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406 Cards in this Set
- Front
- Back
When does standard HCG test for pregnancy become positive?
|
2 weeks after conception
|
|
What is Heagar's sign
|
sofetening and compressivility of the lower uterine segment indicating pregnancy
|
|
What is Chadwick's sign
|
dark discoloration of the vulva and vaginal walls
|
|
What is the significance of linea nigra in preganancy?
|
normal benign finding
|
|
What is melasma?
|
hyperpigmentation of sun exposed areas; often in pregnancy
|
|
When does quickening occur?
|
primigravida: 18-20 weeks
multi: 16-18 weeks |
|
When during pregnancy do you need a pap smear?
|
at first visit unless done in last 6 months
|
|
When during pregnancy do you need a urinalysis?
|
at every visit
|
|
Urinalysis in pregnancy is used to screen for...
|
- pre-eclamppsia
- bacteriuria - diabetes |
|
When during pregnancy do you need a CBC?
|
at first visit
|
|
When during pregnancy do you need a blood type/screen?
|
at first visit
|
|
When during pregnancy do you need a syphilis test?
|
at first visit, repeat later if high risk
|
|
When during pregnancy do you need a rubella titer?
|
first visit if vaccination history not known
|
|
When during pregnancy do you need diabetes screening?
|
- betwen 24-28 weeks; at first visit if high risk factors
|
|
High risk factors for gestational diabetes
|
- obese
- family history - age over 30 |
|
When during pregnancy do you need a triple screen?
|
15-20 weeks for older/high risk women
|
|
Significance of low AFP on triple screen
|
- Down syndrome
- fetal demise - inaccurate dates |
|
Significance of high AFP on triple screen
|
- neural tube defects
- ventral wall defects - multiple gestation - inaccurate dates |
|
What do you do if triple screen is abnormal.
|
- order an US to check dates and look for anomalies
- if US not helpful, order amnio for AFP level and cell culture for chromosomes |
|
When during pregnancy do you need a Group b strep culture?
|
35-37 weeks
|
|
How do you treat group B strep in pregnant mom?
|
treat with amoxicillin during labor
|
|
When can fetal heart tones be heard?
|
- doppler: 10-12 weeks
- stethascope: 16-20 weeks |
|
What is significant for size/date discrepency
|
uterine size difference of 2-3 cm to dates; get US
|
|
What do HCG levels do in the first trimester of pregnancy?
|
double every 2 days
|
|
Ongoing increase in HCG or increase after delivery indicates
|
- hydatiform mole
- choriocarcionma |
|
HCG level at 5 weeks
|
>2000
|
|
Transvaginal US can detect intrauterine pregnancy at
|
5 weeks
|
|
Average weight gain of pregnancy
|
28 pounds
|
|
With extra weight gain in pregnancy think
|
diabetes
|
|
With poor weight gain during pregnancy think
|
- hyperemesis gravidum
- psych disorder - major systemic disease |
|
ESR in pregnancy
|
very elevated
|
|
Thyroid tests in pregnancy
|
- free T4 same
- overall total T4 and thyroid binding globulin increase |
|
Hematocrit in pregancy
|
- decreased (increased red cells but fluid increases more)
|
|
BUN and Cr in pregnancy
|
decrease (GFR increases)
|
|
Alkaline phosphatase in pregnancy
|
very increased
|
|
Mild proteinuiria in pregnancy
|
normal
|
|
Mild glucosuria in pregnancy
|
normal
|
|
Electrolyte in pregnancy
|
unchanged
|
|
Liver function tests in pregnancy
|
unchanged
|
|
BP changes in pregnancy
|
decreases slightly
|
|
HR changes in pregnancy
|
increased 10-20 beats per minute
|
|
Stroke volume and cardiac output in pregnancy
|
increase, often by 50%
|
|
Minute ventillation in pregnancy
|
increases (increased tidal volume, rate about the same)
|
|
Residual lung volume in pregnancy
|
decreased
|
|
Respiratory alkalosis in pregnancy is
|
normal
|
|
Definition of IUGR
|
below 10th percentile for age
|
|
3 classes of causes of IUGR
|
- maternal
- fetal - placental |
|
US parameters to look for IUGR
|
- biparietal diameter
- head circumference - abdominal circumference - femur length |
|
Components of biophysical profile (BPP)
|
- heart rate tracing
- US for: * amniotic fluid ndex * fetal breathing movements * fetal body movements |
|
If you are concerned about a fetus, but non-emergent, what is the series of investigations?
|
- BPP, if abnormal then contractile stress test. If decels, usually go to c-section
|
|
What is the contraction stress test
|
- looks for uretroplacental dysfunction.
