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285 Cards in this Set

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What is the risk of spontaneous abortion for all pregnancies?
15%
Chromosomal abnormalities are found in what percentage of spontaneous abortions?
50%
Chromosomal abnormalities are found in what percentage of spontaneous still births?
5%
Chromosomal abnormalities are found in what percentage of spontaneous live births?
0.5%
In spontaneous abortions, what is the most common trisomy seen?
Trisomy 16
In spontaneous abortions, what is the most common single abnormality found?
45,X
What percentage of 45,X conceptuses are lost before birth?
99%
What percentage of Trisomy 21 conceptuses are lost before birth?
75%
What is the most common cause of a lost pregnancy in the first trimester?
Chromosomal abnormalities.
What is the most common cause of a lost pregnancy in the second trimester?
Uterine or environmental/anatomical.
What is the Rad threshold for increased fetal risk to radiation exposure?
10 rads.
High doses of radiation in the first trimester primarily affect developing organ systems such as the heart and limbs; in later pregnancy, what system is more sensitive to radiation exposure?
CNS
It has been shown in numerous studies that nuchal translucency measured between 10-13 weeks is a useful marker for increased risk of what class of fetal disorders?
Chromosomal abnormalities; the larger the nuchal translucency, the greater the risk of other adverse pregnancy outcomes, including fetal demise, cardiac abnormalities, and other genetic syndromes, even if the karyotype is normal. The nuchal translucency will almost always disappear by 15 weeks; this does not reduce the risk of there being an aneuploid condition.
In the first trimester, what are the three most common genetic disorders that are likely to be present, if nuchal translucency is seen on ultrasound?
Down syndrome, followed by Trisomy 18, then Turner syndrome.
What is the most common symptomatic medical complaint in adulthood for patients with Achondroplasia?
Spinal stenosis.
At how many weeks gestation is the MSAFP performed to screen for neural tube defects?
Between 15-21 weeks.
What multiple level is considered to be and elevated MOM on a first MSAFP?
2.5 MOM; if the patient does not have an extremely elevated value (i.e. the value is <4.0 MOM) and is relatively early in pregnancy (<19 week gestation) a second MSAFP is usually drawn.
This ultrasound marker is now appreciated as a sensitive marker for Down syndrome and other aneuploidies between 10 and 13 weeks. Outside this range, this marker disappears. What is this marker?
Nuchal Translucency.
This class of antibiotics should not be used during the Third Trimester because they can cause kernicterus.
Sulfa drugs.
What drug has been associated with an increased risk of ADHD and behavioral and learning problems?
Tobacco.
How long does the CD recommend that a woman wait to become pregnant after receiving a live attenuated vaccine?
3 months.
When does the CDC recommend that women receive the Influenza vaccine during pregnancy?
After the first trimester.
The multiple marker screen test, also referred to as the expanded AFP test or triple screen, consists of maternal serum measurements of what three markers?
Estriol, hCG, AFP; the multiple maker screening test is used to determine a pregnant patient's risk of having a baby with aneuploidy and a neural tube defect.
AFP serum marker screening has the greatest sensitivity when done at what gestational week range in pregnancy?
16-18 weeks.
An MSAFP that is greater than or equal to how many Multiples of the Mean (MOM), indicates an elevated risk for neural tube defects and indicates that further work up and evaluation is needed?
> 2.0-2.5 MOM
There has not been an association of amniocentesis in the second trimester with fetal limb reduction defects. What procedure, when performed at a gestational age of less than 9 weeks has been associated with fetal limb reduction defects?
Chorionic villus sampling.
What is the genetic inheritance pattern of G6PD?
X-linked recessive.
Use of these antibiotics is associated with kernicterus in the newborn. They compete with bilirubin for binding sites on albumin, thereby leaving more free bilirubin free for diffusion into tissues. These antibiotics should be withheld during the last 2-6 weeks of pregnancy. What abx are these?
Sulfonamides.
Nitrofurantoins can cause what hematological problem in the mother and fetus if this genetic disorder is present?
Hemolytic anemia, if G6PD is present.
This drug has been associated with fetal hearing loss with prolonged treatment of Tuberculosis during pregnancy. Which drug is this?
Streptomycin.
What is the recommendation for vaccination of pregnant with regard to Influenza immunization?
Administration of the influenza vaccine is recommended if the underlying disease is serious.
What is the recommendation for vaccination of pregnant with regard to Typhoid immunization?
Typhoid immunization is recommended on travel to an endemic region.
What is the recommendation for vaccination of pregnant with regard to Hepatitis A immunization?
Hepatitis A immunization is recommended after exposure or before travel to developing countries.
What is the recommendation for vaccination of pregnant with regard to Cholera immunization?
Cholera immunization should be given only to meet travel requirements.
What is the recommendation for vaccination of pregnant with regard to Tdap immunization?
Tetanus-diphtheria immunization should be given if a primary series has never been administered or if 10 years have elapsed without the patient receiving a booster.
What is the recommendation for vaccination of pregnant with regard to Poliomyelitis immunization?
Immunization for poliomyelitis is mandatory during an epidemic, but otherwise not recommended.
What is the recommendation for vaccination of pregnant with regard to Smallpox immunization?
Smallpox immunization is unnecessary since the disease has been eradicated.
What is the recommendation for vaccination of pregnant with regard to Yellow fever immunization?
Immunization for yellow fever is recommended before travel to a high risk area.
What is the recommendation for vaccination of pregnant with regard to Mumps and Rubella immunization?
Mumps and Rubella immunization are contraindicated.
What is the recommendation for vaccination of pregnant with regard to Rabies immunization?
Administration of rabies vaccination is unaffected by pregnancy.
The time of the division of a fertilized zygote to form monozygotic twins determines what aspect of the anatomy of the pregnancy?
The placental and membranous anatomy; late division, after formation of the embryonic disk, will result in conjoined twins.
How does sex of the fetuses affect the amnion and chorion when dizygotic twins are present?
Dizygotic twins always have a dichorionic and diamniotic placenta regardless of the sex of the fetuses. The placentas of dizygotic twins may be totally separated or intimately fused.
Monozygotic twins are always of teh same sex byt may be monochorionic or dichorionic depending upon what?
When the division of the twins occurred.
Of monozygotic twins, 20-30% have this type of placentation, which is the result of separation of the blastocyst in the first two days after fertilization. What type of placentation is it?
Dichorionic placentation.
The majority of twins have what type of amniotic and chorionic placenta?
Diamniotic and monochorionic placenta.
What is the least common type of amniotic and chorionic placentation seen with twins?
Monochorionic and monoamniotic; its incidence is only about 1%.
The amount of iron that can be mobilized from maternal stores and gleaned from the diet is insufficient to meet the demands of pregnancy. A pregnant women with a normal hematocrit at the beginning of pregnancy who is not given iron supplementation will suffer from iron deficiency during the latter part of gestations. If the mother is iron deficient will the fetus have impaired hemoglobin production???
NO!!!; it is important to remember that the fetus will not have impaired hemoglobin production, even in the presence of maternal anemia, because the placenta will transport the needed iron at the expense of maternal iron store depletion.
True or False: Bilateral hydronephrosis and hydroureter is a normal finding during pregnancy and does not require any additional workup or concern.
TRUE!!!; when the gravid uterus rises out of the pelvis, it presses on the ureters, causing ureteral dilatation and hydronephrosis. It has also been proposed that the hydroureter and hydronephrosis of pregnancy may be owing to the hormonal effect from progesterone. In the vast majority of pregnant women the ureteral dilatation tends to be greater on the right side as a result of the dextrototation of the uterus and/or cushioning of the left ureter provided by the sigmoid colon.
By tradition the female pelvis is classified as belonging to one of four major groups: Gynecoid, Android, Anthropoid, and Platypelloid. Which is the classic female pelvis with a posterior sagittal diameter on the inlet only slightly shorter than the anterior sagittal diameter?
Gynecoid.
By tradition the female pelvis is classified as belonging to one of four major groups: Gynecoid, Android, Anthropoid, and Platypelloid. Which is defined by the posterior sagittal diameter at the inlet being much shorter than the anterior sagittal diameter, limiting the use of the posterior space by the fetal head?
Android.
By tradition the female pelvis is classified as belonging to one of four major groups: Gynecoid, Android, Anthropoid, and Platypelloid. Which is defined by the AP diameter of the inlet being greater than the transverse diameter resulting in an oval, with large sacrosciatic notches and convergent side walls; the ischial spines are likely to be prominent?
Anthropoid.
By tradition the female pelvis is classified as belonging to one of four major groups: Gynecoid, Android, Anthropoid, and Platypelloid. Which is defined as flattened with a short AP and wide transverse diameter; wide sacrosciatic notches are common?
Platypelloid.
A risk of RDS of 40% exists with an L/S ratio of 1.5:1; when the L/S ratio is less than 1.5, the risk of RDS is 73%. When the L/S ratio is greater than 2, the risk of RDS is slight, however, when the fetus is likely to have a serious metabolic compromise at birth (e.g. diabetes or sepsis), RDS may develop even with a mature L/S ratio (>2.0). This may be explained by lack of what particular phospholipid that enhances surfactant properties? The identification of this phospholipid in amniotic fluid provides considerable reassurance (but not an absolute guarantee) that RDS will not develop. Moreover,, contamination of amniotic fluid by blood meconium, or vaginal secretions with not alter the measurements of this phospholipid. What is the phospholipid?
