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OBGYN Review

Terms in this set (201)

Closed cervix, no passage of fetal tissue + vaginal bleeding in the first trimester. What's going on? How do you treat?
Threatened abortion. Reassurance.
Pregnant and intermittent lower abdominal pain and vaginal spotting. What do you do??
Transvaginal U/S
Milky, nonbloody nipple discharge. What should you test?
Measure prolactin and TSH level; pregnancy test; MRI of brain?
30 or older with a palpable breast mass. What do you do?
Mammogram +/- ultrasonogram. If suspicious, do a core biopsy
Age <30 with a palpable breast meass. What do you do?
Ultrasonogram +/- mammogram. Simple cyst=needle aspiration; Complex cyst: image-guided core biopsy
Gestational diabetes. What blood sugars do you expect? How do you treat?
Fasting >95; 1-hour postprandial>140; 2-hour postprandial >120; 1st line dietary changes; 2nd line insulin + oral agents (metformin, glyburide)
Uncontrolled maternal hyperglycemia. How does it affect the baby?
Fetal hyperinsulinemia; POLYCYTHEMIA (hematocrit>65%) from decreased O2 and increased O2 demand. Also macrosomia, neonatal hypoglycemia, hyperviscocity.
Patient is HIV+ and doesn't want you to tell the BF. What do you do?
Required to inform the local health dept. Encourage pt to tell the BF.
Asymptomatic UTI in pregnancy. What can you give?
Nitrofurantoin; Amoxicillin; Amoxicillin-clavulanate; Cephalexin
AUB + hyperplasia without atypia. Wants babies. Rx?
Progestin therapy. If see atypia and no plans for pregnancy, give a hysterectomy
Foreceps assisted vaginal birth + 3rd degree lac. Small, red velvety area in posterior vaginal wall + brown discharge. Dx?
Rectovaginal fistula
Hypotension after epidural anesthesia. Why?
Vasodilation and venous pooling. (decreased venous return and cardiac output)
Most common cause of postpartum hemorrhage?
Uterine Atony (utuerus becomes fatigued, over-distended, or unresponsive to oxytocin). Uterus fails to contract and is soft/boggy and enlarged
How do you treat postpartum uterine atony?
Bimanual massage. IVF. Infusion of oxytocin!
Pregnant lady from India has cough, progressive dyspnea and orthopnea. Dx?
Rheumatic mitral stenosis
ABO incompatibility occurs in a group _ mother with a group __ baby.
Group O mom with group A or B baby. Less severe hemolytic disease of the newborn than Rh(D) incompatibility. Babies usually asymptomatic with absent or mild anemia + neonatal jaundice (photorx!)
16 yo with LLQ ab pain x1day . LMP 2 wks ago. Normal vitals. Dx?
Mittelschmerz (normal ovulation). Unilateral pain, lasts <1day, resolves without intervention.
What is contraindicated to breastfeeding if mom has it?
Active substance abuse in mom, active TB/HIV; Herpetic breast lesions, Varicella infection; Chemo/radiation. In baby: galactosemia.
Painful genital lesion. What could it be?
Chancroid (H. ducreyi) vs Genital Herpes (multiple ulcers)
Painless genital lesion. What could it be?
Granuloma Inguinale; Syphilis; Lymphogranuloma venereum
Masculinization of mom during pregnancy. Cliteromegaly in utero. Later, see delayed puberty, osteoporosis, and polycystic ovaries. What's wrong?
Aromatase deficiency in baby. Can see undetectable estroen and high concentration of gonadotropins. Normal internal genitalia; ambiguous external genitalia; clitoral hypertrophy; high FSH/LH with low estrogen
Prolonged rupture of membranes with >18 hrs between time of rupture and birth. Patient has fever and uterine tenderness, maternal or fetal tachycardia, and purulent vaginal discharge. Dx? Rx?
Chorioamnionitis (intraamniotic infection). Also see malodorous amniotic fluid. Rx: give oxytocin + broad spectrum abx (Accelerate labor)
Intrauterine fetal demise at >24 wks in the hospital. How do you manage?
