive with documented CIN 2 or CIN 3, regardless of HIV viral load.
CIN 2 and CIN 3 should be treated similarly in women who are HIV positive regardless of their use of antiretroviral therapy.

Front 70

• Is excision or ablation the better treatment for CIN for avoiding stenosis?

Back 70

Rates of cervical stenosis are comparable



Endocervical sampling before ablation is recommended

Ablation should not be performed in patients with dysplasia on endocervical curettage.

Excision offers the advantage of a specimen for histologic examination and the disadvantage of increased surgical complications, primarily bleeding.

Front 71

• How should AIS pap be managed? How should patients with AIS be monitored after treatment?

Back 71

Expert consultation

***Hysterectomy is not appropriate until invasive cancer has been excluded.

Cold-knife conization excision is required

LEEP in this situation is associated with an increase in positive cone margins over cold-knife conization and is not recommended

Front 72

***Endocervical sampling immediately after conization has been reported to have better positive and negative predictive value for residual disease than cone margins.

Back 72

Hmmmm.

Front 73

IN AIS, if the margins of the cone specimen are involved, then what next?

Back 73

conization should be repeated in AIS.

Front 74

Why not immediate hysterectomy if margins positive for AIS?

Back 74

Repeat conization is preferred to immediate hysterectomy so that if invasive cancer is found, the appropriate surgical or radiotherapeutic treatment can be recommended. If no invasive cancer, then hysterectomy is recommended (if undesired fertility).

Front 75

In AIS, if the margins of the cone specimen are not involved, risk of residual disease is still substantial. Therefore, what is recommended?

Back 75

recommendation for hysterectomy when fertility is no longer desired.

Front 76

When fertility is desired and cervical conization margins are clear,

Back 76

conservative follow-up may be undertaken with Pap and ECC every 6 months, provided that the patient understands the risk of subsequent recognition or development of invasive cancer.

Front 77

• How should a colposcopic biopsy with inconclusive results for early invasive cancer be managed?

Back 77

excision to define whether cancer is present and to permit treatment planning.

The management of early invasive cervical cancer depends on the depth of invasion and the presence or absence of LVSI.
Biopsy alone does not adequately provide this information.

Front 78

• How should a patient’s condition be monitored after treatment for CIN I, if LEEP or cone biopsy reveals a positive margin, how should management proceed?

Back 78

For CIN 1 with positive margins, cytology screening at 6 and 12 months or HPV testing at 12 months is a reasonable choice before reestablishing routine screening.

Front 79

Positive margins on a specimen excised for squamous CIN or
ECC positive for squamous CIN performed after excision indicates a risk of persistent disease.
Does this finding require reexcision.

Back 79

No.
This finding necessitates follow-up, including endocervical sampling until routine screening is reestablished, but it does not require reexcision.

Front 80

Reexcision may be elected but should be undertaken with the knowledge that the most common outcome is

Back 80

the absence of residual dysplasia.

Front 81

By not re-excising and therefore sparing the endocervical mucosa from cautery after the excision does what?

Back 81

increases subsequent satisfactory colposcopy results and decreases cervical stenosis, but it also may reasonably be expected to increase recurrence rates in the event of positive margins.

Front 82

What is f/u after TREATMENT of CIN 2 or CIN 3?

Back 82

cytology screening three to four times at 6-month intervals or

undergo a single Pap and HPV test at 6 months before annual follow-up is reestablished.


Human papillomavirus testing is a powerful predictor of the risk of recurrent CIN 2 or CIN 3 after treatment of CIN.

Front 83

When is hysterectomy appropriate in women with CIN 2/3+?

Back 83

may be considered for treatment of persistent or recurrent CIN 2 or CIN 3 or when a repeat excision is indicated but technically unfeasible.

Front 84

What should always be done before a hysterectomy?

Back 84

If excision is indicated, it should be performed (where possible) before hysterectomy to rule out invasive cancer.

Front 85

colposcopic examination during pregnancy should have what as its primary goal

Back 85

exclusion of invasive cancer.

Front 86

During pregnancy
ASCUS and LSIL

Back 86

may undergo colposcopic evaluation either during pregnancy or at 6–12 weeks postpartum

Front 87

During pregnancy
ASC-H, HSIL, AGC, or AIS test results should undergo colposcopy. Who should get a biopsy?

Back 87

colposcopy without endocervical sampling, reserving biopsy for those with visible lesions consistent with CIN 3, AIS, or cancer.

Front 88

During pregnancy
Why noy biopsy for CIN I impression? You could be wrong, so why take a chance and not biopsy?

Back 88

Although many women with colposcopic impressions of CIN 1 harbor either normal histology or CIN 2 or CIN 3, the risk of invasive cancer with a colposcopic impression of CIN 1 is low.

may be spared biopsy if the colposcopic impression is CIN 1.

Front 89

During pregnancy
Excisions should be considered for pregnant women only if a lesion detected at colposcopy is suggestive of

Back 89

invasive cancer.

Front 90

Those with unsatisfactory colposcopy results, and those with satisfactory colposcopy results who are not found to have invasive cancer, should be reevaluated with

Back 90

colposcopy and cytology tests in each trimester until delivery.

Front 91

• What elements of preoperative evaluation are useful for women with endometrial cancer?

Back 91

Only a physical examination and a CXR are required for preoperative staging of the usual (type I endometrioid grade 1) histology, clinical stage I patient.
All other preoperative testing should be directed toward optimizing the surgical outcome.

Front 92

Are CT and MRI necessary?

Back 92

No because the surgeon should be prepared to resect metastatic disease commonly found in patients with endometrial cancer.

Front 93

Are preoperative measurement of the CA 125 level appropriate in endometrial CA?

Back 93

Yes!
CA 125 is frequently elevated in women with advanced-stage disease.

Elevated levels of CA 125 may assist in predicting treatment response or in posttreatment surveillance.

Front 94

Exceptions to the need for endo CA surgical staging include

Back 94

Most women should be surgically staged (ACOG)

young or perimenopausal women with grade 1 endometrioid adenocarcinoma associated with atypical endometrial hyperplasia and women at increased risk of mortality secondary to comorbidities.

Consider staging all past Grade 1, Ia

Front 95

• What constitutes appropriate staging for women with endometrial cancer?

Back 95

Systematic surgical staging, including pelvic washings, bilateral pelvic and paraaortic lymphadenectomy, and complete resection of all disease.

Sampling not enough.

Front 96

• How are women with endometrial cancer treated postoperatively? Discuss radiation:

Back 96

radiation should be tailored to sites of known metastatic disease or reserved for recurrence.

there is no benefit to whole pelvic radiation therapy, except local control in the vagina and pelvis.

Patients with surgical stage I disease, postoperative radiation therapy can reduce the risk of local recurrence.

Front 97

In deciding whether to use radiation, the cost and toxicity should be balanced with the evidence that

Back 97

the therapy does not improve survival or reduce distant metastasis.

routine lymphadenectomy by avoiding teletherapy and substituting brachytherapy .

Front 98

• What are the recommendations for women found to have endometrial cancer after a hysterectomy?

options include

Back 98

no further therapy and surveillance only,

reoperation to complete the surgical staging, or

radiotherapy to prevent local recurrence.

Front 99

The advent of laparoscopic surgical restaging has resulted in less morbidity using this approach.

Back 99

consult gyn onc

Front 100

• What is the mode of therapy for patients with positive pelvic or paraaortic nodes?

Back 100

Every patient found to have extrauterine disease (stage III, IV) is at significant risk for developing persistent or recurrent disease and should be considered a candidate for additional therapy.

Front 101

Women with paraaortic nodal disease should have the tumor completely resected and should have postoperative:

Back 101

postoperative imaging studies (eg, chest computed tomography or positron emission tomography scans) to detect or exclude the presence of occult extraabdominal disease

Front 102

The addition of paraaortic radiation is associated with

Back 102

improved survival

benefit of concomitant or sequential systemic chemotherapy.

Front 103

The use of __________ and ________ in combination, similar to use for ovarian cancer, is favored by some because of the combination’s more favorable toxicity profile.

Back 103

carboplatin and paclitaxel

Front 104

It is challenging to differentiate primary cervical adenocarcinoma from stage II endometrial cancer.
When the diagnosis is unclear, what should be done?

Back 104

radical hysterectomy and lymphadenectomy can be performed, followed by tailored adjuvant therapy based on the pathologic findings.

Front 105

Which is more predictive of survival; grade or depth of cervical invasion?

Back 105

grade is more predictive of survival than depth of cervical invasion.

Front 106

• Is there a role for radiotherapy as an alternative to surgery?

Back 106

a patient is deemed an exceptionally poor surgical candidate, primary therapeutic radiation may be considered for treating the uterine disease.

use of brachytherapy to control disease offers reasonable results in this ultra-high-risk surgical population

Front 107

• Is there a role for progestin therapy in the treatment of atypical endometrial hyperplasia and endometrial cancer?

Back 107

Atypical endometrial hyperplasia and endometrial cancer should be considered part of a continuum.

The diagnosis remains uncertain as long as the uterus is in situ.

Progestational agents have been evaluated as a primary treatment modality of early grade 1 disease in women who wish to maintain their fertility or in those who are extremely poor operative candidates.

Front 108

For women who do not desire fertility, what is recommended for treatment of atypical endometrial hyperplasia?

Back 108

hysterectomy
because of the high risk of an underlying cancer.

Front 109

Women who desire to maintain fertility, whether they have a diagnosis of atypical endometrial hyperplasia or grade 1 endometrioid adenocarcinoma, may be treated with

Back 109

progestins in an attempt to reverse the lesion.

Front 110

How can progesterone be given in these patients?

Back 110

Oral, parenteral, or intrauterine device delivery of progestin has been successful, with response rates ranging from 58% to 100%.

Front 111

Following progesterone therapy, patients should undergo serial complete intrauterine evaluation approximately every _____ to document response.

Back 111

3 months

Progestin therapy may successfully reverse %50 of atypical endometrial hyperplasia as well as an early endometrial carcinoma; conception may then be attempted.

Front 112

Beta-thalassemia is associated with elevated Hb F and elevated Hb A2 levels greater than what?

Back 112

>3.5%

Front 113

What testing can identify individuals with alpha thalassemia trait;

Back 113

only molecular genetic testing can identify this condition.

Front 114

When should alpha thal be tested for/considered?

Back 114

If the MCV is below normal, iron deficiency anemia has been excluded, and the hemoglobin electrophoresis is not consistent with Beta thalassemia trait (ie, there is no elevation of Hb A2 or Hb F)

Front 115

If both parents are determined to be carriers of a hemoglobinopathy, what is recommended next?

Back 115

genetic counseling is recommended

Front 116

It should be noted that ethnicity is not always a good predictor of risk because

Back 116

individuals from at-risk groups may marry outside their ethnic group.

Front 117

Preimplantation genetic diagnosis has been successfully performed for

Back 117

sickle cell disease and most cases of Beta-thalassemia.

Front 118

Women with Hb SS have increased risk for maternal complications, such as

Back 118

PTL

PPROM

antepartum hospitalization,

postpartum infection.

Front 119

Hb SS are at higher risk for fetal complications, such as

Back 119

intrauterine growth restriction (IUGR), low birth weight, and preterm delivery.


Hb SC disease also are at risk for the aforementioned complications but to a lesser extent

Front 120

Do sickle cell mothers need more folate?

Back 120

1 mg per day of folic acid should be prescribed due to the continual turnover of red blood cells.

Front 121

painful crisis.
precipitating by factors such as

Back 121

cold environment, heavy physical exertion, dehydration, and stress should be avoided.

Front 122

Painful crises in pregnancy should focus on detection of serious medical complications requiring specific therapy, such as

Back 122

acute chest syndrome (fever tachypnea, chest pain, and hypoxia),
infection,
dehydration,
severe anemia,
cholecystitis, and
hypersplenism.

Front 123

Goal of transfusion or prophylactic exchange transfusion for pregnancies complicated by sickle cell anemia?

Back 123

Objective is to lower the percentage of Hb S to approximately 40%

while simultaneously raising the total hemoglobin concentration to about 10 g/dL.

Front 124

• Is fetal surveillance useful in pregnancies complicated by sickle cell anemia?

Back 124

serial ultrasound examinations and antepartum fetal testing is reasonable.

Front 125

Beta-thalassemia minor usually causes

Back 125

mild asymptomatic anemia.

Front 126

Are large bladder capacities always pathologic

Back 126

No

Front 127

Limited data support the need for cystometric testing in the routine or basic evaluation of urinary incontinence. It is indicated as part of the evaluation of more complex disorders of bladder filling and voiding, such as the presence of

Back 127

neurologic disease and other comorbid conditions.

Front 128

No studies have determined whether the addition of multichannel cystometry or video assessment over simple filling cystometry improves diagnostic accuracy or outcomes after treatment.

Back 128

Hmmmm.

Front 129

When surgical treatment of stress incontinence is planned, urodynamic testing often is recommended to confirm the diagnosis, unless

Back 129

the patient has an uncomplicated history and compatible physical findings of stress incontinence and has not had previous surgery for incontinence.

Front 130

• When are urethral pressure profilometry and leak point pressure measurements useful for evaluation of incontinence?

Back 130

it does not meet the criteria for a useful diagnostic test.

Leak point pressure measures the amount of increase in intraabdominal pressure that causes stress incontinence, although its usefulness also has not been proved.

Front 131

• When is cystoscopy useful for evaluation of incontinence?

Back 131

sterile hematuria or pyuria;
irritative voiding symptoms, such as frequency, urgency, and urge incontinence, in the absence of any reversible causes;

bladder pain;
recurrent cystitis;

suburethral mass;

and when urodynamic testing fails to duplicate symptoms of urinary incontinence.

Front 132

• Are pessaries and medical devices effective for the treatment of urinary incontinence?

Back 132

objective evidence regarding their effectiveness has not been reported.

Replacement of the prolapsed anterior vaginal wall with a pessary may unmask incontinence by straightening out the urethrovesical kinking that may have been responsible for either continence or some degree of urinary retention.
"Potential incontinence"

Front 133

• Are behavior modifications (eg, bladder retraining, biofeedback, weight loss) effective for the treatment of urinary incontinence?

Back 133

Yes,
improves symptoms of urge and mixed incontinence

combining drug and behavioral therapy in a stepped program can produce added benefit for patients with urge incontinence.

Front 134

• Are pelvic muscle exercises effective for the treatment of urinary incontinence?

Back 134

effective treatment for adult women with stress and mixed incontinence,

Front 135

Which is better, Kegels or cones or electrical stimulation?

Back 135

Pelvic muscle exercise appears to be superior to electrical stimulation and vaginal cones in the treatment of stress incontinence.

Front 136

The most typical side effect of anticholinergic therapy is

Back 136

dry mouth
blurred vision
constipation
nausea
dizziness
headache

Front 137

• Is there a role for bulking agents in the treatment of urinary incontinence?

How long are symptoms relieved after injections?

Back 137

For women with extensive comorbidity precluding surgery or anesthesia or both, injection of bulking agents may provide a useful option for relief of symptoms for a 12-month period.

Front 138

When is surgery indicated for urinary incontinence?

Back 138

when conservative treatments have failed to satisfactorily relieve the symptoms

the patient wishes further treatment in an effort to achieve continence.

Front 139

Is retaining fertility potential is a contraindication for incontinence surgery?

Back 139

No

Front 140

which patients with urinary incontinence do NOT need urodynamic testing before surgery.

Back 140

women who lose urine only with physical exertion;

have normal voiding habits (<8 voiding episodes per day, <2 per night);

have no associated findings on neurologic or physical examination;

have no history of antiincontinence or radical pelvic surgery;

possess a hypermobile urethra, pliable vaginal wall, and adequate vaginal capacity on physical examination;

have a normal postvoid residual volume;

are not pregnant.

Front 141

Retropubic colposuspension procedures are indicated for women with the diagnosis of

Back 141

urodynamic stress incontinence and a hypermobile proximal urethra and bladder neck.

Front 142

Selection of a retropubic approach (versus a sling) depends on many factors, such as:

Back 142

the need for laparotomy for other pelvic disease,

the amount of pelvic organ prolapse and

whether a vaginal or abdominal procedure will be used to suspend the vagina,

the age and health status of the patient, and

the preferences of the patient and surgeon.

Front 143

Does hysterectomy add to the efficacy of Burch colposuspension in curing stress incontinence

Back 143

No

Hysterectomy should be performed only for specific uterine pathology or for the treatment of uterine prolapse.

Front 144

• For patients with both prolapse and urinary incontinence, what surgical procedures are appropriate?
If the prolapse is to be repaired abdominally

Back 144

sacral colpopexy, a retropubic colposuspension may be appropriate.

Front 145

For patients with both prolapse and urinary incontinence, what surgical procedures are appropriate? If transvaginal approach

Back 145

may include a sling placed at the time of repair to treat stress incontinence.

Front 146

Women who have severe pelvic organ prolapse but “potential stress incontinence” present a unique challenge.

Back 146

After hysterectomy and support of vaginal apex,
Suburethral plication of the bladder neck to stabilize a hypermobile urethra is probably appropriate in many cases

Front 147

Combination of cervical cytology and HPV DNA screening is appropriate for women aged 30 years and older.
If this combination is used, women who receive negative results on both tests should be rescreened no more frequently than

Back 147

every 3 years.

HPV neg expires in 1 year

Front 148

Why test HPV only in women > age 30?

Back 148

The decreasing prevalence of HPV DNA positivity in women older than 30 years and the improved specificity of HPV DNA testing in predicting CIN 2 and CIN 3 makes it a more practical screening test, combined with cervical cytology screening, in that age group.

Front 149

Does HPV penetrate condoms?

Back 149

Particles the size of HPV virions do not penetrate an intact latex condom

Front 150

warts on moist or mucosal surfaces are more responsive to topical treatment than are warts on

Back 150

drier surfaces

Front 151

When should warts be reevaluated after treatment?

Back 151

Warts that do not respond to a particular treatment modality after three provider-administered treatments and warts that are not cleared completely after six treatments should be re-evaluated.

Front 152

Podophyllin
The mechanism of action includes

Back 152

antimitosis

damage to vessels within the wart

stimulation of macrophage proliferation

production of interleukin-1 and interleukin-2.

Front 153

podophyllin is applied

Back 153

BID for 3 consecutive days followed by 4 days of no therapy

4 cycles

leave on 8 hours

Front 154

The total area of warts that should be treated with podophyllin should be limited to

Back 154

10 cm2

Front 155

Imiquimod MOA

Back 155

ACTIVATES macrophages

IMIQUIMACROPHAGES

Front 156

imiquimod treatment area should be limited to no more than

Back 156

20 cm2.

Front 157

which is more effective, Podophyllin or Imiquimod?

Can they be used inside vagina?

Back 157

no single treatment for external genital warts can be recommended over another.

Not for use inside vagina/anus.

Front 158

When should provider-applied medication or procedures for genital warts be considered?

Back 158

anatomic location of the warts (inside vagina)
the number and character of the external genital warts

co-existing medical conditions, such as pregnancy and immune deficiency

Front 159

Cryotherapy is effective for

Back 159

both dry and moist warts;

Front 160

Drawback of cryo for warts

Back 160

when treating large warts or large areas, wound care problems can occasionally be encountered.

Front 161

Trichloroacetic acid and bichloracetic acid more appropriate for which characteristic of warts

Back 161

small warts on moist surfaces.

Front 162

Trichloroacetic acid and bichloracetic acid in concentrations of 80–90%
Drawbacks

Back 162

low viscosity, they can run onto adjacent normal tissue if over-applied, causing damage.

should be applied sparingly and allowed to dry before the patient is allowed to sit or stand.

Front 163

Surgical removal of external genital warts may be advantageous because

Back 163

the patient often is cured in one visit.

Front 164

Surgical removal is probably most appropriate when .

Back 164

the patient has only a few small warts or

large numbers of warts over a large surface area that require surgical debulking.

The former generally is done in the office using a local anesthetic, whereas the latter requires general anesthesia

Front 165

Laser ablation requires specialized training and equipment and generally is reserved for

Back 165

extensive and recalcitrant disease.

Front 166

Pain following laser vaporization is dependent on the area being treated.

Laser ablation of large areas can result in severe pain that peaks after 5–7 days and can last up to how long?

What should be applied post ablation?

How many Watts Power?

20 Watts

Back 166

3 weeks.

TCA

Front 167

Laser ablation drawback

Back 167

Vitiligo and hyperpigmentation are possible

scarring is a potential complication of laser vaporization that is very extensive or too deep.

Front 168

. Rarely, infants exposed to HPV may develop warty growths in the throat called laryngeal papillomatosis.

Is CD useful in preventing the transmission of HPV?

Back 168

No.

Front 169

pregestational DM, in response to a report of an increased stillbirth rate in patients with a reactive nonstress test within 1 week of delivery, ____ testing has been widely adopted.

Back 169

twice weekly

Front 170

Contraindications to Intrauterine Device Use

Back 170

Pregnancy
Pelvic inflammatory disease (current or within the past 3 months)
• Sexually transmitted diseases (current)
• Puerperal or postabortion sepsis (current or within the past 3 months)
• Purulent cervicitis
• Undiagnosed abnormal vaginal bleeding
• Malignancy of the genital tract
• Known uterine anomalies or fibroids distorting the cavity in a way incompatible with intrauterine device (IUD) insertion
• Allergy to any component of the IUD or Wilson's disease (for copper-containing IUDs)

Front 171

If a patient had PID or POSTABORTAL/POSTPARTUM SEPSIS, how long must she wait until IUD can be inserted?

Back 171

3 months

Front 172

IUD Uterine perforation, the most concerning complication, is estimated to occur in approximately how many per 1000 insertions?

Back 172

1 in 1,000 insertions.

Front 173

If either the copper T380A or the levonorgestrel intrauterine system perforates into the peritoneal cavity, the location of the IUD should be confirmed by ultrasonography, and then

Back 173

IUD should be removed by laparoscopy or laparotomy.