Phosphotidylglycerol.
True or False: Nulliparity is a risk factor for Pre-eclampsia.
True.
These two types of hypertension seen in prenancy should be controlled with antihypertensive medications. Which types are they?
Severe hypertension associated with preeclampsia, and chronic hypertension; severe, but not mild hypertension associated with preeclampsia, should be controlled with hypertensive medication. Antihypertensive agents are useful in chronic hypertension but not preeclampsia unless the BP is in te severe range (lowering these BPs can help avoid stroke).
The BPP is based on FHR monitoring (generally NST) in addition to four parameters observed on real-time ultrasonography: 1) amniotic fluid volume 2) fetal breathing 3) fetal body movements, and 4) fetal body tones. Each parameter gets a score of 0 to 2. What total score is considered normal?
8 to 10.
The BPP is based on FHR monitoring (generally NST) in addition to four parameters observed on real-time ultrasonography: 1) amniotic fluid volume 2) fetal breathing 3) fetal body movements, and 4) fetal body tones. Each parameter gets a score of 0 to 2. What total score is considered equivocal?
6.
The BPP is based on FHR monitoring (generally NST) in addition to four parameters observed on real-time ultrasonography: 1) amniotic fluid volume 2) fetal breathing 3) fetal body movements, and 4) fetal body tones. Each parameter gets a score of 0 to 2. What total score is abnormal and requires prompt delivery?
4 or less than 4; the false negative rate of BPP is less than 0.1%, but the false positive results are relatively frequent with poor specificity. Testing more frequently than every 7 days is recommended in patients with post-term pregnancies, connective tissue disease, chronic hypertension, and suspected fetal growth retardation, as well as in patients with previous fetal death. In patients with scores of 8, but with spontaneous late decelerations, the rate of cesarian delivery indicated for fetal distress has been 25%.
In the first trimester ultrasound estimate of gestational age is accurate to within 3 to 5 days. Estimating the uterine size on physical examination in the first trimester can result in an error of 1 to 2 weeks. What is the most accurate way of estimating fetal gestational age?
Crown to rump length on ultrasound.
A single serum progesterone can be used to establish that an early pregnancy is developing normally. What is the value that indicates this is occurring?
Serum progesterone level >25 ng/ml usually indicates a normal intrauterine pregnancy; <5 ng/ml usually indicates a non-viable pregnancy; progesterone levels in conjunction with quantitative HCG levels are often used to determine the presence of an ectopic pregnancy.
At what gestational age should the 1 hour glucose tolerance test be performed in a pregnant women, in order to screen for gestational diabetes? Why?!
24 to 28 weeks; the insulin resistance seen in gestational diabetes is thought to be due to the effects of Human Placental Lactogen, which is produced in the highest quantities by the placenta in the 24th to 28th weeks.
How much weight is a woman allowed to gain during pregnancy if she has a BMI between 19 and 25?
25-35 lbs.
How much weight is a woman allowed to gain during pregnancy if she has a BMI less than 19.8?
Up to 40 lbs.
How much weight is a woman allowed to gain during pregnancy if she has a BMI greater than 25?
0-15 lbs.
The fundal height of the uterus in centimeters has been found to correlate with gestational age in weeks with an error of 3 cm during what gestational age range?
16 to 36 weeks.
In an uncontrolled diabetic, what is the most likely cause for excessive fundal height found to be out of proportion to gestational age on physical exam?
Polyhydramnios, which can be a sign of poor glucose control.
In a patient who is 38 weeks gestation, what might be an normal physiologic explanation for a sudden decrease in the fundal height found on physical exam between weekly visits?
The decrease in fundal height between visits can be explained by engagement of the fetal head, which is verified on vaginal examination with determination of the presenting part at 0 station. Engagement of the fetal head commonly occurs before labor in nulliparous patients. Therefore no panic is necessary and it is appropriate for the patient to return for another scheduled visit in a week.
This fetal heart monitoring technique can detect fetal heart action as early as 5 weeks of amenorrhea. What is this technique?
Vaginal ultrasound.
With appropriate Doppler equipment, fetal heart tones can be heard as early as what gestational age?
10 weeks gestational age.
It is in appropriate to deliver any patient early prior to this gestational age, without documentation of fetal lung maturity. What is the gestational age?
39 weeks; this is due to the possibility of development of neonatal respiratory distress syndrome.
Post-term or prolonged pregnancies are those pregnancies that have gone beyond what gestational age?
42 completed weeks.
The Bishop score is a way to determine the favorability of the cervix to induction. The elements of the Bishop score include effacement, dilation, station, consistency, and position of the cervix. Points are assigned for each element and then totaled to give the Bishop score. Induction to active labor is usually successful with what Bishop score?
9 or greater; with a lower score, expectant management is advised.
The BPP consists of 5 tests:

1) Nonstress test
2) Fetal breathing movements- one or more episodes of fetal breathing movements of 30 seconds or more within 30 min
3) Fetal movement- three or more discrete body or limb movements within 30 min
4) Fetal tone- one or more episodes of extension of a fetal extremity with return to flexion, or opening or closure of a hand
5) Determination of Amniotic Fluid Volume- a single vertical pocket of amniotic fluid exceeding 2 cm

What are the components of the modified BPP test?
In the modified BPP, only the NST and determination of amniotic fluid volume are assessed.
The components of the BPP are assigned a score of 2 (normal) or 0 (abnormal or absent). These components include:
1) NST
2) Fetal Breathing Movements
3) Fetal Movement
4) Fetal Tone
5) Determination of Amniotic Fluid Volume

What score indicates a normal BPP?
8 to 10.
The components of the BPP are assigned a score of 2 (normal) or 0 (abnormal or absent). These components include:
1) NST
2) Fetal Breathing Movements
3) Fetal Movement
4) Fetal Tone
5) Determination of Amniotic Fluid Volume

What score indicates imminent delivery because fetal asphyxia is probable?
0 to 2.
The components of the BPP are assigned a score of 2 (normal) or 0 (abnormal or absent). These components include:
1) NST
2) Fetal Breathing Movements
3) Fetal Movement
4) Fetal Tone
5) Determination of Amniotic Fluid Volume

What score indicates repeat testing and delivery if persistent?
4 to 6.
Almost all cases of this type of pregnancy follow early rupture or abortion of a tubal pregnancy. What type is this?
Abdominal pregnancy.
In modern clinical medicine, once the diagnosis of fetal demise has been made, the products of conception are removed. If, however, the gestational age is more than 14 weeks and the fetal death occurred 5 weeks ago, what complication may present?
Coagulation abnormalities.
Acute Polyhydramnios tends to occur early in pregnancy and, as a rule, leads to labor before what gestational age?
28th week.
What are the most frequent maternal complications of polyhydramnios?
Placental abruption, uterine dysfunction, and postpartum hemorrhage.
The incidence of associated malformations in polyhydramnios is ~20%. What are the most common organ system malformations associated?
CNS and GI malformations.
This diagnosis is made based on the presence of painless cervical dilation with a history of pregnancy loss in the second trimester or early-third-trimester preterm delivery. What is the diagnosis?
Cervical insufficiency or incompetence.
A patient with a history of three or more midtrimester pregnancy losses or early preterm deliveries and evidence of cervical incompetency is a candidate for what procedure?
Cerclage; cerclage is not indicated for the prevention of first trimester losses, and it has not been shown to improve preterm delivery rate or neonatal outcome in twin gestations.
What percentage of human pregnancies have bleeding that occurs before 20 weeks of gestation?
30-40%; of these half will end in spontaneous abortion.
This diagnosis is made when uterine bleeding occurs before 20 weeks without any cervical dilation or effacement. Diagnosis?
Threatened abortion.
In a patient bleeding during the first half of pregnancy, this diagnosis is strengthened if the bleeding is profuse and associated with uterine cramping pains. Diagnosis?
Inevitable abortion; if cervical dilation has occurred, with or without rupture of membranes , the abortion is inevitable.
If only a portion of the products of conception have been expelled and the cervix remains dilated, what diagnosis is made?
Incomplete abortion.
If all fetal and placental tissue has been expelled , the cervix is closed, bleeding from the canal is minimal or decreasing, and uterine cramps have ceased, what diagnosis is made?
Completed abortion.
This diagnosis is suspected when the uterus fails to continue to enlarge with or without uterine bleeding or spotting. In this diagnosis fetal death occurs before 20 weeks gestation without expulsion of any fetal or maternal tissue for at least 8 weeks thereafter. Diagnosis?
Missed abortion; when a fetus is retained in the uterus beyond 5 weeks after fetal death, consumptive coagulopathy with hypofibrinogenemia may occur. This is uncommon, however, in gestations less than 14 weeks in duration.`
Though often underutilized, this test is a rapid non-surgical method to confirm the presence of unclotted intraabdominal blood from a ruptured tubal pregnancy. What is this test?
Culdocentesis; a negative test does not rule out a tubal pregnancy, but a positive test makes the likelihood high.
