1
Q
How is enlargement of the uterus achieved during pregnancy?
- Where does most growth occur?
- What other changes occur in the wall?
A
- Enlargement by Hypertrophy
- most in the fundus
- Other changes
- Increased size and number of vessels
- Hypertrophy of nerves
2
Q
Which way does the uterus rotate during pregnancy?
A
To the right
(Dextrorotation)
3
Q
What is a change in contractility of the uterus that does not result in cervical dilation?
A
Braxton Hicks contractions
4
Q
What changes occur in the cervix?
A
- Hypertrophy and hyperplasia of glands
- mucous plug
- Increased vascularity
- Edema
- Increased mechanical strength
- so it can stretchand not get ripped apart!!
5
Q
What is the function of the corpus luteum? When does it function maximally? What takes over its role when it ceases to function?
A
- Function
- secrete progesterone
- Time frame
- 6-7 weeks
- Placenta takes over
6
Q
What is a luteoma? What can it cause?
A
Solid ovarian tumor of pregnancy
- Effect:
- virilization of mother
- (not of female fetus)
7
Q
What is a Hyperreactio Luteinalis? What does it secrete? What does it cause?
A
Cystic ovarian tumor of pregnancy
- Secretes hCG
- SE:
- virilization
8
Q
What is Chadwicks sign?
A
Violet vagina
- Cause:
- increased vascularity during pregnancy
9
Q
How does colostrum benefit the fetus?
A
Provides passive immunity
10
Q
What causes “vascular spiders” and palmar erythema during pregnancy?
A
Increased estrogen
- Increased blood flow throughout the body
11
Q
What is the most important factor in determining degree of striae gravidarum?
A
Genetics!
- Striae gravidarum = stretch marks
- Not a weight gain issue
12
Q
What is the additional RDA of calories for pregnant women?
A
300 kcal/day
13
Q
What common GI issues are experienced during pregnancy?
A
- Morning sickness
- Acid reflux
- decreased sphincter tone
- Increased time in stomach
- Constipation
- Decreased bowel motility
- Gall stone production
- Increased bile production
- Decreased emptying
14
Q
What is hyperemesis gravidarum? What are the physiological consequences?
A
Severe morning sickness
- Weight loss
- Ketonemia
- Electrolyte imbalance
- Dehydration
- Liver/Kidney damage
15
Q
What common upper respiratory tract conditions occur during pregnancy?
A
- Stuffiness
- Hypersecretion
- Epistaxis
- Polyp
16
Q
How does Expiratory Reserve Volume (ERV) change during pregnancy?
A
Decreases
17
Q
How does Functional residual capacity change during pregnancy?
A
Decreases
18
Q
How does Inspiratory Reserve Volume (IRV) change during pregnancy?
A
It stays the same
19
Q
How does Reserve Volume (RV) change during pregnancy?
A
Decreases
20
Q
How does Respiratory Rate (RR) change during pregnancy?
A
It stays the same
21
Q
How does VItal Capacity change during pregnancy?
A
It stays the same
22
Q
How does Total Lung Capacity (TLC) change during pregnancy?
A
Decreases
23
Q
How does minute ventilation change during pregnancy? What is the result?
A
- Minute ventilation Increases
- Result:
- increased alveolar and arterial Pa O2
24
Q
How does PaCO2 levels change during pregnancy? What is the result?
A
- PaCO2 levels decrease
- Result:
- increased gradient between mom and fetus
- facilitates transfer from fetus
25
How does the mother's body compensate for decreased CO2 levels? What is the result?
* Compensation:
* Increased renal excretion of bicarb
* Result
* No change in pH
26
What is believed to cause feelings of dyspnea during pregnancy?
Increased tidal volume that lowers PCO2
27
What is normal weight gain for each of the trimesters?
* First
* 2 lbs
* Second / Third
* 11-14 lbs each
28
What causes pitting edema of the feet during pregnancy?
Decrease in interstitial colloid osmotic pressure
29
How does carb metabolism change during pregnancy? What is the result?
* Metabolism:
* mild fasting hypoglycemia
* Postprandial hyperglycemia
* Hyperinsulinemia
* Peripheral resistance to insulin
* Result:
* Gives baby first dibs on glucose
30
How do blood volume and hematocrit change during pregnancy? What is the result?
* Changes
* Increased _erythrocytes_ / reticulocytes
* Increased plasma (more than erythrocytes)
* Result:
* Physiologic anemia
31
What is the iron requirement for normal pregnancy?
