1
Q
HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome presentation during pregnancy
A
-worsening RUQ pain due to gradual distension of hepatic (Glisson) capsule
-HTN
-proteinuria
-microangiopathic hemolytic anemia
-elevated transaminases
-thrombocytopenia
-widespread endothelial dysfunction leading to microangiopathy, overactivation of coagulation cascade, and excessive platelet consumption
2
Q
life threatening complication of preeclampsia with severe features
A
-pulmonary edema
-caused by increase SVR, capillary permeability, and pulmonary capillary hydrostatic pressure and decreased serum albumin levels
3
Q
preeclampsia with severe features presentation
A
greater or equal 20weeks + HTN (140/90) + HA with vision changes (blurry vision)
increases risk of acute stroke due to endothelial cell damage, dysregulation of cerebral blood flow, cerebral vasospasm, vascular micro thrombi formation
4
Q
Complete abortion
A
passage of products through cervix at <20weeks
-cervix then closes
-pain and bleeding subside
-Ultrasound: empty uterus
5
Q
Transverse lie: presentation and management
A
-fetal spine perpendiculat to long axis of uterus
-common at early gestational ages
-most spontaneously convert to longitudinal lie and cephalic by term (equal or greater 37w)
-preterm transverse lie manangement: expectantly
6
Q
acute postpartum urinary retention: presentation and RF
A
-inability to void and overflow incontinenece due to pudenal nerve injury and bladder atony
-RF: prolonged labor, perineal trauma, regional neuraxial anesthesia
7
Q
Granulosa cell tumor results in?
A
Granulosa cells: primary component of ovarian stroma. converts testosterone to estradial via aromatase
-high levels estrogen and inhibin
-malignant proliferation (sex cord stromal tumors of ovary) results in high estradial levels that affect breast tissue (tenderness, fibrocystic changes) and uterine lining (postmenopausal thickened endometrium)
-px: large ovarian mass + postmeno bleeding (due to endometrial hyperplasia from chronic unopposed estrogen)
-NBS: endometrial biopsy
-juvenile subtype granulosa cell tumors present with precocious puberty and adnexal mass
8
Q
What is ulipristal? MOA
A
-highly effective emergency contraception
-delays ovulaton and impair implantation
-can take up to 120 hours after unprotected sex
9
Q
What is the most accurate way to deteremine estimated gestation age?
A
Ultrasound dating with fetal crown-rump measurement in 1T
10
Q
Signs concerning for breast malignancy (unilateral, blood tinged breast milk or bloody nipple discharge, new breast mass) NBS?
A
breast imaging
11
Q
What is cervical insufficiency?
A
structural weakness of cervix that causes painless cervical dilation and potential 2T pregnancy loss.
-px: mild symptoms (increased vaginal discharge, light vaginal bleeding, pelvic pressure), on exam, bulging amniotic membranes may be seen
managed with prophylactic cerclage performed in 1T to decrease risk of recurrence
12
Q
RF for cervical insuffiency
A
prior cone biopsy (cervical conization)- shortens cervix and alters structural integrity
13
Q
Nonclassic congenital adrenal hyperplasia cause and presentation
A
-partial 21 hydroxylase deficiency
-reproductive age with hyperandrogenism (hirsutism, acne) and AUB
-elevated 17-hydroxyprogestrone level
14
Q
Cervical cancer cause and presentation
A
-cause: high risk 16/18 HPV
-an AIDS defining illness
-px: postcoital bleeding, painless ulcerative lesion, painless inguinal lymphadenopathy, irregular bleeding, vaginal discharge, visible raised cervical lesion
confirm: biopsy
15
Q
Why are estrogen containing contraceptives contraindicated in pts with migraine with aura?
A
-increase for ischemic stroke
-migraine: episodic, severe, unilateral throbbing HA; photophobia , phonophobia, N/V, aura (focal, reversible, neurologic symptoms that precede or accompany HA)
16
Q
What is physiologic leukorrhea?
A
-white, odorless mucoid cervical discharge occurs midcycle due to increasing estrogen prior to ovulation
-microscope: no evidence of inflammation or infection (rare polymorphonuclear leukocytes)
17
Q
Uterine rupture: px, RF, mx
A
-Px: ab pain, fetal heart tracing abnormalities, progressively decreasing contraction amplitude, loss of fetal station
-RF: prior uterine surgery (C section)
-Mx: emergency laparotomy and C section
18
Q
What is androgen insensitivity syndrome?
A
-nonfunction androgen receptor leads to peripheral androgen resistance
-genotypically male (46XY) to appear phenotypically female
-primary amenorrhea (due to lack of female internal genitalia), normal breast and female external genitalia, minimal or no axillary/pubic hair
19
Q
Benign breast pain signs
A
-cyclic (a.w menses), bilateral, and diffuse, no mass
-reassure and symptom management (supportive bra, NSAIDs)
20
Q
Management of uncomplicated (no fever or purulence) perineal lacerations
A
-common after vaginal delivery
-causes perineal edema and pain with urination
-Mx: conservative (NSAIDs, sitz bath)
21
Q
Gestational diabetes mellitus screening when?
A
-at 24-28 weeks with 50 g oral glucose challenge test
-earlier screening (at initial prenatal visit): for pts with obesity and additional RF for undiagnosed pregestational DM (prior macrosomic infant, PCOS)
-during 2T and 3T, placental hormones increase maternal insulin resistance, which can result in pathologic maternal hyperglycemia and fetal macrosomia
22
Q
What is postpartum thyroiditis?
A
-form of painless AI thyroiditis within 12 months of delivery
-px: signs of hyperthyroidism (weight loss, tremor, elevated T4 and T3) and low uptake on RAI uptake scan
23
Q
Stress urinary incontinence occurs due to? txt?
A
-Weakened pelvic floor muscles that cause urethral hypermobility and reduced bladder support
-intermittent loss of urine from increased intraabdominal pressure (lifting, coughing, laughing, jogging, sex)
-first line txt: pelvic floor muscle (Kegel) exercises or surgical midurethral sling placement
-common in postmenopausal women due to weakened pelvic floor muscles and urogenital mucosa atrophy
24
Q
Ovarian torsion: px and mx
A
-rotation of ovary around infundibulopelvic ligament, causing ovarian vessel occlusion and ischemia
-px: n/v, new onset severe unilateral pelvic pain, adnexal tenderness, palpable adnexal mass
-mx: emergency requiring diagnostic laparoscopy
25
What is cornual ectopic pregnancy?
-pregnancy implantation in upper outer corner of uterine fundus
-highly vascular and rupture can cause life threatening intrabdominal hemorrhage
-hemodynamically unstable + hemoperitoneum = emergency surgical exploration
26
When do you give intrapartum antibiotic (penicllin) prophylaxis for GBS?
-unknown GBS status
-RF for vertical transmission: ROM for more than 18 hours, intrapartum fever, fetal prematurity (<37 weeks)
27
What are early decelerations?
uniform, shallow decels with gradual onset that occur symmetrically with contractions
-nadir at peak of contraction and return to baseline at end of contraction
-benign finding caused by fetal head compression
-expectant management
28
IUD have higher risk for what? Dx?
-lower absolute risk for ectopic pregnancy but higher risk for ectopic implantation
-dx: transvaginal US, better visual of pelvic structures compared to transab US
29
PCOS causes infertility due to? Px?
-anovulation
-Px: irregular menses, enlarged ovaries, signs of insulin resistance
30
Ovulation can be induced in PCOS with?
letrozole (aromatase inhibitor)
31
What is pelvic organ prolapse?
-herniation of pelvic organs (rectum) into vagina
-due to damage levator ani muscle complex
-prolapse vaginal wall (rectocele): chronic constipation and vaginal bulge
32
What is postpartum endometritis?
-fever >24h postpartum, uterine tenderness, purulent or malodorous lochia
-polymicrobial infection of uterine decidua
-if symptoms do not improve with antibiotics, do blood cultures and pelvic US to exclude retained products and pelvic abscess
-txt: clindamycin + gentamicin
33
What is rectus abdominis diastasis?
weakening of linea alba between rectus abdominis muscles
-px: nontender ab bulge in pregnant or postpartum
-mx: conservation with observation and reassure
34
life threatening complication of epidural anesthesia
high spinal anesthesia or accidental injection of local anesthetic into subarachnoid space that causes ascending motor, sensory, and sympathetic blockage.
-at risk for respiratory paralysis (dyspnea, hypoxemia)
35
what is genitourinary syndrome of menopause (atrophic vaginitis)
-low estrogens causes decrease vulvovaginal tissue elasticity and blood flow
-dyspareunia due to narrowing of vaginal introitus and dryness from loss of natural lubrication
-vaginal pruritis, thin vulvar skin with decreased elasticity, pale/dry vagina
-Tx: lubricants or moisturizers; vaginal estrogen for persistent or severe symptoms
36
When is a biophysical profile performed? What is an abnormal test?