This diagnosis can be made clinically by the presence of maternal fever, tachycardia, and uterine tenderness. Diagnosis?
Chorioamnionitis; when chorioamnionitis is diagnosed, fetal and maternal morbidity increases and delivery is indicated regardless of the fetal age. Antibiotics must be administered to avoid neonatal sepsis.
What tocolytic agent should not be used in the setting of oligohydramnios?
Indomethacin; this is a prostaglandin synthesis inhibitor that can decrease fetal urine production and, itself, can cause oligohydramnios, and thus would exacerbate the condition.
This tocolytic agent should never be used in a patient who is actively bleeding because it is associated with maternal tachycardia and vasodilation. What is the tocolytic agent?
Tertbutaline.
This diagnosis is made when the weight of the fetus falls below the tenth percentile for a given age. Diagnosis?
Intrauterine Growth Restriction; IUGR.
IUGR can be classified as either symmetric or asymmetric. In asymmetric IUGR, the abdominal circumference is low, but the biparietal diameter may be at or near normal. In cases of symmetric IUGR, all fetal structures (including both head and body size) are proportionately diminished in size. What are the main causes of symmetric IUGR?
Fetal infections, chromosome abnormalities, and congenital anomalies.
IUGR can be classified as either symmetric or asymmetric. In asymmetric IUGR, the abdominal circumference is low, but the biparietal diameter may be at or near normal. In cases of symmetric IUGR, all fetal structures (including both head and body size) are proportionately diminished in size. What are the main causes of asymmetric IUGR?
Asymmetric IUGR is seen in cases where fetal access to nutrients is compromised, such as with severe maternal nutritional deficiencies or hypertension.
This virus is one of the most teratogenic agents known. Risk of congenital infection with this virus in the fetus is 80% when the mother has the infection in the first trimester, while the risk is decreased to 25% by the end of the second trimester; thus this virus is mostly a 1st trimester risk!!! What is the virus?
Rubella.
What is the treatment of choice for pregnant women who have asymptomatic N.gonorrhoeae infections and who are allergic to penicillin?
Spectinomycin; erythromycin is another drug that is effective in treating asymptomatic gonorrhea.
Patients with a history of thromboembolic disease in pregnancy are at high risk of developing it in subsequent pregnancies. Impedance plethysmography and Doppler ultrasonography are useful techniques even in pregnancy and should be done as baseline studies. Patients should be prophylactically treated with what medication even through the postpartum period, as this is the time of highest risk disease?
Low-dose heparin therapy.
The most important laboratory finding in pregnant patients with this condition is an elevation of serum amylase levels, which appears 12 to 24 hours after the onset of clinical disease. A useful diagnostic tool in the pregnant patient with only modest elevation of amylase values is the amylase creatinine ratio. In patients with this condition, the ratio of amylase:creatinine clearance is always greater than 5% to 6%. Diagnosis?
Acute Pancreatitis.
Although quite effective in treating UTI, this drug class should be avoided during the last few weeks of pregnancy because they competitively inhibit the binding of bilirubin to albumin, which increases the risk of neonatal hyperbilirubinemia. Which drug class is this?
Sulfonamides.
This drug that is commonly used to treat UTI in pregnancy may cause severe nausea and thus not be tolerated. It should also be avoided in late pregnancy because of the risk of hemolysis caused by deficiency of erythrocyte phosphate dehydrogenase in the newborn. What drug is this?
Nitrofurantoin.
What are the two drugs of choice for treatment of UTI in pregnancy?
Ampicillin and the Cephalosporins.
By how much does the heart rate increase in pregnancy?
10 to 15 beats per minute.
True or False: an S3, a 2/6 systolic ejection murmur greater during inspiration, and a soft diastolic murmur can all be normal findings in a pregnant woman?
TRUE!!!
This is the most common dermatologic condition of pregnancy. It is more common in nulliparous women and occurs most often in the second and third trimesters of pregnancy. It is characterized by erythematous papules and plaques that are intensely pruritic and appear first on the abdomen. The lesions then commonly spread to the buttocks, thighs, and extremities with sparing of the face. Diagnosis?
Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP).
This is a blistering skin eruption that occurs more commonly in multiparous patients in the second or third trimester of pregnancy. The presence of vesicles and bullae help differentiate this skin condition from PUPPP. Diagnosis?
Herpes gestationis.
This is a very rare dermatosis of pregnancy that is characterized by small, pruritic excoriated lesions that occur between 25 and 30 weeks. The lesions first appear on the trunk and forearms and can spread throughout the body as well. Diagnosis?
Prurigo gestationis.
This is a rare pustular eruption that forms along the margins of erythematous patches. This skin condition usually occurs in late pregnancy. The skin lesions usually begin at points of flexure and extend peripherally; mucous membranes are commonly involved. Patients with this condition usually do not have intense pruritis, but more commonly have systemic symptoms of nausea, vomiting, diarrhea, chills, and fever. Diagnosis?
Impetigo herpetiformis.
What is the incidence of major malformations in women with diabetes?
5-10%; it is believed that they are a consequence of poorly controlled diabetes in the preconception and early pregnancy period.
A hemoglobin A1c level greater than 10.6 has what % risk of fetal malformations?
25%.
Cardiac (38%), Musculoskeletal (15%), and CNS (10%) are the most common single organ system anomalies seen in pregnant women with what chronic disease?
DIABETES!!!
Sacral agenesis is a rare malformation seen commonly in pregnant women with what severe chronic disease?
Diabetes.
Pregnancy has not been found to exacerbate or modify diabetic nephropathy. Diabetic neuropathy and gastroparesis may complicate some pregnancies, but pregnancy does not affect the overall disease process. What is the one diabetic complication that pregnancy is thought to worsen?
Diabetic proliferative retinopathy.
Pregnant women who remain hyperthyroid despite therapy have a higher incidence of what two medical conditions?
Preeclampsia and Heart Failure.
This is a rare condition that affects the liver during pregnancy. This disorder is usually fatal for both mother and baby. It manifests itself late in pregnancy and is more common in nulliparous women. Typically a woman will present with a several-day or -week history of general malaise, anorexia, nausea, emesis, and jaundice. Liver enzymes are usually not elevated above 500. Indicators of liver failure are present, manifested by elevated PT/PTT, bilirubin, and ammonia levels. In addition there is marked hypoglycemia. Low fibrinogen and platelets occur secondary to a consumptive coagulopathy. Diagnosis?
Acute fatty liver of pregnancy; recently it has been suggested that recessively inherited mitochondrial abnormalities of fatty acid oxidation predispose women to fatty liver in pregnancy.
This condition occurs in up to 8% of pregnancies. Affected women are usually asymptomatic, have no prior history of bleeding and usually maintain platelet counts above 70,000. With this disorder, platelet count usually return to normal in about three months. Diagnosis?
Gestational Thrombocytopenia.
In this condition there is maternal alloimmunization to fetal platelet antigens. The mother is healthy and has a normal platelet count, but produces antibodies that cross the placenta and destroy fetal/neonatal platelets. Diagnosis?
Neonatal alloimmune thrombocytopenia.
Asymptomatic pregnant women with a platelet count over 50,000 do not need to be treated, because this count is sufficient to prevent bleeding complications. For severely low platelet counts, what therapies should be considered?
Prednisone, IVIg, splenectomy.
Maternal infection with this virus in the first half of pregnancy can cause malformations such as cutaneous and bony defects, chorioretinitis, cerebral cortical atrophy, and hydronephrosis. Adults with this infection fare much worse than children; about 10% will develop a pneumonitis, and some of these will require ventilatory support. Diagnosis?
Varicella-zoster infection.
Fetal manifestations of this infection correlate with time of maternal infection and fetal organ development. If infection occurs within the first 12 weeks, 80% of fetuses manifest the associated congenital syndrome, while only 25% manifest the syndrome if it occurs at the end of 24 weeks. The congenital syndrome cause by this virus includes one or more of the following: eye lesions, cardiac disease, sensorineural deafness, CNS defects, growth restriction, thrombocytopenia, anemia, liver dysfunction, interstitial pneumonitis, and osseous changes. Diagnosis?
Rubella syndrome.
In the past this infection accounted for about 1/3 of all stillbirths. Transplacental infection can occur with any stage of this disease, but the highest incidence is with the primary and secondary stages. The fetal and neonatal effects include hepatosplenomegaly, edema, ascites, hydrops, petechiae or purpuric skin lesions, osteochondritis, lymphadenopathy, rhinitis, penumonia, myocarditis, and nephrosis. The placenta is enlarged, sometimes weighing as much as the fetus. Diagnosis?
SYPHILIS!!!
This bacterial infection during pregnancy can be asymptomatic or cause a febrile illness that is confused with influenza, pyelonephritis, or meningitis. Fetal infection is characterized by granulomatous lesions with microabscesses. Early onset neonatal sepsis is a common manifestation of this infection during pregnancy, and late onset disease occurs after 3 to 4 weeks as meningitis, which is similar to Group B Strep. This, however, is a much less common infection. Diagnosis???
Listeria monocytogenes infection.
This type of forceps delivery requires a visible scalp, the fetal skull on the pelvic floor, the sagittal suture essentially in the OA position, and the fetal head on the perineum. A rotation can occur but only up to 45 degrees. What kind of forceps are these?
