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OBGYN step 3

Terms in this set (105)

What should be performed at every prenatal visit?
Mom weight, blood pressure, assess gestational age, fetal heart tones, ask about fetal movements, check fetal presentation in 3rd trimester
Smoking in pregnancy risk
increase risk of placental abruption, preterm birth, low birth weight, and SIDS
Smoking cessation options in pregnancy
Buproprion, nicotine replacement
Alcohol use in pregnancy
Fetal alcohol syndrome
- CNS issues, growth retardation, facial abnormalities
Fetal alcohol syndrome facies
short palpebral fisses, smooth philtrm, thin vermillion boarder
Leiomyomata uteri
Leiomyomas, fibroids
Benign smooth muscle tumors of uterus
Patient with leiomyomata uteri, increasingly heavy menstrual periods, and decreased Hgb management options
Hormonal contraceptives will decrease bleeding, may increase size of fibroids
Endometrial ablation
Myomectomy (surgical removal)
uterine artery ablation (MUST be done with childbearing)
Hysterectomy

Iron for iron def. anemia
How to treat normal N/V in pregnancy?
Lifestyle: bland foods, small frequent meals, eat slowly, avoid triggers
1st line medical: Pyridoxine (Vit. B6) + doxylamine
Then can add dyphenhydramine, meclizine, ondansetron
Management of benign ovarian cyst
5-10 cm and asymptomatic, observation
>10 cm needs surgical removal due to risk of ovarian torision
When do yo screen for syphilis during pregnancy?
RPR or VDRL at 1st visit then 3rd trimester if high risk
When do you screen for HIV during pregnancy?
1st visit then 3rd trimester if high risk
When do you do triple or quadruple screen?
@ 15-20 weeks
for NTD and aneuploidy
When do you screen for gestational diabetes?
24-28 weeks with 1 hour 50g GTT
if abnormal, follow up with 3 hr 100g GTT
over 140 is abnormal
When do you administer Rh immune globlin (RhoGAM) if Rh negative?
28 weeks, after delivery, and any other time there is a risk of fetomaternal hemorrhage
When do you screen for gonorrhea and chlamydia in pregnancy?
1st visit then 3rd trimester if high risk
When do you screen for group B streptococcs during pregnancy?
35-37 weeks
If positive give IV PCN during labor
How do you manage asymptomatic bacteruria during pregnancy?
Pregnancy causes dilation of uterus which increases risk of pyelonephritis
Treat with nitrofurantoin, amoxicillin, augmentin, cephalexin, or fosfomycin
Repeat urine culture 1 week after abx
At what BhCG level should you be able to visualize an IUP by TVUS?
>1500

if >1500 and nothing visible in uterus then suspect ectopic pregnancy
What are the components of BPP?
NST, fetal breathing, fetal movement, fetal tone, AFI
What are the risks of a congenital syphillis infection?
growth restrictions, prematurity, still birth, snuffles, hutchinson teeth, saber shins
How do you screen for syphillis? How do you confirm?
Screen with RPR or VDRL
Confirm with treponemal antibody test
How do you treat a pregnant patient with syphilis?
ONLY IM benzathine PCN G
If allergy, desensitize
MCC of vaginal bleeding post-menopaus
atrophy of endometrium
How do you manage post-menopausal vaginal bleeding?
10% have endometrial cancer, mst do bx to rule out endometrial hyperplasia and cancer

Can do TVUS looking for abnormally thick endometrial layer
How should patients be counseled regarding nutrition during pregnancy?
Supplement folic acid and iron, need an additional 300-500 kcal/day
Must fully cook meals, avoid unpastrurized dairy, avoid lunch meats, avoid fish high in mercury
Appropriate weight gain during pregnancy for woman with BMI <18.5
28-40#
Appropriate weight gain during pregnancy for woman with BMI 18.5-24.9
25-35#
Appropriate weight gain during pregnancy for woman with BMI 25-29-9
15-25#
Appropriate weight gain during pregnancy for woman with BMI >30
11-20#
What teratogenic agent is associated with ebstein cardiac anomaly?
lithium
What teratogenic agent is associated with clear cell adenocarcinoma of the vagina?
diesthystilbesterol
What teratogenic agent is associated with microcephaly, intellectual disability, smooth philtrum?
fetal alcohol
What teratogenic agent is associated with gray baby syndrome?
Chloramphenicol
What teratogenic agent is associated with phocomelia?
thalidomide
What teratogenic agent is associated with craniofacial anomalies, fingernail hyperplasia, and developmental delay?
phenytoin
What abx is used in the treatment of pelvic inflammatory disease?
outpatient: ceftriaxone + doxycycline, cefoxitin +probenacid + doxycycline

