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104 Cards in this Set
- Front
- Back
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Normal rate of hCG rise early in pregnancy
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Doubles every 48 hours
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Which supplements are recommended for all pregnancies?
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Folic acid
Iron Calcium Vit D, Vit B12 for vegetarians |
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How does respiration change with pregnancy?
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RR unchanged
Vt increases = Ve increases! Expiratory reserve decreases |
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TORCH infections
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Toxoplasma
Other (see below) Rubella CMV HIV, HSV Other: - Parvovirus - Syphilis - Varicella - Mumps - Listeria - TB - Malaria - Fungi |
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What prenatal testing is done on initial visit?
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Heme:
- CBC - HbA1c - Sickle cell screening if indicated - Rh factor - Type and screen ID: - UA/culture - Rubella Ab titer - HBsAg - RPR/VDRL - Cervical gonorrhea, chlamydia - PPD - HIV - Pap smear - HCV - Varicella Genetic screening: - Tay-Sachs - Cystic fibrosis |
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What is the screening for Down syndrome/Edward syndrome? When is it done?
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PAPP-a + nuchal transparency + free hCG - can detect 90% of Down, 95% of Edward
Available 9-14 weeks |
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When is CVS/amnio offered?
What are the risks/disadvantages of these tests? |
CVS: 10-12 weeks
Amnio: 15-20 weeks CVS - Risk of fetal loss 1% - Cannot detect open NTDs Amnio: - PROM - Chorioamnionitis - Fetal-maternal hemorrhage |
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When is Quad Screening offered?
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15-20 weeks (same time as amnio)
MSAFP hCG Estriol Inhibin |
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When is full anatomic screening U/S done?
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18-20 weeks
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When is 1 hr OGTT done? Describe the test. How is the test interpreted?
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24-28 weeks
Given glucose solution to drink (50g glucose) and accucheck done 1 hr later < 140: normal > 140: requires 3 hr OGTT to confirm > 200: gestational diabetes for sure |
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When should Rhogam be given to Rh (-) women? (6)
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1. At 28-30 weeks (if father is Rh (+) or unknown)
2. Post-partum if Rh (+) infant 3. At time of procedures or conditions with possible maternal-fetal bleeding (CVS, amnio, abdominal trauma, previa/abruption) 4. After ectopic pregnancy 5. After threatened, spontaneous, induced abortion 6. Unexplained vaginal bleeding |
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What is tested in the last few weeks of pregnancy/prior to delivery?
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GBS
Gonorrhea/chlamydia HIV RPR |
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Quad screen interpretation
1. All low 2. hCG, inhibin elevated |
1. Edwards (trisomy 18)
2. Down (trisomy 21) |
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What are the indications for amniocentesis? (4)
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1. Women > 35 yo at time of delivery
2. Abnormal quad screen 3. Rh-sensitized pregnancy to determine fetal blood type or hemolysis 4. Evaluate fetal lung maturity - L:S ratio >= 2.5 |
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Blueberry muffin rash
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Rubella
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Describe threatened, inevitable, and missed abortions
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Threatened
- No POC expelled, but +bleeding/abdominal pain - Closed os + intact membranes + fetal cardiac motion on U/S Inevitable - No POC are expelled, but +bleeding/pain - Open os +/- ROM Missed - No POC are expelled - No bleeding - Closed os but no fetal cardiac activity |
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Mifepristone and misoprostol MOA
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Mifepristone - progesterone receptor antagonist
Misoprostol - PGE1 |
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Options for elective pregnancy termination and "deadlines"
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Up to 7 weeks GA (49 days)
1. Mifepristone + misoprostol 2. Methotrexate + misoprostol 3. High dose misoprostol Up to 13 weeks GA 4. Manual aspiration 5. D&C with vacuum aspiration 13-24 weeks, depending on state law 6. Induction of labor (misoprostol, oxytocin, AROM) 7. D&E |
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Dilation
Effacement Station |
Dilation of the cervical os (cm)
Effacement - shortening of the cervix (%) Station - how low head is in the pelvis - -5 to +5 - 0 is ischial spine and sign of engagement of the pelvis, having negotiated the pelvic inlet |
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Stages of labor
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1. First
- Latent: onset to 4cm dilation - Active: >4cm dilation 2. Second - Complete dilation until delivery 3. Third - After delivery of infant until delivery of placenta 4. Fourth - Immediate post-partum period (~2hr) |
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Explain fetal heart rate monitoring, including normal and pathologic findings
- Rate - Variability - Accels - Decels |
1. Rate
- Normal 110-160 - Bradycardia: congenital heart disease vs severe hypoxia (e.g. uterine hyperstimulation, cord prolapse, rapid fetal descent) - Tachycardia: hypoxia, maternal fever, fetal anemia 2. Variability - Undetected: fetal distress - Minimal (< 6 bpm): fetal hypoxia or opioids, Mg, sleep cycle - Moderate (6-25 bpm): normal - Marked (> 25 bpm): fetal hypoxia 3. Accels - Increase in FHR to peak in < 30 sec = reassuring! 4. Decels - Early: mirrors contractions, caused by compression from contraction = NORMAL - Late: after contractions, caused by uteroplacental insufficiency + fetal hypoxemia = BAD - Variable - umbilical cord compression --> often fixed by changing maternal position |
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Describe a NST. What defines a reactive NST?