Outlet forceps.
This type of forceps delivery requires a station of at least +2, but not on the pelvic floor. Rotation can be more than 45 degrees. What type of forceps delivery is this?
Low forceps delivery.
This type of forceps delivery is from a station above 2+, but with an engaged head. What type of forceps delivery is this?
Midforceps delivery.
What percentage of women are colonized with GBS in the vagina or rectum?
10-30%.
Routine screening for GBS in pregnant women occurs between what range of gestational weeks?
35-37 weeks.
What is the preferred method of treatment for GBS colonization of the pregnant woman?
Penicillin; ampicilin is an acceptable alternative treatment, but penicillin is preferred. If penicillin allergic, but not at high risk for anaphylaxis, cefazolin is recommended. If penicillin allergic and high risk for anaphylaxis, use clindamycin or erythromycin if the isolate is susceptible to both. If penicillin allergic and high risk for anaphylaxis and the GBS is resistant to clindamycin or erythromycin, or susceptibilities are not available, use vancomycin.
The preferred method of treatment for pregnant women colonized with this bacteria is penicillin; ampicilin is an acceptable alternative treatment, but penicillin is preferred. If penicillin allergic, but not at high risk for anaphylaxis, cefazolin is recommended. If penicillin allergic and high risk for anaphylaxis, use clindamycin or erythromycin if the isolate is susceptible to both. If penicillin allergic and high risk for anaphylaxis and the isolate of this bacteria is resistant to clindamycin or erythromycin, or susceptibilities are not available, use vancomycin. What is the bacteria treatment with this protocol?
Group B strep.
Prolongation of the latent phase in the multiparous patient is considered at how many hours?
20 hours; the diagnosis of this category of uterine dysfunction is difficult and is made, in many cases, only in retrospect. Only rarely is there a need to resort to oxytocic agents or to cesarean section. The recommended management is meperidine (Demerol) 100mg intramuscularly; this will allow most patients to rest and wake up in active labor.
Prolongation of the latent phase in the nulliparous patient is considered at how many hours?
14 hours; he diagnosis of this category of uterine dysfunction is difficult and is made, in many cases, only in retrospect. Only rarely is there a need to resort to oxytocic agents or to cesarean section. The recommended management is meperidine (Demerol) 100mg intramuscularly; this will allow most patients to rest and wake up in active labor.
Early decelerations occur before the onset of contractions and represent what type of nervous system response to increased intracranial pressure form the uterine pressure on the fetal head?
A Vagal response.
This is perhaps the most common form of anesthesia used for vaginal delivery. It provides adequate pain relief for episiotomy, spontaneous delivery, forceps delivery, or vacuum extraction. What type of anesthesia is this?
Pudendal nerve block.
This type of labor anesthesia was a popular form of anesthesia for the first stage of labor until it was implicated in several fetal deaths. It has been shown that this technique was associated with fetal bradycardia in 25-35% of cases, probably due to the response to rapid uptake of the drug from the highly vascular surrounding tissue with a resultant reduction of uteroplacental blood flow. Death in some cases was related to direct injection of the local anesthetic into the fetus. What type of anesthesia is this?
Paracervical block.
This type of anesthesia bock provides prompt and adequate relief for spontaneous and instrument-assisted delivery. The local anesthetic is injected at the level of the L4-L5 interspace with the patient sitting. Hypotension and a decrease in uteroplacental perfusion are common results of the profound sympathetic blockade caused by spinal anesthesia. What type of block is this?
Low spinal anesthesia (saddle block).
This form of labor anesthesia provides effective pain relief for the first and second stages of labor and for delivery. It may be associated with late decelerations suggestive of uteroplacental insufficiency in as many as 20% of cases, but the frequency of this complication may be reduced by prehydration of the mother and by avoiding the supine position. This type of block appears to lengthen the second stage of labor and is associated with an increased need for augmentation of labor with oxytocin and for instrument-assisted delivery. In experienced hands, however, this mode of anesthesia has an excellent safety record. What type of anesthesia is this?
Epidural block.
What type of labor is characterized by contractions that are irregular in timing and duration and do not result in any cervical dilation. The intensity of this type of labor does not change and the discomfort is mainly felt in the lower abdomen and is usually relieved by sedation. What type of labor is this?
False labor, or Braxton-Hicks contractions.
In the case of this type of labor, the uterine contractions occur at regular intervals and tend to become increasingly more intense with time. In this labor, the contractions tend to be felt in the patients back and abdomen, and cervical change occurs over time. Sedation does not stop the discomfort. What type of labor is this?
True labor.
What is the major complication of general anesthesia when performing C-sections?
Maternal aspiration, which can result in fatal aspiration pneumonitis.
This is perhaps the most common form of anesthesia used for vaginal delivery. It provides adequate pain relief for episiotomy, spontaneous delivery, forceps delivery, or vacuum extraction. What type of anesthesia is this?
Pudendal nerve block.
This type of labor anesthesia was a popular form of anesthesia for the first stage of labor until it was implicated in several fetal deaths. It has been shown that this technique was associated with fetal bradycardia in 25-35% of cases, probably due to the response to rapid uptake of the drug from the highly vascular surrounding tissue with a resultant reduction of uteroplacental blood flow. Death in some cases was related to direct injection of the local anesthetic into the fetus. What type of anesthesia is this?
Paracervical block.
This type of anesthesia bock provides prompt and adequate relief for spontaneous and instrument-assisted delivery. The local anesthetic is injected at the level of the L4-L5 interspace with the patient sitting. Hypotension and a decrease in uteroplacental perfusion are common results of the profound sympathetic blockade caused by spinal anesthesia. What type of block is this?
Low spinal anesthesia (saddle block).
This form of labor anesthesia provides effective pain relief for the first and second stages of labor and for delivery. It may be associated with late decelerations suggestive of uteroplacental insufficiency in as many as 20% of cases, but the frequency of this complication may be reduced by prehydration of the mother and by avoiding the supine position. This type of block appears to lengthen the second stage of labor and is associated with an increased need for augmentation of labor with oxytocin and for instrument-assisted delivery. In experienced hands, however, this mode of anesthesia has an excellent safety record. What type of anesthesia is this?
Epidural block.
What type of labor is characterized by contractions that are irregular in timing and duration and do not result in any cervical dilation. The intensity of this type of labor does not change and the discomfort is mainly felt in the lower abdomen and is usually relieved by sedation. What type of labor is this?
False labor, or Braxton-Hicks contractions.
In the case of this type of labor, the uterine contractions occur at regular intervals and tend to become increasingly more intense with time. In this labor, the contractions tend to be felt in the patients back and abdomen, and cervical change occurs over time. Sedation does not stop the discomfort. What type of labor is this?
True labor.
What is the major complication of general anesthesia when performing C-sections?
Maternal aspiration, which can result in fatal aspiration pneumonitis.
This is perhaps the most common form of anesthesia used for vaginal delivery. It provides adequate pain relief for episiotomy, spontaneous delivery, forceps delivery, or vacuum extraction. What type of anesthesia is this?
Pudendal nerve block.
This type of labor anesthesia was a popular form of anesthesia for the first stage of labor until it was implicated in several fetal deaths. It has been shown that this technique was associated with fetal bradycardia in 25-35% of cases, probably due to the response to rapid uptake of the drug from the highly vascular surrounding tissue with a resultant reduction of uteroplacental blood flow. Death in some cases was related to direct injection of the local anesthetic into the fetus. What type of anesthesia is this?
Paracervical block.
This type of anesthesia bock provides prompt and adequate relief for spontaneous and instrument-assisted delivery. The local anesthetic is injected at the level of the L4-L5 interspace with the patient sitting. Hypotension and a decrease in uteroplacental perfusion are common results of the profound sympathetic blockade caused by spinal anesthesia. What type of block is this?
Low spinal anesthesia (saddle block).
This form of labor anesthesia provides effective pain relief for the first and second stages of labor and for delivery. It may be associated with late decelerations suggestive of uteroplacental insufficiency in as many as 20% of cases, but the frequency of this complication may be reduced by prehydration of the mother and by avoiding the supine position. This type of block appears to lengthen the second stage of labor and is associated with an increased need for augmentation of labor with oxytocin and for instrument-assisted delivery. In experienced hands, however, this mode of anesthesia has an excellent safety record. What type of anesthesia is this?
Epidural block.
What type of labor is characterized by contractions that are irregular in timing and duration and do not result in any cervical dilation. The intensity of this type of labor does not change and the discomfort is mainly felt in the lower abdomen and is usually relieved by sedation. What type of labor is this?
False labor, or Braxton-Hicks contractions.
In the case of this type of labor, the uterine contractions occur at regular intervals and tend to become increasingly more intense with time. In this labor, the contractions tend to be felt in the patients back and abdomen, and cervical change occurs over time. Sedation does not stop the discomfort. What type of labor is this?
True labor.
What is the major complication of general anesthesia when performing C-sections?
Maternal aspiration, which can result in fatal aspiration pneumonitis.
What injury to the fetus is more common with forceps versus vacuum assisted delivery?
Corneal abrasions and ocular trauma.
Is there a higher rate of neonatal cephalhematomas, retinal hemorrhages, intracranial hemorrhages and jaundice associated with forceps or vacuum deliveries?