-in patients at risk for uteroplacental insufficiency (equal or greater than 41 weeks)
-chronic hypoxemia causes abnormal BPP score and suggests imminent risk of fetal demise; delivery is indicated
37
what is sertoli-leydig tumors
testosterone secreting sex cord stromal ovarian tumors that present with rapid onset virilization (bitemporal hair thinning, clitoromegaly, voice deepening increased muscle bulk), amenorrhea, large pelvic mass, signs of estrogen def (breast atrophy, vulvovaginal atrophy)
38
endometrial polyps presentation and treatment
regular monthly menses + intermenstrual bleeding
-symptomatic polyps are treated with hysteroscopic polpectomy
39
When does endomentrial cells on Pap require additional evaluation (biopsy)?
-when they are symptomatic (AUB) or high risk for endometrial hyperplasia and cancer (obesity)
40
pregnancy presentation in perimenopausal women
insomnia, fatigue, weight gain, amenorrhea, enlarged uterus
-evaluate with hCG levels
41
Low back pain is common in 3T due to?
postural changes, weakended abdominal muscles, joint/ligament laxity
-reassure and conservative mx (exercise, heating pads, massage)
42
Turner syndrome patients are at risk for?
-AI disorders, including celiac disease which can present with signs of micronutrient malabsorption (IDA, vit D def) without overt GI symptoms.
-first step evaluation: tissue transglutaminase antibody level measurement
43
What is gestational thrombocytopenia?
-usually asymptomatic (no bruising, bleeding, anemia)
-mildly reduced platelet counts of 100-150k
-benign, self limited, reassure and observe
44
what is pemphigoid gestationis?
-AI disease in 2T or 3T
-pruritis, erythematous plaques that involve umbilicus that develop into vesicles and bullae
-Tx: high potency topical corticosteroids
45
Neuraxial anesthesia (epidural) can cause sympathetic block resulting in?
-maternal hypotension and decreased placental perfusion = recurrent late decelerations
-mx: left lateral positioning, IV fluidbolus, vasopressors (phenylephrine)
46
What is active phase arrest
- occurs at cervical dilation of >6cm and no cervical change in 4h with adequate contractions or 6h with inadequate contractions
-labor arrest managed with C section
47
what is vasa previa
-fetal vessels overlie cervix, making them prone to tear and bleed with ROM or contractions
-painless vaginal bleeding and rapid fetal deterioration or demise
-Mx of ruptured fetal vessel: emergency section because of high risk of fetal exsanguination and demise
48
short interpregancy intervals (<6-18 months between delivery and next pregnancy) are a/w?
preterm labor, preterm prelabor ROM, low birth weight
49
First stage of labor
latent phase (0-6 cm)
active phase (6-10 cm)
normal labor progession: equal or greater 1cm every 2h
50
What is preeclampsia? what is severe features
new onset HTN at >/20 weeks + proteinuria or signs of end organ damage (renal dysfunction)
-severe features: serum creatinine >1.1 or transaminases >2x normal. This increases morbidity (abruptio placentae, fetal demise)
51
Severe HTN increase maternal risk for? fetal risks?
Severe range HTN: systolic 160+ or diastolic 110+
Mom: stroke, pulmonary edema, MI
Baby: abruptio placentae and intrauterine demise
treat: hydralizine, labetalol, nifedipine
52
what is local anesthetic systemic toxicity?
-a complication of epidural
-can cause CNS overactivity (perioral numbness, metallic taste, tinnitus) and generalized tonic clonic seizures
53
what is hidradenitis suppurativa?
-chronic inflammatory condition in intertriginous areas (inguinal region)
-lesions occur due to occluded follicles that cause painful nodules and abscesses that can develop into draining sinus tracts and significant scarring
54
what is antiphospholipid antibody syndrome?
-prothrombic AI disorder presents with recurrent pregnancy loss, arterial or venous thrombosis (transient ischemic attack), mild thrombocytopenia, stillbirths
-stillbirths occurs due to uteroplacental artery thrombosis, leads to uteroplacental insufficeincy and asymmetric fetal growth restriction
-APS pts require anticoagulation (LMWH in pregnants) to decrease risk of complications
55
what is amniotic fluid embolism syndrome
rapid onset respiratory failure, obstructive shock with severe hypotension, DIC during labor or immediate postpartum period.
-Dx is clinical and managed supportively (intubate with mechanical ventilation)
56
Breech + contraindications to vaginal (prior c section, placenta previa)
external cephalic version not recommended, do a c section
57
Leiomyomata uteri (uterine fibroids) can cause what in pregnancy
uterine size greater than date discrepancy and irregular uterine contour
58
pregnancy can worsen diabetic kidney disease leading to?
HTN, elevated creatinine, frank proteinuria.
59
RF for superficial surgical site infection (cellulitis)
RF: obesity and emergency surgery (inadequate skin antisepsis or antibiotic prophylaxis)
-can occur after c section and presents with postpartum fever and incisional induration and erythema
60
what is placenta previa
-placenta covers cervix, creating potential massive antepartum painless hemorrhage from cervical dilation
-maternal blood loss, fetal monitor reassuring
-labor and vaginal delivery CI; c section at 36-37 weeks
-asymptomatic: routine care and 3T US; pelvic rest
-RF: prior c section
61
what is hyperemesis gravidarum
severe, persistent n/v leading to inadequate gestational weight gain and weight loss of >5% of prepregnancy weight, electrolyte abnormalitis, ketonuria
-increase risk for fetal growth restriction and preterm delivery
62
chlamydia trachomatis urethritis
-dysuria + sterile pyuria
-do nucleic acid amplification testing for C + G
63
what is endometrial ablation
minimimal invasive procedure that destroys and/or resects endometrial lining to decrease uterine bleeding
-candidates: ovulatory (cyclic) heavy menstrual bleeding, no plans for future fertility, low risk endometrial malignancy
-causes intrauterine scarring and adhesions that limit future endometrial evaluation (endometrial biopsy), ablation is CI in pts at high risk for endometrial cancer (postmenopausal, Lynch syndrome)
64
elevated maternal serum alpha-fetoprotein meaning
-congenital defects (ab wall defect, open neural tube defect)
-next: fetal anatomy US
65
what is choriocarcinoma
metastatic form of gestational trophoblastic neoplasia that may occur after a hydatidiform mole, normal pregnancy, or spontaneous abortion.
-lungs are frequent site of mets
-suspect in postpartum women with enlarged uterus, irregular vaginal bleeding, pulmonary symptoms, multiple infiltrates on CXR
-Dx: confirmed with elevated b-hCG
66
what is PCOS
-irregular menses and hyperandrogenism
-infertility due to anovulation from failed follicular maturation
67
prescribe ___ for pts at high risk for preeclampsia (multiple gestations, prior preeclampsia)
low dose aspirin at 12-28 weeks (optimally before 16 weeks)
68
what is endometriosis
-ectopic implant of endometrial tissue in the abdomen and pelvis
-chronic inflammation, pain, fibrosis
-indications for txt: chronic pelvic pain, dysmenorrhea, dyspareunia, infertility. txt with NSAIDs and/or combined OCP, which treats inflammation and suppress stimulation of endometriosis
-failed medical management can go for laparoscopy
-asymptomatic: observe and reassure
-increased risk of infertility due to chronic pelvic inflammation, adhesions, distorted pelvic anatomy
-exam: lateral cervial displacemnet or cervical motion tenderness
-bladder implant: cyclic hematuria, dysuria, suprapubic tenderness, negative urine culture
69
uncomplicated preterm prelabor ROM at <34weeks management
expectantly with prophylactic latency antibiotics, corticosteroids, inpatient monitoring.
delivery is at 34 weeks or earlier if complicated (intraamniotic infection, placental abruption)
70
what is polymorphic eruption of pregnancy?
3T, pruritic erythematous papular rash that is limited to abdominal striae and spares umbilicus
-resolves spontaneously, txt: topical corticosteroids
71
genital tract trauma (vaginal laceration) can cause?
postpartum hemorrhage.
72
systemic lupus erythematosus flare complicated by nephritis presentation
HTN during pregnancy with edema, joint pain, malar rash, UA with proteinuria and RBC casts
73
what is cell free fetal DNA testing
noninvasive and highly sensitive and specific screening test for fetal aneuploidy (trisomy 21,18,16)
-perform at more than 10 weeks
-abnormal results confirmed by chorionic villus sampling or amniocentesis
74
RF for breech presentation
uterine leiomyomas, which can distort uterine cavity, thereby limiting fetal mobility and preventing fetal cephalic engagement
75
if fetal presentation (cephalic, breech) is uncertain on digital cervical exam, NBS?
transabdominal US to confirm fetal presentation and determine safest route of delivery
76
When is exercise contraindicated in pregnancy?
high risk for preterm birth (cervical insufficiency), have antepartum bleeding, or underlying condition exacerbated by exercise
77
In teens, the immature HPO axis causes what?