Front 174

when removing IUDs is the lack of visible strings, what may be helpful in the office?

Back 174

Cytobrush

Front 175

If the cytobrush maneuver is not helpful, what should be done?

Back 175

ultrasonography should be performed to ensure intrauterine location of the IUD.

Front 176

What next if can't get with cyto brush and IUD is intrauterine confirmed by u/s?

Back 176

attempt to remove the IUD with an "IUD hook" under sterile conditions in the outpatient setting or may elect to remove the IUD in the operating room, where hysteroscopic guidance may be helpful.

Front 177

• Is routine screening for STDs (eg, gonorrhea and chlamydia) required before insertion of an IUD?

Back 177

women at high risk of STDs may benefit from screening.

Front 178

number of new cases in a period of time

Back 178

Incidence

NEW POrT (period of time)

Front 179

If GC/Chl cultures are not done before IUD placement, and pt later found to have chlamydia infection, should IUD be pulled?

Back 179

Clinical judgment should be used to determine whether the IUD should be removed

look for purulent discharge
abdominal pain
incidental finding
multiple partners

Front 180

• Is the presence of bacterial vaginosis a contraindication to IUD insertion?

Back 180

No

Front 181

Does antibiotic prophylaxis before IUD insertion decrease the risk of subsequent pelvic infection?

Back 181

unlikely to be cost-effective in populations with a low prevalence of STDs.

Front 182

SBE px for IUD insertion or removal needed?

Back 182

Not recommended for insertion or removal.

Front 183

asymptomatic patient with an IUD who has actinomyces identified on a Pap test:

Back 183

Management of the asymptomatic IUD user whose Pap test shows actinomyces is not clearly established.

actinomyces found via a Pap test is not diagnostic of actinomycosis infection, nor is it predictive of future disease.

options for management of asymptomatic IUD users with actinomyces on Pap test are expectant management, an extended course of oral antibiotics, removal of the IUD, and both antibiotic use and IUD removal.

Tetracycline

Front 184

history of ectopic pregnancy considered a contraindication to IUD use?

Back 184

No.

Front 185

Pregnancy with IUD. What to do:

Back 185

FDA recommends that IUDs be removed from pregnant women when possible without an invasive procedure.

Front 186

Do most women continue to ovulate while using the levonorgestrel intrauterine system?

Back 186

Yes.

Front 187

Which intrauterine system resulted in a substantial reduction in menstrual blood loss

Back 187

The levonorgestrel intrauterine system

may be an acceptable alternative to hysterectomy in women with menorrhagia.

Front 188

When should an IUD be removed in a menopausal woman?

Back 188

Awaiting 1 year of amenorrhea to ensure menopausal status is advisable before removing the device.

it seems prudent to remove the IUD placed for contraception from a menopausal woman.

Front 189

in the perimenopausal period, unexpected bleeding in women with an IUD should prompt

Back 189

an endometrial biopsy evaluate the possibility of endometrial pathology.

Front 190

Which IUD is appropriate for emergency contraception in women who meet standard criteria for IUD insertion and is most effective if inserted within 5 days after unprotected intercourse.

Back 190

The copper T380A

Front 191

Ultrasonography should be performed only when there is a valid medical indication, and the lowest possible ultrasonic exposure setting should be

Back 191

as low as reasonably achievable (ALARA) principle.

Front 192

Is a physician is not obligated to perform ultrasonography in a patient who is at low risk and has no indications?

Back 192

No.
However, if a patient requests ultrasonography, it is reasonable to honor the request. The decision ultimately rests with the physician and patient jointly

Front 193

• What gestational age represents the optimal time for an obstetric ultrasound examination?

Back 193

16–20 weeks

Front 194

fetus found to have IUGR. What should one look for?

Back 194

detailed ultrasound survey for the presence of fetal structural and functional defects may be indicated.

Front 195

is an important diagnostic and prognostic parameter in fetuses with IUGR.

Back 195

Amniotic fluid volume

Front 196

is highly suggestive of growth failure and indicates an increased risk of fetal death.

Back 196

Oligohydramnios

the absence of oligohydramnios should not diminish the importance of the diagnosis of IUGR.

Front 197

In pregnancies at risk for IUGR. Doppler velocimetry has been shown to both

Back 197

reduce interventions
and improve fetal outcome

Front 198

Identification of IUGR is improved by

Back 198

recording growth velocity or through 2 sets of examinations generally 2–4 weeks apart.

Front 199

Macrosomia implies growth

Back 199

beyond a specific weight, usually 4,000 g or 4,500 g,

regardless of gestational age.

Front 200

is the test of choice in the diagnosis of herpes-related infections of the central nervous system (meningitis and encephalitis.

Back 200

PCR

Front 201

More sensitive than viral culture for diagnosis of herpes

Back 201

PCR

Front 202

The problem with viral culture for dx herpes

Back 202

not sensitive

Front 203

The incubation period for HSV is

Back 203

short (approximately 4 days),

Front 204

Antibodies to HSV-2 are detected how long after acquisition of infection and persist indefinitely.

Back 204

2–12 weeks

Front 205

• Is there a role for testing an asymptomatic patient who reports possible exposure?

Back 205

Yes.
type-specific antibody testing is more accurate than assessment of infection based on symptoms or past sexual behavior.
knowledge of infection may result in decreased distress

Front 206

• Is there a role for postexposure prophylaxis in an asymptomatic patient?

Back 206

some physicians offer antiviral therapy in the setting of unanticipated known high-risk exposure (for example, rape or intercourse without a condom with a partner who had an unnoticed recurrence).

Front 207

Acyclovir MOA

Back 207

interrupt viral DNA synthesis

Front 208

Acyclovir is not activated unless

Back 208

HSV is actively replicating.

Front 209

Suppressive therapy (in which the medication is taken daily) for genital herpes prevents approximately ___% of recurrences.

who gets suppression?

Back 209

80%

recurrences >6 times/year

Front 210

In those taking daily HSV antiviral therapy:

viral shedding from the genital area is markedly decreased,

the breakthrough shedding contains reduced amounts of viral DNA.

This reduction in shedding translates into what % reduction in transmission?

Back 210

48%

Front 211

Women in whom a first episode genital HSV infection is diagnosed should be told

Back 211

they are likely to have recurrences and that these will be milder than the first episode

Front 212

Do they still shed even if don't have HSV symptoms?

Back 212

Yes.

they may have viral shedding with or without symptoms and that they are infectious at that time.

May shed for 7 days

Front 213

Women who have partners with genital herpes should be .

Back 213

tested with type-specific serology to assess the woman's risk of infection

Front 214

If the partners have discordant HSV types, the couple should be counseled about

Back 214

consistent use of condoms or dental dams, although condoms do not offer total protection from acquisition of HSV-2 infection.

Front 215

, use of suppressive antiviral therapy in the potential source partner has been shown to decrease transmission of HSV-2 by ___%to susceptible partners

Back 215

48%

Front 216

What is strongly predictive of preterm delivery in twin pregnancies.

Back 216

shortened cervix identified by endovaginal ultrasonography

Front 217

How do digital exams compare to u/s of cervical length?

Back 217

digital examination may be less objective than ultrasonographic measurement and does not allow assessment of the internal os.

Front 218

Has FFN been studied with multiple gestations?

Back 218

No

Front 219

Px cerclage in twins?

Back 219

does not prolong gestation or improve perinatal outcome

Front 220

tocolytics in multiples...

Back 220

should be used judiciously.

Front 221

Steroids in multiples?

Back 221

National Institutes of Health recommends that all women in preterm labor who have no contraindications to steroid use be given one course of steroids, regardless of the number of fetuses.

Front 222

How is the death of one fetus managed?

Back 222

if the death is the result of an abnormality of the fetus itself rather than maternal or uteroplacental pathology, and the pregnancy is remote from term, expectant management may be appropriate.

Front 223

The most difficult cases are those in which the fetal demise occurs in 1 fetus of a monochorionic twin pair.

Back 223

By the time the demise is discovered, the greatest harm has most likely already been done, and there may not be any benefit in immediate delivery, especially if the surviving fetuses are very preterm and otherwise healthy.

Front 224

How to manage fetal demise of 1 twin?

Back 224

Fibrinogen and fibrin degradation product levels can be monitored serially until delivery, and delivery can be expedited if DIC develops.

Front 225

• Is there a role for routine antepartum twin fetal surveillance?

Back 225

Multiple gestations are at increased risk of stillbirth.

Front 226

Twin–Twin Transfusion Syndrome A variety of therapies have been attempted, but what is most frequently used?

Back 226

serial therapeutic amniocenteses of the recipient twin's amniotic sac

Front 227

More aggressive therapies, include abolishing the placental anastomoses by endoscopic laser coagulation or selective feticide by umbilical cord occlusion usually are considered only for

Back 227

very early, severe cases,

Front 228

IN TTT, death of one fetus has been reported to result in the sudden transfusion of blood from the viable fetus to the low pressure system of the dead fetus, resulting in exsanguination of the viable twin.
If the gestational age is such that survival is likely, what should be done?

Back 228

immediate delivery should be considered, recognizing that damage to the remaining viable fetus may already have occurred.

Front 229

Beyond ____ weeks of gestation, the biochemical markers of pulmonary maturity (lecithin/sphingomyelin ratio or fluorescence polarization immunoassay) are higher in twin pregnancies than in singleton pregnancies at comparable gestational ages.

Back 229

31–32

Front 230

The nadir of perinatal mortality for twin pregnancies occurs at approximately ___ completed weeks of gestation

Back 230

38

Front 231

• For a postterm patient with a favorable cervix, does the evidence support labor induction or expectant management?

Back 231

generally is induced in postterm pregnancies in which the cervix is favorable because the risk of failed induction and subsequent cesarean delivery is low.

Front 232

• For a postterm patient with an unfavorable cervix, what are options of management?

Back 232

The introduction of preinduction cervical maturation has resulted in fewer failed and serial inductions, reduced fetal and maternal morbidity, reduced medical cost, and possibly a reduced rate of cesarean delivery

Front 233

Prostaglandin (PG) is a valuable tool for improving cervical ripeness and inducing labor.

Back 233

changes in Bishop scores,

shorter durations of labor,

lower maximum doses of oxytocin, and a

reduced incidence of cesarean delivery among postterm patients who received PGE2 gel?

Front 234

For women with 2 prior cesarean deliveries, only those with what should be considered candidates for a spontaneous trial of labor.

Back 234

a prior vaginal delivery

Front 235

Women who attempt VBAC who have interdelivery intervals of less than 24 months have a ____x increased risk of uterine rupture when compared with women who attempt VBAC more than 24 months after their last delivery.

Back 235

2–3-fold

Front 236

A second-trimester hysterotomy is associated with its own risks, and the decision to attempt a trial of labor in the midtrimester should probably be based on

Back 236

individual circumstances, including but not limited to the

number of previous cesarean deliveries,

gestational age, placentation, and the

woman's desire to preserve reproductive function.

Front 237

• What are contraindications for VBAC?

Back 237

• Previous classical or T-shaped incision or extensive transfundal uterine surgery
• Previous uterine rupture
• Medical or obstetric complication that precludes vaginal delivery
• Inability to perform emergency cesarean delivery because of unavailable surgeon, anesthesia, sufficient staff, or facility
• Two prior uterine scars and no vaginal deliveries

Front 238

Does epidural analgesia masks the signs and symptoms of uterine rupture?

Back 238

Rarely. So, no.

Front 239

internal better than external monitoring for TOLAC?

Back 239

No data suggest monitoring with intrauterine pressure catheters is superior to external monitoring

Front 240

Should scar dehiscences after SVD that are stable be repaired?

Back 240

***Most asymptomatic scar dehiscences heal well, and there are no data to suggest that future pregnancy outcome is better if the dehiscence is surgically repaired

Front 241

If the site of the ruptured scar is confined to the lower segment of the uterus, the rate of repeat rupture or dehiscence in labor is

Back 241

6%.

Front 242

If the scar includes the upper segment of the uterus, the repeat rupture rate is

Back 242

32%.

Front 243

How are patients with hydatidiform moles managed?

Back 243

• Complete blood count with platelet determination
• Clotting function studies
• Renal and liver function studies
• Blood type with antibody screen
• Determination of hCG level
• Preevacuation chest X-ray

Front 244

Medical complications of hydatidiform moles

Back 244

anemia,

infection,

hyperthyroidism,

pregnancy-induced hypertension, and

coagulopathy.

Front 245

Women with signs and symptoms of these complications will need more intensive evaluation (ie, thyroid-stimulating hormones and coagulopathy studies).

Moles should be evacuated when?

Back 245

as soon as possible after stabilization of any medical complications

Front 246

To manage potential complications of molar evacuation in a woman with a large uterus, consideration should be given to performing the evacuation in a facility with:

Back 246

an intensive care unit, a blood bank, and anesthesia services.

Front 247

After serial dilation of the cervix, uterine evacuation is accomplished with what size cannula?

Back 247

the largest cannula that can be introduced through the cervix.

Front 248

What should you have in the OR to assist with suction D&C of mole?

Back 248

ultrasound guidance may facilitate complete evacuation of the uterus.

Front 249

This sequelae/sydrome has been emphasized as an underlying cause of respiratory distress syndrome following molar evacuation:

There are many other potential causes of pulmonary complications in these women.

Back 249

the syndrome of trophoblastic embolization (deportation)

Front 250

in moles, respiratory distress syndrome can be caused by

Back 250

high-output congestive heart failure caused by
anemia
hyperthyroidism
preeclampsia
iatrogenic fluid overload

Front 251

Generally, these respiratory complications should be treated aggressively with

Back 251

therapy directed by central venous or Swan-Ganz catheter monitoring and assisted ventilatory support, as required.

Front 252

Surgical intervention for molar pregnancy should be reserved for

Back 252

rupture or torsion, which is rare

Front 253

an alternative to suction D&C for molar evacuation in selected patients who do not wish to preserve childbearing.

Back 253

Hysterectomy with preservation of the adnexa

reduces the risk of malignant postmolar sequelae when compared with evacuation by D&C.

Front 254

Ideally, serum hCG levels should be obtained within how long after evacuation,

Back 254

48 hours

every 1–2 weeks while elevated, and then at monthly intervals for an additional 6 months.

Front 255

What are performed while hCG values are elevated, and why?

Back 255

Frequent pelvic examinations

to monitor the involution of pelvic structures and to aid in the early identification of vaginal metastases.

Front 256

Compared with singleton hydatidiform moles, do twin pregnancies with a fetus and a mole carry an increased risk for postmolar gestational trophoblastic disease?

Back 256

Yes.
And with a higher proportion of patients having metastatic disease and requiring multiagent chemotherapy.

Front 257

with co-existing hydatidiform moles and fetuses suspected on the basis of ultrasound findings,
ultrasound examination should be repeated to exclude:

Back 257

retroplacental hematoma, other
placental abnormalities, or
degenerating myoma and to
fully evaluate the fetoplacental unit for evidence of a partial mole or gross fetal malformations.

Front 258

If the diagnosis is still suspected and continuation of the pregnancy is desired, what should be done?

Back 258

fetal karyotype
chest X-ray
serial serum hCG values monitored.

Front 259

• How is nonmetastatic (confined to uterus) gestational trophoblastic disease treated?

In a patient with nonmetastatic gestational trophoblastic disease, which is better: hysterectomy alone or in combination with chemotherapy?

Back 259

Essentially all patients with this condition can be cured, usually without hysterectomy.

weekly methotrexate regimen is the preferred choice

early hysterectomy will shorten the duration and amount of chemotherapy required to produce remission.

Front 260

Patients whose hCG levels reach a plateau or increase during therapy should be switched to an alternative single-agent regimen.
If metastases appears or alternative single-agent chemotherapy fails, then what?

Back 260

the patient should be treated with multiagent regimens

Front 261

• How is low-risk metastatic gestational trophoblastic disease treated?

Back 261

Low Risk treatment is similar to the treatment of women with nonmetastatic gestational trophoblastic disease, 1–2 cycles of chemotherapy should continued after the first normal hCG level.

Front 262

Compared to patients with nonmetastatic or low-risk metastatic gestational trophoblastic disease, does early hysterectomy improve the outcome in women with high-risk metastatic disease?

Back 262

no.

Front 263

Management of cerebral metastases is controversial.

Back 263

Brain irradiation combined with systemic chemotherapy

Front 264

After hCG remission has been achieved, patients with malignant gestational trophoblastic disease should undergo serial determinations of hCG levels at

Back 264

2-week intervals for the first 3 months of remission and then at 1-month intervals until monitoring has shown 1 year of normal hCG levels.

Front 265

may be considered as a last resort in patients who will require enteral or parenteral nutrition because of weight loss.

Back 265

Corticosteroids

Front 266

Common laboratory abnormalities in hyperemesis gravidarum include:

Back 266

increased liver enzymes (usually <300 U/L),

serum bilirubin (<4 mg/dL), and

serum amylase or lipase concentrations (up to 5 times greater than normal levels).

Primary hepatitis as a cause of nausea and vomiting of pregnancy results in increased liver enzyme levels, often in the thousands;

bilirubin concentrations usually are greatly increased as well.

Acute pancreatitis may cause vomiting and elevated amylase concentrations, but serum amylase concentrations usually are 5–10 times greater than the elevations associated with nausea and vomiting of pregnancy.

Front 267

Patients with persistent hyperemesis gravidarum that is unresponsive to standard therapy may have what abnormality?

Back 267

PUD

treatment with antibiotics and H2 receptor antagonists
OCLAM

Front 268

• When is enteral or parenteral nutrition recommended?

Back 268

persistent weight loss.

cannot maintain their weight despite antiemetic therapy

Front 269

Correction of ketosis and vitamin deficiency should be strongly considered. Dextrose and vitamins, especially which vitamin, should be included in the therapy when prolonged vomiting is present.

Back 269

thiamine

Front 270

Because life-threatening complications of parenteral nutrition have been described, it is reasonable to attempt what type of feeding initially?

Back 270

enteral tube feeding initially
(NGT)

Front 271

Which type of nutrition using a high-lipid formula can be used for patients whose calorie requirements are not great and those whose length of treatment is anticipated to be no more than several days.

Back 271

Peripheral parenteral nutrition

Front 272

For women who need longer-term support and who cannot tolerate enteral tube feedings, the use of what modality has been described for hyperemesis gravidarum?

Back 272

total parenteral nutrition

A peripherally inserted central catheter can be used to avoid some of the complications of central access, but it is still associated with significant morbidity.

Front 273

Gonadotropin-releasing hormone agonists MOA

Back 273

"down-regulate" hypothalamic–pituitary gland production and the release of FSH and LH

leading to dramatic reductions in estradiol levels.

Decapeptide released from the hypothalamus

Front 274

In addition to endometriosis GnRH agonists may be used to treat pelvic pain associated with

Back 274

ovarian retention syndrome (residual ovary syndrome) and ovarian remnant syndrome.

Front 275

effective in the treatment of chronic pelvic pain associated with endometriosis and pelvic congestion syndrome.

Back 275

Progestins

Medroxyprogesterone acetate (Provera), 30–100 mg per day


PROVERA = PELVIC congestion Sydrome

Front 276

effectively decreases pain from endometriosis and pelvic congestion syndrome in most studies.

Back 276

Progestins

Medroxyprogesterone acetate (Provera), 30–100 mg per day

Front 277

Surgical resection of this plexus is sometimes useful for central dysmenorrhea unresponsive to other treatments.

Back 277

superior hypogastric plexus (presacral nerve)

actually found in Lumbar region

Front 278

provides additional pain relief mostly of midline pain associated with menses, with little additional effect on dyspareunia and nonmenstrual pain.

Back 278

presacral neurectomy

Front 279

Uterine nerve ablation is less effective for the treatment of primary dysmenorrhea than what procedure?

Back 279

presacral neurectomy.

Front 280

useful for central dysmenorrhea unresponsive to other treatments.

Back 280

presacral neurectomy

Front 281

besides Dexa, other modalities to measure BMD:

Back 281

Quantitative Ultrasonography
“Achilles Express Ultrasonometer” - low cost and lack of ionizing radiation. predict hip fractures

Peripheral Quantitative CT

Front 282

Meds not to forget to counsel to avoid when assessing fall risk

Back 282

Medications that reduce strength and balance (such as sedatives, narcotic analgesics, anticholinergics/dizzy and dry, and antihypertensives) should be avoided, if possible.

Front 283

Has Hip fracture reduction has been demonstrated in raloxifene?

Back 283

No.

Front 284

This SERM has androgenic and progestogenic properties and has demonstrated efficacy in the prevention of postmenopausal bone loss.

Back 284

Tibolone

investigational, still.

Front 285

available as both a subcutaneous injection and as a nasal spray, is approved for the treatment of osteoporosis in women 5 or more years after menopause.

Back 285

Salmon calcitonin

reducing bone turnover

Front 286

Recommended Daily Elemental
Calcium Requirements
National Institutes of Health
Premenopausal women aged 25–50 years:

Back 286

1,000 mg

Front 287

Postmenopausal women younger than 65 years using estrogen therapy:

Back 287

1,000 mg

Front 288

Postmenopausal women not using estrogen therapy:

Back 288

1,500 mg

Front 289

All women older than age 65 years:

Back 289

1,500 mg

Front 290

therapy should be limited to patients who have not responded to antiresorptive therapies, those with very severe disease, and those for whom therapeutic alternatives are limited.

Back 290

Daily subcutaneous injections of recombinant human PTH

Front 291

The recommendations for these supplements apply to what type of calcium?

Back 291

elemental

Front 292

Clinical pelvimetry can be useful to

Back 292

qualitatively identify the general architectural features of the pelvis and identify patients at risk for dystocia.

Front 293

Active management of labor is confined to

Back 293

nulliparous women with singleton, cephalic presentations at term that show no evidence of fetal compromise.

Front 294

• Should women with twin gestations undergo augmentation of labor?

Back 294

Twin gestation is not a contraindication to augmentation of labor, but it does warrant special attention.

