Ob-Gyn Flashcards

Question

when would you c-section

Answer 1

fetal distress (category 3 tracing and remote from delivery), breech presentation, multiple prior C-sections after maternal trauma if - imminent maternal death, to assist with CPR in mom, due to category 3 tracing PGs - cervical ripening, contraindicated in pts with hx of c-section due to increased risk of uterine rupture

Answer 2

risk factors - precipitating factor (exercise)+ ovarian mass, women of repro age, infertility treatment with ovulation induction presents - sudden onset unilateral pelvic pain, *N&V*, sometimes palpable adnexal mass adnexal mass with *absent Doppler flow to ovary* - but according to UWISE - if you suspect ovarian torsion DONT get doppler - because normal blood flow does not rule out ovarian torsion - escalate to surgical exploration treat - lap detorsion, ovarian cystectomy, oophorectomy (if necrosis or malignancy) - you would only drain a cyst if it is large, simple, and there is little likelihood of malignancy to help with - clomiphene citrate...

Answer 3

risk factors for cancer - ...white race, increasing age, residence in NA or N. Europe - NOT smoking - OCPs that cause anovulation are *protective* functional ovarian cysts = smaller, simple cysts serous (uniloculated?) and mucinous (multiloculated) - larger cystic teratoma - hyperechoic nodules and calcifications, surgically resect - median age 30, most common tumor in women of all ages - typically dont rupture - side note - signs of rupture are peritoneal signs = pleurtiic chest pain, rigid abdomen, rebound, involuntary guarding epithelial tumors (90%) - typical in 60s germ cell tumors - ages 10-30 theca-lutein cyst - due to stimulation by bHCG - multiseptated bilateral cystic masses - present IN pregnancy or moles, *regresses spontaneously after delivery* granulosa(-theca) cell tumor - large adnexal mass - child - precocious puberty - postmenopausal woman - bleeding, endometrial hyperplasia - other features - breast tenderness sertoli-leydig - 20-40, unilateral - suppression of FSH and LH, elevation of testosterone luteomas - large (6-10 cm) yellow or yellow-brown masses (with areas of hemorrhage), 50% are bilateral, will regress spontaneously after delivery - hyperandrogenism in pregnancy - symptomatic maternal luteoma puts female fetus at high risk of virilization - watch luteoma for mass effect consequency Krunkenburg tumor - bilateral solid ovarian masses on US, mets from primary GI prognosis - by *stage* and volume of residual disease following surgery - histology is important - poorly diff or clear cell tumors have worse survival treatment - op and post-op chemo + taxane and platinum adjuncts

Answer 4

reccurrent mild, *unilateral* mid-cycle pain prior to OVULATION - for example, severe LLQ pain can occur with every cycle or just be a single episode side notes - appy is RLQ pain and fever - ovarian torsion - severe unilateral pain and an *adnexal mass* side note - mid-cycle bleeding occurs during ovulation - due to a drop in estrogen

Answer 5

AD inheritance, Ashkenazi Jew risk modification - *bilateral salpino-oophrectomy* in premenopausal women (most effective), OCP, age < 30 aft first live birth, breastfeeding, tubal - BSO is not routinely recommended to prevent OVARIAN cancer in pts wo a hereditary increased risk

Answer 6

HELLP - hemolysis, elevated liver enzymes, low plts - severe type of preelcampsia - due to abnormal placentation --> systemic inflammation and activation of coagulation cascade - microangiopathic hemolytic anemia - particularly detrimental to liver - liver problems include centrilobular necrosis, hematoma formation, and thrombi in portal system --> distention of hepatic capsule --> RUQ pain - pt presents with preeclampsia, N&V, and RUQ pain - treat with delivery (at > 34 wks or when appropriate), Mg for seizure ppx, antiHTNs - note - ppx transfusion at 20K plts, preop transfusion at <40K plts ******* Acute fatty liver of pregnancy -can cause hepatic failure in third trimester or early PP - malaise, RUQ pain, N&V, *sequelae of liver failure* - prolonged PT and PTT, encephalopathy - hypoglycemia - AKI - possible DIC - can look like HELLP but these pts will have NOT have severe HTN and will have extrahepatic complications ******* Intrahepatic cholestasis of pregnancy - pruritus, hyperbilirubinemnia, transaminitis - ddx of exclusion - side note - alk phos is normally elevated in pregnancy - pruritis resolves in the weeks following delivery, prescribe ursodeoxycholic acid prescribed during pregnancy (can start with antihistamines and other topical for initial anti-itch relief) - early delivery is recommended once fetal maturity is achieved to avoid fetal complications - intrauterine demise, NRDS side note: elevated alk phos is elevated in normal pregnancy

Answer 7

recurrent pregnancy loss - >2 consecutive or >3 total spont losses before 20 wks gestation = absence of fetal cardiac activity on *US* - 50% of cases have no etiology - HTN and APAS - oligo and intrauterine GR - APAS - workup with anticardiolipin and b-2-glycoprotein antibody, PTTP, russell viper venom time - mat hypothyroidism - increased risk of miscarriageb - blood antibody screen can tell if maternal alloimmunization was the cause - Kleihauer-Betke can tell of fetomaternal hemorrhage risk factors - nullip, obesity, HTN, DM treat - 20-23 wks - dilation and evacuation or delivery - >24 wks - delivery (can be delayed until the pt is ready) - autopsy and karyotype, microscopic placental evaluation, inspect membranes and cord - after the fact - check mom for antiphospholipid antibody syndrome and fetomaternal hemorrhage (Kleihauer-Betke) complication - coagulapathy after several WEEKS of fetal *RT* - check coag panel, serial fibrinogen levels

Answer 8

classical - salt-losing crisis, virilization nonclassical (21-hydroxylase deficiency): oligoovulation, hyperandrogenemia (hirsuit), increased 17-OH-progesterone levels - can also have mineralocorticoid excess - hypertension, hypokalemia - precocious puberty in boys androgen excess impairs hypothalamic sensitivity to progesterone --> rapid GnRH secretion --> hypersecretion ofLH and FSH --> increased gonadal steroid production

Answer 9

cystocele, rectocele, enterocele, procidentia (uterus and vaginal walls herniate through the vagina), apical prolapse (uterus, vaginal vault) - can also present with tissue damage - erosions risk factors - obesity, multip, hysterectomy, post-menopausal age features - pelvic pressure, obstructed voiding or incontinence - pts have to put vaginal pressure to void management - weight loss, pelvic floor exercises, vaginal pessary, surgical repair (required if there is complete herniation)

Answer 10

but has a thin endometrial stripe - no need for endometrial bx but you would want to bx in a post-menopausal or perimenopausal woman

Answer 11

benefits - endometrial and ovarian cancer risk reduction, reduction in risk of benign breast disease, ... - decreased risk of endometrial cancer due to progestin - decreased risk of ovarian cancer due to ovulation suppression risks - VTE, HTN, hepatic adenoma, stroke and MI (rare) - why HTN - increased angiotensinogen synthesis by estrogen during hepatic first-pass metabolism - side note - hepatic adenoma --> intra-abdominal bleeding + peritonitis --> immediate surgical intervention

Answer 12

due to incomplete regression of Wolffian duct - single or multiple cysts (submucosal) along lateral upper anterior vagina

Answer 13

asymptomatic - no intervention, observe symptomatic - I&D, - same for Bartholin abscess - note for abscess, only add abx if you cellulitis is present - Word catheter