-anovulation and heavy, irregular menstrual
-hemodynamically stable= heavy vaginal bleeding managed with high dose oral contraceptive to stablize endometrium and stop the acute bleeding
78
what is labor
painful, regular contractions that cause cervical change
79
what is false labor (braxton-hicks contractions)
mild, irregular contractions that cause no cervical change and resolve without intervention.
-patients can be d/c home with labor precautions
80
what is infertility
inability to conceive after 12 months of regular unprotected sex in women <35
-male factor infertility is a common cause and intitial eval is semen analysis
-hysterosalpinogram is used to dx an anatomic cause (tubal obstruction from prior pelvic infection)
81
what is genitourinary syndrome of menopause
causes estrogen deficiency that results in urogenital atrophy
-presents wtih dysuria, urgency incontinence, recurrent UTIs
-Txt: nonhormonal moisturizers, vaginal estrogen for severe symptoms
82
first line for primary dysmenorrhea in sexually active patients
Combined OCPs
-AE: irregular, unscheduled bleeding, HTN, venous thromboembolism
83
combined OCPs and cancer relation
-decrease risk of ovarian and endometrial (if ever used)
-increase risk of cervical (if currently or recently used)
84
Endometrial hyperplasia are at risk for
endometrial cancer.
-pt who desire future fertility: treat with progestin therapy (progestin releasing IUD)
85
Uncomplicated preterm prelabor ROM at <34 weeks management
expectantly with antibiotics and corticosteroids to promote in utero fetal development.
delivery is indicated: intraamniotic infection or deteriorating fetal/maternal status or pregnancy reached 34 weeks
86
ABO incompatibilty occurs when?
mother with O and infant with group A or B bood, which can cause mild hemolytic disease of newborn
-affected infants are usually asymptomatic at birth and have mild anemia and may develop neonatal jaundice that responds to phototherapy
87
Patients with PCOS are at increased risk for?
endometrial hyperplasia and cancer due to unregulated endometrial proliferation from unopposed estrogen.
88
what is congenital aromatase def?
-rare enzyme def that prevents conversion of androgens to estrogens
-causes virilization of females resulting in normal internal genitalia with ambigous external genitalia
89
menopausal with moderate to severe vasomotor symptoms (hot flash), first line txt?
patients with a uterus: estrogen + progesterone therapy
patients without uterus: estrogen only therapy (transdermal estrogen patch)
90
complete hydatidiform moles present
1T bleeding, uterine size greater than gestational age, elevated hCG, theca lutein cysts, bilateral multiloculated ovarian cysts, overt hyperthyroidism
US with snowstorm and no fetus.
management: suction D&C
can present with preeclampsia with severe featuers at <20weeks
91
secondary syphillis presentation
diffuse maculopapular rash along skin-cleavage lines of trunk (christmas tree pattern) that extends to extremities, palms and soles
92
Preventive migraine therapy may benefit patients with severe migraines (more than 4x/month, significant impairment). During pregnancy, first line prevention is with?
beta blockers (propanolol, metoprolol)
93
secondary amenorrhea
amenorrhea for more than 3 months who previously had regular menses (or more than 6 months in women with irregular periods)
initial eval: pregnancy test, serum prolactin, TSH, FSH levels
94
what is contraindicated in patients with active breast cancer due to risk for stimulating estrogen receptor+ and/or progestrone receptor+ tumor cells?
hormonal contraception (estrogen and/or progestin methods)
-these patients can use copper IUD
95
acute pyelonephritis in prgenancy presentation
fever, maternal and fetal tachycardia, flank pain or costovertebral angle tenderness.
due to high risk of severe complications (maternal sepsis, preterm delivery), managment= hospitalization and empiric IV ceftriazone
if no improvement 48-72h of IV antibiotics then do renal US to r.o renal abscess
96
what is active phase protraction adn the RF?
<1cm cervical dilation in 2h during active phase (6-10cm dilation)
-RF: cephalopelvic disproprtion, inadequate contractions, maternal obesity, fetal malposition (occiput posterior)
97
Vulvar lichen sclerous presentation and txt
common in prepubertal girls with pruritus and thin, white lesions on vulva and perianal region.
txt: superpotent topical corticosteroids
RF for vulvar cancer
98
what is oligohydraminios?
AFI less than 5 cm or single deepest pocket amniotic fluids <2cm on US.
2T and 3T oligo: due to ROM or chronic uteroplacetal insufficiency
99
gestational DM with suboptimal glycemic control and/or need for pharmacotherapy (insulin) are at increase risk for?
stillbirth.
these patients require 3T antenatal fetal surveillance (nonstress testing at regular intervals)
100
What are the most effetive emergency contraceptive methods?
IUD (cooper or progestin releasing)
101
what is ovarian hyperstimulation syndrome
complication of ovulation induction for infertility treatment.
-symptoms within 1-2 weeks: ab pain, ascites, bitlateral enlarged, cystic ovarias, third spacing leading to intravascular volume depletion (hemoconcentration)
-severe complications: thromboembolism, multiorgan failure and death
102
uterine sarcoma presentation and RF?
postmenopausal bleeding and uterine mass that causes bulk symptoms (pelvic pressure, constipation)
RF: tamoxifen (estrogen agonist on uterus and antagonist on breast)
103
what is vesicovaginal fistula
-may occur after pelvic surgery (hysterectomy) or pelvic radiotherapy
-presents: continous, painless watery discharge from urine leaking into vagina (pooling of clear fluid), area of raised, red granulation tissue on anterior vaginal wall
-obstructed labor in resource limited areas is the most common cause worldwide
dx: pelvic exam and bladder dye test
104
what is eclampsia
Preeclampsia with severe features + seizures
-eclamptic seizures are typically generalized tonic clonic, last several minutes, a/w postitcal phase with headache and hyperreflexia
txt: prompt delivery and magnesium sulfate infusion
105
what is osteogenesis imperfeta
AD, mutations in type 1 collagen
type II OI: most severe form, a/w multiple fetal fractures and IUFD; limb deformities, fetal growth restriction, hypoplastic thoracic cavity.
106
Renal colic in pregnancy
ab pain, flank tenderness, hematuria, often irregular uterine contractions.
diagnositc imaging: US
107
premenopausal women with adnexal mass on pelvic exam NBS
pregnancy test and pelvic US
108
what is von willebrand disease
common bleeding disorder causing impaired platelet adhesion and most common cause of heavy regular meneses in teens.
labs: aPTT normal or prolonged, platelet count and PT both normal.
txt: desmopressin
-can cause postpartum hemorrahge and prolonged bleeding
109
symptomatic cholelithiasis (bilary colic) is common in pregnancy due to?
increased gallstone formation.
recurrent RUQ and/or epigastric pain from intermittent obstruction of cystic duct
110
what is a vaginal hematoma
potentially life threatening postpartum complication that presents with a vaginal mass and possible hypovolemic shock due to massive occult bleeding
111
intraamniotic infection (chorioamnioitis) presents and txt
in patients with premature or prolonged ROM or preterm prelabor ROM or protracted labor, materal and fetal tachy, uterine fundal tenderness, maternal leukocytosis
-polymicrobial; migration of vaginal or enteric flora through cervix
-txt: broad spectrum IV antibiotics (amp + gent) and expedited delivery to decrease neonatal and maternal morbidity
112
parvo b19 infection in pregnancy can cause severe fetal anemia due to?
viral cytotoxicity to fetal erythrocyte precursors.
fetal anemia increases cardiac output, which can lead to high output fetal heart failure, subsequent hydrops fetalis (skin edema, ascites) and fetal demise
113
during pregnancy, sickle cell disease pts are more likley to have acute vasooclusive pain episodes (ab pain) due to?
increased metabolic demands and hypercoagulable state
-txt: aggressive pain control and IV hydration
114
chronic HTN in pregnancy diagnosis and increased risks
dx: prepregnancy HTN and those with HTN at <20 weeks
increased risk for obstetic complications, superimposed preeclampsia, fetal growth restriction and preterm delivery
115
postpartum fecal or flatal incontinence can occur due to?
external anal sphincter injury a/w 3rd or 4th degree perineal laceration
-weakened anal sphincter tone, asymmetric sphincter contraction, palpaable defect on exam.
eval with endoanal US
116
significant obsteteric bleeding (postpartum hemorrhage) can cause?