Labor induced in hospital when you feel ready. Don't delay too long (can lead to coagulopathy)
Chronic pelvic pain, dysmenorrhea, deep dyspareunia, and dyschezia. Dx? Rx?
Endometriosis. Rx: NSAIDs +/- OCPs. If that doesn't work, laparoscopy
Heavy peripartum blood loss + hypotension and/or blood transfusion. What do you expect clinically?
Sheehan syndrome! Hypopituitary sx: lactation failure, amenorrhea, loss of sexual hair, anorexia/weight loss, lethargy, hyponatremia
T/F: OCPs can worsen HTN.
TRUE. Also risk of VTE, hepatic adenoma, stroke and MI
T/F: Pregnant woman with capacity can refuse rx, even if it places her unborn child at risk.
TRUE
When should you give Rhogam?
28-32 wks gestation and again after delivery if the baby is Rh +. (Mom is Ab screen -)
Baby dies of SIDS. Three days later, mom has amplified breast fullness and tenderness. Rx?
Engorgement with no erythema and afebrile. Give NSAIDs + ice packs!! Avoid breast binder (casues nipple stimulation)
What stimulates and inhibits prolactin production?
TRH and serotonin stimulate prolactin production. Dopamine inhibits prolactin. Hypothyroidism-->amenorrhea and galactorrhea (increased prolactin)
G1 at 18 wks shows low AFP and unconjugated estriol and increased beta-hCG and inhibin A. What do you do?
Ultrasound to see if she baby is at risk for Down's. (18-20 wks).
Prior c-section; on baby #2 with intense ab pain, relieved, then resumes in a diffuse distribution. Hyperventilation and tachycardia. Vaginal bleeding. Loss of fetal station. Dx?
Uterine rupture.
Chronic HTN predates pregnancy but can be diagnosed any time before __ wks gestation
20 wks. Need 2 measurements taken >4 hrs apart. Increased risk preterm labor
What are some pregnancy-related risks from HTN?
Maternal: Superimposed PEC, postpartum hemorrhage, gestational DM, abruptio placentae, Cesarean delivery; Fetal: Fetal growth restriction, perinatal mortality, preterm delivery, oligohydramnios
46 yo with 5 cm irregular right adnexal mass and negative pregnancy test. What do you want to do?
Pelvic u/s (epithelial ovarian carcinoma: increased CA-125, SOB, N/V, ab distension)
Spiculated breast mass with coarse calcifications in upper outer quadrant. Shows foamy macrophages and fat globules. What is it?
Fat necrosis of th ebreast (benign, post-trauma/surgery)
Risk factors for breast cancer?
HRT, nulliparity, increased age at 1st live birth, alcohol consumption; Genetic mutation or breast ca in 1st degree relatives; white race; increasing age (>50); early menarche/late menopause
What are some severe features seen with PEC?
Thrombocytopenia, Increased creat, ALT/AST, pulm edema, new-onset visual/verebral sx, >160/110 on 2 occasions >4 hrs apart
What is the mechanism behind breastfeeding causing amenorrhea?
Increased prolactin inhibits GnRH, which decreases LH/FSH production
What causes variable decels?
Umbilical cord compression; oligohydramnios; OR cord prolapse. Try maternal repositioning.
What causes late decels?
Uteroplacental insufficiency
What causes early decels?
Fetal head compression; Can be normal fetal tracing
Induction at 42 wks=increased risk for what?
Baby: Oligohdramnios, meconium aspiration, stillbirth, macrosomia, convulsions; Maternal: cesarean delivery, infection, postpartum hemorrhage, perineal trauma
Placenta covering internal os at 21 wks. What do you recommend for the patient?
PELVIC REST AND Abstain from coitus; DON'T do DIGITAL CERVICAL EXAM OR VAGINAL DELIVERY.
How is hemophelia A passed on?