Answer 14

BV (pH > 4.5) - po metro or clinda for pt - side note - TMP is a dihydrofolate reductase inhibitor (risk of fetal malformations) - metro po for 10 days Trichomoniasis (pH >4.5) - thin, yellow-green discharge + significant vaginal and vulvar inflammation, strawberry cervix (erythematous patches on cervix) - po metro for pt AND her partner - single dose 2 grams or 500mg bid 7 dyas candida - normal pH + vulvar erythema and excoriations - microscopy may be negative in 50% of cases vulvovaginal candidiasis - risk factors - DM, immunosuppression, pregnancy, OCPs, antibiotic use - estrogen increases the risk of candidiasis note - dont use metronidazole with alcohol --> disulfuram-like reaction

Answer 15

optimal fertility = 18 yo decreased fertility = 37 yo end of fertility = 41 yo irregular cycles starting at 45 infertility - lack of conception after 6 mo of intercourse in a woman > 35 yo FSH testing on day 3 (early follicular phase)

Answer 16

co-testing preferred in women 30-65 in general - all abnormal pap smear results + pos HPV --> colpo - ASCUS --> reflex HPV testing - repeat cytology in 1 year is also acceptable if HPV testing cant be done - HPV testing negative --> routine screening in 3 yrs ASCUS or LSIL --> HPV co-testing - high-grade HPV --> colp HSIL (concerning for CIN2 or worse) --> immediate colp (or LEEP if the pt is not pregnant) colp - apply acetic acid --> aceto-white changes will occur on abnormal cells endocervical curettage if colp was "inadequate" - not performed during pregnancy because it is an invasive procedure cervical neoplasia typically occurs at the transformation zone note - HPV testing is not recommended for ages 21-29 because most HPV infections clear spontaneously in these pts women who have hx of cervical cancer, have HIV, or were exposed to DES dont follow regular guidelines ******* when would you do embx? - for >45 - abnormal uterine bleeding, postmenopausal uterine bleeding - <45 - unopposed estrogen (obesity, anovulation), failed medical management, Lynch syndrome - >35 - atypical glandular cells on pap note - endometrial stripe of <4mm excludes endometrial cancer in postmenopausal pts with AUB, cant reliably do so in premenopausal pts (?) ******* after hysterectomy - still need bimanual and rectovaginal exam

Answer 17

blue cervix = Chadwicks sign - due to increased blood flow to the cervix many changes are mediated by PROgesterone - progesterone causes smooth muscle dilation (?) renal and urinary changes - increased RBF and GFR - also increased renal BM permeability - -> decreased serum BUN and Cr, increased renal protein excretion, increased Na excretion - increased ADH release from pituitary R>L hydronephrosis - due to sigmoid colon cushioning on the left - greater compression of the R ureter due to uterus and right ovarian vein complex note - renally excreted meds (gabapentin) need to be closely monitored **** heme - decreased protein S activity, increased fibrinogen and coag factors, increased resistance to activated protein C gestational thrombocytopenia = normal CV - increased cardiac output and HR, decreased SVR and decreased BP - when would you work up a murmur in pregnancy - holosystolic mitral murmur - mitral stenosis can worsen during pregnancy, can present with AF with RVR and cough, progressive dyspnea, and orthopnea (consider rheumatic fever) **** pulm - chronic respiratory alkalosis with metabolic compensation increased PaO2 and decreased PaCO2 - why? due to increased tidal volume and minute ventilation (RR is unchanged) if pregnant woman complains of SOB during exercise think = physiologic dyspnea of pregnancy asthma worsens in pregnant women - move to next line of treatment if mom is using b-agonists more than 2x/wk - next line - add inhaled corticosteroids or cromolyn sodium - subQ terb and systemic corticosteroids in acute cases ****** thyroid - total T4 increased, free T4 will be unchanged, TSH decreased (feedback inhibition) - high TRH --> stimulates prolactin secretion --> inhibits GnRH --> low FSH and LH - bHCG stimulates thyroid hormone in the first trimester - estrogen stimulates TBG - BUT pt is clinically euthyroid - pts with Hashimotos or other impaired thyroid function - cant increased thyroid hormone --> relative hypothyroidism (so levothryoxine needs to be increased during pregnancy) ***************** back pain - benign - rule out preterm labor and pyelo

Answer 18

produced by fetal yolk sac, liver, and GI tract - confirm gestational age - AFP levels change with age increased - under-dating - open neural tube defects (rel rare) - ventral wall defects - multiple gestation - fetal demise - -> next steps are to obtain an US decreased - aneuploidies - 21, 18 - 21 - low AFP, low estriol *elevated bHCG*, elevated inhibin - 18 - low AFP, very low estriol, *low bHCG*, normal inhibin abnormal quad screen --> can offer cell-free fetal DNA testing (DNA is in maternal plasma) - perform US

Answer 19

ob emergency risk factors - **fetal macrosomia** (>4000 g), maternal obesity (and excessive pregnancy weight gain), *GDM*, post-term pregnancy, prolonged second stage of laber, prior hx warning signs - protracted labor, retraction of fetal head into perineum after delivery (turtle sign) conversely - HTN and short interpregnancy interval (<18 mo) are risk factors for FGR management = BE CALM - breathe, dont push - elevate hips against abdomen (flattens sacral promontory) - call for help - apply suprapubic pressure - episiotomy - maneuvers - deliver posterior arm --> rotate 180 --> collapse anterior shoulder --> replace fetal head into pelvis for c-section (last) complications - fractured clavicle - decreased moro reflex due to pain on affected side - fractured humerus - again decreased moro due to pain - Erb-Duchenne palsy (C5-C6) - decreased moro AND biceps reflexes, intact grasp - 80% of pts have spontaneous recovery wi 3 mo, treat with gentle massage and physical therapy - Klumpke palsy (C8 and T1) aka claw hand and absent grasp (hand paralysis), Horners, intact reflexes - perinatal asphyxia - AMS, respiratory/feeding difficulties, poor tone, seizure - perinatal stroke - hyperreflexia and hypertonia

Answer 20

why? - because of bladder atony risk factors - nulliparity, prolonged labor, perineal injury, regional analgesia, C-section, instrumental vaginal delivery - sacral nerve "depression", pudendal nerve palsy, perineal edema clinical features - RT and dribbling - confirmed by inability to void for 6 hrs after delivery - or if cath produces >150 mL urine manage - analgesics, ambulations, cath

Answer 21

risk factor - BRCA, age, use of fertility drugs, uninterrupted ovulation sxs -.... and SOB (due to ascites) elevated CA-125 - useful in POSTmenopausal women (low specificity in premenopausal women) - leiomyomata, endometriosis cause elevated CA-125 findings on US - solid mass, thick septations, ascites - originates from ovary, fallopian tube, and peritoneum - with pelvic and abdominal mets - side note - peritoneal fluid in postmenopausal women is pathologic steps: 1) US, 2) CA-125, 3) further imaging manage with - ex lap for resection, staging, and inspection - chemo with platinum-based agents following surgery - DONT do image-guided biopsy - seding

Answer 22

chronic alcoholism, malnutrition, hyperemesis gravidarum - hyperemesis gravidarum - hypochloremic metabolic alkalosis, hypokalemia, hypoglycemia, elevated serum LFTs - and concurrent volume contraction metabolic alkalosis features - encephalopathy, nystagmus or bilateral abducens palsy, gait ataxia treat with IV thiamine and then glucose - glucose infusion prior will worsen Wernickes side note - neurosyphilis will show tabes dorsalis (sensory ataxia, lancinating pain) and Argyll Robertson pupils (constrict to accommodation but not light)

