Obgyn Case Files

Front 1

menopause

Back 1

the point in time in a woman's life when there is cessation of menses due to follicular atresia occuring after age 40 (mean age 51 years in US)

Front 2

perimenopause (climacteric)

Back 2

the transitional 2 to 4 years spanning from immediately before to immediately after the menopause

Front 3

hot flushes

Back 3

irregular unpredictable episodes of increased skin temperature and sweating lasting about 3-4 minutes caused by vasomotor changes.

Front 4

premature ovarian failure

Back 4

the cessation of ovarian function due to atresia of follicles prior to age 40 years (at ages younger than 30 years-- consider autoimmune diseases and karyotypic abnormalities)

Front 5

What blood tests can be ordered when perimenopause is suspected?

Back 5

LH and FSH (ovarian inhibin levels decrease before estradiol decreases-- leading to increased LH and FSH)

Front 6

potential negative effects of continuous estrogen-progestin treatment?

Back 6

breast cancer, heart disease, pulmonary embolism, and stroke

Front 7

effects of decreased estrogen in women

Back 7

decreased libido, vaginal atrophy, bone loss, hot flushes

Front 8

symptoms of polycystic ovarian syndrome

Back 8

hirsuitism, anovulation, insulin resistance, estrogen excess

Front 9

what is the mechanism of amenorrhea in anorexia?

Back 9

hypothalamic dysfunction

Front 10

sheehan syndrome

Back 10

hemorrhagic necrosis of the anterior pituitary associated with postpartum hemorrhage

Front 11

group A streptococcal toxic shock syndrome

Back 11

rapidly progressing infection of the episiotomy or cesarean delivery incision ("flesh eating bacteria")

Front 12

Management of septic shock

Back 12

IV fluids, monitoring UOP, and blood pressure. Invasive hemodynamic monitoring with Swan Ganz may be necessary.
- broad spectrum abx-- penicillin, gentamycin, `metronidazole,

Front 13

Gas/crepitus in a wound/muscle/fascia infection most likey indicates...

Back 13

necrotizing fascitis -- likely clostridial species like c. perfringens

Front 14

latent phase

Back 14

the initial part of labor when the cervix is mainly effaced rather dilated (<4cm)

Front 15

active phase

Back 15

the portion of labor where dilation occurs more rapidly, usually when the cervix is greater than 4 cm dilation

Front 16

protraction of the active phase

Back 16

cervical dilation in the active phase is less than expected (normal > 1.2 cm/hr for nulliparous woman, and > 1.5 cm/hr for a woman who has had at least one vaginal delivery

Front 17

arrest of active phase

Back 17

no progress in the active phase of labor for 2 hours

Front 18

stages of labor

Back 18

1. onset of labor to complete dilation of the cervix
2. complete dilation of the cervix to delivery of the infant
3. delivery of the infant to delivery of the placenta

Front 19

fetal heart rate accelerations

Back 19

episodes of fetal heart rate acceleration where the HR increases above baseline for at least 15 bpm for at least 15 seconds

Front 20

What can be given when insufficient contraction strength is suspected?

Back 20

oxytocin increases strength of contractions and their frequency

Front 21

cephalopelvic disproportion

Back 21

the pelvis is too small for the baby of baby is too big for the pelvis

Front 22

define clinically adequate contractions

Back 22

contractions every 2-3 minutes, uterus firm on palpation, lasting for at least 40-60 seconds (greater than or equal to 200 montevideo units)
MVUs = total rise above baseline for each contraction over 10 minute period

Front 23

montevideo unit

Back 23

measurement of strength of uterine contractions
MVU = total rise above baseline for each contraction over 10 minute period (Add all of them together)

Front 24

normal length of active phase of labor ...
1. in nulliparous without epidural
2. np with epidural
3. multip without epidural
4. multip with epidural

Back 24

1. < 2 hours
2. < 3 hours
3. < 1 hour
4. < 2 hours

Front 25

normal length of the third stage of labor

Back 25

< 30 minutes for everyone

Front 26

normal length of the latent phase of labor for...
1. nullip
2. multip

Back 26

1. <18-20 hours
2. < 14 hours

Front 27

3 P's to assess when there is a labor abnormality

Back 27

Power- of contractions
Pelvis- is there CPD?
Passenger

Front 28

bloody show

Back 28

sticky mucus mixed with blood that comes from losing cervical mucus plug-- sign of impending labor

Front 29

early decelerations

Back 29

mirror images of uterine contractions, caused by fetal head compression

Front 30

variable decelerations

Back 30

abrupt decline and abrupt resolution in deceleration of FHR that is caused by cord compression

Front 31

late decelerations

Back 31

gradual in shape and offset from the uterine contractions, caused by uretoplacental insufficiency
(hypoxia)

Front 32

normal fetal HR

Back 32

110-160 bpm

Front 33

threatened abortion

Back 33

pregnancy with vaginal spotting during the first half of pregnancy (<20 weeks).

Front 34

what produces bHcg during pregnancy?

Back 34

chorionic villi- usually there is a logarithmic rise in early pregnancy

Front 35

bhcg threshold- discriminatory zone

Back 35

bhcg between 1500-2000 mIU/mL indicates when a normal, viable, intrauterine singleton pregnancy would be visible on TVS

Front 36

what should be done when ectopic pregnancy is possible but bhcg is below the discriminatory zone?

Back 36

if patient is stable, discuss the signs of rupture ectopic pregnancy and bring the pt back to recheck bhcg in 48 hours. If <66% rise this indicates increased likelihood of ectopic pregnancy.

Front 37

progesterone levels indicating normal IUP? nonviable IUP?

Back 37

>20 ng/mL viable
<5 ng/mL nonviable

Front 38

what is looked for on D&C to prove there was an intrauterine pregnancy?

Back 38

chorionic villi-- IUP
if none, then likely was not an IUP

Front 39

placenta accreta

Back 39

abnormal adherence of the placenta to the uterine wall due to an abnormality of the decidua basalis layer of the uterus. The placental villi are attached to the myometrium

Front 40

placenta increta

Back 40

the abnormally implanted placenta penetrates into the myometrium

Front 41

placenta percreta

Back 41

abnormally implanted placenta penetrates through the entire myometrium in the serosa. Often there is invasion into the bladder. Fistulas may develop.

Front 42

risk factors placenta accreta

Back 42

1. placenta previa
2. implantation over the lower uterine segment (low lying placenta)
3. Prior c/s scar or other uterine scar
4. uterine curettage
5. fetal down syndrome

Front 43

management if placenta accreta

Back 43

hysterectomy-- because attempts to remove a firmly attached placenta often leads to maternal hemorrhage or death

Front 44

conservative management of placenta accreta in women who wish to maintain childbearing potential

Back 44

remove as much of placenta as possible and pack uterus. Ligate umbilical cord as high as possible and IV methotrexate

Front 45

Risk of placenta accreta in women with three or more prior c/s and a low-lying anterior placenta

Back 45

40-50%

Front 46

Blue tissue densely adherent between the bladder and uterus suggests what dx?

Back 46

placenta percreta

Front 47

What do placental polyps result from

Back 47

retains products after a term pregnancy or incomplete abortion

Front 48

What is expected of low lying or marginal placentas discovered in the 2nd trimester?

Back 48

they will often resolve so repeat US should be done in the 3rd trimester

Front 49

mucopurulent cervicitis

Back 49

yellow exudative discharge arising from the endocervix with 10 or more PMNs per hpf

Front 50

lower genital tract

Back 50

vulva, vagina, cervix

Front 51

upper genital tract

Back 51

uterus, fallopian tubes, ovaries

Front 52

what is the most common organism implicated in mucopurulent cervicitis

Back 52

Chlamydia trachomatis

Front 53

treatment for gonorrhea

Back 53

125-250 mg IV Ceftriaxone plus tx for chlamydia (1 g azithromycin or 100 mg doxycycline BID x 7-10 days)

Front 54

If mucopurulent discharge is seen on pelvic exam and gram stain is negative, what is the likely diagnosis?

Back 54

Chlamydia trachomatis
tx: azithromycin or doxycycline

Front 55

disseminated gonorrhea

Back 55

septic arthritis that is classically migratory, painful pustular rash

Front 56

What is the management when complete abortion is suspected?

Back 56

follow b-hcg levels to zero. Levels should halve in 48-72 hours if dx correct. plateau in bhcg level indicates incomplete abortion or ectopic pregnancy

Front 57

threatened abortion

Back 57

a pregnancy less than 20 weeks associated with vaginal bleeding, but without cervical dilation

Front 58

inevitable abortion

Back 58

a preg less than 20 weeks associated with cramping, bleeding and cervical dilation--no passage of tissue

Front 59

incomplete abortion

Back 59

pregnancy of less than 20 weeks gestation associated with cramping, vaginal bleeding, and an open cervical os, and SOME passage of tissue per vagina, but some retained in utero. The cervix remains open due to the continued uterine contractions in attempt to expel the remaining tissue

Front 60

complete abortion

Back 60

a pregnancy less than 20 weeks gestation in which ALL of the products of conception have passed. the cervix is generally closed because all of the products have passed and the uterus is no longer contracting.

Front 61

inevitable abortion vs incompetent cervix

Back 61

with inevitable abortion there are uterine contractions with cervical dilation but with cervical incompetence the cervix opens spontaneously without uterine contractions-- painless cervical dilation

Front 62

molar pregnancy

Back 62

trophoblastic tissue (placenta-like tissue) without a fetus
- presents with vaginal spotting, absence of fetal heart tones, size greater than dates, and markedly elevated HCG levels.
- dx by US which shows a "snow storm" like pattern in the uterus
- tx: uterine suction curettage followed by weekly hcg levels, if some retained gestational trophoblastic disease can result and require chemotherapy

Front 63

tx of incomplete abortion

Back 63

D&C to prevent hemorrhage and infection- send products of conception to pathology to confirm dx

Front 64

what is vaginal bleeding after 20 weeks gestation called?

Back 64

antepartum bleeding (not an abortion)
most common causes placenta previa and placental abruption

Front 65

most common cause of first trimester miscarriage

Back 65

chromosomal abnormality

Front 66

shoulder dystocia

Back 66

inability of the fetal shoulders to deliver spontaneously, usually due to the impaction of the anterior shoulder behind the maternal pubic symphasis

Front 67

mcroberts maneuver

Back 67

first step tx for shoulder dystocia- maternal thighs are sharply flexed against maternal abdomen to straighten the sacrum relative to the lumbar spine and rotate the symphasis pubis anteriorly toward the maternal head

Front 68

risk factors for shoulder dystocia

Back 68

1. gestational diabetes
2. multiparity
3. post term--> macrosomia
4. macrosomia
5. maternal obesity
6. prolonged 2nd stage of labor (for multiparous women without epidural 1 hour, with epidural 2 hours)
7. operative vaginal delivery (vaccuum etc) in the face of macrosomia

Front 69

suprapubic pressure

Back 69

tx for shoulder dystocia-- push down or lateral on suprapubic region to push fetal shoulder into oblique plane from behind the pubic symphysis

Front 70

fetal complication of shoulder dystocia?

Back 70

erb duchene palsy -- brachial plexus injury involving C5-6 nerve roots, which may result from downward traction on the anterior shoulder. Baby has weakness of the deltoid and infraspinatus muscles as well as flexors of the forearm.
- the arm hands limply at the side internally rotated-- "waiter's tip position"
- fetal hypoxia may also result

Front 71

signs of shoulder dystocia

Back 71

1. external rotation of the fetal head is difficult
2. fetal head retracts towards maternal introitus ("turtle sign"

Front 72

maneuvers for management of shoulder dystocia

Back 72

1. mcroberts maneuver- flex maternal hips toward her abdomen
2. suprapubic pressure
3. wood's corkscrew maneuver (progressively rotating the posterior shoulder 180 degrees in a corkscrew fashion)
4. delivery of the posterior arm
5. Zavanelli maneuver (cephalic replacement with immediate c/s)

Front 73

complication of hysterectomy presenting with CVA tenderness

Back 73

ureteral obstruction/injury
risk factors- cancer, extensive adhesions, endometriosis, tubo-ovarian abscess, residual ovaries, and interligamentous leiomyomata

Front 74

anatomical location of ureter and uterine artery

Back 74

uterine artery is above (more anterior) than ureter (bridge over water)

Front 75

most common location for ureteral injury after hysterectomy

Back 75

near the cardinal ligament (attaches cervix to the pelvic side walls and has uterine arteries traveling through)

Front 76

best way to evaluate potential ureteral injury?

Back 76

IVP (intravenous pyelogram to access kidney, ureter and bladder)

Front 77

If IVP shows hydroureter or hydronephrosis, what is the management?

Back 77

antibiotics, and cytoscopy to attempt retrograde stent passage

Front 78

percutaneous nephrostomy

Back 78

placement of stent into renal pelvis through skin

Front 79

fever and flank pain after hysterectomy or oopherectomy?

Back 79

ureteral ligation
- tx: abx and relief of obstruction

Front 80

What should be done first when a women presents with post-menopausal bleeding?
what is the concern?

Back 80

1. endometrial biopsy
2. endometrial cancer

Front 81

risk factors for endometrial cancer

Back 81

1. early menarche
2. late menopause
3. Obesity
4. chronic anovulation-proliferation of endometrium
5. estrogen-secreting ovarian tumors
6. unopposed estrogen ingestion
7. HTN
8. DM
9. personal or family history of breast or ovarian cancer
10. nulliparity

Front 82

sensitivity of blind endometrial biopsy?

Back 82

90-95% in detecting endometrial carcinoma. If clinical suspicion is high (multiple risk factors) and bx is negative, then a hysteroscopy should be done.

Front 83

endometrial polyps

Back 83

a growth of endometrial glands and stroma, which projects into the uterine cavity, usually on a stalk.
- cause of postmenopausal bleeding

Front 84

atrophic endometritis

Back 84

the most common cause of postmenopausal bleeding-- friable tissue in the endometrium or vagina due to low estrogen levels

Front 85

endometrial stripe

Back 85

transvaginal US assessment of the endometrial thickness. Thickness > 5 mm in postmenopausal women is abnormal

Front 86

In a women not on HRT who presents with postmenopausal bleeding what is the incidence of endometrial carcinoma?

