Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
237 Cards in this Set
- Front
- Back
- 3rd side (hint)
|
weight gain has been reported in association with which OCP?
|
medroxyprogesterone
|
weight gain is not associated with the use of combination oral contraceptive pills.
|
|
|
gestational trophoblastic disease should be ruled out in pregnant pts with severe vomiting by what test?
|
quantitative beta hCG first.
|
if beta hCG markedly elevated, then perform pelvic ultrasound.
|
|
|
classical clinical triad for hydatidiform mole?
|
enlarged uterus, hyperemesis, and markedly elevated beta hcg (>100,000)
|
|
|
|
features of hyperemesis gravidarum?
|
persistent vomiting, weight loss (loss >5% pre-pregnancy weight), and ketonuria
|
|
|
|
best managment of intrauterine fetal demise?
|
prompt delivery of fetus and remaining products of conception
|
retained products of conception can result in hypofibrinogenemia and coagulopathy
|
|
|
primary syphilis ulcers vs. granuloma inguinale vs. chancroid vs. herpes genitalis
|
primary syphilis and granuloma inguinale are painLESS. Chancroid vs. herpes are painFUL. Syphilis ulcers will heal spontaneously within 1-3 months whereas granuloma inguinale does not resolve wo ABX. Syphilis ulcers have a punched-out base and raised indurated margins with painLESS inguinal adenopathy whereas granuloma inguinale have red, beefy base and no adenopathy.
|
chancroid ulcers have deep, purulent bases and painFUL adenopathy. herpes presents with multiple vesicles that coalesce into ulcers following a prodrome of burning and pruritus.
|
|
|
serologic testing for primary syphilis can be used for screening pts but is not diagnostic because...
|
many pts with primary syphilis have yet to form antibodies against the organism (treponema pallidum) resulting in a HIGH RATE of FALSE NEGATIVES.
|
nontreponemal serology (VDRL, RPR) used for screening and treponemal serology (FTA-ABS) used for confirmation.
|
|
|
test most likely to reveal diagnosis for primary syphilis?
|
spirochete identification on dark field microscopy.
|
|
|
|
It is strongly recommended that asymptomatic bacteriuria in pregnant woman (especially btn 12-16 wks GA) be treated with what ABX?
|
amoxicillin, nitrofurantoin, and oral cephalosporins
|
treatment recommended to decrease invasive UTIs, preterm deliveries, and low birth weight children.
|
|
|
Fluoroquinolones are class C drugs in pregnancy and may cause _____ in the unborn fetus?
|
arthropathy
|
|
|
|
doxycycline and other tetracyclines are class D meds in pregnancy because theay cause?
|
interference with tooth development and should not be used in the second half of pregnancy or in children < 8 years.
|
|
|
|
TMP-SMX is a class C med in pregnancy and is contraindicated during the FIRST and THIRD trimesters because...
|
it interferes w folic acid metabolism during the 1st trimester and increases the risk of kernicterus during the 3rd trimester.
|
|
|
|
Premature activation of the hypothalamic-pituitary-gonadal axis causes what type of precocious puberty?
|
idiopathic central precocious puberty with pubertal levels of basal LH (increased by GnRH stimulation), whereas pts with a peripheral source of precocious puberty such as certain ovarian pathologies, have low LH levels with no response to GnRH.
|
All pts with central precoious puberty should have brain imaging to rule out an underlying CNS lesion. Pts should also be managed with GnRH agonist therapy in order to prevent premature fusion of the epiphyseal plates.
|
|
|
Treatment for central precocious puberty?
|
brain imaging to rule out CNS lesion and GnRH agonist therapy to prevent premature fusion of epiphyseal plates otherwise leading to short stature.
|
|
|
|
Steroid induced acne is characterized by?
|
monomorphous pink/erythematous papules and ABSENCE of comedones.
|
can be distrubited on face, trunk and extremeties
|
|
|
adolescent acne is characterized by?
|
open and closed comedones and inflammatory nodules in DIFFERING states of evolution
|
primarily affects face, chest and back
|
|
|
androgen excess is associated with what type of acne?
|
acne vulgaris
|
common in PCOS with other findings like irregular menses, anovulation and hirsutism
|
|
|
HTN in pregnancy in the setting of MASSIVE proteinuria, malar rash, and a STRONGLY positive ANA titer is most likely due to?
|
SLE; additionally RBC casts indicates lupus nephritis rather than simple protein loss
|
note that ANA titers may be WEAKLY positive in normal pregnancy
|
|
|
MCC of yellow mucopurulent cervicitis?
|
Chlamydia trachomatis
|
May be asymptomatic in more than 50% of women; cervical ectopy due to oral contraceptives predisposes to colonization with C. trachomatis
|
|
|
Magnesium sulfate in preeclampsia/eclampsia is given to?
|
PREVENT seizures NOT control/stop current seizures
|
|
|
|
Manage placental abruption aggressively by?
|
insert large-bore IV line, Foley catheter, make blood products available, and insure rapid vaginal delivery.
|
section only if there are OB indications or rapid deterioration of mother/fetus. Delivery removes the retroplacental hemorrhage which acts as the impetus for DIC and hemorrhage.
|
|
|
Intrauterine fetal demise is defined by death of fetus in utero that occurs?
|
after 20 weeks gestation and before onset of labor
|
beta-hCG levels may continue to be elevated due to ongoing placental production of that hormone
|
|
|
Most reliable tool for confirming diagonsis of IUFD?
|
real time ultrasonography to demonstrate absence of fetal movement and cardiac activity
|
|
|
|
Parasthesia/pain in the distribution of the median nerve during pregnancy is likely due to?
|
carpal tunnel syndrome which has increased incidence in pregnancy 2dry to estrogen-mediated depolymerization of ground substance leading to intersitial edema in the hands (and face) with resultant increased pressure within the carpal tunnel
|
initial treatment in pregnancy? wrist splinting. NSAIDs are associated with increased risk of miscarriage and may promote premature closure of the fetal ductus areteriosus; second line - local corticosteriod injection
|
|
|
Lochia rubra (bloody vaginal discharge) associated with _____ and _____ are common during the first 24 hours postpartum.
|
low-grade fever and leukocytosis. after 3-4 days, locia rubra becomes lochia serosa (pale) and finally turns lochia alba (white/yellow)
|
if lochia is foul smelling, endometritis should be suspected.
|
|
|
treatment of asymptomatic bacteriuria in pregnancy is important to prevent progression to?
|
pyelonephritis (in up to 30-40% of untreated cases)
|
treat asymptomatic bacteriuria or UTI in pregnancy with amoxicillin, ampicillin, nitrofurantoin or cephalexin
|
|
|
failure to lactate is the classic initial presentation of ?
|
Sheehan's syndrome or postpartum ischemic necrosis of the anterior pituitary resulting in prolactin, TSH, and FSH deficiency.
|
other complications include hypothyroidism, amenorrhea, genital atrophy, loss of pubic and axillary hair, and fatigue.
|
|
|
Unsensitized women with Rh-positive or Rh-unknown partners should have blood typing and Rh-antibody testing when?
|
At the first prenatal visit as well as repeat Rh-antibody testing between 24-28 weeks.
|
|
|
|
Rh-negative patients at risk of alloimmunization shoud be given anti-Rh immune globin (RHO-gam) when?
|
at 28 weeks GA and again at time of delivery.
|
|
|
|
Pregnant women with unknown immunization status should be checked for rubella immunity and if non-immune...
|
then be advised to avoid individuals potentially infected with rubella bc the MMR vaccine is not recommended in pregnancy.
|
|
|
|
Is the pneumococcus vaccine recommended in pregnancy?
|
no but influenza vaccine is recommended.