Answer 23

1/8 lifetime risk risk factors - HRT, nulliparity, increased age at first live birth, *alcohol consumption (dose-dependent effects) BRCA increases risk in premenopausal women non-modifiable risk factors - genetic mutations/first degrees relatives with breast cancer (<50), white race, increasing age, early menarche or late menopause - bilateral mastectomy can be offered to BRCA carriers

Answer 24

late-term = 41-42 weeks past 42 weeks - post-term pregnancy risk factors - nulliparity, **hx of prior postterm pregnancy**, maternal obesity, fetal anomalies, fetal adrenal hypoplasia, anencephaly, inaccurate dates fetal - oligo, meconium aspiration, stillbirth, macrosomia, convulsions, uteroplacental insufficiency, dysmaturity - why oligo? - aging placenta --> decreased fetal perfusion --> decreased renal perfusion... maternal - C-section, infection, PPH, perineal trauma - emergent C-section is advised if there are signs of fetal distress or oligo if mom comes in at 40 weeks and is uncomfortable - it is reasonable to induce - why? - because waiting longer may increase risk of perinatal mortality (perinatal mortality increases at 41 weeks gestation) - beginning at 41 weeks - some practioners do 2x/wk testing with amniotic fluid volume (so BPP) for a mom with a favorable cervix at 41 weeks gestation - induce fetal dysmaturity - increased incidence after 43wks - withered, meconium stained, long-nailed, fragile, with small placenta - greatest risk for stillbirth

Answer 25

all pts should be screened for illicit drug use - f/u with serial urine drug tests risk factors - adolescent pregnancy, late/noncompliant RPN, inadequate pregnancy weight gain ob complications - spont abortion, preterm birth, preeclampsia, abruptio placentae, FGR, intrauterine fetal demise - threatened abortion - vaginal bleeding, closed cervix, fetal heart beat

Answer 26

decreased fetal movements - concerned about fetal compromise - -> NST - reactive test means that there are 2 accelerations in 20 min - reactive NST has a high negative predictive value - -> further testing for nonreactive stress test - usu due to fetal sleep - use vibroacoustic stimulation to awaken the fetus

Answer 27

cause of PPH - usu accompanied by hemorrhagic shock and lower abd pain risk factors - nulliparity, fetal macroscomia, placenta accreta, rapid L&D treatment - aggressive fluid replacement, manual replacement of the uterus - THEN placenta removal and uterotonic drugs (because uterine atony is commonly encountered) after uterine replacement

Answer 28

confirm with transabdominal US - most fetus are vertex by 37wks (<4% are breech) risk factors - prematurity, multiparity, multiple gestation, uterine anomalies, fetal anomalies (hydrocephaly, anencephaly), abnormal placentation, polyhydramnios ECV at >37 weeks gestation - contraindications to ECV - active labor, ROM, abnormal fetal HR tracing, oligohydramnios (or decreased amniotic fluid), placental abnormalities, hyperextended fetal head, multiple gestation, fetal or uterine abnormality internal podalic version - used for breech extraction of malpresenting second twin (- contraindicated in active labor) frank breech most common = butts first 2 incomplete breech 3 complete breech forceps are use to assist in flexion of after coming head vacuum - contraindication

Answer 29

placenta previa, active herpes lesions, prior *classical* c-section

Answer 30

infants with A or B, mom is O MILD (why mild - because A and B antigens are present on blood cells and cells of other fetal tissues--> neutralizes the antibody response) jaundice w/i 24hrs of birth, anemia, increased retics, hyperbilirubinemia, positive Coombs reaction to A or B during pregnancy --> IgM - but a person with blood type O has been exposed to A/B antigens early in their life --> they have IgG in their bloodstream, this can cross the placenta manage - serial bili, oral hydration and phototherapy for most neonates - exchange transfusion for severe anemia/hyperbili

Answer 31

weight < 10% for GA - on delivery - thin, loose skin, thin umbilical cord, wide anterior fontanel - cause may be anything --> utero-placental insufficiency is the result (so examine placenta) - severe IUGR is <3% 1st trimester onset (something is wrong with baby) - *chromosomal abnormalities*, congenital infection - growth lag - look for hints - ASD hints at chromosomal abnormalities - intracerebral calcifications and ventriculomegaly + maternal illness hints at infection 2nd/3rd trimester abnormalities (something is wrong with mom, more common) - **utero-placental insufficiency** (HTN, DM), maternal malnutrition (tobacco use) - head-sparing growth lag cocaine, tobacco, and alcohol also associated with FGR neonatal complications - polycythemia, hypoglycemia, hypocalcemia, poor thermoregulation consequences for baby in the future - increased risk of developing CVD, HTN, stroke, COPD, DM2, obesity manage with once-twice weekly biophysical profiles, serial umbilical artery Doppler sonography, serial growth US - many pts will have oligo (2/2 fetal anemia) - S/D ratio of umbilical artery by doppler - increase reflects increased vascular resistance delivery indicated for fetus with IUGR at 36 wks - with oligo and abnormal umbilical artery doppler studies - regardless of fetal lung maturity

Answer 32

fasting < 95 1-hr postprandial <140 2 hr postprandial < 120 screen ALL at 24-28 weeks gestation - screen earlier for pts with obesity, previous GDM, previous macrosomic infant and again at 24-28 weeks treatment - 1) diet, 2) insulin, metformin, glyburide (other meds have shown adverse effects in infants) - insulin doesnt cross the placenta neonatal acidosis occurs with poor glycemic control

Answer 33

in 10% of cases - anesthesia will result in hypotension due to vasodil and venous pooling treat with aggressive IVF volume expansion prior to epidural placement - left uterine displacement - to improve VENOUS return - vasopressors side note - anesthesia can ascend toward the head --> brain stem depression

Answer 34

criteria 1) fetal pole outside uterus 2) bHCG over discriminatory zone and no IUP 3) pt has bHCG increase of <50% in 48hrs and levels dont fall after D&C note- thick endometrial stripe suggestive of intrauterine pregnancy? greatest risk factor is prior hx of ectopic features - abdominal pain, vaginal bleeding (can be spotting over several days), hypovolemic shock if ruptured - CMT, adnexal tenderness, or abdominal tenderness - palpable adnexal mass rare type of ectopic - cornual or interstitial ectopic pregnancy - gestational sac is supposed to implant in the upper fundus - cornual area as abundant blood supply --> ectopic can lead to life-threatening hemorrhage ddx by TVUS - discriminatory zone - ... below --> repeat bHCG in 2 days - above --> repeat bHCG and TVUS in 2 days - bHCG will double every 2 days for viable pregnancy treatment - methotrexate in stable folk, surgery for unstable methotrexate IF - hemodynamically stable - non-ruptured - size of ectopic <4cm wo HR or <3.5 cm w HR - normal liver enzymes and renal function - normal WBC - ability for rapid f/u in pts with hemoperitoneum and unstable vitals (hypotension and tachy) - requires emergency surgical exploration

Answer 35

=PGE1 causes cervical dilation and myometrial contraction = aka ripening useful to treat incomplete or missed abortion mifepristone - progestin receptor antagonist - used for emergency contraception, prevents ovulation - used with misoprostol for pregnancy termination

Answer 36

presents - abnormal *vaginal bleeding* +/- hydropic tissue - theca lutein ovarian cysts - hyperemesis gravidarum - preeclampsia with severe features - hyperthyroidism - partial mole will more likely be diagnosed as a missed or incomplete abortions dont rule out mole based on a single bHCG value risk factors - extremes of maternal age, hx of past mole, asian race, increased in women with 2+ miscarriages - risk of second mole = 1-2% - risk of 3rd mole = 10% snowstorm appearance - anechoic, cystic spaces dont want to biopsy - these lesions are highly vascular treat - ... contraception - persistent disease can be *easily* cured with chemo if you are concerned about mets - get CT first abd/pelvis (may get brain MRI) pt wants to get pregnant after a mole - wait at least 6 mo after negative b-HCG levels (GTN is rare after 6 mo post suction curettage) ******************** if gestational trophoblastic neoplasm develops - use methotrexate or hysterectomy