X-linked recessive
When do you check GBS?
3-5 wks before expected delivery date (35-37 wk gestation). UNLESS hx of GBS bacteriuria, UTI, or infant with early onset GBS: get Abx ppx
T/F: The etiology of intrauterine fetal demise is frequently unknown.
TRUE
What's the most appropriate diagnostic test for endometritis?
Laparoscopy. At increased risk of infertility!
Gestational HTN. How often do they need to be monitored?
Weekly biophysical propfile starting at 32 wks gestation.
Why are biophysical profiles done?
Rule out fetal hypoxia (if 8-10/10)
Mom doesn't gain enough weight while pregnant. What are they at risk for?
Fetal growth restriction; pretern delivery
Mom gains too much weight during pregnancy. What are they at risk for?
Gestational DM; Fetal macrosomia; Cesarean delivery
Klumpke palsy. What nerve is injured and where?
C8 and T1. See ipsilat miosis and ptosis (Horner's Syndrome)
Placenta extracted in pieces-->profuse vaginal bleeding. Firm uterus, bleeding doesn't respond to uterine response. Dx?
Placenta accreta. Risk factors: prior c-section; hx of d&c, and advaced maternal age
What is physiologic leukorrhea?
Normal vaginal discharge (white, mucoid, no odor; mostly squamous cells and rare PMNs)
Ovarian torsion. What should you do?
Laparascopy with detorsion; ovarian cystectomy; oophorectomy if necrosis or malignancy
60 yo with SOB and decreased appetite, Non-mobile mass in adnexa. Next step?
Exploratory lapartomy for epithelial ovarian carcinoma
Pruritis and elevated total bile acids and/or aminotransferases in pregnancy. Dx?
Intrahepatic cholestasis of pregnancy
First prenatal visit in november at 8 wks gestation. What should you do?
FLU VACCINE!
T/F: OCPs case weight gain.
FALSE. SE: breakthrough bleeding, HTN, and increased risk of VTE
Beta <1500. What should you do?
Repeat beta in 2 days
T/F: Cervical mucus secretion close to ovulation increases in quantity and is clear, elastic and thin.
TRUE (like an uncooked egg white). AFTER ovulation, it becomes thick and less hospitable to sperm
46 yo with heavy painful periods + pelvic pain btwn periods. Symmetrically enlarged boggy, tender, mobile uterus. Not pregnant. Dx?
Adenomyosis. (Think about fibroids and endometrial cancer/hyperplasia)
57 yo with vaginal spotting and large, nontender left adnexal mass. What do you do?
Endometrial biopsy
35 wks with ROM. What do you do?
Abx (penicillin for GBS) +/- corticosteroids then delivery if 35-37 wks with PPROM. If <32 wks, give magnesium before delivery!
67 yo with severe vulvar itching/burning, dyspareunia, and dry, white plaque-like vulvar skin with loss of labia minora. What do you do?
Vulvar punch biopsy (lichen sclerosis) to check for premalignant lesion of squamous cell carinoma
How do you treat lichen sclerosus (white vulvar plaque, spares vagina)?
Topical corticosteroids (clobetasol)
How do you treat atrophic vaginitis (vulvovaginal dryness)?
Low-dose topical estrogen
Increased AFP. What's the most likely abnormality you'll find?
Fetal abdominal wall defect (omphalocele/gastroschisis); Open neural tube defects (anencephaly, open spina bifida), multiple gestation
Where does choriocarcinoma usually spread to? How do you confirm dx?
Spreads to the LUNGS (postpartum with pulm sx and multiple nodules on CXR). Confirmed with elevated beta hCG
What is th emost important direct role of hCG in pregnancy?
Maintains corpus luteum
53 yo with itchy rash on left breast. Postmenopausal. What's associated with her disease?
Mammary Paget disease, associated with adenocarcinoma
What should a woman expect for her postpartum period?