|
|
|
|
Pregnant women should be screened for HIV when?
|
At the first prenatal visit bc early initiation of anti-retrovirals meds can significantly decrease disease transmission to the fetus.
|
|
|
|
Criteria for diagnosis of pelvic inflammatory disease includes
|
1) fever > 38C
2) leukocytosis 3) elevated ESR 4) purulent cervical discharge 5) adnexal tenderness 6) cervical motion tenderness 7) lower abdominal tenderness |
|
|
|
Complications of PID include?
|
1) most common cause of infertility in women under 30 wiht normal menstruation
2) tubo-ovarian abscess 3) abscess rupture 4) pelvic peritonitis 5) sepsis |
|
|
|
Indications for inpatient management of PID?
|
1) high fever
2) failure to respond to oral antibiotics 3) inability to take oral meds due to nausea and vomiting 4) pregnancy 5) risk of non-compliance (teenagers, low SES) |
|
|
|
Parenteral regimens for PID?
|
1) Cefoxitin or Cefotetan with Doxycycline
2) Clindamycin/Gentamicin **to eradicate most common pathogens: N. gonorrhoeae, C. trachomatis and genital mycoplasmas |
The patient's partner should also be treated.
|
|
|
PID treatment for non-hospitalized patients?
|
Cefoxitin (IM) concurrently with Probenecid (PO)
PLUS Doxycycline (PO) alone OR Ceftriaxone (IM) and Doxycycline (PO) |
|
|
|
Should ABX treatment of PID be started before or after culture results are obtained?
|
Never delay treatment for culture results.
|
|
|
|
Which drugs can induce ovulation in PCOS patients?
|
clomiphene citrate (an estrogen analog) that improves GnRH release and FSH release
metformin treatment has also independently shown to improve ovulation |
PCOS pts are often infertile/subfertile bc of their anovulatory menstural cycles. Anovulation is in part caused by imbalances in LH/FSH production and insulin resistence. Note that ovaries are still functional which is why ovulation can be induced.
|
|
|
Anovulation and galactorrhea can be treated with?
|
Dopamine agonists
|
|
|
|
Supplementation of which hormone is recommeded in patients with a luteal phase defect?
|
Progesterone
|
|
|
|
The ideal range of maternal fasting glucose is between?
|
75 and 90 mg/dL.
Treatment of gestational DM is with SQ insulin (classified as category B med and does not cross the placenta) |
DM treatments including exenatide, sulfonylureas, thiazolidinediones, metformin, chlorpropamide, and tolbutamide are all class C drugs in pregnancy and not recommended.
|
|
|
What is an analog of the hormone incretin that increases insulin production by pancreatic beta cells, stimulates growth and replication of beta cells, and slows gastric emptying?
|
Exenatide. (Works synergistically with sulfonylureas, thiazolidinediones, and metformin.
|
|
|
|
Gestational DM carries what risks for a fetus?
|
Macrosomia, hypOcalcemia, hypOglycemia, hyperviscocity due to polycythemia), respiratory difficulties, cardiomyopathy and congestive heart failure.
|
gestational DM is not commonly associated with metal retardation.
|
|
|
What causes polycythemia in the fetus of a diabetic mother?
|
Polycythemia in an infant of a diabetic mother is the result of fetal hypoxia occuring because of the increased basal metabolic rate induced by hyperglycemia. Increased erythropoietin prodxn by the fetus increases RBC mass and oxygen carrying capacity of blood.
|
|
|
|
What causes hypOglycemia in the fetus of a diabetic mother?
|
High baseline insulin production in the fetus caused by the high glucose load from mother. Once delivered, the high glucose load from mother is removed and the infant's hyperinsulinemia then causes hypOglycemia.
|
|
|
|
What causes hypOcalcemia in the fetus of a diabetic mother?
|
Parathyroid hormone suppression
|
|
|
|
maternal serum alpha-fetoprotein levels can be increased in the presence of...
|
neural tube defects, abominal wall defects (gastroschisis, omphalocele), multiple gestation, and inaccurate gestational age.
|
|
|
|
maternal serum alpha-fetoprotein can be decreased in the presence of...
|
chromosomal anomalies such as Down's syndrome and trisomy 18, and inaccurate gestational age.
|
|
|
|
The next step in management of abnormal MSAFP levels?
|
ultrasonography to rule out inaccurate gestational dates, detect fetal structural anomalies, detect multiple gestation, and to confirm a viable pregnancy.
|
|
|
|
When is amniocentesis indicated?
|
Between 16-20 weeks in cases where the MSAFP or triple/quad screen is abnormal BUT ONLY AFTER ultrasonography to rule out nonviable pregnancy or multiple gestation.
|
|
|
|
When is chorionic villus sampling indicated?
|
Between 10-12 weeks GA as early screening in women with KNOWN genetic diseases or who already have children affected by a genetic condition.
|
|
|
|
When is cordocentesis used?
|
For rapid karyotype analysis or when fetal blood dyscrasias (such as fetal anemia and Rhesus isoimmunization) are suspected.
|
|
|
|
What is the value of estradiol levels in pregnancy?
|
none - however estriol levels can be measured along with MSAFP and beta hCG (triple test) as a screening tool for chromosomal anomalies.
|
|
|
|
A hysterosalpingogram is used to stdy/explore what?
|
the uterine cavity and fallopian tubes
|
|
|
|
The gold standard for the diagnosis of endometriosis?
|
Laparoscopy. .
CA-125 levels are an inadequate tool for diagnosis but levels do tend to correlate with the severity of disease. |
|
|
|
What is the mechanism responsible for decreased fertility/infertility in women with endometriosis?
|
Adhesion formation within the peritonieum that interferes with the normal transfer of oocytes from the ovarian surface to the fallopian tubes, endometrial factors within the uterus that may provide a suboptimal environment for implantation, and hormonal issues that may affect ovarian function.
|
|
|
|
Risk factors for endometrial carcinoma?
|
advancing age, use of unopposed estrogen at any point, prolonged use of tamoxifen, obesity, nulliparity, and PCOS.
|
|
|
|
Risk factors for abruptio placenta?
|
HTN, cocaine use, smoking, advancing age, and preeclampsia
|
|
|
|
Findings characteristic of trichomonal vaginitis?
|
thin vaginal discharge, erythematous vaginal mucosa, and motile pear shaped organisms on wet-mount.
treatment of choice: metronidazole (do not use with alcohol bc associated with disulfiram-like rxn) |
|
|
|
Most common form of vaginal cancer?
|
squamous cell carcinoma
treatment depends on staging: stage 1/2 are less than 2 cm (with no extension into the pelvic wall and no metastases)and may be removed surgically. Stage 3/4 are greater than 2 cm and treated with radiation. |
Combination chemotherapy is used for stage 3/4 as well as tumors > 4cm when radiation alone might not be sufficient.
|
|
|
Risks vs. benefits of OCPs?
|
Risks include venous TE, CV events such as stroke or MI, elevation of triglycerides, cholestasis/cholecystitis, worsening of DM, HTN, breast cancer, and cervical cancer.