Front 295

elective cerclage for purely historical factors generally should be confined to patients with

Back 295

3 or more otherwise unexplained second-trimester pregnancy losses or preterm deliveries.

Front 296

Urgent, or therapeutic, cerclage often is recommended for women who

Back 296

have ultrasonographic changes consistent with a short cervix or the presence of funneling.

Front 297

If transvaginal ultrasonography before 16–20 weeks of gestation identifies a short cervix, what should be done?

Back 297

the examination should be repeated because of the inability to adequately distinguish the cervix from the lower uterine segment in early pregnancy.

Front 298

Identification of a short cervix at or after 20 weeks of gestation should prompt assessment of

Back 298

1) the fetus for anomalies,

2) uterine activity to rule out preterm labor, and

3) maternal factors to rule out chorioamnionitis.

Front 299

If cervical shortening or funneling is detected, the appropriate management is?

Back 299

remains unclear, and the decision to proceed with urgent cerclage should be made with caution.

Front 300

A woman with advanced cervical effacement or dilatation or both should be counseled about

Back 300

the paucity of data to support the efficacy of emergency cerclage,

as well as the potential associated maternal and neonatal morbidity.

Front 301

emergency cerclage may be considered in such women in the absence of

Back 301

clinical chorioamnionitis

or labor.

Front 302

The role of cerclage in the treatment of patients with cervical insufficiency after fetal viability has not been adequately assessed.

Back 302

Hmmmm.

Front 303

• Is there a role for scheduled early or first-trimester cerclage in patients with a suspicious clinical history (eg, a few contractions or short or dilated cervix at 20 weeks of gestation)?

Back 303

No.
The evidence-based risk-benefit ratio does not support first-trimester cerclage, even with transabdominal procedures.

Front 304

Transabdominal cerclage placed how?

Back 304

tunneled between the bifurcation of the uterine artery,

Front 305

• Should perioperative antibiotics and tocolytics be used in association with cerclage placement?

Back 305

No

Front 306

What is the purpose of antibiotic prophylaxis appropriate for patients undergoing cesarean delivery?

Back 306

febrile morbidity,

urinary tract infection,

wound infection

are reduced by antibiotic prophylaxis

Front 307

Because those antibiotics with a narrower spectrum (Cefoxitin/Ancef/first generation) have been shown to be as efficacious as the newer, broad-spectrum agents, the practitioner should choose from

Back 307

among those with a narrower spectrum.

Front 308

Single-dose therapy, usually given when the umbilical cord is clamped, has been shown to be as efficacious as

Back 308

multidose therapy

Front 309

prevention of bacterial endocarditis dose

Back 309

2 g of ampicillin ( [IM] or [IV]) plus 1.5 mg/kg of IV gentamicin (to a maximum of 120 mg), within 30 min.

followed by 1 g of ampicillin (IM or IV) or 1 g of oral amoxicillin 6 hours later.

Front 310

In patients who are allergic to penicillin for SBE px

Back 310

vancomycin (1 g IV over 1–2 hours) should be substituted for ampicillin.

Front 311

Is antibiotic prophylaxis appropriate for patients undergoing manual removal of the placenta?

Back 311

no data exist to either support or refute this practice.

Front 312

Failure rates of tubal sterilization are roughly comparable with those of the

Back 312

IUD

Front 313

5-year cumulative failure rate for the copper T 380-A IUD of ___ per 1,000 procedures.

Back 313

14

Front 314

5-year cumulative pregnancy rate for levonorgestrel-releasing IUDs ranges between ___ per 1,000 procedures.

Back 314

5

Front 315

______ had the highest cumulative probability of ectopic pregnancy (17.1/1,000), and _______ had the lowest cumulative probability (1.5/1,000).

Back 315

Bipolar coagulation
postpartum partial salpingectomy

Front 316

Bipolar coagulation had a cumulative probability ____ times higher than unipolar coagulation

Back 316

10

Front 317

the only method reported by the CREST study that did not have a higher 10-year cumulative probability of ectopic pregnancy in younger women

Back 317

Postpartum partial salpingectomy was

Front 318

Perforation rates vary based on the type of IUD, less than ____ in 1,000 insertions generally is recognized.

Back 318

1

Front 319

Annual cytology screening should be recommended for women younger than

Back 319

30 years

Front 320

Women aged 30 years and older who have had three consecutive cervical cytology test results that are negative for intraepithelial lesions and malignancy may be screened every

Back 320

2–3 years.

Front 321

Women with any of the following risk factors may require more frequent cervical cytology screening:

Back 321

Women who are infected with human immunodeficiency virus (HIV)
•
Women who are immunosuppressed (such as those who have received renal transplants)
•
Women who were exposed to diethylstilbestrol in utero

Front 322

Human papillomavirus infections are commonly acquired by young women, but, most cleared by the immune system within how much time without producing neoplastic changes?

Back 322

1–2 years

Front 323

Women with previously normal cervical cytology results whose most recent cervical cytology sample lacked endocervical cells or transformation zone components and those with partly obscuring red or white blood cells should be rescreened in

Back 323

1 year.

Front 324

women in both of these categories should continue to have routine cervical cytology examinations no matter what age (past 70)

Back 324

An older woman who is sexually active and has had multiple partners

woman with a previous history of abnormal cytology

Front 325

Women who have had a total hysterectomy and have no prior history of ____ may discontinue screening.

Back 325

HIGH-grade CIN

Front 326

Women who have had a hysterectomy and have a history of CIN 2 or CIN 3—OR in whom a negative history cannot be documented—should continue to be screened ANNUALLY until

Back 326

three consecutive satisfactory negative cervical cytology results are obtained. Routine screening may then be discontinued.

Front 327

A woman who has had three consecutive satisfactory negative examinations following treatment for CIN 2 or CIN 3 before she had a hysterectomy also may discontinue screening.

Back 327

Hmmmm.

Front 328

• How do the various methods of cervical cytology compare in terms of effectiveness?

Back 328

liquid-based thin-layer cervical cytology appears to have increased sensitivity for detecting cancer precursor lesions over the conventional method

Front 329

• Is the recommended frequency of screening affected by the method of screening?

Back 329

The American Cancer Society recommends that women younger than 30 years undergo cervical cancer screening annually if the conventional method is used or every 2 years if a liquid-based method is used.

Front 330

SurePath technique may be marketed as equivalent to the ______ Pap test.

Back 330

conventional

Front 331

Why is it has been suggested that HPV DNA testing might be a more selective test in older women (>30)?

Back 331

Because HPV is more prevalent in younger women and the rate of CIN 2 and CIN 3 increases with age,

Front 332

Another clinical setting in which HPV DNA testing may be useful is .

Back 332

in the secondary triage of women with ASC-US, ASC-H, or LSIL in whom colposcopy is negative or biopsy fails to reveal CIN. A protocol of follow-up in 1 year with HPV DNA testing has been suggested as an alternative to repeat cytology in this group, with repeat colposcopy for those with positive test results

Front 333

Any woman aged 30 years or older who receives negative test results on both cervical cytology screening and HPV DNA testing should be rescreened no more frequently than

Back 333

every 3 years.

use of this approach is only for the panel of high-risk HPV types.

Front 334

the combination of cytology and HPV DNA screening should be restricted to women aged 30 years and older because

Back 334

transient HPV infections are common in women younger than 30 years, and a positive test result may lead to unnecessary additional evaluation and treatment. Routine testing using cytology alone remains an acceptable screening plan.

Front 335

folic acid is now widely acknowledged as beneficial in preventing isolated nonsyndromic NTDs, it must be ingested before conception and at least through the first ___ weeks of fetal development to be effective.

Back 335

4

Front 336

There have been concerns that supplemental folic acid could mask the symptoms of ________ and thus delay treatment.

Back 336

pernicious anemia

However, folic acid cannot mask the neuropathy typical of this diagnosis.

Front 337

women taking what medication may have lower serum drug levels and experience an associated increase in sequelas frequency while taking folic acid supplements.

Back 337

seizure meds

more seizures while taking folate

Front 338

Increased seizures while taking folate:

What may help to avert this complication.

Back 338

Monitoring drug levels and increasing the dosage as needed

Front 339

Dilantin MOA

Back 339

inhibits Na dependent channels

Front 340

vitamin A is potentially teratogenic at high doses, and pregnant women should not take more than ____IU per day

Back 340

5,000 IU

Front 341

• Which NTDs may not be affected by increased folic acid supplemenation?

Back 341

Diabetes
Sauna
Seizures

high first-trimester blood glucose levels

high first-trimester maternal temperature/fever/sauna, or

in women who take valproic acid.

Front 342

In women with high glucose levels, the exact mechanism of NTD is unknown but may involve

Back 342

inhibition of fetal glycolysis,

a functional deficiency of arachidonic acid or myoinositol in the developing embryo, or


alterations in the yolk sac.

Front 343

MSAFP screen-positive cutoff is set at

Back 343

2.5 multiples of the median (MoM)

Front 344

Don't forget false elevations of MSAFP due to

Back 344

fetal demise
Placental abnormalities - chorioangioma/accreta/mole

Front 345

Which women can forgo the MSAFP and be offered a diagnostic test directly?

Back 345

already known to be at high risk of having a fetus with an NTD because of a previously affected pregnancy,

a positive family history,

medication exposure,

diabetes, or

another risk factor,

Front 346

considered diagnostic for a fetal NTD.

Back 346

Elevated amniotic fluid AFP together with the presence of acetylcholinesterase is

Front 347

In the hands of experienced operators, ultrasonography alone has up to ___%sensitivity and ___% specificity in the diagnosis of NTDs

Back 347

97%

100%

Front 348

To take advantage of both types of testing and to minimize risk, many centers now offer specialized ultrasound examinations initially to all high-risk women, and perform amniocenteses only in a subset of patients.

Back 348

If a high-quality ultrasound examination is performed and no fetal defects are identified, the risks and benefits of both amniocentesis and specialized ultrasound examination can be discussed with the patient.

Some authorities dispute the use of ultrasonography as a diagnostic test and recommend that amniocentesis be offered to all women with elevated MSAFP levels

Front 349

Individuals with an NTD are at risk of developing a severe, potentially life-threatening allergy to what?

Back 349

latex, clinicians handling the infant should wear wear latex-free gloves.

Front 350

Generally, NTD delivery at term is preferred. However, once fetal lung maturity has been documented, rapidly increasing ventriculomegaly may prompt delivery before term so that

Back 350

a ventriculo-peritoneal shunt can be placed

Front 351

For the breech fetus with an NTD, what mode of delivery is standard.

Back 351

cesarean delivery

Front 352

fetal fibronectin testing, their clinical usefulness

Back 352

negative predictive value

Front 353

Beta-mimetics are a potent cardiovascular stimulants and can cause serious complications, such as

Back 353

maternal myocardial ischemia,
hyperglycemia
hypo-kalemia
fetal cardiac effects

Front 354

Should women with preterm contractions without cervical change be treated?

(re infection)

Back 354

No.

If ctxing due to infection, will be at even more risk of pulmonary edema if give tocolytics.

Front 355

Should women with multiple gestations be treated for preterm contractions?

Back 355

No.
Women with multiple gestations who have preterm contractions but no cervical change do not require tocolytic therapy

Front 356

women with multiple gestations who are experiencing preterm labor may benefit from short-term tocolysis to allow for steroid administration, but they have a greater risk of _______when exposed to beta-mimetics or magnesium sulfate.

Back 356

pulmonary edema

Front 357

Is there a role for amniocentesis in diagnosing chorio?

Back 357

no evidence to suggest that routine amniocentesis to check for infection in these women can provide information that could be used to improve perinatal outcomes

The results of amniotic fluid cultures, the best method for diagnosing intraamniotic infection, are unlikely to be available quickly enough to affect decision making

Both amniotic fluid Gram stain and glucose levels have been used as rapid diagnostic tests of intraamniotic infection.

Front 358

BRCA1 or BRCA2 carriers, the Cancer Genetics Studies Consortium has offered Level-III provisional Breast Cancer screening recommendations of :

Back 358

1) education regarding monthly breast self-examination,
2) annual or semiannual clinical breast examination beginning at age 25-35 years, and
3) annual mammography beginning at age 25-35 years.

Front 359

If a cyst is aspirated and the fluid is _____ there is no need for cytology.

Back 359

clear (transparent and not bloody),

Front 360

If the cyst does not disappear after aspiration or recurs within ____, surgical follow-up should be considered.

Back 360

6 weeks

Front 361

• Who should be referred for genetic counseling?

Back 361

family history,

including age at diagnosis and type of all cancers (in any relatives, female and male),

suggests a possible autosomal dominant cancer pattern

BRCA mutation has been discovered in their family.

Front 362

• Who should be screened for nonclassical congenital adrenal hyperplasia, and how should screening be performed?

Back 362

adult women with anovulation and hirsutism

17-OHP levels

Front 363

To screen for nonclassical congenital adrenal hyperplasia caused by CYP21 mutations

Back 363

fasting level of 17-hydroxyprogesterone

Front 364

High levels of 17-hydroxy-progesterone should prompt what test.

Back 364

adrenocorticotropic hormone stimulation

Front 365

• Does PCOS increase the risk of developing type 2 diabetes?

Back 365

Yes.

Front 366

Does the American Diabetes Association recommend screening for insulin resistance with measures of insulin or other markers of the insulin resistance syndrome.

Back 366

No

Front 367

However, it may be useful to screen selected women with PCOS for hyperinsulinemia—for example, those with

Back 367

severe hyperandrogenism and acanthosis nigricans
younger women,
or those undergoing ovulation induction.

Front 368

Fasting glucose levels are poor predictors of glucose intolerance risk in women with

Back 368

PCOS

Front 369

Women with PCOS should be screened for type 2 diabetes and impaired glucose tolerance with

Back 369

a fasting glucose level followed by a 2-hour glucose level after a 75-g glucose load.

Front 370

Two modalities that significantly reduce the risk of developing diabetes in women with impaired glucose tolerance

Back 370

lifestyle interventions

metformin

Front 371

• Does PCOS have a long-term impact on the development of cardiovascular disease?

Back 371

Dyslipidemia

due obesity and impaired glucose tolerance

Front 372

All women with PCOS should be screened for cardiovascular risk by determination of

Back 372

BMI

waist–hip ratio

measurement of fasting lipid and lipoprotein levels (total cholesterol, HDL cholesterol, and triglycerides).

Front 373

• In a woman with PCOS who is not attempting to conceive, what is the best medical maintenance therapy to treat anovulation and amenorrhea?

Back 373

Combination Oral Contraceptives


monophasic OCPs are associated with a significant reduction in the risk for endometrial cancer

Front 374

Medical treatment for PCOS

Back 374

OCPs
Progestins
Insulin sensitizers - inhibits liver gluconeogenesis

Front 375

What do insulin sensitizers do?

Back 375

improve peripheral insulin sensitivity by decreasing circulating insulin levels

Front 376

improving insulin sensitivity (metformin) is associated with

Back 376

a decrease in circulating androgen levels, (by increasing SHBG) (drilling also decreases circulating androgens) therfore causes ovulation.

improved ovulation rate (they get pregnant!),


improved glucose tolerance.

Front 377

Metformin also may be associated with weight loss

Back 377

biguanides bisect weight!

Front 378

Up to ___% of women with PCOS will ovulate in response to clomiphene treatment, and ___% of these women will conceive.

Back 378

80

50

Front 379

Generally, NTD delivery at term is preferred. However, once fetal lung maturity has been documented, rapidly increasing ventriculomegaly may prompt delivery before term so that

Back 379

a ventriculo-peritoneal shunt can be placed

Front 380

For the breech fetus with an NTD, what mode of delivery is standard.

Back 380

cesarean delivery

Front 381

fetal fibronectin testing, their clinical usefulness

Back 381

negative predictive value

Front 382

Beta-mimetics are a potent cardiovascular stimulants and can cause serious complications, such as

Back 382

maternal myocardial ischemia,
hyperglycemia
hypo-kalemia
fetal cardiac effects

Front 383

Should women with preterm contractions without cervical change be treated?

Back 383

No.

If ctxing due to infection, will be at even more risk of pulmonary edema if give tocolytics.

Front 384

Should women with multiple gestations be treated for preterm contractions?

Back 384

No.
Women with multiple gestations who have preterm contractions but no cervical change do not require tocolytic therapy

Front 385

women with multiple gestations who are experiencing preterm labor may benefit from short-term tocolysis to allow for steroid administration, but they have a greater risk of _______when exposed to beta-mimetics or magnesium sulfate.

Back 385

pulmonary edema

Front 386

Is there a role for amniocentesis in diagnosing chorio?

Back 386

no evidence to suggest that routine amniocentesis to check for infection in these women can provide information that could be used to improve perinatal outcomes

The results of amniotic fluid cultures, the best method for diagnosing intraamniotic infection, are unlikely to be available quickly enough to affect decision making

Both amniotic fluid Gram stain and glucose levels have been used as rapid diagnostic tests of intraamniotic infection.

Front 387

BRCA1 or BRCA2 carriers, the Cancer Genetics Studies Consortium has offered Level-III provisional Breast Cancer screening recommendations of :

Back 387

1) education regarding monthly breast self-examination,
2) annual or semiannual clinical breast examination beginning at age 25-35 years, and
3) annual mammography beginning at age 25-35 years.

Front 388

If a cyst is aspirated and the fluid is _____ there is no need for cytology.

Back 388

clear (transparent and not bloody),

Front 389

Alternative clomiphene regimens for PCO have been developed, including:

Back 389

prolonging the period of administration and

adding dexamethasone

Front 390

Dexamethasone as adjunctive therapy with clomiphene citrate has been shown to increase ovulation rates in women with PCOS with

Back 390

higher DHEAS levels >2000 ng/mL

Dex for patients with deux thousand DHEAS!

Front 391

Dex for patients with deux thousand DHEAS!

Back 391

Dex for patients with deux thousand DHEAS!

Front 392

frequently are used to induce ovulation in women with PCOS for whom clomiphene treatment has failed.

Back 392

Gonadotropins

Front 393

Cycle cancellation means

Back 393

can’t use this ovarian stimulation (via FSH) cycle for IVF

Estradiol level is too high because follicles are too large.

couples with HCG innjection will increase risk of OHSS

Front 394

• In women with PCOS who are attempting to conceive, which methods of ovulation induction are effective?

Back 394

weight loss/exercise
clomid
clomid with Dex
Gonadotropins
Ovarian drilling - reduces androgens
Metformin 1,500 mg per day
Thiazolidinediones - hepatotoxicity

Front 395

This outcome is reduced in those women who conceive after laparoscopic drilling

Back 395

Multiple pregnancy rates

Front 396

This drug also has been used successfully as an adjunctive agent with both clomiphene citrate (just as Dex is an adjunct to clomiphene citrate) and gonadotropins.

Back 396

Metformin

Front 397

Metformin carries a small risk of

Back 397

lactic acidosis

contraindicated in renal/liver disease

Front 398

thought to improve insulin sensitivity through a postreceptor mechanism

Back 398

Thiazolidinediones

troglitazone - liver toxicity

Front 399

Flutamide most common side effect is

Back 399

dry skin,

Front 400

Flutamide MOA

Back 400

androgen-receptor antagonist,

nonsteroidal antiandrogen effective against hirsutism

Front 401

Finasteride MOA

Back 401

inhibits both forms of the enzyme 5-alpha reductase

Finasteride is better tolerated than other antiandrogens

Front 402

Eflornithine MOA

Back 402

inhibits ornithine decarboxylase

topical eflornithine -approved by the FDA for treating hirsutism.

Front 403

• Do labor abnormalities predict shoulder dystocia?

Back 403

No

Front 404

McRoberts maneuver

Back 404

hyperflexion and abduction of the hips causing cephalad rotation of the symphysis pubis and flattening of the lumbar lordosis that frees the impacted shoulder.

Front 405

Suprapubic pressure may be used AT THE SAME TIME to assist in dislodging the impacted shoulder.

Back 405

Hmmmm.

Front 406

• How should a woman with a history of delivery complicated by shoulder dystocia be counseled regarding subsequent deliveries?

Back 406

the true incidence may remain unknown

most subsequent deliveries will not be complicated by shoulder dystocia,

benefit of universal elective cesarean delivery is questionable

After discussion with the patient, either method of delivery is appropriate.

Front 407

Who are appropriate candidates for Tamoxifen?

Back 407

1. DCIS and lobular carcinoma in situ who do not choose surgical therapy,
2. women with ductal hyperplasia with atypia, and
3. women with a high risk on the basis of personal and family history

Front 408

Raloxifene is approved by the FDA for

Back 408

prevention AND treatment of osteoporosis.

Front 409

is appropriate for the prevention and treatment of osteoporosis in women who have a family history of breast or endometrial cancer.

Back 409

Raloxifene

Front 410

Raloxifene is contraindicated in

Back 410

pregnant women or those who may become pregnant

women with a current or past history of venous thromboembolic events, including deep vein thrombosis, pulmonary embolism, and retinal vein thrombosis.

Front 411

• Is raloxifene appropriate for breast cancer patients who have completed a 5-year course of tamoxifen?

Back 411

No studies have investigated the use of raloxifene after a 5-year course of tamoxifen

Front 412

In premenopausal women, tamoxifen may cause decreases in bone mineral density for ___ years after initiation of therapy, which stabilizes after this period.

Back 412

3

, tamoxifen has not been evaluated prospectively in women with osteoporosis, and its effects in the bone remain to be established.

Front 413

With this SERM, many patients experience vaginal dryness.

Back 413

Raloxifene

Front 414

• In patients using SERMs, are there beneficial effects on vaginal dryness and hot flashes with the addition of estrogen?

Back 414

No published trials have studied the combination of systemic estrogen and SERMs to reduce vasomotor symptoms.

Front 415

• In patients using SERMs, are there benefits with the addition of bisphosphonates?

Back 415

The addition of alendronate to raloxifene therapy significantly enhances the antiresorptive efficacy beyond that of either agent independently.

The effect on actual fracture rates and the long-term safety of such combinations of antiresorptive agents remain unknown.