DIC: bleeding, thrombosis (acute pumonary embolus), thrombocytopenia, prolonged PT and PTT
117
Toxoplasma gondii US findings
hydrocephalus and intracranial calcifications, particularly in basal ganglia
-hepatosplenomegaly and fetal growth restriction
118
what is restless legs syndrome
urge to move legs and dysesthesia that is worsened by inactivity and improve with movement
-symptoms worse in evening or night and may impair sleep
119
what is septic pelvic thrombophlebitis
postop or postpartum infected thrombosis of deep pelvic or ovarian veins, persistent fever unresponsive to antibiotics
txr: anticoagulation and broad spectrum antibiotics
120
blunt abdominal trauma (MVA) in pregnancy can cause?
severe maternal bleeding and hemorrhagic shock (abruptio placentae)
trauma pts with hemorrhagic shock require replacement of intravascular volume, transitioning from crystalloid to blood product resuscitation ASAP
121
what is paget disease of the breast
malignant; unilateral erythematous, intensely pruritic, ulcerative lesion of the nipple/areolar
-requires diagnostic mammography
122
spontanous abortion and ectopic can cause Rh D alloimmunization in Rh D negative women due to?
fetomaternal blood mixing and maternal anti-D antibody production if fetal blood type is RhD+.
RhD negative women require anti-D immunoglobulin after spontaneous abortion and ectopic pregnancies
123
Txt of acute cervicitits
can presesnt as 1T bleeding and mucopurulent endocervical discharge
-empiric txt with ceftriazone and azithromycin followed by a test of cure
124
what is a urethral diverticulum
abnormal localized outpouching of the urethral mucosa into surrounding tissues
-can cause dyspareunia
-palpable, tender mass on anterior vaginal wall a.w purulent discharge
125
congenital uterine anomalies, which typically lead to separate, smaller uterine cavities, can increase risk for?
preterm labor because uterus cannot accommodate the size of a full term pregnancy
126
how does duodenal atresia prsent on fetal US
-congenital anomaly causing complete bowel obstruction
-px: fluid filled stomach and duodenum (double bubble sign) with polyhydraminos
-common in Down syndrome and VACTERL association (vertebral, anal atresia, cardiac, tracheoesphageal atresia, renal, limb)
-presence of duodenal atresia requires eval for other fetal malformations (ventricular septal defects)
127
what are mature cystic teratomas (dermoid cyst)
benign germ cell tumors common in premenopausal women.
-heterogenous tumors (hair, teeth): complex ovarian cysts with calcified hyperechoic areas on US
-txt: surgical removal to reduce risk of ovarian torsion
128
in multifetal pregnancies (triplets), pregnancy reduction to lesser order gesteration (twin, singleton) decreases the risk for?
fetal growth restriction, intrauterine fetal deminse, and preterm delivery
129
pelvic inflammatory disease presentation
fever, diffuse lower ab pain, mucopurulent cervical discharge, cervical motion/uterine/adnexal tenderness, inflamed friable cervix (cervicitis)
indications for inpatient txt with IV antibiotics: high fever, inability to tolerate oral antibiotics, risk of nonadherence to outpatient treatment
130
intrahepatic cholestasis of pregnancy increase risk of?
-3T; pruritis worse on hands and feet
-increased risk of fetal complications: intrauterine fetal demise, especially with markedly elevated total bile acids
mx: ursodeoxycholic acid and deliver at 37weeks
131
ovarian failure levels of FSH and LH
ovarian failure may occur secondary to chemotherapy and present with amenorrhea and signs of estrogen def (vaginal dryness)
-increased FSH and LH due to lack of feedback inhibition from estrogen
132
uterine rupture presentation
severe ab pain, intraabdominal and/or vaginal bleeding, and abnormal fetal HR tracing (late decels)
ab exam may show palpable fetal parts (irregular protuberance)
133
acute appendicitis presenation
fever,n/v, RLQ pain.
dx is clx. atypical presenation can occur postpartum due to displacement of appendix by enlarged uterus. right mid to upper quad or flank pain.
mx: surgery
134
RF for shoulder dystocia
-inability to deliver fetal shoudlers with usual obstetric maneuvers
-warning signs: prolonged first or second stage of labor and retraciton of fetal head into perineum after it delivers (turtle sign)
-maternal obesity which predisposes to fetal macrosomia is a RF
135
amphetamine intoxication presentation
HTN, agitation, diaphoresis, dilated pupils, generalized tonic clonic seizure due to hyponatremia
-use in pregnancy increases risk for spontaenous abortion, preeclampsia, abruptio placentae, fetal growth restriction, preterm delivery, intrauterine fetal demise
136
fetal tachycardia is a/w?
maternal fever due to intraamniotic infection (chorioamnionitis)
137
hyperandrogenism in pregnancy is commonly due to?
benign bilateral ovarian masses such as luteomas and theca lutein cysts
pts with virilization during pregnancy and bilateral ovarian masses are observed and managed expectantly, as the symptoms and masses spontaneously regress after delivery
138
what is placenta accreta
abnormal attachment of placental villi to uterine myometrium rather than decidua basalis
-US: low lying placenta, myometrial thinning, numerous placental lacunae
-increased risk for postpartum hemorrahge
-px: difficulty detaching placenta after fetal delivery. attempts at manual placental extraction are unsuccessful and can cause profuse vaginal bleeding.
txt: emergency hysterectomy
139
a positive tuberculin skin or interferon gamma release assay should be followed with?
CXR to differientiate latent infection vs active disease
140
hyperprolactinemia in women of reproductive age
-irregular menses, infertility, galactorrhea
-MCC= prolactinma
-can be treated with dopamine agonists (cabergoline, bromocriptine) to decrease prolactin secretion and tumor size
141
Turner syndrome LH and FSH levels
-short stature and primary amenorrhea
-ovarian dysgenesis results in low E and T levels, high FSH and LH
142
absolute contraindications to pregnancy
pulmonary arterial HTN
peripartum cardiomyopathy with residual LV dysfunction
HF with LVEF <30%
severe coarctation, severe mitral stenosis, severe symptomatic aortic stenosis, severe aortic dilation (Marfan)
143
incisional hernias develop due to?
fascial closure breakdown and may have a delayed presentation (months-years)
-slowly enlarging ab mass (protruding ab contents) that is palpable while supine and enlarges with valsalva
144
what is face presentation?
type of fetal malpresenation resulting from inadequate neck flexion during labor.
face presentation with a persistent mentum posterior position cannot deliver vaginally and requires c section
145
elevated prolactin levels leads to
inhibits release of GnRH, suppressing LH and FSH, low estrogen
-women who breastfeed experience anovulation and lactational amenorrhea. dyspareunia
146
adnexal mass in premenopausal woman
benign, related to ovulation, resolves spontaneously.
manage with observation and repeat exam
147
stillbirth with umblical cord inflammation and necrosis surrounding umbilical vessels NBS
prompt testing for infectious causes of stillbirth such as syphilis serologies
148
primary dysmenorrhea occurs due to
increased endometrial prostaglandin production during menses that causes uterine hypercontractility and ischemia.
-midline lower ab pain with nausea, diarrhea
first line: NSAIDs
149
evaluation of atypical glandular cells on Pap
colpo, endocervical curettage, and endometrial biospy in women age >35
150
congential CMV findings
bilateral periventricular intracranial calcifications, intrahepatic calcifications, fetal growth restriction
151
Neonatal lupus can occur due to
passive placental transfer of maternal anti-SSA(Ro) and anti-SSB(La) antibodies
patient may develop fetal AV block, appears on tracing as persistent bradycardia
152
Excessive oxytocin can cause?
severe hyponatremia, cerebral edema, generalized tonic clonic seizures because oxytocin has a similar structure to antidiuretic hormone
153
when does ectopic require surgical management
medical contraindications to methotrexate (breastfeeding) or hemodynamically unstable
154
ectopic pregnancy will have no what?
chorionic villi
155
what is imperforate hymen and the txt
-defect in female genital outflow tract, resulting in hematocolpos
-anatomic cause of primary amenorrhea
-pelvic exam: smooth blue bulging vaginal mass that swells with increased intraabdominal pressure
-can cause pain and difficulty defecating
-txt: hymenal incision and drainage
156
first line txt optionfor migraines
acetaminophen
2nd and 3rd line: opioids (acetaminophen-codeine), antiemetics, NSAIDs (in 2T only)
157
second stage arrest of labor
-insufficient fetal descent after pushing more than 3 hours in nulliparous patients without epidural (more than 2h in multiparous)
-manage: operative vaginal delivery (vacuum-assisted)
MCC of second stage arrest: fetal malposition (nonocciput anterior) contributes to cephalopelvic disproportion
158
pregnant with prior cervical surgery (cold knife conization) are at increased risk for?