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FHR monitored by Doppler + tocodynamometer
Reactive NST (normal) - 2 accels > 15 bpm lasting for at least 15 sec over 20min period Lack of accels: - GA < 32 weeks - Fetal sleeping - CNS anomalies - Maternal sedatives/narcotics |
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Describe a CST
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FHR monitored during spontanous/induced contractions
Negative CST (normal) - No late or significant variable decels in 10 mins with at least 3 contractions - Highly predictive of fetal well being with normal NST Positive CST - Late decels following >50% of contractions in 10 min - Fetal compromise...delivery usually warranted |
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When is CST contraindicated? (4)
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Hx PROM
Known placenta previa Hx uterine surgery High risk for preterm labor |
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Describe a biophysical profile (BPP)
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Real-time U/S to assign score of normal (2) or abnormal (0) to 5 parameters:
Tone Breathing Movement Amniotic fluid volume NST 8-10 - reassuring 0-4 worrisome |
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What is the amniotic fluid index? What defines oligohydramnios?
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AFI - sum of measurements of deepest amniotic fluid measurements
Oligohydramnios: AFI < 5 cm Polyhydramnios: AFI > 20 cm |
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Treatment for hyperemesis gravidarum
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Vitamin B6
Doxylamine/Promethazine/dimenhydrinate IVFs and nutritional supplementation if needed If severe: metoclopramide, zofran, ... |
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Criteria for gestational diabetes and management
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1hr 50g OGTT: > 140 abnormal
3hr 100g OGTT: abnormal if - @ 1 hr: > 180 - @ 2 hr: > 155 - @ 3 hr: > 140 Treatment: 1. ADA diet 2. Glucose goals: - Fasting < 90 - 1-2hr postprandial < 140 3. Insulin if necessary |
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How is glucose control different for pregestational diabetes?
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2hr postprandial goal < 120 (instead of 140)
Very strict glucose control (80-100) during labor with IV insulin gtt |
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Fetal complications of pregastational DM
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Macrosomia or IUGR
Cardiac/renal defects NTDs Polylcythemia Hyperbili Hypoglycemia RDS Mortality |
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Which medications may be used for treatment of hypertension in pregnancy?
