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96 Cards in this Set

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w/u of pregnancy

p/w amenorrhea




enlarged uterus




confirm with u/s at 4-5 weeks --> should see gestational sac




confirm with serum b-hcg that should be ~1500




fetal heart motion present on u/s at 5-6 wks




fetal heart sounds heard at 8-10 wks




fetal movements felt by MD at 20 wks

First-trimester screening

CBC (MCV is most reliable indicator of anemia) --> iron




type & screen -> give Rhogam at 28 wks & wihtin 72 hrs of delivery




cervical pap smear




UA & urine cx --> ONLY time you tx Asx bacteremia




immunizations --> flu


test rubella but dont give vaccine


Hep B surface Ag




VDRL/RPR --> desensitized with penicillin allergy




HIV testing --> start mom on HAART




cervical cx for chlamydia/gonorrhea --> tx if they are positive (PO azithro & IM CTX)




PPD & if positive do xray after 28 wks



Early trisomy 21 testing

b-HCG




pregnancy-associated plasma protein A (PAPP-A)




fetal nuchal translucency




if concerning, do CVS

Second trimester screening

done btwn 15-20 wks




MS-AFP - high in NTD


b-HCG


estriol




can add inhibin A in high-risk women (inc sensitivity to 80%)

Inhibin A

made by placenta during preg




remains constant during 15th-18th week




inhibin A is increased in Downs

Triple screen results for Downs

low MS-AFP


low estriol


high b-hcg

Oral glucose tolerance test

test at 24-28 wks



oral glucose tolerance test - drink 50g glucose then check sugar 1 hr later --> >140 is abnormal




if 1 hr test is >140 then perform 3hr 100g glucose test. Need 2 or more abnormal values


>180 at 1 hr


>155 at 2 hr


>140 at 3 hr

GBS screening

vaginal & rectal cx at 35-37 wks




tx with either IV pen G or clinda or erythro is allergic




if positive tx with IV abx




if previous hx of baby with GBS, give IV abx regardless of cx results




if mom got infection during current preg, give IV abx regardless of cx result

Abruptio placenta

occurs in 3rd trimester




placenta prematurely seperates from uterus




p/w sudden onset vaginal bleeding




severe, constant pelvic pain --> one of few things that gives pain in 3rd trimester




look for hx of HTN, trauma, cocaine use

Placenta previa

placenta covers internal os

sudden-onset of vaginal bleeding

painless

hx of trauma, coitus, or pelvic exam

NEVER do digital or speculum exam

placenta covers internal os




sudden-onset of vaginal bleeding




painless




hx of trauma, coitus, or pelvic exam




NEVER do digital or speculum exam

Vasa previa

life threatening to fetus

when membranes rupture, fetal vessels are torn leading to sig blood loss in fetus

painless to mom

if seen, requires c-section

life threatening to fetus




when membranes rupture, fetal vessels are torn leading to sig blood loss in fetus




painless to mom




if seen, requires c-section

Placenta accreta

accreta - does not penetrate entire thickness of endometrium




increta - extends further into the myometrium




percreta - placenta penetrates entire myometrium to uterine serosa

Uterine rupture

hx of uterine scar --> vaginal birth after c-sect




sudden-onset of abd pain and vaginal bleeding




assoc with loss of electronic fetal heart rate, uterine contractions, & recession of fetal head

GBS in newborn

pneumonia & sepsis within HRS




50% mortality rate




GBS meningitis occurs after wk & is hospt acquired NOT via vertical transmission




tx with intrapartum IV penicillin




allergy --> IV cefazolin, clinda, or erythro




no need to give abx with cx+ if doing c-sect

Toxoplasmosis

chorioretinitis + intracranial calcifications + hydrocephalus




handling cat feces, litter boxes, drinking raw goat milk, or eating raw meat




vertical transmission is ONLY with primary infection of mom




most serious infections occurs in 1st trimester




mom has mono-like syndrome




IUGR




test with serologies




tx with pyrimethamine & sulfadiazine

Varicella

causes by herpes virus type 3




due to primary infection in mom




greatest risk to fetus if rash appears in mom btwn 5 days antepartum & 2 days postpartum




neonate has:


zigzag skin lesions


limb hypoplasia


microcephaly


microphthalmia


chorioretinitis


cataracts




vaccinate against varicella BEFORE preg bc it's live-attenuated




w/o vaccine & exposure, give VariZig to mom & neonate + oral acyclovir to mom

Rubella

caused by togavirus (ssRNA)