preterm delivery
-these patients require transvaginal US cervical length measurement at 16-24 weeks to guide potential preventative measures (vaginal progestrone)
159
RF for pelvic organ prolapse
-descent of pelvic organs through vagina
-px: pelvic pressure, urinary retention, incontinenece, obstructed voiding
RF: muliparity, postmenopausal age, hysterectomy, obesity
160
primary ovarian insufficiency
<40 with secondary amenorrhea and signs of ovarian failure (elevated GnRH, elevated FSH, low estrogen)
-occurs due to accelerated ovarian primordial follicle depletion resulting in estrogen def (vaginal atrophy, thin endometrium)
-RF: FMR1 gene premutation for fragile X syndrome
161
why does hypotension occur in epidural anesthesia?
caused by blood redistribution to lower extremities from venous pooling from sympathetic blockade
162
what is acute fatty liver of pregnancy
3T; microvesicular fatty infiltration of hepatocytes leading to liver inflammation (RUQ pain, elevated aminotransferases, leukocytosis) and fulminant liver failure (profound hypoglycemia, thrombocytopenia
management: immediate delivery
163
Quadruple marker test for Down syndrome
low maternal serum alpha fetoprotein
low unconjugated estroil
high b-hCG
high inhibin
confirmation is with amniocentesis
164
medical therapy for ectopic
methotrexate, a folate antagonist that inhibits DNA synthesis in rapidly dividing cells (trophoblasts)
-ectopic can be diagnosed by persistent rise in b-hCG level following diagnosistic dilation and curettage
165
advanced ovarian cancer may present in postmenopausal women with?
an immobile pelvic mass.
suspected ovarian ancer with no distant mets is managed with exploratory laporatomy, staging, and tumor debulking
166
ovrian masses in postmenopausal are initially evaluated with?
pelvic US and then CA-125
167
what is indicated if diet and exercise fails to control gestational diabetes?
insulin or oral antoglycemic meds
168
what is shoulder dystocia?
-impaction of fetal anterior shoulder behind materal pubic symphysis that results in inability to deliver shoulders with routine gentle traction
-initial mx: McRoberts manuever (flexion of pt's hips back against abdomen) and application of suprapubic pressure
169
laboring patients at high risk of uterine rupture require what?
-laparotomy and c cestion
-labor and vaginal delivery are contraindicated after classical c section or extensive myomectomy due to significant risk of uterine rupture.
170
why does preeclampsia with severe features increase the risk of fetal growth restriction (small for gestational age infant)
uteroplacental insufficiency
171
what is vulvar lichen sclerosus? txt?
chronic inflammatory condition that can present with vulvar pruritis, white vulvar plaques, and loss of normal architecture (loss of labia minora)
confirm dx with vulvar punch biopsy and r.o vulvar cancer
txt: superpotent topical corticosteroids (clobetasol): decreases chronic inflammation, thereby improving symptoms and preventing disease progression
172
leiomyomata uteri (particularly submucosal fibroids) can cause?
heavy prolonged menses. are at risk for prolapse through cervix
symptomatic submucosal fibroids + desire fertility can be treated with hysteroscopic myomectomy: improves heavy bleeding and restores normal uterine anatomy, decreasing infertility and future pregnancy complications (recurrent pregnancy loss)
dx: pelvic US
173
pubic symphysis diastasis px and txt
can occur after traumatic delivery
px: radiating suprapubic pain that is exacerbated by ambulation or weight bearing.
txt: conservative with supportive care
174
heparin induced thrombocytopenia px
mild-moderate thrombocytopenia and paradoxical thrombosis (pulmonary embolus) withtin 5-10 days starting heparin
175
what is uterine inversion
uterine fundus inverts and prolapses through cervix or vagina after delivery
-appears as firm, rounded mass protruding through
-severe ab pain, heavy vaginal bleeding, nonpalpable uterine fundus
176
treatment of uterine inversion
discontinue uterotonics (oxytocin) and immediate manual replacement of uterus to prevent exsanguination.
-uterine relaxants and laparotomy may be required if initial attempts at manual reduction are unsuccessful
177
magnesium sulfate toxicity signs and txt
signs of progressive neuromuscular inhibition (areflexia, respiratory depression)
txt: stop mag and start calcium gluconate to reverse neuromuscular paralysis and prevent cardiac arrest
178
vaginal squamous cell carcinoma results from
persistent infection with HPV 16 and 18.
chronic tobacco use decrease the normal immune response which allows persistent HPV infection and squamous cell metaplastic changes
-vulvar irritation, intermittent bleeding, unifocal friable mass commonly located on labia majora, malodorus discharge, irregular lesion
RF: >60, tobacco, HPV
Dx: biopsy lesion
179
menopausal symptoms in women less than 45 require what?
>45 with AUB and classic menopause symptoms (night sweats, insomnia, difficult concentrating) require no additional testing.
<45 with these symptoms, require FSH, TSH, and prolactin to exclude underlying endocrine disorder (hyperthyroidism)
180
prepubertal girls with vaginal foreign bodies px
malodorous discharge and spotting.
mx: topical anestheic application and removal with swab or by vaginal irrigation with warmed fluid. exam under anesthesia may be required.
181
hypothyroidism and menstrual and labs
menstual irregularities (irregular menses, infertility) are common in hypothyroidism.
Labs: elevated prolactin and low FSH and LH with low serum estradiol (low testoserone in men)
Reproductive function usually normalized with levothyroxine
182
Risk of pregnancy in ulcerative colitis
Pregnanacy is a high risk period for ulcerative colitis; often worsening disease activity can lead to fetal complications- preterm delivery and small for GA.
Remission should ideally be achieved before conception. Most meds used to control UC are safe for continuation in preg
183
bartholin duct cysts
soft mobile nontender masses at base of labia major at 4 and 8 oclock
-asymptomatic: observe and expectant management
-symptomatic: incision and drainage, followed by Word catheter placement
184
patients with gestational diabetes mellitus are screened with?
-at increased risk for develping T2DM, screened with 2 hour (75g) oral glucose tolerance test at 6-12 weeks postpartum
185
hydronephrosis in pregnancy occurs due to?
ureteral compression from uterine enlargement and decreased ureteral peristalsis due to increased progesterone
US: bilateral renal enlargement (R > L) with dilated renal pelvises and proximal ureteres
physiologic hydronephrosis of pregnancy requires no additional mx
186
asymmetric and symmetric fetal growth restriction is due to
2T and 3T placetal insufficeincy (HTN) that results in restricted abdominal growth that is more pronouced than restricted head growth.
symmetric FGR: due to congental disorders or 1T infections
187
monochorionic monoamniotic twin pregnancy
single placenta and no intertwin membrane on US.
-risk of cord entanglement and fetal demise; pt require inpt monitoring
-delivery: 32-34 weeks via c section
188
what is mullerian agenesis
causes primary amenorrhea due to failed development of uterus, cervix, upper third vagina. (blind vaginal pouch)
-normal external genitalia and secondart sex characteristics
urogenital structures develop from a common embryologic source, therefore renal malformations are common so patients require renal US
189
later term (>41 weeks) and post term (>42 weeks) are increased risk for?
oligohydraminoas, a marker for placental insufficiency (as well as late decels) and indication for delivery
190
postdural puncture headaches after neuaxial anesthesia (epidural) occur due to?
unintentional dural puncture.
-develop a positional headache (worsens when upright, improves when supine) within 72h of procesure and have n/v and neck stiffness
191
postmenopausal bleeding require eval for endometrial cancer with either?
transvaginal US or endometrial biopsy.
TVUS: endometrium <4mm = no additional
endometrium >4mm= require biopsy
192
genitourinary tract infection, particularly asymptomatic bacteria, is a RF for?
preterm prelabor ROM.
Universal urine culture screening, timely treatment, and reculturing for test of cure are recommended in pregnancy
193
functional hypothalamic amenorrhea results from?
suppression of HPO axis by strenuous exercise, calorie restriction, increased stress, chronic illness.
patients at risk for decreased bone mineral density due to estrogen def
194
What is a common cause of fecal incontinence?
external anal sphincter injury a/w obstetric trauma, which can cause direct sphincter muscle injury and/or denervation, resulting in decreased anal sphincter tone.
patients can have a delayed or intermittent presentation due to the gradual loss of compensatory pelvic floor stability with age
195
what is tuberous sclerosis complex?
AD; neurocutaneous disorder that causes seizures.
skin findings= shagreen patches, periungal fibromas
benign tumors of skin, brain, kidney.
