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78 Cards in this Set

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Pre eclampsia
Mild vs Severe
Mild BP > 140/90 with proteinuria of > 0.3g/24h
Severe: BP >160/110 and proteinuria >5g/24 h, oliguria, elevated liver enzymes, thrombocytopenia and possibly pulmonary embolism
pregs 36 week with eclampsia who is actively seizing. Tx?
1.respiratory and cardio resuscitation, a2 large bore needles
2. anticonvulsant med, Mag sulf - serves to prevent further seizure activity
(Dont't attempti to deliver while seizing)
what is the gold standard for eval.ing the cervix for possible cervical incompetence?
What should cervical length be at 25 weeks?
transvaginal US
More than 25 mm
biophysical profile:
-when is it indicated?
-what is it comprised of?
-How do you score it?
-high risk pregs, <ed fetal movements, or a non-reactive NST
-NST and four parameters assessed by US (1/fetal tone; 2/fetal movements (3/10min); 4/amniotic fluid index (5-20)
-Each of these five variables is given a score of 2 when present and 0 when absent or abnormal; total score of 8-10 is normal
what is the MCC of abnormal uterine bleeding?
dysfunctional uterine bleeding (DUB). it is a Dx of exclusion and is most often due to anovulation. High dose estrogen is the management of choice for uncontrolled bleeding.
In women >35 with DUB, endometrial Bx is indicated
Tx of DUB in adolescent females:
Mild DUB
Moderate DUB w/o active bleeding
Moderate DUB with active bleeding
-Fe supplements
- Progestin
-Estrogen therapy
down synd :
high vs low levels of BhCG, MSAFP, Estriol, InhibinA
high BhCG, low MSAFP, low Estriol, high inhibin A
MCC of postpartum hemorrhage (PPH)
uterine atony
DUB in premenopausal woman with simple or complex hyperplasia w/o atypia, Tx?
cyclic progestins and repeat Bx in 3-6 mo.s of Tx.
risk of progression ot endometrial CA is only 1-2% so doesn't warrent hysterectomy.
> in BP that appears b4 20-weeks in gestation is due to ?
either chronic HTN or hydatiform mole
US will show snow storm appearance for hydatiform mole.
risk factors for uterine atony
uterine overdistention (multiple gestation, polyhydramnios and macrosomia) and uterine fatigue (prolonged labor)
Risks assoc.d with OCP use
-venous thromboembolism
-stroke
-MI
-HTN
-high TGs
-worsening of DM
- > risk of Breast CA
- > risk of cervical CA
(while risk of ovarian and endometrial is <ed)
How do you differentiate btwn early viable intrauterine pregs, ectopic pregs, or nonviable intratuterine pregs (completed abortion) with BhCG of < 1000 and nothing seen on transvag US?
come back in 48 hrs and repeat transvag US and BhCG.
intrauterine pregs should be seen with transvag US at BhCG levels of 1500-2000 mIU/mL
when do you do NST? how do you interpret it?
Done 32-34 weeks if fetal movement <es or becomes imperceptible to mom.
Reactive (normal) = in 20 minutes 2 accel.s of fetal HR of at least 15 bpm above baseline lasting at least 15 seconds each.
MCC of nonreactive (abnormal) NST?
what do you do?
sleeping baby.
use vibroacoustic stim. to wake up baby and test again.
sudden onset hirsutism or virilization during pregnancy, you do PE and pelvic US.
US shows no ovarian mass,
what do you do?
Abdominal CT scan to r/o adrenal mass
virilization during pregnancy, you do PE and pelvic US.
US shows bilateral cystic masses,
what is it?
theca lutein cysts (r/o high B-hCG states)
virilization during pregnancy, you do PE and pelvic US.
US shows bilateral solid masses,
what is this, what do you do?
Mostly pregnancy luteoma. Reassurance and f/u with US.

solid ovarian tumors are almost always malignant and demand immediate and aggressive eval and Tx, EXCEPT IN PREGNANCY
virilization during pregnancy, you do PE and pelvic US.