leads to:


deafness (most common)


cardiac - PDA


cataracts


MR


HSM


TCP


blue berry muffin rash




mom gets primary infection in first 10 wks of gestation




no post-exposure ppx

CMV

most common of sensorineural deafness in children




spread by infected body fluids




IUGR


prematurity


microcephaly


jaundice


HSM


periventricular calcifications


chorioretinitis


pneumonitis




tx with ganciclovir or foscarnet

Herpes simplex

most common cause of transmission is contact with maternal genital lesions during active HSV episode




greatest risk is primary infection in 3rd trimester




neonatal infection acquired during delivery has 50% mortality rate




meningoencephalitis


MR


pneumonia


HSM, jaundice


petechia




if active lesions, deliver via c-sect




tx with acyclovir 4 weeks before delivery date

HIV

viral load >1000 --> elective c-sect




baby gets ZDV for 6 wks after delivery




NO BREASTFEEDING WITH HIV




avoid efavirenz

Syphilis

first trimester:


non-immune hydrops fetalis


maculopapular or vesicular peripheral rash


anemia


TCP


HSM




late-acquired:


dx after 2 yrs of age


hutchinson teeth (notches in teeth)


saber shins (curved shins)


mulberry molars


deafness due to CNVIII palsy


saddle nose




tx with IM penicllin

Hep B virus

primary infection in 3rd trimester




get vertical transmission during vaginal delivery BUT NOT indication for c-sect




neonate gets vaccination & Ig




mom gets vaccine & Ig

Contraindications to breastfeeding

HIV


active Tb


HTLV-1


herpes simplex with lesions on breast


drugs of abuse


cytotoxic meds (eg MTX, cyclosporine)


galactosemia

HTN in pregnancy

>140/90




gestation HTN is after 20 wks




with end-organ damage or neuro sxs:


preeclampsia


eclampsia


HELLP syndrome




sustained HTN --> IUGR




HTN also increases risk of abruptio placenta

Preeclampsia

HTN + sudden weight gain + edema + proteinuria




mild


sustained BP >140/90


proteinuria (>300mg/day)




severe


sustained BP >160/110


>5g/day proteinuria




risk factors:


multiple gestation


hydatidiform mole


DM


chronic HTN


chronic renal dz

Tx of HTN

only tx if BP >160/100




goal is 140-150/90-100




tx with b-blocker (labetalol), methyldopa, CCB

Eclampsia

preeclampsia + tonic-clonic seizures




occurs in last half of preg




seizure thought to be secondary to diffuse cerebral vasospasm leading to cerebral perfusion deficits & edema




tx with IV hydralazine or labetalol for BP control & Mg sulfate for seizures




NEVER GIVE ACEI OR THIAZIDES

HELLP syndrome

5-10% of preeclamptic pts develop HELLP




tx with IV MgSO4




if before wk 36, give steroids to help fetal lung maturity




can lead to:


DIC


abruptio placenta


fetal demise


ascites


hepatic rupture

High risk cardiac problems that should avoid preg

pulm HTN




Eisenmenger syndrome




severe valvular dz




prior postpartum cardiomyopathy

Peripartum cardiomyopathy

heart failure with no identifiable cause




develops last month of preg to 5 months postpartum




risk factors:


multiparity


age >30


multiple gestations


preeclampsia

Cardiac drugs to avoid in preg

ACEI




aldosterone antagonists




amiodarone




warfarin

PE in preg

leading cause of maternal death in US




50% of these pts have underlying thrombophilic d/o

Anticoagulation in preg

DVT or PE




A-fib with underlying heart dz (EF <30%)




Eisenmenger syndrome




anti-coagulate with LMWH




NO WARFARIN DURING PREGNANCY

Thyroid d/o in preg

HYPERthyroid - IUGR & stillbirths



HYPOthyroid - intellectual deficits in offspring & miscarriage



if hypothyroid, increase thyroxine dose 25-30%



tx hyperthyroid with PTU in first trimester or methimazole afterwards

Diabetes in preg

target glucose <90 or <120 1 hr post meal




GDM is initially managed by diet & light exercise




if lifestyle changes dont improve --start insulin




if pt refuses, can give metformin & glyburide




during breastfeeding, avoid oral hypoglycemics




HbA1c in each trimester




starting at 32 wks, do wkly NST & AFI




fetus has delayed fetal maturity so prefer to deliver at 39-40 wks




do c-sect if fetus is >4500g (shoulder dystocia)