Answer 37

due to immature HPA - normally estrogen build endometrium --> corpus luteum produces progesterone --> corpus luteum degeneration and progesterone withdrawal produces menses in AUB following menses - menses like bleeding occurs because of estrogen breakthrough bleeding can treat with progestin-only or combo contraceptives - but will usually resolve 1-4 yrs postmenarche

Answer 38

side effects and risks - breakthrough bleeding - breast tenderness, nausea, and bloating - amenorrhea - HTN, VTE - decreased risk of ovarian and endometrial cancer - INCREASED risk of cervical cancer - hepatic adenoma - increased triglycerides (due to estrogen) can be used >6 weeks PP while breastfeeding OCPs will decrease risk of ovarian AND endometrial cancer - progesterone IUD may decrease a woman's risk for endometrial cancer only note - OCPs decrease pain symptoms by thinning endometrial lining, reducing PG, and decreasing uterine contractions - OCPs and progestins manage AUB in premenopasual pts - OCPs prescribed in a continuous fashion = no placebo pill so no withdrawal bleeding Cu IUD - inflammatory reaction, may increase dysmenorrhea and pain symptoms, heavy bleeding progestin implants - commonly cause amenorrhea progestin-only pills have a much higher failure rate than the progesterone IUD medroxyprogesterone (depo) - inhibits GnRH release - give every 3 months - may *increase body fat*, decrease lean muscle mass, loss of bone mineral density, breast tenderness, fatigue - initially menstrual irregularities, 50% have amenorrhea after 1 year of use progesterone - less effective dysmenorrhea and contraception because they dont inhibit ovulation progesterone stimulates differentiation of endometrial cells and prevents endometrial hyperplasia/cancer absolute contraindications to combined hormonal contraceptives (worried about estrogen and progesterone) - migraine with aura - >15 cigs/day + >35 - HTN > 160/100 - heart disease - DM with end-organ damage - hx of thromboembolic disease, hx of stroke, major surgery with prolonged immobilization, APA syndrome - breast cancer - cirrhosis and liver cancer - use < 3 weeks PP - women who are lactating - women who develop severe N&V with OCPs - these ladies are ideal candidates for progestin-only pills - note progestins should be used cautiously in ladies with hx of depression most effective contraception with <1% risk of pregnancy - Depo (medroxyprogesterone acetate) - sterilization - LARC - nexplanon (etonogestrel implant, can cause irregular spotting) and IUD

Answer 39

evaluates for fetal hypoxia NST - 20-40 min, reactive if 2 accels in 20 min biophysical profile - NST + US assessment for amniotic fluid volume, fetal breathing movement, fetal movement, and fetal tone (x/2 for each category) - single pocket > 2x1 cm or amniotic fluid index > 5 - >3 body movements - >1 episode of flexion/extension - >1 breath for > 30 seconds - normal result is 8-10/10 - 6/10 - repeat in 24hrs - 0-4/10 - urgent delivery - abnormal result indicative of fetal hypoxia due to placental dysfunction contraction stress test - FHR during contraction - normal is NO late or recurrent variable decels - contraindicated in placenta previa or hx of myomectomy doppler of umbilical artery - for FGR

Answer 40

normal internal genitalia first manifestation - inability for placenta to convert androgens to estrogens --> maternal masculinization estrogen absence.... - and high concentration of gonadotropins --> polycystic ovaries

Answer 41

cafe au lait spots, polyostotic fibrous dysplasia, autonomous endocrine hyperfunction gonadotropin-ind precocious puberty premature menses before breast and pubic hair development

Answer 42

virilization in postmenopausal women + insulin resistance solid-appearing enlarged ovaries

Answer 43

systemic illnesses - DM (insulin dependent), CKD, lupus, thyroid disease - APA syndrome - pregnancy loss or demise, give ASA AND heparin in future pregnancies - APA syndrome - can have vascular thrombosis (TIA, stroke, DVT) recurrent pregnancy loss - systemic disease testing - mom and dad karyotypes - uterine imaging missed - no vaginal bleeding, closed os - will be some visible tissue or fetal pole within the uterus = retention of nonviable pregnancy for sometime threatened - vaginal bleeding, closed os, fetal cardiac activity inevitable - vaginal bleeding, dilated cervical os, US shows intrauterine gestation in lower uterine segment - incomplete - complete - vaginal bleeding, closed cervical os septic abortion - broad spectrum abx and uterine evacuation (want prompt evacuation) expectant management is acceptable in early pregnancy loss D&C - use this when pt is UNSTABLE - anesthesia risk, bowel/bladder injury, cervical lac (vaginal bleeding), uterine perf - uterine perf - increasing lower abd pain, nausea, scant bleeding, fever, rebound tenderness and abd guarding, uterus soft and tender retained products of conception - PROFUSE vaginal bleeding hematometra (collection of blood in the uterus) - cyclic midline abd pain

Answer 44

from 10cm --> delivery arrest - >3 hrs if nullip, >2hrs if multip - risk factors are maternal obesity and excessive pregnancy weight gain, DM - etiology - cephalopelvic disproportion, **malposition**, inadequate contractions, maternal exhaustion - optimal fetal position is occiput anterior - inadequate contractions <3 in 10 min (most common cause of protracted first stage of labor) - treat with op vaginal delivery or C-section

Answer 45

risk factors for PPROM - *genital tract infection*, hx of PPROM, smoking PROM at <34 weeks - no infection - antibiotics, corticosteroids, fetal surveillance - infection - antibiotics, corticosteroids, Mg < 32 weeks, delivery PROM at 34-37 weeks - antibiotics - +/- corticosteroids - delivery complications - chorio/endometritis, cord prolapse, abruptio placenta

Answer 46

edema, malar rash, arthritis, *hematuria*, hypertension, arthralgias ob complications - preeclampisa, preterm birth, c-section, FGR, fetal demise

Answer 47

tamoxifene - treats breast cancer raloxifene - used in postmenopausal osteoporosis both - used to PREVENT BC in high-risk pts adverse effects of tamoxifen and raloxifine - hot flashes, VTE, endometrial hyperplasia/cancer (tamoxifen only)

Answer 48

progesterone and relaxin increase pelvic mobility risk factors - fetal macrosomia, multip, precipitous labor, operative vaginal delivery present with difficulty ambulating, *radiating suprapubic pain, pubic symphysis tenderness, intact neuro exam manage conservatively, pelvic support, PT