1 gram/day
* Uses
* Goes to fetus/placenta
* Increase # RBCs
32
How do immunologic functions change during pregnancy? What is the result?
1. Decreased functioning
2. Increased leukocytes
33
How do levels of clotting factors change during pregnancy? What is the result?
* Changes
* Increased:
* Fibrinogen
* Factors VII, VIII, IX, X
* Decreased:
* Platelets
* Result:
* Decreased PT and PTT but still w/i normal limits
34
How do pulse, Stroke volume, and CO change during pregnancy?
All increase!
35
How do heart sounds change during pregnancy?
* Exaggerated splitting of S1
* Systolic murmur
36
How does BP change during pregnancy? How does it change in different body positions and why?
* During pregnancy:
* Decreases in 2nd tri
* Body positions
* Highest when sitting
* Lowest when lying on left side
* Uterus not compressing IVC
* Intermediate when standing
37
How does kidney function change during pregnancy?
* Increased flow
* Increased GFR
* decreased creatinine and urea
* _Glucosuria_
* Proteinuria is NOT normal!!!
* at least 300 mg in 24 hours
38
Why are pregnant women more likely to get a UTI?
* Dextrorotation puts pressure on ureter (esp. right side)
* Increased length and pressure
* Increased likeliness of infxn
39
What pituitary hormone is significantly increased during pregnancy? What is its function?
Prolactin
* Function: lactation
40
What risk is present to the fetus of a woman with Graves Disease?
Thyrotoxicosis
* Long-acting thyroid stimulator (LATS) may cross placenta
41
What is the result of the physiologic hyperparathyroidism found in pregnancy?
Supply fetus with calcium
42
What adrenal hormones increase during pregnancy? What are their functions?
* Cortisol
* Bound to transcortin, so no effect
* Aldosterone
* Counters natriuretic effect of progesterone
* Adrostenedione and Testosterone
* converted to estradiol in placenta
43
What is a Blastocyst?
Fluid filled ball of cells
44
What is a zygote?
Fertilized egg
45
What is a Fetus?
Conceptus after 7 weeks
46
What is a Morula?
Solid ball of 16 cells
47
What is an embryo?
Conceptus that forms from the _inner cell mass_
48
What is a blastomere?
Conceptus after the first cell division
49
When does a blastocyst implant into the endometrium?
Day 21 of cycle
| (normally first day of period)
50
What cell types are present in blastocysts? Which are the progenitor cells?
* Cytotrophoblasts
* progenitor
* Location: next to embryonic side
* Syncytiotrophoblasts
* Contiguous with decidua at first
* Later form villi
51
What are the two placental membranes?
* Chorion
* outer cell layer
* Amnion
* forms delamination of cytotrophoblast or
* extention of fetal ectoderm
* Located on fetal side
52
When is hCG detectable in the serum? By what cells is it produced?
* Detectable w/i 24 hours of implantation
* Produced by syncytioblasts
53
What can cause abnormally high hCG levels?
1. Twins
2. Hydatidiform moles
3. Choriocarcinoma
54
What are the functions of hCG?
* Promotes ovulation
* Maintain corpus luteum in early pregnancy
* Promotes testosterone synthesis in fetal testis
* male sexual differentiation
* (LH surrogate)
55
When does morning sickness usually occur?
6-12 weeks
56
What are the most common causes of uterine bleeding during the first trimester?
1. Spontaneous abortion
2. Ectopic pregnancy
3. Gestational Trophoblastic Disease
* aka Molar Pregnancy
57
Describe the following types of spontaneous abortion:
* Threatened
* Incomplete
* Missed
* Threatened
* bleeding but no passage of tissue
* Incomplete
* Bleeding with passage of tissue
* Missed
* No symptoms but ultrasound shows no evidence of viable pregnancy
58
What are the symptoms of spontaneous abortion?
* Bleeding
* Cramping
* pain is bilateral
* Unilateral = more likely to be ectopic pregnancy
* No fetal heart sounds
59
What is the difference in treatment of spontaneous abortion if the woman is less than 8 weeks compared to over 8 weeks pregnant?
* Less than 8 wks
* More likely to allow absorption / spontaneous passage
* Over 8 wks
* D & C
* Stimulate contractions
60
Ectopic Pregnancy
* Symptoms
* Diagnosis
* Treatment
* Symptoms
* Bleeding
* Cramping (_unilateral_)
* Diagnosis
* hCG \>1500
* Empty uterus on _Transvaginal_ ultrasound
* Treatment
* Methotrexate (kill dividing cells)
* Surgery
61
What is the most common site of ectopic pregnancy?