Benefits of OCPs are decreased risk of endometrial cancer, ovarian cysts/cancer, PID, ectopic pregnancy, benign breast disease, and dysmenorrhea |
|
|
|
Symmetric vs. asymmetric fetal growth restriction?
|
symmetric - begins before 28 weeks gestation and growth of BOTH head and body is deficient 2ndry to FETAL factors such as chromosomal abnormalities, congenital infections, and congenital anomalies.
asymmetric - fetal adaptation as a result of late exposure to non-ideal MATERNAL factors (such as HTN, hypoxemia, smoking, vascular disease, and toxic exposures) and characterized by normal or almost normal head size but reduced abdominal circumference. |
|
|
|
Most accurate method for pregnancy dating?
|
ultrasound btn 16-20 weeks
|
|
|
|
hCG in pregnancy originates from? to promote?
|
originates from the syncytiotrophoblast and mainly promotes preservation of the corpus luteum during early pregnancy to maintain progesterone secretion until the placenta is able to produce progesterone on its own.
other biological functions of hCG include promotin of male sex diiferentiation and stimulation of the maternal thyroid gland. |
|
|
|
hCG production begins when? and levels peak when?
|
begins about 8 days after fertilization, doubles every 48 hours, and peaks at 6-8 weeks.
|
hCG is composed of two subunits: alpha and beta.
alpha subunit is common to hCG, TSH, LH and FSH. beta subunit is specific to hCG and used as the basis of virtually all pregnancy tests. |
|
|
definition of PPROM (preterm premature rupture of membranes)?
|
rupture of amniotic membranes before 37 weeks gestation BUT WITH the onset of labor.
|
|
|
|
amniotic fluid pH vs. vaginal pH?
|
amniotic fluid pH is 7.0-7.5 vs. more acidic vaginal pH btn 3.8-4.5.
|
|
|
|
what should be suspected in the setting of prolonged or premature rupture of membranes in the presence of maternal fever, leukocytosis, uterine tenderness, maternal/fetal tachy?
|
intraamniotic infection aka chorioamnionitis
|
|
|
|
Most appropriate treatment of chorioamnionitis?
|
systemic, broad spectrum ABX therapy and expedited delivery of fetus.
C-section should be reserved for cases where fetal distress is evident. |
|
|
|
Betamethasone administered in effort to improve fetal lung maturity has little benefit beyond what gestational age?
|
32-34 weeks
|
|
|
|
The single most useful parameter for predicting fetal WEIGHT by ultrasonogram in suspected FGR?
|
Abdominal circumference because it is affected in both symmeteric and asymmetric FGR.
|
|
|
|
What discrepancy in fundal height is suspicious of FGR?
|
fundal height that is at least 3 cm less than expected given the actual GA in weeks.
|
|
|
|
The head to abdomen circumference ratio can be used to differentiate?
|
symmetric from asymmetric FGR
|
|
|
|
Definitive treatment for HELLP syndrome?
|
delivery (same as in preeclampsia/eclampsia)
|
|
|
|
Three tests to evaluate anovulation?
|
basal body temperature measurement, serum progesterone measurement, and endometrial sampling.
|
|
|
|
Investigative procedure of choice to evaluate suspected renal calculi in pregnancy?
|
Pelvic/abdominal ultrasound bc there is no radiation and is useful for detecting secondary signs of obstruction such as obstructive hydronephrosis and hydroureter.
|
|
|
|
When is a biophysical profile indicated?
|
high risk pregnancies, decreased fetal movements or a non-reactive non-stress test.
|
|
|
|
A biophysical profile includes the NST in addition to what four parameters?
|
1) fetal tone
2) fetal movements (3 per 10 minutes) 3) fetal breathing (30 per 10 minutes) 4) amniotic fluid index btn 5-20 **Each variable is given a score of 2 when present and a score of 0 when absent or abnormal. Score of 8-10 is considered normal. |
|
|
|
oligohydramnios has a amniotic fluid index of...
|
< 5
delivery should be considered since it can result in cord compression. |
|
|
|
When should a contraction stress test be ordered?
|
AFI index = 6 (no oligohydramnios). IF contraction stress test is non-reassuring, delivery is indicated. If it is suspicious, repeat the next day.
|
|
|
|
If the AFI index < 4, then?
|
Delivery is indicated!
|
|
|
|
What effect does raloxifine have on breast and vaginal tissue?
|
It is an ANTagonist therefore decreases breast cancer risk.
|
Raloxifene (a selective estrogen receptor modulator aka SERM) is a mixed agonist/antagonist of estrogen receptors.
|
|
|
What effect does raloxifene have on bone tissue?
|
it is an AGONIST therefore used as a first-line agent for the prevention of osteoporosis although somewhat less effective than bisphosphonates or estrogen.
|
Raloxifene (a selective estrogen receptor modulator aka SERM) is a mixed agonist/antagonist of estrogen receptors.
|
|
|
What is a contraindication to raloxifene?
|
history of DVT bc it increases risk of thromboembolism.
|
It may also cause hot flashes and leg cramps.
|
|
|
What is the effect of raloxifene on the risk of ovarian cancer?
|
no effect
|
|
|
|
What is the effect of raloxifene on the risk of endometrial cancer?
|
no effect unlike tamoxifen which increases the risk.
|
|
|
|
Abdominal pain in a young woman in the middle of her cycle with a benign history and clinical examination is most likely?
|
Mittelschmerz (midcycle pain) pain - common in women with REGULAR menstrual cycles who are not taking OCPs i.e. women who are ovulating. The pain often lateralizes to the ovary so can be unilateral.
|
|
|
|
Should pregnant women exercise?
|
Yes - daily for 30 minutes at a moderate intesity that allows the mother to carry on a conversation while exercising.
|
|
|
|
Besides shorter urethral lengths in women, what are other predisposing factors for UTIs?
|
recent ABX use altering the normal vaginal flora, sexual intercourse, diaphragm or spermicide use, or a family history of multiple UTIs and a close proximity of the urethra to the anus.
|
|
|
|
premature ovarian failure is characterized by?
|
amenorrhea, hypOestrogenism, and ELEVated serum gonadotropin levels in women younger than 40 years. (Signs/symptoms similar to menopause).
|
Secondary to accelerated follicle atresia or a low initial number of primordial follicles. Commonly idiopathic in origin but may also be due to mumps, oophoritis, irradiation, chemotherapy or in association with autoimmune disorders (such as Hashimoto's, Addison disease, DMT1, and pernicious anemia).
|
|
|
A luteal phase defect is characterized by?
|
failure of the corpus luteum to produce sufficient progesterone to maintain the endometrium and allow implantation of an embryo.
|
|
|
|
Does anesthesia have any negative effects on labor?
|
if administered in the latent phase of labor, both general and spinal anesthesia and sedation may reduce uterine activity.
|
treatment is to allow the responsible drug to be naturally eliminated. The uterus will resume normal activity afterward.
|
|
|
How is a prolonged latent phase defined? And what is it caused by?
|
When it exceeds 20 hours in the primiparous and 14 hours in the multiparous woman. It can be caused by hypotonic uterine contractions, uncoordinated uterine contractions, fetopelvic disproportion or premature or excessive use of anesthesia/sedation.
|
|
|
|
Definition of menorrhagia?
|
prolonged or heavy menstruation typically longer than 7 days or exceeding 80 mL.
|
|
|
|
Why are most (up to 90%) of menstural cycles in the first 1-2 years following menarche irregular and complicated by menorrhagia?
|
Due to anovulatory cycles bc women in this age group have an immature hypothalamic-pituitary-ovarian axis that may fail to produce gonadotropins in the proper quantities/ratios to induce ovulation. Bleeding occurs nevertheless because the endometrium is responsive to baseline estrogen levels during the female's cycle leading to endometrium development and eventually sloughing which is seen as CYCLIC breakthrough bleeding.
|
|
|
|
early decelerations are caused by
|
fetal head compression and are reassuring because have no association with negative fetal outcomes.
|
|
|
|
late decelerations are caused by
|
uteroplacental insufficiency and are associated with fetal acidosis and negative neonatal outcoumes.
|
|
|
|
fetal cord compression presents how on a fetal heart rate monitor?
|
variable decelerations
|
|
|
|
The first step in management of a patient with secondary amenorrhea is...
|
rule out common situations first: pregnancy, HYPERprolactinemia, and hypOthyroidism.