US shows unilateral solid mass, what is this, what do you do?
laparotomy or laporoscopic Bx to r/o malignancy.
Mag sulfate is used for what?
when is it administered in mild vs severe preeclampsia?
Used to prevent ecclamptic seizures.
Mild: administer mag sulf during labor and w/in 24 hrs delivery
Severe: administer from time of admission and carried on until 24 hours after delivery
preg pt. with HTN, proteinuria, edema, malar rash, positive ANA.
pt. has SLE not preeclampsia (though appears to).
Signs that favor lupus as origin of proteinuria include presence of RBC casts in UA indicating GLOMERULONEPHRITIS rather than simple protien loss.
What's the Tx of choice for postpartum endometritis?
POstpartum endometritis is a polymicrobial infxn so:
IV chlindamycin and Gentamycin
glucose tolerance test for pregos?
what's normal?
one hour 50 g oral glucose
<140 mg/dL is normal
CIN 1 preceded by low-grade abnormalities (ASC-US, ASC-H, LSIL) -> what do you do next?
A. Repeat Pap in 6 & 12 mo.s
or
B. HPV testing in 12 mo.s
A. -> 2 neg smears -> f/u screen in 1yr
or
->ASC-US or ASC-H
->colposcopy:
if Neg -> repeat Pap in 6 and 12 mos.
if Persistent CIN after 24 mo.s -> Dxic excisional procedure
B. -> HPV Neg ->f/u screen in 1 yr
->HPV Pos -> colposcopy:
->Neg colpo -> repeat pap in 6 & 12 mo.s
->persistent CIN after 24 mo.s
->Dxic excisional proc.
Risks of gestational diabetes for the fetus:
-macrosomia
-hypOcalcemia
-hypOglycemia
-hyperviscosity(polycythemia)
-resp. difficulties
-cardiomyopathy
-CHF
Lichen sclerosus
-postmenopausal women
-vulvar pruritis and discomfort
-porcelain white vulvar atrophy
-Bx to r/o vulvar SCC
-Tx with high-potency topical corticosteroid
PPROM
preterm premature rupture of membranes = rupture of amniotic membranes before 37 weeks
Normal amniotic fluid pH
Normal vaginal pH
7 -7.5
3.8 to 4.5
Continuous GnRH therapy
desensitizes GnRH signaling pathwayss-> anovulation and amenorrhea
Used in kids with GnRH-dependent precocious puberty and in men and women with sex hormone-dependent tumors (i.e. prostate and breast)
Pulsatile GnRH therapy
causes pituitary LH and FSH prdxn to increase
Used for infertility from acquired hypogonadotripic hypogonadism which is assoc.d with significant stress, eating disorders, and excessive exercise.
(bc imbalance of LH and FSH production causes suppression of ovarian estrogen production and ovulation, leading to amenorrhea.)
when do you perform transvag US?
B-hCG is 1500-6500 IU/L and nothing is seen in the intrauterine gestational sac on transabdominal US.
tamoxifen is Tx for which CA and a risk for which CA?
Tx for breast CA
Risk for endometrial CA
Bc. it is a selective estrogen receptor modulator (SERM) with mixed agonist/antagonis effects on estrogen receptors. It is an antagonis in the breast and a partial-agonist of estrogen on the endometrium and increases risk of endometrial carcinoma
Pt. with primary amenorrhea:
what test do you order?
-1st FSH is ordered if there is no breast development
-GnRH stim test is the next step if FSH is <ed
-Karyotyping is the next step if FSH is increased
Central vs. Peripheral precocious puberty
Central :
-Caused by activation of hypothalamic-pituitary-ovaria (HPO) axis
-presents with >ed FSH and LH
-give CT or MRI
-Tx with GnRH analog therapy
Peripheral:
Caused by gonadal or adrenal release of excess sex hormones
-Presents with low FSH and LH
Pt. with primary amenorrhea, female phenotype, and lacking normal vagina and uterus?