Back 86

20%

Front 87

what is the most common female genital tract malignancy?

Back 87

endometrial carcinoma

Front 88

How is staging for endometrial carcinoma conducted?

Back 88

surgically-- TAHBSO, omenectomy, lymph node sampling, peritoneal washings

Front 89

what is the biggest risk factor for the development of endometrial carcinoma?

Back 89

unopposed estrogen

Front 90

antepartum vaginal bleeding

Back 90

vaginal bleeding that occurs after 20 weeks' gestation

Front 91

complete placenta previa

Back 91

placenta completely covers the internal os of the cervix

Front 92

partial placenta previa

Back 92

placenta partially covers the internal os of the cervix

Front 93

marginal placenta previa

Back 93

the placenta abuts against the internal os of the cervix

Front 94

low lying placenta

Back 94

the edge of the placenta is within 2-3 cm of the internal cervical os

Front 95

placental abruption

Back 95

premature separation of a normally implanted placenta

Front 96

vasa previa

Back 96

umbilical cord vessels that insert into the membranes with the vessels overlying the cervical os, thus being vulnerable to fetal exsanguination upon rupture of membranes

Front 97

painless vaginal bleeding after 20 weeks gestation

Back 97

likely placenta previa

Front 98

painful contractions + vaginal bleeding after 20 weeks gestation

Back 98

likely placental abruption

Front 99

what should be done first when a patient presents with antepartum vaginal bleeding?

Back 99

ultrasound to determine the location of the placenta (r/o placenta previa) as pelvic exam (speculum or digital) may cause more bleeding

Front 100

management of stable patient with placenta previa?

Back 100

bed rest and observation, then c/s at 36-37 weeks once fetal lung maturity achieved
- if 2-3 episodes of bleeding may have to do c/s earlier

Front 101

what other placental condition are women with placenta previa at risk for ?

Back 101

placenta accreta -- especially if prior uterine scar

Front 102

risk factors for placenta previa

Back 102

1. grand multiparity
2. prior c/s
3. prior uterine curretage
4. previous placenta previa
5. multiple gestation

Front 103

postcoital spotting may be an indication of ?

Back 103

placenta previa or cervicitis (chlamydia or gonorrhea)-- however it may be normal

Front 104

in antepartum bleeding, what should be the order of examination (digital, US, speculum)?

Back 104

US then speculum exam then digital exam

Front 105

complications of placental abruption

Back 105

hemorrhage, fetal to maternal bleeding, coagulopathy, preterm delivery

Front 106

risk factors for placental abruption

Back 106

1. HTN
2. Cocaine
3. short umbilical cord
4. trauma
5. Uteroplacental insufficiency
6. submucous leimyomata
7. sudden uterine decompression (polyhydramnios)
8. cigarette smoking
9. PPROM

Front 107

treatment of placental abruption

Back 107

natural history of placental abruption is toward extension and of the separation, so delivery should be the goal if > 34 weeks
- US is poor at diagnosing because clotted blood behind placenta had the same echo density as the placenta

Front 108

concealed abruption

Back 108

when bleeding occurs completely behing the placenta and no external bleeding is noted, this condition is less common than overt hemorrhage but is more dangerous

Front 109

fetomaternal hemorrhage

Back 109

fetal blood that enters into the maternal circulation

Front 110

couvelaire uterus

Back 110

bleeding into the myometrium of the uterus giving a discolored appearance to the uterine surface

Front 111

one test diagnostic for abruptio placentae?

Back 111

there is no one diagnostic test-- US is poor at picking it up-- must look at the whole clinical picture

Front 112

what is found in 1/3 of cases where fetal death occurs as a result of abruptio placentae?

Back 112

coagulopathy in mom-- hyprofibrogenemia--> bleeding

Front 113

what are some ways to follow suspected abruptio placentae?

Back 113

serial hemoglobins, following fundal height, fetal heart tracing

Front 114

in the case of fetal death from placental abruption, what is the best method of delivery for mom's health?

Back 114

vaginal delivery- often occurs quickly. blood products and IVF should be given to keep HCT > 25-30 and UOP > 30mL/hr--> this may lead to HTN or preeclampsia so MgSO4 may be needed

Front 115

what is the most common cause of antepartum bleeding with coagulopathy?

Back 115

abruptio placentae

Front 116

risk factors for cervical cancer?

Back 116

1. early age of coitus
2. STDs
3. early childbearing
4. low socioeconomic status
5. HPV
6. HIV infection
7. cigarette smoking
8. multiple sexual partners

Front 117

most common presenting symptom of cervical cancer?

Back 117

abnormal vaginal bleeding-- including postcoital spotting

Front 118

cervical intraepithelial neoplasia (CIN)?

Back 118

preinvasive lesions of the cervix with abnormal cellular maturation, nuclear enlargement, and atypia

Front 119

human papillomavirus

Back 119

circular, double stranded DNA virus that can become incorporated into the cervical squamous epithelium, predisposing cells to dysplasia and/or cancer

Front 120

radical hysterectomy

Back 120

removal of the uterus, cervix, and supportive ligaments, such as the cardinal ligament, uterosacral ligament, and proximal vagina

Front 121

radiation brachytherapy

Back 121

radioactive implants placed near the tumor bed

Front 122

radiation teletherapy

Back 122

external beam radiation where the target is at some distance from the radiation source

Front 123

HPV vaccine

Back 123

killed virus vaccing, FDA approved for females 9-26. Quadrivalent vaccine against HPV types 6, 11 (genital warts) and 16, 18 (associated with 50% of cervical dysplasia and cancer)

Front 124

where to the majority of cervical cancers arise?

Back 124

near the squamocolumnar junction (transitional zone)

Front 125

what should be done when a pap smear is abnormal?

Back 125

colposcopy with biopsies. Acetic acid may be added to observe for color change-- if the lesions turn white (acetowhite change)

Front 126

how is cervical cancer staged?

Back 126

clinically

Front 127

how is early stage (contained within the cervix) cervical cancer treated?

Back 127

early stage may be treated just as successfully with radiation as with hysterectomy

Front 128

how is advanced cervical cancer treated?

Back 128

combination of radiotherapy (consisting of brachytherapy (implants) and teletherapy (whole pelvis radiation), along with chemotherapy (usually platinum-based- to sensitize the tissue to radiation)

Front 129

what is the most common cause of death in cervical cancer?

Back 129

bilateral ureteral obstruction leading to uremia

Front 130

Should pap smears still be done on women who have had hysterectomies?

Back 130

depends if the hysterectomy was for benign or malignant condition
- if for benign reason and no h/o of CIN then no
- if for malignant or pre-malignant (CINIII) then need pap of vaginal cuff

Front 131

ASCUS

Back 131

atypical squamous cells of undetermined significance- if low grade intraepithelial legion (LSIL) or high grade intraepithelial lesion (HSIL) may need colpo. In adolescents and pregnant women-- ASCUS may be observed instead of doing colpo

Front 132

are most cervical cancers squamous or adenomatous?

Back 132

squamous

Front 133

Staging procedures for cervical cancer?

Back 133

examination under anesthesia
IVP
CXR
barium enema or proctoscopy
cystoscopy

Front 134

what is the treatment for HSIL with possibility of endocervical disease demonstrated on colposcopy?

Back 134

cervical excisional procedure (either Loop-electrosurgical excisional procedure) or cone biopsy

Front 135

amenorrhea

Back 135

no menses for 6 or more months

Front 136

sheehan syndrome

Back 136

anterior pituitary hemorrhagic necrosis caused by hypertrophy of the prolactin-secreting cells in conjuction with a hypotensive episode, usually in the setting of postpartum hemorrhage. The bleeding in the anterior pituitary leads to pressure necrosis

Front 137

asherman's syndrome

Back 137

intrauterine adhesions - scar tissue that forms in the endometrium leading to amenorrhea caused by unresponsiveness of the endometrial tissue (may also lead to inability to bear children)-- risk factors include repeated D&Cs

Front 138

postpartum hemorrhage

Back 138

bleeding greater than 500 mL for a vaginal delivery and greater than 1000 mL for a c/s. The amount of bleeding that results in or threatens to result in hemodynamic instability if untreated.

Front 139

amenorrhea and inability to breastfeed after postpartum hemorrhage

Back 139

likely result of sheehan's syndrome

Front 140

when should menstruation resume in a non-breast feeding woman postpartum?

Back 140

12 weeks postpartum- otherwise pathology must be considered

Front 141

What lab findings may be seen with sheehan's syndrome?

Back 141

dec thyroid, cortisol, prolactin, FSH and LH

Front 142

excess estrogen without progesterone, obesity, hirsuitism and glucose intolerance, oligomenorrhea

Back 142

polycystic ovarian syndrome (LH:FSH > 2:1)

Front 143

tx of sheehan syndrome?

Back 143

replacement of all deficient hormones

Front 144

tx of asherman syndrome?

Back 144

hysteroscopic resection of scar tissue (may put balloon in to prevent re-adhesion post-op)

Front 145

Will there be bleeding in response to estrogen and progesterone tx (OCP) in sheehans? ashermans?

Back 145

1. yes in sheehans
2. no in asherman's

Front 146

what is the first test that should be done when there is secondary amenorrhea with a h/o postpartum hemorrhage?

Back 146

bhcg- pregnancy test. Remember that pregnancy is still the most common cause of amenorrhea

Front 147

hypothyroidism and monophasic basal body temperature after postpartum hypotension?

Back 147

sheehan's syndrome

Front 148

most common cause of ovulatory dysfunction in women of reproductive age?

Back 148

PCOS- obesity, anovulation, hirsuitism, glucose intolerance, and estrogen excess

Front 149

predisposing conditions to umbilical cord prolapse

Back 149

AROM with unengaged fetal head, transverse lie, or footling breech

Front 150

dx and management of umbilical cord prolapse

Back 150

dx: vaginal/cervical exam- feel umbilical cord
tx: emergent cesarean section. in the meantime the doctor should put the patient in trendelenburg and use his/her hand to elevate the fetal presenting part to keep pressure off the cord

Front 151

engagement

Back 151

largest transverse (biparietal) diameter of the fetal head has negotiated the pelvic inlet

Front 152

fetal bradycardia

Back 152

baseline fetal heart rate less than 110 bpm for greater than 10 minutes

Front 153

umbilical cord prolapse

Back 153

umbilical cord enters through the cervical os presenting in front of the presenting part and making it especially prone to compression

Front 154

initial management of fetal bradycardia

Back 154

1. confirm fetal heart rate vs maternal heart rate
2. vaginal exam for umbilical prolapse
3. rotation of mom onto left lateral side to offload IVC- positional changes
4. IV fluid bolus if volume depleted
5. 100% O2
6. stop oxytocin if running

Front 155

dx and tx of hyperstimulation with oxytocin

Back 155

uterus become tetanic or contractions are frequent (q1 min)
tx: b-agonist like terbutaline given IV helps uterine relaxation

Front 156

causes of fetal bradycardia

Back 156

1. umbilical cord prolapse
2. uterine tetany
3. hypotension following epidural placement (give fluids first, then pressors)

Front 157

what is the most common finding in uterine rupture?

Back 157

fetal heart rate abnormality such as bradycardia, deep variable decels, or late decels
tx: immediate c/s

Front 158

uterine hyperstimulation

Back 158

greater than 5 uterine contractions in a 10 minute period
- can be caused by misoprostol or oxytocin (and prostaglandin cervical ripening agent can do this but higher risk misoprostol)

Front 159

what is the first step in evaluating fetal bradycardia

Back 159

differentiating fetal HR from maternal HR- with fetal scalp electrode or US

Front 160

oligomenorrhea/amenorrhea and white watery breast discharge

Back 160

hyperprolactinemia

Front 161

causes of galactorrhea

Back 161

1. pregnancy (first r/o this)
2. pituitary adenoma
3. hypothyroidism
4. breast stimulation
5. chest wall trauma
6. drugs (dopamine antagonists, antihypertensives, narcotics, OCPs)
7. hypothalamic causes (craniophargioma, etc)
8. hyperplasia of lactotrophs
9. empty sella syndrome
10. acromegaly
11. renal dz (acute or chronic)

Front 162

galactorrhea

Back 162

nonpuerperal watery or milky breast secretion that contains neither blood nor mucus. Either spontaneous or only on exam.

Front 163

pituitary secreting adenoma

Back 163

a tumor in the pituitary gland that produces prolactin.
sx: galactorrhea, headache, peripheral vision deficit (bitemporal hemianopsia)

Front 164

approach to patients with mildly elevated PRL level? markedly increased?

Back 164

1. check TSH, TRH
2. MRI for pituitary adenom

Front 165

what are women with secondary amenorrhea and low estrogen levels at greater risk for

Back 165

having a pituitary adenoma and osteoporosis

Front 166

tx of women with galactorrhea but normal menses and normal prolactin levels

Back 166

observation, yearly prolactin levels

Front 167

how does hypothyroidism lead to galactorrhea?

Back 167

low thryoid levels--> inc TRH--> dec dopamine inhibition on the anterior pituitary--> increased release of prolactin
tx: levothyroxine

Front 168

complications of transphenoidal resections of pituitary adenomas

Back 168

1. diabetes insipidus in 1/3 (low ADH- large volumes of dilute urine)
2. hemorrhage
3. meningitis
4. CSF leak
5. panhypopituitarism

Front 169

tx of prolactinoma

Back 169

med management- bromocriptine or cabergoline- dopamine agonists. If not tolerated orally can give vaginally
- surgery reserved for failure or medical management-- can shrink with meds then surg

Front 170

how does a prolactinoma/hyperprolactinemia cause oligo/amenorrhea

Back 170

Prolactin inhibits GnRH

Front 171

what can be used to treat prolactinomas in pregnancy?

