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1042 Cards in this Set

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  • Back
  • 3rd side (hint)
The use of EFM
increased the overall cesarean delivery rate

The use of EFM increased the use of vacuum and forceps

did not reduce overall perinatal mortality
What % of cases of CP occur before the onset of labor
Decrease in FHR variability with betamethasone but not
Normal FHR _____ provides reassurance about fetal status.
scalp pH not very predictive
(single contraction lasting more than 2 minutes)
Any conditions in which the risks of emergency contraception use outweigh the benefits?
Women with previous ectopic pregnancy, cardiovascular disease, migraines, or liver disease and women who are breastfeeding may use emergency contraception.
women who are breastfeeding may use emergency contraception?
emergency contraception to women with undiagnosed genital bleeding?
Don't deny anyone emergency contraception.
• What screening procedures are needed before provision of emergency contraception?
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.
• When should emergency contraception be initiated?
up to 120 hours after intercourse
which is more effective for Emergency contraception - levonorgestrel or combined estrogen-progesterone?
The levonorgestrel-only regimen is preferred to the combined estrogen–progestin regimen,
PLAN B is Best TT
Are antiemetics useful as an adjunct to treatment with the levonorgestrel-only regimen?
not necessary
Are antiemetics useful as an adjunct to treatment with the combined regimen?
may be beneficial because the incidence of nausea
Antiemetic taken _____ before the first dose of emergency contraception has been shown to decrease the incidence or severity of nausea
1 hour
Emergency contrception dose should be repeated if vomiting occurs within ____ of taking a dose.
2 hours
If severe vomiting occurs, emergency contraception may be administered how?
Is emergency contraception safe if used repeatedly?
May be used even if the woman has used it before, even within the same menstrual cycle
What clinical follow-up is needed after use of emergency contraception?
No scheduled follow-up is required after use of emergency contraception
For what reasons should patient f/u after emergency contraception?
menstrual period is delayed by a week or more

persistent irregular bleeding

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

short term contraception
longterm contraception
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.
• How can access to emergency contraception be facilitated?
Providing an advance prescription or supply

prescribing it by phone without requiring an office visit
copper IUD for emergency contraception - pregnancy rate of
When is an intrauterine device appropriate for emergency contraception?
women who desire long-term contraception and who are otherwise appropriate candidates for IUD use.
copper IUD for emergency contraception most effective if inserted within ____ after unprotected intercourse
5 days
Emergency contraception progestin-only regimen, which consists of
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.
Emergency contraception combined estrogen–progestin regimen, which consists of
two doses—each containing 100 µg of ethinyl estradiol plus 0.50 mg of levonorgestrel—taken 12 hours apart.
Preliminary Classification Criteria for Antiphospholipid Syndrome in PREGNANCY
Criteria Definition

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
Preliminary Classification Criteria for Antiphospholipid Syndrome*
Criteria Definition
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
Preliminary Classification Criteria for Antiphospholipid Syndrome*
Criteria Definition

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 present in plasma, on TWO or more occasions at least 6 weeks apart.
*Definite antiphospholipid syndrome is considered to be present if at least one of the clinical criteria and one of the laboratory criteria are met.
How should antiphospholipid syndrome be managed during pregnancy and the postpartum period? Treatment of women with antiphospholipid syndrome without a thrombotic event
prophylactic heparin and aspirin

6–8 weeks of postpartum thromboprophylaxis

referred to an internist or hematologist
How should antiphospholipid syndrome be managed during pregnancy and the postpartum period? antiphospholipid syndrome who have had a thrombotic event
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
Should women with antiphospholipid syndrome have antepartum surveillance?
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
Are estrogen-containing oral contraceptives in women with well-characterized antiphospholipid syndrome okay?
Estrogen-containing oral contraceptives in women with well-characterized antiphospholipid syndrome should be avoided.
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

better than oral
Medical contraindications to abortion with mifepristone regimens include:
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.
Misoprostol contraindications:
uncontrolled seizure disorder
allergy or intolerance to misoprostol or other prostaglandins.
Asthma is not a contraindication because misoprostol is a weak bronchodilator.
• Do nonsteroidal antiinflammatory drugs affect the success rates for medical abortion?
• How should a patient be counseled about potential teratogenicity if a medical method fails to lead to abortion?
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.
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
3 years
• Normal Pap but HPV positive, what is the appropriate follow-up?
Repeat cytology and HPV test in 6–12 months

Colposcopy is not recommended as further testing after a single HPV-positive, Pap-negative result.
• ASCUS Pap, how should the patient be treated?
Immediate colposcopy
Triage to colposcopy by HPV DNA testing (except adolescents)
Repeat cytology tests at 6 and 12 months.
If HPV testing is elected, those women whose test results are HPV positive should
be referred for colposcopy.
Those women who test negative for HPV can be scheduled for
repeat cytology testing in 1 year.

HPV neg expires in 1 year
As an alternative to immediate colposcopy, adolescents with ASC HPV-positive test results may be monitored with
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.
follow-up of LSIL in adolescents.

think of ASC HPV+ = LSIL
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
Pap LSIL how should the patient be treated?
colposcopy is recommended for evaluation of LSIL, except in adolescents
Pap ASCUS-H, how should the patient be treated?
colposcopy is recommended for evaluation of ASCUS –H, or triage with HPV for >30yo
Follow-up of a colposcopy result of CIN 1 or normal

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

No excision necessary
• 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?
Repeat cervical cytology screening tests at 6 and 12 months or an HPV test at 12 months.
If the follow-up cytology result is ASC or higher-grade cytology or a positive HPV test, what should be done?
colposcopy should be repeated.
Pap HSIL, how should the patient be treated?
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.
Pap HSIL, what is an alternative to how this patient should be treated?
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.
• When the initial evaluation of an HSIL Pap result is Colpo CIN 1 or less, how should the patient be treated?
Review of the cytology/Pap and histology/Colpo results

If review is not undertaken or colposcopy results are not satisfactory, excision is recommended.
For HSIL Pap result is Colpo CIN 1 or less. Who is an exception to excision?
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.
• When the results of Pap AGC or AIS, how should the patient be treated?
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.”
The most common significant lesions associated with AGC are

At least half of AIS and adenocarcinoma results will be accompanied by squamous CIN.
Women with atypical endometrial cells and a normal endometrial sampling should undergo
colposcopy and endocervical sampling
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
abnormal bleeding, morbid obesity, oligomenorrhea, or clinical evaluation suggesting endometrial cancer.
• When the results of the initial evaluation of AGC reveal no neoplasia, how should the patient be treated if original pap was AGC-NOS?
repeat cytology testing and ECC FOUR times at 6-month intervals
Like squamous CIN, HPV is found in more than 95% of AIS and 90–100% of invasive adenocarcinomas of the cervix.