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Methyldopa
Labetalol Nifedipine Hydralazine Thiazides Propranolol |
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Define:
Preeclampsia Eclampsia HELLP |
Preeclampsia:
- New HTN (BP > 140/90) AND - Proteinuria (> 300mg/24 hr) at > 20 weeks GA - Edema Severe preeclampsia: - BP > 160/110 - Proteinuria > 5g/24hr - Neuro findings: HA, somnolence, blurred vision, scotomata, hyperactive reflexes, HELLP Eclampsia: - New onset tonic-clonic (grand mal) seizure in woman with preeclampsia HELLP - Hemolysis - Elevated LFTs - Low Platelets |
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Treatment of preeclampsia
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Induce delivery if close to term, worsening
Far from term: - Expectant management - Magnesium for seizure prophylaxis - Control BP with labetalol, hydralazine |
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Treatment of eclampsia
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Magnesium for prophylaxis
Diazepam if recurrent seizures Most seizures occur within 48 hours after delivery |
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Magnesium toxicity and treatment
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Decreased DTRs
Respiratory paralysis Coma IV calcium gluconate |
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Triad of ectopic pregnancy
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Pain
Amenorrhea Vaginal bleeding |
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Risk factors for ectopic pregnancy (4)
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Things that scar fallopian tubes
- PID - Pelvic surgery - DES use - Endometriosis |
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Painful dark bleeding that does not cease spontaneously vs painless bright red bleeding that stops 1-2 hrs
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Abruption vs. Previa
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Risk factors for IUGR (4)
Symmetric vs Asymmetric |
1. Uteroplacental insufficiency 2/2 systemic disease
- Intrauterine infection - Hypertension - Anemia - Diabetes (NOT GESTATIONAL) 2. Maternal substance abuse 3. Placenta previa 4. Multiple gestations Symmetric = early event --> aneuploidy, intrauterine infx Asymmetric = late --> uteroplacental insufficiency |
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Risk factors for and complication of macrosomia (LGA)
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Gestational diabetes
Risk of shoulder dystocia = brachial plexus injury, Erb-Duchenne palsy |
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Causes of polyhydramnios (5)
Workup |
AFI > 20
1. Pulmonary abnormalities 2. Duodenal atresia, T-E fistula, anencephaly 3. Maternal DM 4. Multiple gestation, twin-twin transfusion syndrome 5. Isoimmunization U/S for fetal anomalies Glucose testing for DM Rh screen |
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Causes of Oligohydramnios (3)
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AFI < 5
1. Urinary tract abnormalities - Renal agenesis - GU obstruction (e.g. posterior urethral valves) 2. Chronic uteroplacental insufficiency 3. ROM |
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Oligohydramnios is associated with _____ hypoplasia.
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pulmonary!!
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Complete vs Incomplete molar pregnancy
Which is more likely to become malignant? |
Complete:
- 1 or 2 x sperm, 1 x ovum without DNA = PATERNAL DNA - 46 XX - No fetal tissue **More likely to progress to malignant post-molar GTD Incomplete: - 2 x sperm, 1 x ovum - 69 XXY - Contains fetal tissue |
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GTD presentation and findings (3)
What happens to hCG levels? Classic findings on U/S, D&C |
1. PAINLESS uterine bleeding
2. Hyperemesis gravidarum 3. Uterine size >> dates 4. Hypertension, preeclampsia at < 24 weeks hCG super high (> 100,000!!) U/S: snowstorm appearance +/- fetal tissue D&C: "cluster of grapes" tissue |
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Most common GTD metastasis?
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Lung! --> need CXR
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Erb-Duchenne palsy from shoulder dystocia
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C5-C6 brachial plexopathy = waiter's tip phenomenon
- Wrist flexion, arm extension, arm adduction - Sensory loss over lateral arm and forearm |
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Types of labor failure and 3 general causes
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1. Arrest of dilation
2. Arrest of descent 3 Ps: - Power (contractions) - Passenger (baby) - Passage (pelvis) |
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What is the major complication with failure to progress?
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Chorioamnionitis
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How to confirm rupture of membranes?
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1. Pooling of fluid on speculum exam
2. Nitrazine test - pH paper turns blue (amniotic fluid is more basic than vaginal contents) 3. Ferning on microscopy 4. U/S - decreased amniotic fluid seen **Gold standard is U/S guided instillation of indigo carmine dye and watching it drain out...rarely done |
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What should you avoid in patients with PROM?
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Vaginal examinations
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Biggest concern with PROM?
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INFECTION
- Check GBS status - Antibiotics |
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Definition of preterm labor (3)
Braxton-Hicks contractions? |
< 37 weeks gestation
Regular uterine contractions Concurrent cervical change Braxton-Hicks - NO cervical change |
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Management of preterm labor if delivery is likely
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Tocolytics: may delay for ~48hrs
1. Magnesium - blocks Ca entry 2. Nifedipine - blocks Ca channels 3. Indomethacin - decreases PG synthesis 4. Terbutaline - beta-agonist, increases cAMP = decreases free Ca Steroids to accelerate lung maturation Penicillin/ampicillin for GBS |
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Fetal fibronectin?