Back 171

bromocriptine (if headaches and visual disturbances arise- if pt is symptomatic) - safe during pregnancy

Front 172

cholestasis of pregnancy

Back 172

intrahepatic cholestasis of unknown etiology in pregnancy whereby the patient usually complains of pruritis with or without jaundice and NO SKIN RASH
- often occurs in the 3rd trimester

Front 173

Pruritic Urticarial Papules and Plaques of pregnancy (PUPPPs)

Back 173

a common skin condition of unknown etiology unique to pregnancy characterized by intense pruritis and erythematous papules and hives on the abdomen and extremities (usually starts on abdominal striae)-- often spreads to butt
- narrow pale halo around papules
- histo: lymphs and macs with edema of dermis
- occurs more often with the 1st pregnancy and usually does not recur
- no adverse effects on fetus or mom
- tx: topical steroids or antihistamines

Front 174

Herpes gestationis

Back 174

rare skin condition only seen in pregnancy that is characterized by intense itching and erythematous vesicles/blisters on the abdomen and extremities
- etiology- autoimmune- IgG autoanitbodies activate complement against basement membrane
- dx: immunofluorescence of biopsy specimens
- inc risk of fetal growth retardation and stillbirth, or transient same dz in newborn
- tx: corticosteroids

Front 175

most common cause of pruritis in pregnancy

Back 175

intrahepatic cholestasis of pregnancy

Front 176

laboratory findings in intrahepatic cholestasis of pregnancy

Back 176

increased circulating bile acids with normal LFTs (no hepatic damage)

Front 177

consequences of intrahepatic cholestasis of pregnancy

Back 177

increased risk of prematurity, fetal distress and fetal loss
(especially when there is maternal jaundice)
- increased incidence of gallstones

Front 178

tx for intrahepatic cholestasis of pregnancy

Back 178

1st line- antihistamines and cornstarch baths
other tx- bile acid binders (cholestyramine- associated with vit K def), ursodeoxycholic acid (better tolerated than cholestyramine)

Front 179

lower abdominal pain, bilateral adnexal tenderness, dyspareunia and hyperemic cervix on exam

Back 179

saplingitis (new dyspareunia, and hyperemic cervix are indirect markers of cervical motion tenderness)

Front 180

When are infections most likely to ascend from the cervix into the uterus and fallopian tubes?

Back 180

during menses-endometrial breakdown

Front 181

pelvic inflammatory disease

Back 181

= salpingitis or infection of the fallopian tubes

Front 182

cervical motion tenderness

Back 182

extreme tenderness when the cervix is digitally manipulated--suggesting PID/salpingitis

Front 183

tubo-ovarian abscess (TOA)

Back 183

collection of purulent material around the distal tube and ovary, which unlike the typical abscess is often treatable by antibiotic therapy rather than surgical drainage

Front 184

how is PID/salpingitis diagnosed

Back 184

clinical diagnosis based on abdominal tenderness, cervical motion tenderness and adnexal tenderness
- may be confirmed by positive GC/chlamydia or TOA
- if diagnosis is in doubt then a surgeon can perform a diagnostic laparoscopy and look for purulent material extruding from the fimbria of the tubes

Front 185

ddx for presentation of PID

Back 185

appendicitis, cholecystitis, diverticulitis, pancreatitis, ovarian torsion, pyelonephritis, gastroenteritis

Front 186

tx of PID/acute salpingitis

Back 186

depends on pt-- candidate for inpatient or outpatient
-outpatient criteria: low grade-fever, tolerates oral meds, no peritoneal signs, compliant pt (IM ceftriaxone single injection + 10-14 days of oral doxycycline BID)
- inpatient criteria: failed outpatient treatmentm pregnant, extremes of age, cannot tolerate oral meds, TOA (IV Cefotetn and oral or IV doxycycline)
-- MUST re-revaluate in 48 hours to determine response to tx-- if not improvement consider laparoscopy

Front 187

Tx of tubo-ovarian abscess

Back 187

these can usually be treated with abx
- usually caused by anaerobic organisms
- if rupture-- surgical emergency
(may feel adnexal mass or see complex cyst on US)
- admit patient and give IV clindamycin or metronidazole

Front 188

long-term complications of salpingitis/PID

Back 188

chronic pelvic pain, ectopic pregnancy, infertility (directly related to the number of PID episodes)

Front 189

role of contraceptives in increasing or decreasing risk of PID

Back 189

inc risk with IUD- allows for ascending infection

dec risk with OCPs because progestin thickens the cervical mucus

Front 190

cultures obtained during laparoscopy of purulent drainage in PID would most likely reveal what?

Back 190

multiple organisms- N. gonorrhea, c. trachomatis, anaerobic bacteria, gram negative rods-- for this reason abx must be broad spectrum

Front 191

what is the gold standard for diagnosing salpingitis (allows differentiation between appendicitis and PID?)

Back 191

diagnostic laparoscopy- direct visualization of the tubes- look for purulent discharge from the fimbria of the tubes

Front 192

risk factors for PID

Back 192

nulliparity, young age of first coitus, multiple sexual partners, IUD

Front 193

how does having an IUD lead to increased risk of PID

Back 193

during IUD placement, there is breakdown of the endocervical barrier as the device enters the uterus and this allows the infection to ascend

Front 194

actinomyces

Back 194

gram-positive anaerobe that is more common cause of PID in the setting of IUD
- characteristic sulfur granules
- sensitive to penicillin

Front 195

how normal pH, pO2, pCO2, and HCO3 levels affected in pregnancy?

Back 195

pH is increased from 7.4 to 7.45
pO2 is increased from 90-100 to 95-105 (inc tidal volume-> inc minute ventilation)
pCO2 is decreased from 40 to 28 (inc tidal volume-> inc minute ventilation)
HCO3 is decreased from 24 to 19

Front 196

hypoxemia on arterial blood gas, tachycardia, tachypnea and a clear chest xray in a pregnant woman

Back 196

think pulmonary embolism

Front 197

Tx for DVT or PE during pregnancy?

Back 197

full IV anticoagulation for 5-7 days to stabilize the clot and prevent propogation, then switch to subQ heparin or LMWH for at least 3 months with a gold aPTT 1.5-2.5 x normal.
After 3 months may continue full heparin or switch to prophylactic heparin until 6 weeks pp

Front 198

although pregnancy itself induces a hypercoaguable state, what other conditions might contribute to DVT/PE during pregnancy?

Back 198

protein C or S deficiency, antithrombin III def, Factor V leiden, prothrombin 20210A, hyperhomocysteinemia, antiphospholipid antibody syndrome

Front 199

most common symptom of PE?
most common sign?

Back 199

1. dyspnea
2. tachycardia

Front 200

what is the most common cause of maternal mortality?

Back 200

thromboembolism-- pregnant women are in a hypercoaguable state until 6 weeks pp

Front 201

what acid base status does pregnancy induce

Back 201

a respiratory alkalosis with partial metabolic compensation

Front 202

herpes simplex virus prodromal symptoms

Back 202

prior to the outbreak of the classic vesicles, the patient may complain of burning, itching or tingling

Front 203

neonatal herpes infection

Back 203

HSV can cause disseminated infection with major organ involvement, be confined to encephalitis, eyes, skin or mucosa or be asx. The vast majority of neonatal herpes infections occur via exposure to virus in fluids and secretions of the genital tract, although 5-10% may occur in the antepartum period transplacentally (most likely due to primary episodes and significant viremia)

Front 204

management of delivery in a patient with HSV

Back 204

give acyclovir ppx, do careful examine prior to delivery, ask about prodromal sx. If no lesions or sx, may proceed to vaginal delivery. If lesions or prodrome--> c/s

Front 205

what is the most common reason for hysterectomy in the US?

Back 205

symptomatic uterine fibroids

Front 206

what is the most common symptom of uterine fibroids?

Back 206

menorrhagia

Front 207

leiomyomata

Back 207

benign, smooth muscle tumors, usually of the uterus

Front 208

leiomyosarcoma

Back 208

malignant smooth muscle tumor with numerous mitoses

Front 209

submucous fibroid

Back 209

leimyomata that are primarly on the endometrial side of the uterus and may impinge on the uterine cavity (as opposed to serous fibroids on the outside of the uterus)

Front 210

intramural fibroids

Back 210

leiomyomata that are primarily in the uterine muscle

Front 211

subserousal fibrouds

Back 211

leiomyomata that a primarily on the outside of the uterus, on the serosal surface. physical exam may reveal a "knobby" sensation

Front 212

pedunculated fibroid

Back 212

leiomyoma on a stalk

Front 213

cancerous degeneration

Back 213

aka red degeneration-- chainges of the leiomyomata due to rapid growth; the center becomes red- causing pain. This occurs rarely.
- signs of malignant transformation include rapid growth-- increase in gestational size more than 6 weeks in one year
- risk factor is prior pelvis radiation

Front 214

symptoms of uterine fibroids

Back 214

menorrhagia, pressure in pelvis
- rarely twisting of the fibroid leads to necrosis and pain
- may prolapse causing contraction pain

Front 215

typical physical exam in uterine leiomyomata

Back 215

irregular, midline, firm non-tender mass that moves contiguously with the cervix
- confirmed with US
- unusual for them to be lateral, fixed or fluctuant
- ddx includes ovarian mass, TOA, pelvic kidney, endometrioma

Front 216

Tx of uterine fibroids

Back 216

initially- NSAIDs or progestin
- GnRH angonists can be used to shink the fibroid- will reach max effect in 3 mo, but after cessation, fibroid will regrow (used to shrink fibroid or decrease anemia before surgery)
- if do not want more kids-- hysterectomy is definitive
- if want kids-- myomectomy
- uterine artery embolization = another option
--surgery is indicated after failure of medical therapy

Front 217

chronic hypertension

Back 217

blood pressure of 140/90 mmHg before pregnancy or at less than 20 weeks' gestation

Front 218

gestational hypertension

Back 218

hypertension without proteinuria at greater than 20 weeks' gestation

Front 219

preeclampsia

Back 219

hypertension with proteinuria (>300 mg over 24 hours) at a gestational age greater than 20 weeks, caused by vasospasm

Front 220

eclampsia

Back 220

seizure disorder associated with preeclampsia

Front 221

severe preeclampsia

Back 221

vasospasm associated with preeclampsia to such an extent that maternal end organs are threatened, usually necessitating delivery of the baby regardless of the gestionational age
- bp >160 systolic or > 110 diastolic on 2 occassions at least 6 hours apart with the patient on bed rest
- marked proteinura >5 g/24 or 3+ dipstick x 2, 4 hrs apart
- oliguria <500mL urine/24 hour
- cerebral or or visual disturbances such as HA or scotomata
- pulmonary edema or cyanosis
- epigastric or RUQ pain- probably caused by subcapsular hepatic hemorrhage or stretching
- evidence of hepatic dysfxn
- thrombocytopenia
- IUGR

Front 222

superimposed preeclampsia

Back 222

development of preeclampsia in a patient with chronic hypertension

Front 223

features of preeclampsia

Back 223

hypertension (>140 SBP, >90 DPB), proteinuria and often non-dependent edema (facial or hand)

Front 224

etiology of preeclampsia

Back 224

unknown but thought to be due to vasospasm and endothelial damage

Front 225

complications of preeclampsia

Back 225

placental abruption, eclampsia, coagulopathies, renal failure, hepatic subcapsular hemorrhage, hepatic rupture, uteroplacental insufficiency

Front 226

risk factors for preeclampsia

Back 226

- nulliparity
- african american race
- extremes of age
- person h/o severe preeclampsia
- family history
- chronic htn
- chronic renal disease
- APA syndrome
- diabetes
- multifetal gestation

Front 227

lab tests for evaluation of preeclampsia

Back 227

- CBC
- UA
- 24 hour urine protein
- LFTs
- LDH

Front 228

tx of preeclampsia

Back 228

- if >37 weeks (term) or severe at any GA--> Mag sulfate and delivery
- < 37 weeks and non severe-- expectant management until term or severe

Front 229

when is there the greatest risk for eclampsia

Back 229

just prior to delivery, during labor, or within 24 hours pp

Front 230

What should be monitored when pt on mgso4?

Back 230

UOP, respiratory depression, dyspnea (pulmonary edema), abolishment of DTRs

Front 231

what is the first sign of magnesium toxicity?

Back 231

loss of DTRs

Front 232

what is the role of MgSO4 in preeclampsia?

Back 232

prevention of seizures. It actually does not decrease BP

Front 233

medications for BP control during pregnancy

Back 233

hydralazine, labetalol (methylodopa sometimes)

Front 234

when should MgSO4 be discontinued pp?

Back 234

after 24 hours pp

Front 235

most common cause of maternal death in eclampsia?

Back 235

intracerebral hemorrhage

Front 236

most common cause of significant proteinuria in pregnancy

Back 236

preeclampsia

Front 237

firm, nontender, rubbery mobile breast mass

Back 237

fibroadenoma-- does not change with the menstrual cycle as fibrocystic breast disease does

Front 238

fine needle aspiration (FNA)

Back 238

the use of small gauge needle with associatied vacuum via a syringe to aspirate fluid or some cells from a breast mass or cyst. gives loose cells for cytology. good if there is a low risk of cancer-- otherwise need more tissue (either core needle biopsy or excisional bx)

Front 239

fibroadenoma

Back 239

benign, smooth muscle tumor of the breast, usually occuring in young women

Front 240

multiple irregular lumps throughout the breast that are painful and engorged in a cyclic fashion with the menstrual cycle

Back 240

fibrocystic breast disease-- exaggerated response to ovarian hormones
- common in premenopausal women but rare after menopause

Front 241

tx of fibrocystic breast disease

Back 241

-decrease caffeine intake
- NSAIDs
- tight fitting bra
- OCPs or oral progestin
-- if severe danazol (weak antiestrogen) or mastectomy may be considered

Front 242

what needs to be done for any three dimensional dominant breast mass?

Back 242

biopsy-- need tissue to make dx. if low risk of cancer then FNA, if higher risk core needle bx or excisional bx

Front 243

triple assessment for breast mass

Back 243

clinical exam, imaging (US or MG) and histology
- if all are in agreement then higher reliability of FNA or core needle bx
- most of the time any mass in a woman over 35 or with a family history of breast cancer will require excision

Front 244

intraductal papilloma

Back 244

most common cause of bloody (Serosanguinous) nipple discharge
- small benign tumor of the milk ducts most common in women 35-55
- must r/o breast cancer

Front 245

galactocele

Back 245

mammayy gland tumors that cystic in nature and contain milk or milky fluid-- they occur when there is any sort of obstruction of milk flow in a lactating breast

Front 246

what is the best way to image the breast of a woman less than 30?