Induced abortion

D&C - perform before week 13




medical abortion - mifepristone (progesterone antagonist) and misoprostol (prostaglandin E1)




most common delayed complication is cervical trauma & cervical insufficiency

Spont abortion/fetal demise

spont abortion - < 500g OR < 20 wks


advanced maternal age


previous spont abortion


maternal smoking




fetal demise - >20 wks


most common sx is loss of fetal movement


antiphospholipid syndrome


overt GDM


maternal trauma


severe maternal isoimmunization


fetal infection

Types of natural abortion

painful cramps
continued bleeding
dilated cervix

painful cramps


continued bleeding


dilated cervix

Missed abortion

loss of early preg sxs (eg nausea, breast tenderness)




loss of fetal cardiac activity




nonviable fetus on u/s

Ectopic pregnancy

most common risk factor is PID




any tubal scarring or adhesions increases risk -


infections


IUD


tubal ligation/surg


congenital risks




dx with b-HCG >1500 & no intrauterine preg on u/s

Ruptured ectopic pregnancy

assume when:


unstable (hypotension, tachycardia)


sxs of peritoneal irritation (guarding/rigidity)




tx with immediate laparotomy/salpingectomy

Vaginal vs abd sono

intrauterine preg seen:




vaginal - 5 wks & b-hcg >1500




abd - 6 wks & b-hcg >6500

Indications to use MTX

preg mass <3.5cm




absence of fetal heart motion




b-hcg <6000




no hx of folate supplementation

IUGR

weight is <5-10 percentile for gestational age or <2500g (5lb 8oz)




accurate early preg dating is essential




symmetic IUGR:


aneuploidy


infection (TORCH)


structural anomalies (eg cardiac, NTD, ventral wall defects)




aymmetric IUGR --> derives from issues in mom


HTN


small vessel dz (SLE)


malnutrition


tobacco, etoh, street drugs




follow with serial u/s, NST, AFI, biophysical profiles, & umbilical artery doppler

Macrosomia

weight >90-95 percentile for gestational age




birth weight is 4000-4500g




risk factors include:


DM


prolonged gestation


obesity


multiparity




tx with elective c-sect

Invasive fetal testing

CVS


performed at 12-14 wks


preg loss rate is 0.7%



amnio


after 15 wks


AFP & Achase screen for NTD


preg loss rate is 0.5%



percutaneous umbilical blood sample


u/s guided aspiration of fetal blood from umbilical vein after 20 wks


preg loss 1-2%



fetoscopy


transabd fiberoptic scope


performed at 20 wks for intrauterine surg & fetal skin bx


preg loss is 2-5%

Premature rupture of membranes

rupture of fetal membranes before onset of labor




most common cause --> ascending infection from lower genital tract




dx with sterile speculum exam --> post fornix pooling of AF (nitrazine & ferning positive)

Chorioamnionitis

maternal fever + uterine tenderness + PROM




if contractions are present --> NO tocolysis




get cervical cx, IV abx & deliver

Tx of PROM

<24 wks


bed rest at home




24-33 wks


hospt & give IM betamethasone, cervical cx, & amp + erythromycin




>34 wks


initiate delivery

Stages of labor

Stage 1a - latent phase (can take days)


begins with regular contractions & ends with acceleration of cervical dilation (up to 3cm)




Stage 1b - active phase


begins at acceleration of cervical dilation & ends at 10cm (>1.2cm/hr)


tx with IV oxytocin




Stage 2 - descent


begins at cervical dilation of 10 cm and ends with delivery of fetus


should occur in <2hr




Stage 3 - expulsion


begins with delivery of baby and ends with removal of placenta


should last <30 mins


tx with IV oxytocin

Umbilical cord prolapse

emergency!




compressed cord jeopardizes fetal oxygenation




most often occurs with ROM




occurs before fetal head is engaged




bradycardia maybe only clue




terbutaline (beta-2 agonist) may be used to reduce contractions --> emergency c-sect