Answer 49

``` initial - Rh, antibodies - Hb/Hct, MCV - would screen for hemoglobinopathies in pts with microcytic anemia - HIV, VDRL/RPR, HBsAg - Rubella and varicella titers (- pap) - chlamydia PCR - urine culture and protein ``` 24-28weeks - Hg/Hct - antibody screen for Rh negative - 50 g 1 hr GCT - why HPL increased (to promote fetal growth and metabolism) - confirm with 3-hr 100g glucose tolerance test 35-37 - GBS culture side note - treat asymptomatic bacteriuria (>100,000 CFUs) in pregnant pts due to increased risk of ascending infection (aka acute pyelo) (in the first trimester) - asx bacteruria also associated with preterm labor and low birth weight - treat with cephalexin, amox-clav (augmentin), nitrofurantoin, fosfomycin

Answer 50

unilateral bloody nipple d/c single dilated breast duct on mammogram and US - confirm ddx with biopsy and excision compare to infiltrating ductal carcinoma - would present with breast mass and LAD

Answer 51

can be isolated or as a manifestation of another autoimmune phenomenon sicca syndrome - generalized dryness of mucous membranes - dental caries, dry eyes, dyspareunia other manifestations - arthritis, Raynauds, respiratory tract involvement, increased risk for non-Hodgkins lymphoma

Answer 52

associated with HTN and placental insufficiency

Answer 53

= loss of fetal station FHR - tachy and recurrent decels emergency laparatomy

Answer 54

get a pregnancy test before CT/imaging if pt presents with acute onset abdominal pain ex if you suspect kidney stone - get US of kidney and pelvix

Answer 55

S aureus, group A strep, superantigen - tampon use, recent surgery, skin lesions/burns, sinusitis/nasal surgery - superantigen - exaggerated immune response --> shock and multiorgan failure high fever, hypotension, diffuse macular rash involving palms and soles --> desquamation, vomiting, diarrhea, AMS supportive therapy, removal of tampon, abx compare to gonorrrhoeae - pustular dermatitis, tenosynovitis, migratory asym polyarthralgia

Answer 56

1) breast development - 8-12 2) pubic hair 3) growth spurt 4) menarche approx 2-2.5 yrs after breast bud development, lack of menses < 15 is NORMAL (as long as secondary sex characteristics have been appropriate) - body weight needs to be 85-106lbs before menses can start - other things for menses - sunlight and sleep reevaluate if menarche does not occur by age 15 (16 according to first aid) OR if amenorrheic and no secondary sex characteristics at 13 (14 according to FA) - TSH, pelvic US (look for organs), MRI potentially when would you get a karyotype - if pt has no breast bud development and amenorrhea CT abdomen to look for adrenal tumor - can get cortisol levels Rokitansky-Kuster-Hauser - vaginal and uterine agenesis kallmann syndrome - treat with pulsatile GnRH true precocious puberty - ddx of exclusion - bone age is greater than chronological age - increased pulsatile GnRH secretion - tumors, CNS injury, congenital anomalies - pos stim test = central lesion, negative = peripheral lesion - treat with leuprolide idiopathic isosexual precocious puberty - early puberty

Answer 57

onset of contraction-10cm dilated - active phase starts at 6cm dilation - active phase progression - 1(-2)cm/hr note latent phase is before 6cm dil - prolonged is >20, >14 - treat with rest or augmentation of labor - DONT do amniotomy because this places pt at a greater risk of infection adequate contractions - contractions >200 MV units in a 10 min interval (summed) protraction - cervical change is slower than expected +/- inadequate contractions - -> oxytocin - if this doesnt help --> IUPC arrest - no cervical change for >4 hrs with contractions OR no cervical change for >6hrs with inadequate contractions --> amniotomy --> oxytocin --> C-section scenario - pt is contracting but you are not sure if her contractions are adequate - IUPC

Answer 58

note - ovulation on day 14, fertilization possible 24hrs after ovulation emergency contraception can cause the next period to be irregular cu iud - 0-120 hrs after intercourse, 99% efficacy (all other methods have less efficacy) ulipristal pill - anti-progestin, delays ovulation, 0-120hrs (5 days) levonorgestrel pill (plan B) - progestin, delays ovulation, 0-72hrs following intercourse OCPs (multiple pills taken simultaneously)- progestin, delays ovulation, 0-72 hrs

Answer 59

20-30 min of moderate intensity exercise on most/all days is recommended absolute contraindications - amniotic fluid leak, cervical incompetence, multiple gestation, placenta abruption or previa, premature labor, preeclampsia/gestational HTN, severe heart or lung disease - so in anything that is NOT normal gestation unsafe activities - contract sports, high fall risk, scuba diving, hot yoga

Answer 60

typically does NOT affect the quantity or quality of breast milk production

Answer 61

sxs - ....urinary incontinence and recurrent UTIs, pelvic pressure - bladder, urethra, pelvic floor muscles, and endopelvic fasica posses estrogen receptors - urinary sxs (can mimic UTI) - because genital and urinary tracts have a common embryologic origin - can have petechiae and fissures on exam on physical - narrowed introitus, loss of labial volume, ... treat with vaginal lubricant and topical estrogen - Ca daily - 1200mg in postmenopausal women (need increasing amts with age due to lower amts of active vitamin D) - HRT is the best treatment for severe menopausal sxs - smallest effective dose for shortest time - estrogen is most effective for hot flashes HRT - start wi 10 yrs of menopause or younger than age 60 - contraindications - CAD, breast cancer, prior DVT/stroke, liver disease - risks are increase in breast cancer and reduction in colon cancer - benefits - increased HDL, lowered LDL risk factors for osteoporosis - hx of fracture as an adult, low body weight, current smoker, FHx, white or asian, dementia or hx of falls, poor nutrition, estrogen def, alcoholism, insufficient activity - osteopenia - -1 to -2.5 - BMD and repeat every 2 yrs --> start bisphosphonates - other treatments - good diet, exercise, stop drinking and smoking - HRT has not shown benefits wrt osteoporosis note - if you remove ovaries in post menopausal woman --> she will experience vasomotor sxs again - because ovary is still producing androgens --> peripherally converted

Answer 62

placenta attached to myometrium - risk factors - prior c-section, hx of d&c, maternal age > 35 intraplacental villous lakes on US if antenatally diagnosed --> planned c-section hysterectomy

Answer 63

lady with curved spine - think compression fractures

Answer 64

this is allowed dr should honor this decision - schedule after 39 wks

Answer 65

pharmaceutical companies can support conferences where physicians receive CME credit

Answer 66

recommended for pts with RISK factors for osteoporosis before 65 osteoporosis - strongest predictor is FHx - age >50 (But bone breakdown begins after 35) - gender - small-frame, thin - heavy alcohol consumption best prevention - regular exercise (weight bearing)

Answer 67

ACOG - recommends that women 40+ yrs be offered annual mammograms US can be used an adjunct - evaluate inconclusive mammogram findings - women dense breast tissue - cyst v.s. solid mass

Answer 68

high risk individuals - start at 40 OR start 10 yrs before relative ddx and repeat every 5 yrs

Answer 69

recommended - tdap, flu, rhogam for high risk pts - hep A and B, pneumococcus, H flu (for high risk pts, so HIV, sickle cell dz, prior splenectomy), meningococcus, varicella zoster Ig MMR, varicella, HPV, live attenuated flu are contraindicated - can give MMR immediately PP

Answer 70

BMI < 18.5 - 28-40lbs gain 18.5-24.9 --> 25-25 lbs 25-29.9 --> 15-25 lbs >30 --> 11-20 lbs

Answer 71

increased risk for being carriers of cystic fibrosis | - carrier freq is 1/25 in the non-hispanic *white* population

Answer 72

first trimester combined test - nuchal translucency, PAPP-A, b-HCG triple screen - second trimester, AFP, bHCG< uE3 quad screen - second trimester triple + inhibin A sequential screen - first trimester nuchal translucency and PAPP-A + second trimester quad screen - second best detection rate, after cell-free DNA serum integrated screen (when unable to obtain nuchal translucency) - first trimester PAPP-A + second trimester quad screen cell-free DNA - best for detect of DS, detection rate of 99% ex: say fetus as increased NT --> next step to rule out anomalies is detailed fetal Us and echo at 18-20wks

Answer 73

fragile x syndrome side note - DS is genetic but the majority of cases are not inherited

Answer 74

gestational DM - risk factors - previous baby >9lbs, hx of abnormal glucose tolerance, pre-pregnancy weight for 110% or more of ideal body weight, ethnicity initially - start with diet and BG monitoring - values should be less than 90 fasting, less than 120 1-2hrs post-prandial babies born to diabetic mothers - increased risk of hypoglycemia, polycythemia and hyperbili, hypocalcemia, and respiratory distress

Answer 75

0.6mg/d for women with a previous pregnancy complicated by fetal neural tube defect - 4 mg/d

Answer 76

can take it until 32 weeks - at this time premature closure of DA becomes a risk

Answer 77

review prenatal records vitals and abd/pelvic exam a speculum exam with nitrazine test to confirm ROM - if pts hx suggests or if pt is unsure ************* pt cant deliver the baby with one or two pushes but fetus has descended and fetal HR is dropped --> operative vaginal delivery

Answer 78

normal contractions - <5 over a 10 min period (averaged over 30 min) if you place an IUPC and a significant amount of vaginal bleeding is noted - think placental separation or uterine perf - -> withdraw catheter and monitor the fetus - if fetal status is reassuring --> try to place IUPC again

Answer 79

elevate the fetal head with a vaginal hand - to avoid compression of cord AND arrange for c-section

Answer 80

flat nasal bridge, small, small rotated ears, sandal gap toes, hypotonia, protruding tongue, Simian creases, epicanthic folds, oblique palpebral fissures

Answer 81

if meconium present in the amniotic fluid and the newborn is DEPRESSED --> intubate the trachea and suction meconium, etc. from beneath the glottis - give surfactant meconium is present in more postterm pregnancy - 1) greater amt of time in utero, 2) fetal hypoxia

Answer 82

occurs in monochorionic pregnancies - most commonly in mono and diamniotic twins fat twin - plethoric not macrosomic - polycythemia is a complication for the plethoric twin - volume overload polyhydramnios --> HF and hydrops thin twin - IUGR, oligo both twins have high risk of death in utero - surviving twin has increased risk of neurological morbidity and CP - recipient twin, excess volume - cardiomegaly, tricuspid regurg, v hypertrophy, hydrops fetalis - donor twin - anemic, high-output HF, hydrops

Answer 83