VACUUM DELIVERIES!!!
This type of tear seen during delivery involves the vaginal mucosa or perineal skin, but not the underlying tissue. What type of tear is this?
First-degree tear.
This type of tear seen during delivery involves the vaginal mucosa or perineal skin, and the underlying subcutaneous tissue is also involved, but not the rectal sphincter or rectal mucosa. What type of tear is this?
Second-degree tear.
This type of tear seen during delivery involves the vaginal mucosa or perineal skin, and the underlying subcutaneous tissue is also involved, as well as the rectal sphincter. What type of tear is this?
Third degree tear.
This type of tear seen during delivery involves the vaginal mucosa and extension into the rectal mucosa. What type of tear is this?
Fourth degree tear.
This phase of labor begins with the onset of regular uterine contractions and is accompanied by progressive but slow cervical dilation. This phase of labor ends when the cervical dilation rate reaches about 1.2cm/hr in the nulliparous patient and 1.5cm/hr in the multiparous patient. Which phase of labor is this?
Latent Phase of labor.
The latent phase of labor usually lasts less than 20 hours in the nulliparous or multiparous patient?
Nulliparous patient.
The latent phase of labor usually lasts less than 14 hours in the nulliparous or multiparous patient?
Multiparous patient.
To correct this prolonged phase of labor, it is generally recommended that a strong sedative such as morphine be administered to the patient. This is preferred over augmentation with Pitocin or performing amniotomy, because 10% of patients will actually have been in false labor and these patients will stop contracting after administration of morphine. If the patient is truly in labor, then after the sedative wears off she will have undergone cervical change and will have benefited from the rest in terms of having additional energy to proceed with labor. What prolonged phase of labor is this?
Latent phase.
Ambiguous genitalia at birth is a medical emergency, not only for psychological reasons for the parents, but also because hirsute female infants with congenital adrenal hyperplasia (CAH) my die if undiagnosed. CAH is an autosomally inherited disease of adrenal failure taht causes hyponatremia and hyperkalemia because of lack of mineralocorticoid. What is the best initial step in evaluation of such a patient?
A thorough physical exam; while it may not give the definitive diagnosis of the sex it can provide clues. Are gonads palpable in the inguinal canal? Are the labia fused? Is there hypo- or hypertension, or signs of dehydration?
Sheehan syndrome is a condition of anterior pituitary necrosis related to obstetric hemorrhage. Symptoms include amenorrhea, atrophy of the breasts, and loss of thyroid and adrenal function. How soon can Sheehan syndrome be diagnosed how soon after delivery?
By 1 week, as lactation fails to commence normally.
Puperpal fever from breast engorgement is relatively uncommon, affecting 13-18% of postpartum women. Temperatures range from 38-39 degrees C (100.4-102.2 degrees F). Pain is an early and common symptom. Treatment consists of breast support, ice packs, and pain relievers. How quickly does this condition appear postpartum?
24-48 hrs following initiation of lacteal secretion.
What hormone is involved in milk production in the breast feeding response?
Prolactin.
What hormone is responsible for causing milk to be expressed from the alveoli into lactiferous ducts?
Oxytocin.
Suckling suppresses the expression of what hormone-releasing factor, and as a result acts as a mild contraceptive?
Lutenizing hormone-releasing factor; because the midcycle surge of lutenizing hormone does not occur.
The clinical presentation of this condition classically occurs after cesarian delivery with signs of a pelvic infection with pain and fever. Following antimicrobial therapy, clinical symptoms usually resolve, but fever spikes may continue. Commonly, patients do not appear clinically ill. The diagnosis is made by CT or by MRI. Before these modalities were available, the heparin challenge test was advocated. Lysis of fever after IV administration of heparin was accepted as diagnostic for this condition. It seems, however, that the course of clinical symptoms is not changed significantly by administration of heparin. Diagnosis?
Septic pelvic thrombophelbitis.
This condition occurs postpartum more often in the primiparous or older patient. They may have had a long interval between pregnancies, an unplanned pregnancy, or be without a supportive partner. Patients that have histories of depression or postpartum depression are at increased risk for development of this condition. Diagnosis?
Post-partum depression!!!
The most common offending organism in puerperal mastitis is Staph aureus, which is probably transmitted from the infants nose and throat. A culture of breast milk should be done prior to initiation of antibiotic therapy. What is the treatment of choice for Mastitis?
Dicloxicillin, a penicillinase-resistant antibiotic, is the initial treatment of choice?
The most common offending organism in puerperal mastitis is Staph aureus, which is probably transmitted from the infants nose and throat. A culture of breast milk should be done prior to initiation of antibiotic therapy. What is the treatment of choice for Mastitis in penicillin allergic patients?
Erythromycin!!!
An inability to void in often leads to inspection of the vagina and diagnosis of this lesion in the postpartum period. Such lesions are large enough to apply pressure on the urethra and cause an absence of voiding. Midline lacerations and side wall lacerations are predisposing conditions. Diagnosis?
Vulvar hematoma; pain from urethral lacerations is is another reason why women have difficulty voiding after delivery.
Breast feeding is inadvisable when the mother is being treated with antimitotic drugs, tetracyclines, diagnostic or therapeutic radioactive substances, or this psychiatric drug used to treat mood disorders.
Lithium carbonate.
Bloody lochia can persist for how long postpartum, without indicating underlying pathology?
2 weeks.
If this symptom persists beyond 2 weeks postpartum, it may indicate placental site subinvolution, retention of small placental fragments, or both. What persistent symptom would this be?
Bloody lochia.
The etiology of metritis, like that of all pelvic infections, is polymicrobial. Therefore, the antibiotic coverage selected should treat aerobic and anaerobic organisms. Common aerobes associated with metritis are staphylococci, streptococci, enterococci, E.coli, Proteus, and Klebsiella. The anaerobic organisms associated with pelvic infections are most commonly Bacteroides, Peptococcus, Peptostreptococcus, and clostridium. Generally a broad spectrum, such as the cephalosporins cefotetan or cefotoxin, is administered IV. The antibiotic therapy should be continued until what end point?
Until the patient has been afebrile for at least 24 hours.
Postpartum depression is characterized by an onset about 2 weeks to 12 months post-delivery, with an average duration of 3 to 14 months. Women with postpartum depression have the following symptoms: irritability, labile mood, difficulty sleeping, phobias and anxiety. What percentage of women develop postpartum depression?
8-15%.
About 50% of women experience this condition within 3 to 6 days after delivering. This mood disturbance is thought to be precipitated by progesterone withdrawal following delivery and usually resolves within 10 days. Diagnosis?
Postpartum blues.
About 40% of women elect not to breast-feed. These women experience milk leakage, engorgement, and breast pain that begins 3 to 5 days postpartum. Ice packs applied to breasts a well-fitting bra or binder, and analgesics are all appropriate methods to manag engorged breasts. This drug, used to lower prolactin levels and suppress lactation, is no longer recommended in postpartum women because this medication has been associated with an increased risk of stroke, myocardial infarction, seizures, and psychiatric disturbances. What drug is this?
Bromocriptine!!!
Use of an IUD, barrier methods, and hormonal contraceptive agents containing progestins are all appropriate methods of birth control for breast feeding women. Why is it best for breast-feeding mothers to avoid estrogen containing contraceptives?
Because estrogen preparations can inhibit lactation or decrease milk supply.
Mammography should be performed how often in women over 50 years old?
Annually.
Postmenopausal women, who are not on hormone replacement therapy and all women 65 years or older should be screened for osteoporosis with what test to determine bone mineral density?
DEXA scan.
How often should women more than 65 years old undergo cholesterol screening?
Every 3-5 years.
How often should women more than 65 years old undergo fasting glucose screening?
Every 3 years.
How often should women more than 65 years old undergo Thyroid screening with TSH?
Every 3-5 years.
A urinalysis that is positive for blood should be followed up with what test before further workup is done and referral to a urologist is made?
Urine culture to test for asymptomatic UTI.
In order of decreasing incidence, the following are the leading causes of death in women over what age?: diseases of the heart, cancer, cerebrovascular disease, COPD, pneumonia and influenza, DM, accidents, and Alzheimer's.
> 65 years.
In order of decreasing frequency, the following are the leading causes of death in women over what age?: MVA, homicide, suicide, cancer, all other accidents, diseases of the heart, congenital anomalies, and COPD.
Teenagers 13-18 years old.
This vaccine is indicated in immunocompromised persons, those with chronic illnesses, and individuals more than 65 years old. Which vaccine is this?
Pneumococcal vaccine.
This vaccine is especially indicated in pregnant women, individuals with chronic disease, and those in long-term-care facilities. Which vaccine is this?
Influenza vaccine.
This type of speculum works best for nulliparous women and menopausal women with atrophic vaginas; the blades are flat and narrow and barely curve on the sides. Which speculum is this?
Pederson.
This blades of this speculum are wider, higher, and curved on the sides; they work better for parous women with looser vaginal walls. Which speculum is this?
Graves.
In order of decreasing incidence, the following are the leading causes of death in women over what age: cancer, diseases of the heart, cerebrovascular disease, accidents, COPD, DM, chronic liver disease and cirrhosis, pneumonia and influenza.