Approach to non-reassuring fetal tracings

d/c meds


IV bolus


high-flow O2


change mom's position


vaginal exam to r/o prolapsed cord


scalp stimulation to observe for accelerations


deliver via c-sect if tracing does not normalize

Postpartum hemorrhage

uterine atony - most common cause


rapid or protracted labor


chorioamnionitis


MgSO4


overdistended uterus


tx with oxytocin or uterine massage




retained placenta


assoc with accessory placental lobe or abnormal uterine invasion


tx with manual removal




uterine inversion


beefy bleeding mass appearing from vagina


tx with uterine replacement & IV oxytocin

Postpartum fever

day 0 - atelectasis




day 1 - UTI tx with IV abx




day 2-3 - endometritis (hx c-sect or PROM) --> tx with clinda & genta




day 4-5 - wound infection tx with IV abx, wet-to-dry wound packing




day 5-6 - septic thrombophlebitis (wide fever springs) --> tx with IV heparin




day 7-21 --> infectious mastitis tx with clox

Benign breast dz

1) fibroadenoma


2) fibrocystic dz


3) intraductal papilloma


4) fat necrosis - trauma to breast


5) mastitis - inflamed & painful

Malignant breast disease

1) ductal carcinoma in situ


2) lobular carcinoma in situ


3) invasive ductal carcinoma


4) invasive lobular carcinoma


5) inflammatory breast cancer


6) Paget's disease of the breast/nipple

Nipple discharge

bilateral = prolactinoma


get prolactin level & TSH




unilateral non-bloody - intraductal papilloma




unilateral bloody - cancer




order mammogram

Fibrocystic disease

occurs in age 20-50




cyclical & b/l painful lumps




pain varies with menstrual cycle




simple cyst has sharp margins & post acoustic enhancement on u/s




will collapse on FNA




tx with OCP

Fibroadenoma

discrete, firm, non-tender




highly mobile breast nodule




next step is clinical breast exam then order mamogram for >40 & u/s otherwise




bx has to be done to confirm




surg for growing fibroadenoma

DCIS

surgical resection with clear margins




RT with tamoxifen for 5 yrs

LCIS

only tamoxifen for 5 yrs




no surg needed




usually pre-menopausal

Risks with tamoxifen

endometrial carcinoma




thromboembolism




contraindications:


active smoker


previous or at high-risk thromboembolism

Invasive ductal carcinoma

most common form of breast cancer




85% of all cases




b/l in 20%

Paget's disease of the breast/nipple

pruritic, erythematous, scaly nipple lesion




can be confused with eczema or psoriasis




look for inverted nipple with d/c

Breast cancer screening guidelines

mamogram q1-2 yrs for ages 50-74

Aromatase inhibitors

eg anastrozole, exemestane, letrozole




block estrogen synthesis




standard in HR+ post-menopausal woman




increase risk of osteoporosis

Leiomyoma

most common benign uterine tumor




smooth muscle growth of myometrium




enlarged, firm, asymmetric, non-tender uterus




b-hcg negative




p/w intermenstrual bleeding and menorrhagia




dx with either u/s, hysteroscopy, but histology is definitive dx




can observe with serial pelvic exam or give GnRH analog 3-6 months but ultimately may need to surgically remove




myomectomy preserves fertility but increases risk of uterine rupture

Adenomyosis

abnormal location of endometrial glands & stroma




found within myometrium




causes dysmenorrhea & menorrhagia




uterus is soft, symmetrical but tender




dx with u/s with cystic areas




tx with observation or give IUD

Endometrial carcinoma

post-menopausal woman with vaginal bleeding




most important risk factor --> unopposed estrogen state

Ovarian simple cyst

luteal or follicular cysts




most common cyst during reproductive age




usually asx but can cause torsion




f/u in 6-8 wks




contraception can prevent new cysts

Ovarian complex cyst

dermoid cyst - benign cytic teratoma


rarely develop into squamous cell carcinoma




tx with laparoscopic removal

Germ cell tumor

most common in young woman




present in early-stage disease




most common type is dysgerminoma




tumor markers - LDH, b-hcg, AFP

Epithelial tumor

most common ovarian cancer in post-menopausal women




most common type is serous




tumor markers - CA-125 & CEA

Granulosa-theca stromal tumor

seen in post-menopausal women




secrete estrogen --> lead to endometrial hyperplasia




tumor marker - estrogen

Sertoli-Leydig cell stromal tumor

secretes testosterone so p/w masculinization sxs




tumor marker - testosterone

Krukenberg tumor

metastatic gastric cancer to ovary




hx of peptic ulcer dz




mucin-producing adenocarcinoma




tumor marker - CEA

Cervical cancer HPV types

HPV 16, 18, 31, 33, 35




HPV 6 & 11 are assoc benign condyloma acuminata

Cervical neoplasia screening

start at age 21 regardless of everything else




conventional method - 50% sensitivity




liquid-based method - 75-80% sens




for ASCUS - do HPV PCR




for age <30 q3yr with cytology only




for age >30 q5yr with cytology+HPV testing



Management of abnormal pap in preg

CIN/dysplasia


pap & colposcopy q3 months


repeat pap & colposcopy 6-8 wks post-partum




micro invasive cervical cancer


cone bx to ensure no frank invasion


deliver vaginally & re-evaluate & tx 2 months post-partum




invasive cancer


before 24 wks - definitive tx (radical hysterectomy +RT)