Back 246

US because the breasts are usually too dense for accurate mammography

Front 247

inflammatory breast cancer

Back 247

aggressive, with skin changes - redness, induration-- causes by cancer cells in the subdermal lymph channels
- more often found in young women

Front 248

five basic etiologies of infertility

Back 248

1. ovulatory
2. uterine
3. tubal
4. male factor
5. peritoneal factor (endometriosis)

Front 249

infertility

Back 249

inability to conceive after 1 year of unprotected intercourse

Front 250

primary infertility

Back 250

a woman has never been able to get pregnant

Front 251

secondary infertility

Back 251

a woman has been pregnant in the past, but has 1 year of inability to conceive

Front 252

fecundability

Back 252

the probability of achieving a pregnany within one menstrual cycle is 20-25% for a normal couple
- 10-15% of couples at any age group experience infertility

Front 253

what is the easiest method of detecting ovulation in determining an ovarian cause of infertility?

Back 253

basal body temperature (BBT)
- measured orally first thing in the morning, to detect 0.5 degree F raise in body temperature that occurs after ovulation due to release of progesteron

Front 254

within how long of LH surge (as can be measured by a urine kit) does ovulation occur?

Back 254

36 hours

Front 255

what is the initial test to detect uterine problems in evaluation of infertility?

Back 255

hysterosalpingogram- assesses uterine shape and tubal patency. -- then hysteroscopy if there is a defect noted on HSG
- tx - hysteroscopic procedure, surgery to correct anatomical defect

Front 256

tubal causes of infertility? how to assess?

Back 256

chlamydia or gonorrhea infection, may initially inspect with HSG but laparoscopy is the gold standard
tx - IVF

Front 257

how long does spermatogonia take?

Back 257

74 days-- so wait 2-3 months between different semen analysis
- normal semen analysis = volume > 2 mL, conc > 20 million/mL, motility > 50% and > 30% normal morphology

Front 258

how might endometriosis cause infertility?

Back 258

inhibiting ovulation, inducing adhesions, and maybe interfering with fertilization
- laparoscopy is the gold standard for dx of endometriosis
- tx- ablation of endometriosis or medical tx (OCPs)

Front 259

tx for ovulatory dysfunction as a cause for infertility?

Back 259

clomiphene citrate

Front 260

5 most common cause of acute abdominal pain in pregnancy

Back 260

1. appendicitis
2. cholecystitis
3. ovarian torsion
4. ectopic pregnancy
5. placental abruption

Front 261

what is the best treatment for ovarian torsion due to cyst?

Back 261

if the ovarian tissue is still viable then laparoscopic cystectomy should be attempted

Front 262

when does ovarian torsion usually happen during pregnancy?

Back 262

either 14 weeks gestation-- when the uterus rises above the pelvic brim or immediately pp

Front 263

complications of appendicitis during preg

Back 263

preterm labor or abortion

Front 264

presentation of appendicitis during pregnancy

Back 264

n/v, fever, anorexia, leukocytosis, pain superior and lateral to mcburney's point-- enlarged uterus pushes the appendix up and out toward the flank
tx- surgery + IV abx

Front 265

acute cholecystitis in preg

Back 265

- in preg there is an increase in gallbladder volume and biliary sludge--> leads to gallstones
- sx: RUQ pain after meal, nausea, bloating, fever and infectious signs

Front 266

tx of simple biliary colic in preg

Back 266

low fat diet and observation

Front 267

what is the most common complication of a benign ovarian cyst?

Back 267

ovarian torsion
- preg = risk factor, esp at 14 weeks
- sx: unilateral abdd and pelvic colicky pain with n/v (acute nset of colicky pain)
- tx: surgery-- untwist-- if reperfusion then cystectomy

Front 268

risk factors for placental abruption

Back 268

htn, trauma, cocaine, smkoing PPROM
- persistent crampy midline pain, abn fetal heart tracing
- us not very accurate

Front 269

ectopic pregnacy presentation

Back 269

amenorrhea, spotting, lower abd pain, n/v, slightly enlarged uterus, adnexal mass, with rupture-- syncope and hypovolemia
- TVS and bhcg

Front 270

what produces bhcg during pregnancy?

Back 270

synciotrophoblasts

Front 271

threshold hcg for TVS?

Back 271

1500-2000 mIU/mL-- at this point you should be able to visualize a normal, singleton, intrauterine, viable pregnancy by TVS-- if cannot then ectopic more likely

Front 272

most common cause of maternal mortality in the first 20 weeks of gestation

Back 272

hemorrhage from an ectopic preg

Front 273

risk factors for ectopic pregnancy

Back 273

salpingitis
tubal adhesive disease
infertility
progesterone secreting IUD
tubal surgery
prior ectopic preg
ovulation induction
congenital abn of tube

Front 274

culdocentesis

Back 274

spinal needle is used to pierce the posterior vaginal fornix into the cul-de-sac

Front 275

pseudogestational sac

Back 275

fluid in the uterus associated with an ectopic pregnancy

Front 276

pseudogestational sac

Back 276

fluid in the uterus associated with an ectopic pregnancy

Front 277

if hcg level less than 1500, no severe abd pain, hypotension or adnexal mass, how can suspected ectopic preg be managed

Back 277

repeat bhcg in 48 hours, if greater than 66% rise than likely normal/viable pregnancy

Front 278

pseudogestational sac

Back 278

fluid in the uterus associated with an ectopic pregnancy

Front 279

how do progesterone levels help predict normal IUPs or abn pregnancies?

Back 279

progesterone > 25 ng/mL almost always normal IUP
if < 5 ng/mL then abn preg

Front 280

if hcg level less than 1500, no severe abd pain, hypotension or adnexal mass, how can suspected ectopic preg be managed

Back 280

repeat bhcg in 48 hours, if greater than 66% rise than likely normal/viable pregnancy

Front 281

if hcg level less than 1500, no severe abd pain, hypotension or adnexal mass, how can suspected ectopic preg be managed

Back 281

repeat bhcg in 48 hours, if greater than 66% rise than likely normal/viable pregnancy

Front 282

management of microcytic anemia in a pregnant women of non-SE asian decent

Back 282

therapeutic trial of iron and recheck hgb in 3 weeks- if no improvement than do iron studies and hgb electrophoresis

Front 283

how do progesterone levels help predict normal IUPs or abn pregnancies?

Back 283

progesterone > 25 ng/mL almost always normal IUP
if < 5 ng/mL then abn preg

Front 284

how do progesterone levels help predict normal IUPs or abn pregnancies?

Back 284

progesterone > 25 ng/mL almost always normal IUP
if < 5 ng/mL then abn preg

Front 285

management of microcytic anemia in a pregnant women of non-SE asian decent

Back 285

therapeutic trial of iron and recheck hgb in 3 weeks- if no improvement than do iron studies and hgb electrophoresis

Front 286

anemia in pregnancy

Back 286

hgb level of 10.5 or less in preg woman

Front 287

management of microcytic anemia in a pregnant women of non-SE asian decent

Back 287

therapeutic trial of iron and recheck hgb in 3 weeks- if no improvement than do iron studies and hgb electrophoresis

Front 288

anemia in pregnancy

Back 288

hgb level of 10.5 or less in preg woman

Front 289

anemia in pregnancy

Back 289

hgb level of 10.5 or less in preg woman

Front 290

G6PD deficiency

Back 290

x-linked condition whereby RBCs may have decreased capacity for anaerobic glucose metabolism. oxidizing agents like nitrofurantoin, sulfa drugs, antimalarial drugs can can cause hemolysis

Front 291

most common cause of anemia during pregnancy?

Back 291

iron deficiency-- icreased iron demands

Front 292

sickle cell disease in preg

Back 292

women with sickle cell disease often have more anemia (fatigue and SOB), more frequent vasooclusive/pain crises, and more frequent infections/pulm complications
- higher chance of IUGR and perinatal mortality-- serial US
-- good hydration is key!
- inc risk of preterm labor and low birth weight baby

Front 293

african american woman who has dark urine, jaundice and fatigue after being treated for a UTI with nitrofurantoin

Back 293

G6PD deficiency

Front 294

most common cause of macrocytic anemia in pregnancy?

Back 294

folate deficiency

Front 295

elevated A2 hemoglobin level is suggestive of ? hemoglobin F?

Back 295

1. b-thalassemia
2. a-thalassemia

Front 296

preterm labor

Back 296

cervical change associated with uterine contractions prior to 37 completed weeks and after 20 weeks. I a nulliparous woman, uterine contractions and a single cervical exam revealing 2-cm dilation and 80% effacement or greater is sufficient to make the dx

Front 297

elevated A2 hemoglobin level is suggestive of ? hemoglobin F?

Back 297

1. b-thalassemia
2. a-thalassemia

Front 298

tocolysis

Back 298

pharmacologic agents used to delay delivery once preterm labor is diagnosed. most common agents include- indomethacin, nifedipine, terbutaline, ritodrine
MgSO4 might not be effective

Front 299

preterm labor

Back 299

cervical change associated with uterine contractions prior to 37 weeks and after 20 weeks. I a nulliparous woman, uterine contractions and a single cervical exam revealing 2-cm dilation and 80% effacement or greater is sufficient to make the dx

Front 300

fetal fibronectin assay

Back 300

a basement membrane protein that helps bind placental membranes to the decidua of the uterus. A vaginal swab is used to detect its presence. Its best utility is a negative result, which is associated with a 99% chance of not delivering within 1 week

Front 301

tocolysis

Back 301

pharmacologic agents used to delay delivery once preterm labor is diagnosed. most common agents include- indomethacin, nifedipine, terbutaline, ritodrine
MgSO4 might not be effective

Front 302

cervical length assessment

Back 302

TVS to measure cervical length. cervical length less than 25 mm results in increased risk of preterm delivery.
- impinging of the amniotic cavity into the cervix (aka funneling) increases risk of preterm delivery

Front 303

fetal fibronectin assay

Back 303

a basement membrane protein that helps bind placental membranes to the decidua of the uterus. A vaginal swab is used to detect its presence. Its best utility is a negative result, which is associated with a 99% chance of not delivering within 1 week

Front 304

cervical length assessment

Back 304

TVS to measure cervical length. cervical length less than 25 mm results in increased risk of preterm delivery.
- impinging of the amniotic cavity into the cervix (aka funneling) increases risk of preterm delivery

Front 305

G6PD deficiency

Back 305

x-linked condition whereby RBCs may have decreased capacity for anaerobic glucose metabolism. oxidizing agents like nitrofurantoin, sulfa drugs, antimalarial drugs can can cause hemolysis

Front 306

most common cause of anemia during pregnancy?

Back 306

iron deficiency-- icreased iron demands

Front 307

sickle cell disease in preg

Back 307

women with sickle cell disease often have more anemia (fatigue and SOB), more frequent vasooclusive/pain crises, and more frequent infections/pulm complications
- higher chance of IUGR and perinatal mortality-- serial US
-- good hydration is key!
- inc risk of preterm labor and low birth weight baby

Front 308

african american woman who has dark urine, jaundice and fatigue after being treated for a UTI with nitrofurantoin

Back 308

G6PD deficiency

Front 309

most common cause of macrocytic anemia in pregnancy?

Back 309

folate deficiency

Front 310

elevated A2 hemoglobin level is suggestive of ? hemoglobin F?

Back 310

1. b-thalassemia
2. a-thalassemia

Front 311

preterm labor

Back 311

cervical change associated with uterine contractions prior to 37 weeks and after 20 weeks. I a nulliparous woman, uterine contractions and a single cervical exam revealing 2-cm dilation and 80% effacement or greater is sufficient to make the dx

Front 312

tocolysis

Back 312

pharmacologic agents used to delay delivery once preterm labor is diagnosed. most common agents include- indomethacin, nifedipine, terbutaline, ritodrine
MgSO4 might not be effective

Front 313

fetal fibronectin assay

Back 313

a basement membrane protein that helps bind placental membranes to the decidua of the uterus. A vaginal swab is used to detect its presence. Its best utility is a negative result, which is associated with a 99% chance of not delivering within 1 week

Front 314

cervical length assessment

Back 314

TVS to measure cervical length. cervical length less than 25 mm results in increased risk of preterm delivery.
- impinging of the amniotic cavity into the cervix (aka funneling) increases risk of preterm delivery

Front 315

risk factors for preterm labor

Back 315

1. PPROM
2. multiple gestations
3. previous preterm labor
4. hydramnios
5. uterine anomaly
6. history of cervical cone bx
7. cocaine
8. african american race
9. abd trauma
10. pyelonephritis
11. abd surgery during pregnancy

Front 316

risk factors for preterm labor

Back 316

1. PPROM
2. multiple gestations
3. previous preterm labor
4. hydramnios
5. uterine anomaly
6. history of cervical cone bx
7. cocaine
8. african american race
9. abd trauma
10. pyelonephritis
11. abd surgery during pregnancy
12. bacterial vaginosis
13. UTI and pyelo

Front 317

management of preterm labor

Back 317

1. tocolysis if < 34-35 weeks
2. identify and treat cause if possible
3. steroids if gestational age <34 weeks

Front 318

management of preterm labor

Back 318

1. tocolysis if < 34-35 weeks
2. identify and treat cause if possible
3. steroids if gestational age <34 weeks

Front 319

speculated MOA of MgSO4 in tocolysis

Back 319

competitive inhibition of calcium

Front 320

speculated MOA of MgSO4 in tocolysis

Back 320

competitive inhibition of calcium

Front 321

side effects of mgSO4

Back 321

pulmonary edema, resp depression
- neonatal depression, osteoporosis if used long-term

Front 322

side effects of mgSO4

Back 322

pulmonary edema, resp depression
- neonatal depression, osteoporosis if used long-term

Front 323

side effects of nifedipine

Back 323

- pulmonary edema
- increased pulse pressure
- hyperglycemia
-hypokalemia
- tachycardia

Front 324

side effects of nifedipine

Back 324

CHF, Mi, pulmonary edema, severe hypotension

Front 325

MOA, use, SE, CI of terbulatine and ritodrine

Back 325

use: tocolysis
MOA: b2 agonists that stimulate smooth muscle relaxation
SE: pulmonary edema, increased pulse pressure, hyperglycemia, hypokalemia, tachycardia
CI: arrythmia, htn, seizure disorder

Front 326

MOA, use, SE, and CI of indomethacin

Back 326

NSAID- decreased prostaglandin synthesis
SE: closure of ductus arteriosus--> pulm htn, oligohydramnios
CI: 3rd trimester

Front 327

17 hydroxyprogesterone caproate

Back 327

used for tocolysis/prevention of preterm labor
MOA: synthetic progesterone, HRT, inhibits pituitary gonadotropin release to maintain a pregnancy
SE: breast pain, dizziness abd pain, intermittent bleeding
CI: undiagnosed vaginal bleeding

Front 328

work-up for preterm labor

Back 328

- h/o risk factors
- serial digital cervical exams
- CBC
- UDS
- UA, urine culture
- GC/Chlamydia test
- GBS swab
- US for fetal weight and presentation

Front 329

when a corticosteroids given during pregnancy for preterm labor? what for?