``` activity pulse grimace, response to stimluation appearance respiration ``` infant born and shows no respiratory effort - give pos pressure ventilation and intubate - -> adjust head to sniffing position, 10L/min O2 flow, .... DONT give naloxone if mom is on narcotics --> life-threatening withdrawal for infant

Answer 84

screen in first trimester, screen high risk pts again in the 3rd trimester testing for viral load and CD4 count (1-3mo) HAART antepartum and IV zidovudine during labor - viral load <1000 - continue HAART and vaginal delivery - >1000 - zidovudine and c-section start AZT (zidovudine) immediately after delivery in infant, for >6 weeks - test baby for HIV at 24hrs - and serial testing - for mom's who didnt receive antepartum HAART, add nevirapine DONT breastfeed less than 1% transmission risk for moms who have undetectable viral loads **************** HAART = 2NRTIs and NNRTI/protease inhibitor

Answer 85

begins w/i 2wks - 6 mo delivery - mood changes, insomnia, phobias, irritability signs and sx of depression that last <2wks = PP blues, self-limiting PP depression - may see ambivalence toward newborn most sig risk factor is prior hx of depression treatment - SSRIs - fluoxetine - causes insomnia - SSRIs can be used safely during lactation SI with plan - inpt management

Answer 86

initially colostrum produced --> next 2-3d milk will be produced, after prog and estrogen are cleared belly-to-belly is required for good latch --> poor latch --> cracked and bleeding nipples things that promote breast-feeding - baby on breast within and hour of delivery and unlimited access to baby how you know the baby is getting adequate milk - 3-4 stools/24hrs - 6 wet diapers/24hrs - weight gain - sounds of swallowing how to help with engorgement - frequent nursing, warm shower/compress to enhance milk flow - massage breast + hand express - wearing a good support bra - use analgesic 20 min before feeding **************** breast candidiasis - severe discomfort and pain - antifungal topical - clotrimazole or miconazole - can add topical antibiotic or mupirocin be S. aureus often co-exists with nipple fissures - topical steroid crem to faciliate healing - check baby's oropharynx and treat baby with oral nystatin then oral fluconazole ********************* best method to suppress lactation - breast binding, ice packs, analgesia - avoid breast stimulation (--> natural inhibition of prolactin secretion) bromocriptine associated with HTN, stroke, seizures OCPs, hormones - associated with thromboembolis, rebound engorgement

Answer 87

DONT give I-131 - will accumulate in the fetal thyroid --> congenital hypothryoidism thyroid storm - propranolol, PTU, sodium iodide, dexamethasone

Answer 88

pts with pulm HTN - 25-50% risk of death | - similar risk with aortic coarctation with valve involvement or Marfans with valve involvement

Answer 89

clicking systolic ejection murmur sxs - anxiety, palpitations, atypical CP, syncope for symptomatic women - b-blocker

Answer 90

risks - chronic *HTN*, GDM, **preeclampsia**, fetal macrosomia, C-section, PP complications

Answer 91

NSAIDs for athralgias and serositis severe disease - corticosteroids hydroxychloroquine - control skin manifestations

Answer 92

breast cancer is more aggressive in younger women delays of 1-2 mo in clinical workup are common in pregnant women with breast tumors

Answer 93

clinical findings - fever, N&V, mid-abd pain - note enlarged uterus shifts the appendix up and out towards the flank ddx by graded compression US

Answer 94

amnio, CVS, abortion, ectopic, D/C, abruption, hemorrhage, preeclampsia, C-section, manual removal of placenta, external version risk = 20% how to test for fetal anemia - peak systolic velocity in MCA - invasive techniques include amniocentesis and cordocentesis fetal hydrops - develops in the presence of decreased hepatic protein production --> collection of fluid in 2(+) body cavities - ascites, pericardium, pleural fluid, scalp edema - can see this on US - sometimes if extramedullary hematopoiesis is extensive --> HSM - placentomegaly (placental edema) and polyhydramnios Lewis antibodies are IgM - DONT cross placenta bilirubin in amniotic fluid is a sign of hemolysis - spectrophotometric measurements Liley curve - OD450 deviation v.s. gestational age, tells of hemolytic disease - zone 3 - means the baby will die in 7-10d --> immediate delivery or fetal tranfusion - first step in treatment - intravascular transfusion into umbilical vein (otherwise intraperitoneal transfusion) - maternal plasmapheresis where intrauterine transfusions are not possible

Answer 95

AFP is doubled in twin pregnancies, fundal height will exceed GA - other reasons for high AFP = ...pilonidal cysts, cystic hygroma, sacrococcygeal teratoma, fetal death twin death rate is 5x that of singletons - risk of CP is 5-6x higher - twins have a higher incidence of IUGR and premature delivery - how to prevent premies and low birth weight- adequate weight gain in the first 20-24 wks gestation - increased risk of congenital malformations - MOST concerning complication - premie fraternal twins signs - dividing membrane thickness > 2mm - twin peak (lambda) sign, diff gender, A&P placentas superfecundation - two ova fertilized separately during the same cycle ****************** identical twins diamniotic dichorionic placentation - division prior to morula state (3d post fertilization) diamniotic monochorionic placentation - 4-8d post fertilization monoamniotic monochorionic - division between d8-12 division at or after 13 d --> conjoined twins ********** when twin A is breech --> C-section