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.
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?
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.
• When should endocervical curettage be used in the colposcopic examination?
ECC should be performed if colposcopy results are unsatisfactory or if ablative treatment, such as cryotherapy or laser ablation, is contemplated
In women with ASC-H, HSIL, AGC, or AIS cytology results, ECC should be considered as part of the initial colposcopic evaluation, unless
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.
• How should CIN 1 be managed?
Younger women, observation provides the best balance between risk and benefit and should be encouraged
If observation of CIN I, then how should it be done
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.
• How should CIN 2 and CIN 3 be managed?
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
• Does management of CIN 2 or CIN 3 differ for women who are HIV positive?
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.
• Is excision or ablation the better treatment for CIN for avoiding stenosis?
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.
• How should AIS pap be managed? How should patients with AIS be monitored after treatment?
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
***Endocervical sampling immediately after conization has been reported to have better positive and negative predictive value for residual disease than cone margins.
IN AIS, if the margins of the cone specimen are involved, then what next?
conization should be repeated in AIS.
Why not immediate hysterectomy if margins positive for AIS?
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).
In AIS, if the margins of the cone specimen are not involved, risk of residual disease is still substantial. Therefore, what is recommended?
recommendation for hysterectomy when fertility is no longer desired.
When fertility is desired and cervical conization margins are clear,
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.
• How should a colposcopic biopsy with inconclusive results for early invasive cancer be managed?
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.
• 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?
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.
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.
This finding necessitates follow-up, including endocervical sampling until routine screening is reestablished, but it does not require reexcision.
Reexcision may be elected but should be undertaken with the knowledge that the most common outcome is
the absence of residual dysplasia.
By not re-excising and therefore sparing the endocervical mucosa from cautery after the excision does what?
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.
What is f/u after TREATMENT of CIN 2 or CIN 3?
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.
When is hysterectomy appropriate in women with CIN 2/3+?
may be considered for treatment of persistent or recurrent CIN 2 or CIN 3 or when a repeat excision is indicated but technically unfeasible.
What should always be done before a hysterectomy?
If excision is indicated, it should be performed (where possible) before hysterectomy to rule out invasive cancer.
colposcopic examination during pregnancy should have what as its primary goal
exclusion of invasive cancer.
During pregnancy
may undergo colposcopic evaluation either during pregnancy or at 6–12 weeks postpartum
During pregnancy
ASC-H, HSIL, AGC, or AIS test results should undergo colposcopy. Who should get a biopsy?
colposcopy without endocervical sampling, reserving biopsy for those with visible lesions consistent with CIN 3, AIS, or cancer.
During pregnancy
Why noy biopsy for CIN I impression? You could be wrong, so why take a chance and not biopsy?
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.
During pregnancy
Excisions should be considered for pregnant women only if a lesion detected at colposcopy is suggestive of
invasive cancer.
Those with unsatisfactory colposcopy results, and those with satisfactory colposcopy results who are not found to have invasive cancer, should be reevaluated with
colposcopy and cytology tests in each trimester until delivery.
• What elements of preoperative evaluation are useful for women with endometrial cancer?
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.
Are CT and MRI necessary?
No because the surgeon should be prepared to resect metastatic disease commonly found in patients with endometrial cancer.
Are preoperative measurement of the CA 125 level appropriate in endometrial CA?
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.
Exceptions to the need for endo CA surgical staging include
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
• What constitutes appropriate staging for women with endometrial cancer?
Systematic surgical staging, including pelvic washings, bilateral pelvic and paraaortic lymphadenectomy, and complete resection of all disease.

Sampling not enough.
• How are women with endometrial cancer treated postoperatively? Discuss radiation:
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.
In deciding whether to use radiation, the cost and toxicity should be balanced with the evidence that
the therapy does not improve survival or reduce distant metastasis.

routine lymphadenectomy by avoiding teletherapy and substituting brachytherapy .
• What are the recommendations for women found to have endometrial cancer after a hysterectomy?

options include
no further therapy and surveillance only,

reoperation to complete the surgical staging, or

radiotherapy to prevent local recurrence.
The advent of laparoscopic surgical restaging has resulted in less morbidity using this approach.
consult gyn onc
• What is the mode of therapy for patients with positive pelvic or paraaortic nodes?
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.
Women with paraaortic nodal disease should have the tumor completely resected and should have postoperative:
postoperative imaging studies (eg, chest computed tomography or positron emission tomography scans) to detect or exclude the presence of occult extraabdominal disease
The addition of paraaortic radiation is associated with
improved survival

benefit of concomitant or sequential systemic chemotherapy.
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.
carboplatin and paclitaxel
It is challenging to differentiate primary cervical adenocarcinoma from stage II endometrial cancer.
When the diagnosis is unclear, what should be done?
radical hysterectomy and lymphadenectomy can be performed, followed by tailored adjuvant therapy based on the pathologic findings.
Which is more predictive of survival; grade or depth of cervical invasion?
grade is more predictive of survival than depth of cervical invasion.
• Is there a role for radiotherapy as an alternative to surgery?
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
• Is there a role for progestin therapy in the treatment of atypical endometrial hyperplasia and endometrial cancer?
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.
For women who do not desire fertility, what is recommended for treatment of atypical endometrial hyperplasia?
because of the high risk of an underlying cancer.
Women who desire to maintain fertility, whether they have a diagnosis of atypical endometrial hyperplasia or grade 1 endometrioid adenocarcinoma, may be treated with
progestins in an attempt to reverse the lesion.
How can progesterone be given in these patients?
Oral, parenteral, or intrauterine device delivery of progestin has been successful, with response rates ranging from 58% to 100%.
Following progesterone therapy, patients should undergo serial complete intrauterine evaluation approximately every _____ to document response.
3 months

Progestin therapy may successfully reverse %50 of atypical endometrial hyperplasia as well as an early endometrial carcinoma; conception may then be attempted.
Beta-thalassemia is associated with elevated Hb F and elevated Hb A2 levels greater than what?
What testing can identify individuals with alpha thalassemia trait;
only molecular genetic testing can identify this condition.
When should alpha thal be tested for/considered?
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)
If both parents are determined to be carriers of a hemoglobinopathy, what is recommended next?
genetic counseling is recommended
It should be noted that ethnicity is not always a good predictor of risk because
individuals from at-risk groups may marry outside their ethnic group.
Preimplantation genetic diagnosis has been successfully performed for
sickle cell disease and most cases of Beta-thalassemia.
Women with Hb SS have increased risk for maternal complications, such as


antepartum hospitalization,

postpartum infection.
Hb SS are at higher risk for fetal complications, such as
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
Do sickle cell mothers need more folate?
1 mg per day of folic acid should be prescribed due to the continual turnover of red blood cells.
painful crisis.
precipitating by factors such as
cold environment, heavy physical exertion, dehydration, and stress should be avoided.
Painful crises in pregnancy should focus on detection of serious medical complications requiring specific therapy, such as
acute chest syndrome (fever tachypnea, chest pain, and hypoxia),
severe anemia,
cholecystitis, and
Goal of transfusion or prophylactic exchange transfusion for pregnancies complicated by sickle cell anemia?
Objective is to lower the percentage of Hb S to approximately 40%

while simultaneously raising the total hemoglobin concentration to about 10 g/dL.
• Is fetal surveillance useful in pregnancies complicated by sickle cell anemia?
serial ultrasound examinations and antepartum fetal testing is reasonable.
Beta-thalassemia minor usually causes
mild asymptomatic anemia.
Are large bladder capacities always pathologic
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
neurologic disease and other comorbid conditions.
No studies have determined whether the addition of multichannel cystometry or video assessment over simple filling cystometry improves diagnostic accuracy or outcomes after treatment.
When surgical treatment of stress incontinence is planned, urodynamic testing often is recommended to confirm the diagnosis, unless
the patient has an uncomplicated history and compatible physical findings of stress incontinence and has not had previous surgery for incontinence.
• When are urethral pressure profilometry and leak point pressure measurements useful for evaluation of incontinence?
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.
• When is cystoscopy useful for evaluation of incontinence?
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.
• Are pessaries and medical devices effective for the treatment of urinary incontinence?
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"
• Are behavior modifications (eg, bladder retraining, biofeedback, weight loss) effective for the treatment of urinary incontinence?
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.
• Are pelvic muscle exercises effective for the treatment of urinary incontinence?
effective treatment for adult women with stress and mixed incontinence,
Which is better, Kegels or cones or electrical stimulation?
Pelvic muscle exercise appears to be superior to electrical stimulation and vaginal cones in the treatment of stress incontinence.
The most typical side effect of anticholinergic therapy is
dry mouth
blurred vision
• Is there a role for bulking agents in the treatment of urinary incontinence?

How long are symptoms relieved after injections?
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.
When is surgery indicated for urinary incontinence?
when conservative treatments have failed to satisfactorily relieve the symptoms

the patient wishes further treatment in an effort to achieve continence.
Is retaining fertility potential is a contraindication for incontinence surgery?
which patients with urinary incontinence do NOT need urodynamic testing before surgery.
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.
Retropubic colposuspension procedures are indicated for women with the diagnosis of
urodynamic stress incontinence and a hypermobile proximal urethra and bladder neck.
Selection of a retropubic approach (versus a sling) depends on many factors, such as:
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.
Does hysterectomy add to the efficacy of Burch colposuspension in curing stress incontinence

Hysterectomy should be performed only for specific uterine pathology or for the treatment of uterine prolapse.
• For patients with both prolapse and urinary incontinence, what surgical procedures are appropriate?
If the prolapse is to be repaired abdominally
sacral colpopexy, a retropubic colposuspension may be appropriate.
For patients with both prolapse and urinary incontinence, what surgical procedures are appropriate? If transvaginal approach
may include a sling placed at the time of repair to treat stress incontinence.
Women who have severe pelvic organ prolapse but “potential stress incontinence” present a unique challenge.
After hysterectomy and support of vaginal apex,
Suburethral plication of the bladder neck to stabilize a hypermobile urethra is probably appropriate in many cases
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
every 3 years.