Transient rigors/chills; peripheral edema; lochia rubra; uterine contraction and involution; breast engorgement. Rx: exam for uterine atony/bleeding; perineal care; voiding trial; pain management
HTN, proteinuria, edema, positive ANA and malar rash. Dx?
LUPUS (SLE) leading to glomerulonephritis
Pt with cold knife conization 2 yrs ago. How do you evaluate risk of preterm delivery?
Transvaginal U/s to check cervical length. If short, give vaginal progesterone w/o hx of preterm labor. If short w/ hx of preturm labor, do cerclage + serial TVUS-CL until 24 wks
What should be screened for at the first prenatal visit?
HIV, HBV, Chlamydia, and syphilis
Low FHS/LH, normal prolactin and TSH. Infertile. How do you treat?
Pulsatile GnRH rx
22 yo with 6 months amenorrhea from intense exercise. What is she at risk for?
Decreased bone mineral density
Decreased fetal movement with nonreactive nonstress test, what should you do next?
Biophysical profile or contraction stress test. Don't do CST if placenta previa or myomectomy!
What is a nonstress test? When is it normal and abnormal?
External FHM for 20-40 min. Reactive: >/=2 accels; Nonreactive: <2 accels or recurrent variable/late decels
What is a biophysical profile? When is it normal and abnormal?
Nonstress test + u/s to asses amniotic fluid, fetal breathing, movment and tone. Normal is 8-10 pts; Equivocal=6 pts; Abnormal=0,2,4 pts (oligohydramnios)
What is a Contraction stress test? When is it normal and abnormal?
External FHM during spontaneous or induced uterine contractions (oxytocin, nipple stimulation). Abnormal if late decels with >50% contractions
What is a doppler sonography of the umbilical artery? When is it normal and abnormal?
Eval of umbilical artery flow in fetal IUGR only. Abnormal if decreased, absent or reversed end-diastolic flow.
What 5 factors do biophysical profiles look at?
Nonstress test; Amniotic fluid volu e; Fetal movements; Fetal tone; Fetal breathing mvmts. If <4, shows fetal hypoxia due to placental dysfunction (AMA, tobacco, HTN, DM)
What's the biggest risk factor for clear cell adenocarcinoma?
In utero exposure to DES (diethylstilbestrol). Also at increased risk of ectopic pregnancy and pre-term delivery along with infertility
5cm ovarian cyst in a 62 yo. What should you do?
Serum CA-125. If elevated or malignant (solid, thick septations, loculations or large)-->CT/MRI and exploratory surgery
Bacterial Vaginosis in pregnancy. How do you treat?
Oral metronidazole
29 yo with palpable mobile breast mass. What do you do?
Breast u/s. If simple breast cyst (clear fluid when aspirated), return in 2-4 months for follow-up
Why do UTI's happen more in F>M?
Shorter urtheral length in F. Also sex, recent Abx, spermicidal contraceptives, and urethra close to anus
Mom has HIV. How do you prevent spread to baby?
HAART as soon as possible during pregnancy, regardless of maternal CD4 count or viral load (with zidovudine)
36 wks with ab pain + vaginal bleeding x3 hrs. 75 mL red blood in vagina. FHR 108; Mom's bP 160/100 and pulse 118. Dx?
Premature placental separation (placental abruption)
What are some risk factors for cocaine use and HTN?
Placental abruption
Asymptomatic chlamydia. Rx?
One dose azithromycin or 7-day course doxycycline. DON'T need to treat for gonorrhea!
Hyperandrogenism during pregnancy with bilat ovarian masses. What do you do?
Luteoma of pregnancy (BENIGN)--regress after delivery. Krukenberg can also cause fetal virilization
How do you prevent baby from getting rubella?
Vaccination prior to conception
Infant with hydrocephalus, intracranial calcifications, tonic-clonic seizures, jaundice, hepatosplenomegaly and lymphadenopathy. Dx?
Congenital toxoplasmosis
Gestational diabetes that doesn't improve with dietary modifications. Rx?
Insulin (doesn't cross the placenta)
What's the best maneuver to help with shoulder dystocia?