after 24 wks - c-sect at 32-33 wks then start tx

HPV vaccine

protects aginast HPV 6, 11, 16, 18




guard against HPVs assoc with 70% of cervical cancer & 90% of genital warts




give to ALL males & females before age 26




vaccine not recommended for preg, lactating or immunosuppressed women

Primary dysmenorrhea

recurrent, crampy lower abd pain




n/v/d during menstruation




sxs begin 2-5 yrs after onset of menstruation




normal pelvic exam




due to excessive endometrial prostaglandin F2




tx with NSAIDs then OCP

Secondary dysmenorrhea

dysmenorrhea due to:




endometriosis


adenomyosis


leiomyomas

Endometriosis

occurs in women >30




endometrial glands outside the uterus




causes


dysmenorrhea


dyspareunia


dyschezia (painful bowel movements)




most common site is in ovary




definitive dx is with laproscopic visualization




tx with OCPs & second line is testosterone derivatives or GnRH analogs

Primary amenorrhea

absence of menses at age 14




usually no secondary sexual development




breasts indicate adequate estrogen production




if breasts & uterus are present --> secondary amenorrhea




if breast & uterus absent --> order FSH & karyotype


gonadal dysgenesis (Turners)


hypothalamic-pituitary failure

Secondary amenorrhea

imperforate hymen --> bulging bluish membrane btwn labia (hematocolpos)


vaginal septum


anorexia nervosa


excessive exercise


preg before first menses

Mullerian agenesis

with breasts but no uterus, fallopian tubes, cervix, or upper vagina




XX with normal female secondary sexual characteristics




normal estrogen & testosterone levels




tx with surgical vaginal reconstriction

Kallmann syndrome

anosmia + amenorrhea




hypothalamus doesnt produce GnRH




tx with hormone replacement

Secondary amenorrhea w/u

1) b-hcg


2) TSH (r/o hypothyroidism)


3) prolactin (most common is med side effect)


4) progesterone challenge test - w/d bleeding is diagnostic of anovulation


5) estrogen-progesterone challenge test

Causes of anovulation

PCOS


hypothyroid


pituitary adenoma


elevated prolactin


meds (anti-psychotics & anti-depressants)

PCOS

gradual onset of hirutism




obesity




acne, irregular bleeding, & infertility




chronic anovulatory cycle




dx with elevated LH/FSH ratio (3:1) & u/s shows b/l enlarged ovaries




predisposition to endometrial cancer bc of high estrogen




tx with OCP & spironolactone to suppress hair follicles



HRT

tx for:


menopausal hot flashes


GU atrophy


dyspareunia




start with lowest dose




can only give for 4 yrs




NOT FOR:


osteoporosis


liver dz


active thrombosis


unexplained vaginal bleeding




with a uterus - give estrogen + progestin


w/o uterus - continuous estrogen

Molar pregnancy

hypertension




hyperthyroidism




hyperemesis gravidarum




no fetal heart tones




fundus larger than dates

Hydatiform mole

serial b-hcg

CXR (r/o mets)

D&C

OCP for 1 yr

serial b-hcg




CXR (r/o mets)




D&C




OCP for 1 yr

Post-partum hemorrhage

Post-partum thyroiditis

can occur up to 1 yr after delivery




can present as hyperthyroid alone, hypothyroid alone, or hyperthyroid followed by hypothyroid




similar to Hashimoto's thyroiditis so can have anti-peroxidase Abs




can have re-occurrences




assoc with goiter & hypothyroid within 5-10 yrs so should get annual TSH




tx sxs with propranolol or atenolol

Pregnancy induced thyrotoxicosis

with signs of hyperthyroid, test only TSH relative to pregnancy ref ranges

with signs of hyperthyroid, test only TSH relative to pregnancy ref ranges