Next determine the pts endogenous estrogen production using a progestin challenge test. |
the progestin challenge test has been progressively abandoned since it relies on the patient's compliance and may not result in w/drawal bleeding despite the presence of adequate endogenous estrogen.
|
|
|
Lithium is associated with _____ in pregnancy?
|
congenital heart disease, classically Ebstein's anomaly and should be weaned off in pregnant women with stable bipolar disorder.
|
|
|
|
Isotretinoin should not be taken by women of reproductive age unless...?
|
2 effective forms of contraception have been used for at least 1 month prior to initiating treatment. Contraception must continued during treatment and for 1 month after isotretinoin is discontinued. In addition, pts should have a pregnancy test the week before beginning treatment and periodic pregnancy tests during therapy.
|
|
|
|
Pseudocyesis will show what on an ultrasound and what result for a pregnancy test?
|
Ultrasound will show a normal endometrial stripe and a negative pregnacy test. Pseudocyesis is a rare state of depression (a form of conversion disorder) due to a need/want to be pregnant that causes some hormonal changes mimicking pregnancy.
|
|
|
|
Definition and signs of a missed abortion? What is necessary for a diagnosis?
|
Defined as fetal demise before the 20th week of gestation and with a fetus weighing < 500 g. Characterized by fetal demise with RETAINED products of conception and a CLOSED cervix. Many pts experience a loss of their pregnancy symptoms (i.e. decreased nausea and breast tenderness) and some brown discharge may be noted. A transvaginal ultrasound is necessary to confirm the diagnosis.
|
|
|
|
Prolonged retention of the products of conception in fetal demise can cause what problem in the mother?
|
Coagulopathy
|
|
|
|
How can the products of conception be removed?
|
surgically with dilation and curettage, medically with vaginal misoprostol, or expectantly with serial imaging to ensure complete natural expulsion.
|
|
|
|
How are TBG, total T4/T3, free T4/T3 and TSH values affected in pregnancy?
|
THe increase in circulating estrogen levels during pregnancy causes an increase in production of TBG resulting in increased TBG-bound T3 and T4.
Therefore total T3 and T4 are increased. Elevated levels of hCG in pregnancy cause mild stimulation of the TSH receptor resulting in a TINY increase in T3 and T4. This in turn causes a tiny decrease in TSH (from negative feedback) but free T3, free T4, and TSH values remain within NORMAL range. |
|
|
|
Pathogenesis of PCOS?
|
abnormal GnRH secretion resulting in EXCESS LH and INSUFFICIENT FSH.
Excess LH stimulates excess androgen production by ovarian thecal cells which causes signs of androgen excess such as hirsutism, male-pattern hair growth, acne, ovarian cysts. Anovulation or oligo-ovulation is caused by imbalances in LH and FSH production and in part by insulin resistance. |
|
|
|
Increased blood pressure that appears before 20 wks of gestation?
|
Due to chronic hypertension or a hydatiform mole.
|
|
|
|
Transient HTN of pregnancy is defined as...
|
HTN that appears in the 2nd half of pregnancy or during labor/delivery and is NOT accompanied by proteinuria (i.e. proteinuria < 300 mg/24 hr).
|
|
|
|
Placental abruption is defined by...
|
premature separation of the placenta from the site of uterine IMPLANTATION--> causing maternal hemorrhage and interruption of placental perfusion.
|
|
|
|
The most significant risk for placental abruption?
|
hypertension of any kind
|
|
|
|
female offspring of women who ingested diethylstilbestrol during pregnancy are at increased risk for?
|
clear cell ADENOcarcinoma of the vagina/cervix, cervical anomalies (hypoplasia), uterine malformations (T-shaped/small uterine cavity), vaginal adenosis, and vaginal septae. Many will have difficulty conceiving and maintaining pregnancy.
|
|
|
|
When is RhoGAM indicated?
|
In unsensitized (antibody titers < 1:6), Rh-negative women at 28 weeks gestation and within 72 hours of any procedure or incident such as abortion, ectopic pregnancy and delivery.
If a mother is already sensitized, RhoGAM is not helpful and close fetal monitoring for hemolytic disease is required. |
|
|
|
What is RhoGAM?
|
anti-D gamma globulin that binds the D-antigens (Rhesus-positive) on fetal blood in the maternal circulation thereby preventing the mother's immune system from reacting to them.
|
|
|
|
What is the first step in management after fetal demise is confirmed by ultrasound?
|
Obtain a coagulation profile to detect incipient DIC.
Fibrinogen values in the LOWER normal ranges may indicate an early sign of consumptive coagulopathy, especially if there is an associated decrease in platelet count, increase in PT/PTT, or the presence of fibrin split products. If DIC is suspected, delivery (preferrably vaginal) should be performed without delay. |
|
|
|
Infertility due to aging can be assessed using?
|
an early follicular phase FSH level, a clomiphene challenge test, or an inhibin-B level.
|
|
|
|
Antibodies to ABO antigens belong to what immunoglobin class? Anti-rhesus (aka anti-D antibodies) belong to what immunoglobin class?
|
anti-ABO antibodies are IgM class, thus too bulky to cross the placenta.
anti-D antibodies belong to the IgG class and cross the placenta easily. |
|
|
|
Lichen slerosus atrophicus is a chronic inflammatory condition which may have an autoimmune pathogenesis and is characterized clinically by what signs and symptoms?
|
anogenital discomfort including pruritus, dyspareunia, dysuria and painful defecation. Physical exam revals porcelain-white polygonal macules and patches with an atrophic "cigarette paper" quality. Sclerosus and scarring can lead to obliteration of the labia minora and clitoris and a decrease in the diameter of the introitus.
|
vulvur SCC occurs more commonly in women with lichen sclerosus atrophicus so a punch biopsy of any suspicious lesion should be performed.
|
|
|
what is first-line therapy for lichen sclerosus?
|
high potency topical steroids.
|
Estrogen creams are helpful in menopause-related atrophic vaginitis which can also cause vaginal pruritus and dyspareunia.
|
|
|
How can the levels of FSH/LH help differentiate Kallmann's syndrome and primary ovarian failure?
|
Kallman's syndrome will show low FSH/LH levels due to a CONGENITAL absence of GnRH secretion associated with anosmia, whereas FSH/LH levels are elevated in primary ovarian failure.
|
Pts with Kallmann's syndrome have normal XX genotype and normal female internal reproductive organs. THe present with primary amenorrhea and absent secondary sexual characteristics.
|
|
|
The benefits of metformin use in PCOS:
|
1) helps prevent DMT2
2) Helps losing weight (most PCOS pts are obese) 3) In conjugation with clomiphene citrate, it helps to induce ovulation in infertile PCOS pts with anovulation; however it is not FDA approved to be used just for this purpose. 4) It has a modest effect in suppressing androgen production and, thus, helps correct hirsutism to some extent. |
|
|
|
A glucose tolerance test is recommended in all PCOS patients bc it is more sensitive than a fasting glucose. What values would indicate insulin resistance vs. diabetes mellitus.
|
A 2-hr glucose of >140 mg/dL indicateds insulin resistance while a value >200 indicates DM.
|
|
|
|
What is the primary pathophysiologic cause of preeclampsia?
|
vasospasm
|
|
|
|
fetal loss in antiphospholipid antibody syndrom is most likely due to?
|
thrombus development within the placenta.
|
|
|
|
Acquired hypogonadotropic hypogonadism due to hypothalamic dysfunction is commonly associated with?
|
severe life stressors, eating disorders, and excessive exercise causing insufficient pulses of GnRH from the hypothalamus --> low pituitary LH/FSH production --> supression of ovarian estrogen production and ovulation leading to amenorrhea
|
If eliminating stressors, eating disorder, or exercise does not correct imbalance, treat with pulsatile GnRH supplementation.