HPV neg expires in 1 year
Why test HPV only in women > age 30?
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.
Does HPV penetrate condoms?
Particles the size of HPV virions do not penetrate an intact latex condom
warts on moist or mucosal surfaces are more responsive to topical treatment than are warts on
drier surfaces
When should warts be reevaluated after treatment?
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.
The mechanism of action includes

damage to vessels within the wart

stimulation of macrophage proliferation

production of interleukin-1 and interleukin-2.
podophyllin is applied
BID for 3 consecutive days followed by 4 days of no therapy

4 cycles

leave on 8 hours
The total area of warts that should be treated with podophyllin should be limited to
10 cm2
Imiquimod MOA
ACTIVATES macrophages

imiquimod treatment area should be limited to no more than
20 cm2.
which is more effective, Podophyllin or Imiquimod?

Can they be used inside vagina?
no single treatment for external genital warts can be recommended over another.

Not for use inside vagina/anus.
When should provider-applied medication or procedures for genital warts be considered?
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
Cryotherapy is effective for
both dry and moist warts;
Drawback of cryo for warts
when treating large warts or large areas, wound care problems can occasionally be encountered.
Trichloroacetic acid and bichloracetic acid more appropriate for which characteristic of warts
small warts on moist surfaces.
Trichloroacetic acid and bichloracetic acid in concentrations of 80–90%
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.
Surgical removal of external genital warts may be advantageous because
the patient often is cured in one visit.
Surgical removal is probably most appropriate when .
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
Laser ablation requires specialized training and equipment and generally is reserved for
extensive and recalcitrant disease.
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
3 weeks.

Laser ablation drawback
Vitiligo and hyperpigmentation are possible

scarring is a potential complication of laser vaporization that is very extensive or too deep.
. Rarely, infants exposed to HPV may develop warty growths in the throat called laryngeal papillomatosis.

Is CD useful in preventing the transmission of HPV?
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.
twice weekly
Contraindications to Intrauterine Device Use
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)
If a patient had PID or POSTABORTAL/POSTPARTUM SEPSIS, how long must she wait until IUD can be inserted?
3 months
IUD Uterine perforation, the most concerning complication, is estimated to occur in approximately how many per 1000 insertions?
1 in 1,000 insertions.
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
IUD should be removed by laparoscopy or laparotomy.
when removing IUDs is the lack of visible strings, what may be helpful in the office?
If the cytobrush maneuver is not helpful, what should be done?
ultrasonography should be performed to ensure intrauterine location of the IUD.
What next if can't get with cyto brush and IUD is intrauterine confirmed by u/s?
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.
• Is routine screening for STDs (eg, gonorrhea and chlamydia) required before insertion of an IUD?
women at high risk of STDs may benefit from screening.
number of new cases in a period of time

NEW POrT (period of time)
If GC/Chl cultures are not done before IUD placement, and pt later found to have chlamydia infection, should IUD be pulled?
Clinical judgment should be used to determine whether the IUD should be removed

look for purulent discharge
abdominal pain
incidental finding
multiple partners
• Is the presence of bacterial vaginosis a contraindication to IUD insertion?
Does antibiotic prophylaxis before IUD insertion decrease the risk of subsequent pelvic infection?
unlikely to be cost-effective in populations with a low prevalence of STDs.
SBE px for IUD insertion or removal needed?
Not recommended for insertion or removal.
asymptomatic patient with an IUD who has actinomyces identified on a Pap test:
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.

history of ectopic pregnancy considered a contraindication to IUD use?
Pregnancy with IUD. What to do:
FDA recommends that IUDs be removed from pregnant women when possible without an invasive procedure.
Do most women continue to ovulate while using the levonorgestrel intrauterine system?
Which intrauterine system resulted in a substantial reduction in menstrual blood loss
The levonorgestrel intrauterine system

may be an acceptable alternative to hysterectomy in women with menorrhagia.
When should an IUD be removed in a menopausal woman?
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.
in the perimenopausal period, unexpected bleeding in women with an IUD should prompt
an endometrial biopsy evaluate the possibility of endometrial pathology.
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.
The copper T380A
Ultrasonography should be performed only when there is a valid medical indication, and the lowest possible ultrasonic exposure setting should be
as low as reasonably achievable (ALARA) principle.
Is a physician is not obligated to perform ultrasonography in a patient who is at low risk and has no indications?
However, if a patient requests ultrasonography, it is reasonable to honor the request. The decision ultimately rests with the physician and patient jointly
• What gestational age represents the optimal time for an obstetric ultrasound examination?
16–20 weeks
fetus found to have IUGR. What should one look for?
detailed ultrasound survey for the presence of fetal structural and functional defects may be indicated.
is an important diagnostic and prognostic parameter in fetuses with IUGR.
Amniotic fluid volume
is highly suggestive of growth failure and indicates an increased risk of fetal death.

the absence of oligohydramnios should not diminish the importance of the diagnosis of IUGR.
In pregnancies at risk for IUGR. Doppler velocimetry has been shown to both
reduce interventions
and improve fetal outcome
Identification of IUGR is improved by
recording growth velocity or through 2 sets of examinations generally 2–4 weeks apart.
Macrosomia implies growth
beyond a specific weight, usually 4,000 g or 4,500 g,

regardless of gestational age.
is the test of choice in the diagnosis of herpes-related infections of the central nervous system (meningitis and encephalitis.
More sensitive than viral culture for diagnosis of herpes
The problem with viral culture for dx herpes
not sensitive
The incubation period for HSV is
short (approximately 4 days),
Antibodies to HSV-2 are detected how long after acquisition of infection and persist indefinitely.
2–12 weeks
• Is there a role for testing an asymptomatic patient who reports possible exposure?
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
• Is there a role for postexposure prophylaxis in an asymptomatic patient?
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).
Acyclovir MOA
interrupt viral DNA synthesis
Acyclovir is not activated unless
HSV is actively replicating.
Suppressive therapy (in which the medication is taken daily) for genital herpes prevents approximately ___% of recurrences.

who gets suppression?

recurrences >6 times/year
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?
Women in whom a first episode genital HSV infection is diagnosed should be told
they are likely to have recurrences and that these will be milder than the first episode
Do they still shed even if don't have HSV symptoms?

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

May shed for 7 days
Women who have partners with genital herpes should be .
tested with type-specific serology to assess the woman's risk of infection
If the partners have discordant HSV types, the couple should be counseled about
consistent use of condoms or dental dams, although condoms do not offer total protection from acquisition of HSV-2 infection.
, use of suppressive antiviral therapy in the potential source partner has been shown to decrease transmission of HSV-2 by ___%to susceptible partners
What is strongly predictive of preterm delivery in twin pregnancies.
shortened cervix identified by endovaginal ultrasonography
How do digital exams compare to u/s of cervical length?
digital examination may be less objective than ultrasonographic measurement and does not allow assessment of the internal os.
Has FFN been studied with multiple gestations?
Px cerclage in twins?
does not prolong gestation or improve perinatal outcome
tocolytics in multiples...
should be used judiciously.
Steroids in multiples?
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.
How is the death of one fetus managed?
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.
The most difficult cases are those in which the fetal demise occurs in 1 fetus of a monochorionic twin pair.
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.
How to manage fetal demise of 1 twin?
Fibrinogen and fibrin degradation product levels can be monitored serially until delivery, and delivery can be expedited if DIC develops.
• Is there a role for routine antepartum twin fetal surveillance?
Multiple gestations are at increased risk of stillbirth.
Twin–Twin Transfusion Syndrome A variety of therapies have been attempted, but what is most frequently used?
serial therapeutic amniocenteses of the recipient twin's amniotic sac
More aggressive therapies, include abolishing the placental anastomoses by endoscopic laser coagulation or selective feticide by umbilical cord occlusion usually are considered only for
very early, severe cases,
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?
immediate delivery should be considered, recognizing that damage to the remaining viable fetus may already have occurred.
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.
The nadir of perinatal mortality for twin pregnancies occurs at approximately ___ completed weeks of gestation
• For a postterm patient with a favorable cervix, does the evidence support labor induction or expectant management?
generally is induced in postterm pregnancies in which the cervix is favorable because the risk of failed induction and subsequent cesarean delivery is low.
• For a postterm patient with an unfavorable cervix, what are options of management?
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
Prostaglandin (PG) is a valuable tool for improving cervical ripeness and inducing labor.
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?
For women with 2 prior cesarean deliveries, only those with what should be considered candidates for a spontaneous trial of labor.
a prior vaginal delivery
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.
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
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.
• What are contraindications for VBAC?
• 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
Does epidural analgesia masks the signs and symptoms of uterine rupture?
Rarely. So, no.
internal better than external monitoring for TOLAC?
No data suggest monitoring with intrauterine pressure catheters is superior to external monitoring
Should scar dehiscences after SVD that are stable be repaired?
***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
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
If the scar includes the upper segment of the uterus, the repeat rupture rate is
How are patients with hydatidiform moles managed?
• 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
Medical complications of hydatidiform moles