196
what is used to treat high grade cervical intraepithelial neoplasia?
cervical conization then HPV testing 6 months postprocedure
complications: cervical stenosis, cervical insufficiency, preterm delivery
197
Maternal sickle cell disease can cause?
vasoocclusion that can result in placental infarction, ischemia, uteroplacental insufficiency
198
how does uteroplacental insufficiency present?
decreased fetal movement and oligohydraminos (AFI less than 5cm) due to decreased fetal perfusion
199
tay sachs inheritance pattern
AR; both parents must have it for child to get it
200
what is abruptio placentae?
premature separation of placenta from uterus prior to fetal delivery can lead to fetal hypoxia and maternal hemorrhage
presents: ab pain, painful vaginal bleeding, high frequency uterine contractions, abnormalities on fetal heart tracing. firm tender uterus
RF: uterine overdistension (twins, severe polyhydramnios), tobacco, cocaine, HTN, abdominal trauma
201
acid base for severe vomitting (hyperemesis gravidarum)
metabolic alkalosis: elevated pH, elevated bicarb, compensatory elevation in PaCO2
202
during follicular phase of menstrual cycle, rising estrogen levels result in?
clear, odorless, physiologic cervical discharge
203
Uterine tachysystole (>5contractions/10 min) may cause fetal compromise (hypoxemia, academia) due to?
interupption of intervillious blood flow and inadequate recovery time between contractions (late decelerations)
Mx: supportive and dc uterotonic agents (ocytocin)
204
retroperitoneal hematomas may occur postpartum due to?
uterine artery injury, leading to massive blood loss and hemodynamic instability despite minimal ab pain and no obvious source of bleeding.
requires emergency laparotomy
205
dichorionic-diamniotic twin pregnancy on US
2 intrauterine gestations, 2 placentas, 2 amniotic sacs
206
tamoxifen MOA and AE
used for adjuvant therapy for hormone+ breast cancer
-estrogen antagonist on breast
-estrogen agonist on uterus
-AE: hot flashes, venous thromoembolism, increase risk for endometrial cancer, uterine sarcoma, increase risk for endometrial polyps
207
magnesium sulfate toxicity
used for eclamptic seizure prevention and fetal neuroprotection
signs of toxicity: somnolence, areflexia, respiratory suppression.
excreted by kidneys, patients with renal insufficiency are at increased risk for toxicity
208
vertical transmission of GBS during vaginal delivery causes?
early-onset neonatal GBS infection (sepsis, pneumonia)
patients with GBS bacteriuria in current or prior infant with GBS are at high risk for transmission - require intrapartum antibiotic prophylaxis (IV penicillin)
209
define infertility
inability to conceive after 6 months of unprotected intercourse in women age >35
can occur due to diminished ovarian reserve = regular menstrual cycles and decreased oocyte number and quality
210
MOA of levonorgestrel (plan B)
delays ovulation
211
idiopathic intracranial hypertension presentation and dx
-most common in obese women of childbearing age
-px: positional headaches, pulsatile tinnitus, papilledema
-dx: MRI of brain followed by lumbar puncture
212
recurrent UTIs (more than 3 in a year or more than 2 in 6m) commonly occur in postmeno patients due to?
estrogen deficiency, which causes vulvoaginal atrophy, decreased bulk and elasticity of the bladder trigone and urethra, and increased vaginal pH
txt: vaginal estrogen
213
Actinomyces
normal GI flora, may colonize genital tract, sometimes causing severe PID
incidiental findings + asymptomatic: do not indicate active pelvic infection and does not require txt
214
pH for BV
ph > 4.5
215
what is mittelschmerz
physiologic cause of unilateral ab pain in young women. Pain occurs middle of cycle (follicular phase) corresponding with ovulation
216
what increased risk for uterine rupture
prior uterine surgery (c section) are at increase risk for uterine rupture, a disruption of uterine wall typically associated with contractions.
Uterine rupture may present with intense ab pain, vaginal bleeding, fetal heart tracings abnormalities, and loss of fetal station
217
what is lochia
physiologic vaginal bleeding after delivery due to endometrial shedding and regeneration
-lasts 6-8 weeks postpartum
218
what is premenstrual syndrome
causes both physical and affective symptoms, which commonly include fatigue, bloating, hot flashes, mood swings, irritability
Dx: symptom diary that reveals recurring symptoms in luteal phase (1-2 weeks prior to menses) that resolve with menses
219
pregnant + acute pyelonephritis txt
IV broad spectrum (ceftriaxone)
symptomatic improvement (afebrile for 48h) can be transitioned to oral antibiotics. penicillins and cephalosporoins are safe during all trimesters
220
PID complicated by perihepatitis px
PID can spread to intraperitoneal cavity and cause perihepatitis (Fitz Hugh Curtis syndrome)
px: fever, vomiting, pain in RUQ and lower abdomen
221
what is chemical pneumonitis
self limited inflammatory respinse caused by direct pulmonary injury from aspirated acidic gastric contents
-dyspnea, hypoxemia, alveolar infiltrates in the dependent lung segments within hours of aspiration
222
thyroid hormone in pregnancy
thyroid hormone production increases to cope with metabolic demands.
estrogen causes an increase in thyroxine-binding globulin, leading to increased total (but not free) thyroid hormone levels.
hCG directly stimulates TSH receptors, causing increased production of thyroid hormones
223
most common cause of a nonreactive nonstress test (no accelerations)
quiet fetal sleep. fetal sleep cycle can last as long as 40 minutes, a nonreactive nonstress test is extended (40-120 min) to ensure that fetal activity outside of sleep is captured
224
preeclampsia can present up to how many weeks postpartum?
6 weeks; headache and HTN
-increased risk of stroke
225
what is adenomyosis
woman age >40, dysmenorrhea, heavy bleeding, progressive chronic pelvic pain, boggy, tender symmetriccally enlarged uterus
226
why are leiomyomata uteri more likely to degenerate during pregnancy?
because myometrial blood flow shifts toward the developing fetus and placenta.
An infarcted, degenerating uterine fibroid can cause severe abdominal pain, uterine tenderneess, and a palpable firm tender mass and signs of inflammation (leukocytosis)
-fibroids increase in response to estrogen
227
bilateral nonbloodly nipple discharge workup
nipple discharge can be physiologic (galactorrhea) or pathologic (bloody, unilateral, abnormal breast findings).
bilateral nonbloodly nipple discharge = physiologic, requires prolactin and TSH levels + pregnancy test
physiologic galactorrhea: bilateral, nonbloody, clear or milky, yellow/brown/gray/green
-hyperprolactinemia is the MCC
228
what is asherman syndrome (intrauterine synechiae)
development of intrauterine adhesions. a possible complication of intrauterine surgery (suction curettage, hysteroscopic myomectomy) caused by scarring and obliteration of endometrial tissue.
The risk for adhesion formation increases with concomitant intrauterine infection (septic abortion)
-amenorrhea that does not respond to progestrone challenge due to obliteration of endometrium
229
stress urinary incontinence after vaginal delivery
its common after vaginal delivery due to pelvic floor muscle weakness (results in urethral hypermobility) and stretch injury to the pudenal nerve
Patients in the immediate postpartum period (<6 weeks after delivery) are managed with observation and reassurance because its typically self limited
230
US findings concerning for ovarian malignancy of adnexal mass
complex appearance and abnormal internal features (irregular thickened septations, papillary projections)
231
patients with gestation diabetes mellitus are at high risk for developing?
T2DM; require postpartum diabetes screening with a 2 hour 75g glucose tolerance test
232
Pelvic organ prolapse presentation
pelvic pressure or urinary dysfunction (retention, stress urinary incontinence)
howevere many are asymptomatic and managed with reassurance and obs
233
difference between symmetric and asymmetric fetal growth restriction
symmetric FGE: 1T and due to fetal conditions: aneuploidy, congenital anomalies, intrauterine infections
asymmetric: 2T or 3T; due to maternal conditions that cause placental insufficiency (HTN)
234
what is secondary (late) postpartum hemorrhage
heavy vaginal bleeding occuring >24h after delivery
causes: retained products of conception, postpartum endometritis, placental site subinvolution
235
sinusoidal fetal heart tracings are a/w?
severe fetal anemia.
Cat III tracing that reflects increased risk of fetal compromise (hypoxemia, acidemia).
Requires urgent c section
236
what is a missed abortion
pregnancy loss at <20 weeks prior to explusion of products of conception
-typically asymptomatic but can have symptoms of loss of pregnancy or light vaginal bleeding.
-findings: closed cervix, decreasing hCG levels, US: nonviable (no heartbeat) intrauterine preg
237
what is meralgia paresthetica?
caused by compression of lateral femoral cutaneous nerve
px: pain and paresthesia over upper outer thigh
a/w pregnancy and self limiting and resolves post partum
238
most common cause of postpartum hemorrhage and txt
uterine atony: results from inadequate uterine contractility and inability to compress placental bed blood vessels; soft boggy enlarged uterus with blood clots in lower uterine segment and profuse vaginal bleeding
txt: bimanual uterine massage and high dose oxytocin
in patients with persistent bleeding, give tranexamic acid, an antifibrinolytic agent that prevents the breakdown of bloodclots to achieve hemostasis
RF: fetal macrosomia, prolonged induction of labor, operative vaginal delivery
239
initial eval of mixed urinary incontinence
voiding diary to classify predominant type of urinary incontinence (stress, urgency) and to determine optimal treatment (bladder training)
240
what is sjogren syndrome
AI; inflammation of exocrine glands.
dry mouth, AI sialadenitis, keratoconjunctivitis sicca, arthritis, raynaud, dyspareunia, cutaneous vasculitis, interstitial lung disease, non Hodgkin lymphoma
241
what is pseudocyesis
persistent, nondelusional belief of being pregnant when not.
can have symptoms of early pregnancy (morning sickness, ab distension) but preg testing isnegative and US shows empty uterus (thin endometrial stripe)
242
what is postpartum urinary retention
inbility to void for >/6h after vaginal delivery, may have dribbling of urine from overflow incontinence.