Back 329

between 24-34 weeks
24-28 weeks the goal is to prevent intraventricular hemorrhage
28-34 weeks the goal is to dec risk of Neonatal RDS

Front 330

what type of STD is most strongly associated with preterm labor

Back 330

gonorrhea (chlamydia is not as strongly associated with PTL)

Front 331

should tocolysis be given if there is a placental abruption?

Back 331

no, because the abruption may extend and cause fetal distress and in that case, delivery is the best option
- if delivery occured there would be greater chance of PPH due to uterine atony

Front 332

SE of b2 agonists given for tocolysis

Back 332

pulmonary edema!
- tachycardia
- hyperglycemia
- hypokalemia
- increased pulse pressure

Front 333

cystitis

Back 333

bacterial infection of the bladder (most commonly caused by E coli) defined as having > 100,000 CFUs/mL on a single bacterial type on midstream specimen

Front 334

urethritis

Back 334

infection of the urethra commonly caused by c. trachomatis

Front 335

urethral syndrome

Back 335

urgency and dysuria caused by urethral inflammation of unknown etiology, urine cultures are negative

Front 336

why does pregnancy predispose women to UTIs

Back 336

incomplete bladder emptying, ureteral obstruction, immune suppression

Front 337

management of asx bacteriuria in pregnancy

Back 337

- this leads to acute UTI in 25% of cases so it should always be treated with abx

Front 338

frequent agent for UTI ppx in preg?

Back 338

nitrofurantoin (macrobid)

Front 339

yuzpe regimen

Back 339

use of specific oral contraceptive regimen consisting of two tablet of OCPs at 0 and 12 hours after intercourse- emergency contraceptive

Front 340

plan b

Back 340

progesterone only- levonorgestrel 0.75 mg taken at time 0 and 12 hours after intercourse for emergency contraception

Front 341

vaginal diaphragm

Back 341

form of contraceptive that must be placed 1-2 hours before sex and left in place for at least 8 hours after sex

Front 342

active agent in spermicidals

Back 342

nonoxynol-9-- disrupts sperm ell membrane and provides a mechanical barrier

Front 343

moa of OCPS

Back 343

prevention of ovulation by use of progesterone-- also causes thickening of the cervical mucus

Front 344

effect of estrogen in OCPs

Back 344

maintainence of the epithelium, prevention of unscheduled bleeding, and inhibition of follicular development

Front 345

contraindications of OCP use

Back 345

1. thrombogenic mutations
2. prior VTE
3. cerebrovascular or CAD
4. uncontrolled HTN
5. migraines with aura
6. diabetes with peripheral vascular disease
7. smoking and age >35
8. known or suspected breast cancer
9. estrogen-dependent neoplasia
10 undiagnosed abn genital bleeding
11. benign or malignant liver tumors, active liver dz
12. known or suspected pregnancy

Front 346

what is the comparative risk of DVT with the patch vs combined OCP?

Back 346

2x greater risk of VTE with the patch

Front 347

active agent in spermicidals

Back 347

nonoxynol-9-- disrupts sperm ell membrane and provides a mechanical barrier

Front 348

moa of OCPS

Back 348

prevention of ovulation by use of progesterone-- also causes thickening of the cervical mucus

Front 349

effect of estrogen in OCPs

Back 349

maintainence of the epithelium, prevention of unscheduled bleeding, and inhibition of follicular development

Front 350

contraindications of OCP use

Back 350

1. thrombogenic mutations
2. prior VTE
3. cerebrovascular or CAD
4. uncontrolled HTN
5. migraines with aura
6. diabetes with peripheral vascular disease
7. smoking and age >35
8. known or suspected breast cancer
9. estrogen-dependent neoplasia
10 undiagnosed abn genital bleeding
11. benign or malignant liver tumors, active liver dz
12. known or suspected pregnancy

Front 351

what is the comparative risk of DVT with the patch vs combined OCP?

Back 351

2x greater risk of VTE with the patch

Front 352

implant contraceptive/implanon

Back 352

placed in women's upper arm, releases steady amount of levonorgestrel
- lasts 3 years

Front 353

how long can a levonorgestrel containing IUD be left in? copper?

Back 353

5 years
-10 years for copper

Front 354

what patients are IUDs most beneficial for?

Back 354

women in stable monogamous relationships with a low risk for STDs

Front 355

contraindications to IUD

Back 355

1. current pregnancy
2. current STD
3. current PID or PID within the last 3 mo
4. unexplained vaginal bleeding
5. malignant gestational trophoblastic disease
6. untreated cervical cancer
7. utreated endometrial cancer
8. uterine fibroids distorting the uterine cavity
9. current breast cancer-- for prog IUD only
10. wilson's disease for copper IUD
11. known pelvic TB

Front 356

which type of emergency contraception is most effective?

Back 356

progestin only type-- 85% effective, combined OCP (Yuzpe method) = 75% effective

Front 357

when can IUDs be placed for emergency contraception?

Back 357

within 5 days of unprotected sex

Front 358

what is the best type of contraception while breast feeding?

Back 358

progesterone only pill (minipill)
-- very dependent on taking the pill each day at the same time

Front 359

what is the contraceptive method best suiding for sickle cell disease and epilepsy?

Back 359

depo-medroxyprogesterone acetate

Front 360

what are the main side effects of emergency contraceptive methods?

Back 360

n/v (less with progesterone only option- plan b)

Front 361

effect of OCP on risk of ovarian ca, breast ca, endometrial ca, and benign breast disease

Back 361

dec risk of endometrial and ovarian cancer as well as benign breast disease
slightly inc risk of breast ca

Front 362

acute respiratory distress syndrome

Back 362

alveolar and endothelial injury leading to leaky pulmonary capillaries, clinically causing hypoxemia, large alveolar-arterial gradient and loss of lung volume

Front 363

what is the most common cause of sepsis in pregnant women?

Back 363

pyelonephritis

Front 364

treatment of pyelonephritis in pregnant women

Back 364

hospitalize and treat with IV abx-- either cephalosporin like cefriaxone or cefotetan or a combination of ampicllin and gentamycin.
- should continue IV abx until fever and flank pain resolve then switch to oral abx followed by ppx for the rest of pregnancy-- up to 1/3 will have recurrence if no ppx

Front 365

If no clinical improvement within 48-72 hours with appropriate antibiotic therapy for pyelonephritis then what should be suspected?

Back 365

urinary tract obstruction (ureterolithiasis) or perinephric abscess

Front 366

what is a risk of pyelonephritis in pregnancy which has sx of dyspnea and tachycardia?

Back 366

ARDS-2-5% of women will get ARDS and this is usually related to sepsis from endotoxins (component of gram negative bacteria cell wall that enters blood stream often after abx treatment)--
- may see diffuse bilateral infiltrates on CXR
- may also inc risk of PTL

Front 367

tx of ARDS

Back 367

supportive-- priorities are oxygenation and careful fluid management
- may require mechanical ventilation if severe

Front 368

what are the most common organisms that cause pyelonephritis?

Back 368

E. coli, Klebsiella, Proteus, and S. aureus

Front 369

hemolytic uremic syndrome

Back 369

hemolytic anemia, acute renal failure (uremia) and thrombocytopenia-- often caused by E.coli that presents with bloody diarrhea

Front 370

what is the best way to dx asx bacteriuria in pregnancy?

Back 370

prenatal UA and urine culture
- UA at every prenatal visit

Front 371

what predisposed women to DVT during pregnancy?

Back 371

hypercoaguability due to increased levels of clotting factors (particularly fibrinogen) and venous stasis-- may be caused by IVC compression

Front 372

Homan's sign

Back 372

dorsiflexion of the foot in attempt to elicit tenderness in the leg of pt to screen for DVT- not very sensitive
- may theoretically inc risk of embolization
- doppler US is better

Front 373

signs and sx of DVT

Back 373

muscle/calf pain, deep linear cords of the calf, tenderness and swelling of the lower extremity (2cm difference in leg circumference)
- exam in normal in 1/2
- if undx and untx-- inc risk of death
- 40% chance of PE in untx DVT

Front 374

tx of DVT

Back 374

anticoagulation with bed rest and leg elevation
-- HEPARIN during pregnancy-- inhibits clot propogation
- full IV anticoag for 5-7 days then switch to subQ to maintain aPTT from 1.5-2.5 for at least 3 mo, then either full or ppx heparin for rest of pregnancy and 6 weeks pp
-coumadin is a teratogen

Front 375

long term complications of heparin use

Back 375

osteoporosis and thrombocytopenia

Front 376

what is the most important risk factor for breast cancer?

Back 376

age
- the overall lifetime risk of breast cancer is 1 in 8

Front 377

when should yearly mammograms be instituted?

Back 377

at age 50 or earlier if a positive family history then at 35 (or 10 years before the first diagnosed case in the family)

Front 378

false negative rate of mammograms

Back 378

10% so any palpable dominant breast mass must be biopsied. greater risk for cancer then the more tissue that needs to be biopsied

Front 379

BRCA mutation

Back 379

autosomal dominant mutation that confers 50-70% chance of breast cancer and 30% chance of ovarian cancer
- more common in ashkenazi jews
- all women with 2 or more first degree family members with breast cancer should be offered screening

Front 380

what is the most common cause of unilateral serosangiouneous nipple discharge?

Back 380

intraductal papilloma

Front 381

what is the most common type of breast cancer?

Back 381

infiltrated intraductal carcinoma

Front 382

what is a complex cyst?

Back 382

partially solid and partially cystic

Front 383

epithelial ovarian tumor

Back 383

neoplasm arising from the outer layer of the ovary, which can imitate the other epithelium of the gynecologic or urologic system. The most common type of ovarian malignancy, usually occuring in older women

Front 384

functional ovarian cyst

Back 384

physiologic cysts of the ovary, which occur in reproductive-aged women of follicular, corpus luteal, or theca lutein origin

Front 385

struma ovarii

Back 385

teratoma in which thyoid tissue has overgrown the other elements.
- often appear as multilobulated masses with thick septa
- 10% may have malignant changes

Front 386

1. what is the most common ovarian tumor in women > 30?
2. less than 30?

Back 386

1. epithelial tumors of the serous subtype (often bilateral)
2. cystic teratoma/ dermoid cyst

Front 387

management of adnexal masses

Back 387

any mass > 8 cm is likely a tumor and must be explored
- if a prepubertal girl than any mass 2-3 cm should be surgically explored
- if < 5cm is likely a functional cyst- may observe and reassess in 1-2 months
- if 5-8 the US feature might help differentiate

Front 388

what components/appearance of ovarian tumors on US indicates a likely cancerous process?

Back 388

septatiions, solid components, or excrescences (growth on the surface or inner lining)

Front 389

granulosa theca cell tumor

Back 389

sex cord stromal tumor (usually solid) that may produce estrogen and thus cause precocious puberty

Front 390

how are malignant teratomas graded

Back 390

these contain immature neural elements are graded by the amount of neural tissue involved
- they contain all 3 germ layers, occur mostly in the 1st and 2nd decades of life

Front 391

risk factos for fascial dehiscence

Back 391

obesity, diabetes, cancer, intra-abdominal distention, exposure to radiation, corticosteroid use, infection, coughing, malnutrition, and vertical incision

Front 392

hours of profuse serosangiunous drainage from an incision site is indicative of what?

Back 392

fascial disruption--surgical emergency-- start broad spectrum IV abx and head to the OR- often occurs 5-14 days after surgery

Front 393

wound dehiscence

Back 393

a separation of part of the surgical incision but with an intact peritoneum

Front 394

surgical site infection

Back 394

infection related to the operative procedure that occurs at or near the surgical incision within 30 days of an operation.

Front 395

superficial wound infection

Back 395

anterior to the fascia, usually occurs 4-10 days post-op
- most open, and drain, then wet to dry dressings, abx and allow for secondary closure

Front 396

float test

Back 396

place tissue passed per vagina in saline and observe to see if it floats in a "frond pattern"-- 95% sensitive for presence of chorionic villi/products of conceptus

Front 397

corpus luteum

Back 397

a physiologic ovarian cyst formed from mature graafian follicles following ovulation, which secretes progesterone

Front 398

hemorrhagic corpus luteum

Back 398

bleeding occurring in a corpus luteum which may cause enlargement and eventual rupture leading to hemoperitoneum
- more likely to rupture during pregnancy because of increased incidence and friability of the corpus lutea
- progesterone is largely produced by the corpus luteum until about 10 weeks gestation when the placenta takes over-- so if corpus luteum is surgically removed prior to 10-12 weeks gestation, then progesterone should be given to sustain the pregnancy

Front 399

hemoperitoneum

Back 399

a collection of blood in the peritoneal cavity. The blood initially clots then lyses, so that there may be a combinations of clots and hemorrhagic fluid

Front 400

tx of corpus luteal cyst

Back 400

medication to prevent ovulation

Front 401

what is the first sign of hypovolemia?

Back 401

decreased UOP, then positive tilt table test, then tachycardia then hypotension
- in a young healthy person, generally 30-40% of blood is lost before hypotension is apparent

Front 402

most common cause of hemoperitoneum in early pregnancy?

Back 402

ruptured ectopic pregnancy

Front 403

intrauterine adhesions/asherman syndrome

Back 403

condition when scar tissue or synechiae form to obliterate the endometrial cavity, usually occuring because of uterine curettage following a pregnancy
- cause of secondary amenorrhea where the endometrium is no longer hormone responsive, no progesterone induced
withdrawal bleeds occur
- dx by hysterosalpingogram showing no uterine cavity, but hysteroscopy is the gold standard-- can se extent
- worst prognosis is with atrophic and sclerotic endometrium without adhesions usually found after radiation or endo TB- not amenable to tx

Front 404

tx of intrauterine adhesions

Back 404

lysis of adhesions followed by IUD insertion or pediatric foley catheter to prevent adhesions from reforming
- combined OCP
- look at uterine cavity before conception

Front 405

if cervical stenosis goes untreated, what is likely to occur?