pregnancy-induced hypertension, and

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?
as soon as possible after stabilization of any medical complications
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:
an intensive care unit, a blood bank, and anesthesia services.
After serial dilation of the cervix, uterine evacuation is accomplished with what size cannula?
the largest cannula that can be introduced through the cervix.
What should you have in the OR to assist with suction D&C of mole?
ultrasound guidance may facilitate complete evacuation of the uterus.
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.
the syndrome of trophoblastic embolization (deportation)
in moles, respiratory distress syndrome can be caused by
high-output congestive heart failure caused by
iatrogenic fluid overload
Generally, these respiratory complications should be treated aggressively with
therapy directed by central venous or Swan-Ganz catheter monitoring and assisted ventilatory support, as required.
Surgical intervention for molar pregnancy should be reserved for
rupture or torsion, which is rare
an alternative to suction D&C for molar evacuation in selected patients who do not wish to preserve childbearing.
Hysterectomy with preservation of the adnexa

reduces the risk of malignant postmolar sequelae when compared with evacuation by D&C.
Ideally, serum hCG levels should be obtained within how long after evacuation,
48 hours

every 1–2 weeks while elevated, and then at monthly intervals for an additional 6 months.
What are performed while hCG values are elevated, and why?
Frequent pelvic examinations

to monitor the involution of pelvic structures and to aid in the early identification of vaginal metastases.
Compared with singleton hydatidiform moles, do twin pregnancies with a fetus and a mole carry an increased risk for postmolar gestational trophoblastic disease?
And with a higher proportion of patients having metastatic disease and requiring multiagent chemotherapy.
with co-existing hydatidiform moles and fetuses suspected on the basis of ultrasound findings,
ultrasound examination should be repeated to exclude:
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.
If the diagnosis is still suspected and continuation of the pregnancy is desired, what should be done?
fetal karyotype
chest X-ray
serial serum hCG values monitored.
• 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?
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.
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?
the patient should be treated with multiagent regimens
• How is low-risk metastatic gestational trophoblastic disease treated?
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.
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?
Management of cerebral metastases is controversial.
Brain irradiation combined with systemic chemotherapy
After hCG remission has been achieved, patients with malignant gestational trophoblastic disease should undergo serial determinations of hCG levels at
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.
may be considered as a last resort in patients who will require enteral or parenteral nutrition because of weight loss.
Common laboratory abnormalities in hyperemesis gravidarum include:
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.
Patients with persistent hyperemesis gravidarum that is unresponsive to standard therapy may have what abnormality?

treatment with antibiotics and H2 receptor antagonists
• When is enteral or parenteral nutrition recommended?
persistent weight loss.

cannot maintain their weight despite antiemetic therapy
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.
Because life-threatening complications of parenteral nutrition have been described, it is reasonable to attempt what type of feeding initially?
enteral tube feeding initially
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.
Peripheral parenteral nutrition
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?
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.
Gonadotropin-releasing hormone agonists MOA
"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
In addition to endometriosis GnRH agonists may be used to treat pelvic pain associated with
ovarian retention syndrome (residual ovary syndrome) and ovarian remnant syndrome.
effective in the treatment of chronic pelvic pain associated with endometriosis and pelvic congestion syndrome.

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

PROVERA = PELVIC congestion Sydrome
effectively decreases pain from endometriosis and pelvic congestion syndrome in most studies.

Medroxyprogesterone acetate (Provera), 30–100 mg per day
Surgical resection of this plexus is sometimes useful for central dysmenorrhea unresponsive to other treatments.
superior hypogastric plexus (presacral nerve)

actually found in Lumbar region
provides additional pain relief mostly of midline pain associated with menses, with little additional effect on dyspareunia and nonmenstrual pain.
presacral neurectomy
Uterine nerve ablation is less effective for the treatment of primary dysmenorrhea than what procedure?
presacral neurectomy.
useful for central dysmenorrhea unresponsive to other treatments.
presacral neurectomy
besides Dexa, other modalities to measure BMD:
Quantitative Ultrasonography
“Achilles Express Ultrasonometer” - low cost and lack of ionizing radiation. predict hip fractures

Peripheral Quantitative CT
Meds not to forget to counsel to avoid when assessing fall risk
Medications that reduce strength and balance (such as sedatives, narcotic analgesics, anticholinergics/dizzy and dry, and antihypertensives) should be avoided, if possible.
Has Hip fracture reduction has been demonstrated in raloxifene?
This SERM has androgenic and progestogenic properties and has demonstrated efficacy in the prevention of postmenopausal bone loss.

investigational, still.
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.
Salmon calcitonin

reducing bone turnover
Recommended Daily Elemental
Calcium Requirements
National Institutes of Health
Premenopausal women aged 25–50 years:
1,000 mg
Postmenopausal women younger than 65 years using estrogen therapy:
1,000 mg
Postmenopausal women not using estrogen therapy:
1,500 mg
All women older than age 65 years:
1,500 mg
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.
Daily subcutaneous injections of recombinant human PTH
The recommendations for these supplements apply to what type of calcium?
Clinical pelvimetry can be useful to
qualitatively identify the general architectural features of the pelvis and identify patients at risk for dystocia.
Active management of labor is confined to
nulliparous women with singleton, cephalic presentations at term that show no evidence of fetal compromise.
• Should women with twin gestations undergo augmentation of labor?
Twin gestation is not a contraindication to augmentation of labor, but it does warrant special attention.
elective cerclage for purely historical factors generally should be confined to patients with
3 or more otherwise unexplained second-trimester pregnancy losses or preterm deliveries.
Urgent, or therapeutic, cerclage often is recommended for women who
have ultrasonographic changes consistent with a short cervix or the presence of funneling.
If transvaginal ultrasonography before 16–20 weeks of gestation identifies a short cervix, what should be done?
the examination should be repeated because of the inability to adequately distinguish the cervix from the lower uterine segment in early pregnancy.
Identification of a short cervix at or after 20 weeks of gestation should prompt assessment of
1) the fetus for anomalies,