- mom is given oxytocin and HR is monitored. If decels, then usually to c-section |
|
Define oligohydramnios
|
<300-500 ml
|
|
4 major causes of oligohydramnios
|
- IUGR
- premature rupture of membranes - postmaturity - renal agenesis (Potter disease) |
|
4 complications of oligohydraminios
|
- pulmonary hypoplasia
- cutaneous problems (compression) - skeletal problems (compression) - hypoxia (cord compression) |
|
Define polyhydramnios
|
>1700-2000ml
|
|
5 major causes of polyhydramnios
|
- maternal diabetes
- multiple gestation - neural tube defects - GI anomolies - hydrops fetalis |
|
Maternal complications of polyhydramnios
|
- uterine atony
- dyspnea from large uterus |
|
At term normal fetal heart rate is
|
110 to 160 bpm
|
|
Discuss early decelerations
|
- low point of fetal HR and high point of uterine contraction coincide
- from head compression - normal |
|
Discuss varible decelerations
|
- most common
- variable occurance with contractions - signifies cord compression |
|
Treatment of variable decelerations
|
- mom in lateral decub
- give O2 by facemask - stop oxytocin - if brady (<90) or doesn't resolve measure fetal O2 |
|
Discuss late decelerations
|
- fetal HR nadir occurs after contraction
- uteroplacental insufficiency - worrisome |
|
Treatment in late decelerations
|
- lateral decub, O2, stop oxytocin
- give tocolytic - give IVF if BP not optimal - if persist, measure fetal O2 |
|
Examples of tocolytic agents
|
- ritodrine
- magnesium sulfate |
|
Discuss the loss of fetal variability if heart rate in labor
|
- check fetal scalp pH
- if associated with variable or late decels, likely need to deliver |
|
In labor, what are the scalp pH parameters that indicate need for delivery?
|
- fetal scalp pH < 7.2 or abnormal O2
|
|
How can you distinguish true labor
|
- regular contraction (every 3 minutes)
- associated with cervical changes |
|
Describe "false labor"
|
aka Braxton-Hicks contraction
- irregular - no cervical changes |
|
Desribe the stages of labor
|
1st- true labor to full dilation
2nd- full dilation to dirth 3rd- delivery of baby 4th- placenta to stabilization |
|
1st stage of labor lasts how long?
|
- nuligravida: < 20 hours
- multigravida: < 14 hours |
|
In the active phase of 1st stage of labor, how fast does the cervix dilate?
|
- nuligravida: >1cm/hr
- multigravida: >1.2 cm/hr |
|
Time from full cervical dilation to start delivery of baby
|
- nuligravida: 30min - 3 hrs
- multigravida: 5-30 min |
|
Time to delivery baby
|
0-30 minutes
|
|
Time to delivery placenta and maternal stabilization
|
up to 48 hours
|
|
What is protraction disorder
|
Labor takes long than expected
|
|
What is labor arrest disorder?
|
No change in cervical dilation occurs over 2 hours and no change in fetal descent after 1 hour
|
|
Treatment of arrest disorder
|
- check fetal lie
- check for cephalopelvic disproportion - augment labor |
|
Name 3 ways to augment labor
|
- oxytocin
- prostaglandin gel - amniotomy |
|
Most common cause of "failure to progress" in labor
|
cephalopelic disporoprtion (labor augmentation contraindicated)
|
|
Half life of oxytocin
|
less than 10 minutes
|
|
Side effects of oxytocin
|
- uterine hyperstimulation
- uterine rupture - fetal heart deccelerations - hyponatremia |
|
Side effects of PGE2 used for ripening cervix
|
uterine hyperstimulation
|
|
Decision of vaginal delivery with HSV based on...
|
if active lesions during labor, opt for c-section
|
|
Orientation of "classic" c- section incision
|
vertical
|
|
Signs of placental separation
|
- fresh blood from vagina
- umbilical cord lengthens - fundus rises and becomes firm and globular |
|
What is the first step during delivery with shoulder dystocia
|
- McRobert maneuver: mother sharpely flexes thighs against abdomen
|
|
List the order of labor positions
|
- descent
- flexion - internal rotation - extension - external rotation - expulsion |
|
Postpartum discharge
|
- red the first few days, usually white by day 10
|
|
Foul smelling lochia is concerning for
|
endometritis
|
|
What is the underlying likely cause when new mom develops PE
|
PE from amniotic fluid
|
|
Definition of post-partum hemorrhage
|
>500 cc with vaginal
>1000cc with c-section |
|
Most common cause of post-partum hemorrhage
|
uterine atony
|
|
Complication of severe post-partum hemorrhage
|
Sheeham sydrome
|
|
Risk factors for retained placenta after delivery
|
- previous uterine surgery
- previous c- section |
|
Risk factors for uterine atony
|
- overdistended
- prolonged labor - oxytocin - more than 5 deliveries - precipitous labor (<3h) |
|
Treatment of uterine atony
|
1. uterine massage with low dose oxytocin
2. ergot drug or PGF2-alpha 3. hysterectomy |
|
Treatment of retained products of conception
|
- remove placenta manually to stop bleeding
- curettage in OR - if placental accreta, likely to need hysterectomy |
|
Most common cause of uterine inversion
|
iatrogenic; pulling too hard on the cord
|
|
Treatment of uterine inversion
|
- manually replace uterus may need anesthesia)
- IVF, oxytocin |
|
Definition of post-partum fever
|
fever for 2 days
|
|
5 most common causes of post-partum fever
|
- breast engorgement
- UTI - endometritis - endomyometritis - puerperal sepsis |
|
Risk factors for endometritis
|
- C-section
- PROM - prolonged labor - frequent vaginal exams - manual removal of placenta |
|
Treatment of endometritis
|
- obtain cultures of endometrium, vagina, blood and urine
- treat with broad spectrum antibiotics |
|
If endometritis doesn't resolve, what's likely going on?