Women aged 40-64 years.
This type of cyst arises from embryonic remnants of the mesonephric duct that courses along the lateral vaginal wall. These are usually small and asymptomatic and are found incidentally during pelvic examination. They can be followed conservatively unless the patient become symptomatic, at which time excision is recommended. Diagnosis?
Gartner duct cyst.
These cysts are usually seen on the posterior vaginal surface. They are the most common vaginal cysts and result from birth trauma or previous GYN surgery. Diagnosis?
Inclusion cyst.
This cyst is the most common large cyst of the vulva. The ducts that this cyst arises from open into a groove between the hymen and the labia minora on the posterior vaginal opening. Diagnosis?
Bartholin duct cyst.
In women 40 to 64 years old, how often should mammography be performed?
Every 1-2 years, until age 50 and then annually.
Migraine HA's, accompanied by neurologic symptoms such as loss of vision, parasthesias, and numbness are generally considered to be contraindications to what type of contraceptive therapy?
Combination oral contraceptive therapy.
These are the most common germ cell tumors and they account for about 20-25% of all ovarian neoplasms. They occur primarily during the reproductive years, but may also occur in postmenopausal women and children. They are usually unilateral, but 10-15% are bilateral. Usually these tumors are asymptomatic, but they can cause severe pain if there is torsion or if the contain material perforates and spills and creates a reactive peritonitis. Diagnosis?
Benign cystic teratoma (Dermoid cyst).
What is the appropriate treatment for a woman older than 40 years of age, who presents with a symptomatic cystic or solid mass in the area of the Bartholin gland?
Surgical excision; although rare, adenocarcinoma of the Bartholin gland must be excluded in a woman over 40 years of age. The appropriate treatment in these cases is surgical excision of the Bartholin gland to allow for a careful pathologic examination. In the case of the asymptomatic Bartholin cyst, no treatment is necessary.
What is the treatment of microinvasive carcinoma of the cervix?
Simple hysterectomy.
What is the most radiosensitive tissue in the pelvis?
Ovarian tissue.
Approximately 20% of ovarian neoplasms are considered malignant on pathologic examination. Still, all must be considered as placing the patient at risk. Given that most ovarian tumors are not found until significant spread has occurred, it is not unreasonable to attempt to operate on such patients as soon as there is a suspicion of tumor. Papillary vegetation, size greater than 10 cm, ascites, possible torsion, or solid lesions are automatic indications for what intervention?
Exploratory laparotomy.
In a younger women an ovarian mass can be followed for what length of time, in order to determine if it is a follicular (physiologic) cyst?
The length of 1-2 menstrual cycles; since a follicular cyst should regress after onset of the next menstrual period. If regression does not occur, then surgery is appropriate.
This procedure involves excision of the uterus, the upper third of the vagina, the uterosacral and uterovesical ligaments, and all of the parametrium, and pelvic node dissection including the ureteral, obturator, hypogastric, and iliac nodes. It is most often used as the primary treatment for early cervical cancer (stages Ib-IIa). What procedure is this?
Radical Hysterectomy; this procedure thus attempts to preserve the bladder, rectum, and ureters while excising as much as possible of the remaining tissue around the cervix that might be involved in microscopic spread of the disease. Preservation of the ovaries is generally acceptable, particularly in younger women unless there is some reason to consider oophorectomy.
The most common ovarian neoplasms in young women in their teens and early twenties are of germ cell origin, and about half of these tumors are malignant. Functioning ovarian tumors have been reported to produce precocious puberty in about 2% of affected patients. Epithelial tumors of the ovary, which are quite rare in pubertal girls, are benign in approximately 90% of all cases. What is an example of a malignant epithelial tumor that might be found in a younger patient?
Papillary serous cystadenocarcinoma.
Sarcoma botryoides is a malignancy associated with Mullerian structures such as the vagina and uterus, including the uterine cervix. What age group is this seen in?
Children.
This is the most common epithelial tumor of the ovary. On histological examination, psammoma bodies can be seen in approximately 30% of these tumors. Bilateral involvement (buzz word) characterizes about 1/3 of these tumors. Diagnosis?
Serous carcinoma.
Mesonephroid carcinomas are associated with what chronic pelvic pain condition/neoplastic condition?
Endometriosis.
Patients with this condition of the vulva tend to be older; they typically present with pruritis, and the lesions are usually white with crinkled skin and well-defined borders. The histological appearance includes loss of the rete pegs within the dermis, chronic infiltrate below the dermis, the development of a homogenous subepithelial layer in the dermis, a decrease in the number of cellular layers, and a decrease in the number of melanocytes. Mechanical trauma produces bullous areas of lymphedema and lacunae, which are then filled with erythrocytes. Ulcerations and ecchymoses may be seen in the traumatized regions as well. Mitotic figures are rar in this condition, and hyperkeratosis is not a feature. While a significant cause of symptoms, this condition is not a premalignant condition. Its importance lies in the fact that it must be distinguished from vulvar squamous cancer. Diagnosis?!?
Lichen sclerosis (formerly lichen sclerosis et. atrophicus; but recent studies indicate that atrophy does not exist.)
What are the four HPV strains associate with cervical malignancy?
16, 18, 31, 45.
What are the two HPV strains are most associated with benign condyloma?
HPV 6 and 11.
These tumors represent less than 1% of ovarian tumors and may produce symptoms of virilization. Histologically they resemble fetal testes; clinically these tumors must be distinguished from other functioning ovarian neoplasms as well as from tumors of the adrenal glands, since they produce androgens. The androgen production can result in seborrhea, acne, menstrual irregularity, hirsutism, breast atrophy, alopecia, deepening of the voice, and clitoromegaly. DIagnosis?
Sertoli-Leydig cell tumors.
These ovarian tumors are often associated with excessive strogen production, which may cause pseudoprecocious puberty, postmenopausal bleeding, or menorrhagia. This neoplasm is associated with endometrial carcinoma in 15% of patients. Because these tumors are quite friable, affected women frequently present with symptoms caused by tumor rupture and intraperitoneal bleeding. Diagnosis?
Granulosa-Theca cell tumors.
This ovarian tumor frequently contains calcifications that can be detected by plain radiograph of the pelvis. Women who have these neoplasms often have ambiguous genitalia. The tumors are usually small and are bilateral in 1/3 of affected women (like serous carcinoma). Diagnosis?
Gonadoblastoma.
The malignant potential of a teratoma correlates with what histological feature?
The degree of immature embryonic tissue present.
In a Teratoma, the presence of choriocarcinoma can be determined histologically as well as by hCG assay. How would this finding affect the patient's prognosis?
The presence of choriocarcinoma in an immature teratoma worsens the prognosis.
These tumors are typically bilateral, solid masses of the ovary that nearly always represent metastases from another organ, usually the stomach or large intestine. They contain large numbers of signet ring adenocarcinoma cells within a cellular hyperplastic but nonneoplastic ovarian stroma. Diagnosis?
Krukenberg tumor.
Production of allergic reactions and bone marrow suppression are side effects seen with what chemotherapeutic agent?
Taxol.
In young, menstruating women, these are the most common reason for an enlargement of one ovary. This type of ovarian cyst is usually asymptomatic, unilateral, thin-walled, and filled with a watery, straw-colored fluid. Diagnosis?
Functional cyst, which is physiologic and forms during the normal functioning of the ovaries.
These types of ovarian cysts are less common, are usually unilateral, but often appear complex, as they may be hemorrhagic. Patients with this type of ovarian cyst may complain of a dull pain on the side of the affected ovary. Diagnosis?
Corpus luteum cyst.
This ovarian cyst is the least common of all three types of functional ovarian cysts. They are almost always bilateral and are associated with pregnancy. Diagnosis?
Theca-lutein cyst.
Lymphogranuloma venerum is a chronic infection most commonly found in the tropics. The primary infection begins as a painless ulcer on the labia or in the vaginal vestibule; the patient usually consults the physician several weeks after the development of painful adenopathy in the inguinal and perirectal areas. Diagnosis can be established by culture or by demonstrating the presence of serum antibodies to what bacterium?
Chlamydia trachomatis.
Donovan bodies are present in patients with Granuloma inguinale. Therapy for this disease as well as LGV is administration of tetracycline. What is the bacteria responsible for causing Granuloma inguinale?
Chlamydia granulomatis.
The antibody titer for HIV becomes positive approx. how many weeks after exposure?
4 to 10 weeks after exposure; because of the occasional delayed appearance of the antibody after initial exposure, it is important to follow up patients for 1 year after exposure.
1) Unsatisfactory colposcopic examination (i.e. the entire transformation zone cannot be seen), 2) a colposcopically directed cervical biopsy that indicates the possibility of invasive disease, 3) neoplasm in the endocervix, 4) cells seen on cervical biopsy that do not adequately explain the cells seen on cytologic examination (ie the Pap), are all indications for what next step?
Cone biopsy.