Front 416

An increased risk of what specific type of cancer has been observed in women taking tamoxifen

Back 416

uterine sarcoma

Front 417

. Factors That Increase the Relative Risk for Breast Cancer in Women

Back 417

Certain inherited genetic mutations for breast cancer
Two or more first-degree relatives with breast cancer diagnosed at an early age
Personal history of breast cancer
Age (>=65 years vs <65 years, although risk increases across all ages until age 80 years)
One first-degree relative with breast cancer
Nodular densities on mammogram (>75% of breast volume)
Atypical hyperplasia
High-dose ionizing radiation to the chest
Ovaries not surgically removed (age <40 years)
High socioeconomic status
Urban residence
Northern U.S. residence
Early menarche (age <12 years)
Late menopause (age >=55 years)
No term pregnancies (for breast cancer diagnosed at age >=40 years)
Late age at first term pregnancy (>=30 years)
Never breastfed a child
Postmenopausal obesity
Alcohol consumption
Recent hormone replacement therapy
Recent oral contraceptive use
Tall stature
Personal history of cancer of endometrium, ovary, or colon
Jewish heritage

Front 418

• How long should patients take raloxifene?

Back 418

The use of raloxifene for osteoporosis prevention is not time-limited.

Front 419

tamoxifen use for _____ is currently recommended.

Back 419

5 years

Front 420

extremely preterm or extremely LBW infants

major morbidities influencing later development in these children include

Back 420

chronic lung disease,

severe brain injury
(intraventricular hemorrhage and periventricular leukomalacia),
NEC

nosocomial infections,


retinopathy of prematurity.

Front 421

Most ultrasound fetal weight formulas will yield a weight estimate within ___% of the actual weight (for weights <____ g) and a gestational age estimate within 2 weeks of the actual gestational age (from 20 to 30 weeks).

Back 421

15

1,500

Front 422

In a pregnant patient suspected of being hyperthyroid or hypothyroid, what should be measured.

Back 422

TSH and FT4 or FTI

Front 423

Measurement of FT3 usually is only pursued in patients with

Back 423

thyrotoxicosis with suppressed TSH but normal FT4 measurements.

Front 424

Propylthiouracil MOA

Back 424

reduces the peripheral conversion of T4 to T3 and, thus, may have a quicker suppressant effect than methimazole.

Therefore, give PTU for thyrotoicosis

Front 425

has been associated with PTU/Methimazole treatment for Graves' disease, presumably caused by drug-induced fetal hypothyroidism.

Back 425

Fetal goiter

Front 426

secondary to maternal antibodies, this affect on the fetus is usually due to Maternal graves

Back 426

Fetal thyrotoxicosis - check maternal serum TSH Ab titers and treat with maternal PTU

rare, but all fetuses of women with Graves' disease should be monitored for appropriate growth and normal heart rate.

Front 427

Can Women taking PTU/Methimazole breastfeed?

Back 427

Yes

Front 428

once treatment has started, it may be helpful to measure FT4 or FTI every

Back 428

2–4 weeks

Front 429

One side effect of thioamides (PTU/methimazole) is

Back 429

agranulocytosis

incidence of agranulocytosis is 0.1–0.4%;

Front 430

The incidence of agranulocytosis is 0.1–0.4%; it usually presents with

Back 430

a fever and sore throat.

Front 431

THioAmides side effects=

Back 431

Hepatitis
Agranulocytosis
Thrombocytopenia

Front 432

This treatment should be reserved for women in whom thioamide treatment is unsuccessful.

Back 432

Thyroidectomy

Front 433

Iodine 131 is contraindicated in pregnant women because of the risk of fetal thyroid ablation;
therefore, women should avoid pregnancy for how long after I-131 treatment.

Back 433

4 months

Front 434

. If the woman was at less than ____weeks of gestation when exposed to I-131, it is unlikely the fetal thyroid was ablated.

Back 434

10

Front 435

If exposure occurred at 10 weeks of gestation or later, the woman must consider the risks of induced ______ and consider whether to continue the pregnancy.

Back 435

congenital hypothyroidism

Front 436

Breastfeeding should be avoided for at least _____after treatment with I-131.

Back 436

4 months

Front 437

levothyroxine therapy should be adjusted at ______ intervals until TSH levels are stable.

Back 437

4-week

Front 438

In STABLE patients, it is prudent to check TSH levels how often in pregnant women with hypothyroidism.

Back 438

every trimester

Front 439

Hyperemesis gravidarum is associated with biochemical hyperthyroidism but rarely with clinical hyperthyroidism and is largely transitory, requiring no treatment.

Routine measurements of thyroid function are not recommended in patients with hyperemesis gravidarum unless

Back 439

sxs predate pregnancy
sxs continue past 20 weeks
TSIg present

Front 440

Thyroid storm is a medical emergency characterized by

Back 440

an extreme hypermetabolic state.

Front 441

Thyroid storm has a high risk of

Back 441

maternal heart failure.

Front 442

Thyroid storm is diagnosed by a combination of the following signs and symptoms:

Back 442

fever

tachycardia out of proportion to the fever

changed mental status

including restlessness, nervousness, confusion

seizures

vomiting
diarrhea
cardiac arrhythmia.

Front 443

consequences of untreated thyroid storm, which include

Back 443

shock, stupor, and coma.

Front 444

If thyroid storm is suspected

Back 444

serum FT4, FT3, and TSH levels should be evaluated to help confirm the diagnosis,

but
therapy should not be withheld pending the results.

Front 445

MOA Propylthiouracil or methimazole

Back 445

blocks additional synthesis of thyroid hormone, and PTU also inhibits peripheral conversion of T4 to T3.

Front 446

MOA potassium iodide and sodium iodide

Back 446

block the release of thyroid hormone from the gland.

Front 447

MOA Dexamethasone

Back 447

decreases thyroid hormone release and peripheral conversion of T4 to T3

Front 448

MOA propranolol

Back 448

inhibits the adrenergic effects of excessive thyroid hormone.

Front 449

MOA phenobarbital in thryroid storm treatment

Back 449

can be used to reduce extreme agitation or restlessness and may increase the catabolism of thyroid hormone.

Front 450

thermoregulation during thyroid storm consists of

Back 450

use of antipyretics,

use of a cooling blanket,

Front 451

in addition to rehydration in thyroid storm by maintenance of intravascular volume and electrolytes, what else may be warranted in severe dehydration due to vomiting/diarrhea/tachy/fever?

Back 451

invasive central monitoring and
continuous maternal cardiac monitoring in an intensive care setting may be indicated.

Front 452

Often in thyroid storm,there is an identified inciting event such as

Back 452

infection, surgery, labor, or delivery.

Front 453

Should the baby be delivered in thyroid storm?

Back 453

it is prudent to avoid delivery in the presence of thyroid storm unless fetal indications for delivery outweigh the risks to the woman.

Front 454

. If oral administration is not possible, use methimazole in what form?

Back 454

rectal suppositories.

Front 455

in thyroid cancer during pregnancy, can/should thyroidectomy be performed? when?

Radiation should be deferred until after pregnancy.

Back 455

Yes.
preferably in the second trimester

Front 456

Can the pt be treated with radiation for thyroid cancer during pregnancy?

Back 456

Radiation should be deferred until after pregnancy.

Front 457

After radiation therapy for thyroid cancer in pregnancy, when can the mother breastfeed?

Back 457

Breastfeeding should be avoided for at least 4 months after I-131 treatment.

Front 458

The diagnosis of postpartum thyroiditis is made by

Back 458

documenting new-onset abnormal levels of TSH or FT4 or both.

Front 459

may be useful to confirm the diagnosis of postpartum thyroiditis

Back 459

anti-microsomal or

antithyroid peroxidase antibodies

Front 460

Which patients should have their TSH and FT4 levels evaluated for possible postpartum thyroiditis:

Back 460

goiter in pregnancy or postpartum

postpartum hypothyroid or hyperthyroid symptoms

excessive fatigue,

weight gain,

dry skin/dry hair,

cold intolerance,

persistent amenorrhea,

difficulty concentrating,

depression,

nervousness,
or
palpitations

Front 461

If the patient has hypothyroidism, the decision to treat depends on

Back 461

the severity of abnormality and symptoms.

Front 462

Which women have the highest risk for developing permanent hypothyroidism.

Back 462

with the highest levels of TSH and antithyroid peroxidase antibodies

Front 463

Are TFTs in asymptomatic pregnant women who have a mildly enlarged thyroid is warranted?

Back 463

No. Not if only mildly enlarged.

However, development of a significant goiter or distinct nodules should be evaluated as in any patient.

Front 464

Butorphanol (Stadol) may increase blood pressure levels and should be avoided in patients with

Back 464

chronic hypertension or preeclampsia.

Front 465

also has been used during labor as an alternative drug because of its relatively short half-life;

Back 465

Fentanyl

Front 466

Naloxone MOA

Back 466

pure opioid antagonist

drug of choice in the treatment of maternal respiratory and neurobehavioral depression secondary to opioid agonist drugs

Front 467

• Does epidural analgesia increase the rate of operative delivery and rate of third and fourth degree laceration?

Back 467

Yes
Excessive operative vaginal deliveries have been implicated in

the increased rate of third- and fourth-degree lacerations seen in women with epidural analgesia.

Front 468

WHEN FEASIBLE, obstetric practitioners should delay the administration of epidural analgesia in nulliparous women until cervical dilatation reaches ___ cm

Back 468

4–5

early placement of epidural analgesia significantly increases the risk of cesarean delivery

Front 469

Women in labor should not be required to reach 4–5 cm of cervical dilatation before receiving epidural analgesia.

Back 469

Women in labor should not be required to reach 4–5 cm of cervical dilatation before receiving epidural analgesia. !!!!!!

Front 470

Patients on unfractionated heparin therapy should be able to receive regional analgesia if

Back 470

they have a normal activated partial thromboplastin time (aPTT).

Front 471

Patients taking prophylactic doses of unfractionated heparin or low-dose aspirin are not at increased risk and can be

Back 471

offered regional analgesia.

Front 472

In patients receiving once-daily, low-dose LMWH, regional anesthesia should not be offered until _____ hours after the last injection of low-molecular-weight heparin.

Back 472

12-24

Front 473

In addition, low-molecular-weight heparin should be withheld for at least____ hours after the removal of an epidural catheter.

Back 473

2

Front 474

In patients on LMWH, because the onset of labor often is difficult to predict, it may be reasonable to

Back 474

convert patients to unfractionated heparin as they approach term.

Front 475

Who needs preop anesthesia consult?

Back 475

Obesity
short webbed neck
goiter
cardiac disease
bleeding disorders
severe preeclampsia

Front 476

Can hysteroscopy be part of clinical staging of cervical carcinoma?

Back 476

Yes

Front 477

is the most important adverse predictor of survival in cervical cancer

Back 477

presence of lymph node metastasis

Front 478

Although it remains controversial, it is the best method of assessing nodal involvement in cervical cancer?

Back 478

surgical evaluation of cervical cancer

Front 479

provides important information about treatment planning and prognosis.

Back 479

Retroperitoneal surgical lymph node dissection of the pelvic and paraaortic lymph nodes

Patients with positive lymph nodes can have radiation fields modified appropriately to cover areas at risk using lymphangiography to hone in.

Front 480

surgical evaluation of cervical cancer allows

Back 480

individualization of therapy and may result in better clinical outcomes.

Front 481

presence of lymphatic-vascular invasion would suggest the need for

Back 481

more radical treatment to obtain the optimal outcome.

Front 482

Those who favor radical surgery point out the benefits less morbidity of what

Back 482

it leaves the vagina in more functional condition,

Front 483

The disadvantage to radiation therapy is that it results in what effect to the vagina?

Back 483

a reduction in

length
caliber
lubrication

Front 484

In premenopausal women, ovarian function can be preserved with

Back 484

surgery.

Front 485

The surgical approach also provides the opportunity for

Back 485

pelvic and abdominal exploration and provides better clinical and pathologic information with which to individualize treatment.

Front 486

Surgery may be preferred over radiation therapy in women who have:

Back 486

diverticular disease
tuboovarian abscess
appendiceal abscess
have had prior radiation therapy
have congenital pelvic located kidney; or are
psychotic or noncompliant

Front 487

Proponents of radiation therapy advocate primary radiation to avoid

Back 487

surgical morbidity or mortality, risk of blood loss and transfusion, and excessive anesthesia time.

Front 488

• What is the role of adjuvant therapy following primary surgery in early-stage carcinoma?

Back 488

pelvic nodal involvement, positive margins, or parametrial extension—are treated with concurrent pelvic radiation therapy and cisplatin-based chemotherapy.

Front 489

• Should squamous cell cancer and adenocarcinoma of the cervix be treated differently?

Back 489

No

Front 490

Discuss therapy for recurrent cervical cancer.

Patient present many years later with leg edema, sciatic pain

Back 490

radical radiation therapy is used for recurrent cervical cancer after primary hysterectomy,

salvage surgery is required for those who relapse after primary radiation therapy.

Front 491

Is cervical adenocarcinoma is a contraindication to hormone replacement therapy?

Back 491

No

Front 492

A pregnant patient with (Stage 0 and Stage Ia1) carcinoma in situ and microinvasive squamous carcinoma of 3 mm or less should deliver how?

Back 492

vaginally and be reevaluated and treated at 6 weeks postpartum.

Front 493

If the patient opts to continue the pregnancy, predelivery assessment of what should be strongly considered,

Back 493

fetal lung maturity by amniotic fluid analysis

Front 494

If possible, the patient should give birth by classical cesarean delivery at the time of planned radical surgery, and vaginal delivery should be reserved for those patients with

Back 494

preinvasive disease or stage Ia invasive disease with planned postpartum fertility-sparing therapy.

Front 495

Any possibility/cases of implantation of malignancy at the episiotomy site?

Back 495

Yes, it is a possibility.

Front 496

Treatment of recurrent disease in the episiotomy consists of

Back 496

excision followed by radiation.

Front 497

When radical cesarean hysterectomy is performed, a what type of uterine incision is preferred.

Back 497

classical

Front 498

Most pregnant patients who are candidates for radical surgery will benefit from surgery rather than radiation therapy, given the advantage of

Back 498

ovarian preservation and

the avoidance of radiation-associated vaginal fibrosis.

Front 499

Patients with advanced disease who elect to delay treatment should have documented fetal pulmonary maturity prior to classic cesarean delivery and should start their radiation therapy when?

Back 499

postdelivery following uterine involution.

Pelvic and paraaortic lymph node dissection can be performed at the time of cesarean delivery to aid treatment planning.

Front 500

Patients opting for primary radiation therapy with the intent of pregnancy termination should begin with external-beam therapy. It is common for the pregnancy to abort spontaneously when the woman is irradiated with less than ____ cGy of external-beam radiation

Back 500

4,000

Front 501

If the patient is amenorrheic, the minimal laboratory evaluation should include measurement of serum levels of:

Back 501

HCG


FSH/estradiol
thyroid-stimulating hormone, and
prolactin.

Front 502

If the patient has a BMI higher than 30, testing what disease may be indicated before inducing ovulation.

Back 502

for diabetes mellitus

To decrease the risk of congenital malformations, diabetes mellitus should be treated before inducing pregnancy.

Front 503

hysterosalpingography should be considered to establish tubal patency if the woman has a history of:

Back 503

sexually transmitted diseases,
pelvic inflammatory disease,
appendicitis with rupture,
in utero exposure to diethylstilbestrol, or
previous pelvic surgery,

Front 504

Before giving clomid, make sure to do this test...

Back 504

HCG

It is important to give clomiphene only after menstrual bleeding to help ensure that the patient is not pregnant.

should also gove provera to induce a menses and make sure hypothalamus/FSH working okay

Front 505

Patients taking clomiphene should be monitored for

Back 505

ovulation,
pregnancy, and
ovarian enlargement, as clinically indicated.

Front 506

Ovulation can be determined by:

Back 506

measuring serum progesterone levels (about 14 days after the last dose of clomiphene),
basal body temperature charting,

Front 507

Intense cycle monitoring with frequent measurement of serum estradiol levels and pelvic ultrasonography is generally not necessary with the use of clomiphene but is required for what mode of treatment?

Back 507

gonadotropin therapy.

Front 508

The most common symptoms experienced by women taking clomiphene include

Back 508

vasomotor symptoms
adnexal tenderness
nausea
headache
blurring of vision or scotomata.

Front 509

Many clinicians permanently discontinue clomiphene treatment in women with clomiphene-induced

Back 509

visual changes.

Front 510

The main contraindications to the use of clomiphene are

Back 510

pregnancy,
hypersensitivity to the medication, and
ovarian cysts.

Front 511

If the patient is amenorrheic, the minimal laboratory evaluation should include measurement of serum levels of:

Back 511

HCG


FSH/estradiol
thyroid-stimulating hormone, and
prolactin.

Front 512

If the patient has a BMI higher than 30, testing what disease may be indicated before inducing ovulation.

Back 512

for diabetes mellitus

To decrease the risk of congenital malformations, diabetes mellitus should be treated before inducing pregnancy.

Front 513

hysterosalpingography should be considered to establish tubal patency if the woman has a history of:

Back 513

sexually transmitted diseases,
pelvic inflammatory disease,
appendicitis with rupture,
in utero exposure to diethylstilbestrol, or
previous pelvic surgery,

Front 514

Before giving clomid, make sure to do this test...

Back 514

HCG

It is important to give clomiphene only after menstrual bleeding to help ensure that the patient is not pregnant.

Front 515

Patients taking clomiphene should be monitored for

Back 515

ovulation,
pregnancy, and
ovarian enlargement, as clinically indicated.

Front 516

Ovulation can be determined by:

Back 516

measuring serum progesterone levels (about 14 days after the last dose of clomiphene),
basal body temperature charting,

Front 517

Intense cycle monitoring with frequent measurement of serum estradiol levels and pelvic ultrasonography is generally not necessary with the use of clomiphene but is required for what mode of treatment?

Back 517

gonadotropin therapy.

Front 518

The most common symptoms experienced by women taking clomiphene include

Back 518

vasomotor symptoms
adnexal tenderness
nausea
headache
blurring of vision or scotomata.

Front 519

Many clinicians permanently discontinue clomiphene treatment in women with clomiphene-induced

Back 519

visual changes.

Front 520

The main contraindications to the use of clomiphene are

Back 520

pregnancy,
hypersensitivity to the medication, and
ovarian cysts.

Front 521

Which women with PCOS appear to have decreased ovulation and pregnancy rates when they are treated with clomiphene

Back 521

serum DHEAS concentration higher than the middle of the normal range (>2 µg/mL)

Front 522

Investigators observed significantly higher rates of ovulation and conception in women treated with clomiphene plus what medication than with clomiphene alone, in the women with a DHEAS concentration higher than 2 µg/mL.
.

Back 522

dexamethasone

The impact of combined therapy was especially marked in the women with a DHEAS concentration higher than 2 µg/mL.

Front 523

• In women who do not ovulate using clomiphene alone, can the chances of ovulation be improved by adding an hCG injection?

Back 523

Yes.
NOT evidenced based!!!

Front 524

After the last dose of clomiphene, pelvic ultrasonography can be used to monitor follicle size. When the mean diameter of the lead follicle reaches ___mm, a single dose of hCG can be administered.

Back 524

18

Front 525

Injections with FSH for ovulation induction are associated with a high rate of multiple gestations

Back 525

20%

Front 526

clomid has what rate of multiple gestations?

What % ovulate?

Back 526

8%

80% will ovulate

Front 527

• In women with hyperprolactinemia, which medical treatments stimulate the resumption of ovulation?

Back 527

Bromocriptine
Cabergoline

Front 528

The main side effects associated with bromocriptine are

Back 528

nausea/vomiting

orthostatic hypotension.

Front 529

To minimize these potential side effects, it is recommended that bromocriptine

Back 529

be initiated at a dosage of 1.25 mg at bedtime.

given vaginally

Front 530

Insulin sensitizers can be used alone or in combination with clomiphene to induce ovulation in infertile women with oligo-ovulation, hyperandrogenism, and insulin resistance.
A commonly used dosage of metformin is

Back 530

500 mg three times daily.

Front 531

most common side effects of metformin are

Back 531

gastrointestinal disturbances, including diarrhea, nausea, vomiting, and abdominal bloating.

lactic acidosis
Think of lactose intolerant

Front 532

If ovulation has not occurred after 4–8 weeks of metformin therapy, clomiphene (50 mg daily for 5 days) can be administered after doing what first

Back 532

progestin-induced menstrual withdrawal bleeding.

That way we'll know when Day 5-9 is.

And that the patient is not pregnant

Front 533

Before treatment with metformin is initiated, it is recommended that serum creatinine levels be demonstrated to be lower than

Back 533

1.4 mg/dL.

Just in case lactic acidosis occurs

***Also, metformin should be discontinued 48 hours before—and not restarted for 72 hours after—any radiologic test involving intravenous contrast or before surgery.

Front 534

contraindication of metformin

Back 534

liver disease
renal disease

Front 535

in women with PCOS, ovulation induction with weight loss, clomiphene, clomiphene plus metformin, clomiphene plus glucocorticoid, and ovarian surgery are associated with low rates of

Back 535

triplet pregnancy.

Front 536

Are there evidence-based guidelines about the appropriate duration of gonadotropin administration?

Back 536

No

Front 537

How to determine the diastolic blood pressure on sphagmomanomater

Back 537

the sound disappears (Korotkoff phase V).

Front 538

appropriate size cuff should be used

Back 538

length 1.5 times upper arm circumference (can wrap around 1.5 times)

a cuff with a bladder that encircles 80% or more of the arm

Front 539

The blood pressure level should be taken with the patient in what position

Back 539

in an upright position, after a 10-minute or longer rest period.

The patient should not use tobacco or caffeine for 30 minutes preceding the measurement.

Front 540

With mild disease and no progression, these Preeclamptic lab tests can be repeated how often if ever?

Back 540

repeated weekly

Front 541

What is often initially recommended for women with new-onset preeclampsia.