|
- pelvic abscess
OR - Pelvic thrombophlebitis (get a CT) |
|
Treatment of post-partum pelvic thrombphlebitis
|
heparin
|
|
3 major things to think of with postpartum shock and no evident bleeding
|
- amniotic fluid embolus
- uterine inversion - concealed hemorrhage |
|
If a woman doesn't want to breastfeed, what would you prescribe
|
- tight bra
- ice - analgesia - bromocriptin - birth control pills |
|
Mastidis after delivery usually occurs
|
within 2 months
|
|
Usual organism of mastidis
|
staph aureus
|
|
Treatment of mastidis
|
* keep breast feeding
- analgesia - warm compresses - antibiotics if more than mild (cephalexin, dicloxacillin) |
|
Contraindications to breast feeding
|
- maternal HIV
- illicit drug use - sedatives - stimulants - lithium - chemotherapy |
|
Define abortion
|
termination of pregnancy before 20 weeks or fetus less than 500 grams
|
|
Define threatened abortion
|
uterine bleeding without cervical dilation and no expulsion of tissue
|
|
Treatment of threatened abortion
|
pelvic rest
|
|
What percentage of pregnancies with threatened abortion go on to be normal?
|
50%
|
|
Define inevitable abortion
|
uterine bleeding with cervical dilation, crampy pain and no tissue
|
|
Treatment of inevitable abortion
|
follow, D&C of uterine cavity
|
|
Define incomplete abortion
|
passage of some products of conception through cervix
|
|
Treatmetn of incomplete abortion
|
observation, often need D&C
|
|
Define complete abortion
|
expulsion of all products of conception from the uterus
|
|
Treatment of complete abortion
|
Serial HCGs to be sure returns to zero. D&C if pain or opeen cervical os
|
|
Define missed abortion
|
fetal death without expulsion of fetus
|
|
Treatment of missed abortion
|
most women go on to have spontaneous miscarriage but D&C often performed
|
|
Define induced abortion
|
intentional temination prior to 20 weeks (elective or therapeutic)
|
|
Define recurrent abortion
|
two or three successive unplanned abortions
|
|
4 infectious causes of recurrent abortion
|
- syphilis
- Listeria - Mycoplasma - Toxoplasma |
|
3 environmental causes of recurrent abortion
|
- alcohol
- tobacco - drugs |
|
2 metabolic causes of recurrent abortion
|
- hypothyroidism
- diabetes |
|
3 autoimmune causes of recurrent abortion
|
- lupus
- anitphospholipid antibodies - lupus anticoagulant |
|
3 anatomic causes of recurrent abortion
|
- cervical incompience
- congenital female tract abnormalities - fibroids |
|
Classic cause of painless recurrent abortions in the second trimester
|
cervical incompetence
|
|
Treatment of cervical incompetence
|
cerclage at 14-16 weeks
|
|
Typical time when ectopic pregnancy presents
|
4-10 weeks.
|
|
Definitive diagnosis and treatment of ectopic pregnancy in unstable patient
|
laparoscopy
|
|
Major risk factors for ectopic pregancy
|
** history of PID
- previous ectopic - history of tubal ligation - pregnancy with IUD in place |
|
In 3rd trimester bleeding always do a ______ before a ______
|
always do an US before a pelvic exam
|
|
Ddx of 3rd trimester bleeding
|
- placenta previa
- abruptio placentae - uterine rupture - fetal bleeding - cervical/vaginal lesions - cervical/vaginal trauma - bleeding disorder - cervical cancer - "bloody show" |
|
In all patients with 3rd trimester bleeding, what do you do?
|
- IV
- blood if needed - O2 - order CBC, coags - do US - setup maternal and fetal monitoring - tox screen if suspected - give Rh immune globuline if mother Rh negative |
|
Risk factors for placenta previa
|
- multiparity
- older age - multiple gestation - prior previa |
|
Why do you do an US before a pelvic exam in 3rd trimester bleeding
|
because of placenta previa.