2) uterine activity to rule out preterm labor, and

3) maternal factors to rule out chorioamnionitis.
If cervical shortening or funneling is detected, the appropriate management is?
remains unclear, and the decision to proceed with urgent cerclage should be made with caution.
A woman with advanced cervical effacement or dilatation or both should be counseled about
the paucity of data to support the efficacy of emergency cerclage,

as well as the potential associated maternal and neonatal morbidity.
emergency cerclage may be considered in such women in the absence of
clinical chorioamnionitis

or labor.
The role of cerclage in the treatment of patients with cervical insufficiency after fetal viability has not been adequately assessed.
• 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)?
The evidence-based risk-benefit ratio does not support first-trimester cerclage, even with transabdominal procedures.
Transabdominal cerclage placed how?
tunneled between the bifurcation of the uterine artery,
• Should perioperative antibiotics and tocolytics be used in association with cerclage placement?
What is the purpose of antibiotic prophylaxis appropriate for patients undergoing cesarean delivery?
febrile morbidity,

urinary tract infection,

wound infection

are reduced by antibiotic prophylaxis
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
among those with a narrower spectrum.
Single-dose therapy, usually given when the umbilical cord is clamped, has been shown to be as efficacious as
multidose therapy
prevention of bacterial endocarditis dose
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.
In patients who are allergic to penicillin for SBE px
vancomycin (1 g IV over 1–2 hours) should be substituted for ampicillin.
Is antibiotic prophylaxis appropriate for patients undergoing manual removal of the placenta?
no data exist to either support or refute this practice.
Failure rates of tubal sterilization are roughly comparable with those of the
5-year cumulative failure rate for the copper T 380-A IUD of ___ per 1,000 procedures.
5-year cumulative pregnancy rate for levonorgestrel-releasing IUDs ranges between ___ per 1,000 procedures.
______ had the highest cumulative probability of ectopic pregnancy (17.1/1,000), and _______ had the lowest cumulative probability (1.5/1,000).
Bipolar coagulation
postpartum partial salpingectomy
Bipolar coagulation had a cumulative probability ____ times higher than unipolar coagulation
the only method reported by the CREST study that did not have a higher 10-year cumulative probability of ectopic pregnancy in younger women
Postpartum partial salpingectomy was
Perforation rates vary based on the type of IUD, less than ____ in 1,000 insertions generally is recognized.
Annual cytology screening should be recommended for women younger than
30 years
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
2–3 years.
Women with any of the following risk factors may require more frequent cervical cytology screening:
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
Human papillomavirus infections are commonly acquired by young women, but, most cleared by the immune system within how much time without producing neoplastic changes?
1–2 years
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
1 year.
women in both of these categories should continue to have routine cervical cytology examinations no matter what age (past 70)
An older woman who is sexually active and has had multiple partners

woman with a previous history of abnormal cytology
Women who have had a total hysterectomy and have no prior history of ____ may discontinue screening.
HIGH-grade CIN
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
three consecutive satisfactory negative cervical cytology results are obtained. Routine screening may then be discontinued.
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.
• How do the various methods of cervical cytology compare in terms of effectiveness?
liquid-based thin-layer cervical cytology appears to have increased sensitivity for detecting cancer precursor lesions over the conventional method
• Is the recommended frequency of screening affected by the method of screening?
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.
SurePath technique may be marketed as equivalent to the ______ Pap test.
Why is it has been suggested that HPV DNA testing might be a more selective test in older women (>30)?
Because HPV is more prevalent in younger women and the rate of CIN 2 and CIN 3 increases with age,
Another clinical setting in which HPV DNA testing may be useful is .
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
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
every 3 years.

use of this approach is only for the panel of high-risk HPV types.
the combination of cytology and HPV DNA screening should be restricted to women aged 30 years and older because
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.
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.
There have been concerns that supplemental folic acid could mask the symptoms of ________ and thus delay treatment.
pernicious anemia

However, folic acid cannot mask the neuropathy typical of this diagnosis.
women taking what medication may have lower serum drug levels and experience an associated increase in sequelas frequency while taking folic acid supplements.
seizure meds

more seizures while taking folate
Increased seizures while taking folate:

What may help to avert this complication.
Monitoring drug levels and increasing the dosage as needed
Dilantin MOA
inhibits Na dependent channels
vitamin A is potentially teratogenic at high doses, and pregnant women should not take more than ____IU per day
5,000 IU
• Which NTDs may not be affected by increased folic acid supplemenation?

high first-trimester blood glucose levels

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

in women who take valproic acid.
In women with high glucose levels, the exact mechanism of NTD is unknown but may involve
inhibition of fetal glycolysis,

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

alterations in the yolk sac.
MSAFP screen-positive cutoff is set at
2.5 multiples of the median (MoM)
Don't forget false elevations of MSAFP due to
fetal demise
Placental abnormalities - chorioangioma/accreta/mole
Which women can forgo the MSAFP and be offered a diagnostic test directly?
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,
considered diagnostic for a fetal NTD.
Elevated amniotic fluid AFP together with the presence of acetylcholinesterase is
In the hands of experienced operators, ultrasonography alone has up to ___%sensitivity and ___% specificity in the diagnosis of NTDs

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.
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
Individuals with an NTD are at risk of developing a severe, potentially life-threatening allergy to what?
latex, clinicians handling the infant should wear wear latex-free gloves.
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
a ventriculo-peritoneal shunt can be placed
For the breech fetus with an NTD, what mode of delivery is standard.
cesarean delivery
fetal fibronectin testing, their clinical usefulness
negative predictive value
Beta-mimetics are a potent cardiovascular stimulants and can cause serious complications, such as
maternal myocardial ischemia,
fetal cardiac effects
Should women with preterm contractions without cervical change be treated?

(re infection)

If ctxing due to infection, will be at even more risk of pulmonary edema if give tocolytics.
Should women with multiple gestations be treated for preterm contractions?
Women with multiple gestations who have preterm contractions but no cervical change do not require tocolytic therapy
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.
pulmonary edema
Is there a role for amniocentesis in diagnosing chorio?
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.
BRCA1 or BRCA2 carriers, the Cancer Genetics Studies Consortium has offered Level-III provisional Breast Cancer screening recommendations of :
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.
If a cyst is aspirated and the fluid is _____ there is no need for cytology.
clear (transparent and not bloody),
If the cyst does not disappear after aspiration or recurs within ____, surgical follow-up should be considered.
6 weeks
• Who should be referred for genetic counseling?
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.
• Who should be screened for nonclassical congenital adrenal hyperplasia, and how should screening be performed?
adult women with anovulation and hirsutism

17-OHP levels
To screen for nonclassical congenital adrenal hyperplasia caused by CYP21 mutations
fasting level of 17-hydroxyprogesterone
High levels of 17-hydroxy-progesterone should prompt what test.
adrenocorticotropic hormone stimulation
• Does PCOS increase the risk of developing type 2 diabetes?
Does the American Diabetes Association recommend screening for insulin resistance with measures of insulin or other markers of the insulin resistance syndrome.
However, it may be useful to screen selected women with PCOS for hyperinsulinemia—for example, those with
severe hyperandrogenism and acanthosis nigricans
younger women,
or those undergoing ovulation induction.
Fasting glucose levels are poor predictors of glucose intolerance risk in women with
Women with PCOS should be screened for type 2 diabetes and impaired glucose tolerance with
a fasting glucose level followed by a 2-hour glucose level after a 75-g glucose load.
Two modalities that significantly reduce the risk of developing diabetes in women with impaired glucose tolerance
lifestyle interventions

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

due obesity and impaired glucose tolerance
All women with PCOS should be screened for cardiovascular risk by determination of

waist–hip ratio

measurement of fasting lipid and lipoprotein levels (total cholesterol, HDL cholesterol, and triglycerides).
• In a woman with PCOS who is not attempting to conceive, what is the best medical maintenance therapy to treat anovulation and amenorrhea?
Combination Oral Contraceptives

monophasic OCPs are associated with a significant reduction in the risk for endometrial cancer
Medical treatment for PCOS
Insulin sensitizers - inhibits liver gluconeogenesis
What do insulin sensitizers do?
improve peripheral insulin sensitivity by decreasing circulating insulin levels
improving insulin sensitivity (metformin) is associated with
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.
Metformin also may be associated with weight loss
biguanides bisect weight!
Up to ___% of women with PCOS will ovulate in response to clomiphene treatment, and ___% of these women will conceive.

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
a ventriculo-peritoneal shunt can be placed
For the breech fetus with an NTD, what mode of delivery is standard.
cesarean delivery
fetal fibronectin testing, their clinical usefulness
negative predictive value
Beta-mimetics are a potent cardiovascular stimulants and can cause serious complications, such as
maternal myocardial ischemia,
fetal cardiac effects
Should women with preterm contractions without cervical change be treated?