This is a syndrome of unknown etiology. To make the diagnosis of this disorder, the following three findings must be present: 1) severe pain on vestibular touch or attempted vaginal entry, 2) tenderness to pressure localized with in the vulvar vestibule, 3) visible findings confined to vulvar erythema of of various degrees. To treat this condition the first step is to avoid tight clothing, tampons, hot tubs, and soaps which can all act as vulvar irritants. If this fails topical treatments include lidocaine, estrogen, and steroids. TCAs and intralesional interferon injections have also been used. For women refractory to medical therapy, surgical excision of the vestibular mucosa may be helpful. Diagnosis?
Vulvar vestibulitis.
This is a precancerous lesion of the vulva that has a tendency to progress to frank cancer. Women with this condition complain of vulvar pruritus, chronic irritation, and raised lesions. These lesions are most commonly located along the posterior vulva and in the perineal body and have a whitish cast and rough texture. What is this condition?
Vulvar intraepithelial neoplasia (VIN).
How are pregnant women with bacterial vaginosis treated?
The same way that non-pregnant women are treated; Metronidazole 500 mg BID x 7 days.
Diflucan is used in the treatment of what gynecological condition?
Candidiasis.
The classical lesion of strawberry cervix is associated with vaginal Trichomonas infection. What is the appropriate treatment for a diagnosed Trichomonas infection?
One-time dose of Metronidazole 2g PO.
Postmenopausal patients with atypical complex hyperplasia of the endometrium have a 25% to 30% risk of having an associated endometrial carcinoma in the uterus. For this reason, hysterectomy is the recommended treatment. If hysterectomy is not medically advisable what is an alternative therapy that can be used?
Continuous high-dose progesterone therapy.
Absolute contraindications to postmenopausal HRT include the presence of estrogen-dependent tumors (breast or uterus), active thromboembolic disease , undiagnosed genital tract bleeding, active severe liver disease, or malignant melanoma. How does a past or current history of HTN, DM, or biliary stones affect the patient's ability to qualify for HRT?
HTN, DM, and biliary stones do not affect a patient's ability to qualify for HRT.
In the United States the appearance of breast buds (thelarche) is usually the first sign of female puberty, generally occurring between the ages of 9 and 11 years. This is subsequently followed by the appearance of pubic and axillary hair (adrenarche or pubarche), the adolescent growth spurt, and finally menarche. These events are considered to be delayed if thelarche has not occurred by the age of 13, adrenarche by the age of 14, or menarche by the age of 16. On average, this sequence of developmental changes take about how long to complete?
4.5 years; with a range of 1.5 to 6 years.
What are the average ages of adrenarche/pubarche (appearance of axillary and pubic hair) and menarche?
11.0 and 12.8 years respectively.
This syndrome, also called polyostotic fibrous dysplasia) is relatively rare and consists of fibrous dysplasia and cystic degeneration of the long bones, sexual precocity , and cafe au lait spots on the skin. Diagnosis?
McCune-Albright syndrome.
In North America, pubertal changes before what age, are regarded as precocious?
Before the age of 8 in girls and 9 in boys.
A major menopausal health issue is osteoporosis, which can result in fractures of the vertebral bodies, humerus, upper femur, forearm, or ribs. Patients with vertebral fractures experience back pain, GI motility disorders, restrictive pulmonary symptoms, and loss of mobility. There may be a gradual decrease in height as well. Although all races experience osteoporosis, white and asian women lose bone earlier and at a more rapid rate than black women. Thin women and those who smoke are at increased risk for developing osteoporosis. How does physical activity affect the bones of postmenopausal women?
Increases the mineral content.
Significant emotional concerns develop when puberty is delayed. By definition, if breast development has not begun by age 13, delayed puberty should be suspected. Menarche usually follows 1 to 2 years after thelarche (breast development); if menarche is delayed beyond the age of 16, delayed puberty should be investigated. Hypergonadotropic hypogonadism is seen in girls with gonadal dysgenesis, such as occurs with Turner syndrome. An FSH value greater than what level, define hypertrophic hypogonadism as a cause of delayed puberty?
> 40 mIU/mL.
Dysmenorrhea is considered secondary if associated with pelvic disease such as endometriosis, uterine myomas, or PID. Primary dysmenorrhea is associated with a normal pelvic examination and with ovulatory cycles. The pain of dysmenorrhea is usually accompanied by other symptoms (nausea, fatigue, diarrhea, and HA), which may be related to excess of what prostaglandin?
F2a (F-2-alpha); the two major drug therapies effective in treating dysmenorrhea are OCPs and antiprostaglandins, such as NSAIDS.
Danazol is used to treat what gynecologic condition?
Endometriosis.
Ergot derivatives are used to treat what hyperhormone condition?
Hyperprolactinemia.
This condition produces a state of hypogonadotropic hypogonadism, and it should be suspected in an amenorrheic patient of normal stature with delayed or absent pubertal development, especially when associated with the classic finding of anosmia. Testing the sense of smell with coffee or perfume is a simple way to screen for this disorder. These individual have a structural defect of the CNS involving the hypothalamus and the olfactory bulbs (located in proximity to the hypothalamus) such that the hypothalamus does not secrete GnRH in a normal pulsatile fashion, if at all. Diagnosis?
Kallmann syndrome.
Failed fusion of the Mullerian ducts can give rise to several types of uterine anomalies of which bicornuate uterus is a representative type. This condition is associated with higher risk of obstetric complications, such as an increase in the rate of second trimester abortion and premature labor. If these pregnancies fo to term, malpresentations such as breech and transverse lie are more frequent. Also, prolonged labor (probably attributed to inadequate muscle development in the uterus), increased bleeding, and a higher incidence of fetal anomalies caused by defective implantation of the placenta all occur more commonly than in normal pregnancies. What type of test should be done to rule out anomalies in what other organ system, when you find a patient with Mullerian anomalies such as bicornuate uterus?
IVP or urinary tract ultrasound is mandatory in patients with Mullerian anomalies since approx. 30% will have coexisting congenital urinary tract anomalies.
This condition presents with symptomatic disease that primarily occurs is multiparous women over the age of 35 years compared to endometriosis, in which onset is considerably younger. patients with this condition complain of dysmenorrhea and menorrhagia, and the classical examination findings include a tender, symmetrically enlarged uterus without adnexal tenderness. Diagnosis?
Adenomyosis.
The physical examination of these patients with this condition more commonly reveals a fixed, retroverted uterus, adnexal tenderness and scarring, and tenderness along the uterosacral ligaments. Diagnosis?
Endometriosis.
What is the most important indication for surgery in women who have a double uterus?
Habitual abortion; the abortion rate in women who have a double uterus is two to three times greater than that of the general population. Therefore, women who present with habitual abortion should be evaluated to detect a possible double uterus. Hysterosalpingography, hysteroscopy, ultrasound, CT, and MRI are all potentially useful modalities in this investigation. Dysmenorrhea, premature delivery, dyspareunia, and menometrorrhagia are other, less important indicators for surgical intervention.
In an amenorrheic patient who has had pituitary ablation for craniopharyngioma, what treatment is used in order to create and ovulatory cycle?
Exogenous gonadotropin (FSH and LH) in the form of human menopausal gonadotropin (hMG). hMG contains an extract from urine from postmenopausal women with FSH and LH in varying ratios. Recombinant human FSH (rhFSH) is now also available. Carefully timed administration of hCG, which takes the place of an endogenous LH surge, will be needed to complete oocyte maturation and induce ovulation.
This fertility drug works by competing with endogenous circulating estrogens for estrogen binding sites in the hypothalamus. Therefore, it blocks the normal negative feedback of the endogenous estrogens and stimulates release of endogenous GnRH. Which fertility drug is this?
Clomiphene citrate.
There is a marked increase in levels of serum prolactin during pregnancy to over 10 times those values seen in nonpregnant women. The physiologic significance of increasing prolactin in pregnancy is what?
The increase is involved in preparation of the breasts for lactation.
Parlodel is a dopamine agonist used to treat what condition?
Hyperprolactinemia.
Medical treatment of endometriosis currently involves a selection of four medications- OCPs, continuous progestins, Danazol, and GnRH analogues. Surgery, both via a laparoscopic approach and laparotomy is also used to treat endometriosis. Which was one of the first medical treatments used for endometriosis, but one that is not used as often today as it once was?
Uninterrupted (acyclic) administration of high-dose OCPs for prolonged periods of time.
Medical treatment of endometriosis currently involves a selection of four medications- OCPs, continuous progestins, Danazol, and GnRH analogues. Surgery, both via a laparoscopic approach and laparotomy is also used to treat endometriosis. Which therapy has problems associated with it that include breakthrough bleeding and depression? Overall the side effects of the therapy in question are less than those seen with other treatments in most patients, and this therapy is generally reserved for those patients who do not desire fertility. Which therapy is this?
Continuous progestin.
Medical treatment of endometriosis currently involves a selection of four medications- OCPs, continuous progestins, Danazol, and GnRH analogues. Surgery, both via a laparoscopic approach and laparotomy is also used to treat endometriosis. Which therapy involves administering an isoxazol derivative of 17-alpha-ethinyl testosterone, which has been characterized as a pseudomenopausal treatment for endometriosis. Side effects of this therapy include weight gain, edema, decreased breast size, acne, and other menopausal symptoms. Which treatment is this?
Danazol.