Don't push; Lower the head of th ebed; Flex the hips against the abdomen; Call for help; Apply suprapubic pressure; Episiotomy; Maneuvers: deliver posterior arm, press against posterior shoulder (woods corkscrew or rubin maneuver), Gaskin maneuver (all 4s), replace head in vagina then CS (Zavanelli maneuver)
What is the Zavanelli maneuver?
Replace the head back in the vagina then do a CS
Postpartum urinary retention and overflow incontinence. What are some risk factors?
Nulliparity, prolonged labor, instrumental delivery, regional anesthesia, perineal trauma. Regional anesthesia can cause bladder atony (unabe to void 6 hrs after vaginal delivery)
What is the most common cause of primary postpartum hemorrhage?
Uterine atony; See profuse vaginal bleeding + soft "boggy" and enlarged uterus. Risks: prolonged labor, IOL, operative vaginal delivery, fetal weight>4000 g
How do you treat uterine atony?
Infusion of oxytocin, methylergonovine, carboprost (not in asthmatic pts), misprostol. Also bimanual uterine massage, IV fluids, O2
36 yo with breast lump. What do you do?
>30 yo, do Mammogram (+/0 u/s)-->then core biopsy
BRCA mutation. How do you decrease risk of cancer?
Breast/ovarian Cancer: BSO; OCPs; Age <30 at 1st live birth; Breastfeeding; Tubal ligation
Maternal fever + fetal tachycardia on FHM. Dx?
Intraamniotic infection
What are risks to mom and baby from HTN?
Mom: PEC, postpartum hemorrhage, GDM, placental abruption, CS; Baby: fetal growth restriction, perinatal mortality, preterm delivery, oligohydramnios
What are adverse effects of oxytocin?
Hyponatremia, hypotension, tachysystole
Claw hand + horner syndrome after delivery. What's wrong?
C8/T1 traction from shoulder dystocia (Klumpke palsy)
Waiter's tip after delivery. What's wrong?
CN5/CN6 (Erb palsy)
What is mittelschmerz?
Pain in the middle of the menstrual cycle during ovulation
Frank breech with closed cervix at 37 wks. What do you do?
External cephalic version (37 wks to labor) UNLESS oligohydramnios, ROM, hyperextended fetal head, fetal/uterine anomaly, multiple gestation, placenta previa/abruption
Pregnant lady with severe vomiting and weight loss. What should you do?
Ultrasound!
Symmetric IUGR. Causes?
Genetic disorders, congenital heart disease, intrauterine infection..
Asymmetric IUGR. Causes?
Vascular disease, Antiphospholipid Antibody syndrome, SLE, Cyanotic cardiac disease, Tobacco, alcohol, cocaine
Bilateral renal agenesis in 28 wk old + labor started. What should you do?
Let spontaneous vaginal delivery (anomaly is already incompatible with life)
Continuous painless urine leakage after recent pelvic surgery. Dx?
Vesicovaginal fistula
What causes amenorrhea in avid athletes?
Decreased LH and GnRH-->estrogen deficiency-->infertility, vaginal atrophy, breast atrophy, osteopenia
20 minutes after SVD, mom has brief tonic-clonic seizure--breathless and cyanotic. Purpuric rash + bleeding from IV site. Dx and rx?
Amniotic fluid embolism-->intubation + mechanical ventilation
What is the pathogenesis of HELLP syndrome?
Hepatic and systemic inflammation, activation of the coagulation cascade, and platelet consumption. Rx: deliviery!
Infant born to mom with graves' disease is at risk for __.
Thyrotoxicosis from passage of maternal TSH receptor antibodies across the placenta. Rx: Methimazole + beta blocker
T/F: Alcohol consumption increases risk of breast cancer.
TRUE
Why would obese women experience milder menopausal sx?
Conversion of adrenal androgens to estrogens by adipose tissue
When would you give magnesium for a preterm delivery?