Back 405

endometriosis due to retrograde menstruation
- cervical stenosis would present as secondary amenorrhea with crampy abdominal pain but without passage of blood q month

Front 406

if a breast mass is felt on exam in a patient with a normal MG, what should be done?

Back 406

biopsy

Front 407

MG findings suspicious for breast cancer

Back 407

a small cluster of calcifications (especially if linear or wispy) or masses with ill-defined borders, distortion of architecture, assymetric tissue densities
(fat necrosis from breast trauma can appear similar to breast cancer)

Front 408

primary amenorrhea

Back 408

no menarche by age 16 years

Front 409

androgen insensitivity

Back 409

an androgen receptor defect in which 46 XY individuals are phenotypically female with normal breast development but scant or absent pubic hair and high testosterone levels
- requires gonadectomy to remove testes that could develop cancer

Front 410

mullerian agenesis

Back 410

congenital absence of the development of the uterus, cervix and fallopian tubes in 46 XX females that leads to primary amenorrhea
- often have associated renal anomalies
- normal breast development and axillary and pubic hair

Front 411

differential diagnosis of primary amenorrhea with normal breast development

Back 411

mullerian agenesis vs androgen insensitivity
- there are normally functioning ovaries in mullerian agenesis- since ovaries are not mullerian structures
- normal breast development in XY individuals with androgen insensitivity syndrome occurs due to peripheral conversion of testosterone to estrogen

Front 412

most common cause of delayed puberty

Back 412

gonadal dysgenesis (as in Turner's syndrome 45 X,O)
- hypergonadotropic hypogonadism

Front 413

what can help distinguish androgen insensitivity syndrome from mullerian agenesis

Back 413

karyotype and testosterone levels
- androgen insensitivity- 46 X,Y with high testosterone levels
- mullerian agenesis- 46 X,X with normal testosterone levels

Front 414

septic abortion

Back 414

any type of abortion associated with uterine infection
tx: broad spectrum abx and D&C

Front 415

incomplete abortion, lower abd cramping, vaginal bleedings, fever and chills, open cervical os

Back 415

septic abortion-- retain products of conceptus is a nidus for infection

Front 416

what is the usual etiology of septic abortion

Back 416

almost always polymicrobial source ascending from the vagina or cervix: anaerobic strep, bacteroides, e. coli, GBS, gram neg rods

Front 417

tx of septic abortion

Back 417

IV abx- gentamycin plus clindamycin
- stabilize blood pressure with IVF or pressors if needed
- uterine evacuation of products of conceptus after 4 hours of abx- may lead to hemorrhage though
- monitor UOP for signs of shock -- oliguria is first sign

Front 418

GI illness in pregnant woman that leads to amnionitis, amniocentesis reveals gram positive rods and meconium staining

Back 418

listeria monocytogenes-- often from deli meats and cheeses-- passes through the placenta
- tx: metronidazole, ampicillin and aminoglycoside
- if appropriate abx tx may avoid having to delivery

Front 419

postpartum hemorrhage

Back 419

loss of > 500 mL of blood during a vaginal delivery or > 1000 mL of blood during a c/s
- may lead to hemodynamic instability if untreated

Front 420

uterine atony

Back 420

lack of myometrial contraction clinically manifested by a boggy uterus and inc risk of post partum hemorrhage

Front 421

risk factors for uterine atony

Back 421

- MgSO4
- oxytocin use during labor
- rapid labor or delivery
- overdistention of the uterus (macrosomia, multifetal gestation, hydramnios)
- intramniotic infection
- prolonged labor
- high parity

Front 422

tx for uterine atony

Back 422

1st- uterine massage and dilute oxytocin
- if ineffective may try methergine (if pt is not hypertensive) or prostaglandin F2 alpha (if pt is not an asthmatic) or rectal misoprostol (preferred- less SE)

Front 423

methylgonovine maleate (methergine)

Back 423

an ergot alkyloid agent that induces myometrial contraction as a treatment of uterine atony, contraindicated in htn because of risk of stroke

Front 424

prostaglandin f2- alpha

Back 424

a prostaglandin compound that causes smooth muscle CONTRACTION, contraindicated in asthmatics-- bronchocontstriction

Front 425

if there early (within 24 hours pp) postpartum hemorrhage and the uterus is firm, what should be expected?

Back 425

genital tract lacerations

Front 426

causes of late postpartum hemorrhage

Back 426

subinvolution of the placental site and retained products of conceptus
(usually have cramping and bleeding +/- fever and/or foul smelling lochia)

Front 427

subinvolution of the placental site

Back 427

- usually occur at 10-14 days after delivery where the eschar over the placental bed falls off and there is a lack of myometrial contraction to stop the bleeding
tx: ergot alkaloid (methergine) and f/u

Front 428

surgical treatment for uterine atony

Back 428

ligation of blood supply to the uterus-- suture ligation of the ascending branch of the uterine artery (utero-ovarian ligament) or internal iliac/hypogastric artery, hysterectomy as las resort
- if you ligate the uterine arteries in the cardinal ligament then usually a hysterectomy is required

Front 429

delayed puberty

Back 429

lack of secondary sexual characteristics (breasts and pubic hair) by age 14

Front 430

gonadal dysgenesis

Back 430

failure of development of the ovaries, usually associated with a karyotypic abnormality (such as 45 X,O) and often associated with streaked gonads/ovaries. Less commonly, 46,XX or 46 X,Y

Front 431

4 stages of pubertal development

Back 431

1. Thelarche- breast budding- age 10.8
2. pubarche/adrenarche- pubic and axilarry hair- 11
3. growth spurt- one year after thelarche
4. menarche- 2.3 years after thelarche, 12.9 yo

Front 432

2 broad categories of etiology for delayed puberty

Back 432

gonadotropic or gonadal (differentiate by FSH level, if high then a gonadal problem, if low HPA problem)

Front 433

hypergonadotrophic hypogonadism

Back 433

high FSH, low estrogen--most common cause of this type of delayed puberty is Turner syndrome.
- internal and external genitalia are female but they remain infantile even in adulthood
- also have short stature, webbed neck, shield chest, increased carrying angle at elbow
- 46 xy then the gonads should be removed to prevent malignant transformation
- other causes: ovarian damage due to radiation, chemo, inflammation, torsion

Front 434

hypogonadotropic hypogonadism

Back 434

low FSH and estrogen-- secondary to a central defect
- may occur due to poor nutrition or eating disorders, extremes in exercise, chronic stress or illness
- also cushing syndrome, pituitary adenomas, craniopharyngiomas

Front 435

laboratory tests for evaluation of delayed puberty

Back 435

FSH, prolactin, TSH, free T4
- if FSH increased then get karyotype

Front 436

tx for delayed puberty

Back 436

hormonal therapy (OCPs) and human growth horman

Front 437

what is the most important test for primary amenorrhea with normal breast development?

Back 437

pregnancy test

Front 438

mastitis

Back 438

- infection of the breast parenchyma that typically presents as indurated, erythematous region of the breast, accompanied by fever and pain
- usually occurs between 2-4 weeks pp
- continue breast feeding to prevent abscess development
- 1 in 10 cases complicated by abscess formation (persistent fever after 48 hours of abx)

Front 439

most common etiology of mastitis?
tx?

Back 439

s. aureus
tx? dicloxacillin- continue breaste feeding or pumping

Front 440

if there is fluctuance noted on breast exam with a presentation of mastitis, what is dx? tx?

Back 440

dx: breast abscess
tx: incision and drainage, abx

Front 441

breast abscess

Back 441

the presence of a collection of purulent material in a breast which usually requires I&D

Front 442

galactocele

Back 442

a non-infected collection of milk due to a blocked mammary duct leading to palpable mass and sx of breast pressure and pain
- non erythematous, fluctuant breast mass

Front 443

breast engorgement

Back 443

breast pain and induration with possibly low grade fever
- due to vascular congestion and milk accumulation
- round the clock infant feeding tends to help

Front 444

tx for galactocele

Back 444

aspiration if it does not resolve spontaneously because it could become an abscess

Front 445

contraindications to breast feeding

Back 445

- infant with classic galactosemia
- mother with untreated TB or HIV
- mother getting radiation or chemo or antimetabolite meds
- mother using street drugs
- mother has herpes simplex lesions on breast

Front 446

what vitamin is not found in breast milk and thus needs to be given as a supplement to babies?

Back 446

vitamin D beginning at 2 months of age if child is exclusively breast fed

Front 447

benefits of breast feeding

Back 447

babies have less infections, including meningitis, UTIs and sepsis due to Igs and WBCs in breast milk
- less risk of diabetes and childhood obesity
- breast milk contains whey and casein, lactoferrin, IgA, and lysozyme
less casein than formula allows for easier digestion

Front 448

most common cause of hyperthyroidism in the US?

Back 448

graves disease-- painless, uniformly enlarged thyroid gland with proptosis or pretibial myxedema

Front 449

hyperthyroidism

Back 449

a syndrome caused by excess thyroid hormone, leading to nervousness, tachycardia, palpitations, weight loss, diarrhea, heat intolerance, tremor, throid bruit, exopthalamos, and systolic htn

Front 450

thyroid storm

Back 450

extreme thyrotoxicosis leading to CNS dysfunction (coma or delirium), diarrhea, and autonomic instability (hyperthermia, hypertension or hypotension)
- CHF can result
- high mortality with this condition-- ICU

Front 451

treatment of hyperthyroidism in pregnancy

Back 451

propythiouracil (PTU) and methimazole are ok to use in pregnancy even though both cross the placenta, but PTU generally preferred
- SE of PTU: bone marrow aplasia
- SE of Methimazole : aplasia cutis- skin or scalp defects

Front 452

graves disease

Back 452

the most common cause of hyperthyroidism in pregnancy in which the there are autoantibodies that stimulate the TSH receptors on the thryoid gland leading to excess thyroid hormone production
- dx by inc t4 and low TSH

Front 453

treatment of thyroid storm

Back 453

PTU, beta blocker such as propanolol, and corticosteroids to prevent peripheral conversion of T4 to T3

Front 454

what problems can maternal hyperthyroidism cause in fetus? management?

Back 454

hyper or hypothyroidism
- maternal admin of PTU for hyper
- intra-amniotic thyroxine for hypo
- if untx can lead to nonimmune hydrops and fetal demise

Front 455

what happens to TSH, thyroid binding globulin, total T4 and gree T4 in pregnancy?

Back 455

thyroid binding globulin and total T4 increase, but free/active T4 and TSH remain the same, thus pregnancy is euthryoid state

Front 456

what is the best screening test for hyperthyroidism?

Back 456

TSH but free T4 is a good follow up test if TSH is abn

Front 457

what is the most common cause of hyperthyroidism in the postpartum period

Back 457

destructive lymphocytic thyroiditis
- occurs 1-4 months pp, associated with antimicrosomal abs (can start hyper then turn hypo)
- high corticosteroid levels in pregnancy supress autoimmune antibodies and a flare occurs postpartum when the CS levels fall after delivery of the placenta
- often antimicrosomal and antiperoxidase enzymes are present

Front 458

consequence of untreated maternal hypothyroidism

Back 458

neonatal and childhood neurodevelopmental delays

Front 459

complications of chlamydia infection during pregnancy

Back 459

- is NOT known to cause preterm labor, PPROM
- neonatal conjuctivitis and pneumonia
- erythromycin eye ointment given after delivery protects against gonoccal eye infection but NOT chlamydia
- if baby gets chlamydial eye infection then tx is oral erythromycin for 14 days

Front 460

when should chlamydia screening take place during pregnancy?

Back 460

in the third trimester because the complications of the infection occur in the neonatal period

Front 461

treatment of chlamydial infection during pregnancy

Back 461

erythromycin or amoxicillin for 7 days or azithromycin as a one time dose
- tetracyclins such as doxycycline are CONTRAINDICATED- because of risk of staining neonatal teeth

Front 462

most common cause of conjuctivitis in the first month of life

Back 462

chlamydial conjuctivitis

Front 463

what is a potential cause of late postpartum endometritis?

Back 463

chlamydia
- 2-3 weeks after delivery

Front 464

complications of gonococcal disease in pregnancy

Back 464

abortion, preterm labor, PPROM, chorioamnionitis, neonatal sepsis and postpartum infection
- disseminated gonococcal infection is more common in pregnancy-- presents as pustular skin lesions, arthralgias, and septic arthritis

Front 465

what is a complication of untreated gonococcal opthalmia in a neonate?

Back 465

corneal scarring and blindness

Front 466

when are antibodies of HIV detectable?

Back 466

after 1 mo and almost always by 3 mo

Front 467

risk of HIV transmission to fetus in utero or during delivery?

Back 467

decreased substantially if undetectable viral load
- women with HIV should be tested with viral load and CD4 counts- evaluate monthly until viral load is undectable- keep viral load less than 1000 RNA copies/mL
- combination retroviral tx decreases transmission to less than 2%

Front 468

route of delivery for HIV positive women

Back 468

schedule c/s before labor or ROM-- but if vaginal then give zidovudine during labor- avoid trauma to baby that will allow blood exposure-- FSE or mechanical delivery
- to decrease risk of vertical transmission c/s must be done before ROM or labor
- no breast feeding
- baby gets oral zidovudine syrup

Front 469

chlamydia trachomatis in pregnancy

Back 469

most common STD in US
- not seen on gram stain as it is an obligate intracellular organism (long replication cycle)
- cause of late postpartum (2-3 weeks pp) endometritis
- has propensity for transitional and columnar epithelium
- can cause neonatal pneumonia or conjuctivitis
- worldwide it is the most common cause of preventable blindness

Front 470

uterine size great than predicted for dates and fetal parts are difficult to palpate

Back 470

hydramnios
- US will show excess of amniotic fluid

Front 471

positive IgG negative IgM for parvovirus in pregnancy

Back 471

mom is immune, reassurance
- about 50% of adult women are immune

Front 472

negative IgG and IgM for parvovirus in pregnancy plus exposure, managment?