inpatient: IV cefoxitin or cefotetan +doxycycline, IV clindamycin +IV gentamycin
Increased AFP on second trimester maternal serum screening
NTD, abdominal wall defect, multiple gestation, incorrect dating (MCC)
Decreased AFP, decreased estriol, increased hCG on second trimester maternal serum screening
downs syndrome
decreased AFP, decreased estriol, decreased hCG on second trimester maternal serum screening
trisomy 18 (edwards)
If abnormalities on second trimester maternal serum screen what should you offer mom?
targeted sonogram or amniocentesis
What is the recommended screening for ovarian cancer?
Pray like hell you dont get it
aka none
Bleeding before 20 weeks gestation + no passage of production of conception +closed cervix
threatened abortion
bleeding before 20 weeks gestation + cramping + no passage of POC + open cervix
inevitable abortion
passage of some POC + open cervix
incomplete abortion
passage of all POC + closed cervix
complete abortion
fetal death before 20 weeks gestation + no passage of POC + closed cervix
missed abortion
spontaneous abortion complicated by uterine infection
septic abortion
What is cervical insufficiency?
painless dilation of the cervix during the 2nd trimester

treat with placement of cerclage
What is the treatment of Graves dz during pregnancy?
MCC of hyperthyroidism
autoAb that stimulate the TSH receptor and can cross the placenta and case fetal hyperthyroidism
treatment in pregnancy: thionamides
-Propylthiouracil (1st trimester only): can cause liver failure so dont want to use it long
-Methimazole (2nd +3rd trimester): causes birth defects if used in 1st trimester - aplasia cutis

PT and methimazole can both cause agranulocytosis

If mom cant take these meds then thyroidectomy

B blockers like atenolol and propanolol can be used to control symptoms but long term use can case fetal growth restrictions
What patients should receive intrapartum prophylaxis against GBS?
IV PCN G
patients with + GBS screen, + GBS bacteruria this pregnancy, previous infant with early onset GBS, anyone with unknown screening results, or 1. intrapartum fever or 2. prolonged rupture of membranes or 3. preterm labor
What are the current guidelines for cervical cancer screening?
Begin PAP at 21
21-29 PAP every 3 years
30 + PAP every 3 years or PAP + HPV every 5 years
stop screening at 65 if no + PAP hx
What does early deceleration in fetal heart rate pattern indicate?
head compression
What does variable deceleration in fetal heart rate pattern indicate?
umbilical cord compression
What does late deceleration in fetal heart rate pattern indicate?
fetal hypoxia (uteroplacental insufficiency)
What does sinusoidal waveforms in fetal heart rate pattern indicate?
severe fetal anemia
What are the defining features of preeclampsia?
New onset HTN in 2nd half of pregnancy (BP > 140/90 after 20 weeks)
Proteinuria
End organ dysfunction: thrombocytopenia, renal insufficiency, impaired liver fxn, pulmonary edema, cerebral or visual sxs
What management of PCOS?
can be oligo or amenorrhea, hyperandrogenism -> hirsituism, polycystic ovaried on US, infertility, obesity, insulin resistance, endometrial hyperplasia