Other less common causes include marijuana use, starvation, depression, and chronic illness. |
|
|
Anabolic steroid abuse causes azoospermia by...
|
Decreasing GnRH production by the hypothalamus due to feedback inhibition by the exogenous testosterone analog. Decreased GnRH leads to decreased LH/FSH production. LH and FSH are trophic on the testes in the normal state and are required for normal hormone and sperm production by the testes.
|
|
|
|
Signs and symptoms of anabolic steroid abuse?
|
acne, erythrocytosis, gynecomastia, azoospermia, decreased testicular size, cholestasis, hepatic failure and dyslipidemia. Behavioral effects include aggressiveness and psychotic symptoms.
|
|
|
|
Signs/symptoms of an inevitable abortion?
|
vaginal bleeding, fluid discharge (amniotic fluid draining from a ruptured amniotic membrane), lower abdominal cramps, and a dilated cervix through which the products of conception can occasionally be visualized.
Ultrasound demonstrates a ruptured or collapsed gestational sac and absence of fetal cardiac motion. |
|
|
|
what is the next step in management of a low-grade squamous epithelial lesion in a post-adolescent, premenopausal pt?
|
via colposcopy
|
|
|
|
what is the next step in management of a low-grade squamous epithelial lesion in an adolescent pt?
|
Repeat pap in 12 months because LSIL as well as ASCUS in adolescent women are most often due to transient HPV infection with the risk of cancer being very low. If repeat pap after 12 months is also abnormal, then a colposcopy should be performed.
|
|
|
|
what is the next step in management of a low-grade squamous epithelial lesion in a post-menopausal pt?
|
Reflex HPV testing, and if positive, followed by colposcopy.
|
|
|
|
LSIL is usually attributable to...?
|
HPV infection or CIN 1.
CIN 1 does not require treatment, only observation. Uncommonly, LSIL may be observed in the setting of CIN 2 or 3 which requires treatment. |
|
|
|
How does galactorrhea present?
|
guaiac NEG BILATERAL nipple discharge that is most often milky or clear in color but can also be yellow, brown, or green. In absence of breast mass, mammography is not necessary and pt can be reassured that breast cancer is very unlikely.
|
|
|
|
Common causes of galactorrhea?
|
prolactinoma, hypothyroidism, overstimulation of the nipple, OCPs, and meds which lower dopamine levels are common causes.
Workup includes ruling out pregnancy, measuring serum prolactin and TSH levels, and possible brain MRI to rule out prolactinoma. |
|
|
|
Red flags to watch for in cases of nipple discharge?
|
UNIlateral secretion, guaiac positive fluid, andbreast lump.
|
|
|
|
Low back pain is a very common complaint in the third trimester of pregnancy and is caused by?
|
increase in lumbar lordosis and the relaxation of ligaments supporting the sacroiliac and other joints of the pelvic girdle due to hormonal factors.
|
|
|
|
Epidural anesthesia may cause overflow incontinence as a transient side effect which is best treated with?
|
intermittent catheterization
|
|
|
|
Prolactin production is inhibited by ______ and stimulated by ________?
|
inhibited by dopamine and stimulated by serotonin and TRH. An increase in TSH and TRH production and consequently in prolactin release may be the result of hypothyroidism (2ndry to decreased negative feedback).
Hyperprolactinemia may also affect GnRH and gonadotropin secretion resulting in amenorrhea. Other causes of hyperprolactinemia include dopamine antagonists (antipsychotics, TCAs, and MAOIs) as well as hypothalamic and pituitary tumors. Rule out the most benign etiology first by measuring TSH, especially in the absence of CNS signs. |
|
|
|
Granulosa cell tumors produce excessive amounts of estrogen and have a bimodal age distribution. What are the expected manifestations in the two different age groups?
|
Young children - presents as precocious puberty with early development of secondary sex characteristics, hypertrophy of breasts and external genitalia, pubic hair growth and hyperplasia of the uterus.
Postmenopausal women - postmenopausal bleeding, uterus shows myohyperplasia, and estrogenic features such as hypertrophy of the breasts and absence of postmenopausal signs (i.e. absence of vaginal atrophy) |
Make sure to differentiate from heterosexual precocious puberty or virilizing symptoms which are usually produced by excessive androgens.
|
|
|
What should be done in a pregnant patient with confirmed syphilis if she is allergic to penicillin?
|
allergy should be confirmed with skin testing and pt should undergo desensitization so that she can safely take the medication. Untreated syphilis is associated with very high prevalance of adverse fetal outcomes (up to 80%) including stillbirth, neonatal death, and MR.
|
|
|
|
A patient presents with primary amenorrhea and has a female phenotype but lacks a normal vagina and uterus. What etiology could cause this?
|
1) mullerian agenesis
2) androgen insensitivity 3) 5-alpha reductase deficiency **karyotyping is the determining test because androgen insesitivity and 5-alpha reductase deficiency is only seen in XY genotypes and mullerian agenesis is only seen in XX genotypes. |
The mullerian duct normally leads to the development of the proximal vagina and the uterus; therefore pts with mullerian agenesis have a blind ended vagina with little to no uterine tissue. Pts with mullerian agenesis also have normal axillary and pubic hair development since they can respond appropriately to testosterone.
|
|
|
Mullerian inhibiting factor is secreted by the ?
|
testes
|
|
|
|
Androgen insensitivity is caused by?
|
an abnormality in the androgen receptor - therefore external genitalia develop as female but mullerian inhibiting factor which is still secreted by the testes prevents the development of internal female organs.
|
|
|
|
Indications for GBS prophylaxis in pregnancy?
|
1) delivery at < 37 wks
2) duration of membrane rupture greater than or equal to 18 hours 3) temp > 100.4 or 38.0C 4) GBS bacteriuria in any concentration during the current pregnancy 5) previous birth to infant with Group B streptococcal disease. 6) unknown GBS status of woman |
|
|
|
Management of a pregnancy after 34 weeks gestation with PPROM?
|
induction of delivery NOT expectant management
|
|
|
|
What causes amenorrhea in lactating mothers?
|
high levels of circulating prolactin suppress GnRH release thereby suppressing LH/FSH production and ovulation.
**50% of nursing mothers will ovulate wi 6-12 months of delivery |
|
|
|
What role does oxytocin play during the postpartum period?
|
It is elevated during lactation for milk expulsion from the glands and plays an important role in uterine involution.
|
|
|
|
What role does human placental lactogen play?
|
It is produced by the placenta, and serum levels quickly decrease after delivery of the placenta. hPL has an insulin ANTagonist effect playing an important role in the nutrition of the fetus. It causes maternal lipolysis and insulin resistance thus increasing delivery of fatty acids and glucose ot the fetus.
|
|
|
|
Definition of precocious puberty?
|
development fo secondary sex characteristics before the age of 8 in girls and 9 in boys. Accelerated bone growth and advanced bone age are also common.
|
|
|
|
Difference between central precocious puberty and peripheral precocious puberty?
|
Centeral precocious puberty is the result of early activation of the hypothalamic-pituitary-ovarian axis. Therefore, FSH and LH leves are HIGH. In contrast, patients with peripheral precocious puberty present with LOW FSH and LH levels caused by gonadal or adrenal release of excess sex hormones (that negatively feedback on FSH/LH production).
|
All patients with central precocious puberty should receive brain imaging with a CT or MRI. Treatment is pulsatile GnRH analog therapy.
|
|
|
What is the cause of hypotension as a side effect of epidural anesthesia (up to 10% of blocks)?
|
Sympathetic fiber block that causes vasodilation of the lower extremity vessels. Venous pooling occurs, cardiac output decreases, and hypotension results.
|
|
|
|
Characteristics of fetal alcohol syndrome?
|
intrauterine growth restriction, midfacial hypoplasia, a smooth philtrum, short palpebral fissures, a thin upper lip and CNS abnormalities such as irritability, ADHD, learning disabilities and frank MR.
|
|
|
|
How does placenta previa present?
|
painLESS 3rd trimester bleeding
|
|
|
|
How does placental abruption present?
|
Variably - asymptomatic with intrauterine fetal death or dark red vaginal bleeding associated with painFUL uterine contractions.