|
|
Accuracy of US in dx placenta previa
|
95-100%
|
|
Characteristics of bleeding in placenta previa
|
**painless
- may be profuse |
|
Treatment of placenta previa
|
- if premature, can try rest and tocolysis if stable
***otherwise needs c-section |
|
Risk factors for abruptio placentae
|
- HTN
- cocaine - trauma - polyhydramnios with rapid decompression with membrane rupture - tobacco preterm PROM |
|
3rd trimester bleeding where blood may not be visible
|
abruptio placentae
|
|
Woman in 3rd trimester with uterine pain/tenderness and hyperactive contraction pattern and fetal distress is concerning for
|
abruptio placentae
|
|
Use of US in diagnosing abruptio placentae
|
may be falsely normal
|
|
Complication of abruptio placentae
|
maternal DIC if fetal products enter blood stream
|
|
Treatment of abruptio placentae
|
rapid delivery (vaginal preferred)
|
|
Risk factors for uterine rupture
|
- previous uterine surgery
- trauma - oxytocin - grand multiparity - excessive uterine distention - abnormal fetal lie - CPD - shoulder dystocia |
|
Sudden onset of abdominal pain in 3rd trimester with sudden materal hypotension most concerning for
|
uterine rupture
|
|
Changes in maternal abdomen that occur with uterine rupture
|
- fetal parts palpable in abdomen
- abdominal contour may change |
|
Treatment of uterine rupture
|
- laparotomy for delivery
- usually requires hysterectomy |
|
2 major causes of 3rd trimester fetal bleeding
|
- vasa previa
- velamentous insertion of the cord |
|
Major risk factor for 3rd trimester fetal bleeding
|
multiple gestation (higher # of fetuses = higher risk)
|
|
3rd trimester bleeding with painless bleeding, stable mom and fetal distress
|
from fetal bleeding
|
|
How do you differentiate maternal from fetal blood (such as in 3rd trimester bleeding?)
|
The Apt test
|
|
Treatment of fetal bleeding in 3rd trimester
|
c-section
|
|
Cervical/vaginal lesions commonly causing 3rd trimester bleeding
|
- herpes
- gonorrhea - chlamydia - candida |
|
How can you decide on the dose of rhogam needed in a pregnant mom with 3rd trimester bleeding?
|
Use the Kleihauer-Betke test to quantify fetal blood in maternal circulation and use this to calculate dose
|
|
Define preterm labor
|
labor between 20-37 weeks
|
|
1st line treatment of preterm labor
|
- lateral decub position
- fluids - bed/pelvic rest - O2 - tocolytics |
|
Can a patient in preterm labor on tocolytics be discharged home?
|
yes, on oral tocolytics
|
|
List the more common contraindications to tocolysis in preterm labor
|
- herat disease
- HTN - DM - hemorrhage - pre-eclampsia - chorioamnionitis - IUGR - ruptured membranes - cervical dilation >4cm - fetal demise - fetal abnormalities incompatible with survival |
|
Describe the use of fetal fibronectin
|
- useful in preterm labor between 22-34 weeks
- if negative in vaginal secretions, very low chance of delivery in next 2 weeks |
|
What action for the fetus must be taken in a stable patient with possible pre-term labor and positive fetal fibronectin?
|
measures for lung maturity
|
|
Amniocentesis results that indicate immature lungs
|
- lecithin : sphingomyelin (L:S) ration less than 2:1
OR - phosphatidylglycerol negative |
|
At what age in premature labor do you give steroids to hasten lung maturity
|
between 26 and 34 weeks
|
|
Define premature rupture of membrance
|
- ruputre of amniotic sac prior to onset of labor
|
|
3 critera for premature rupture of membranes
|
- pooling of amniotic fluid
- ferning pattern - positive nitrazine test |
|
What test should be done in confirmed premature rupture of membranes
|
US
|
|
How long do you give a mom at full term with PROM before inducing labor?
|
6-8 hours
|
|
Mom with PROM, fever and tender uterus likely has
|
chorioamnionitis
|
|
Classic cause of chorioamnionitis
|
premature rupture of membranes
|
|
Complications of chorioamnionitis in mom and fetus
|
- neonatal sepsis
- maternal sepsis - maternal endomyometritis |
|
Empiric treatment of chorioamnionitis
|
ampicillin
|
|
Define preterm PROM
|
premature rupture of membranes before 36-37 weeks
|
|
What do you need to test for with preterm PROM
|
culture fluid for group B step and treat mom with ampicillin if positive culture
|
|
2 major clues that twins are dizygotic
|
- different sexes
- different blood types |
|
If placenta is monochorionic then twins are
|
monozygotic
|
|
What can you do to further investigate if twins are mono or dizygotic?
|
HLA typing
|
|
4 major maternal complications of multiple gestations
|
- anemia
- HTN/pre-eclampsia - postpartum uterine atony - postpartum hemorrhage |
|
9 major fetal complications of multiple gestations
|
- polyhydramnios
- malpresentation - placenta previa - abruptio placentae - velamentous cord/vasa previa - umbilical cord prolapse - IUGR - congenital anomalies - increased morbidity/mortality |
|
When can you try to delivery twins vaginally?
|
When they are BOTH vertex; any other combo, do c-section
|
|
Define post-term pregnancy
|
after 42 weeks
|
|
If dates for pregnancy are known and reach 42 weeks, what do you do?
|
induce labor
|
|
If dates for pregnancy are unknown and reach 42 weeks, what do you do?
|
twice weekly BPP
|
|
Post post-maturity for fetus increase risk of morbidity and mortality?
|
yes
|
|
Prolonged gestation is classically associated with what congenital anomaly?
|
anencephaly
|
|
Fetus with "frog-like" appearance on US likely has
|
anancephaly
|
|
Risk factors for hyperemesis gravidarum
|
- younger
- first pregnancy - underlying stressors |
|
Hyperemesis gravidarum presents in which trimester?