TXT: diet and exercise, OCP, metformin, spironolactone (hirsituism), clomiphene to help fertility
What is the management of shoulder distocia?
call for help
suprapubic pressure
McRoberts manuver: flex both mom legs agaisnt abdomen
Try to deliver posterior shoulder
Zavanelli manuver: push infant back in and do C/S
Infants of mothers with pregestaional diabetes are at increased risk for what complications?
Polyhydramnios, congenital malformations (caudal regression syndrome aka sacral dysgenesis, situs inversus, NTD, transposition of great arteries), preterm birth, macrosomnia, still birth, hypoglycemia + hypocalcemia
How do you treat symptomatic menopaus?
HRT with estrogen + progesterone
Never give estrogen alone in patients with a uterus due to cancer risk
use lowest dose necessary to control sxs
How is genital herpes simplex virus infection managed during pregnancy?
Rare for HSV to cross placenta
worry abot direct contact in birth canal
pts with HSV are offered suppressive therapy with acyclovir @ 36 weeks
If prodromal sxs or active outbreak then do C/S
Complete mole
46 XX, no fetal tissue
Vaginal bleeding, N/V, hyperemesis gravidarum
uterus larger than given dates
BhCG markedly increased
snowstorm appearance
Risk of malignant choriocarcinoma
Management of complete mole
suction curretage and serial BhCG to zero
if not back to zero consider invasive/ malignant mole---gets chemotherapy
Stress incontinence
MC
caused by weakening of pelvic floor
sxs: occurs with increased abdominal pressre
txt: wt loss, avoid caffeine and EtOH, do keigles, bladder training, use pessary, surgical txt
Urge incontinence
cause: overactive detrusor muscle
sxs: preceded by sudden urge to void
txt: life style, antimuscarinics (oxybutinin, darifenacin, tolterodine)
Overflow incontinence
Cause: bladder obstruction or neuropathy, unable to void normally--> over distention of bladder
sxs: continuous leak of urine
txt: treat underlying cause, intermittent caths
How is HIV managed throughout pregnancy?
Screen at 1st and 3rd
Antiretroviral therapy (HAART): continue current therapy if on. If not on, initiate regimine (avoid efavirenz if possible-- NTD)
Monitor viral load periodically: if <1000 then SVD, if >1000 intrapartm IV Zidovdine and C/S
Infant gets ZIdovudine for 6 weeks and do not breastfeed
What is the triple test for breast mass workup?
Clinical exam, imaging (diagnostic mammo or US dependent on age), needle biopsy
If all negative, good to go
If any one is positive, suspicious mass--> do excisional biopsy
Patient develops DVT during the first trimester of her pregnancy. How do you manage?
Anticoagulate with LMWH (enoxaparin) subQ or unfractionated heparin SbQ

NEVER warfarin

Stop anticoag when in labor or 24 hours prior if possible. Resme anticoag 12 hours post partm and continue for 6 weeks
What are the symptoms of intrahepatic cholestasis of pregnancy? Management?
pruritis especially on acral surfaces, worse at night
Elevated total serum bile acid levels
Txt: ursodeoxycholic acid, hydroxizine, early delivery at 36 weeks