Back 541

Hospitalization

Front 542

Ambulatory management at home or at a day-care unit has been evaluated as an option for monitoring women with mild gestational hypertension or

Back 542

preeclampsia remote from term.

Front 543

Who should be hospitalized long term?

Back 543

difficulty with compliance,

logistic barriers,

manifest signs of disease progression

who have severe preeclampsia

Front 544

For mild preeclampsia, vaginal delivery is preferred when?

Back 544

at term

Front 545

Hydralazine:
dose

Back 545

5–10-mg doses intravenously every 15–20 minutes until desired response is achieved*

Front 546

Labetalol:
Dose

Back 546

20-mg intravenous bolus dose followed by 40 mg if not effective within 10 minutes; then, 80 mg every 10 minutes to maximum total dose of 220 mg

Front 547

The presence of either a cervix less than __ mm in length at less than 35 weeks of gestation or a positive fFN test result was strongly associated with preterm birth, especially in women with a history of preterm birth.

Back 547

25

Front 548

Why has it been customary to recommend the 50-g, 1-hour oral glucose challenge test be administered at 24–28 weeks of gestation.

Back 548

attempt to balance two competing interests.

Insulin resistance increases as pregnancy progresses, therefore, testing later in pregnancy will result in a higher yield of abnormal tests.

However, the later the abnormality is diagnosed, the less time will be available for intervention.

Front 549

What does GTT consist of?

Back 549

50-g, 1-hour glucose challenge

Front 550

What is the appropriate threshold value for the GTT laboratory screening test?

Back 550

130 (or 140)

Front 551

Rules for the 3 hour GTT:

Back 551

should not smoke before the test
should remain seated during the test.

Patients should be instructed to follow an unrestricted diet, consuming at least 150 g of carbohydrate per day for at least 3 days prior to the test.

This should avoid carbohydrate depletion, which could cause spuriously high values on the GTT.

Front 552

Which glucose values appear to be most effective at determining the likelihood of macrosomia and other adverse pregnancy outcomes in patients with GDM.

Back 552

postprandial

fetus more sensitive to peak rather than nadir levels of glucose.

Front 553

American Diabetes Association also recommends an average of __kcal/kg/d based on PREPREGNANT body weight for NONOBESE individuals.

Back 553

30 kcal/kg/d

PREPREGNANT body weight

Front 554

insulin therapy should be considered for patients treated with medical nutrition therapy when

Back 554

1-hour postprandial values exceed 130–140 mg/dL or

2-hour postprandial values exceed 120 mg/dL or

fasting glucose exceeds 95 mg/dL.

95/140/120

Front 555

Women with GDM who lead an active lifestyle should be encouraged to continue a program of exercise approved for pregnancy.

Back 555

Walk around the block after meals!

Front 556

When glucose control is good and no other complications supervene, there is no good evidence to support routine delivery before ___weeks of gestation.

Back 556

40

Front 557

When early delivery is planned because of maternal or fetal compromise, the urgency of the indication should be considered in the decision to perform amniocentesis.

Back 557

Hmmmm.

Front 558

in GDM, when the estimated weight is 4,000–4,500 g, additional factors such as what factors may be helpful to consider in determining mode of delivery.

Back 558

PAST delivery history
PELVIMETRY
PROGRESS of labor

Front 559

PAST delivery history
PELVIMETRY
PROGRESS of labor

:) :) :)

Back 559

PAST delivery history
PELVIMETRY
PROGRESS of labor

Front 560

Diagnosis in nonpregnant state of Diabetes Mellitus by what Fasting Plasma Glucose level and 2-h PG?

Using 75-g, 2-h OGTT

Back 560

>=126 mg/dL

>=200 mg/dL

Front 561

• In the initial evaluation of a pregnant woman with hypertension, which clinical tests are useful?

Back 561

electrocardiography,
echocardiography,
ophthalmologic examination,
and renal ultrasonography.

Front 562

Women with significant left ventricular hypertrophy secondary to hypertension may experience what as pregnancy progresses.

Back 562

cardiac decompensation and heart failure

Front 563

Renal artery stenosis appears to be more prevalent in patients with

Back 563

type-2 diabetes and coexistent hypertension.

Front 564

How to detect renal artery stenosis?

Back 564

Doppler flow studies or

magnetic resonance angiography MRA

Front 565

Do negative results from renal ultrasonography rule out renal artery stenosis?

Back 565

No

Front 566

serum uric acid level of mg/dL could identify women with an increased likelihood of having superimposed preeclampsia.

Back 566

5.5

Front 567

Is there scientific evidence that antihypertensive therapy will improve perinatal outcome?

Back 567

No

Treatment with antihypertensive medications did not decrease the incidence of complications such as IUGR, superimposed preeclampsia, placental abruption, or perinatal mortality.

Front 568

HTN meds

Back 568

therapy may offer long-term benefits to the mother, such therapy is of unproven short-term benefit and could interfere with uteroplacental blood flow and fetal growth.

Front 569

In women with severe chronic hypertension (systolic pressure >=180 mmHg or diastolic pressure >=110 mmHg), antihypertensive therapy should be initiated or continued

Back 569

:0

Front 570

therapy could be increased or reinstituted for women with blood pressures exceeding

Back 570

150–160 mmHg systolic

or 100–110 mmHg diastolic.

Front 571

It would seem reasonable not to start antihypertensive therapy in women with mild hypertension who become pregnant unless

Back 571

they have other complicating factors (eg, cardiovascular or renal disease) and to either stop or reduce medication in women who are already taking antihypertensive therapy.

Front 572

"If diuretics are indicated, they are safe and efficacious agents that can markedly potentiate the response to other antihypertensive agents and are not contraindicated in pregnancy except

Back 572

in settings in which uteroplacental perfusion is already reduced (preeclampsia and IUGR)" .

Front 573

Angiotensin–converting enzyme (ACE) inhibitors are contraindicated during which trimesters?

Back 573

second and third trimesters of pregnancy.

Front 574

ACE inhibitors have been associated with:

Back 574

renal failure
hypocalvaria
renal agenesis
oligo

Front 575

Delivery should be considered in all women with superimposed severe preeclampsia at or beyond ___ weeks of gestation and in women with mild superimposed preeclampsia at or beyond ____ weeks of gestation .

Back 575

28

37

Front 576

it is generally recommended that antihypertensive medications be given to women with preeclampsia for systolic blood pressure of ____ mmHg or diastolic blood pressure of _____mmHg or greater

Back 576

>160

105–110

Front 577

Why does general anesthesia may pose a risk in pregnant women with severe hypertension or superimposed preeclampsia?

Back 577

Intubation/extubation may be associated with acute and significant elevations in blood pressure and

an agent such as labetalol usually is given acutely to minimize this effect.

Front 578

What general anesthesia induction drug, because of its association with hypertension, is not considered first line therapy for the induction of general anesthesia.

Back 578

Ketamine

Front 579

The problem with Use of Botanicals

Back 579

in vitro effects
animal models
nonrandomized studies.
do not meet the current standards for evidence-based recommendations.

products may be adulterated or contaminated

Front 580

St. John's wort is also potentially photosensitizing, and concern has been raised about an increased rate of

Back 580

cataracts

Front 581

In addition to women age 35 years and older, patients with a risk of fetal aneuploidy high enough to justify an invasive diagnostic procedure include the following:

Back 581

previously had pregnancies complicated by autosomal trisomy
A fetus with a major structural defect identified by ultrasonography
previously had a pregnancy complicated by a sex chromosome aneuploidy.
Men or women with a chromosome translocation
Men or women who are carriers of chromosome inversions
Parental aneuploidy

Front 582

What happened to early amnios?

Back 582

higher fetal loss rate
talipes (clubfoot)

No longer done

Front 583

When do fetal u/s markers warrant further testing?

Back 583

combination of two or more positive findings substantially increases risk and warrants further counseling regarding invasive testing.

Front 584

When should a finding of an isolated choroid plexus cyst be further evaluated?

Back 584

may be associated with trisomy 18

if serum screening results are abnormal

or the patient is older than 32 years at delivery.

Front 585

• Is there a role for serum screening in women who will be age 35 years and older at delivery?

Back 585

discussion of age-specific multiple-marker screening detection rates and screen-positive rates,

the detection rate of aneuploidies other than Down syndrome, (MSAFP doesn't detect trisomy 13, Turners)

the identity and prognosis of the aneuploidies likely to be missed by serum screening, and

the risks and benefits of replacing a diagnostic test with a screening test.

Front 586

It has been estimated that the midtrimester risk of fetal Down syndrome in a twin pregnancy in women age ___ years is approximately the same as the risk for that of a singleton pregnancy in women age 35 years, thus justifying counseling for amniocentesis.

Back 586

33

Twin "3's"

Front 587

Traditionally, recurrent pregnancy loss has been defined as three consecutive spontaneous abortions.

Back 587

However, the risk of abortion after two successive abortions (30%) is clinically similar to the risk of recurrence among women with three or more consecutive abortions (33%).

Front 588

• When is a diagnosis of recurrent pregnancy loss appropriate?

Back 588

two or more consecutive SAB

Front 589

• Should all couples with recurrent pregnancy loss have chromosomal analysis performed?

Back 589

Yes.
balanced chromosome abnormalities

Front 590

In addition, many experts obtain a karyotype of the abortus tissue when a couple with recurrent pregnancy loss experiences a subsequent spontaneous abortion.
The rationale is

Back 590

that if the abortus is aneuploid, the physician and patient may conclude that a maternal cause of pregnancy loss is excluded.

Front 591

• Should thyroid tests and tests for glucose intolerance be performed in women with recurrent pregnancy loss?

Back 591

only if pt is

at risk for those diseases

has symptoms

Front 592

• Should women with recurrent pregnancy loss be evaluated for luteal phase defect?

Back 592

No.
The measurement of luteal phase progesterone concentrations is not an adequate method for diagnosing or excluding luteal phase defect.


It has not been shown conclusively that progesterone treatment or corpus luteum support influences pregnancy outcome in women with recurrent pregnancy loss.

Front 593

• Should women with recurrent pregnancy loss be evaluated for possible infectious causes, and should they be treated?

Back 593

No.

routine serologic or endocervical cultures for Chlamydia or Mycoplasma and vaginal evaluation for bacterial vaginosis are not useful in evaluating otherwise healthy women presenting with recurrent abortion.

empiric treatment with antibiotics in the absence of documented infection is not warranted.

Front 594

• Should women with recurrent pregnancy loss be evaluated for antiphospholipid syndrome?

Back 594

YES.

women with recurrent pregnancy loss should be tested for antiphospholipid syndrome using standard assays for anticardiolipin antibodies and lupus anticoagulant.

Front 595

ACA and LA should be drawn how?

Back 595

two occasions at least 6 weeks apart.

Front 596

The IgG isotype of anticardiolipin is most relevant clinically, but tests else may be used to make the diagnosis.

Back 596

repeatedly positive for IgM anticardiolipin

Front 597

In individuals demonstrating only anticardiolipin antibodies, definite APS is diagnosed when the antibody levels are repeatedly ___units or greater.

Back 597

20

Front 598

• Should women with recurrent pregnancy loss be evaluated for possible ALLOimmune causes? (against paternal leukocytes)

Back 598

No

human leukocyte antigen types, maternal serum blocking factors, or maternal antileukocytic antibodies directed against the male partner'sleukocytes have not been shown to predict subsequent pregnancy outcome.

Front 599

Is antibiotic prophylaxis needed for
Hysterectomy—Vaginal, Abdominal, or Laparoscopically Assisted.

Back 599

Yes

Front 600

Is antibiotic prophylaxis needed for
Laparoscopy and Laparotomy.

Back 600

No

Front 601

Is antibiotic prophylaxis needed for
Hysterosalpingography,

Back 601

In patients with no history of pelvic infection, HSG can be performed without prophylactic antibiotics.

Front 602

If HSG demonstrates what finding, the patient should be given doxycycline, 100 mg twice daily for 5 days, to reduce the incidence of post-HSG PID.

Back 602

dilated tubes

Front 603

In patients thought to have an active pelvic infection, should HSG be performed?

Back 603

No

Front 604

Is antibiotic prophylaxis needed for Sonohysterography?

Back 604

patients undergoing sonohysterography, prophylaxis should be based on the individual patient's risk of PID;

routine use of antibiotic prophylaxis is not recommended.

Front 605

Is antibiotic prophylaxis needed for hysteroscopy?

Back 605

No

Front 606

Is antibiotic prophylaxis needed for Induced Abortion and Dilation and Curettage?

Back 606

Yes.
prophylactic antibiotics are effective for these women, regardless of risk.

Front 607

Is antibiotic prophylaxis needed for Intrauterine Device Insertion, Endometrial Biopsy?

Back 607

No

Front 608

Induced Abortion and Dilation and Curettage prophylactic antibiotic regimen:

Back 608

doxycycline, 100 mg orally 1 hour before the abortion followed by 200 mg after the procedure

may help against ashermans

Front 609

IN THE PRESENCE OF INFECTION, removal of an IUD or other genitourinary procedures require endocarditis prophylaxis.

Back 609

Hmmmm.

Front 610

Because bacteriuria and urinary tract infection can be a cause of detrusor instability, pretest screening by urine culture or urinalysis, or both, is recommended

Back 610

Hmmmm.

Front 611

Cephalosporin prophylaxis is acceptable in those patients with a history of penicillin allergy NOT felt to be which type of hypersensitivity reaction?

Back 611

immunoglobulin-E (IgE) mediated (immediate hypersensitivity).

IMEEEEEEEDIATE HYPERSENSITIVITY RXN

Front 612

• How much would be saved each year in the United States in direct treatment costs alone by providing antibiotic prophylaxis to women at average risk undergoing induced abortion.?

Back 612

$500,000

Front 613

although ultrasound-derived estimates are more accurate for newborns weighing between ____g and ___g, above this level, ultrasound measurement and clinical palpation have similar accuracy

Back 613

2,500 g and 4,000 g

Front 614

To be useful, measurement of the uterine fundal height must be combined with

Back 614

clinical palpation or Leopold's maneuvers.

Front 615

the true value of ultrasonography in the management of expected fetal macrosomia may be its ability to

Back 615

rule out the diagnosis of macrosomia

Front 616

excessive weight gain during pregnancy is associated with

Back 616

fetal macrosomia
possible role for caloric restriction

Front 617

two of the strongest birth weight predictors

Back 617

maternal obesity and
weight gain during pregnancy

Front 618

cesarean delivery reduces—but does NOT do what to—the risk of birth trauma and brachial plexus injury associated with fetal macrosomia

Back 618

eliminate

Front 619

Along with a description of the limitations of estimating fetal weight, the obstetrician should present

Back 619

accurate statistics for the short- and long-term risks of maternal and fetal morbidity for both vaginal and cesarean delivery as discussed previously.

Front 620

Early induction of labor for macrosomia, why not?

Back 620

at least doubles the risk of cesarean delivery without reducing shoulder dystocia or newborn morbidity

Front 621

How many elective cesarean deliveries for suspected fetal macrosomia would have to be performed to prevent one case of brachial plexus injury?
if the cutoff for cesarean delivery were 4,500 g among patients without diabetes

Back 621

443

Front 622

Rates of shoulder dystocia with midforceps deliveries of infants greater than 4,500 g have been reported to be above .

Back 622

50%

Front 623

If a decision is made to proceed with cesarean delivery in the presence of suspected macrosomia, discuss incision on uterus.

Back 623

the incision should be large enough to avoid a difficult abdominal delivery.

Front 624

cesarean delivery should be performed for midpelvic arrest of the fetus with suspected macrosomia unless

Back 624

Barring extreme emergencies

Front 625

Is suspected fetal macrosomia a contraindication to attempt vaginal birth after prior cesarean delivery

Back 625

No

Front 626

Patients in the moderate-risk DVT category would likely benefit from prophylaxis with either

Back 626

graduated compression stockings,
pneumatic compression,

low-dose unfractionated heparin (5,000 U every 8 hours) in which the first dose is given before surgery, or
low-dose LMWH (dalteparin, 2,500 U once a day, or enoxaparin, 40 mg once a day).

Front 627

High-risk for DVT patients should be offered

Back 627

standard heparin, 5,000 U every 8 hours

Front 628

The hypercoagulable changes induced by oral contraceptives do not return to normal for how long after discontinuation of therapy

Back 628

4–6 weeks

Think Postpartum

Front 629

Fasting plasma homocystine levels may be assessed, especially in women of childbearing age who have had venous or arterial thrombosis, because elevated levels can be treated with

Back 629

vitamins (folic acid, vitamin B12, and vitamin B6)

Front 630

Because of its high prevalence in the Caucasian population, all patients who are not Hispanic, Asian, or African American who have a history of DVT may be tested for the

Back 630

factor V Leiden mutation

Front 631

Patients with a strong family history of thrombosis who are negative for the factor V Leiden mutation may benefit from testing for

Back 631

the prothrombin gene mutation G20210A
deficiencies in protein C, protein S, and AT-III

Front 632

Patients with a history of thrombosis, recurrent fetal loss, early or severe preeclampsia, severe unexplained intrauterine growth restriction, or unexplained thrombocytopenia may be tested for

Back 632

antiphospholipid antibodies

PIS T

Front 633

Heparin-induced osteoporosis appears to occur predominantly in patients taking heparin for ______-or longer

Back 633

7 weeks

Front 634

How should women on prolonged heparin be evaluated for heparin-induced thrombocytopenia?

Back 634

Platelet counts should be monitored at the initiation of standard heparin therapy and periodically up to 15 days after starting heparin

Front 635

If Heparin-induced thrombocytopenia confirmed,

Back 635

heparin therapy should be stopped immediately.

LMWH (danaparoid sodium) is available

Front 636

Besides LMWH, what is also is available for intravenous use in patients with heparin-induced thrombocytopenia

Back 636

Lepirudin (recombinant hirudin), a direct thrombin inhibitor

Front 637

• What special considerations should be given when using low-molecular-weight heparin in patients undergoing regional anesthesia?

Back 637

No regional anesthesia should be employed within 12 hours of an injection of LMWH, and

LMWH should be withheld for at least 2 hours after removal of an epidural catheter

Front 638

A cost-analysis in the United States determined that pneumatic compression was more cost-effective than either LMWH or unfractionated heparin

Back 638

Hmmm!

Front 639

• How is MATERNAL CMV infection diagnosed?

Back 639

culture

PCR

Front 640

The problem with using IgM in CMV

Back 640

Not completely reliable

IgM titers may not be positive during an acute infection, or they may persist for months after the primary infection

Front 641

How is fetal CMV infection diagnosed?

Back 641

ultrasound findings suggestive of infection

amniotic fluid of infected fetuses by either culture or PCR.

Front 642

ultrasound findings suggestive of infection with CMV

Back 642

Toxo=CMV findings
(except substitute Ventriculomegaly for chorioretinitis)

cmV=Ventriculomegaly

abdominal and liver calcifications
intracranial calcifications hydrops
ascites
HSM
ventriculomegaly

Front 643

Can detection of CMV in amniotic fluid predict the severity of congenital CMV infection?

Back 643

No

Front 644

How are maternal, fetal, and congenital neonatal infections with cytomegalovirus treated?

Back 644

no therapies are available

A live vaccine is in the works

Front 645

How should women at high risk be counseled about prevention of CMV?

Back 645

preventive measures
hand-washing when around young children or immunocompromised individuals

intravenous drug use

Front 646

• Which methods are available to diagnose maternal parvovirus B19 infection?

Back 646

Maternal serology
ELISA and Western
IgM in maternal serum is diagnostic of a primary infection,

Front 647

Does presence of antiparvovirus B19 IgG in the absence of IgM and been associated with adverse perinatal outcome?

Back 647

No

Front 648

• What methods are available for diagnosing fetal parvovirus B19 exposure/infection?

Back 648

PCR

Front 649

CMV serology can be obtained from where?

Back 649

autopsy tissue, serum, amniotic fluid, and placenta

Front 650

Why not check IgM in the fetal serology?

Back 650

IgM antibodies appear in the fetal circulation after 22 weeks of gestation, limiting the usefulness of such tests.

Front 651

What has been the mainstay for diagnosing fetal parvovirus infection.

Back 651

Ultrasonography

evidence of hydrops fetalis

Front 652

How long after maternal infection with Parvo should ultrasounds be done? Should they continue until delivery?

Back 652

up to 10 weeks after maternal infection

If no signs of hydrops fetalis, additional tests are unnecessary.

Front 653

After documented EXPOSURE to parvovirus B19, the woman should have what done?

Back 653

serologic testing to determine if she is immune with evidence of antiparvovirus IgG.

Front 654

If nonimmune to Parvo, then what next?

Back 654

test should be repeated in 3–4 weeks and paired samples tested to document whether the woman is seropositive for parvovirus.

If seroconversion does not occur, the fetus is not at risk for in utero infection.

Front 655

If seroconversion does occur, then what?

Back 655

the fetus should be monitored for 10 weeks by serial ultrasound examination to evaluate for presence of hydrops fetalis, placentomegaly, and growth disturbances

Consider weekly u/s

Front 656

If hydrops fetalis develops, then what?

Back 656

PUBS to determine fetal hematocrit, leukocyte and platelet count, and viral DNA in preparation for supportive care using transfusion

Intrauterine transfusion should be considered if anemia is present

Front 657

• Should seronegative women with work-related exposure be taken out of work?

Back 657

Not recommended.
Exposure cannot be eliminated
20% asymtomatic
those with infection are infectious before they develop symptoms

Front 658

• How is maternal VZV infection diagnosed?

Back 658

based on clinical findings

Front 659

• How is fetal VZV infection diagnosed?

Back 659

can be suspected by the presence of ultrasonographic abnormalities.