Placental abruption is the premature placental separation from the site of uterine attachment that initiates with the hemorrhag of the DECIDUA BASALIS. |
|
|
|
How does vasa previa present?
|
painLESS antepartum hemorrhage associated with rapid deterioration of the fetal heart tracina s the hemorrhage is of fetal origin.
Vasa previa is a rare condition in which the fetal blood vessels cross the fetal membranes in the lower segment of the uterus btn the fetus and the internal cervical os. |
|
|
|
How does uterine rupture present?
|
classically with sudden onset of intense abdominal pain and vaginal bleeding associated with hyperventilaitn, agitiation, and tachycardia.
|
|
|
|
What causes the bloody show in normal labor?
|
Cervical dilation releases the mucous plug and the bloody show is due to the tearing of small cervical veins.
|
|
|
|
How common are threatened abortions?
|
25% of pregnancies have some extent of vaginal bleeding in the first trimester. HALF of these cases will end in spontaneous abortion.
|
|
|
|
How soon should an outpatient follow up be for a threatened abortion?
|
One week - in the interim bed rest and abstaining from sexual intercourse is usually recommended because this will prevent any feelings of guilt on the part of the parents in case the pregnancy is actually lost.
|
|
|
|
What is the differential diagnosis for adenomyosis?
|
leiomyoma and endometrial carcinoma
For women above 35, it is madatory to perform an endmetrial curettage to rule out endometrial carcinoma. |
|
|
|
How does adenomyosis typically present?
|
Most frequently in multiparous women over 40 years of age with severe dysmenorrhea and menorrhagia. Physical exam reveals an enlarged and generally SYMMETRICAL uterus.
|
|
|
|
Definition of adenomyosis?
|
presence of endometrial glands in the uterine muscle - invasion may extend through the full thickness of the myometrium and in some instances to the serosa of the uterus.
|
|
|
|
Why are the initial menstrual cycles in pubertal women usually irregular and often anovulatory.
|
Because of an immatury hypothalamic-pituitary-gonadal axis. Ovulation is thus absent and the endometrium builds up under the influence of estrogen but without the influence of progesterone (the cue to slough the endometrium). The menstrual like bleeding that does occur at irregular intervals is due to estrogen breakthrough bleeding. Normally progesterone is produced in increased amounts by the corpus luteum following ovulation, and withdrawal of progesterone as the corpus luteum degenerates during menses.
|
|
|
|
How does androgen insensitivity aka testicular feminization present?
|
With amenorrhea, normally developed breasts, ABSENT pubic and axillary hair, and absent internal reproductive organs. Pts have a female phenotype buth a 46 XY karyotype. Serum testosterone levels are in a range typical for males. The internal reproductive organs do not develop because the testes are still present (typically in the abdomen or inguinal canal) and secrete mullerian inhibiting factor.
Androgen resistance is due to a defect or absence of the androgen receptors. |
|
|
|
How should Chlamydia be treated?
|
A single dose of azithromycin or a course of doxycycline.
Concurrent treatment for Gonorrhea (with Ceftriaxone) is not needed if screening for Gonorrhea is negative. |
|
|
|
What is the management protocol for CIN 1 preceded by low grade abnormalities (ASC-US; ASC-H, LSIL)?
|
Repeat cytology in 12 months and at 24 months. If abnormal after 24 months, a diagnostic excisional procedure should be performed such as cold knife conizaiton or LEEP. These procedures carry the risk of cervical stenosis or incompetence and preterm birth.
|
CIN 1 regresses to normal in 57% of cases.
|
|
|
When are pregnant women tested and treated for Group B streptococcus (Streptococcus agalactiae)?
|
All pregnant women are screened with vaginal and rectal swabs at 35-37 weeks. Women who are colonized with GBS will receive prophylactic ABX at the time of delivery. Women who have had GBS bacteriuria during pregnancy or who have previously delivered a child that developed an early-onset GBS infection are automatically given prophylactic ABX regardless of the results of a rectovaginal culture.
|
|
|
|
How does uterine rupture present?
|
With intense abdominal pain associated with vaginal bleeding which can range from spotting to massive hemorrhage. After rupture occurs, the patient may fell slightly relieved but soon after the pain returns in a more diffuse fashion. Patients also typically exhibit vital signs consistent with hypovolemia, retraction of the presenting parts on pelvic exam, and palpability of fetal extremeties (felt as irregular contours) on abdominal exam.
|
|
|
|
Should all PCOS pts be tested for DMT2?
|
Yes - standard 2-hour oral glucose tolerance test is better than fasting glucose alone in identifying most patients with insulin resistance or DMT2.
|
|
|
|
What is vaginismus?
|
The involuntary contraction of the perineal musculature. The underlying cause is psychological. Most often diagnosed in teenagers and young adult females.
|
|
|
|
Treatment for vaginismus?
|
Refer to a sex therapist. Success rates of 80% or better. Typically treatment includes relaxation, Kegel exercises, and insertion of dilators, fingers, etc gradually increasing size and to encourage desensitization.
|
|
|
|
What should be the first step in management of all cases presenting with secondary amenorrhea?
|
pregnancy test
|
|
|
|
Risk factors for uterine rupture?
|
preexisting uterine scar or abdominal trauma
|
|
|
|
Treatment for uterine rupture?
|
Treatment of choice is a total abdominal hysterectomy to stop the bleeding in most instances (after delivery if pregnant). However, debridement and closure of rupture site can be considered in women with low parity who desire more children.
|
|
|
|
what are variable decelerations?
|
decelerations of variable shape that do not coincide with the intrauterine pressure curve in any way. The onset of the decelerations varies in relationship to the contractile phase of the uterus. Caused by umbilical cord compression.
|
|
|
|
What is a sinusoidal fetal heart pattern?
|
uniform oscillatins of 3-5 cycles per minute. Considered a sign of fetal distress and the inability of the CNS to control the heart rate.
|
|
|
|
The cause of early decelerations?
|
fetal head compression - Usually seen in active labor when the patient is dilated 5 cm or more. At this stage, the cervix is usually in close contact with the fetal anterior fontanel which may result in a vagal response in the fetus slowing the fetal heart rate.
|
|
|
|
What causes late decelerations?
|
uteroplacental insufficiency --> fetal hypoxia -->fetal acidosis
|
|
|
|
What is the next step in management of a young woman who presents with a self-palpated breast mass with no obvious signs of malignancy?
|
Ask pt to return shortly after her menstrual period for reexamination. If the mass decreases in size after the menstrual period, the probablility of benign disease is very high. Otherwise it is advisable to proceed with ultrasound, fine needle aspiration biopsy, and/or excisional biopsy. Mammography is usually not helpful in interpreting the mass bc the density of breast tissue is high in young women.
|
|
|
|
What is the treatment of choice for an inevitable abourtin?
|
Suction curettage.
|
|
|
|
What is the treatment of choice for a missed abortion diagnosed after the 16th week fo gestation?
|
Induction of labor
|
|
|
|
What are some causes of active, uncontrolled antepartum hemorrhage in patients with placenta previa?
|
Placenta accreta (an abnormal insertion of the placenta through the uterine wall), uterine atony, DIC, or placental abruption.
|
Pts with a prior C-section carry a 25% risk of developing placenta accreta and about 2/3 of cases of placental accreta require a hysterectomy to stop bleeding.
|
|
|
When is forcep use during delivery considered?
|
in active labor when the fetus whose head is enaged begins to exhibit an abnormal heart rate pattern or when the second stage of labor is prolonged.
|
|
|
|
What is the best test for detection of fetal chromosomal abnormalities in the first trimester of pregnancy?
|
chorionic villus sampling - involves aspiration of a small quantity of chorionic villi from the placenta and can be done btn 10-12 weeks gestation. The fetus derived cells are then karyotyped using FISH to detect aneuploidies, enzymatic deficiencies and specific known defects can also be screened for. It is indicated in women over 35 years following an abnormal ultrasound. The risk of complications is slightly higher than in amniocentesis.
|
|
|
|
What is an option for detecting fetal chromosomal abnormalities in the first trimester for a pt in whom chorionic villus sampling cannot be performed?
|
Early amniocentesis can be performed before 15 weeks and has the same advantage as CVS but is reserved for patients in whom CVS cannot be performed.