Intrahepatic cholestasis has an increased risk of fetal demise so we deliver at 36 weeks
Most likely cause of amenorrhea in ballet dancer with eating disorder?
functional hypothalamic amenorrhea
Most likely cause of amenorrhea in short stature, low set ears, webbed neck
Turners XO
Most likely cause of amenorrhea following dilation and curettage after spontaneous abortion
asherman
Most likely cause of amenorrhea in cyclic pelvic pain + blue bulge at introits on exam
imperforate hymen
Most likely cause of amenorrhea in elevated testosterone level and no axillary or pubic hair on exam
androgen insensitivity
Most likely cause of amenorrhea in overweight female with acne and hirstutism
PCOS
Most likely cause of amenorrhea in postpartum patient with inability to breastfeed
Sheehan
Most likely cause of amenorrhea in patient with anosmia
Kallmann
Most likely cause of amenorrhea in patient with galactorrhea
Prolactinoma
Most common cause of amenorrhea
pregnancy
Describe the management of postpartum hemorrhage due to uterine atony
fundal or bimanual massage
explore uterine cavity for clots/placenta
give uterotonic agent: oxytocin, methylergonovine, carboprost, misoprostol
Give IV fluids, possibly blood
Suurgery --> artery ligation versus hysterectomy
What agents are used in the induction of labor?
Oxytocin--> IV short half life, give easy titration
MIsoprostol --> prostaglandin E1 oral or vaginal
Dinoprostone --> Prostaglandin E2 vaginal or cervical
What is the msot appropriate next step for ASCUS?
Atypical Squamos Cell of Unknown Significance
Age 21-24 > repeat PAP in 1 year if positive colposcopy
Age 25+ > HPV test > if positive then colposcopy
What is the msot appropriate next step for ASC-H?
colposcopy
What is the msot appropriate next step for LSIL?
low grade squamous intraepithelial lesion
Age 21-24 > repeat PAP in 1 year if positive colposcopy
Age 25-29 > colposcopy
Age 30+ > HPV test > if positive then colposcopy
What is the msot appropriate next step for HSIL?
high grade squamous intraepithelial lesion
Age 21-24 > colposcopy
Age 25+ colposcopy or LEEP
What are the risk factors for chorioaminonitis?
prolonged rupture of membrances, prolonged labor, multiple cervical exams, meconim fluid, internal monitors
What is the treatment for chorioamnionitis?
IV broad spectrm abx usually ampicillin + gentamycin
How do you manage a patient with Preterm Premature Rupture of Membranes that is stable and the FHT are reassuring?
Admit, manage expectantly, give mom IM betamethasone
Tocolysis: indomethacin, nifedipine, Atosiban
Prophylactic Abx: apicillin or azithromycin
Deliver at 34 weeks if possible to make it that long
Gardnrella vaginalis
Discharge: thin, gray-white, fishy odor
Vaginal pH: >4.5
Wet mount: clue cells (epithelial cells with bacteria coating them), + Whiff test (add KOH and its stinky)
Treatment: metronidazole, clindamycin
Candida spp.
Discharge: thick, white, cottage cheese
Vaginal pH: 4-4.5
Wet mount: yeast forms
Treatment: oral fluconazole, topical clotrimazole, miconazole, nystatin
Trichomonas
Discharge: frothy, yellow-green, fishy
Vaginal pH: >4.5
Wet mount: motile, pear shaped
Treatment: metronidazole
What should you counsel patients about when taking metronidazole?
Avoid EtOH for at least 3 days after finishing medication.
Disulfram reaction
Patient with fever one day after emergent C/S, PE shows uterine tenderness and foul smelling lochia
Endometritis
Treat with broad spectrm antibiotics like gent+clindamycin
What is the management of preeclampsia with severe features?
BP control with IV hydralazine, IV labetalol, oral nifedipine
Seizure prophylaxis with IV MgSO4
Delivery
What are the treatment options for primary dysmenorrhea?
Basic period cramps
Heat therapy, NSAIDS, combined OCP, GnRH agonist (leuprolide)-> medical menopause, surgery (laparoscopy for endometriosis or hysterectomy)
What is the ddx for third trimester bleeding?
Bloody show- ok
Placenta previa
Vasa previa
Placental abruption
Uterine Rupture
What is the ddx for first trimester bleeding?
Possible causes of bleeding include subchorionic hemorrhage,
embryonic demise,
anembryonic pregnancy,
incomplete abortion,
ectopic pregnancy,
gestational trophoblastic disease.
What is the ddx of vaginal bleeding before 20 weeks gestation?
Miscarriage
Cervical insufficiency
cervical, vaginal, or uterine pathology
ectopic pregnancy
placental abruption
G2P2 woman did not receive prenatal care. 1 day old infant has severe anemia. Labs confirm anti-D Abs in mom. What could have prevented this?
Hemolytic disease of the newborn
If mom is Rh (-) she can develop Ab if the fets is Rh (+).
In future pregnancies, the Abs can attack fetal RBCs giving hemolytic disease of the newborn > severe anemia > death

You can prevent this by giving Rh immune globulin (RhoGam, Rhophylac) at 28 weeks, after delivery, and any time there is risk of fetomaternal hemorrhage.
32 year old woman with fibroids, heavy bleeding, and HgB of 8. What medications can be used to terminate this episode of bleeding?
High dose estrogen (follow with course of progestin)
Combined OCP taper
High dose progestin
Transxemic acid
What is the treatment of mastitis is the postpartum period?
Inflammation of breast tissue most commonly caused by Staph aureus
Continue breat feeding or pumping
Antistaphylococcal PCN > dicloxacillin
Vancomycin for MRSA
U/S if abscess then I&D
Menstrual periods with urinary frequency, dysuria, painful defecation, pain upon deep penetration. PE with tenderness to palpation of the posterior wall of vagina.
What is the most appropriate treatment for this patient?
Endometriosis
NSAIDS, Combination OCPs

GnRH agonist (leuprolide)> medically induced menopause
Progestin
Danazol
Surgery
__________________ play a critical role in cervical ripening by increasing inflammatory mediators in the cervix and inducing cervical remodeling.
Prostaglandins
While both dinoprostone and misoprostol are effective in cervical ripening and labor induction, they differ in their clinical and pharmacological profiles. PGE2 has been shown to stimulate interleukin-8, an inflammatory cytokine that promotes the influx of neutrophils and induces remodeling of the cervical extracellular matrix, and to induce functional progesterone withdrawal. Misoprostol has been shown to elicit a dose-dependent effect on myometrial contractility, which may affect rates of uterine tachysystole in clinical practice.
PGE2= dinoprostone

PGE1= misoprostol
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