|
1st
|
|
With all high risk pregnancies, consider weekly _____ during the third trimester
|
biophysical profiles
|
|
Can chorionic villi sampling detect neural tube defects?
|
no
|
|
When can chorionic villi sampling be done?
|
at 9-12 weeks (earlier than amniocentesis)
|
|
chorionic villi sampling is generally reserved for
|
testing of genetic diseases
|
|
What is the miscarriage rate of chorionic villi sampling compared to amniocentesis
|
higher with chorio
|
|
How do you know if a woman has pre-eclampsia if she already had HTN?
|
Increased greater than 30/15
|
|
What does HELLP syndrome stand for?
|
H- hemolysis
EL-elevated liver enzymes LP-low platelets |
|
S/s for pre-eclampsia
|
- HTN
- 2+ proteinuria - oliguria - facial/hand edema - headache - visual changes - HELLP syndrome |
|
Pain in what location often does with HELLP syndrome?
|
RUQ or epigastric pain
|
|
When does pre-eclampsia usually occur?
|
3rd trimester
|
|
Main risk factors for pre-eclampsia
|
- chronic renal disease
- HTN - family history - multiple gestation - nulliparity - extremes of reproductive age - DM - black race |
|
Treatment of pre-eclampsia
|
- stabilization
- if at term, delivery the baby |
|
Treatment for pre-eclampsia if fetus is not full term
|
- hydralazine or labetalol
- magnesium sulfate (seziure prophylaxis) - bedrest - hospital observation |
|
Indications in pre-eclampsia to delivery baby regardless of gestational age
|
- oliguria
- mental status change - headache - blurred vision - pulmonary edema - cyanosis - HELLP - BP > 160/110 - ecclampsia (seizures) |
|
Is severe ankle edema normal in pregnancy?
|
No, look for pre-ecclampsia
|
|
HTN + proteinuria in pregnancy = ______ until proven otherwise
|
pre-eclampsia
|
|
Complications of pre-eclampsia and eclampsia
|
- uretoplacental insufficiency
- IUGR - fetal demise - increased maternal morbidity and mortality |
|
Does pre-eclampsia during pregnancy mean higher risk for HTN later in life?
|
No, not generally
|
|
Pre-eclampsia prior to the third trimester is likely
|
molar pregnancy
|
|
Best way to prevent eclampsia?
|
routine prenatal care
|
|
Initial treatment of choice for eclamptic seizures?
|
- Magnesium sulfate wthich also lowers blood pressure
|
|
Toxic effects of magnesium sulfate
|
- hyporeflexia (1st sign)
- respiratory depression - CNS depression - coma - death |
|
3 maternal complications of gestational diabetes
|
- polyhydramnios
- pre-eclampsia - complications of DM |
|
2 difference is fetus for gestational DM vs. pre-existing DM
|
- gestational: macrosomia
- pre-existing: IUGR |
|
6 fetal complications of gestational DM
|
- respiratory distress syndrome
- cardiovascular defects - colon defects - craniofacial defects - neural tube defects - caudal regression syndrome |
|
What is caudal regression syndrome?
|
lower half of body incompletely formed (risk with gestational DM)
|
|
Use of oral hypoglycemics in pregnancy
|
contraindicated (use insulin)
|
|
Infants born to DM mothers are classically at risk for what right after birth?
|
postdelivery hypoglycemia
|
|
Why do babies of DM mother's get hypoglycemic after delivery?
|
fetal islet cell hypertrophy
|
|
Only maternal antibody category to cross the placenta
|
IgG
|
|
Meaning of elevated neonatal IgM concentration?
|
never normal
|
|
Meaning of elevated neonatal IgG concentration
|
often represents maternal antibodies
|
|
When does Rh incompatilbity occur
|
mom Rh negative
baby Rh positive |
|
At what time do you give Rh immune globulin
|
- 28 weeks
- within 72 hours of delivery - after any procedures which may cause transplacental hemorrhage (amnio) |
|
What type of prevention is Rh immune globulin?
|
primary
|
|
IS Rh immune globulin effective if maternal Rh antibodies are strongly postiive?
|
no
|
|
What is hydrop fetalis
|
edema, ascites, pleural/pericardial effusions
|
|
Undetected Rh incompatability can lead to
|
- hemolytic disease of newborn
- hydrops fetalis |
|
Who do you test the severity of fetal hemolysis
|
Amniotic fluid spectrophotometry
|
|
Treatment of hemolytic disease of the fetus
|
- delivery if mature
- intrauterine blood transfusion - phenobarbital (helps fetal liver break down bilirubin) |
|
Mother with type O blood and baby with any other type, baby at risk for
|
hemolytic disease of the newborn
|
|
Snow storm pattern on US =
|
hydatiform mole
|
|
"grape like vesicles" with 1st or 2nd trimester bleeding
|
hydatiform mole
|
|
uterine size/dates discrepancy brings concerns for
|
hydatiform mole
|
|
Karyotype of complete moles
|
46XX or 46 XY (all from father)
|
|
Do complete moles contain fetal tissue?