Answer 96

factor V is unable to be inactivated by protein C associated with *stillbirth*, preeclampsia, placental abruption, and IUGR fetal demise - fetal HC wont match with age wont match with bone lengths

Answer 97

associated with stillbirth, preeclampsia, gestation DM, IUGR

Answer 98

denial, anger, bargaining, depression, and acceptance DABDA

Answer 99

yolk sac, appropriate levels of hCG and progesterone - even if there is no heartbeat - repeat US in 7 days missed abortion - CRL > 7mm + no cardiac activity - medical induction with misoprostol - methotrexate for ECTOPICs, can be used for intrauterine pregnancies if LMP < 6wks ago

Answer 100

because *VBACs* have decreased - due to increased risk of complications (uterine rupture) also many obs dont perform vaginal breech deliveries or instrumental vaginal deliveries

Answer 101

risk of placenta accreta - previous c-sections and low anterior placenta uterine rupture is a lesser risk

Answer 102

contains fibrinogen and clotting factors V and VII cryo - fibrinogen, factor VIII, and vWF

Answer 103

*placental abruption*, placenta previa, FGR, preeclampsia, and infection

Answer 104

cervix is extremely vascular and bleeds during DILATION normal

Answer 105

polyps (soft) v.s. cancer (hard) - risk factors for cancer are lack of healthcare f/u, smoking hx, etc. polyps are benign - polypectomy (note colposcopy is to test for cervical dysplasia) nabothian cysts- doesnt cause bleeding

Answer 106

age of consent is 16 yo antibiotic ppx should be offered to all adult rape victims immediately after rape - samples for evidence, serology/STIs, pregnancy test, emergency contraception, and antibiotics - at 6 wk f/u - repeat serology for syphilis and HIV (syphilis takes 6wekks to become detectable, 6 mo for HIV) physical and sexual abuse is associated with chronic - so think in a lady with a new partner and recent onset pelvic pain intimate partner violence - woman chooses to report this to the police (child abuse has to be reported)

Answer 107

estrogen cream - if using longterm, add progestin due to potential systemic absorption concerns - estrogen is contraindicated with breast cancer ddx water-based lubricants (NOT pet jelly) - normally - lubrication during arousal phase is due to transudation across vaginal mucosa from increased blood flow sexual stimulation promotes blood flow to genitalia ... less dyspareunia oral prog - helps decrease hot flushes side notes - thin habitus and tamoxifen are associated with lowered estrogen effects

Answer 108

perpetuated by a cycle of anxiety and pain treatment - vaginal dilators + counseling note - sensate focus is a therapy indicated for arousal and orgasmic disorder

Answer 109

symptomatic cancer - usu bleeding/spotting - sometimes discharge most sig risk factor - obesity - esp when pt is 50lbs over ideal body weight - other risk factors - ... DM but an even more sig risk factor is complex atypical hyperplasia --> 29% chance of progressing to invasive cancer - 30% of women with CAH will have invasive endometrial cancer on final bx in postmenopausal women - thin endometrium does not exclude risk of non-estrogen dependent endometrial cancer treat with - hysterectomy + BSO + pelvic and para-aortic lymphadendctomy - note endometrial ablation is contraindicated in pt with endometrial cancer

Answer 110

fibrocystic change - associated with cyclic mastalgia - caffeine intake can increase the pain that is associated with fibrocystic change breast lump --> FNA (regardless of normal mammo) - clear fluid and mass resolves --> re-examine in 2 mo - yields bloody fluid --> excisional bx - FNA is negative --> excisional bx to rule out false negative result

Answer 111

major sx = heavy menstrual bleeding (due to increased surface and vasculature disruption) submucosal or intracavitary myomas are most likely to interfere with pregnancy - but RARE - treat with hysteroscopic resection - exclude other causes of infertility first fibroids may grow or become symptomatic in pregnancy due to hemorrhagic changes associated with rapid growth = red or carneous degeneration rarely, fibroids can be located below the fetus --> C-section due to soft tissue dystocia temporary treatment (3-6 mo) = GnRH agonists - temporarily reduces sxs and reduces myoma size - stop treatment - everything returns to persons baseline in 3-4 mo *get embx in women over 40 with irregular bleeding*

Answer 112

greatest risk factor is related to HPV exposure - so for a pt with a vaginal condyloma - consider that she has been exposed to the high risk HPV types as well not genetically inherited if you cant visualize a lesion in the endocervical canal --> conization or co-testing at 12 and 24 mos - conization (aka with cold-knife or leep) will provide a sample - you can test for invasive cancer microinvasive cancer - 3mm beyond BM stage 2 - involvement of parametria stage 3 - involvement of side wall concerning path findings - punctuations and mosaicism = new blood vessels - **atypical vessels** - greater angiogenesis - ectropion (red ring of tissue around ext os) - columnar epithelium that has not undergone squamous metaplasia - acetowhite changes can indicate dysplasia pos endocervical curretage --> cervical conization (for further ddx) - note cryo will not provide you with a sample but can be used to treat dysplasia (after cancer has been ruled out) *********************** side note - HPV can cause oral cancer - bleeding, mass, dysphagia

Answer 113

deliver baby - can vaginally if fetal heart tones are reassuring low amniotic fluid glucose is the best indication

Answer 114

Mag sulfate contraindicated in myasthenia - Mag sulfate works as a tocolytic by competing with Ca entry into cells terb and ritodrine are contraindicated in diabetics methylergonovine - ergot, potent smooth muscle constrictor, contraindicated in HTN/preeclampsia PGF2a (hemabate) - has bronchio-constrictive effect, contraindicated in asthma

Answer 115

b-agonists like terbutaline increase cAMP in the cell - decrease free calcium side effects - tachy, hypotension, anxiety, CP or tightening terb has been found to not be effective and is dangerous if used for longer than 48 hrs

Answer 116

*vaginal fluid* ferning and nitrazine testing DONT do digital exam in pt with PPROM - risk of introducing bacteria PPROM - tocolysis may be administered in so steroids can give maximum effect - risk of chorio with tocolytics beyond 48hrs ROM outweighs benefits of lung maturity for PPROM - give amp and erythromycin --> prolongs latency period for 5-7d (better than tocolytics), reduces incidence of amnionitis and neonatal sepsis to prevent - 17-a-hydroxyprogesterone - give weekly from 16-20 weeks --> 36 weeks gestation

Answer 117

begin in luteal phase, resolve shortly after onset of menses PMS is milder than PMDD (mood sxs) - PMS becomes more common as women age risk factors for PMS - fhx, B6, *calcium*, or Mg deficiency - for PMDD - psych hx treat pain with NSAIDs treat PMDD with OCPs - suppresses HPA - SSRIs also work - pts can take the medication only during the luteal phase if they like

Answer 118

infection risk is due to mode of delivery - C-section - vaginal birth + prolonged labor, prolonged ROM, multiple vaginal examinations, internal fetal monitoring, removal of placenta manually, low socioeconomic status endometritis - mat tachy and fever - risk factors - c-section, chorio, GBS pos, prolonged ROM, operative vaginal delivery, prolonged labor, multiple vaginal exams - polymicrobrial, anaerobes - treat until afebrile for 24hrs, amp/*clinda* and genta (gram negatives) - note erythro good for URI, cipro good for g neg and pseudomonas acute cystitis - risk is increased with indwelling catheter - *ecoli*, proteus, kleb, others mastitis breast engorgement lungs - are the most common source of fever on PP day 1 - esp if pt had general anesthesia - atelectasis may be associated with PP fever PP wound infection 1) open wound, check for fascial dehiscence, drainage and assessment of fluid 2) packing wound 3) broad spectrum antibiotics for cellulitis or abscess septic pelvic thrombophlebitis (venous system) - high fever not responsive to antibiotics - ddx of exclusion - treat with anticoags, in the short term