Ampulla
62
What is the main cell type of a molar pregnancy?
Placental trophoblast
63
What hCG level is associated with the following:
* Ectopic pregnancy:
* Gestational Trophoblastic Disease (Molar pregnancy)
* Ectopic pregnancy: **_\> 1500_**
* Molar pregnancy: **_\> 100,000_**
64
What is seen on ultrasound that results in the diagnosis of a molar pregnancy?
"snowstorm" or "Swiss Cheese"
65
What immunoglobulin class is associated with fetal complications in isoimmunization? Why? What results?
* Immunoglobulin: IgG
* Why?
* can cross placenta
* Result
* Hemolysis of fetal RBCs
* Severe anemia
* Hydrops Fetalis (end stage)
66
At what level antibody titer should you worry isoimmunization and fetal complications? What else can you check?
* Ab titer:
* follow until **_\> 1:32_**
* Also check **_fetal MCA flow_** via ultrasound
67
What is the treatment for fetal anemia arising due to isoimmunization?
* Immature fetus
* PUBS infusion
* Mature
* Delivery
68
What are the causes of 2nd trimester abortions?
1. Intrauterine fetal demise (IUFD)
2. Abruptio Placenta
3. Placenta Previa
4. Intrauterine Infxn
69
Incompetent Cervix / Premature Dilation
* Symptoms
* History
* Treatment
* Symptoms
* Feeling of a significant change in pressure
* Discharge
* History
* Prior 2nd trimester pregnancy loss
* Treatment
* **_Cerciage_** = put stitch around cervix to prevent opening until baby is ready to be born
70
What are some causes of a uterus that is small for gestational age (SGA)?
* Incorrect dates
* Chromosomal abnormality of fetus
* Chronic illness (mom)
* Smoking
* Preterm Premature rupture of membranes
71
What are some causes of a uterus that is large for gestational age (LGA)?
* **Incorrect dates**
* **Multiple gestation**
* **Molar pregnancy**
* Polyhydramnios
* Maternal diabetes
72
When is appropriate to do a vaginal exam to determine cause of 3rd trimester bleeding?
When Placenta Previa has been excluded!
73
What are the most common causes of bleeding in the 3rd trimester?
* Placenta Previa
* _Painless_ bleeding
* Placenta covers cervical os
* **_Do not do a vaginal exam until this is excluded!!!_**
* Placenta Abrupta
* _Painful_ bleeding
* Premature separation of placenta
* Associated with DIC
74
How will a baby be delivered following placenta previa?
C section
75
What characterizes premature labor?
Contractions and cervical dilation _\< 36 weeks_
76
Why are NSAIDS _only_ given to treat tocolysis if the fetus is _less than 32 weeks_?
If given after 32 weeks, _premature closure of ductus arteriosus_
77
How is PPROM diagnosed?
* Rupture of membranes \< 36 wks
* Dx:
* History of leading fluid
* Sterile speculum
* Fern test: NaCl crystalizes on proteins
* Sample fluid from vagina
* Fern appearance if amniotic fluid is present
* Ultrasound
* Fluid volume
* Fetal growth / position
78
When are steroids given in the treatment of PPROM? Why?
* Given if fetus \< 35 wks
* Purpose
* Stimulate maturation of fetal lung
* More surfactant
79
What is the difference between PIH and Preeclampsia?
* Pregnancy Induced HTN (PIH)
* No proteinuria
* Preeclampsia
* Proteinuria
80
What is the pathophysiology of Preeclampsia / Eclampsia?
* Generalized increase in
* Systemic vascular resistance
* or
* Vasoconstriction
81
What is the goal in treatment of HTN in pregnancy?
Goal:
* Make only mildly HTN, NOT normotensive
* b/c Normotensive would lead to decreased blood flow to baby
82
How long can a placenta can sustain a fetus?
42-44 weeks
83
What are the 4 T's of Postpartum Hemorrhage?
1. Tissue
* Are there pieces of placenta left behind
2. Tone
* Cause uterus to contract in order to stop bleed
* massage, give meds
3. Trauma
* Is there a tear?
4. Thrombin
* DIC common
* Must replace blood products immediately!
84
Endometritis
* Symptoms
* Treatment
* Symptoms
* fever
* uterine pain
* foul drainage
* Treatment
* broad spectrum Abx
* (mixed infxn)
85
What is Septic Pelvic Thrombophlebitis?
Infected clot ("plegmon") in veins around the uterus
86
What is the definition of a reactive response to a non-stress test?