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The D-dimer of preterm labor.
If negative, very likely that will not deliver in 7 days. High NPV |
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Management of breech presentation
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1. Up to 75% change to vertex on their own
2. External cephalic version - pressure on abdomen to turn infant 3. Trial of vaginal delivery - only if imminent 4. Elective C-section - lower risk of fetal morbidity |
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What quantifies postpartum hemorrhage?
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A loss of > 500ml (vaginal) or > 1000ml (C-section)
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Common causes and treatments of postpartum hemorrhage? (3)
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1. Uterine atony - MOST COMMON
- Overdistention, exhausted, infection, anesthesia, ... - Boggy, enlarged uterus - Tx: uterine massage, methergine, oxytocin 2. Genital tract trauma - Inspect and repair lacerations 3. Retained placental tissue - Accreta, previa, previous C-section, ... - Manual/visual inspection, may use U/S - Manual removal vs curettage |
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Causes of postpartum fever (10 days post delivery, not counting first 24 hrs)
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Womb - endometritis
Water - UTI Wind - pneumonia (atelectasis?? meh...) Walk - DVT, PE Wound - incision Weaning - breast engorgement, abscess, mastitis Wonder drugs |
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What is Septic Pelvic Thrombophlebitis?
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Pelvic infection --> infection of vein wall + damage --> thrombosis --> clot invaded by microbes
Can lead to septic emboli Dx with blood cultures, CT looking for pelvic abscess Tx: broad antibiotics and anticoagulation |
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What is Sheehan's Syndrome? Dx? Tx?
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Pituitary ischemia --> necrosis 2/2 obstetric hemorrage/shock
= anterior pituitary insufficiency - Presents as failure to lactate Dx: MRI Tx: hormonal replacement |
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Which Ig is in colostrum?
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Secretory IgA
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Describe the phases of the menstrual cycle. Which are variable/fixed?
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1. Follicular phase (~13 days but varies)
- FSH rises causing growth of follicles causing increase in E = proliferation of uterine lining 2. Ovulation (day 14) - LH and FSH spike (reversal of negative feedback from E) = rupture of ovarian follicle and ovum release - Ruptured follicular cells involute and create corpus luteum 3. Luteal phase (14 days, fixed) - Corpus luteum makes E and P = thick endometrial glands and secretions (secretory phase) - Without implantation, cannot be sustained, and sloughs off |
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What is the main source of estrogen in post-menopausal women?
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Estrone, comes from conversion of androstenedione in adipose tissue
= fat people have increased risk of endometrial hyperplasia/CA |
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How does hormonal contraception work? What are some types?
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Estrogen - suppresses FSH, prevents follicle maturation
Progestin - suppresses LH, suppresses ovulation, thickens cervical mucus OCPs Patch - qWeek Ring - q 3 weeks Progestin only: Depo-Provera - q 3 months, risk of osteopenia, delayed fertility afterwards Implanon - q 3 months, weight gain, depression Progestin only pills - daily, strict compliance |
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Describe IUDs and how they work
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Mirena (progestin)
- Inflammation from foreign body - Cervical thickening and endometrial decidualization from progestin - 5 years - Decreases bleeding, cramping Paragard (copper) - Inflammation from foreign body - Copper has spermicidal effect - 10 years - May increase cramping, bleeding (bad choice for someone with heavy periods) - May be used as emergency contraception |
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DDx of primary amenorrhea
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Absence of secondary sexual characteristics (low estrogen):
1. Constitutional growth delay 2. Primary ovarian insufficiency - Turner's syndrome - Radiation/chemo 3. Central hypogonadism - HyperPRL - Malnutrition, anorexia nervosa - CNS tumor - Kallmann's syndrome (isolated gonadotropin deficiency with anosmia) Presence of secondary sexual characteristics 1. Mullerian agenesis - Absence of 2/3 of vagina - Uterine abnormalities 2. Imperforate hymen - blood in vagina, bulging hymen 3. Complete androgen insensitivity - Testosterone aromatized to estrogen leads to breast development, but have no periods or pubic hair |
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Workup of primary amenorrhea
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1. hCG!!