Possibilities:
-mullerian agenesis (XX)
-androgen insensitivity (XY)
-5 alpha reductase deficiency (XY)
Mullerian agenisis
XX genotype
blind ended vagina
little or no uterine tissue
androgen insensitivity
XY
but there is abnormal androgen receptor
So, external genitalia develop as female, butmullerian inhibiting factor is still secreted by testes preventing the development of internal female organs
5 alpha reductase deficiency
XY
can't convert testosterone to more potent DHT
have female external genitalia, but show virilization at puberty
Plan B
Levongestrol
given up to 120 hr (5 days) after unprotected sex
Granulosa cell tumors
-make XS estrogen
-can present with precocious puberty in younger kids and postmenopausal bleeding in elderly
dysgerminomas
-avg incidence ~ 20 yo
-can ->torsion
-doesn't secrete male or female hormones, its neutral
sertoli-leydig
-androgen producing ->
masculinization->amenorrhea
serous cystadenomas
-MC cystic ovarian neoplasm, 30% of all ovarian tumors
-25% are malignant
-50% are bilateral
-don't make estro or andro
-presenting features are ovarian mass and abdo pain
Raloxifene major contraindication
risk of DVT.
1st line in prevention of osteoporosis, and it decreases breast CA
prolonged (postterm) pregs (> 42 weeks) should be monitored for and are at >ed risk forwhat?
oligohydramnios
and should be monitored twice weekly.
oligohydram = no vertical pocket of fluid > 2cm, or amniotic fluid index of 5 cm or less
risk of intrauterine fetal demise .
Management
DIC and chorioamnionitis.
check coagulation profile (fibrinogen, fibrin split products, PT, PTT)
hypotension is a common side effect of epidural anesthesia. what causes it?
blood redistribution to the lower extremities and venous pooling.
Dysfunctional Uterine Bleeding (DUB)
-heavy vaginal bleeding that happens in the absence of structural or organic dz.
-Endometrial Bx required for women >35, and in women with HTN, DM, or obesity.
-If Bx is neg for hyperplasia or carcinoma, then Tx with cyclic progestins
32 week preganancy with Placenta previa anduncontrolled antepartum hemorrhage, unstable vital signs, and unreassuring fetal heart rates. what do you do?
emergent cesarean section
what do you do?
-PPROM at 34 weeks
-PPROM at <32 weeks
-give her penicillin prophylaxis and then deliver
-giver her corticosteroids
what do you do?
palpation of vertex at the fundus:
-at 34 weeks
-at 37 weeks
= breech
most breech will self-correct by 37th week
so do nothing at 34 weeks
- at 37 weeks attempt external cephalic version. if this fails plan for a cesarean
These contraceptions are contraindicated in:
-any contraception containing estrogen
-depot medroxyprogesterone:
-IUD
- progestin-only "minipill"
- >35 yr. heavy smokers
- obese pt.s
- previous ectopic
- no real contraindications
amenorrhea in lactating mother is caused by?
high prolactin -> inhibit prdxn of hypothalamic hormone GnRH.
Pulsatile GnRH release from hyothal is necessary for prdxn and release of LH and FSH by ant. pit.
LH an FSH are required to induce ovulation.
Menses don't occur when ovulation is suppressed.
>40 yo with dysmenorrhea and menorrhagia:
- with enlarged and symmetrical uterus
-enlarged and irregularly shaped uterus
-adenomyosis
-fibriod uterus
(women >35, mandatory to perform endometrial curettage to r/o endometrial carcinoma)
In pt. Tx for PID:
IV Cefoxitin/Doxycyclin
IV Cetotetan/Doxy
IV Clindamycin/gentamicin
What BPP consists of
2 points when present & 0 points when absent:
1. Nonstress test (reactive is good)
2. Fetal tone (flexion of extension of an extremity)
3. Fetal movements (at least 2 in 30 min.s)
4. Fetal breathing movements (at least 20 seconds in 30 minutes)
5. Amniotic fluid vol. (single poscket greater than 2cm. in vertical axis)
How to interpret BPP
- 8-10 is normal
-but, BPP of 8 with <ed AFI = delivery (fetal compromise likely)
- BPP 6 and >37weeks w/o oligo ; consider delivery
-BPP 6 and <37weeks w/o oligo, repeat BPP in 24 hr; deliver if not improved
-BPP 6 w/ oligo >32 weeks = delivery
-BPP 6 w/ oligo <32 = daily monitoring
-BPP <or=4 and >26weeks = delivery
MCC of abnormal maternal serum MSAFP?
gestational age error
Vasa Previa
- =
-why is this bad?