The usual form of amniocentesis is performed during the 2nd trimester btn weeks 16 and 18. |
|
|
|
When is MSAFP routinely performed?
|
2nd trimester along with serum estriol and beta hCG levels.
|
|
|
|
What are the risks of chorionic villus sampling and when are they most significant?
|
Risks include fetal death and limb reduction defects. CVS BEFORE 10 weeks gestation is associated with a greater incidence of distal limb reduction defects.
|
|
|
|
How can ovulation be confirmed?
|
A midluteal phase serum progesterone level. When ovulation occurs, the corpus luteum produced progesterone. Detection of this increased progesterone level >10 ng/mL (nomral is < 2ng/mL) on the 21st day fo a 28 day cycle indicates that ovulation has occurred.
|
Endometrial biposy can be used as an indicator of ovulation bc increased levels of progesterone are trophic on the endometrium. A luteal phase defect is dagnosed when progesterone-related changes are not observed on a biopsy. However this test is subect to error in pathologic interpretation and in the time that the biopsy is taken.
|
|
|
How might a patient with endometritis present?
|
1) fever > 100.4 or 38 C outside of the first 24 hours postpartum
2) uterine tenderness 3) foul smelling lochia 4) leukocytosis |
|
|
|
Risk factors for endometritis include but are not limited to:
|
prolonged rupture of membranes (>24 hrs), prolonged labor (>12 hours), C-section, and use of intrauterine pressure catheters or fetal scalp electrodes.
|
|
|
|
Treatment for endometritis?
|
broad spectrum ABX to cover for a typically polymicrobial infection.
Drugs of choice are IV clindamycin and gentamicin. |
|
|
|
What is the most common cause of a puerperal fever on the 2nd and 3rd day postpartum?
|
Endometritis - a polymicrobial infection composed of g+ and g- organisms, aerobic and anaerobic organisms and occasionally other organisms such as Mycoplasma and Chlamydia.
|
|
|
|
What is the most likely cause of thyrotoxicosis in an infant born to a mother who was surgically treated for Graves disease prior to pregnancy?
|
Persistence of thyroid stimulating immunoglobin in the mother.
In many patients, circulating levels of thyroid stimulating immunoglobin (TSI) remain as high as 500 times the normal value for several months following thyroidectomy. These IgG autoantibodies cross the placenta and can cause thyrotoxicosis in the fetus and the neonate by directly stimulating the fetal thyroid gland. |
|
|
|
What test helps to determine the extent of feto-maternal hemorrhage and whether or not a standard dose of RhoGAM should be administered?
|
The rosette test - if negative, the standard dose of anti-D immune globulin should be given.
If positive, the amount of hemorrhage can be evaluated using the Kleihauer-Betke stain or fetal red cell stain using flow cytometry; the dose of RhoGAM should be corrected accordingly. |
|
|
|
How is physiologic leukorrhea defined?
|
Copious vaginal discharge that is white or yellow in color, nonmalodorous, and occurs in the absence of other symptoms or vaginal exam findings
**The amount of vaginal discharge can vary significantly between women at different stages of the menstrual cycle |
|
|
|
What 3 of 4 Amsel criteria must be met for a diagnosis of bacterial vaginosis?
|
1) thin, gray-white vaginal discharge
2) vaginal pH>4.5 3) A positive "whiff" test upon addition of KOH ot the vaginal discharge 4) "Clue cells" (vaginal epithelial cells with adherent coccobacilli on wet mount) |
|
|
|
Treatment of choice in bacterial vaginosis?
|
Metronidazole
|
|
|
|
Which segments of the femoral vein are considered deep veins?
|
All the segments. The term "superficial femoral vein' is used by some specialists to differentiate the distal segment of the femoral vein from the deep femoral vein.
DVT requires anticoagulation with heparin. |
|
|
|
MCC of excess postpartum blood loss?
|
uterine atony
steps for management: 1) fundal or bimanual massage (stimulates the uterus to contract and rsolves hemorrhage in most cases) 2) IV access 3) Crystalloid infusion ot keep SBP above 90 mmHg 4) Notification of blood bank for PRBC 5) Administer a uterotonic agent (oxytocin, methylergonovine, carboprost) |
|
|
|
Risk factors for uterine atony?
|
uterine overdistention (multiple gestation, polyhydramnios, and macrosomia) and uterine fatigue (prolonged labor)
|
|
|
|
How is DUB defined? and when is endometrial biopsy indicated?
|
Dysfunctional uterine bleeding refers to heavy vaginal bleeding in the ABSENCE of structural or organic disease. Endometrial biopsy to rule out endometrial hyperplasia or carcinoma in pts who are
1) >35 years 2) chronically hypertensive 3) diabetic If biopsy is negative for hyperplasia or carcinoma, the pt can be treated with cyclic progestins. Endometrial ablation or hysterectomy is inicated only if hormonal therapy fails. |
|
|
|
What are the characteristic fetal heart changes seen in ruptured fetal umbilical vessels (vasa previa)?
|
Fetal heart changes progress from tachy to brady and finally to a sinusoidal pattern.
If fetal bleeding is suspected, an Apt test can help differentiate btn maternal and fetal blood. |
bleeding in this setting is fetal in origin, so maternal vital signs will remain stable while the fetus exsanguinates.
|
|
|
Treatment of vasa previa?
|
immediate c-section
|
|
|
|
What disorder can mimick symptoms of menopause?
|
Hyperthyroidism - serum TSH and FSH levels should thus be checked in patients wiht symptoms of irregular/absent menses, heat intolerance, flushing, insomnia, and night sweats
During menopause, the circulating estrogen level decreases, resulting in a decrease in the feedback inhibition on the hypothalamic-pituitary axis. This results in the elevation of serum FSH and LH levels. |
|
|
|
What does a serum inhibin B level determine?
|
ovulatory reserve - inhibin B levels will be decreased in older women who have a decreased capacity to ovulate.
|
|
|
|
How does condyloma acuminata present and what is it caused by?
|
Condyloma acuminata are genital warts caused by HPV infection - appear as clusters of pink or skin-colored lesions wiht a smooth, teardrop appearance. Lesions can be internal and/or external vaginal lesions as well as anogenital. Diagnosis can be made based solely on the characteristic appearance, although application of acetic acid will turn the lesions white and/or biopsy may be used to support the diagnosis.
|
|
|
|
How do you treat condyloma acuminata (warts caused by HPV)?
|
Treatment depends on the size of lesions. Small lesions may be treated in the office with trichloroacetic acid or podophyllin. Larger lesions are often treated with excision or fulguration (electric current). Regardless of method of treatment, rates of recurrence are high.
|
|
|
|
What is condyloma lata?
|
Flat, velvety lesions caused by secondary syphilis which respond to penicillin.