<32 weeks. Also give betamethasone, tocolytics, and penicillin if GBS + or unknown
Woman with medroxyprogesterone experiencing breast tenderness, weight gain and fatigue. No menses x>1 month. What do you do?
Pregnancy test! (similar sx to Depot side effects)
What happens to Total T4, Free T4 and tSH during pregnancy?
Increased Total T4, Slight increased free T4, Decreased TSH
T/F: Prior to term, fetus in transverse lie will ilkely spontaneously convert to breech or vertex.
TRUE. If persistent at term, do external cephalic version or CS
Mucopurulent discharge and cervical friability in a 22yo. Dx?
Cervicitis--most commonly Chlamydia trachomatus (or Neisseria)
How do you confirm intrauterine fetal demise?
Transabdominal u/s. Do fetal autopsy and evaluate placenta to evaluate more
Pseudohyphae on wet mount. How do you treat?
Candida. Giva azoles (eg fluconazole)
How does renal blood flow, GFR, BUN, creat and protein excretion change with pregnancy?
Increased RBF, GFR, and protein excretion; Decreased GFR, BUN and creatinine
What tests do you order at 24-28 wks?
Hb/Hct; Ab screen if Rh(D) negative; 50g 1hr oral glucose challenge test
What tests do you order at 35-37 wks?
GBS culture
What tests do you order at the initial prenatal visit?
Rh(D) type and screen; Hb/Hct, MCV; HIV, VDRL/RPR, HBsAg; Rubella and varicella immunity; Pap smear (if indicated); Chlamydia PCR; Urine culture and urine protein. IF AT RISK, screen for HbA1C or glucose tolerance test!
Crampy lower abdomen and back pain during menses with normal exam. Dx?
Primary dysmenorrhea
Pain peaks before menses, dyspareunia, infertility. Dx?
Endometriosis
Heavy menses with clots; Constipation, urinary frequency, pelvic pain/heaviness; Enlarged uterus on exam. Dx?
Fibroids
Dysmenorrhea, pelvic pain; Menorrhagia; Bulky globular and tender uterus. Dx?
Adenomyosis
Dull and ill-defined pelvic ache that worsens with standing. Dyspareunia. Dx?
Pelvic congestion
How do you treat Hep C in pregnancy?
May lead to GDM, cholestasis of pregnancy and preterm delivery.Avoid Csection and scalp electrodes. Encourage breastfeeding unless see maternal blood. Give pt Hep A and B vaccines now!! Safe in pregnancy
Suspected gyn tumor. What do you do?
Pelvic ultrasound->see uterine fibroids and ovarian pathology
No cervical change for >/= 4 hrs with adequate contractions OR no cervical change for >/=6 hrs with inadequate contractions. Rx?
Cesarean delivery for arrest
Cervical change slower than expected +/- inadequate contractions. Rx?
Oxytocin for protraction
What are side effects of magnesium toxicity? How do you treat?
Mild: N, flushing, h/a, hyporeflexia; Moderate: areflexia, hypocalcemia, somnolence; Severe: Respiratory paralysis, cardiac arrest. Rx: stop Mg and give IV calcium gluconate! (May be seen with renal insufficiency)
What does Mg prevent in the infant?
Cerebral palsy in premature infants
Mom with edematous, erythematous and painful breast with superficial dimpling. Axillary lymphadenopathy. Dx? Rx?
Inflammatory breast carcinoma (peau d'orange). Mammography + u/s. Tissue biopsy to confirm.
Abrupted placenta. What should you do first?
Aggressive fluid resuscitation with crystalloids + move mom to Left lateral decubitus position to optimize maternal circulation.
When would you use trastuzumab? What should you check before using it?
HER2 positive breast cancer. Check echocardiography first because can cause cardiac toxicity!
Untreated PID can lead to what?
Tubo-ovarian abscess, abscess rupture, pelvic peritonitis, sepsis. If can't take PO meds from N/V, need inpatient rx.
Why is HELLP syndrome associated with RUQ pain?