Urethral cath is indicated for dx and txt
243
signs of unilateral ureteral laceration
large volume of intaabdominal fluid (uroperitoneum) but normal voiding, serum creatinine, UA due to functional contralateral kidney and ureter
244
pregnant with incidental short cervix (less than 2.5cm) are increased risk for?
preterm delivery; can give vaginal progesterone which maintains uterine relaxation and decreases risk for preterm labor
245
epithelial ovarian cancer can present as?
complex adnexal mass with pelvic pain, decreased appetite, and bloating. Ovarian carcinogenesis often involves the abnormal prolifetation of the tubal epithelium that secondarily involves the ovary and peritoneum
246
what is vulvar lichen planus?
chronic inflammatory disorder; multiple glazed, erythematous vulvar erosions bordered by white striae (Wickham striae)
-vaginal and oral lesions
-txt: topical corticosteroids
247
RF for vulvovaginal candidiasis
diabetes mellitus, immunosuppression, antibiotic use
248
pregnant with HIV
-should start combination antiretroviral therapy ASAP, independent of HIV RNA viral load or CD4 count.
-(>1000), decrease risk for neonatal infection by: early initiation of ART + intrapartum zidovudine + cesarean and postexposure ART prophlyaxis for infant
-optimal viral load reduction (<1,000) may deliver vaginally without zidovudine
249
adenocarcinoma in situ originating within the endocervical canal requires?
cervical conization, a cone shaped biopsy that allows sufficient depth within endocervical canal to remove transformation zone and premalignant lesion
250
lactational mastitis + no improvement with antibiotics NBS
breast US to evaluate for breast abscess.
mx: abscess drainage (US-guided needle aspiration)
251
ACEinhibitors and angiotensin II receptor blockers in pregnancy
fetal renal hypoplasia (bilateral underdeveloped fetal kidneys) and oligohydraminios
252
persistently absent or minimal variability on fetal heart rate monitors indicates
fetal metabolic acidosis
-certain meds (opiods) can cause decreased variability (fetal CNS depression)
253
multiple sclerosis can develop urgency incontinence due to?
loss of cortical (UMN) inhibition of detrusor contraction
254
complications of abruptio placentae
maternal hemorrhage, hypovolemic shock, DIC
255
genito-pelvic pain/penetration disorder
pain on attempted vaginal penetration that prevents sex
256
RF for hyperemesis gravidarum
twin gestation due to elevated hCG and progesterone
257
RF for squamous cell cervical carcinoma
tobacco use because it impairs the immune system's ability to clear high risk HPV
258
STI screening in pregnancy
all in intitial prenantal visit and high risk pts (<25, prior STI) require repeat screen in 3T
259
most common pathologic cause of hyperprolactinemia in women of reproductive age
pituitary adenoma (prolactinoma)
dx: MRI of head
-secondary amenorrhea and anovulatory infertility because high prolactin levels suppress GnRH, LH, estrogen
260
breast engorgement
common 3-5 days after delivery when colostrum is replaced by milk
-bilateral breast fullness, tenderness, warmth, without fever
-improvement is expected as breastfeeding starts
261
complication of hyperemesis gravidarum that results from thiamine deficiency
wernicke encephalopathy
-encephalopathy, oculomotor dysfunction, gait ataxia
262
persistent nipple pain with breastfeeding
due to nipple injury
px: bilateral nipple abrasions and bloody nipple discharge
-underlying causes: poor infant positioning and improper latch on technique
263
listeria monocytogenes
common foodborne unfection due to contaminated food (unpasteurized milk, deli meats)
-causes a self limited gastroenteritis
-during pregnancy= transplacental fetal infection and possible intrauterine fetal demise
264
why do neural tube defects increase risk for c section?
the abnormal fetal anatomy predisposes to malpresentation through limited fetal mobility or inability to properly descend into pelvis
265
what is alpha thalassemia major
inherited disroder of absent alpha globin chain production necessary to form hemoglobin F
-hemoglobin Barts (4 gamma chains), which does not release oxyfen to tissues; results in severe fetal hypoxemia, high output HF, hydros fetalis (skin edema, ascites), fetal demise
266
initial periods in teens are irregular and anovulatory due to?
HPO axis immaturity and insufficient secretion of GnRH
267
bladder outlet obstruction in women can results from?
large fibroids compressing the bladder neck and/or urethra
-urinary retention and overflow incontinence (persistent urine dribbling, incomplete bladder emptying)
268
condylomata acuminata (anogenital warts)
-HPV 6/11
-nontender smooth or verrucous anogenital -lessions that can be asymptomatic, friable, or pruritic
-Preventation: HPV vaccine
txt: topical meds (tricloroacetic acid) or surgical excision
269
what is done to differentiate gestation HTN and preeclampsia?
24h urine collection for total protein
270
underweight prepregnancy BMI and inadequate gestational weight gain at increased risk for?
low birth weight and preterm delivery
271
BMI <18.5 idea weight gain
28-40 lbs
272
BMI 18.5 - 24.9 ideal weight gain
25-35 lbs
273
BMI 25-29.9 ideal weight gain
15-25 lbs
274
BMI >30 ideal weight gain
11-20 lbs
275
syphilis treatment
IM benzathine penicillin G
276
positive for GBS + penicillin allergy that is low risk for anaphylaxis can receive?
cefazolin
277
Cat III tracings are increased risk of?
fetal hypoxia and fetal acidemia, hypoxic brain injury and demise.
initial mx: intrauterine resuscitative interventions (oxygen, IV fluids, discontinue uterotonics) if no improvement then do c section
278
fibroadenoma in teens
observation and reexamination after completion of full period
279
what is bloody show
normal labor progression can cause mucoid vaginal bleeding (bloody show), during active labor due to rapid cervical dilation
expectant management can continue for pts with bloody show and reassuring materal fetal status (stable vitals, cat I tracing)
280
greatest RF for epithelial ovarian cancer
family history
281
RF for endometrial adenocarcinoma
excessive uterine estrogen exposure = obesity and chronic anovulation
282
what is a tuboovarian abscess
complication of PID a polymicrobial infection of upper genital tract.
-fever, diffuse ab pain that gradulaly worsens on one side, and both uterine and adnexal tenderness.
-US: complex multiloculated adnexal mass with thick walls and internal debris
283
normal biophysical profile values
8-10 of 10
284
toxic shock syndrome
-staph aureus exotoxins
-retained foreign body (tampon, nasal packing) or surgical/postpartum wound infection
-rapid onset fever, hypotension, tachycardia, diffuse macular rash
-txt: supportive care, foreign body removal, surgical debridement; vancomycin, cefepime, and clindamycin
285
more than 37 weeks + breech. can offer what?
external cephalic version
286
maternal vascular disease (T1DM) can cause?
uteroplacental insufficiency, presents with FGR and oligo.
-due to high risk of stillbirth, pts with FGR require umbilical artery Doppler US to assess placental perfusion and the need for urgent delivery
287
what is rectovaginal fistulas
can occur after obstetric trauma (3rd or 4th degree perineal lacerations)
-incontinence of flatus and feces (malodorous, tan brown discharge) through vagina
-dark red, velvety rectal mucosa may be seen posterior vaginal wall
288
sexual abuse of elderly px
postmenopausal bleeding. pelvic pain, behavioral changes, signs of genital trauma (perineal laceration)
-report immediately to adult protective services
289
what is twin twin transfusion syndrome
potential fatal condition that results from unbalanced vascular anastomoses between the vessels supplying the umbilical cords of each twin
-monochorionic twin can be complicated by this
290
when should anti-D immune globulin be adminstered?
to any Rh D- mom who delivers Rh D+ baby
-standard dose at 28 weeks gestation
-after delivery, the Kleihauer-Betke test is used to determine whether a higher dose is needed due to increased risk of fetal blood cells entering maternal circulation
291
septic abortion
commonly occurs after unsterile and/or incomplete procedure for an elective abortion
px: fever, heavy vaginal bleeding, purulent discharge, uterine tenderness
-medical emergency: broad spectrum antibiotics and surgical evacuation of uterus (suction curettage)
292
what is interstitial cystitis (painful bladder syndrome)
idiopathic, chronic condition. pain exacerbated by bladder filling and relieved by voiding.
