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