If ctxing due to infection, will be at even more risk of pulmonary edema if give tocolytics.
Should women with multiple gestations be treated for preterm contractions?
Women with multiple gestations who have preterm contractions but no cervical change do not require tocolytic therapy
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.
pulmonary edema
Is there a role for amniocentesis in diagnosing chorio?
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.
BRCA1 or BRCA2 carriers, the Cancer Genetics Studies Consortium has offered Level-III provisional Breast Cancer screening recommendations of :
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.
If a cyst is aspirated and the fluid is _____ there is no need for cytology.
clear (transparent and not bloody),
Alternative clomiphene regimens for PCO have been developed, including:
prolonging the period of administration and

adding dexamethasone
Dexamethasone as adjunctive therapy with clomiphene citrate has been shown to increase ovulation rates in women with PCOS with
higher DHEAS levels >2000 ng/mL

Dex for patients with deux thousand DHEAS!
Dex for patients with deux thousand DHEAS!
Dex for patients with deux thousand DHEAS!
frequently are used to induce ovulation in women with PCOS for whom clomiphene treatment has failed.
Cycle cancellation means
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
• In women with PCOS who are attempting to conceive, which methods of ovulation induction are effective?
weight loss/exercise
clomid with Dex
Ovarian drilling - reduces androgens
Metformin 1,500 mg per day
Thiazolidinediones - hepatotoxicity
This outcome is reduced in those women who conceive after laparoscopic drilling
Multiple pregnancy rates
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.
Metformin carries a small risk of
lactic acidosis

contraindicated in renal/liver disease
thought to improve insulin sensitivity through a postreceptor mechanism

troglitazone - liver toxicity
Flutamide most common side effect is
dry skin,
Flutamide MOA
androgen-receptor antagonist,

nonsteroidal antiandrogen effective against hirsutism
Finasteride MOA
inhibits both forms of the enzyme 5-alpha reductase

Finasteride is better tolerated than other antiandrogens
Eflornithine MOA
inhibits ornithine decarboxylase

topical eflornithine -approved by the FDA for treating hirsutism.
• Do labor abnormalities predict shoulder dystocia?
McRoberts maneuver
hyperflexion and abduction of the hips causing cephalad rotation of the symphysis pubis and flattening of the lumbar lordosis that frees the impacted shoulder.
Suprapubic pressure may be used AT THE SAME TIME to assist in dislodging the impacted shoulder.
• How should a woman with a history of delivery complicated by shoulder dystocia be counseled regarding subsequent deliveries?
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.
Who are appropriate candidates for Tamoxifen?
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
Raloxifene is approved by the FDA for
prevention AND treatment of osteoporosis.
is appropriate for the prevention and treatment of osteoporosis in women who have a family history of breast or endometrial cancer.
Raloxifene is contraindicated in
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.
• Is raloxifene appropriate for breast cancer patients who have completed a 5-year course of tamoxifen?
No studies have investigated the use of raloxifene after a 5-year course of tamoxifen
In premenopausal women, tamoxifen may cause decreases in bone mineral density for ___ years after initiation of therapy, which stabilizes after this period.

, tamoxifen has not been evaluated prospectively in women with osteoporosis, and its effects in the bone remain to be established.
With this SERM, many patients experience vaginal dryness.
• In patients using SERMs, are there beneficial effects on vaginal dryness and hot flashes with the addition of estrogen?
No published trials have studied the combination of systemic estrogen and SERMs to reduce vasomotor symptoms.
• In patients using SERMs, are there benefits with the addition of bisphosphonates?
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.
An increased risk of what specific type of cancer has been observed in women taking tamoxifen
uterine sarcoma
. Factors That Increase the Relative Risk for Breast Cancer in Women
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
• How long should patients take raloxifene?
The use of raloxifene for osteoporosis prevention is not time-limited.
tamoxifen use for _____ is currently recommended.
5 years
extremely preterm or extremely LBW infants

major morbidities influencing later development in these children include
chronic lung disease,

severe brain injury
(intraventricular hemorrhage and periventricular leukomalacia),

nosocomial infections,

retinopathy of prematurity.
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).

In a pregnant patient suspected of being hyperthyroid or hypothyroid, what should be measured.
TSH and FT4 or FTI
Measurement of FT3 usually is only pursued in patients with
thyrotoxicosis with suppressed TSH but normal FT4 measurements.
Propylthiouracil MOA
reduces the peripheral conversion of T4 to T3 and, thus, may have a quicker suppressant effect than methimazole.

Therefore, give PTU for thyrotoicosis
has been associated with PTU/Methimazole treatment for Graves' disease, presumably caused by drug-induced fetal hypothyroidism.
Fetal goiter
secondary to maternal antibodies, this affect on the fetus is usually due to Maternal graves
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.
Can Women taking PTU/Methimazole breastfeed?
once treatment has started, it may be helpful to measure FT4 or FTI every
2–4 weeks
One side effect of thioamides (PTU/methimazole) is

incidence of agranulocytosis is 0.1–0.4%;
The incidence of agranulocytosis is 0.1–0.4%; it usually presents with
a fever and sore throat.
THioAmides side effects=
This treatment should be reserved for women in whom thioamide treatment is unsuccessful.
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.
4 months
. If the woman was at less than ____weeks of gestation when exposed to I-131, it is unlikely the fetal thyroid was ablated.
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.
congenital hypothyroidism
Breastfeeding should be avoided for at least _____after treatment with I-131.
4 months
levothyroxine therapy should be adjusted at ______ intervals until TSH levels are stable.
In STABLE patients, it is prudent to check TSH levels how often in pregnant women with hypothyroidism.
every trimester
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
sxs predate pregnancy
sxs continue past 20 weeks
TSIg present
Thyroid storm is a medical emergency characterized by
an extreme hypermetabolic state.
Thyroid storm has a high risk of
maternal heart failure.
Thyroid storm is diagnosed by a combination of the following signs and symptoms:

tachycardia out of proportion to the fever

changed mental status

including restlessness, nervousness, confusion


cardiac arrhythmia.
consequences of untreated thyroid storm, which include
shock, stupor, and coma.
If thyroid storm is suspected
serum FT4, FT3, and TSH levels should be evaluated to help confirm the diagnosis,

therapy should not be withheld pending the results.
MOA Propylthiouracil or methimazole
blocks additional synthesis of thyroid hormone, and PTU also inhibits peripheral conversion of T4 to T3.
MOA potassium iodide and sodium iodide
block the release of thyroid hormone from the gland.
MOA Dexamethasone
decreases thyroid hormone release and peripheral conversion of T4 to T3
MOA propranolol
inhibits the adrenergic effects of excessive thyroid hormone.
MOA phenobarbital in thryroid storm treatment
can be used to reduce extreme agitation or restlessness and may increase the catabolism of thyroid hormone.
thermoregulation during thyroid storm consists of
use of antipyretics,

use of a cooling blanket,
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?
invasive central monitoring and
continuous maternal cardiac monitoring in an intensive care setting may be indicated.
Often in thyroid storm,there is an identified inciting event such as
infection, surgery, labor, or delivery.
Should the baby be delivered in thyroid storm?
it is prudent to avoid delivery in the presence of thyroid storm unless fetal indications for delivery outweigh the risks to the woman.
. If oral administration is not possible, use methimazole in what form?
rectal suppositories.
in thyroid cancer during pregnancy, can/should thyroidectomy be performed? when?

Radiation should be deferred until after pregnancy.
preferably in the second trimester
Can the pt be treated with radiation for thyroid cancer during pregnancy?
Radiation should be deferred until after pregnancy.
After radiation therapy for thyroid cancer in pregnancy, when can the mother breastfeed?
Breastfeeding should be avoided for at least 4 months after I-131 treatment.
The diagnosis of postpartum thyroiditis is made by
documenting new-onset abnormal levels of TSH or FT4 or both.
may be useful to confirm the diagnosis of postpartum thyroiditis
anti-microsomal or

antithyroid peroxidase antibodies
Which patients should have their TSH and FT4 levels evaluated for possible postpartum thyroiditis:
goiter in pregnancy or postpartum

postpartum hypothyroid or hyperthyroid symptoms

excessive fatigue,

weight gain,

dry skin/dry hair,

cold intolerance,

persistent amenorrhea,

difficulty concentrating,


If the patient has hypothyroidism, the decision to treat depends on
the severity of abnormality and symptoms.
Which women have the highest risk for developing permanent hypothyroidism.
with the highest levels of TSH and antithyroid peroxidase antibodies
Are TFTs in asymptomatic pregnant women who have a mildly enlarged thyroid is warranted?
No. Not if only mildly enlarged.