Answer 119

1) fetal heart tones for 30 wks by doppler 2) 36 wks since pos serum or urine HCG 3) 30 US of crown-rump length obtained at 6-12 wks supports gestation of 39 wks 4) US at 13-20 wks confirms gestational age of 39 wks (determined by clinical and physical exam) crown-rump length will reliably date a pregnancy w/i 5-7 d (in the first trimester?) if woman presents with discrepancy in size and dates --> pelvic US to confirm dates, exclude multiple gestations, uterine abnormalities, and molar pregnancy

Answer 120

if you see fatty appearing tissue - that means youre sucking out omentum - -> laparoscopy will allow closer examination - -> laparotomy can be used for closer evaluation

Answer 121

vacuum cup -...risk neonatal jaundice (cephalohematoma?), transient neonatal lateral rectus paralysis

Answer 122

most likely complication is risk of future pregnancy, <1% tubal has a protective effect on ovarian cancer incidence

Answer 123

CVS - 10-12 wks - CVS before 10 weeks is associated with an increased risk in rare limb abnormalities - more likely to involve multiple attempts - failure to obtain adequate sample, requires repeat test later on - loss rate - 1-3% (NOT related to prior miscarriage) amnio - after 15 wks - loss rate - 0.5%

Answer 124

aka bladder pain syndrome chronic inflammatory condition - urine culture negative but signs of UTI pelvic pain reported by 70% of women, dyspareunia can also occur tenderness over anterior vaginal wall

Answer 125

pelvic varicosities presents with premenstrual or pain during pregnancy - aggravated by standing, fatigue, coitus - pelvic fullness or heaviness - associated sx - vaginal discharge, backache and urinary frequency

Answer 126

following pelvic surgical procedures * iliohypogastric (groin and pubis), ilioinguinal nerves (groin, pubis, labium, and upper inner thigh) (T12-L1) - susceptible to injury with low transverse incision injury to obturator nerve --> inability to abduct thigh

Answer 127

overflow incontinence - failure of bladder to empty adequately - postvoid residual >300 cc (nl is 50-60cc) - due to underactive detrusor muscle or obstruction (postop, prolapse) - treat with cholinergic agonists and intermittent cath stress incontinence - bladder P > urethral P - due to *urethral hypermobility* and/or intrinsic sphincter deficiency - lifestyle modification, pelvic floor exercise, pessary, pelvic floor surg (urethral sling) - retropubic urethropexy = best - for instrinsic sphincter deficiency (so urethral doesnt move)- urethral bulking procedure overactive detrusor contractions - can override urethral pressure resulting in urine leakage - lifestyle, bladder training, antimuscarinics - oxybutynin - anticholinergic properties mixed - stress and urge pseudoephedrine - a-adrenergic properties, may improve urethral tone in stress incontinence - bethanechol for overflow incontinence (neuropathy) vaginal estrogen has been shown to help in urgency transvaginal tape can be used for urinary incontinence ************** risks for pelvic organ prolapse - increasing parity (increased risk with vaginal delivery), increasing age, obesity, CT disorders, chronic constipation, FHx (increases risk 2.5 fold) - treat uterine prolapse by colpocleisis - cystolcele by anterior repairs

Answer 128

BX vulvar cancer risk factors - HPV, smoking, vulvar dystrophy (lichen sclerosis, specifically the pruritus is an issue), immunocompromised state lichen simplex chronicus - NON-neoplastic - topical corticosteroids and antihistamines lichen sclerosis - treat with steroids --> itch-scratch cycle --> can progress to squamous cell carcinoma - which would need to be resected (but less than 5%) chance - extreme vulvar pruritus, dyspareunia,... scarring with loss of architecture, stenosis, resorption of clitoris and labia minora - can have perianal involvement in figure 8 - premenarchal or postmenopausal - note SCC is 90% of vulvar cancers - treat with high-potency steroids - clobestasol (- disease can be autoimmune related) pagets disease - plaque-like lesions and poorly demarcated erythema - with hyperkeratotic overlay melanoma and high-grade vulvar intraepithelial neoplasia - have a similar appearance - for VIN3 (white plaques) - superficial local excision + close f/u Bartholin gland firm mass (esp in postmenopausal woman) = suspicious for malignancy - fixed nature of the mass - adenocarcinoma HPV-related conditions - condyloma - vulvar dysplasia path says cancer --> radical vulvectomy and groin node dissection would not laser a malignant lesion - can laser multiple VIN2 lesions cryotherapy for cervical dysplasia

Answer 129

hysteroscopic tubal occlusion (essure) - need back-up contraception for 3 mo --> hysterosalpingogram confirming tubal occlusion - can be done in office tubal - but consider pt's risk for surgery **************** vasectomy done under local anesthesia

Answer 130

medical abortion associated with higher blood loss than surgical abortion - mifepristone (antiprogestin, termination) and misoprostol (PG, induces contractions) - if heavy bleeding - likely due to retained products of conception --> D&C manual vaccuum aspiration - < 8 weeks oxytocin ineffective because those receptors have not been upregulated at early gestational ages concerned about endometritis - begin abx, then look for retained products of conception (US)

Answer 131

idiopathic treat with TCADs, pelvic floor rehab, biofeedback, topical anesthetics vulvadynia - treat with estrogen cream and clobetasol

Answer 132

post-exposure ppx - 7 d after blood contact, 14 d after sexual exposure - 1 dose HBIG and HBV series - if source is HBsAG neg or unknown, then only use HBV series - vaccinated person and responder - no further treatment needed incubation period for virus is 6 mo

Answer 133

starts on day 1 of menses, follicular phase, ovulation, luteal phase follicular phase - estrogen and progesterone are low --> shedding - FSH increases - stimulates follicle development - then FSH decreases - single follicle dominates ovulation - LH surge (and FSH surge) - danazol blocks this - estrogen peaks during surge, progesterone begins to rise luteal phase - LH and FSH decrease - ruptured follicle closes and produces progesterone - estrogen and progesterone thicken lining for implantation - if egg is not fertilized, follicle degenerates inhibin - increased in luteal phase

Answer 134

premies - intraventricular hemorrhage, RDS

Answer 135

concerning d/c - serous, bloody, unilateral, skin changes benign - guaiac, TSH, prolactin, UPT cytology for unilateral or guaiac pos d/c meds - dopamine inhibitors, combined OCPs (stimulate lactotrophs), H-blockers (cimetidine) can inhibit estradiol mechanism...

Answer 136

SCC - the usual, posterior vaginal wall clear cell adenocarcinoma - <20 yo, DES, anterior vaginal wall clinical features - malodorous vaginal d/c, bleeding, irregular mass/plaque or ulcer on vagina BX side note - local metastatic dz to vagina is more common than primary disease

Answer 137

ovarian arteries off the aorta

Answer 138

PALM COEIN polyps, adenomyosis, leiomyomas, malignancy - endometrial polyp - observation, medical management with progestin, curettage, polypectomy, DONT observe if polyp is > 1.5 cm coagulopathy (vwf, may show up as menorrhagia), ovarian dysfunction, problems of endometrium, iatrogenic (IUD), other during pregnancy - viable, ectopic, abortion, subchorionic hemorrhage - check mat blood type...Rhogam

Answer 139

chlamydia treatment - doxy, re-infection by partner is a cause of recurrent infections frequent UTIs - postcoital single-dose nitrofurantoin therapy

Ob-Gyn Flashcards

(163 cards)