-How to confirm Dx?
-Tx
= fetal blood vessels cross btwn baby and internal cervical os (velamentous cord insertion). these vessels are vulnerable to tearing during rupture of membranes.
-high fetal mortality rate (75%) due to fetal exsanguination
-Apt test = differentiates maternal from fetal blood
-Crash C-section
Uterine rupture:
-how presents
-risk factors
-Tx
-sudden onset of abdo pain and vag bleeding, fetal HR abnormalities during active labor
-Risk factors: preexisting uterine scar or abdo trauma
-C section and subsequent TAH (unless wants more kids then debride and close site of rupture)
when do you screen for gestational DM?
How?
Results?
-btwn 24 - 28 weeks
-one hour 50g oral glucose tolerance test (OGTT)
-after one hour if blood gluc is <140 then DM is r/o
if it is >140 then a three hour OGTT is performed
When is RhoGAM given?
Rh-neg women at 28 weeks gestation and w/in 72 hours of any procedure or incident like abortion, ectopic pregs, and delivery
When is anesthesia given during labor?
during active phase
-if given during latent phase then may reduce uterine activity
Interstitial cystitis
-ie
-presentation
-painful bladder syndrome
-chronic condition assoc.d with pelvic pain worsened by bladder filling or intercourse accopmanied by urinary frequency, urgency, and nocturia.
Pain is typically relieved by voiding.
DES is assoc.d with which CA?
female offspring of women who ingested DES during pregs are at >ed risk of developing:
Clear cell adenocarcinoma of vagina and cervix
MSAFP levels are abnormal in pregs pt. whats the next step?
US to confirm gestational age, detect fetal structural anomalies, detect multiple gestation and confirm a viable pregs
what is the gold standard for evaluating the cervix for cervical incompetence
what measurement is considered incompetent?
transvaginal US
< 25mm @ 25 weeks
-when is preterm labor =
-definition of labor
- after 20 weeks and before 37 weeks gestation.
-4 contrxns/20 minutes + cervical changes
UTI drugs recommended in pregs
nitrofurantoin, amox, amox-clav, cephalexin
best intervention for reducing maternal-fetal transmission of HIV infection:
AZT for mom throughout pregs and labor and AZT for newborn for 1st 6 weeks of life reduces HIV transmission by 70%
what is the best test to confirm intrauterine fetal demise?
real time ultrasonography (to demonstrate the absence of fetal movement and cardiac activity)
Intrauterine fetal demise
- def
- Dx
- Next step after confirming Dx
-after 20 weeks and b4 onset of labor
-US
- coag profile to detect for DIC and if fibrinogen levels <100mg/dL then give platelet transfusion.
-if coag levels are fine then induce labor
Most useful parameter for predicting fetal weight by US in suspected FGR?
Abdo circumference
screening for syphilis
- when
-how
-1st prenatal visit
- RPR or VDRL if comes back + then FTA-ABS to confirm
eeclamptic Pt being treated w/ MgSO4 showing w/ depressed DTRs. what do you do?
Calcium gluconate and discontinue mag sulfate
93 yo pt. w/ vaginal SCC (comorbidities HTN, DM, post MI).
Tx
Generally speaking:
if < 2cm in size surgical removal
if > 2 cm in size radiation
But this pt.'s age and comorbidities makes radiation the better option
when do you use suction curettage vs. induction of labor for inevitable abortion Tx?
after 16th week = induction
before 16th week = curettage
how are BUN and CR affected in pregs?
they are <ed due to > in renal plasma flow