|
no
|
|
Karyotype of incomplete moles
|
69 XXY
|
|
Do incomplete moles contain fetal tissue?
|
yes
|
|
Treatment of moles
|
D&C, follow HCG levels to zero
|
|
What happens if patient treated for hydatiform mole and HCG doesn't return to zero
|
invasive mole or choriocarcinoma and patient needs chemo
|
|
Chemo options for invasive mole or choriocarcinoma
|
- methotrexate
- actinomycin D |
|
Source of choriocarcinoma
|
- denove
- complete mole |
|
Can choriocarcinoma develop from incomplete mole?
|
no
|
|
Prevention of aborption in when with antiphsophlipid antibodies and previous pregnancy problems
|
Low dose ASA and heparin
|
|
How do you treat TB in a pregnant patient
|
same treatment
|
|
Drug to avoid if need to treat pregnant patient for TB
|
streptomycin
|
|
Streptomycin given during preganancy risks causing ____ and ____ in the fetus
|
- deafness
- nephrotoxicity |
|
Fetal defect caused by thalidomide
|
phocomelia
|
|
Fetal defect caused by tetracycline
|
yellow/brown teeth
|
|
Fetal defect caused by aminoglycoside
|
deafness
|
|
Fetal defect caused by valproic acid
|
- spina bifida
- hypospadias |
|
Fetal defect caused by progestersone
|
masculinization of females
|
|
Fetal defect caused by cigarettes
|
- IUGR
- low birth weight - prematurity |
|
Fetal defect caused by birth control pills
|
VACTRERL syndrome:
- veterbral - anal - cardiac - tracheal - esophageal - renal and - limb malformations |
|
Fetal defect caused by llithium
|
Ebstein anomalies (atrialization of right ventricle)
|
|
Fetal defect caused by aminopterin
|
- IUGR
- CNS defects - cleft lip/palate |
|
Fetal defect caused by radiation
|
- IUGR
- CNS/face defects - leukemia |
|
Fetal defect caused by phenytoine (diphenyhydantoin)
|
- craniofacial defects
- limb defects - mental retardation - cardiac defects |
|
Fetal defect caused by trimethadione
|
- craniofacial defects
- cardiovascular defects - mental retardation |
|
Fetal defect caused by warfarin
|
- craniofacial defects
- CNS defects - IUGR - stillbirth |
|
Fetal defect caused by carbamazepine
|
- fingernail hypoplasia
- craniofacial defets |
|
Fetal defect caused by isotretinoin
|
- CNS defects
- craniofacial/ear defects - cardiovascular defects |
|
Fetal abnormalities caused by iodine
|
- goiter
- cretinism |
|
Fetal abnormalities caused by cocaine
|
- cerebral infarcts
- mental retardation |
|
Fetal abnormalities caused by diazepam
|
- clef lip/palate
|
|
Fetal abnormalities caused by diethylstilbestrol
|
- clear cell vaginal cancer
- adenosis - cervical incompetence |
|
Is acetaminophen safe in preganancy?
|
Yes
|
|
Is penicillin safe in preganancy?
|
Yes
|
|
Is cepahlosporins safe in preganancy?
|
Yes
|
|
Is erythromycin safe in preganancy?
|
Yes
|
|
Is nitrofurantoin safe in preganancy?
|
Yes
|
|
Is H2-blocker safe in preganancy?
|
Yes
|
|
Is antacid safe in preganancy?
|
Yes
|
|
Is heparin safe in preganancy?
|
Yes
|
|
Is hydralazine safe in preganancy?
|
Yes
|
|
Is methyldopa safe in preganancy?
|
Yes
|
|
Is labetalol safe in preganancy?
|
Yes
|
|
Is insulin safe in pregnancy?
|
yes
|
|
Is docusate safe in pregnancy?