2. Bone age radiograph - constitutional growth delay 3. FSH, LH, estrogen 4. TRH, TSH, PRL 5. Progestin challenge 6. MRI of pituitary 7. Karyotyping |
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Workup of secondary amenorrhea
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1. hCG!!!
2. TSH, PRL 3. Progestin challenge 4. Adrenal - cortisol levels, dexamethasone suppression test, etc. 5. Testosterone, DHEAS, 17-hydroxyprogesterone |
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Explain the progestin challenge
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10 days of progestin
If withdrawal bleed, indicates anovulation - PCOS (high LH) - Early menopause (very high LH) - Idiopathic If no withdrawal bleed, suggests low estrogen or uterine abnormality - High FSH = hypergonadotropic hypogonadism/ovarian failure - Low FSH ***Hypogonadotropic hypogonadism ***Endometrial/anatomic problem (e.g. Asherman's syndrome) |
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Common causes of secondary dymenorrhea
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Endometriosis/adenomyosis
Fibroids (leiomyomata) Adhesions Polyps PID |
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Endometriosis vs Adenomyosis
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Endometriosis:
- Endometrial tissue outside uterus - CYCLICAL pain (dysmenorrhea, dyspareunia, dyschezia) - Most common cause of infertility in women > 30 Adenomyosis - Endometrial tissue in myometrium - NONCYCLICAL pain - Menorrhagia, enlarged uterus - Rarely progresses to endometrial CA |
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What is dysfunctional uterine bleeding?
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Abnormal uterine bleeding without evidence of underlying cause
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Define:
1. Oligomenorrhea 2. Polymenorrhea 3. Menorrhagia 4. Metrorrhagia 5. Menometrorrhagia |
1. Oligomenorrhea - fewer periods
2. Polymenorrhea - increased periods 3. Menorrhagia - increased flow or length of bleeding 4. Metrorrhagia - bleeding between periods 5. Menometrorrhagia - 3 + 4 |
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Etiologies of abnormal uterine bleeding (non-pregnant) (6)
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1. Anovulation/oligo-ovulation
- Noncyclic estrogens stimulate growth/development of endometrium which outgrows blood supply and sloughs off unpredictably 2. Uterine leiomyomata (fibroids) 3. GU infection 4. Cervical or endometrial polyps/hyperplasia/CA 5. Vaginal lesions 6. Bleeding diathesis, thrombocytopenia, etc. |
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Diagnostic criteria for PCOS
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2/3:
1. Polycystic ovaries 2. Oligo/anovulation 3. Clinical/biochemical evidence of hyperandrogenism |
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Treatment of PCOS
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Treat symptomatically - OCPs, antiandrogens, metformin, statins/weight loss
If trying to conceive, can try clomiphene |
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Infetility etiologies (general schema)
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1. Ovaries (anovulation)
2. Uterus (implantation) 3. Tubules (transport) 4. Male 5. Endometriosis |
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Treatment of Bartholin's duct abscess
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I&D with Word Catheter
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Workup of vaginitis
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1. Cervical fluid
- pH - Amine (whiff) test - Wet mount - KOH microscopy 2. Gonorrhea/Chlamydia cultures if c/w story/slides |
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Criteria for BV
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3/4:
- Abnormal whitish-gray discharge - Vaginal pH > 4.5 - (+) amine (whiff) test - Clue cells > 20% of wet mount |
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Trichomonas
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- Yellow-green, frothy discharge
- Strawberry cervix - Pear-shaped motile flagellated organisms on wet mount |
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Treatment for BV/trichomonas
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Flagyl
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Treatment for gonorrhea and chlamydia
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Gonorrhea - ceftriaxone IM single dose
Chlamydia - azithromycin PO single dose |
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Differential of acute pelvic pain
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Appendicitis
Ruptured ovarian cyst Ovarian torsion Ovarian abscess PID Ectopic pregnancy |
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Classical symptoms of chlamydia
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Easily induced bleeding - friable! e.g. with sexual intercourse
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Antibiotics of choice for toxic shock syndrome
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Nafcillin, oxacillin
Vanc only if pen-allergic |
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Risk factors for endometrial CA
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Unopposed estrogen
- Ovarian - Peripheral fat (obesity, PCOS) - Granulosa cell tumor - Nulliparity, infertility; early menarche, late menopause - Exogenous (patches, creams, HRT, tamoxifen) |
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Screening for endometrial CA
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NOT RECOMMENDED for asymptomatic patients
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Where does cervical cancer occur?