Front 660

. Ultrasound findings suggestive of congenital varicella

Back 660

Pox/hydrops- Warfare (like warfarin)

limb deformities,
microcephaly,
IUGR
hydrops,
HYPERECHOGENIC FOCI IN LIVER AND BOWEL (think of it has the liver and bowel having pox!)
cardiac malformations,

Front 661

Oral acyclovir, if instituted when, has been shown to reduce the duration of new lesion formation and the total number of new lesions and to improve constitutional symptoms

Back 661

within 24 hours of the rash,

Front 662

Maternal varicella complicated by pneumonia should be treated with

Back 662

intravenous acyclovir,

Front 663

Has maternal treatment with acyclovir been shown to ameliorate or prevent the fetal effects of congenital varicella syndrome?

Back 663

No

Front 664

Varicella-zoster immune globulin (VZIG) should be given to infants born to women who develop varicella when?

Back 664

between 5 days before and 2 days after delivery

although this does not universally prevent neonatal varicella

Front 665

Infants who develop varicella within the first 2 weeks of life should be treated with

Back 665

intravenous acyclovir

Front 666

Conception should be delayed until how long after the second vaccination dose is given.

Back 666

1 month

Front 667

VZIG is effective in reducing the severity of maternal varicella when administered up to how long after exposure

Back 667

72 hours

VZIG should be given as soon as possible

Front 668

Does maternal administration of VZIG ameliorate or prevent fetal infection?

Back 668

No!

Front 669

• How is maternal toxoplasmosis infection diagnosed?

Back 669

Serologic testing

Sabin-Feldman-Toxo dye test is the IgG test

Testing of serial specimens 3 weeks apart if the initial test results are equivocal

Front 670

Does maternal serology need to be sent somewhere special for testing?

Back 670

a well-recognized reference laboratory should be performed if there is evidence of a primary infection.

Front 671

• Which methods are available for diagnosing and monitoring fetal infection?

Back 671

Ultrasonography
fetal blood samples

Front 672

What is the most sensitive test in diagnosing congenital toxoplasmosis?

Back 672

fetal blood samples after 20 weeks of gestation for the presence of specific IgM

Front 673

u/s findings of toxo?

Back 673

Ventriculomegaly, intracranial calcifications, microcephaly, ascites, hepato-splenomegaly, and intrauterine growth restriction.

Front 674

Does treatment of the pregnant woman with acute toxoplasmosis reduce the risk of congenital infection?

Back 674

Yes.

reduces but does not eliminate

Front 675

What medication may reduce the RISK OF FETAL TRANSMISSION by 60%

Back 675

Spiramycin

Spiro 1960's = 60%

but as a SINGLE agent, it does not treat established fetal infection.

Front 676

Who gets Spiramycin?

Back 676

recommended for pregnant women at risk unless fetal infection is documented.

available only through the U.S. FDA after serologic confirmation at a reference laboratory

Front 677

If fetal Toxo infection is established, what medications are added to Spiramycin?

Back 677

pyrimethamine,
sulfonamides, and
folinic acid

Front 678

What do you tell mother about success of Toxo treatment?

Back 678

With treatment, even early fetal infection with toxoplasmosis can result in successful pregnancy outcomes

Front 679

which women are screened for toxoplasmosis during pregnancy?

Back 679

women infected with HIV

Front 680

Cat owners who are pregnant should be counseled how?

Back 680

recommended avoiding eating undercooked or raw meat, wearing gloves when working with soil, and avoiding caring for cats unless they are strictly "indoor cats" whose food is rigidly controlled

Front 681

New VIAGARA

conditions are at highest risk and should have ADJUSTED-dose heparin prophylaxis

Pneumatics are as effective!!!! And cost less!

Back 681

V Valves mechanical
I inherited thrombophilia homozygous FVL, Prothrombin mutation
A APS, ATIII deficiency
G
A Active DVT
R Recurrent DVT
A Afib from RHD

Front 682

Pregnant patients who require adjusted-dose heparin for anticoagulation for long-term prophylaxis may theoretically benefit from the higher bioavailability and more consistent therapeutic anticoagulation with

Back 682

LMWH

Front 683

• Who should be tested for inherited or acquired thrombophilias?

Back 683

history of thrombosis
first-degree relative with an AT-III deficiency or homozygous factor V Leiden or prothrombin G20210A mutation

Front 684

Which patients may be tested for antiphospholipid antibodies.

Back 684

history of thrombosis,

RPL

EARLY or SEVERE
preeclampsia,

severe unexplained IUGR

Front 685

What other thrombophilias also have been associated with severe early preeclampsia, unexplained fetal loss or stillbirth, and placental abruption

Back 685

Deficiencies in protein C, protein S,
AT-III
including factor V Leiden,
prothrombin G20210A,

methylenetetrahydrofolate reductase (MTHFR) gene associated with hyperhomocystinemia

Front 686

methylenetetrahydrofolate reductase (MTHFR) gene associated with hyperhomocystinemia

Back 686

!!!!!!!


methylenetetrahydrofolate reductase (MTHFR) gene associated with hyperhomocystinemia

Front 687

The following tests may be ordered to evaluate the risk for thromboembolic events in women with a history of thrombosis, a family history of thrombosis, or a first-degree relative with a specific mutation

Back 687

• Lupus anticoagulant (for women with a personal history of VTE)
• Anticardiolipin antibodies (for women with a personal history of VTE)
• Factor V Leiden mutation
• Prothrombin G20210A mutation
• AT-III antigen activity levels
• Fasting homocysteine levels or the MTHFR mutation
• Protein C antigen activity levels
• Protein S antigen activity levels (free and total)

Front 688

It is important to note that physiologic changes in normal pregnancy result in marked alterations in protein S and activated protein C resistance, which is associated with the factor V Leiden mutation; therefore, deferral of testing until when may be warranted.

Back 688

after pregnancy

Front 689

If the clinical suspicion of DVT is high and noninvasive test results (duplex and IPG) are negative, what should be considered?

Back 689

limited venography with abdominal shielding that results in fetal exposure less than 0.05 rads

Front 690

Diagnosis of pelvic vein thrombosis and internal iliac thrombosis is difficult. Although the use of venography is widespread, what may become the imaging modality of choice in these circumstances?

Back 690

MRI

Front 691

What is another name for duplex ultrasound?

Back 691

CUS
Compression ultrasound

Front 692

• How should heparin be administered to women with acute thrombosis or embolism during pregnancy?

Back 692

intravenous heparin bolus of 5,000 U (80 IU/kg) followed by continuous infusion of at least (18u/kg/hr)30,000 IU for 24 hours titrated to achieve full anticoagulation

Front 693

Intravenous anticoagulation should be maintained for how long?

Back 693

at least 5–7 days

Front 694

What next?

Back 694

The patient can then be changed to subcutaneous adjusted-dose heparin therapy. 5000u SQ BID

Front 695

What is PTT goal?

Back 695

prolong the APTT at least 1.5–2.5 times control

Front 696

Can PTT be used if APS?

Back 696

No.
Need to use Factor Xa levels.

Front 697

Alternative alternative treatment for acute thromboembolism. Although the actual dosing is unclear in pregnancy, dosage should be adjusted based on maternal weight.

Back 697

LMWH

Front 698

How to monitor LMWH in pregnancy:

Back 698

antifactor Xa levels 0.5–1.2 U/mL

Front 699

• How is anticoagulation managed in the intrapartum period?

Back 699

Patients requiring therapeutic adjusted-dose heparin during pregnancy, including those with recent thromboembolism, and patients with mechanical heart valves may be switched to intravenous heparin at the time of labor and delivery to take advantage of its short half-life (1½ hours)

Front 700

How is anticoagulation managed in the postpartum period?

Back 700

bridge warfarin 5-7 days

can breastfeed on warfarin

Front 701

Patients requiring adjusted-dose, prophylactic anticoagulation for high-risk conditions can resume their heparin injections how long after an uncomplicated delivery?

(they should withhold their injections at the onset of labor)

Back 701

4–8 hours

and warfarin can be administered the following morning.

morning wharf warf

Front 702

• Can regional anesthesia be administered to patients receiving anticoagulants?

Back 702

wait 24 hours after last LMWH dose (12 hours if was only on once daily dosing)

wait 2 hours after pulling epidural to give next dose

if on unfractionated, can just make sure PTT normal

Front 703

use of progestin-only oral contraceptives, depot medroxyprogesterone acetate,* or implants may be safer than combination oral contraceptives for these conditions:

Back 703

Migraine headaches
Older than 35 years and smoke cigarettes
History of thromboembolic disease
CAD
CHD
Cerebrovascular disease CVD
Less than 2 weeks postpartum†
Hypertension with vascular disease or older than 35 years
Diabetes with vascular disease or older than 35 years
SLE with vascular disease, nephritis,
antiphospholipid antibodies
Hypertriglyceridemia

Front 704

Perimenopausal women benefit from combination OCPs how?

Back 704

positive effect on BMD

reduce vasomotor symptoms in perimenopausal women

reduced risk of endometrial and ovarian cancers

Front 705

Until a well-validated tool to confirm menopause is available, an alternative approach is for healthy, nonsmoking women doing well on combination OCs to discontinue OCs routinely between the

Back 705

ages of 50 and 55 years.

Front 706

By age __, the likelihood that a woman has reached menopausal status is at least 85%

Back 706

55

Front 707

absolute rates of myocardial infarction increases substantially among OC users who smoked and were in their

Back 707

mid-30s or older

Front 708

When considering OCs for women who are between the ages of 30 and 35 years and are smokers, what should be taken into account.

Back 708

the number of cigarettes smoked and the competing risk of pregnancy

In women who are older than 35 years and are smokers, the risk of using OCs is likely to exceed the risk of pregnancy.

Front 709

• Is combination OC use safe for women with chronic hypertension?

Back 709

well-controlled and monitored hypertension who are aged 35 years or younger are appropriate candidates for a trial

Front 710

Combo OCPSs in coronary artery disease, congestive heart failure, and cerebrovascular disease?

Back 710

No.

give progesterone contraception

DMPA, progestin-only OCs, or levonorgestrel implants

Front 711

• Is combination OC use safe for women with diabetes?

Back 711

use should be limited to nonsmoking, otherwise healthy women with diabetes who are younger than 35 years and show no evidence of hypertension, nephropathy, retinopathy, or other vascular disease.

Front 712

women with the following risk factors should undergo blood glucose screening every 3 years:

Back 712

history of GDM,

FH DM,

obesity (body weight greater than 10% of ideal)

hypertension, and
member of high-risk ethnic groups (African American, Hispanic, Native American).

Front 713

• Is combination OC use safe for women with migraine headaches?

Back 713

may be considered for women with migraine headaches if they do not have focal neurologic signs

Front 714

• Does the use of combination OCs increase the risk of breast cancer in women with fibrocystic breast changes, fibroadenoma, or a family history of breast cancer?

Back 714

A positive family history of breast cancer in a mother or sister, or both, or a history of benign breast disease should not be regarded as contraindications to OC use.

Front 715

• What are the effects of combination OC use in women with uterine leiomyomata?

Back 715

significantly reduced bleeding in women with menorrhagia associated with uterine fibroids

also reduces dysmenorrhea

Front 716

Do combo OCPs cause fibroids to grow?

Back 716

No!
OC use does not induce the growth of uterine fibroids and

may even decrease bleeding disorders in these women

Front 717

• Is combination OC use safe for women with lipid disorders?

Back 717

Not for women with UNCONTROLLED LDL cholesterol greater than 160 mg/dL or multiple additional risk factors for coronary artery disease

Front 718

How often should fasting serum lipid levels be monitored for women after initiating combination OC use in dyslipidemic women?

Back 718

each month
less frequent monitoring is appropriate once stabilization of lipid parameters has been observed.

Concomitant hormonal contraception and lipid-lowering therapy may be appropriate in some women.

Front 719

use of combination OCs by well-nourished breastfeeding
Their use can be considered when?

Back 719

once milk flow is well established.

6 weeks postpartum

Front 720

with DMPA and implants, their immediate postpartum use in both lactating and nonlactating women appears reasonable.

Back 720

with DMPA and implants, their immediate postpartum use in both lactating and nonlactating women appears reasonable. !!!

Front 721

Anticonvulsants that induce hepatic enzymes can decrease serum concentrations of the estrogen or progestin component of OCs, or both. What to do?

Back 721

Use of barrier in conjunction with OCs or use of DMPA or an intrauterine device may be considered for such women

Front 722

Although there have been many anecdotal reports of OC failure in women taking concomitant antibiotics, pharmacokinetic evidence of lower serum steroid levels exists only for what antibiotics?

Back 722

rifampin
griseofulvin

Front 723

A potential advantage of using DMPA in women with seizure disorders is

Back 723

DMPA's intrinsic anticonvulsant effect

Front 724

Women with a documented history of unexplained VTE or VTE associated with pregnancy or exogenous estrogen use should not use combination OCs unless

Back 724

they are currently taking anticoagulants

Front 725

An OC candidate who had experienced a single episode of VTE years earlier associated with a nonrecurring risk factor (eg, VTE occurring after immobilization following a motor vehicle accident) may not currently be at increased risk for VTE. Accordingly, the decision to initiate combination OCs in such a candidate?

Back 725

can be individualized.

Front 726

OCPs in anticoagulated patents okay?

Back 726

OCs can reduce menstrual blood loss
does not increase the risk of recurrent thrombosis in well-anticoagulated women

some authorities recommend their use in such patients.

Because intramuscular injection of DMPA consistently suppresses ovulation DMPA represents another potential contraceptive choice in anticoagulated women.

Front 727

• Are hormonal contraceptives safe for women with SLE?

Back 727

combination OC use should be avoided in SLE patients with a history of vascular disease, nephritis, or antiphospholipid antibodies,

progestin-only methods are safe alternatives.

If such women do not wish to use progestin-only methods, use of combination OCs with close monitoring can be considered in selected cases.

Front 728

• Is hormonal contraceptive use safe for women with sickle cell disease?

Back 728

use of DMPA reduced the incidence of painful crises

consensus is that pregnancy carries a greater risk than combination OC use.


avoid IUD (infection)

Front 729

• What are the effects of DMPA on bone density?

Back 729

no long-term decrease BMD occurs

Estrogen supplementation (eg, conjugated estrogen, 1.25 mg daily, or equivalent doses of other estrogens) can be considered for long-term users of DMPA, including adolescents

No evidence of osteoporosis or fractures in DMPA users.

Front 730

vacuum extraction inappropriate in pregnancies before ___ weeks of gestation. Why? .

Back 730

34

Risk of fetal IVH

Front 731

Operative delivery also is contraindicated if a live fetus is known to have:

Back 731

a bone demineralization condition (eg, osteogenesis imperfecta),
bleeding disorder (eg, alloimmune thrombocytopenia, hemophilia, or von Willebrand's disease)

the fetal head is unengaged,

position of the fetal head is unknown.

need personnel are readily available to perform a cesarean delivery in the event the operative vaginal delivery is unsuccessful.

Front 732

• Is there a role for the use of alternative instruments after a failed attempt?

Back 732

No.
incidence of intracranial hemorrhage

Front 733

higher risk of morbiditiy hysterectomy v myomectomy for fibroids?

Back 733

Same risk morbidity

Front 734

limitation of mymectomy

Back 734

recurrence 18%

Front 735

recurrence risk of LS myomectomy?

Back 735

33% (higher than lap myomectomy)

Front 736

most recommend a laparotomy or a laparoscopically assisted approach with which leiomyomas?

Back 736

> 5–8 cm,
multiple leiomyomas,
the presence of deep intramural leiomyomas

Front 737

risk of LS myomectomy

Back 737

2–8% conversion rate to a more open procedure,

formation of uteroperitoneal fistulas,
possibility of uterine rupture during a subsequent pregnancy

Front 738

What % of patients with submucosal leiomyomas conceived after hysteroscopic myomectomy

Back 738

59%

Front 739

Endometrial Ablation for leiomyomas?

Back 739

no evidence to support the use of this procedure for women with leiomyomas

Front 740

GnRH agonists may be useful when a significant reduction in uterine volume is necessary to achieve surgical goals for example

Back 740

when the patient prefers a low-transverse incision instead of a vertical incision
an endoscopic procedure

Front 741

GnRH agonists when given for 2–3 months preoperatively may be beneficial how?

Back 741

improve hematologic parameters,
shorten hospital stay,

decrease blood loss, operating time, and postoperative pain

Front 742

Then why not always use GnRH if it's so beneficial for myomas?

Back 742

no study has shown a significant decrease in transfusion risk or improvement in quality of life,

cost of these medications is substantial,

the decision to use GnRH agonists preoperatively remains complex

Front 743

How does Iron compare to GnRH in achieved hematologic improvement and in laparotomy operating times?

Back 743

achieved hematologic improvement 50% compared to 74% with GnRH

Operating times equal with laparotomy

Front 744

One surgical disadvantage to preoperative GnRH agonist therapy

Back 744

may make the leiomyomas softer and the surgical planes less distinct.

Front 745

Intraoperative Adjuvants for myomectomies to decrease blood loss at the time of myomectomy.

Back 745

infiltration of vasopressin/vasocontriction into the myometrium

20 U of vasopressin diluted to 20 mL with normal saline


penrose/foley tournquets

Front 746

history of idiopathic thrombosis, extensive or life-threatening thrombosis, recurrent thrombosis, thrombosis related to a high estrogen state, or who have an underlying thrombophilia or postthrombotic syndrome

what px during pregnancy?

Back 746

antepartum thromboprophylaxis beginning in the first trimester and continuing until 6 weeks postpartum.

Front 747

VIAGARA
Unfractionated Heparin
Adjusted dose prophylaxis:

Back 747

>=10,000 U BID to TID

to achieve APTT of 1.5–2.5

Front 748

VIAGARA
LMWH/wt based(alternative to unfractionated)
Adjusted dose prophylaxis:

Back 748

Dalteparin, 5,000–10,000 U BID,
or
enoxaparin, 30–80 mg BID

Front 749

• In women with leiomyomas who desire to become pregnant, does removal of leiomyomas versus expectant management increase the pregnancy rate?

Back 749

It appears that distortion of the uterine cavity may cause infertility and lead to pregnancy complications

Front 750

• In menopausal women with leiomyomas, what is the effect of hormone replacement therapy on leiomyoma bleeding?

Back 750

an increased likelihood of abnormal bleeding

studies unsure about increased growth. only occurred with transdermal, not oral.

Front 751

prevalence of leiomyosarcomas discovered incidentally

Back 751

1:2,000

Front 752

what makes the likelihood of a myoma being a leiomyosarcoma?

Back 752

rapid growth
older age
prior pelvic radiation

Front 753

What appears to be useful in diagnosing sarcomas and differentiating them from other intrauterine lesions

Back 753

endometrial biopsy

magnetic resonance imaging

Front 754

• In asymptomatic women with leiomyomas, does expectant management produce a better outcome than surgical treatment in relation to long-term morbidity?

Back 754

Expectant management in an asymptomatic patient should be the norm;
however, in some instances an asymptomatic leiomyomatous uterus might require treatment.

If there is concern that the mass is not a leiomyoma but instead a sarcoma

Front 755

When to intervene in a patient with an asymptomatic leiomyoma:

Back 755

concern that the mass is a sarcoma

significant compression of the ureters that can lead to the compromise of renal function

woman contemplating pregnancy or experiencing recurrent miscarriage, significant distortion of the uterine cavity

Front 756

leiomyomata appear to increase the obstetric risk of:

Back 756

abruption and
premature labor

Front 757

• In asymptomatic women with leiomyomas planning future pregnancies who are candidates for surgery, should they have a myomectomy?

Back 757

should be managed expectantly

they have no indication for surgery

Front 758

What if these myomas are symptomatic? When should these removals take place?

Back 758

given the risk of recurrence, intervening as close to the desired pregnancy as possible is desirable.

Front 759

In women with leiomyomas planning future pregnancies who are candidates for surgery, what should be discussed prior to removal of myoma if planning future pregnancy?

Back 759

risk of bleeding/hysterectomy should be considered

risk of requiring future CD

Front 760

• How is the diagnosis of PMS established?

Back 760

CONSISTENT
LUTEAL
EXCLUSION
FACET


a) symptoms CONSISTENT with PMS;
b) restriction of these symptoms to the LUTEAL phase of the menstrual cycle assessed prospectively;
c) impairment of some FACET of the woman's life; and
d) EXCLUSION of other diagnoses that may better explain the symptoms.

Hint 760

CLEF

Front 761

Premenstrual syndrome can be diagnosed if the patient reports at least one of the following affective and somatic symptoms during the 5 days before menses in each of the three prior menstrual cycles*:

Back 761

Affective
Depression
Angry outbursts
Irritability
Anxiety
Social withdrawal

Somatic
Breast tenderness
Abdominal bloating
Headache
Swelling of extremities

Front 762

These symptoms are relieved within __ days of the onset of menses, without recurrence until at least cycle day __.

Back 762

4

13

Front 763

The symptoms are present in the absence of any

Back 763

pharmacologic therapy, hormone ingestion, or drug or alcohol use.

Front 764

The symptoms occur reproducibly during ___ cycles of prospective recording.

Back 764

two

Front 765

The patient suffers from identifiable dysfunction in ______ or _____performance.

Back 765

social or economic

Front 766

The diagnosis of PMS should be based on prospective

Back 766

symptom diaries,

Front 767

Because some women experience cycle-to-cycle variability in symptoms, reviewing ___ months of prospective charting is preferable to reviewing a single cycle

Back 767

2–3

Front 768

Types of PMS symptom diaries

Back 768

Simple system - records the dates of her menstrual periods and notes her symptoms on a daily basis

Calendar of Premenstrual Experiences (COPE)

Prospective Record of the Impact and Severity of Menstruation (PRISM)

Front 769

Describe the phenomenon of menstrual magnification

Back 769

Many medical and psychiatric conditions are exacerbated in the late luteal or menstrual phase of the cycle, leading a woman to believe that she must be experiencing PMS.

Front 770

Difference between PMS and depression?

Back 770

depressive disorders, however, is that symptoms are almost always present every day of the cycle.

Front 771

The most common medical disorders subject to menstrual magnification are

Back 771

migraines,
seizure disorders,
irritable bowel syndrome,
asthma,
chronic fatigue syndrome,
allergies.