Centrilobular necrosis, hematoma formation and thrombi in portal capillary system. Causes liver swelling with distended hepatic capsule
Why does severe preeclampsia lead to pulmonary edema?
Generalized arterial vasospasm-->increased systemic vascular resistance + high cardiac afterload. Also, decreased renal function, decreased serum albumin and increased capillary permeability in pregnancy
T/F: Because of changes of pregnancy, should increase levothyroxine dose when hypothyroid pt becomes pregnant.
TRUE. Increase ~30% at time pregnancy is detected (NOT before)
ASCUS found in patient <25 and 25/over. What do you do?
Age 21-25: repeat pap in 1 year. 25 or over, do HPV testing! If HPV positive, do colposcopy. If HPV negative, repeat cytology and HPV in 3 years.
How many babys spontaneous recover from erb's palsy within 3 months?
Up to 80%! May need surgery if not improved by 3-6 months.
Large ovarian mass with thick septations, solid components, and peritoneal free fluid. Experiencing bloating, pain, early satiety and abdominal distension. Dx?
Ovarian cancer. Likely epithelial ovarian carcinoma (abnormal proliferation of tubal epithelium; ovary, fallopian tube and pertioneum)
Decreased fetal movements. What should you do?
Nonstress test (record FHR and watch for spontaneous fetal mvmts). Reactive if 2 accels in 20 minutes. If less, it's nonreactive.
Unilateral bloody nipple discharge without mass or lymphadenopathy. Dx? Rx?
Intraductal papilloma; Do a mammography + u/s; biopsy +/- excision
Fever, breast erythema/warmth/pain, lymphadenopathy. Dx? Rx?
Mastitis from Staph aureus. Direct feeding with both breasts; ibuprofen; Abx (dicloxacillin or cephalexin); nurse infant Q2-3 hrs
Most common sx of fibroids?
Heavy and prolonged menstrual bleeding
Massive postpartum hemorrhage, inability to lactate, hypotension, significant weight loss, and decreased sexual hair. Dx?
Sheehan syndrome (ischemic necrosis of pituitary gland from hemorrhagic shock)
Oligoovulation, hyperandrogenemia (DHEA and testosterone), and increased 17OHprogesterone levels, LH/FSH. Dx?
Nonclassic Congenital Adrenal Hyperplasia (90% from 21-hydroxylase deficiency). Severe=virilization and salt-wasting. NON-severe=nonclassic CAH
Where is clear cell adenocarcinoma usually found?
Upper 1/3 of anterior vaginal wall. Squamous cell is in the upper 1/3 of POSTERIOR vaginial wall
What are two big risks of squamous cell carcinoma of the vagina?
Smoking and HPV
Painless antepartum vaginal bleeding, normal FHM. What happened?
Placenta previa. Note: PAINFUL=placental abruption or uterine rupture. Painless +deteriorating FHM = Vasa previa
Who should get an HPV vaccine?
Girls age 9-26 regardless of HPV status or sexual activity. Also for boys age 9-21.
Myomectomy where uterine cavity was entered. What's she at risk for?
Uterine rupture. If pregnant and come in labor, need laparotomy then hysterotomy for delivery or uterine repair.
What are first line antihypertensive meds in pregnancy?
Methyldopa, labetalol, hydralazine, nifedipine
Woman on tamoxifen (SERM) is at risk for what?
Hyperplasia of the endometrium (carcinoma). Also VTE and hot flashes.
Pt with PCOS and infertility. How do you treat if she wants to get pregnant?
Clomiphene citrate (induces ovulation; estrogen analog that improves GnRH release and FSH release). Also can use metformin
Mom with eclampsia has a seizure. Baby born with loss of external rotation of R arm. Why?
Posterior shoulder dislocation
No menses by age 15 with normal growth and secondary characteristics. 45,XY and female. Dx?
Androgen insensitivity syndrome
Hypogonadism under 40 yo.What are LH/FSH levels?