However, development of a significant goiter or distinct nodules should be evaluated as in any patient.
Butorphanol (Stadol) may increase blood pressure levels and should be avoided in patients with
chronic hypertension or preeclampsia.
also has been used during labor as an alternative drug because of its relatively short half-life;
Naloxone MOA
pure opioid antagonist

drug of choice in the treatment of maternal respiratory and neurobehavioral depression secondary to opioid agonist drugs
• Does epidural analgesia increase the rate of operative delivery and rate of third and fourth degree laceration?
Excessive operative vaginal deliveries have been implicated in

the increased rate of third- and fourth-degree lacerations seen in women with epidural analgesia.
WHEN FEASIBLE, obstetric practitioners should delay the administration of epidural analgesia in nulliparous women until cervical dilatation reaches ___ cm

early placement of epidural analgesia significantly increases the risk of cesarean delivery
Women in labor should not be required to reach 4–5 cm of cervical dilatation before receiving epidural analgesia.
Women in labor should not be required to reach 4–5 cm of cervical dilatation before receiving epidural analgesia. !!!!!!
Patients on unfractionated heparin therapy should be able to receive regional analgesia if
they have a normal activated partial thromboplastin time (aPTT).
Patients taking prophylactic doses of unfractionated heparin or low-dose aspirin are not at increased risk and can be
offered regional analgesia.
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.
In addition, low-molecular-weight heparin should be withheld for at least____ hours after the removal of an epidural catheter.
In patients on LMWH, because the onset of labor often is difficult to predict, it may be reasonable to
convert patients to unfractionated heparin as they approach term.
Who needs preop anesthesia consult?
short webbed neck
cardiac disease
bleeding disorders
severe preeclampsia
Can hysteroscopy be part of clinical staging of cervical carcinoma?
is the most important adverse predictor of survival in cervical cancer
presence of lymph node metastasis
Although it remains controversial, it is the best method of assessing nodal involvement in cervical cancer?
surgical evaluation of cervical cancer
provides important information about treatment planning and prognosis.
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.
surgical evaluation of cervical cancer allows
individualization of therapy and may result in better clinical outcomes.
presence of lymphatic-vascular invasion would suggest the need for
more radical treatment to obtain the optimal outcome.
Those who favor radical surgery point out the benefits less morbidity of what
it leaves the vagina in more functional condition,
The disadvantage to radiation therapy is that it results in what effect to the vagina?
a reduction in

In premenopausal women, ovarian function can be preserved with
The surgical approach also provides the opportunity for
pelvic and abdominal exploration and provides better clinical and pathologic information with which to individualize treatment.
Surgery may be preferred over radiation therapy in women who have:
diverticular disease
tuboovarian abscess
appendiceal abscess
have had prior radiation therapy
have congenital pelvic located kidney; or are
psychotic or noncompliant
Proponents of radiation therapy advocate primary radiation to avoid
surgical morbidity or mortality, risk of blood loss and transfusion, and excessive anesthesia time.
• What is the role of adjuvant therapy following primary surgery in early-stage carcinoma?
pelvic nodal involvement, positive margins, or parametrial extension—are treated with concurrent pelvic radiation therapy and cisplatin-based chemotherapy.
• Should squamous cell cancer and adenocarcinoma of the cervix be treated differently?
Discuss therapy for recurrent cervical cancer.

Patient present many years later with leg edema, sciatic pain
radical radiation therapy is used for recurrent cervical cancer after primary hysterectomy,

salvage surgery is required for those who relapse after primary radiation therapy.
Is cervical adenocarcinoma is a contraindication to hormone replacement therapy?
A pregnant patient with (Stage 0 and Stage Ia1) carcinoma in situ and microinvasive squamous carcinoma of 3 mm or less should deliver how?
vaginally and be reevaluated and treated at 6 weeks postpartum.
If the patient opts to continue the pregnancy, predelivery assessment of what should be strongly considered,
fetal lung maturity by amniotic fluid analysis
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
preinvasive disease or stage Ia invasive disease with planned postpartum fertility-sparing therapy.
Any possibility/cases of implantation of malignancy at the episiotomy site?
Yes, it is a possibility.
Treatment of recurrent disease in the episiotomy consists of
excision followed by radiation.
When radical cesarean hysterectomy is performed, a what type of uterine incision is preferred.
Most pregnant patients who are candidates for radical surgery will benefit from surgery rather than radiation therapy, given the advantage of
ovarian preservation and

the avoidance of radiation-associated vaginal fibrosis.
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?
postdelivery following uterine involution.

Pelvic and paraaortic lymph node dissection can be performed at the time of cesarean delivery to aid treatment planning.
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
If the patient is amenorrheic, the minimal laboratory evaluation should include measurement of serum levels of:

thyroid-stimulating hormone, and
If the patient has a BMI higher than 30, testing what disease may be indicated before inducing ovulation.
for diabetes mellitus

To decrease the risk of congenital malformations, diabetes mellitus should be treated before inducing pregnancy.
hysterosalpingography should be considered to establish tubal patency if the woman has a history of:
sexually transmitted diseases,
pelvic inflammatory disease,
appendicitis with rupture,
in utero exposure to diethylstilbestrol, or
previous pelvic surgery,
Before giving clomid, make sure to do this test...

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
Patients taking clomiphene should be monitored for
pregnancy, and
ovarian enlargement, as clinically indicated.
Ovulation can be determined by:
measuring serum progesterone levels (about 14 days after the last dose of clomiphene),
basal body temperature charting,
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?
gonadotropin therapy.
The most common symptoms experienced by women taking clomiphene include
vasomotor symptoms
adnexal tenderness
blurring of vision or scotomata.
Many clinicians permanently discontinue clomiphene treatment in women with clomiphene-induced
visual changes.
The main contraindications to the use of clomiphene are
hypersensitivity to the medication, and
ovarian cysts.
If the patient is amenorrheic, the minimal laboratory evaluation should include measurement of serum levels of:

thyroid-stimulating hormone, and
If the patient has a BMI higher than 30, testing what disease may be indicated before inducing ovulation.
for diabetes mellitus

To decrease the risk of congenital malformations, diabetes mellitus should be treated before inducing pregnancy.
hysterosalpingography should be considered to establish tubal patency if the woman has a history of:
sexually transmitted diseases,
pelvic inflammatory disease,
appendicitis with rupture,
in utero exposure to diethylstilbestrol, or
previous pelvic surgery,
Before giving clomid, make sure to do this test...

It is important to give clomiphene only after menstrual bleeding to help ensure that the patient is not pregnant.
Patients taking clomiphene should be monitored for
pregnancy, and
ovarian enlargement, as clinically indicated.
Ovulation can be determined by:
measuring serum progesterone levels (about 14 days after the last dose of clomiphene),
basal body temperature charting,
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?
gonadotropin therapy.
The most common symptoms experienced by women taking clomiphene include
vasomotor symptoms
adnexal tenderness
blurring of vision or scotomata.
Many clinicians permanently discontinue clomiphene treatment in women with clomiphene-induced
visual changes.
The main contraindications to the use of clomiphene are
hypersensitivity to the medication, and
ovarian cysts.
Which women with PCOS appear to have decreased ovulation and pregnancy rates when they are treated with clomiphene
serum DHEAS concentration higher than the middle of the normal range (>2 µg/mL)
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.

The impact of combined therapy was especially marked in the women with a DHEAS concentration higher than 2 µg/mL.
• In women who do not ovulate using clomiphene alone, can the chances of ovulation be improved by adding an hCG injection?
NOT evidenced based!!!
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.
Injections with FSH for ovulation induction are associated with a high rate of multiple gestations
clomid has what rate of multiple gestations?

What % ovulate?

80% will ovulate
• In women with hyperprolactinemia, which medical treatments stimulate the resumption of ovulation?
The main side effects associated with bromocriptine are

orthostatic hypotension.
To minimize these potential side effects, it is recommended that bromocriptine
be initiated at a dosage of 1.25 mg at bedtime.

given vaginally
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
500 mg three times daily.
most common side effects of metformin are
gastrointestinal disturbances, including diarrhea, nausea, vomiting, and abdominal bloating.

lactic acidosis
Think of lactose intolerant
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
progestin-induced menstrual withdrawal bleeding.