|
yes
|
|
3 important features of PID
|
- abdominal pain
- adnexal tenderness - cervical motion tenderness |
|
4 supporting features of PID
|
- elevated ESR
- leukocytosis - fever - purulent cervical discharge |
|
3 biggest organisms in PID
|
- Neiseria gonorrhoeae
- Chlamydia - e coli |
|
Organism causing PID in patient with IUD
|
actinomyces israeli
|
|
Most common preventable cause of infertility
|
PID
|
|
Likely cause of infertility in woman under 30 with regular menstrual cycles
|
PID
|
|
Treatment of PID
|
* more than 1 abx
- oupt: ceftriaxone/doxycycline - Inpt: clinda/gent |
|
Unusual feature of tubo-ovarian abscess
|
may resolve with antibiotics alone
|
|
Vaginal discharge like cottage chees
|
candida
|
|
Vaginal discharge with pseudohypahe on KOH
|
candida
|
|
Vaginal discharge with history of diabetes
|
candida
|
|
Vaginal discharge with history of antibiotic treatment
|
candida
|
|
Vaginal discharge with during pregancy
|
candida
|
|
Treatment of candidal vaginitis
|
oral or topical antifungal
|
|
Vaginal discharge with organisms seen swimming under microscope
|
trichomonas
|
|
Vaginal discharge that is pale green, frothy, watery
|
trichomonas
|
|
Vaginal discharge with strawberry cervix
|
trichomonas
|
|
Treatment of trichomonas
|
metronidazole
|
|
Vaginal discharge with fishy smell on KOH prep
|
Gardnerella
|
|
Vaginal discharge with clue cells
|
Gardnerella
|
|
Vaginal discharge that is malodorous
|
Gardnerella
|
|
Treatment of Gardnerella
|
Metronidazole
|
|
Venereal warts are caused by
|
human papillomavirus
|
|
Koilocytosis on pap smear =
|
human papillomavirus venereal warts
|
|
Multiple shallow painful vaginal ulcers =
|
herpes
|
|
Treatment of vaginal herpes
|
acyclovir, valacyclovir
|
|
Most common sexually transmitted disease
|
Chlamydia
|
|
STD that often causes dysuria
|
Chlamydia
|
|
Treatment of chlamydia
|
- doxycycline
- azithromycin |
|
One time oral treamtment option for chlamydia
|
- 1 gram of azithromycin
|
|
Treatment of chlamydia in pregnant patient
|
erythromycin or amoxicillin
|
|
STD for mucopurulent cervicitis
|
Neisseria gonorhoeae
|
|
Gram negative STD
|
Neisseria gonorhoeae
|
|
Treatment of Neisseria gonorhoeae
|
- ceftriaxone
- cipro |
|
STD with intracellular inclusions
|
molluscum
|
|
Treatment of pediculosis
|
(crabs)
- permethrin cream |
|
If a patient has gonorrhea, what should you also treat for?
|
chlamydia
|
|
Typical treatment for fonorrhea
|
ceftraizone and doxycycline (assume also chlaymdia infection)
|
|
STDs where the partner does NOT need to be treated
|
candida, Gardnerella
|
|
Test to do in primary amenorrhea
|
- if basic overview normal, administer progesterone; if no bleeding, likely no estrogen or anatomic abnormality
|
|
If patient with primary amenorrhea bleeds with progesterone test, this means
|
- estrogen is present
- normal uterus |
|
If patient with primary amenorrhea has normal breasts but no pubic/axillary hair, likely
|
androgen insensitvity syndrome
|
|
Features of androgen insensitivity syndrome
|
- phenotypically female
- no uterus - genetically XY |
|
Secondary amenorrhea with + progesterine challenge and HIGH leutinizing hormone
|
polycystic ovarian syndrome
|
|
In polycystic ovarian sydrome, LH is
|
high
|
|
Ddx for secondary amenorrhea with + progesterine challenge and LOW leutinizing hormone
|
- pituitary adenoma
- hypothyroidism - low gonadotropin hormone |
|
Causes of low gonadotropin hormone
|
- drugs
- stress - exercise - anorexia nervosa |
|
Test to check is patient has secondary amenorrhea that you think is from pituitary adenoma
|
prolactin
|
|
Patient with secondary amenorrhea with normal prolactin, normal TSH and low gonadotropin likely has
|
anorexia nervosa
|
|
A patient with secondary amenorrhea with + progesterone bleeding test can likey become pregnant by using which drug?
|
clomiphene
|
|
Secondary amenorrhea with no bleeding on progesterine challenge has (generally)
|
insuffecient estrogen
|
|
Secondary amenorrhea with no bleeding on progesterine challenge with elevated FSH has
|
premature ovarian failure/menopause
|
|
FSH is _____ in premature ovarian failure
|
elevated
|
|
Secondary amenorrhea with no bleeding on progesterine challenge with low/normal FSH may have
|
neoplasm of hypothalamus (get MRI of brain)
|
|
First test to order in amenorrhea
|
pregnancy test
|
|
Nulliparous 35 yr woman with dyspareunia and dyschezia
|
endometriosis
|
|
Most common site for endometriosis
|
- ovaries
|
|
Tender adnexa WITHOUT evidence of PID =
|
endometriosis
|
|
Endometriosis may be associated with this uterine position
|
retroverted
|
|
Gold standard for diagnosis of endometriosis
|
laparoscopy with visualization
|
|
Mulberry spots
|
endometriosis
|
|
flat brown colored powder burns
|
endometriosis
|
|
chocolate cysts
|
endometriosis
|
|
Most likely cause of infertility in menstruating woman over 30
|
endometreosis
|
|
Treatment of endometriosis
|
1st: birth control pills
2nd/3rd: danzol, GnRH agonists |
|
Effect of surgery for endometriosis on fertility
|
often improves it
|
|
Define adenomyosis
|
ectopic endometrial glands within uterine musculature
|
|
Typical characteristics of adenomyosis
|
- over 40
- dysmenorrhea - large boggy uterus |
|
Woman over 40 with large boggy uterus and dymenorrhea
|
adeomyosis
|
|
Treatment of adenomyosis
|
- D&C to r/u endometrial cancer
- consider hysterectomy - may try GnRH agonists |
|
Define dysfunctional uterine bleeding
|
abnormal uterine bleeding not associated with tumor inflammation or pregnancy
|
|
70% of dysfunctional uterine bleeding is associated with
|
anovulatory cycles
|
|
When is dysfunction uterine bleeding common and physiologic?