-dyspareunia, urinary frequency and urgency
293
GBS screening
rectovaginal culture at 36-38 weeks
-if positive then intrapartum prophylaxis
294
posterior urethral valves
congenital disorder resulting from persistent urethral folds that cause bladder outlet obstruction
-diagnosed via prenatal US by signs of urinary obstruction - bladder distension and hydronephrosis
-signifcant obstruction can result in an increased risk of fetal morbidity and mortality because oligo (from decreased urine output) can cause pulmonary hypoplasia
295
Superficial wound dehiscence mx versus deep
superficial: separation of epidermis and/or subcutaneous tissue with intact fascia: conservatively with regular dressing changes
deep (fascial): surgical emergency
296
5 alpha reductase def
causes impaired conversion of testosterone to dihydrotestosterone
in a male fetus, this causes male internal genitalia and female external genitalia. during puberty, the increased testosterone results in virilization (clitoromegaly)
297
twin pregnancies are increased risk for?
preterm delivery (<37weeks) due to spontaneous preterm labor and medically indicated deliveries secondary to maternal (preeclampsia) and fetal (FGR) complications
298
labial adhesions and txt
-fused labia minora; affects prepubertal girls due to low estrogen
-first time for symptomatic lesions: topical estrogen
299
Contraindications to breastfeeding
active untreated TB, varicella infection, herpetic breast lesions, current chemotherapy, active substance use (cocaine, phencyclidine)
300
pregnant + herpes simplex virus
-antiviral prophylaxis from 36 weeks to delivery
-if active lesions present then c section, no lesions vaginal delivery
301
genital herpes simplex virus infection presentation
painful, pruritic, vesicular or ulcerative lesions. dysuria, inguinal lymphadenopathy.
clinical dx requires confirmation with lab testing via viral culture or PCR
302
patient with rapid onset (<1year) of virilization should be evaluated for androgen secreting tumor of ovarian or adrenal origin
-elevated testosterone and normal dehydroepiandrosterone sulfate = ovarian source (sertoli leydig)
-elevated DHEAS and normal T = adrenal tumor
303
methylergonocine is contraindicated in?
hypertensive patients (increased risk for stroke)
-potent vasoconstrictor that stimualtes contractions
304
carboprost tromethamine is contraindicated in?
patients with asthma
-synthetic prostaglandin that can caused bronchospasm
305
tranexamic acid is used with caution in patients with?
hypercoagulability (inherited thrombophilia)
-can be used for PPH of any etiology (uterine atony, retained placenta)
-used to treat heavy menstrual bleeding by preventing formation of plasmin and stablizing thrombi within the endometrium to regulate blood loss
306
cardio and renal changes in pregnancy
increasing cardiac output and blood volume and tidal volume
-systolic ejection murmur, peripheral edema and dyspnea
-increased renal blood flow, GFR, and urine protein excretion
-physiologic decrease in serum BUN and creatinine
307
umbilical cord compression
impedes fetal placental perfusion by occluding the umbilical blood vessels.
cord compression + >50% of contractions (recurrent variable decles) are at risk for fetal hypoxemia and require materal repositioning and possible amnioinfusion
308
management of N/V in pregnancy
first line: diet modification (small frequent meals, bland foods, avoiding food triggers)
-then vitamin B6 and doxylamine succinate, an H1 antihistamine if no improvement
309
MCC of unilateral bloody nipple discharge
benign intraductal papilloma
-no breast mass or lymphadenopathy
-age based breast imagine is required to evaluate for breast cancer
310
in the immediate postpartum period, physiologic changed include?
uterine contraction, lochia, breast milk excretion and milk letdown, chills and shivering causing hyperthermia or low grade fever.
These changes are hormone-mediated (increased oxytocin/prolactin, decreased E/P)
-managed with routine postpartum care
311
primary syphilis
single, painless chancre that begins as papule and becomes nonexudative ulcer with indurated borders. Mild to moderate, painless bilateral lymphadenopathy is often present
-false negative nontreponemal (rapid plasma reagin) is common
txt: IM benzathine pencillin G
312
urethral diverticulum
abnormal localized outpouching of urethral mucosa that can collect urine, resulting in inflammation of surrounding tissue
-dysuria, postvoid dribbling urine, dyspareunia, tender anterior vaginal wall mass that expresses purulent or bloody urethral discharge
313
hyperflexion of hips during second stage of labor can cause?
compress and entrapment of femoral nerve under inguinal ligament and cause a pressure induced ischemia leading to decreased anteromedial thigh sensation and weakness with hip flexion and leg extension
314
patients in preterm labor at <32 weeks requires which meds?
corticosteroids (betamethasone), penicillin, tocolysis (indomethacin), magnesium sulfate to decrease neonatal morbidity and mortality assocaited with preterm delivery
315
inevitable abortion presents
heavy vaginal bleeding, cramping, dilated cervix without passage of gestational tissue.
if pt is unstable = surgical management (suction curettage)
316
fetal hydantoin syndrome
cause: phenytoin, carbamazepine
px: microcephaly, wide anterior fontanelle, cleft lip and palate, distal phalange hypoplasia
317
sheehan syndrome (postpartum ischemic necrosis of anterior pit)
complication of massive postpartum hemorrhage
px: lactation failure (prolactin def), hypotension, anorexia (secondary adrenal insufficiency)
318
discrimatory zone; threshold at which intrauterine pregnancy can be visualized by TVUS
b-hCG <3500
-repeat b-hCG in 2 days
319
inflammatory breast carcinoma symptoms
diffuse breast erythema, pain, edema with thickening and dimpling (peau d'orange), retracted nipple
-rapidly aggressive form of cancer, many may have metastatic disease
320
role of corpus luteum
during early pregnancy, corpus luteum produces progesterone, which prepares endometrium for implantation and maintains pregnancy through 10 weeks.
patients who have corpus lutuem removed (oophorectomy) prior to 10 weeks require prosterone to prevent pregnancy loss
321
pregnant and acute cholangitis
increased risk for gallstones and subsequent acute cholangitis
-charcot triad: fever, RUQ pain, jaundice (direct hyperbilirubinemia)
-severe cases= hypotension and AMS
322
polyhydraminos (>24cm)
most are idiopathic and asymptomatic; expectantly managed
-can occur due to imapired fetal swallowing (tracheoesophageal fistula)
323
indomethacin tocolysis (to inhibit contractions) is indicated in patients with?
preterm labor <32 weeks.
can cause oligo and premature closure of fetal ductus arteriosus
324
secondary (pathologic) causes of dysmenorrhea
>25 onset, unilateral (nonmidline) pelvic pain, lack of systemic symptos, AUB
325
diabetes insipidus
polyuria (24hr output >3L) and excretion of an inappropriately dilute urine with low specific gravity despite normal serum sodium concentration and fluid intake.
during pregnancy, preexisting mild DI smptoms can worsen due to increased turnover of ADH
326
most common congential uterine anomaly
septate uterus; a/w poor obstetric outcomes (recurrent pregnancy loss, FGR, malpresentation, preterm delivery) due to abnormal uterine vascularization, decreased fetal perfusion and impaired uterine distension
327
what confirms recent ovulation
elevated midluteal phase (day 21) progestrone level
328
anencephaly on US
absent cerebrum, a calvarial defect, abnormal cerebellum or brainstem, and polyhydraminos
-inadequate maternal folate intake is a major RF for fetal neural tube defects
329
breastfeeding and wants contraception?
subdermal progestin implain or progestin IUD, they do not increase thromboembolism risk or affect breastfeeding
329
what is anaphylaxis
IgE mediated hypersensitivity reaction caused by mast cell degranualtion with widespread histamine and leukotriene release, resulting in hypotension, tachycardia, bronchoconstriction, increase uterine contractions
329
vitiligo
melanocyte destruction; nonpruritic flat hypopigmented macules without scaling, inflammation or scarring.
-face, hands, genitals, areas of chronic pressure or friction
-a/w AI diseases (thyroiditis)
txt: corticosteroids and phototherapy
330
hypogonadotropic hypogonadism (low FSH and estradiol)
irregular menses and infertility due to loss of pulsatile GnRH secretion preciptated by weight loss, stress, chronic illness
first line: manage any underlying cause
331
coccydynia (tail bone pain)
can occur after vaginal delivery due to coccyx displacement as fetus passes through maternal pelvis during labor and delivery.
dx is cx; txt: reassure and analgesics because most resolve spontaneously
332
test for alloimmunization
not alloimmunized = negative indirect coombs test
Uworld Step2 Shelf
flashcards
Decks in class (4)
# Cards