Medical treatment of endometriosis currently involves a selection of four medications- OCPs, continuous progestins, Danazol, and GnRH analogues. Surgery, both via a laparoscopic approach and laparotomy is also used to treat endometriosis. This treatment is the most recent addition to the armamentarium against endometriosis. These agents produce a medical oophorectomy. Which treatment is this?
GnRH analogue treatment.
In patients with abnormal bleeding who are not responding to standard therapy, what should the next step in management be?
Hysteroscopy; this can rule out endometrial polyps or small fibroids, which if present, can be resected.
Danazol is a prgestational compound derived from testosterone that is used to treat endometriosis. It induces a pseudomenopause, but does not alter basal gonadotropin levels. It appears to act as an antiestrogen and causes endometrial atrophy. Cyclic menses return almost immediately on withdrawal of danazol. How long should be allowed to pass, however, before conception is attempted?
Three menstrual cycles should be allowed to pass before conception is attempted because it is felt that the endometrium is poorly developed with danazol use. Allowing the three cycles to pass will help avoid a higher risk of spontaneous abortion, which could result from implantation in this poorly developed endometrium.
This term is defined as infrequent, irregular uterine bleeding greater than 35 days apart, and is often attributed to anovulation. What is the term called?
Oligomenorrhea; hypomenorrhea is a lighter menstrual flow than normal; amenorrhea is no menstrual flow.
Hysteroscopy with lysis of adhesions is the treatment of choice for what uterine syndrome?
Asherman syndrome.
In premenopausal adult women, most of the estrogen in the body is derived from ovarian secretion of estradiol. In certain patients, however, there can be a increased production of estrone, which will be higher provoking of anovulation and endometrial hyperplasia. What condition exists in these patients to produce higher-than-normal amounts of estrone?
Increased adiposity/obesity; a significant portion of the body's estrogen comes from peripheral conversion of androstenedione to estone in adipose tissue. When there is an increase in fat cells, as in an obese person, estrogen levels (particularly Estrone) are increased.
An abnormal luteal phase is defined as ovulation with poor progestational effect in the second half of the cycle. Luteal function is usually evaluated at the endometrium, which is inadequately prepared for embryo implantation. Therefore what test should be used to evaluate the luteal phase?
Endometrial biopsy is crucial to the diagnosis of this defect because the endometrium will be out of phase with the time of the cycle in these patients. For example, a biopsy taken on day 26 of the cycle will resemble endometrium of day 22 because of decreased progesterone stimulation. Progesterone levels in the mid-luteal phase less than 7 ng/mL are suggestive of a luteal phase defect but not diagnostic.
For many years contraceptives were the most frequently used medical therapy in treatment of PCOS hirsutism. They can suppressing hair growth in up to 2/3 of patients. They act by directly suppressing ovarian steroid production and by increasing hepatic-binding globulin production, which binds circulating hormone and lowers the concentration of of metabolically active (free unbound) androgen. Clinical improvement, however, can take as long as 6 months to manifest. Other medications that have shown promise include medroxyprogesterone acetat, spironolactone,, cimetidine, and GnRH agonists, which suppress ovarian steroid production. GnRH agonists are expensive, however, and have been associated with what significant side effect?
Bone demineralization after only 6 months of use.
Conservative measures for treating dysmenorrhea include heating pads, mild analgesics, sedatives, or antispasmodic drugs, and outdoor exercise. In patients with dysmenorrhea, there is a significantly higher than normal concentration of prostaglandins in the endometrium and menstrual fluid. Prostaglandin synthase inhibitors such as indomethacin, naproxen, ibuprofen, and mefenamic acid are very effective in these patients. For patients who are sexually active with dysmenorrhea, however, OCPs will provide the needed protection from unwanted pregnancy and generally alleviate the dysmenorrhea. What is the mechanism of action of the OCPs in treating the dysmenorrhea?
The OCPs minimize endometrial prostaglandin production during the concurrent administration of estrogen and progestin.
Normal signs of puberty involve breast budding (thelarche, 9.8 years), pubic hair (pubarche, 10.5 years), and menarche (12.8 years). Besides and increase in androgens and a moderate rise in FSH and LH levels, one of the first indications of puberty is a increase in the amplitude and frequency of nocturnal pulses of what hormone?
LH.
An older woman gives a classic presentation with a history of changing from regular, monthly periods to irregular, infrequent episodes of vaginal bleeding. Patients with this diagnosis often have underlying medical problems such as diabetes, thyroid problems, or PCOS. Diagnosis?
Chronic anovulation in an older woman.
In patients who have suffered heavy and acute bleeding attributed to anovulation, what is the preferred medical management?
Administration of high-dose estrogen therapy; 25 mg of conjugated estrogen can be administered q4 hours until bleeding abates. The estrogen will help stop the bleeding by building up the endometrium and stimulating clotting at the capillary level. If bleeding is heavy and acute, a D&C will not help stop the bleeding m because the lining is already thinned and atrophic. In older women, a D&C might be helpful in obtaining tissue for pathology to rule out endometrial cancer.
The us of combined HRT does not increase the risk of uterine cancer, colon cancer, or Alzheimer disease. There is much literature to support the idea that HRT use decreases the risk of colon cancer and Alzheimer disease. It is also well est. that the use of ERT/HRT increases the user's risk of what vascular complication?
Thromboembolic event; risk is increased 2-3 fold.
How does estrogen affect levels of cholesterol and LDL?
Decreases.
How does estrogen affect levels of HDL and triglycerides?
Increases.
What is the first physical symptom of declining ovarian function?
Hot flush; these may begin several years before the cessation of menstruation
This represents premature activation of a normally operating hypothalamic-pituitary axis. Although it is usually idiopathic, it can arise from cerebral causes such as tumors or a history of encephalitis or meningitis, as well as from hypothyroidism, polyostotic fibrous dysplasia, neurofibromatosis, or other disorders. Diagnosis?
True sexual precocity.
In girls who have this disorder, the endocrine glands, usually under neoplastic influences, produce elevated amounts of estrogens (isosexual type) or androgens (heterosexual type). Ovarian tumors appear to be the most common cause of the isosexual type of this disorder; some ovarian tumors, including dysgerminomas and choriocarcinomas, can produce so much gonadotropin that pregnancy tests are positive. Diagnosis?
Precocious pseudopuberty.
What is the most common cause of fecal incontinence in a multiparous woman?
Obstetric trauma with inadequate repair.
This procedure is a reasonable option for elderly patients who are not good candidates for vaginal hysterectomy and anterior and posterior repair as a treatment for vaginal and uterine prolapse. This technique involves parital denudation of opposing surfaces of the vaginal mucosa followed by surgical apposition, thereby resulting in partial obliteration of the vagina. Patients who are candidates for this procedure must have no evidence of cervical dysplasia or endometrial hyperplasia, have an atrophic endometrium, and no longer desire sexual function. Urinary incontinence can be a side effect of this procedure, so in a patient who already has urinary in continence, this operation would be relatively contraindicated. What procedure is this?
Le Fort operation.
Although the actual number of deliveries is probably not important, traumatic deliveries, especially those in which the rectal sphincter is lacerated or improperly repaired, have been associated with this condition. Diagnosis?
Pelvic relaxation.
There are many procedures that will provide successful correction of stress urinary incontinence. This is one of the abdominal procedures that successfully cures stress incontinence, which involves the attachment of the periurethral tissue to the symphysis pubis. The long-term cure rate for this procedure is around 80%. In approx 1% to 2% of patients undergoing the procedure, the painful debilitating condition of osteitis pubis will develop. Treatment of this aseptic inflammation of the symphysis is suboptimal, and the course is usually chronic. What is this procedure?
The Marshall-Marchetti-Krantz procedure.
This urethral condition occurs in 3% to 4% of all women. The typical symptoms include urinary frequency, urgency, dysuria, hematuria, and dyspareunia. Frequently patients will have a history of UTIs, dribbling, or incontinence. There is often a palpable mass on the anterior vaginal wall under the urethra. Although urethral polyps, eversion, fistula, and stricture may present with similar symptoms there would be not urethral mass present. Diagnosis of the condition in question?
Urethral diverticulum.
If a patient most likely has a ureteral injury after a gynecological surgery, what is the best test to make the diagnosis?
Renal ultrasound; it is non-invasive, fast, inexpensive, and accurate. IVPs are outdated and have been replaced by the use of CT. A CT with contrast gives excellent information on the integrity and function of the renal collecting system; however if the serum creatinine is elevated, IV contrast can cause significant renal damage and is contraindicated in these circumstances.
The primary reason to perform a cystometrogram is to rule out uninhibited detrussor contractions. A catheter is introduced for performing a cystometrogram and measurement of residual urine is obtained. A normal first sensation of fullness is felt at what volume?
100 mL.
The primary reason to perform a cystometrogram is to rule out uninhibited detrussor contractions. A catheter is introduced for performing a cystometrogram and measurement of residual urine is obtained. Urgency is felt at approx. what volume?
350 mL.
The primary reason to perform a cystometrogram is to rule out uninhibited detrussor contractions. A catheter is introduced for performing a cystometrogram and measurement of residual urine is obtained. Max capacity of the bladder is about what volume?
450 mL.
Anticholinergic drugs such as Ditropan are used to relax the bladder in the treatment of detrussor instability. What drug is this?
Oxybutinin chloride.