|
Right are menarche and before menopause
|
|
If dysfunctional uterine bleeding that doesn't appear simple, think
|
polycystic ovarian syndrome
|
|
What needs to be done in woman over 35 with dysfunctional uterine bleeding?
|
D&C to r/o endometrial cancer
|
|
Why should you get a CBC in patient with polycystic ovarian syndrome?
|
excess blood loss
|
|
4 uncommon causes of dysfunctional uterine bleeding
|
- infections
- endocrine disorders - coagulation defects - estrogen producing neoplasms |
|
First line treatment for idiopathic dysfunctional uterine bleeding
|
NSAIDs or OCPs
|
|
First line treatment for dysmenorrhea
|
NSAIDs
|
|
Treatment of severe bleeding with dysfunctional uterine bleeding
|
progesterone
|
|
Overweight woman with infertility and amenorrhea
|
polycystic ovarian syndrome
|
|
Most common cause of infertility in woman under 30 with ABnormal menstruation
|
polycystic ovarian syndrome
|
|
LH:FSH in polycystic ovarian syndrome
|
greater than 2:1
|
|
Cancer risk in polycystic ovarian syndome
|
unopposed estrogen causes increased risk for endometrial hyperplasia and enodmetrial carcinoma
|
|
Treatment of polycystic ovarian syndrome
|
- OPCs
- cyclic progesterone - if wants pregnancy, use clomiphene |
|
Treatment of premenstrual dysphoric disorder
|
NSAIDs; antidepressants
|
|
Average age of menopause
|
50
|
|
Increase parabasal cells on vaginal cytology indicates
|
menopause
|
|
Fibroids aka
|
leimyoma
|
|
Are leiomyomas malignant or benign?
|
benign
|
|
Most common indication for hysterectomy
|
leiomyoma
|
|
Rate of malignant transformation of leimyoma
|
<1%
|
|
When do leiomyomas often grow rapidly?
|
During pregnancy or high estrogen (OCPs)
|
|
Anemia with fibroids is an indication for
|
hysterectomy
|
|
Test that should be done in woman over 40 with leiomyoma
|
D&C to r/o endometrial cancer
|
|
Polyp protruding through cervix is likely
|
leiomyoma
|
|
4 non-cancerous causes of breast discharge
|
- birth control pills
- hormone therapies - antipsychotic medications - hypothyroidism |
|
If a patient has bilateral non-bloody breast discharge, what are the chances that it's cancer?
|
very low
|
|
Unilateral breast discharge is concerning for
|
cancer
|
|
Most common breast disorder
|
fibrocystic disease
|
|
Treatment of fibrocystic breast disease if under 35
|
if symptoms are very severe can do progesterone or danazol for a week at the end of each month
|
|
Features of fibrocystic breast disease
|
- under 35
- bilateral - multiple cystic lesions - tender |
|
A painless, shaprly circumscribed, rubbery, mobile breast mass is likely
|
fibroadenoma
|
|
Most common benign tumor of the female breast
|
fibroadenoma
|
|
Age when you become more concerned about breast cancer
|
35
|
|
Treatment of fibroadenoma of the breast
|
excision is curative but often not needed
|
|
Fibroadenoma of the breast often growns quickly in the setting of
|
OCPs or pregnancy (estrogen)
|
|
Is mammogram useful under the age of 35?
|
No. Breast tissue too dense. Proceed directly to biopsy
|
|
Approach to fibrocystic breast disease in woman over 35
|
- aspirate fluid
- baseline mammogram * if fluid is bloody or cyst recurrs, do biopsy |
|
This potentially malignant tumor often masquerades as a rapidly growing fibroadenoma of the breast
|
phylloides tumor
|
|
Treatment of fibroadenoma of the breast if over 35
|
- baseline mammogram
- can observe if very low risk, but low threshold for biopsy |
|
In a woman over 35 with a breast mass, when in doubt...
|
get a biopsy
|
|
A new breast mass in a postmenopausal woman...
|
is breast cancer until proven otherwise
|
|
Pelvic heaviness that is worse with standing and improves with lying down may be
|
vaginal prolapse
|
|
A bulge into the upper vaginal wall is likely
|
a cystocele
|
|
Symptoms of cystocele
|
urianry urgency, frequency and incontinence
|
|
A bulge into the lower posterior vaginal wall is likely
|
a rectocele
|
|
Symptoms of rectocele
|
difficultly defecating
|
|
What is an enterocele
|
bulding of loops of bowel into upper posterior vaginal wall
|
|
Treatment of -celes (cystocele, etc)
|
- pelvic strengthening
- pessary - surgery |
|
Male/female ratio for "problem source" in infertility
|
- male 1/3
- female 2/3 |
|
1st step in eval of infertility (after based H&P)
|
semen anlysis
|
|
Risk factor for uterine synechiae
|
D&C
|
|
What radiographic test do you order to look for uterine structural abnormalities?
|
hysterosalpingogram
|
|
Clomiphene can be used to stimulate ovulation in what setting
|
need adequate estrogen
|