Front 772

Women with severe symptoms or with symptoms resistant to nonmedical approaches should be considered for

Back 772

drug therapy

Front 773

Side effects associated with fluoxetine include

Back 773

headaches
nausea - SSRI GI
jitteriness
Insomnia
decreased libido

Front 774

the only diuretic that has been shown to be of benefit in PMS

Back 774

Spironolactone,

Front 775

Spironolactone MOA

Back 775

potassium sparing diuretic

an aldosterone antagonist

antiandrogenic properties
inhibits 5 alpha reductase

Front 776

Progesterone may be helpful for specific PMS symptoms, such as

Back 776

BREAST tenderness
BLOATING,
WORRYING

Front 777

oral contraceptives should be considered if PMS symptoms are primarily

Back 777

physical,

may not be effective if mood symptoms are more prevalent.

Front 778

Examples of hormonal suppression for PMS

Back 778

OCPs
GnRH - give alendronate
BSO

Front 779

Before BSO for severe PMS, should do what?

Back 779

diagnostic trial with an agonist for a minimum of 3 months to determine if oophorectomy will be effective.

Front 780

with anovulatory bleeding, who should get EMB?

Adolescents (13–18 Years).

Back 780

adolescents who have a history of 2–3 years of untreated anovulatory bleeding and especially for those who are obese.

Front 781

with anovulatory bleeding, who should get EMB?

Women of Reproductive Age (19–39 Years).

Back 781

older than 35 years who is suspected of having anovulatory uterine bleeding.

19 and 35 years who do not respond to medical therapy

have prolonged periods of unopposed estrogen stimulation secondary to chronic anovulation

Front 782

with anovulatory bleeding, who should get EMB?

Back 782

suspected anovulatory uterine bleeding

Front 783

goals of medical treatment for anovulatory bleeding

Back 783

alleviate acute bleeding,
prevent future episodes of noncyclic bleeding,
decrease the patient's risk of long-term complications from anovulation,

improve the patient's overall quality of life.

Front 784

To encourage compliance with medical therapy, it is important to counsel patients that

Back 784

treatment may cause initial heavy menstrual bleeding secondary to endometrial buildup, but will lighten over time (within three cycles).

Front 785

Adolescents (13–18 Years).Patients with blood dyscrasias need to be treated for their specific disease, and _____ needs to be ruled out in this population

Back 785

leukemia

Front 786

to control acute bleeding episodes, options for adolescent are:

Back 786

Conjugated equine estrogens can be administered

PO
2.5 mg 4x/day for up to 24 hours

IV
25 mg every 4 hours for up to 24 hours

Front 787

After acute bleeding has been treated, recurrent anovulatory bleeding should be prevented with

Back 787

cyclic progestogen or

an oral contraceptive

same for adolescents and adults (if no contraindications)

Front 788

Women who are older than 40 years and who have anovulatory uterine bleeding can be treated with .

Back 788

cyclic progestogen,
low-dose oral contraceptives, or
cyclic hormone replacement therapy

Front 789

Women with hot flashes secondary to declining estrogen production can obtain symptomatic relief with

Back 789

estrogen replacement therapy in combination with continuous or cyclic progestogen.

Front 790

• In patients who have completed childbearing, what is the benefit of treating anovulatory bleeding surgically rather than medically?

Back 790

Surgical therapy is indicated for women with excessive anovulatory bleeding in whom medical management has failed and who have completed their childbearing.

Front 791

How does one define success or failure?

Back 791

Success and failure of medical therapy should be defined in partnership with the patient, to better achieve the therapeutic goal.

Front 792

surgical options for DUB include

Back 792

hysterectomy and endometrial ablation.

Front 793

The overall mortality rate for hysterectomy is ___deaths per 10,000 procedures, for all surgical indications

Back 793

13

lucky number

Front 794

Hysteroscopic-assisted endometrial ablation can be performed with the

Back 794

resectoscope.

Front 795

Using the resectoscope, the endometrium can be removed or resected with

Back 795

an electrocautery loop or ablated with the rollerball.

Front 796

Endometrial ablation also can be accomplished with these options:

Back 796

resectoscope - rollerball/loop
YAG laser
thermal balloon 85
Novasure impedence

Front 797

An alternative to hysteroscopic-assisted endometrial ablation is thermal balloon ablation in which the endometrium is ablated by heating saline inside an intrauterine balloon to approximately

Back 797

85 degrees Celcius

185 degrees F

Front 798

most frequently reported complications of hysteroscopy are uterine perforation, which occurs in approximately __ per 1,000 procedures

Back 798

14

perforation = perfourteen!!!

Front 799

hysteroscopy causes complication of fluid overload, which occurs in approximately __ per 1,000 cases.

Back 799

2

2 much fluid!!!

Front 800

The proportion of women who are amenorrheic after undergoing an endometrial resection using the resectoscope or endometrial laser ablation is approximately ___%,

Back 800

45

Front 801

the percentage of women at 12 months postoperatively who are satisfied with their resectoscope/laser/loop therapy approaches __%

Back 801

90

Front 802

Endometrial ablation with the thermal balloon yields an amenorrhea rate of approximately ___% and a 12-month postoperative satisfaction rate of approximately ___%

Back 802

15

90% (same for rectoscope)

Front 803

use of either a gonadotropin-releasing hormone agonist or danazol prior to endometrial ablation or resection with regard to

Back 803

improved intrauterine operating environment and

short-term postoperative outcome

Front 804

in acute vaginal bleeding
Patients who do not respond to 1–2 doses of estrogen with should undergo dilation and curettage if they have one of these two problems:

Back 804

a significant decline in blood loss or
are not hemodynamically stable

Front 805

After the acute episode of bleeding has been controlled, what should be done and why?

Back 805

amenorrhea should be maintained for several weeks to allow for resolution of anemia.

best method of therapy is a combination oral contraceptive.

Front 806

How should OCPs be given after acute bleeding episode is resolved?

Back 806

continuous oral contraceptives for several months

want to create amenorrhea so can recover from anemia

Front 807

All anemic patients should be given

Back 807

iron therapy

Front 808

Why ECV at completed 36 weeks?

Back 808

if spontaneous version is going to occur, it is likely to have taken place

risk of a spontaneous reversion is decreased

if complications arise during an attempted version, emergency delivery of a term infant can be accomplished

Front 809

Fetal heart rate changes during attempted versions, what to do?

Back 809

Fetal heart rate changes during attempted versions are not uncommon but usually stabilize when the procedure is discontinued

Front 810

adverse effects ecv

Back 810

***fetal/maternal hemorrhage (most common)

abruption
PTL

Front 811

In ECV which fetal lie is associated with higher immediate success rates

Back 811

transverse or oblique lie

Front 812

Existing evidence may support the use of a tocolytic agent during ECV attempts, particularly in which patients?

Back 812

nulliparous

Front 813

• How does the use of anesthesia affect the success rate of external cephalic version?

Back 813

May have greater success rate, but not enough consistent evidence to make a recommendation

Front 814

standard protocol for performing an external cephalic version attempt?

Back 814

informed consent
ultrasound
consider tocolyze nullips
NST/BPP
T&S
notify anesthesia
OR readily available

Front 815

if transverse lie, how to manage?

Back 815

if transverse lie late gestation, schedule version at 37 weeks and immediate induction.

due to increased risk of cord prolapse

Front 816

Why immediate induction if successful induction at 37 weeks?

Back 816

increased chance of cord prolapse late gestation if transverse lie.

Front 817

Once IUGR is suspected (ie, lagging fundal height), it should be confirmed how?

Back 817

using multiple ultrasonographic parameters, such as
EFW
AFI
elevated HC/AC
Doppler criteria

Front 818

which IUGR should be delivered, even if premature?

Back 818

abnormal fetal testing with abnormal dopplers

Front 819

How is doppler velocimetry at negative predictive value for IUGR?

Back 819

a normal systolic-diastolic ratio in a growth-restricted fetus has excellent negative predictive value and may be used as a rationale to delay delivery with some reassurance.

Front 820

In addition to IUGR, when else is doppler velocimetry used?

Back 820

monozygotic twins.

Front 821

When one diagnoses IUGR, what should one do to attempt to discover etiology?

Back 821

history - HTN, drugs, smoking
u/s findings - possible karyotype
sickle cell
anticonvulsants
APS
uterine anomaly
fibroid

Front 822

what if see u/s finding or severe IUGR?

Back 822

do karyotype 10%

Front 823

Viral infections associated with IUGR,

Back 823

tORCh

varicella
rubella
cytomegalovirus

No in utero treatments

Front 824

what is Other in TORCH?

Back 824

Parvo and VZV

Front 825

Will spiramycin decrease toxo infection to fetus?

Back 825

Yes.

Front 826

• When should a growth-restricted fetus be delivered?

Back 826

decision to deliver is based often on nonreassuring fetal assessment or a complete cessation of fetal growth assessed ultrasonographically over a 2-4-week interval.

when extrauterine survival is likely despite abnormal antenatal testing.

Front 827

pain associated with endometriosis can be reduced with the use of

Back 827

oral contraceptives,
NSAIDS
progestins
danazol,
GnRH agonists

Front 828

How long should OCP therapy be attempted in endometriosis before trying another option?

Back 828

3 months

Front 829

If recurrent symptoms do not respond to oral contraceptives, then what therapy may be appropriate.

Back 829

medroxy-progesterone acetate (MPA),
danazol, or a
GnRH agonist

Front 830

Surgical therapy for women with endometriosis is associated with a significant reduction in pain symptoms how long following surgery?

Back 830

6 months

Front 831

What portion of women experience recurrence of symptoms within 1 year postoperatively for osis?

Back 831

(44%)

Front 832

A major issue in considering comparisons of surgical treatment with medical treatment of osis is

Back 832

the experience and expertise of the surgeon.

Front 833

Is there evidence that one osis surgical method is better than the other?

Back 833

No

Front 834

Is there data regarding whether osis surgical therapy influences LONG-TERM fertility?

Back 834

No

Front 835

osis surgery techniques:

Back 835

excision,
endocoagulation,
electrocautery,
laser vaporization

no study demonstrates the superiority of any one method,

Front 836

recurrence rates after osis surgery?

Back 836

average 19%

Front 837

it appears that surgical treatment alone will confer pain relief in approximately what % of women for up to 1 year.

Back 837

33%

Front 838

add-back regimens

Back 838

sex-steroid hormones or other specific bone-sparing agents

Front 839

potential advantages of add-back therapy for women undergoing short-term (3-6 months) GnRH agonist therapy are twofold

Back 839

), add-back therapy does reduce the bone loss observed after only 3 months of GnRH agonist therapy

does not diminish the efficacy of pain relief observed during 3 months or 6 months of GnRH agonist therapy

reduce significantly the vasomotor symptoms associated with GnRH agonist treatment

Front 840

danazol adverse effect

Back 840

cholesterol/TG

virilization

permanent voice change

Front 841

After an appropriate pretreatment evaluation (to exclude other conditions) and failure of initial treatment with oral contraceptives and nonsteroidal antiinflammatory drugs, empiric therapy with what is appropriate for osis?

Back 841

a 3-month course of a GnRH agonist

Front 842

Although preliminary data suggest that the destruction of all apparent lesions is associated with improved fecundity during the next 36 months (85), there are no data available on which to make a recommendation regarding medical therapy to prevent progression of disease or to prevent pain symptoms

Back 842

Hmmm.

Front 843

should asymptomatic osis be treated? will it prevent future pain? improve fertility?

Back 843

There are no data to support the suggestion that medical treatment to prevent the progression of the disease will result in successful fertility in the future. It is not even clear whether fertility can be predicted based on the presence of endometriosis unless there is gross distortion of tubal and ovarian anatomy

Front 844

u/s characteristic of endometriomas.

Back 844

Scattered internal echoes

homogeneous

Front 845

• In patients with pain or bleeding arising from known endometriosis affecting nonreproductive organs, what is first line therapy?

Back 845

GnRH agonists

Front 846

CYCLIC episodes of gross hematuria, hematochezia, and hemoptysis are likely

Back 846

osis in
thorax,
full thickness bowel
bladder

Front 847

"definitive" therapy for the treatment of endometriosis associated with intractable pelvic pain, adnexal masses, or multiple previous conservative surgical procedures.

Back 847

Hysterectomy, with or without bilateral oophorectomy

Front 848

can symptoms recur in women even after hysterectomy and oophorectomy.

Back 848

yes

Front 849

The most common site of recurrent osis lesions is

Back 849

the large and small bowel

Front 850

is there an advantage, in terms of recurrence rate, in delaying introduction of estrogen treatment following surgery?

Back 850

No

Front 851

Labor also may be induced for LOGISTIC REASONS, for example,

Back 851

risk of rapid labor,

distance from hospital,

psychosocial indications.

snowstorm-alaska

Front 852

How should the patient be counseled for labor induction?

Back 852

indications

agents

repeat induction or cesarean delivery.

Front 853

If there is inadequate cervical change with minimal uterine activity after one dose of intracervical PGE2, a second dose may be given when?

Back 853

6-12 hours later

Front 854

hyperstimulation

Back 854

single contractions lasting 2 minutes or more or a contraction frequency of five or more in 10 minutes

with NRFHT

Front 855

bradycardia

Back 855

FHR below 110 lasting 2 minutes

Front 856

deceleration

Back 856

FHR below 120 lasting less than 2 minutes

Front 857

• Are the various methods of labor induction equally applicable to patients with intact or ruptured membranes?

Back 857

Yes

Front 858

may occur following a rapid intravenous injection of oxytocin

Back 858

Hypotension

Front 859

Synthetic oxytocin generally is diluted

Back 859

10 U in 1 L of an isotonic solution for an oxytocin concentration of 10 mU/mL

Front 860

Bolus administration of oxytocin can be avoided by

Back 860

piggybacking the infusion into the main intravenous line near the venipuncture site

Front 861

Intravenous oxytocin usually is a safe and effective method of inducing labor for a fetal death near term but is less effective when?

Back 861

remote from term

Front 862

What may be beneficial before the use of oxytocin or PGE for induction

Back 862

Laminaria or hygroscopic cervical dilators

Front 863

Although PGE2 vaginal suppositories have been used safely in the third trimester the risk of what is increased.

Back 863

uterine rupture

Front 864

drawbacks to dinoprostone

Back 864

cost
refrigeration

Front 865

• What are the maternal indications for antepartum fetal surveillance?

Back 865

Antiphospholipid syndrome
–Hyperthyroidism (poorly controlled)
–Hemoglobinopathies (hemoglobin SS, SC, or S-thalassemia)
–Cyanotic heart disease
–Systemic lupus erythematosus
–Chronic renal disease
–Type 1 diabetes mellitus
–Hypertensive disorders
-Pregnancy-induced hypertension

Front 866

What are the fetal indications for antepartum fetal surveillance?

Back 866

–Decreased fetal movement
–Oligohydramnios
–Polyhydramnios
–Intrauterine growth restriction
–Postterm pregnancy
–Isoimmunization (moderate to severe)
–Previous fetal demise (unexplained or recurrent risk)
–Multiple gestation (with significant growth discrepancy)

Front 867

multiple or particularly worrisome high-risk conditions (eg, chronic hypertension with suspected intrauterine growth restriction), testing might begin as early as ___weeks of gestation.

Back 867

26-28

Front 868

fetal test reassurance is defined as:

Back 868

defined as the incidence of stillbirth occurring within 1 week of a normal test result.

Front 869

incidence

Back 869

new cases over period of time

pot incident

Front 870

negative predictive value of the NST is

Back 870

99.8%

Front 871

negative predictive value of CST, BPP, and modified BPP

Back 871

99.9%

Front 872

NST, CST, BPP, modified BPP generally do not predict stillbirths related to ______ changes in maternal-fetal status, such as those that occur with abruptio placenta or an umbilical cord accident.

Back 872

acute

Front 873

umbilical artery Doppler velocimetry negative predictive value of

Back 873

100%

in one study

Front 874

• How should one respond to an abnormal test result?

Back 874

always be considered in the context of the overall clinical picture,

taking into account the substantial possibility that the test result is falsely positive

Front 875

A nonreactive NST or an abnormal modified BPP generally should be followed by

Back 875

either a CST or a full BPP

Front 876

A positive CST result suggests that NST nonreactivity is a consequence of

Back 876

hypoxia-induced acidosis

Front 877

In many circumstances, a positive CST result generally indicates that delivery is warranted. However, the combination of a nonreactive NST and a positive CST result is associated frequently with _________and justifies what, therefore?

Back 877

serious fetal anomalies
ultrasonographic investigation for anomalies whenever possible

Front 878

what should precede any intervention for suspected fetal compromise based on fetal testing whenever possible?

Back 878

evaluation for grossly abnormal fetal anatomy

Front 879

A BPP score of 6
term infant

Back 879

deliver

Front 880

A BPP score of 6
preterm fetus

Back 880

repeat BPP in 24 hours

Front 881

A BPP score of 6
preterm fetus
In the interim of 24 hour wait for next BPP, do what?

Back 881

maternal corticosteroid administration should be considered for pregnancies of less than 34 weeks of gestation.

Front 882

A BPP score of 6 is considered

Back 882

equivocal

Front 883

Repeat equivocal scores should result in

Back 883

delivery or

continued intensive surveillance.

Front 884

BPP score of 4 usually indicates that delivery is warranted, although in which pregnancies, should management be individualized.

Back 884

extremely premature

Front 885

Biophysical profiles less than 4 should result in

Back 885

expeditious delivery

Front 886

Regardless of the overall score, oligohydramnios always requires

Back 886

further evaluation.

Front 887

do abnormal test results always warrant CD?

Back 887

In the absence of obstetric contraindications, delivery of the fetus with an abnormal test result often may be attempted by induction of labor, with continuous monitoring of both the fetal heart rate and contractions.

Front 888

any single antepartum fetal test can be considered superior to any other?

Back 888

No

Front 889

CST is considered relatively contraindicated in:

Back 889

preterm labor and delivery,

uterine rupture

and uterine bleeding

Front 890

• When should oligohydramnios prompt delivery?

Back 890

depends on
gestational age,
maternal and fetal clinical condition as determined by other indices of fetal well-being,
actual measured AFI value.

Front 891

widely used definition of oligohydramnios

Back 891

no measurable VERTICAL pocket of amniotic fluid greater than 2 cm

AFI of 5 cm or less

Front 892

In postterm pregnancy, oligohydramnios is common and is associated with

Back 892

an increased risk of meconium staining

cesarean delivery for nonreassuring fetal heart rate

Front 893

oligohydramnios has been considered an indication for delivery of the postterm pregnancy

Back 893

okay

Front 894

oligo
in certain situations, delivery may be safely postponed (eg, an uncomplicated pregnancy with an AFI of 5 cm but otherwise reassuring fetal testing and an ____________at 37 weeks of gestation

Back 894

unfavorable cervix

Front 895

In the preterm fetus, expectant management may be the most appropriate course of action, depending on

Back 895

the maternal and fetal condition

Front 896

Once oligohydramnios is diagnosed, if delivery is not undertaken, what is indicated.

Back 896

follow-up amniotic fluid volume

fetal growth assessments

Front 897

If umbilical artery Doppler velocimetry is used, decisions regarding timing of delivery should be made using

Back 897

a combination of information from the Doppler ultrasonography and other tests of fetal well-being, such as amniotic fluid volume assessment, NST, CST, and BPP, along with careful monitoring of maternal status.

Front 898

FKK instructions

Back 898

10 movements within 10 hours

Front 899

• How can the diagnosis of HSV be confirmed?

Back 899

viral culture

PCR

Front 900

most sensitive for HSV dx?

Back 900

PCR

Front 901

what % of crusted lesions contain recoverable virus

Back 901

40%

Front 902

When testing for HSV, overt lesions that are not in the ulcerated state should be

Back 902

unroofed and the fluid sampled.

Front 903

Serologic diagnosis of primary infection is possible by documenting

Back 903

seroconversion from a negative to a positive antibody titer

Front 904

The usual time for obtaining a second specimen is how long after the onset of infection.

Back 904

2-3 weeks

Front 905

primary HSV cannot be distinguished from nonprimary first-episode disease unless

Back 905

serology is performed

Front 906

Antiviral therapy for primary infection is recommended for women with ____ HSV infection during pregnancy to reduce viral shedding and enhance lesion healing.

Back 906

primary

Front 907

suppressive therapy for the duration of the pregnancy needs to be considered to reduce the potential of

Back 907

continued viral shedding

recurrence

Front 908

acyclovir given after 36 weeks in beneficial for

Back 908

reduction in the number of cesarean deliveries performed for active infection

Front 909

Acyclovir MOA

Back 909

selectively inhibit viral replication

selective activity against HSV-1 and HSV-2

Front 910

Acyclovir Class-

Back 910

class-C

minimal sides, which is good cause take so often

Front 911

The newer antiherpetic drugs valacyclovir and famciclovir are class-

Back 911

B medications

Front 912

The newer antiherpetic drugs valacyclovir and famciclovir advantage

Back 912

increased bio-availability means that they may require less frequent dosing

Front 913

oral acyclovir significantly reduces

Back 913

symptomatic recurrences

suppresses SUBCLINICAL viral shedding

Front 914

does acyclovir reach therapeutic levels in the fetus?

Back 914

yes

Front 915

• In which situations should cesarean delivery be considered?

Back 915

active genital lesions or symptoms of vulvar pain or burning, which may indicate an impending outbreak.

Front 916

So...do prodromal symptoms mean a pateint should have a CD???

Back 916

YES!!!!!

Front 917

• Is cesarean delivery recommended for women with recurrent HSV lesions on areas distant from the vulva, vagina, or cervix (eg, thigh or buttock)?

Back 917

No.

delivery is not recommended for these women.

Nongenital lesions should be covered with an occlusive dressing; the patient then can deliver vaginally.

Front 918

• In a patient with active HSV infection and ruptured membranes, is there any length of time at which vaginal delivery remains appropriate?

Back 918

No

Always do CD, asap

Front 919

• How should a woman with active HSV and preterm premature rupture of membranes be managed?