Back 472

if > 20 days from exposure then susceptible but not infected
- if < 20 days from exposure then possible infection vs uninfected-- repeat IgG and IgM in 1-2 weeks

Front 473

negative IgG and positive IgM for parvovirus during pregnancy?

Back 473

probable acute infection, possible false positive
- repeat IgG and IgM in 1-2 weeks, expect both to be positive indicating infection-- then weekly US for detection of hydrops

Front 474

one of the first signs of fetal hydrops

Back 474

hydramnios

Front 475

fifth disease

Back 475

aka erythema infectiosum- illness caused by single stranded DNA virus- parvovirus B19
- in kids presents as high fever with slapped cheeks appearance
- in adults- malaise, arthralgias, myalgias, and faint reticular/lacy rash

Front 476

consequence of infection with parvovirus B19 during pregnancy

Back 476

- fetal abortion, stillbirth and hydrops

fetal hydrops- excess fluid in two or more fetal body cavities that is often assoc with hydramnios.- body cavity involvement can lead to-- ascites, skin edema, pericardial effusion, and/or pleural effusion
- severe fetal anemia caused by suppression of eyrthrocyte
precursors in bone marrow-- may lead to extramedullary hematopoeisis in the liver and dec protein production
- pregnancies less than 20 weeks gestation are at particular risk

Front 477

sinusoidal fetal heart rate pattern

Back 477

a fetal heart rate pattern that resembles a sine wave with cycles of 3 to 5 minutes, indicative of fetal anemia or asphyxia

Front 478

management of parvovirus b19 infection during pregnancy

Back 478

weekly ultrasounds fordetaction of fetal hydrops, and if found referal for fetal transfusion

Front 479

causes of polyhydramnios

Back 479

- fetal CNS abn
- fetal GI tract abn
- fetal chromosomal abn
- fetal nonimmune hydrops
- maternal diabetes
- isoimmunization
- multiple gestation
- syphilis

Front 480

most common cause of fever in a woman who has undergone c/s

Back 480

endomyometritis-- usually occurs from an ascending polymicrobial infection
- ddx includes mastitis, wound infection, and pyelonephritis
- atelectasis is rare because most women undergoing c/s have regional anesthesia

Front 481

febrile morbidity postpartum

Back 481

temperature after c/s greater than or equal to 38C or 100.4 F on two occasions that at least 6 hours apart, excluding the first 24 hours pp

Front 482

endomyometritis

Back 482

infetion of the decidua, myometrium and sometimes parametrial tissues
- presentation includes pp fever, abd tenderness, foul-smelling lochia
- risk factors include- c/s, long labor, IUPC, numerous vaginal exams
- most significant risk factor = cesarean section

Front 483

septic pelvic thrombophlebitis

Back 483

bacterial infection of pelvic venous thrombi usually involving the ovarian vein
- bacterial infection at teh placental implantation site spreads to the ovarian plexuses or to common iliac vein and sometimes into IVC
- presentation: hectic fever but look well or may have palpable pelvic mass
- confirm by CT
- tx: abx plus heparin

Front 484

tx of endomyometritis after c/s fs after vaginal delivery

Back 484

after vaginal delivery abx for anaerobes is not necessary-- ampicillin and gentamycin usually adequate
- after c/s need anaerobe coverage- gentamycin and clindamycin
- regardless the fever should improve by 48 hours of abx-- if no improvement- add coverage for enterococcus-- ampicillin
- if no response after 72 hours-- CT abd/pelvis for abscess or infected hematoma

Front 485

wound infection as cause of post-c/s fever

Back 485

usually occurs POD4, erythema and drainage from the wound site
- tx surgical opening of the wound, dressing changes, and abx. inspect integrity of fascial closure
- if wound infection within 24 hours post op-- think group A strep -- necrotizing fascitis -- immediate debridement

Front 486

most commonly isolated organisms in post c/s endometritis

Back 486

anaerobes like bacteriodes (thus give clinda plus gent)

Front 487

non-tender vulvar/labial firm, ulcerated lesion with clean raised borders on indurated erythematous base and non-tender bilateral inguinal lymphadenopathy

Back 487

chancre- primary syphilis
- usually manifests within 2-6 weeks after innoculation

Front 488

two most common causes of vulvar ulcers in the US

Back 488

HSV and syphilis (chancroid is much less common - h. ducreyi)

Front 489

nontreponemal tests for syphilis?
serological syphilis tests?

Back 489

1. VRDL and RPR
2. FTA-ABS, MHA-TP ( remain positive for life after infection)
-- if nontreponemal tests are negative but syphilis is suspected then scrape the lesion and do darkfield microscopy

Front 490

stages of syphilis infection

Back 490

primary syphilis- indurated, non-tender ulcer- chancre- arises 3 weeks after exposure- usually spontaneously resolves in 2-6 weeks
secondary- systemic, 9 weeks after chancre-- macular papular rash across body and palms and soles. may also have chondyloma lata
latency- early < 1 yr, late > 1 yr- if untreated 1/3 will progress to tertiary syphilis
tertiary- optic atrophy, tabes dorsalis (dorsal columns), aortic aneurysms, argyll roberston pupils, charcot joints, gummas

Front 491

treatment for syphillis

Back 491

IM penicillin G- long acting (only need one injection)
- need three courses if in late latent syphilis
- if penicillin allergy then erythromycin or doxycyclin may be used
- if neurosyphilis then IV penicillin x 4-6 doses
- after tx follow nontreponemal test quantitatively every 3 mo for 1 yr - should be 4 fold fall in 3 mo and negative test by 1 yr

Front 492

chancroid

Back 492

soft, tender ulcer of the vulva or penis that has ragged edges on a necrotic base, tender lymphadenopathy
- caused by h. ducreyi- small gram neg rod- gram stain shows classic "School of fish"
- dx by bx and/or culture
tx- oral azithromycin or IM ceftriaxone

Front 493

best test for dx of tertiary syphilis

Back 493

lumbar puncture, RPR of CSF
-should suspect tertiary syphilis if pt undergoes adequate tx for syphilis but their RPR does not fall

Front 494

if a woman if pregnant and dx with syphilis, but is allergic to penicillin, what is the tx of choice?

Back 494

desensitization and then tx with penicillin
- penicillin is the ONLY known effective treatment for preventing congenital syphilis
- cannot use doxy because it can stain child's teeth
- erythromycin not effective

Front 495

what are the two most common acute complications of preterm premature rupture of membranes?

Back 495

infection and labor

Front 496

what is a fetal sign of chorioamnionitis?

Back 496

fetal tachycardia

Front 497

signs of intra-amniotic infection?

Back 497

fever, uterine tenderness, fetal tachycardia, foul-smelling vaginal d/c

Front 498

risk factors for PPROM

Back 498

- lower socioeconomic status
- STDs
- cigarette smoking
- cervical conization
- emergency cerclage
- multiple gestations
- polyhydramnios
- placental abruption

Front 499

premature rupture of membranes

Back 499

ROM prior to the onset of labor

Front 500

preterm premature rupture of membranes

Back 500

ROM in a gestation <37 weeks before the onset of labor

Front 501

latency period

Back 501

the duration of time from ROM to onset of labor

Front 502

how is PROM diagnosed?

Back 502

pooling of amniotic fluid on speculum exam, changes in vaginal pH (more alkalotic)-nitrazine test), ferning on microscopy
- if all of these is negative but clinical suspicion is high then an US can be done to look for oligohydramnios

Front 503

outcome of PPROM

Back 503

50% will go into labor in the next 48 hours
- 90% will go into labor in the next week

Front 504

complications of PPROM

Back 504

- preterm delivery- neonatal RDS
- chorioamnionitis
- placental abruption
- necrotizing entercolitis

Front 505

treatment of PPROM

Back 505

- prior to 32 weeks- antenatal steroids to promote fetal lung maturity if no signs of infection, broad spectrum abx can delay delivery and decrease risk of chorioamnionitis, expectant management
- after 34-35 weeks- tx = delivery

Front 506

risks of expectant management for PPROM

Back 506

stillbirth, cord accident, infection, abruption

Front 507

treatment of chorioamnionitis

Back 507

- broadspectrum abx such ampicillin and gentamycin
- induction of labor

Front 508

what infections are neonates most commonly affected by with intra-amniotic infection?

Back 508

GBS and gram-negative enteric rods such as E. coli

Front 509

If PPROM occurs and there is phosphatidyl glycerol in the vaginal pool of amniotic fluid, what should be done?

Back 509

induction of labor

Front 510

most common complication of PROM?

Back 510

labor

Front 511

what is the most likely etiology of chorioamnionitis with rupture of membranes?

Back 511

listeria monocytogenes-- can occur through transplacental spread
- h/o unpasteurized milk products raises suspicion

Front 512

earliest sign of chorioamnionitis?

Back 512

fetal tachycardia

Front 513

three most common causes of vaginal infections (vaginosis or vaginitis)?

Back 513

1. bacterial vaginosis
2. trichomoniasis
3. candida vulvovaginitis

Front 514

cause of vaginal infection that is non-inflammatory?

Back 514

bacterial vaginosis- most likely caused by anaerobes
-- since non-inflammatory, patients will not complain of irritation or swelling and there will not be WBSs on microscopy

Front 515

treatment for bacterial vaginosis?

Back 515

metronidazole orally or vaginally, or clindamycin
(since most BV is caused by anaerobes)

Front 516

bacterial vaginosis

Back 516

condition of excessive anaerobic bacteria (bacterial overgrowth) in the vagina leading to homogeneous, alkaline vaginal discharge like "spilled milk" with a "fishy" OR "musty" odor that is exacerbated by menses or intercourse since both of these situations introduce an alkaline substance-release of amines
- positive whiff test (fishy odor with KOH due to release of amines)
- clue cells on microscopy-- bacteria stuck to vaginal epithelial cells
- tx metronidazole
- may be sexually transmitted but not always

Front 517

candida vulvovaginitis

Back 517

vaginal and/or vulvar infection caused by candida sp - usually with heterogeneous (curdy, clumpy) discharge and inflammation-intense burning, itching, irritation and swelling, dyspareunia, and normal vaginal pH
(pseudohyphae on microscopy when mixed with KOH which lyses the WBCs and RBCs)
- can be precipitated by recent antibiotic use
tx : oral fluconazole or imidazole cream
- risk factors include diabetes, ICH, and pregnancy

Front 518

trichomonal vaginitis

Back 518

infection of the vagina caused by the protozoa trichomonas vaginalis, usually associated with FROTHY yellow to green vaginal discharge and an inflammatory response (classically red punctate lesions on the cervix -- "strawberry cervix")- may have a somewhat fishy smell and be alkaline
- trichomonads on microscopy- motile flagellated single celled protozoa
- tx: metronidazole in high dose (2 g once and tx for partner)- tinidazole for metronidazole resistant cases
- common STD that can survive on wet surface for 6 hours
- may inhabit vagina, urethra or skenes glands

Front 519

hirsuitism

Back 519

excessive male pattern hair in a female

Front 520

virilization

Back 520

androgen effect other than hair pattern, such as clitoromegaly, male balding, deepening of the voice, acne, oily skin, increased muscle mass, inc libido
- usually caused by adrenal hyperplasia or androgen secreting tumors of the adrenal gland or ovary

Front 521

most sensitive clinical marker of excessive androgen production

Back 521

hirsuitism

Front 522

rapid onset of hirsuitism and virilization most likely indicates?

Back 522

tumor-- sertoli-leydig tumor

Front 523

slow onset of hirsuitism and menstrual irregularity since menarche generally indicates?

Back 523

PCOS

Front 524

sertoli-leydig cell tumor

Back 524

ovarian tumor that is solid and produces testosterone, usually slow growing and low malignant potential but often recur-- need to do surgical staging

Front 525

what determines growth and pigmentation of sex hair?

Back 525

androgens -- especially testosterone

Front 526

what is the action of 5 alpha reductase?

Back 526

converts testosterone to DHT-- more DHT, more stimulation of hair growth

Front 527

ddx for hirsuitism

Back 527

1. anovulation/ PCOS-onset since menarche, elevated LH:FSH (tx: OCPs)
2. late-onset congenital adrenal hyperplasia (21-hydroxylase deficiency)- hypotension, ambiguous genitalia, fhx, inc 17 hydroxy-progesterone, tx- replace cortisol and mineralocorticoid (fludrocortisone)
3. androgen-secreting tumors- rapid onset- abdominal mass, dx: DHEA-S, tx: surgical
4. cushing disease- glucose intolerance, htn, buffalo hump, central obesity, striae, dx by dex suppression test, tx: surgical
5. medications
6. thyroid disease
7. hyperprolactinemia

Front 528

most common cause of ambiguous genitalia in a newborn

Back 528

21 hydroxylase deficiency-- can cause death through salt wasting/hypotension
- late onset can occur in adult females leading to hirsuitism and anovulation
- dx: elevated morning 17 hydroxyprogesterone!
tx: decrease DHT, spironolactone-- testosterone antagonist, OCPs

Front 529

initial treatment of intertility in PCOS

Back 529

clomiphene citrate- induction of ovulation
tx of PCOS in general- OCPs and spirolactone- testosterone antagonist

Front 530

most common cause of abnormal serum screening

Back 530

wrong dates and multiple gestations-- do an US

Front 531

what might a elevated maternal serum AFP indicate? decreased level?

Back 531

1. inc- neural tube defect
2. dec- Down syndrome

Front 532

components of a certain LMP

Back 532

1. patient sure of date of LMP
2. regular menses
3. LMP was normal
4. no spotting or bleeding after LMP
-uterine size should correlate with dates

Front 533

at 20 weeks what is the fundal height generally?

Back 533

at the umbilicus.