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Transformation zone - transition from endocervix (upper 1/3, columnar) to ectocervix (lower 2/3, squamous)
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Risk factors for cervical cancer
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HPV, STD hx, multiple sexual partners
Immunosuppression HIV Tobacco OCPs |
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Cervical cancer screening guidelines
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1. Start at age 21, regardless of sexual encounters
2. Age 21-30 - pap smear q 3 years if normal 3. Age 30-65 - may extend to q5years if combination of pap + HPV testing 4. > 65yo - can stop screening if negative |
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Treatment for CIN1, 2, and 3
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CIN1:
- Close observation, pap @ 6mo, 12mo +/- HPV screening at 12mo - Cryo-laser, Ablation, Excision CIN 2 and 3: - Cryo/laser, LEEP, cold-knife cone - Hysterectomy |
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What are the tumor markers for:
1. Epithelial 2. Endodermal sinus 3. Embryonal ca 4. Choriocarcinoma 5. Dysgerminoma 6. Granulosa cell |
1. Epithelial - CA-125
2. Endodermal sinus - AFP 3. Embryonal ca - AFP, hCG 4. Choriocarcinoma - hCG 5. Dysgerminoma - LDH 6. Granulosa cell - Inhibin |
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Stress vs Urge vs Overflow incontinence
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Stress
- After increasing intra-abdominal pressure (cough, valsalva) - Urethral sphincter insufficiency 2/2 laxity of pelvis floor musculature Urge - Strong unexpected urge to void that is unrelated to position/activity - Detrusor hyperreflexia - Sphincter dysfunction Overflow - Chronic urinary retention - Chronic distension with increased intravesical pressure that causes dribbling of urine |
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When is U/S useful in BrCA?
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Women < 30yo
Can distinguish solid from cystic |
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Functional ovarian cysts (3)
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1. Follicular
- Follicle fails to rupture and ovulation does not occur = transient secondary amenorrhea - Abdominal pain, irregular bleeding - Resolves spontaneous 2. Corpus luteum cyst - Continues to make progesterone = delayed menstruation - Pain with rupture +/- hemoperitoneum - Resolves spontaneously 3. Theca lutein cyst - BILATERAL (usually) - Associated with pregnancy, ovulation induction - Asymptomatic vs. virilization, hyperemesis, preeclampsia - Regresses spontaneously |
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Benign ovarian neoplasms (think anatomically)
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1. Epithelial cells
- Serous cystadenoma - high rate of malignancy - Mucinous cystadenoma - less malignant - Brenner cell tumor - rarely malignant 2. Germ cell - Mature cystic teratoma - multiple tissues (teeth, hair, sebum), may have struma ovarii = thyroid! - Dysgerminoma - Choriocarcinoma - Endodermal sinus (yolk sac) 3. Stromal cell - Granulosa-Theca cell = estrogenic, Call-Exner bodies - Sertoli-Leydig cell = androgenic, Reinke crystals - Ovarian Fibroma = collagen, no sex hormones |
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What is Meigs syndrome? (3)
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Ovarian fibroma
Ascites R pleural effusion |
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Indications for inpatient treatment of PID (5)
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1. High fever
2. Unresponsive to PO antibiotics 3. Unable to take PO (vomiting) 4. Pregnant 5. High risk of noncompliance |
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Most accurate U/S parameter for predicting fetal size
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Abdominal circumference
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At what point are lungs considered to have matured? (Alternately, when is it ok to deliver in HELLP syndrome?)
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34 weeks
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How does hypothyroidism lead to galactorrhea?
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Low FT4 = Increased TRH = increased PRL
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With hyperemesis gravidarum, always think of:
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GTD
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