Back 919

consult MFM

Front 920

• How should a woman with active HSV and preterm premature rupture of membranes be managed?

Back 920

especially in women with recurrent disease, expectant management and glucocorticoids

treatment with an antiviral agent is indicated

Front 921

are there potential effects of glucocorticoids on patients with viral infection,

Back 921

no conclusive evidence that this is a concern in this setting.

Front 922

active HSV and preterm premature rupture of membranes

The decision to perform a cesarean delivery depends on

Back 922

whether active lesions are present at the time of delivery.

Front 923

• Are invasive procedures contraindicated in women with HSV?

Back 923

transcervical procedures should be delayed until lesions appear to have resolved

Front 924

In patients with recurrent HSV, are invasive procedures, such as amniocentesis, percutaneous umbilical cord blood sampling, or transABDOMINAL chorionic villus sampling okay to perform?

Back 924

yes

Front 925

What about PRIMARY HSV and/or systemic symptoms?

Back 925

delay invasive procedures until symptoms appear to resolve.

Front 926

are scalp leads okay in HSV?

Back 926

if there are indications for fetal scalp monitoring, it may be appropriate in a woman who has a history of recurrent HSV and no active lesions

Front 927

• Should women with active HSV breastfeed or handle their infants?

Back 927

if the mother has an obvious lesion on the breast, breastfeeding is contraindicated.

Mothers with active lesions should use caution when handling their babies.

Most strains of HSV responsible for nosocomial neonatal disease are HSV-1

Front 928

• With ovary retention, what is the risk of needing a future oophorectomy for benign disease?

Back 928

5%

Front 929

most commonly cited reason for reoperation

Back 929

pain in the retained ovary or ovaries

Front 930

Patient Factors to Consider in Prophylactic Oophorectomy

Back 930

Age
Parity
Previous abdominal surgery
Risk of ovarian cancer
Menopausal status
Family and personal history
Desire and willingness to use HRT
Risk for osteoporosis
Risk for coronary heart disease
Effect on self-image

SELF
SEX
HORMO
REPRO

Hint 930

SELF
SEX
HORMO
REPRO

Front 931

there may be underlying advantages of ovarian function that have not yet been identified, particularly

Back 931

postmenopausal androgen production.

Front 932

• Should hormone replacement therapy be recommended for women undergoing prophylactic oophorectomy?

Back 932

Yes

If the patient is premenopausal, her need for estrogen replacement may be even greater because of her age and potential life span.

Front 933

• What is the risk-benefit relationship associated with oophorectomy?

Back 933

Compliance with estrogen replacement therapy and the risks of coronary artery disease and osteoporosis versus

the 5% risk of reoperation or ovarian cancer must be considered.

Front 934

When is prophylactic oophorectomy indicated as adjunctive treatment for premenopausal women with breast cancer?

Back 934

an accepted endocrine management strategy for breast cancer.

with the use of multiagent chemotherapy, tamoxifen, and GnRH agonists, the role for oophorectomy is unclear.

Front 935

Women with BRCA1 have a ___%lifetime risk of ovarian cancer, and BRCA2 conveys a ___% risk.

Back 935

45%

26% (chrom 13 x 2 = 26)

Front 936

• Are there genetic risks that should be considered in the decision to perform prophylactic oophorectomy?

Back 936

select women at high risk of inherited ovarian cancer (BRCA1 and BRCA2) should be considered.

Front 937

When should prophylactic oophorectomy be done for BRCA patients be done?

Back 937

age of ovarian cancer in women with these genetic mutations is mid 40s,


should be performed at completion of childbearing or at 35 years of age.

Front 938

management recommendations for women with Lynch syndrome II

Back 938

annual physical examination

biannual rectovaginal examination,

determinations of CA 125 levels,

transvaginal ultrasonography

Front 939

The role of oophorectomy at the time of surgery for primary nonhereditary (sporadic) colorectal cancer is not clear.

Some contemporary literature suggests that removing ovaries in this group of women decreases the likelihood of

Back 939

metastatic disease to the ovary.

Front 940

counseling about BSO

Back 940

SELF-IMAGE

HORMONAL MILEU

REPRODUCTIVE FUNCTION

SEXUALITY

Front 941

posthysterectomy depression risk factors.

Back 941

preoperative depression,

prior psychiatric disturbances,

age younger than 35 years,
nulliparity,

fewer than 12 years of formal education

Front 942

differential diagnosis of thrombocytopenia in pregnancy

Back 942

gestational thrombocytopenia
HIV infection
drug-induced
HELLP/severe preeclampsia
thrombotic thrombocytopenic purpura,
hemolytic uremic syndrome
DIC
SLE
APS
congenital thrombocytopenias
pseudothrombocytopenia

Front 943

generally are indicated in the evaluation of maternal thrombocytopenia.

Back 943

CBC

peripheral blood smear

Front 944

platelet clumping that may be associated with

Back 944

pseudothrombocytopenia

Front 945

can gestational thrombocytopenia and ITP cannot be differentiated on the basis of antiplatelet antibody testing?

Back 945

No!!!

Tests for antiplatelet antibodies are nonspecific

Front 946

If drugs and other medical disorders are excluded, the primary differential diagnosis in the first and second trimesters will be

Back 946

gestational thrombocytopenia

ITP

Front 947

typically becomes manifest later in pregnancy

Back 947

gestational thrombocytopenia

Front 948

If the platelet count is less than _____/µL, ITP is more likely to be present,

Back 948

70,000

if the platelet count is less than 50,000/µL, ITP is almost certainly present.

Front 949

During the third trimester or postpartum period, the sudden onset of significant maternal thrombocytopenia should lead to consideration of

Back 949

PIH
TTP
HUS
AFLP
DIC

ITP

Front 950

Does ITP have a problem with platelet function?

Back 950

No

Front 951

goal of medical therapy during pregnancy in women with ITP is to minimize the risk of

Back 951

bleeding complications associated with severe thrombocytopenia

Front 952

asymptomatic pregnant ITP women with platelet counts greater than ____/µL do not require treatment.

Back 952

50,000

Front 953

• When should women with ITP receive medical therapy?

Back 953

platelet count significantly less than 50,000/µL
or
presence of bleeding

Front 954

Are bleeding times useful in assessing platelet function in patients with ITP?

Back 954

No

Front 955

The first line of treatment for ITP

Back 955

prednisone

Front 956

What is appropriate therapy for cases refractory to steroids

Back 956

Intravenous immune globulin (IVIG)

Front 957

When else should prednisone be used for ITP?

Back 957

platelet counts less than 10,000/µL in the third trimester,

platelet counts less than 30,000/µL associated with bleeding or with preoperative or predelivery status

Front 958

Response to IVIG as early as

Back 958

6 hours

Front 959

for severe cases (platelet counts of less than 10,000/µL) that have failed treatment with antenatal corticosteroids and IVIG

Back 959

Splenectomy

Front 960

Platelet transfusions for ITP when?

Back 960

temporary measure to control life-threatening hemorrhage or

to prepare a patient for surgery.

Front 961

Will the usual increase in platelets of approximately 10,000/µL per unit of platelets transfused be achieved in patients with ITP?

Back 961

No.

because of the decreased survival of donor platelets

Front 962

How much of platelet concentrate should be transfused for ITP?

Back 962

6–10 U

Front 963

• What specialized care should women with ITP receive?

Back 963

serial assessment of the maternal platelet count

every trimester in asymptomatic women in remission and more frequently in thrombocytopenic individuals

Front 964

What instruction should ITP patients be given?

Back 964

avoid nonsteroidal antiinflammatory agents

salicylates

trauma

Front 965

Individuals with splenectomies should be immunized against

Back 965

pneumococcus

Hemophilus influenzae

meningococcus

Front 966

data to recommend maternal medical therapy for fetal indications?

Back 966

No

prednisone and IVIG will not help fetus

Front 967

problem with ITP for fetus

Back 967

maternal antibodies cross placenta
increased risk intracranial hemorrhage

Front 968

Has cesarean delivery been proven to prevent intracranial hemorrhage?

Back 968

No.

Front 969

mode of delivery in ITP should be:

Back 969

based on obstetric considerations alone

Front 970

• What tests or characteristics can be used to predict fetal thrombocytopenia in pregnancies complicated by ITP?

Back 970

None

Front 971

• Is there any role for fetal platelet count determination in ITP?

Back 971

determination of fetal platelet count is unwarranted for ITP

Front 972

What is the appropriate neonatal care for infants born of pregnancies complicated by ITP?

Back 972

delivery should be accomplished in a setting where an available clinician familiar with the disorder can treat any neonatal complications and have access to the medications needed for treatment.

Front 973

When platelet counts are less than _____/µL, epidural anesthesia should not be given.

Back 973

50,000

b/w 50,000 and 100.000 require a consensus among the obstetrician, anesthesiologist, and patient

Front 974

Neonatal alloimmune thrombocytopenia should be suspected in cases of

Back 974

otherwise unexplained fetal or neonatal thrombocytopenia, porencephaly, or intracranial hemorrhage (either in utero or after birth).

Front 975

Neonatal alloimmune thrombocytopenia laboratory diagnosis includes

Back 975

Platelet typing

Front 976

What is Platelet typing?

Back 976

determination of platelet type and zygosity of both parents and the confirmation of maternal antiplatelet antibodies with specificity for paternal (or fetal–neonatal) platelets and the incompatible antigen.

Front 977

Can CVS be performed for platelet typing serology?

Back 977

No

will enhance sensitization to antiplatelet antibodies

Front 978

• Is there any role for fetal platelet count determination in ITP?

Back 978

determination of fetal platelet count is unwarranted for ITP

Front 979

What is the appropriate neonatal care for infants born of pregnancies complicated by ITP?

Back 979

delivery should be accomplished in a setting where an available clinician familiar with the disorder can treat any neonatal complications and have access to the medications needed for treatment.

Front 980

When platelet counts are less than _____/µL, epidural anesthesia should not be given.

Back 980

50,000

b/w 50,000 and 100.000 require a consensus among the obstetrician, anesthesiologist, and patient

Front 981

Neonatal alloimmune thrombocytopenia should be suspected in cases of

Back 981

otherwise unexplained fetal or neonatal thrombocytopenia, porencephaly, or intracranial hemorrhage (either in utero or after birth).

Front 982

Neonatal alloimmune thrombocytopenia laboratory diagnosis includes

Back 982

Platelet typing

Front 983

What is Platelet typing?

Back 983

determination of platelet type and zygosity of both parents and the confirmation of maternal antiplatelet antibodies with specificity for paternal (or fetal–neonatal) platelets and the incompatible antigen.

Front 984

Can CVS be performed for platelet typing serology?

Back 984

No

will enhance sensitizization to antiplatelet antibodies

Front 985

• How can one determine the fetal platelet count in pregnancies complicated by neonatal allo-immune thrombocytopenia?

Back 985

the only accurate means of estimating the fetal platelet count is to sample the fetal blood directly, although this may increase the risk of fetal exsanguination.

Front 986

The primary goal of the obstetric management of pregnancies complicated by neonatal alloimmune thrombocytopenia is to prevent

Back 986

intracranial hemorrhage and its associated complications.

Front 987

In contrast to ITP, however, the higher frequency of intracranial hemorrhage associated with neonatal alloimmune thrombocytopenia justifies more aggressive interventions

Back 987

Hmmmm.

Front 988

How do ITP and FAIT differ for fetus in regards to ICH?

Back 988

FAIT has risk of in utero intracranial hemorrhage.

Front 989

appears to be the most consistently effective antepartum therapy for neonatal alloimmune thrombocytopenia

Back 989

Intravenous immune globulin administered to the mother

like Rhogam for Rh disease!

Front 990

Most investigators recommend determination of the fetal platelet count when?

Back 990

once fetal pulmonary maturity is achieved, but before the onset of labor

37 weeks of gestation

Front 991

• What is appropriate obstetric management for gestational thrombocytopenia?

Back 991

follow-up platelet counts only.

Front 992

Are pregnancies with gestational thrombocytopenia at risk for maternal bleeding complications or fetal thrombocytopenia?

Back 992

No

Front 993

• Is it necessary to treat thrombocytopenia associated with preeclampsia?

Back 993

primary treatment of maternal thrombocytopenia in the setting of preeclampsia or HELLP syndrome is delivery.

Front 994

many authorities recommend platelet transfusions to increase the platelet count to more than _____/µL before cesarean delivery

Back 994

50,000

Front 995

in preeclampsia or HELLP, Platelet counts often decrease for how long after birth, followed by a rapid recovery.

Back 995

24–48 hours

Most patients will achieve normal platelet counts within a few days to a week postpartum

Front 996

Although thrombocytopenia associated with PIH or HELLP syndrome may improve after treatment with _____, the clinical benefit of this therapy also is uncertain.

Back 996

steroids

Front 997

• How should a Du blood type be interpreted, and what management should be undertaken?

Back 997

considered Rh D positive and should not receive anti-D immune globulin.

Front 998

In the rare circumstance of delivery by a woman whose antenatal Rh status is negative or unknown and whose postpartum screen reveals a Du-positive or weak D-positive result,what should be done?

Back 998

anti-D immune globulin should be given, and the possibility of fetomaternal hemorrhage should be investigated

Front 999

• Is threatened abortion an indication for anti-D immune globulin prophylaxis?

Back 999

many physicians do not routinely administer anti-D immune globulin to women with threatened abortion and a live embryo or fetus up to 12 weeks of gestation.

Front 1000

• Should anti-D immune globulin be given in cases of molar pregnancy?

Back 1000

Yes

Front 1001

• Should anti-D immune globulin be given in cases of intrauterine fetal death occurring in the second or third trimester?

Back 1001

Yes

Front 1002

• Is second- or third-trimester antenatal hemorrhage an indication for anti-D immune globulin prophylaxis?

Back 1002

Yes

Front 1003

Management of the patient with persistent or intermittent antenatal bleeding is complex.

Back 1003

monitor the Rh D-negative patient with continuing antenatal hemorrhage with serial indirect Coombs testing approximately every 3 weeks.

Front 1004

If the result is positive, indicating the persistence of anti-D immune globulin, then what?

Back 1004

no additional treatment is necessary.

Front 1005

If the Coombs test is negative, then what?

Back 1005

excessive fetomaternal hemorrhage may have occurred, and a Kleihauer-Betke test should be performed in order to determine the amount of additional anti-D immune globulin necessary.

Front 1006

t 1/2 anti-D immune globulin?

Back 1006

24 days


although titers decrease over time.

Front 1007

• Is anti-D immune globulin prophylaxis indicated after abdominal trauma in susceptible pregnant women?

Back 1007

Yes

Also, all of these patients should be screened for excessive fetomaternal hemorrhage, in case extra dose is needed.

Front 1008

t 1/2 anti-D immune globulin?
t 1/2 anti-D immune globulin?
t 1/2 anti-D immune globulin?

Back 1008

24 days
24 days
24 days

Front 1009

If delivery occurs within how long after administration of the standard antenatal anti-D immune globulin administration, the postnatal dose may be withheld in the absence of excessive fetomaternal hemorrhage.

Back 1009

3 weeks

Front 1010

An excessive amount of fetal erythrocytes not covered by anti-D immune globulin administration can be assumed to have entered maternal blood if either the results of the Kleihauer-Betke test are positive or

Back 1010

the results of the indirect Coombs test are negative.

Front 1011

• Should administration of anti-D immune globulin be repeated in patients with a postdate pregnancy?

Back 1011

One study found that three patients became alloimmunized to the Rh D antigen when delivery occurred more than 12 weeks after the standard prophylaxis at 28 weeks of gestation

Because this recommendation is based on so few cases, the final decision whether to administer a second dose should be left to the physician's judgment.

Front 1012

• Should all Rh D-negative women be screened for excessive fetomaternal hemorrhage after delivery of an Rh D-positive infant?

Back 1012

American Association of Blood Banks has recommended that all Rh D-negative women who deliver Rh D-positive infants be screened using the Kleihauer-Betke or rosette test

Front 1013

Tubal Pregnancy

Absolute criteria for receiving Methotrexate

Back 1013

Hemodynamically stable without active bleeding or signs of hemoperitoneum
Nonlaparoscopic diagnosis
Patient desires future fertility
General anesthesia poses a significant risk
Patient is able to return for follow-up care
Patient has no contraindications to methotrexate

Front 1014

Relative indications for receiving Methotrexate for tubal pregnancies

Back 1014

Unruptured mass 3.5 cm at its greatest dimension
No fetal cardiac motion detected
Patients whose -hCG level does not exceed a predetermined value (6,000-15,000 mIU/mL)

Front 1015

Contraindications to Medical Therapy

Back 1015

Breastfeeding
Overt of laboratory evidence of immunodeficiency
Alcoholism, alcoholic liver disease, or other chronic liver disease
Preexisting blood dyscrasias, such as bone marrow hypoplasia, leukopenia, thrombocytopenia, or significant anemia
Known sensitivity to methotrexate
Active pulmonary disease
Peptic ulcer disease
Hepatic, renal, or hematologic dysfunction

Front 1016

Before methotrexate is injected, blood is drawn to determine

Back 1016

baseline laboratory values for renal, liver, and bone marrow function,

hCG level.

T&S

Front 1017

• What are the potential problems associated with medical management of ectopic pregnancy?

Back 1017

side effects
complications
failure

Front 1018

Side Effects Associated with Methotrexate Treatment

Back 1018

Nausea
Vomiting
Stomatitis

Severe neutropenia (rare)
thrombocytopenia

Pneumonitis

Front 1019

Treatment effects

Back 1019

Increase in abdominal pain (occurs in up to two thirds of patients)
Increase in -hCG levels during first 1-3 days of treatment
Vaginal bleeding or spotting
Signs of treatment failure and tubal rupture
Significantly worsening abdominal pain, regardless of change in -hCG levels Hemodynamic instability
Levels of -hCG that do not decline by at least 15% between day 4 and day 7 postinjection
Increasing or plateauing -hCG levels after the first week of treatment

Front 1020

During treatment, patients should be counseled to discontinue

Back 1020

avoid alcoholic beverages,

vitamins containing folic acid,

NSAIDS

sexual intercourse

Front 1021

Can tubal rupture may occur despite declining BHCG levels

Back 1021

yes

Front 1022

• How should patients be counseled about immediate and long-term effects of medical therapy?

Back 1022

Types of side effects they may experience
Activity restrictions during treatment.
Ongoing risk of tubal rupture during treatment
Educate patients about symptoms of tubal rupture and emphasize the need to seek immediate medical attention if these symptoms occur.

Front 1023

How is premature rupture of membranes diagnosed?

Back 1023

History and physical examination

Front 1024

SSE inspect for

Back 1024

cervicitis
umbilical cord
fetal prolapse,
assess cervical dilatation and effacement,
obtain cultures as appropriate

Front 1025

Nitrazine paper will turn blue with a pH above

Back 1025

6.0

Front 1026

Nitrazine false-positive results may occur in the presence of

Back 1026

blood or semen contamination,
alkaline antiseptics,
bacterial vaginosis.

Front 1027

Membrane rupture can be diagnosed unequivocally with

Back 1027

ultrasonographically guided transabdominal instillation of indigo carmine dye (1 mL in 9 mL sterile normal saline), followed by observation for passage of blue fluid from the vagina within 30 minutes of amniocentesis.

Front 1028

What factors should be considered in patients with term PROM?

Back 1028

Fetal presentation, gestational age, and status should be established

Risks of MATERNAL infection may increase with expectant management

Risk of cesarean delivery and risk of neonatal infectious complications do not appear to depend on the mode of management expectant versus induction

Front 1029

infection risk for expectant management is increased in whom?

Back 1029

The mother!

Front 1030

Management PPROM 32-36 weeks

Back 1030

assessment FLM

Front 1031

If pulmonary maturity has been documented after PROM at 32-36 weeks of gestation, what may be considered.

Back 1031

labor induction

Front 1032

The diagnosis of intra-amniotic infection may be suggested by an amniotic fluid glucose concentration of less than __ mg/dL, by a positive Gram stain, or a positive amniotic fluid culture

Back 1032

20

Don't forget IL-6 predictive of neonatal complications

Front 1033

• Should antenatal corticosteroids be administered to patients with preterm PROM?

Back 1033

corticosteroid use for women with PROM prior to 30-32 weeks of gestation

in the absence of intraamniotic infection

Front 1034

So if PPROM up to 32 weeks has evidence of chorio, should you wait to give steroids before induction?

Back 1034

No!

Front 1035

Significant perinatal benefit with a combination of ampicillin and erythromycin administered intravenously for the first 48 hours, followed by

Back 1035

oral amoxicillin and erythromycin for an additional 5 days if delivery did not occur.

Front 1036

Why shouldn't women with preterm PROM be managed at home?

Back 1036

latency is frequently brief

intrauterine and fetal infection may occur suddenly
the fetus is at risk for umbilical cord compression

Front 1037

• What is the optimal form of antepartum fetal surveillance for patients with preterm PROM managed expectantly?

Back 1037

No evidence exists that any specific form or frequency of fetal surveillance directly improves perinatal outcome.

can do NST daily or BPP daily

Front 1038

• What is the optimal management for a patient with preterm PROM and a cervical cerclage?

Back 1038

The optimal management of preterm PROM in the presence of a cerclage is yet to be determined.

Front 1039

Women presenting with PROM before presumed viability should be counseled regarding

Back 1039

the impact of immediate delivery and the potential risks and benefits of expectant management.

Front 1040

Counseling should include a

Back 1040

REALISTIC appraisal of neonatal outcomes

abstain from intercourse
limit their activities
monitor their temperatures

Front 1041

Compared with the FDA-approved regimen, the EBR regimen of mifepristone–misoprostol regimens using 200 mg of mifepristone orally and 800 µg of misoprostol vaginally are associated with

Back 1041

decreased rate of CONTINUING pregnancies,

decreased time to expulsion,

fewer side effects,

improved COMPLETE abortion rates,

and lower COST

Front 1042

use of prophylactic antibiotics for medical abortion?

Back 1042

No