\>2 HR accelerations of 15 bpm in 20 minutes
87
What are some causes of non-reactivity of fetus in a non-stress test?
* Fetal sleep
* Drugs
* At risk infant
88
What is the definition of a Reactive/Negative Contraction Stress Test? What is its significance?
* Definition
* Positive accelerations
* No decelerations with contractions
* Significance
* Positive sign
89
What is the definition of a Negative Contraction Stress Test?
No decelerations with contractions
This is a positive sign
90
In what order are fetal functions affected by hypoxia?
The reverse of embryogenesis!
1. NST (non stress test; cerebral function)
* Should be reactive
2. Fetal bowel movement (FBM)
3. Fetal Movements
4. Fetal tone
91
When is a Biophysical Profile routinely performed? What are the testing parameters?
* Routine
* Early gestation
* \<34 weeks
* Multiple gestations
* HTN
* Parameters
* Reactivity in NST
* AFV (amnionic fluid volume)
* Gross motor movement
* Fetal Tone
* FBM
92
What is observed in FHR monitoring? What is normal?
* Baseline HR
* 120-160
* Variability
* should be present
* Controlled by SNS/PSNS
* Periodic changes
* Should have accelerations
* No decelerations
* Controlled by carotid baroreceptors
93
What are some causes of fetal bradycardia?
* Maternal hypotension
* this can happen with epidural
* Fetal distress
* Drugs
* SLE
* Congenital heart disease
94
What are some causes of fetal tachycardia?
* Maternal fever
* Most common!
* Fetal distress
* Amnionitis
* Fetal arrhythmia
* Thyrotoxicosis
95
What do the presence of accelerations indicate?
There is no hypoxia
96
What are the types of decelerations and what do they indicate?
* Early (vagal)
* Less ominous
* Occurs _with_ contraction (symmetrical)
* Variable (barometric, carotids)
* caused by cord compression
* Late (Myocardopathy)
* Ominous
* occurs after the contraction
97
What is the cause of early decelerations?
* Vagal effect
* Fetal head compression
98
What is the cause of variable decelerations?
Stimulation of carotid baroreceptors
* Treatment:
* Position change
* O2
* Amnioinfusion
99
What is the cause of late FHR decelerations?
Myocardopathy secondary to acidosis
100
What is the most common GYN CA?
Adenocarcinoma of the endometrium
101
What are the risk factors of uterine carcinoma? What characteristics are common in patients?
* Risk factors: Unopposed E2!
* Chronic anovulation (PCOD)
* Iatrogenic
* Needs to be paired with progesterone
* Characteristic pop.
* Obese
* HTN
* Diabetes
102
What is the presenting symptoms of uterine carcinoma?
Abnormal Uterine Bleeding
103
What endometrial thickness is a risk factor for uterine carcinoma?
Over 4mm in postmenopausal patient
104
When is an adnexal mass most likely neoplasm? What tumor markers are used to evaluate each case?
* Premenarchal
* Most likely germ cell in origin
* AFP, hCG markers
* Postmenarchal
* esp if with ascites
* Most likely epithelial in origin
* CA 125 marker
105
What is a clue that an adnexal mass is more likely metastatic?
Bilateral
* Metastasis location
* Breast
* Colon
106
What is the leading cause of gyn deaths? When do they normally occur?
Ovarian carcinoma
* Usually postmenopausal
* Found late
* vague symptoms
107
What is the most common type of ovarian carcinoma?
Epithelial (CA 125)
108
What is the most common cervical carcinoma?
Squamous cell
109
What does ASC-US mean? What is the next step in workup?
Atypical Cells of Undetermined Significance
* (Pap result)
* Presence of atypical cells
* Workup;
* High risk HPV screen
* If positive, treat like LGSIL
* If negative, treat same as normal
110
What does LGSIL mean? What is the next step in workup?
Low Grade Squamous Intraepithelial Lesion
* (Pap result)
* Mild Dysplasia
* Workup:
* Colposcopy and Bx
111
What does ASC-H mean? What is the next step in workup?
Atypical Squamous Cells cannot rule out High grade intraepithelial lesion
* Pap result
* Moderate dysplasia
* Workup:
* Colposcopy and Bx
112
What does HGSIL mean? What is the next step in workup?
High Grade Intraepithelial Lesion
* Pap result
* Severe/Marked Dysplasia
* May have CIS
* Workup:
* Colposcopy and Bx
113
What does AGUS mean? What is the next step in workup?
Atypical Glandular Cells of Undetermined Significance
* Pap result
* In same class as adenocarcinoma in situ
* Workup:
* Colposcopy and Bx
114
What is the most common vulvar infection?