Premature ovarian failure. Increased FSH>>LH
What are some absolute contraindications for Combined hormonal contraceptives?
Migraine with aura; smoking >35 yo; HTN >160/110; VTE; stroke/ischemic HD; Breast Cancer; Cirrhosis and liver cancer; <3 wks postpartum
Pt with breast cancer wants contraception. What should she use?
Copper IUD
PCOS=increased risk of what type of cancer?
Endometrial carcinoma
T/F: Excessive alcohol use increases risk of osteoporosis.
TRUE. Also advanced age, thin, smoker, corticosteroids, menopause, malnutrition, FH, Asian/Caucasian ethnicity
Endometriosis incidentally found during surgery. How do you treat?
Observe (treatment not indicated unless symptomatic). If symptomatic, OCPs and NSAIDs or progesterone IUD
What is the most effective emergency contraception option?
Copper IUD (up to 5 days)>>Ulipristal pill=Levonorgestrel pill>OCPs
HSIL at 14 wks in 27 yo. Next step?
Cikoiscopy. If negative, repeat pap smear and colposcopy after delivery
What are some fetal complications from preeclampsia?
Oligohydramnios; Fetal growth restriction/small for gestational age (chronic uteroplacental insufficiency)
Pt with premature ovarian failure wants a baby. What do you do?
IVF with donor oocyte
When would you do cell-free fetal DNA testing?
>35 yo at risk of fetal aneuploidy >/=10wks (good sensitivity and specificity for Down's, Edward, and Patau). IF not high-risk, can do combined test(1st trimester) instead or quadruple screen (2nd trimester)
Obese 38 yo with AUB. What should you do?
Endometrial biopsy if AUB + unopposed estrogen; failed medical management or HNPCC. >45: do endometrial biopsy for AUB OR postmenopausal bleeding
Pt unable to void after vaginal delivery. Rx?
Insert a urethral catheter + encourage OOB
Hyperemesis gravidarum causes what metabolic disturbance?
Metabolic alkalosis from volume depletion and loss of gastric acid
60 yo with vaginal itching and dryness and recurrent UTIs +involuntary urine loss throughout the day with urinary urge. Why?
Estrogen deficiency (menopause). Rx: vaginal moisturizer + lubricant or topical vaginal estrogen
Pregnant patient inadvertently received rubella vaccine shortly before getting pregnant. What do you do?
Reassurance + routine prenatal care.
Early decels are caused by what?
Fetal head compression-->vagal response.
Variable and late decels indicate risk for what?
Fetal hypoxemia and acidosis
What can cause asymmetric fetal growth restriction?
HTN, PEC, DM; Antiphospholipid antibody syndrome; SLE; Tobacco/alcohol/cocaine
What can cause symmetric fetal growth restriction?
Aneuploidy; Congenital HD; Intrauterine infection
Decreased AFP and estriol. Increased beta hCG and inhibin A. Why?
Meitic nondiscjunction of chr21.
Increased MSAFP. Why?
Neural tube or abdominal wall defect
Decreased AFP, beta hCG and estriol. Why?
Trisomy 18
Breech presentation >37 wks. Rx?
External cephalic version
57 yo with vaginal pruritis and vagina appears pale, dry and smooth. Rx?
Vaginal estrogen cream for atrophic vaginitis (menopause)
What are some contraindications to raloxifene and tamoxifen?
Hx of VTE. Used for osteoporosis if risk of invasive breast cancer.
What is the most accurate method to estimate current gestational age?
First trimester ultrasound
Persistent amenorrhea, normal beta hCG, TSH and FSH. What should you do?
Check prolactin. If increased, do brain MRI
Active herpes lesions at time of delivery. What do you do?
Cesarean delivery
What are some adverse effects of tamoxifen and raloxifene?
Hot flashes, VTE. Tamoxifen=increased endometrial hyperplasia and carcinoma
What are some problems that can arise from placental abruption?
DIC, hypovolemic shock for mom. Also see hypoxia and preterm delivery for the infant.
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