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

And that the patient is not pregnant
Before treatment with metformin is initiated, it is recommended that serum creatinine levels be demonstrated to be lower than
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.
contraindication of metformin
liver disease
renal disease
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
triplet pregnancy.
Are there evidence-based guidelines about the appropriate duration of gonadotropin administration?
How to determine the diastolic blood pressure on sphagmomanomater
the sound disappears (Korotkoff phase V).
appropriate size cuff should be used
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
The blood pressure level should be taken with the patient in what position
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.
With mild disease and no progression, these Preeclamptic lab tests can be repeated how often if ever?
repeated weekly
What is often initially recommended for women with new-onset preeclampsia.
Ambulatory management at home or at a day-care unit has been evaluated as an option for monitoring women with mild gestational hypertension or
preeclampsia remote from term.
Who should be hospitalized long term?
difficulty with compliance,

logistic barriers,

manifest signs of disease progression

who have severe preeclampsia
For mild preeclampsia, vaginal delivery is preferred when?
at term
5–10-mg doses intravenously every 15–20 minutes until desired response is achieved*
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
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.
Why has it been customary to recommend the 50-g, 1-hour oral glucose challenge test be administered at 24–28 weeks of gestation.
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.
What does GTT consist of?
50-g, 1-hour glucose challenge
What is the appropriate threshold value for the GTT laboratory screening test?
130 (or 140)
Rules for the 3 hour GTT:
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.
Which glucose values appear to be most effective at determining the likelihood of macrosomia and other adverse pregnancy outcomes in patients with GDM.

fetus more sensitive to peak rather than nadir levels of glucose.
American Diabetes Association also recommends an average of __kcal/kg/d based on PREPREGNANT body weight for NONOBESE individuals.
30 kcal/kg/d

PREPREGNANT body weight
insulin therapy should be considered for patients treated with medical nutrition therapy when
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.

Women with GDM who lead an active lifestyle should be encouraged to continue a program of exercise approved for pregnancy.
Walk around the block after meals!
When glucose control is good and no other complications supervene, there is no good evidence to support routine delivery before ___weeks of gestation.
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.
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.
PAST delivery history
PROGRESS of labor
PAST delivery history
PROGRESS of labor

:) :) :)
PAST delivery history
PROGRESS of labor
Diagnosis in nonpregnant state of Diabetes Mellitus by what Fasting Plasma Glucose level and 2-h PG?

Using 75-g, 2-h OGTT
>=126 mg/dL

>=200 mg/dL
• In the initial evaluation of a pregnant woman with hypertension, which clinical tests are useful?
ophthalmologic examination,
and renal ultrasonography.
Women with significant left ventricular hypertrophy secondary to hypertension may experience what as pregnancy progresses.
cardiac decompensation and heart failure
Renal artery stenosis appears to be more prevalent in patients with
type-2 diabetes and coexistent hypertension.
How to detect renal artery stenosis?
Doppler flow studies or

magnetic resonance angiography MRA
Do negative results from renal ultrasonography rule out renal artery stenosis?
serum uric acid level of mg/dL could identify women with an increased likelihood of having superimposed preeclampsia.
Is there scientific evidence that antihypertensive therapy will improve perinatal outcome?

Treatment with antihypertensive medications did not decrease the incidence of complications such as IUGR, superimposed preeclampsia, placental abruption, or perinatal mortality.
HTN meds
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.
In women with severe chronic hypertension (systolic pressure >=180 mmHg or diastolic pressure >=110 mmHg), antihypertensive therapy should be initiated or continued
therapy could be increased or reinstituted for women with blood pressures exceeding
150–160 mmHg systolic

or 100–110 mmHg diastolic.
It would seem reasonable not to start antihypertensive therapy in women with mild hypertension who become pregnant unless
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.
"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
in settings in which uteroplacental perfusion is already reduced (preeclampsia and IUGR)" .
Angiotensin–converting enzyme (ACE) inhibitors are contraindicated during which trimesters?
second and third trimesters of pregnancy.
ACE inhibitors have been associated with:
renal failure
renal agenesis
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 .

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

Why does general anesthesia may pose a risk in pregnant women with severe hypertension or superimposed preeclampsia?
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.
What general anesthesia induction drug, because of its association with hypertension, is not considered first line therapy for the induction of general anesthesia.
The problem with Use of Botanicals
in vitro effects
animal models
nonrandomized studies.
do not meet the current standards for evidence-based recommendations.

products may be adulterated or contaminated
St. John's wort is also potentially photosensitizing, and concern has been raised about an increased rate of
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:
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
What happened to early amnios?
higher fetal loss rate
talipes (clubfoot)

No longer done
When do fetal u/s markers warrant further testing?
combination of two or more positive findings substantially increases risk and warrants further counseling regarding invasive testing.
When should a finding of an isolated choroid plexus cyst be further evaluated?
may be associated with trisomy 18

if serum screening results are abnormal

or the patient is older than 32 years at delivery.
• Is there a role for serum screening in women who will be age 35 years and older at delivery?
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.
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.

Twin "3's"
Traditionally, recurrent pregnancy loss has been defined as three consecutive spontaneous abortions.
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%).
• When is a diagnosis of recurrent pregnancy loss appropriate?
two or more consecutive SAB
• Should all couples with recurrent pregnancy loss have chromosomal analysis performed?
balanced chromosome abnormalities
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
that if the abortus is aneuploid, the physician and patient may conclude that a maternal cause of pregnancy loss is excluded.
• Should thyroid tests and tests for glucose intolerance be performed in women with recurrent pregnancy loss?
only if pt is

at risk for those diseases

has symptoms
• Should women with recurrent pregnancy loss be evaluated for luteal phase defect?
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.
• Should women with recurrent pregnancy loss be evaluated for possible infectious causes, and should they be treated?

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

women with recurrent pregnancy loss should be tested for antiphospholipid syndrome using standard assays for anticardiolipin antibodies and lupus anticoagulant.
ACA and LA should be drawn how?
two occasions at least 6 weeks apart.
The IgG isotype of anticardiolipin is most relevant clinically, but tests else may be used to make the diagnosis.
repeatedly positive for IgM anticardiolipin
In individuals demonstrating only anticardiolipin antibodies, definite APS is diagnosed when the antibody levels are repeatedly ___units or greater.
• Should women with recurrent pregnancy loss be evaluated for possible ALLOimmune causes? (against paternal leukocytes)

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.
Is antibiotic prophylaxis needed for
Hysterectomy—Vaginal, Abdominal, or Laparoscopically Assisted.
Is antibiotic prophylaxis needed for
Laparoscopy and Laparotomy.
Is antibiotic prophylaxis needed for
In patients with no history of pelvic infection, HSG can be performed without prophylactic antibiotics.
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.
dilated tubes
In patients thought to have an active pelvic infection, should HSG be performed?
Is antibiotic prophylaxis needed for Sonohysterography?
patients undergoing sonohysterography, prophylaxis should be based on the individual patient's risk of PID;

routine use of antibiotic prophylaxis is not recommended.
Is antibiotic prophylaxis needed for hysteroscopy?
Is antibiotic prophylaxis needed for Induced Abortion and Dilation and Curettage?
prophylactic antibiotics are effective for these women, regardless of risk.
Is antibiotic prophylaxis needed for Intrauterine Device Insertion, Endometrial Biopsy?
Induced Abortion and Dilation and Curettage prophylactic antibiotic regimen:
doxycycline, 100 mg orally 1 hour before the abortion followed by 200 mg after the procedure

may help against ashermans
IN THE PRESENCE OF INFECTION, removal of an IUD or other genitourinary procedures require endocarditis prophylaxis.
Because bacteriuria and urinary tract infection can be a cause of detrusor instability, pretest screening by urine culture or urinalysis, or both, is recommended
Cephalosporin prophylaxis is acceptable in those patients with a history of penicillin allergy NOT felt to be which type of hypersensitivity reaction?
immunoglobulin-E (IgE) mediated (immediate hypersensitivity).

• 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.?