Do not confuse with condyloma acuminata caused by HPV. |
|
|
|
How does vulvar cancer typically present?
|
A singular, fleshy lesion on the labia majora. Usually seen in elderly indviduals.
|
|
|
|
How does lichen planus present?
|
hyperkeratotic, erosive or papulosquamous leasions typically in middle-aged women. Pruritus, soreness, and vaginal discharge are common.
|
|
|
|
Painful third trimester vaginal bleeding (usually dark red in color) with normal ultrasound is most likely due to...?
|
placental abruption - bleeding can be concealed in 20% of cases which may delay diagnosis. therefore, there should be a high index of suspicion for patients in their 3rd trimester that present with uterine tenderness, hyperactivity, and increased uterine tone. Keep in mind that ultrasound detects as few as 25% of all placental abruptions.
|
|
|
|
Risk factors for placental abruption:
|
-maternal HTN and preeclampsia
-previous placental abruption -trauma -rapid decompression of a hydramnios -short umbilical cord -tobacco or cocaine use -folate deficiency |
|
|
|
Is placenta previa associated with uterine tenderness?
|
20% of placenta previa may be associated with uterine contractions byt typically the uterus is nontender in placenta previa
|
|
|
|
How does BUN and creatinine change in pregnancy?
|
levels are decreased due to increase in renal plasma flow and GFR
|
|
|
|
Is bilateral renal agenesis compatible with life?
|
no bc it is associated iwth severe pulmonary hypoplasia
|
|
|
|
How is premature ovarian failure diagnosed?
|
Marked FSH elevation in a woman under age 40 with amenorrhea for greater than or equal to 3 months confirms the diagnosis of premature ovarian failure.
|
|
|
|
What causes premature ovarian failure?
|
Impaired follicular development is the cause of primary hypogonadism since the developing follicles are the main source of estrogen. Lack of estrogen results in loss of feedback inhibition on FSH and LH, causing both to become elevated. FSH is generally greater than LH due to slower clearance of FSH from the circulation.
Risk factors for impaired follicular development include chemotherapy, radiation, autoimmune ovarian failure, Turner's syndrome, and fragile X syndrome. Symptoms include amenorrhea, hot flashes, vaginal/breast atrophy, and psychological symptoms such as anxiety, depression, and irritability. |
|
|
|
Post term pregnancyies at or beyond 42 weeks gestation should be closely monitored for?
|
oligohydramnios - pts with an unfavorable cervix are typically managed expectantly with twice weekly ultrasound monitoring while pts with a favorable cervix are managed with induction.
Twice weekly monitoring with ultrasound is required bc amniotic fluid can become drastically reduced within 24-48 hours. Oligohydramnios in these cases is defined as no vertical pocket of amniotic fluid greater than 2 cm or an amniotic fluid index of 5 cm or less. |
|
|
|
Treatment of choice for bacterial vaginosis for pregnant vs. non-pregnant patients?
|
oral metronidazole in both pregnant and non-pregnant individuals. Vaginal metronidazole and clindamycin are alternatives.
|
|
|
|
The CDC recommends that all pregnant women without contradictions be vaccinated against influenza at what gestational age?
|
As early as the first trimester.
|
|
|
|
When should fasting blood sugar in pregnancy be tested?
|
24-28 weeks of gestation. High risk pts (marked obesity, family hx of DM) can be screened earlier in pregnancy.
|
|
|
|
What is the single most important intervention for reducing maternal-fetal transmission of HIV infection?
|
Zidovudine treatment to mother throughout pregnancy and labor as well as the neonate for the first 6 weeks of life. This intervention has been shown to decrease the rate of transmission by 70%. The mother should also be counseled to not breastfeed as this increases the risk of transmission.
|
Elective c-section also reduces the risk of perinatal transmission of HIV by 50% (less efficacious than zidovudine). Combining zidovudine with c-section reduces the risk of transmission the most.
|
|
|
What is the recommended method of emergency contraception?
|
Levonorgestrel (plan B) - this progestin only method is considered effective up to 120 hours after intercourse. There are no contraindications to ue and no physical exam or lab testing is required. It has the lowest incidence of side effects amongst emergency contraceptives. It can be obtained over-the-counter by individuals 18 years or older.
|
|
|
|
How does endometriosis appear on an ultrasound?
|
As a homogenous mass on the andexae or within the peritoneal/pelvic regions.
|
|
|
|
How does estrogen replacement therapy affect the metabolism of thyroid hormones?
|
The requirement for L-thyroxine increases most likely due to (although the exact mechanism is unclear) an induction of P450 enzymes in the liver resulting in increased metablism of thyroid hormones.
Other causes include inclreased levels of TBG and an increased volume of distribution of the thyroid hormones. **In pregnancy also, thyroid hormone levels will be increased and the patient should be monitored every 4-6 weeks. |
|
|
|
What is the next step in management of a pt that presents with suspected PMS with cyclic symptoms?
|
Advise a menstrual diary for at least 3 cycles to confirm the diagnosis of PMS. The most common physical manifestations are bloating, fatigue, headaches, and breast tenderness. Psychological symptoms may include anxiety, mood swings, difficulty concentrating, decreased libido, and irritability. Symptoms ususally begin 1-2 weeks prior to menses and regress around the time of menstrual flow. Symptoms are typically absent until the next ovulation.
There is no universally accepted treatment - techniques may include reduction of caffeine intake to reduce breast symptoms, an exercise program, or SSRIs in women whose symptoms are more severe and cause socioeconomic dysfunction. |
|
|
|
What is the most common preventable cause of fetal growth restriction in the U.S.?
|
Smoking - 1 in 3 cases of FGR
|
|
|
|
The most commonly identified infectious agent associated with FGR?
|
cytomegalovirus
|
|
|
|
How does cervical mucous differ during the ovulatory phase from the pre- and post- ovulatory phases?
|
in the ovulatory phase of the menstrual cycle, cervical mucous is profuse, clear, and thin. It will stretch to approximately 6 cm when lifted vertically (spinnbarkeit), its pH is 6.5 or greater (more basic than at other phases), and will demonstrate "ferning" when smeared on a microscope slide.
In the pre- and post-ovulatory phase, it is scant, opaque and thick. |
|
|
|
What results from the quad screen indicate aneuploidy such as Down's syndrome?
|
increased levels of beta hCG and inhibin A and decreased levels of MSAFP and estriol.
|
|
|
|
Why is breast development present in androgen insensitivity syndrome?
|
Because testosterone is converted to estrogen.
|
|
|
|
What is the management of a pt with androgen insensitivity with documented abdominal, inguinal, or labial testes?
|
gonadectomy bc there is a 5% increased risk for testicular carcinoma that develops in the second or third decade of life.
|
|
|
|
What therapy can be used in androgen insensitivity if the diagnoses is made pre-pubrty and a gonadectomy is performed?
|
Estrogen therapy
|
|
|
|
When is ionizing radiation most damaging to a developing fetus?
|
btn 8-15 weeks gestation, however fetal effects have not been observed with exposures less than 5 rad of ionizing radiation.
|
|
|
|
Treatment of choice for an endometrial biopsy that reveals simple or complex hyperplasia withOUT atypia in a premenopausal woman?
|
Cyclic progestins with repeat biopsy after 3-6 months of treatment. Risk of progression to endometrial cancer is low (1-2%).
|
|
|
|
Treatment of choice for an endometrial biopsy that reveals simple or complex hyperplasia WITH atypia in a premenopausal woman?
|
Risk of progression to endometrial cancer is high (30%) so for women who have completed child bearing, total hysterectomy is the treatment of choice.
|
|