Condyloma
115
What is the most common Vulvar Carcinoma? What is the most common risk factor?
* Type
* Squamous cell CA
* Risk Factor
* HPV
116
What hormones are present in DMPA (Depo injection)? What happens to the endometrium?
* Hormones
* Posgesterone only
* Result
* Thin endometrium
* Bleeding
117
What hormones are present in Levonorgestrel implants? What occurs in the endometrium?
* Hormones
* Progesterone only
* Result
* thin endometrium
* bleeding
118
What solution is used to visualize trichomonas and gardnerella vaginalis?
Saline solution
119
What solution is used to visualize candida in vaginitis?
KOH
120
OCPs, Ring, Patch
* Protective against what diseases?
* Non-contraceptive benefits
* Side effects
* Protective against what diseases?
* Endometrial cancer
* Ovarian cancer
* Non-contraceptive benefits
* Lightened / shortened period
* Side effects
* Breakthrough bleeding
* Moodiness
121
Proesterone-based IUD/ Implant
* Protective against what diseases?
* Non-contraceptive benefits
* Side effects
* Protective against what diseases?
* Endometrial cancer
* Non-contraceptive benefits
* Light / absent period
* Side effects
* Breakthrough bleeding
* Depressive symptoms
122
Depo-Provera
* Protective against what diseases?
* Non-contraceptive benefits
* Side effects
Progesterone only
* Protective against what diseases?
* Endometrial cancer
* Non-contraceptive benefits
* Light / absent period
* Side effects
* Breakthrough bleeding
* Depressive symptoms
* Weight gain
* Delayed return to fertility
123
What is characterized by a painful ulcer?
* Herpes
* Chlamydia
* Lymphogranuloma Venerum
124
What is characterized by a painless ulcer?
* Syphilis
* (Single ulcer)
* Klebsiella granulomatis
* Enlargening painless ulcer
125
Symptoms of Primary Syphilis
* Chancre
* Develops into sinle, painless ulcer
126
Symptoms of secondary syphilis
* Fever
* Arthritis
* Rash (palms and soles)
127
What are the neurologic symptoms of Syphilis?
Neurosyphilis
* Argyll-Robertson pupil
* small, accommodates but does not react to light
* Tabes dorsalis
* Sharp back pain
128
What is Gummatous syphilis?
Tertiary syphilis
* Sx:
* Granuloma formation on skin and bone
129
What are the cardiovascular manifestations of tertiary syphilis?
Destruction of elastic tissue
* Aortic dilation
* can cause regurg
* Aortic aneurysm
130
What tests are used to diagnose Syphilis?
1. Cardiolipin Ab test (RPR or VDRL)
* Not specific
2. Fluorescent treponemal Ab absorption test (FTA-ABS)
* If cardiolipin test is positive
131
Patient has acute, unilateral pelvic pain. Doppler shows no flow. What is causing the pain?
Ovarian torsion
132
Patient has acute, unilateral pelvic pain. Sonogram shows free fluid. What is causing the pain?
Ruptured ovarian cyst
| (blood in caul-de-sac = free fluid)
133
What reproductive problem can cause nodularity of the uterosacral ligaments?
Endometriosis
134
What is the only way to definitively diagnose endometriosis?
Laparoscopy with biopsy
135
What is the cause of Primary Dysmenorrhea? How is it treated?
* Cause:
* Increased endometrial prostaglandins
* Treatment:
* NSAIDS
* OCPs
136
What is Stress Incontinence? What is the cause?
* Leaking of urine with activity
* sneezing
* Laughing
* coughing
* Cause
* Intrabdominal pressure becomes greater than urethral sphincter closure pressure
137
What is urge incontinence? What is the cause? Treatment?
* Sudden urge followed by leaking before making it to the bathroom
* Cause
* Spontaneous bladder contractions
* Treatment
* Antimuscarinics
* Alpha agonists
138
What is the definition of menopause?
* Cessation of follicular function
* Absence of menses for 1 year
* FSH \> 40
139
What are the advantages and disadvantages of hormone replacement in postmenopausal women?
* Advantage
* Improves lipid profiles
* Bone health
* Decreased colon cancer risk
* Disadvantage
* Increased risk CV disease
* Increased risk stroke / PE / DVT
* Increased risk breast cancer
140
What are the characteristics of fibroadenoma?
* Painless, solitary mass
* Mobile
* May be bilateral
141
What are the characteristics of fibrocystic breast disease?
* Diffuse, lumpy
* Cyclical changes
ICM II
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