Front 534

alpha-fetoprotein

Back 534

a glycoprotein made by the fetal liver, analogous to adult albumin

Front 535

first trimester screening

Back 535

use of biochemical markers and/or transvaginal US measuring the aspect in the posterior neck region called "nuchal transluceny" giving a risk of down syndrome and trisomy 18

Front 536

neural tube defect

Back 536

failure of closure of the embryonic neural folding leading to an absent cranium and cerebral hemispheres (anenchephaly) or nonclosure of the vertebral arches (spina bifida)

Front 537

open neural tube defect

Back 537

a neural tube defect that is not covered by skin

Front 538

maternal serum alpha-fetoprotein

Back 538

alpha fetoprotein level drawn from maternal blood, this may be elevated due to increased amniotic fluid alpha fetoprotein.
- measured in multiples of the mean (MOM). Outside of 2-2.5 MOM is abnormal

Front 539

trisomy screen

Back 539

three or four serum markers that may indicate and increased risk of chromosomal abnormalities. A common combination includes maternal serum alpha fetoprotein, hcg, inhibin-A and unconjugated estriol. peroformed between 15-21 weeks. Determines risk for neural tube defects and fetal aneuploidy.

Front 540

what causes an increased alpha fetoprotein in maternal serum when the fetus has an open neural tube defect?

Back 540

AFP leaks out of fetal circulation in amniotic fluid due to skin defect over neural tube defect and is them absorbed into maternal circulation

Front 541

Causes of elevated maternal serum AFP

Back 541

- underestimation of gestational age
- multiple gestations
- neural tube defects
- abdominal wall defects
- cystic hygroma
- fetal skin defects
- sacrococcygeal teratoma
- decreased maternal weight
- oligohydramnios

Front 542

causes of low maternal serum AFP

Back 542

- overestimation of gestational age
- chromosomal abnormalities
- molar pregnancy
- fetal death
- increased maternal weight

Front 543

triple screen consistent with down syndrome? quad screen?

Back 543

dec MS-AFP
dec unconj. estriol
inc b-hcg
inc inhibin a (quad)
- 60% of down syndrome pregnancies show abn triple screen

Front 544

triple screen consistent with trisomy 18- edwards syndrome?

Back 544

dec ms-AFP, estriol and b-hcg

Front 545

first trimester screening for down syndrome

Back 545

pregnancy-associated plasma protein (PAPP-A) and free b-hcg. both of these are decreased in abn pregnancies.
nuchal translucency- showing increased thickness also demonstrates abn
- 85% identification of Downs
- 90% identification of Edwards/ trisomy 18

Front 546

management of abnormal maternal serum screening?

Back 546

1st step-- basic US to exclude wrong dates, multigestation, and fetal demise
- if still determined to be at risk then can offer amniocentesis to check levels of AFP and do chromosomal analysis on amniotic fluid
- could also do targeted US to look at spine

Front 547

US characteristics consistent with down syndrome

Back 547

- thickened nuchal fold
- shortened femur length
- echogenic bowel

Front 548

complications of amniocentesis

Back 548

- 0.5% rate of fetal loss
- rupture of membranes
- chorioamnionitis

Front 549

pregnancies with increased ms AFP that are evaluated, but no etiology is found are at risk for...?

Back 549

inc risk of stillbirth, growth restriction, preeclampsia, and placental abruption
-- do serial US if concerned, BPP

Front 550

what are women with PCOS at an inc risk for?

Back 550

1. diabetes mellitus
2. endometrial cancer (unopposed estrogen)
3. hyperlipidemia
4. metabolic syndrome (obesity etc)
5. Cardiovascular disease
6. infertility
7. menstrual irregularity
8. hyperandrogenism- hirsuitism, acne, alopecia

Front 551

Polycystic ovarian syndrome

Back 551

a condition of unexplained hyperandrogenic chronic anovulation associated with excessive estrogen

Front 552

acanthosis nigricans

Back 552

velvety, mossy, verrucous, hyperpigmented skin usually noted on the back of the nexk, in the axilla, and under the breasts that is usually a sign of insulin resistance

Front 553

tests useful in the diagnosis of PCOS

Back 553

TSH, prolactin, lipid profile, glucose-intolerance screening, endometrial biopsy (if longstanding anovulation-unopposed estrogen), pelvic US, 17-hydroxyprogesterone. if clinical signs suggestive -- testosterone and DHEA-S

Front 554

overall treatment goals in PCOS

Back 554

1. reduce circ androgens
2. protect endometrium from unopposed estrogen- reduce risk of endometrial cancer
3. encourage weight loss
4. induce ovulation when pregnancy desired- clomiphene citrate
5. monitor for the development of diabetes and cv disease and modify risk factors if possible
-- primary management is through combination OCPs- more reg menses, dec endometrial ca risk, inc SHBG to dec free testosterone, suppress ovarian androgen production

Front 555

in women with PCOS induced grade I endometrial cancer on endo bx, what can be done if the patient wants to preserve ability to have children?

Back 555

high dose progestin and repeat endometrial bx in 2-3 months

Front 556

testosterone is largely secreted where in female? DHEAS?

Back 556

1. ovary
2. adrenal gland

Front 557

cystocele

Back 557

defect of the pelvic muscular support of the bladder allowing the bladder to fall down into the vagina. often the urethra is hypermobile. anterior pelvic organ prolapse.

Front 558

enterocele

Back 558

defect in the pelvic muscular support of the uterus and cervix (if still situ) or vaginal cuff (if s/p hysterectomy). The small bowel and/or omentum pushes the organs into the vagina. central pelvic organ prolapse defect

Front 559

rectocele

Back 559

defect in the pelvic muscular support of the rectum, allowing the rectum to impinge into the vagina. The patient may have constipation or difficulty evacuating stool. posterior pelvic organ prolapse defect

Front 560

paravaginal defect

Back 560

defect in the levator ani attachment to the lateral side wall leading to lack of support of the vagina, known as lateral pelvic defect

Front 561

symptoms of pelvic organ prolapse

Back 561

heaviness or pressure snesation in the pelvis
- bulging mass (central)
- difficulty voiding or incomplete bladder emptying, urinary incontinence (anterior)
- constipation or having to use fingers in vagina to push poop out (posterior defect)
- sexual dysfunction or dyspareunia

Front 562

risk factors for pelvic organ prolapse

Back 562

- multiple vaginal births
- coughing
- lifting
- connective tissue disorders
- genetic predisposition
- lack of estrogen
- obesity

Front 563

muscles of the pelvic diaphragm

Back 563

pubococcygeus, puborectalis, levator ani

Front 564

q tip test

Back 564

determines presence of hypermobile urethra
- place q tip in the urethra then have patient bear down
- if greater than 60 degree angle between rest and bearing down then positive test

Front 565

procidentia

Back 565

entire uterus prolapsed outside of patient's introitus

Front 566

sacrospinous ligament fixation procedure

Back 566

fixation of the vaginal cuff to the sacrospinous ligament to prevent prolapse

Front 567

sacrocolpopexy

Back 567

using synthetic material to fix vaginal cuff to sacral bone

Front 568

treatment of central pelvic organ prolapse

Back 568

almost always caused by enterocele causing vaginal or uterine prolapse-- tx is resection of enterocele hernia sac and fixation of the vagina to secure ligamentous tissue

Front 569

risks incurred with twin gestation

Back 569

increased risk of...
- congenital abn
- preterm labor
- preeclampsia
- postpartum hemorrhage
- maternal death
- gestation DM
- anemia
- DVT
- need for c/s
- IUGR
- stillbirth
- fetal anomalies
- placenta previa
- placental abruption
- Twin twin transfusion syndrome

Front 570

velamentous cord insertion

Back 570

umbilical vessels separate before reaching the placenta, protected by only a thin fold of amnion, instead of by the cord or the placenta itself; these vessels are susceptible to tearing after rupture of membranes

Front 571

vasa previa

Back 571

umbilical vessels that are not protected by cord or membranes which cross the internal cervical os in front of the fetal presenting part, this most commonly occurs with a velamentous cord insertion or a placenta with or more accessory lobes

Front 572

bilobed or succenturiate-lobed placenta

Back 572

a placenta with either one more accessory lobe

Front 573

monozygotic twins

Back 573

twins formed by the fertilization of one egg by one sperm

Front 574

dizygotic sperm

Back 574

twins formed by the fertilization of two eggs by two sperm

Front 575

chorionicity

Back 575

the number of placentas in a twin or higher order gestation in monozygotic twins, can either be monochorionic or dichorionic. dizygotic twins are always dichorionic

Front 576

amnioncity

Back 576

the number of amniotic sacs in a twin or higher order gestation, monozyogtic twins may be monoamniotic or diamniotic, whereas dizygotic twins are always diamniotic

Front 577

etiology of monozygous twins

Back 577

not completely known
- may be associated with slow tubal motility as when someone is on OCPs within 3 mo of pregnancy
- incidence not affected by race, heredity, or parity

Front 578

etiology of dizygotic twins

Back 578

inc incidence in black women (1:100 white, 1:80 black), inc with age and peaks at 37, when mother is a dizygotic twin, inc rate with fertility tx

Front 579

twin twin transfusion syndrome

Back 579

one twin is donor and one recipient, one gets more blood-- at risk for hemoconcentration, and more amniotic fluid, other has less of both
- tx: laser ablation of the shared anastomotic vessels or serial amniocentesis for decompression

Front 580

risk factors for vasa previa, if have risk factors then?
if vasa previa identified?

Back 580

bilobed placenta, low-lying placenta, multifetal pregnancy, and pregnancy resulting from IVF
- if these risk factors are present then do color doppler US
- if vasa previa then planned c/s at 35-36 weeks before ROM
- digital exam should be avoided!
- identification cuts rate of fetal death in 1/2

Front 581

how are chorionicity and amniocity determined?

Back 581

timing of the division of the embryos
- in first 72 hours-- dichorionic diamniotic
- day 4-8: monochorionic, diamniotic
day 8: monochorionic/monoamniotic
after day 8: conjoined twins

Front 582

maternal effects of twin gestation

Back 582

- increase n/v
- greater physiologic anemia due to greater plasma volume but not proportionately inc red cell volume -- greater risk for pulmonary edema
- greater increase in BP after 20 weeks
- greater increase in size and weight of uterus

Front 583

what are twin gestations without a dividing membrane at risk for?

Back 583

high rate of stillbirth due to cord entanglement

Front 584

What are normal ABGs in a pregnant woman?

Back 584

pH 7.45, PCO2 28, HCO3 18, primary respiratory alkalosis with a partial metabolic compensation

Front 585

What happens to hemoglobin, platelet and WBC counts during pregnancy?

Back 585

hgb and platelets slightly dec, WBCs slightly inc

Front 586

Rh isoimmunization

Back 586

Rh negative woman who develops anti-D antibodies in response to exposure to Rh D antigen

Front 587

vertical transmission

Back 587

the passage of infection from mother to fetus, whether in utero, during labor and delivery or pp

Front 588

what do you do if..
1. rubella nonimmune
2. Rh -
3. positive antibody screen
4. HBsAg positive

Back 588

1. vaccinate pp since live vaccine, avoid sick contacts
2. Rhogam anytime there is bleeding during pregnancy to prevent sensitization, also at 28 weeks and then after delivery if baby is Rh +
3. may have isoimmunization- identify the ab rxn and do a titer
4. patient is infectious with Hep B, check LFTs and hepatitis serology to determine if patient is a chronic carrier or has active hepatitis- baby will need HBIG and hep B vaccine

Front 589

what to do if abnormal pap smear during pregnancy...
1. ASCUS
2. LGSIL, HSIL

Back 589

1. repeat pap pp
2. LGSIL or HSIL- colposcopy
-- only invasive cancer should alter management

Front 590

What do you do if there is an abnormal 1hr glucose screen?

Back 590

do a 3 hour glucose tolerance test to determine if GDM is present- 15% of people screened are positive

Front 591

when does the neural tube close in the fetus?

Back 591

by 21-28 days (5-6 weeks) before many women realize they are pregnant, which is why women need to take prenatal vitamins
- folate supplement decrease risk of neural tube defects by 50%

Front 592

Which of the following antibodies can cross the placenta and thus are dangerous to a fetus...
1. anti-lewis
2. anti-kell
3. anti-duffy

Back 592

1. IgM does not cross placenta-- no problem
2. crosses
3. crosses
Lewis Lives, Kell Kills, Duffy dies

Front 593

what should be done if lichen sclerosus is expected on exam?

Back 593

biopsy- will see thinned epidermis, hyperkeratosis, and elongation of the rete pegs
- vulvar cancer is associated with lichen sclerosus and thus bx is essential

Front 594

lichen sclerosus

Back 594

chronic inflammatory dermatologic disease characterized by pruritis and pain, which affects the anogenital region

Front 595

vulva

Back 595

the external genitalia of the female comprise of the mons pubis, labia majora, the clitoris, the vestibule of the vagina and its glands and opening of the urethra and the vagina

Front 596

vulvar itching in a post menopausal woman that is worse at night, figure of eight pattern on exam, "cigarette paper" skin that is crinkled, fragile, thin and atrophic. May have agglutination of the tissues and pain with intercourse. dz?

Back 596

lichen sclerosus

Front 597

tx of lichen sclerosus

Back 597

avoid irritants, use corticosteroid ointment like Clobetasol, taper with relief, this a chronic disease and needs to be followed for signs of cancer transformation

Front 598

where are the bartholin glands (major vestibular glands) located. If abscess occurs, what is the tx?

Back 598

at 5 and 7 oclock of the labia majora
I&D will likely lead to recurrence, so placing a pediatric foley bulb will help to continue the drainage and allow healing- usually infection is polymicrobial
- bx if >40 bc of risk of cancer

Front 599

lichen sclerosus

Back 599

chronic inflammatory dermatologic disease characterized by pruritis and pain, which affects the anogenital region

Front 600

vulva

Back 600

the external genitalia of the female comprise of the mons pubis, labia majora, the clitoris, the vestibule of the vagina and its glands and opening of the urethra and the vagina

Front 601

vulvar itching in a post menopausal woman that is worse at night, figure of eight pattern on exam, "cigarette paper" skin that is crinkled, fragile, thin and atrophic. May have agglutination of the tissues and pain with intercourse. dz?

Back 601

lichen sclerosus

Front 602

tx of lichen sclerosus

Back 602

avoid irritants, use corticosteroid ointment like Clobetasol, taper with relief, this a chronic disease and needs to be followed for signs of cancer transformation

Front 603

where are the bartholin glands (major vestibular glands) located. If abscess occurs, what is the tx?

Back 603

at 5 and 7 oclock of the labia majora
I&D will likely lead to recurrence, so placing a pediatric foley bulb will help to continue the drainage and allow healing- usually infection is polymicrobial
- bx if >40 bc of risk of cancer