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10_20 OBGYN

QuestionAnswer
on US what measurements most accurate for est GA ~6-10 or 12 wks use crown rump, 12-18 use biparietal
determination of pregnancy--cut off hCG 25mU/ml
how polyhydramnios defined? Oligo? AFI>25 it's poly, if <5 it's oligo
where is top of fundus if 16wk? 20wk? 1/2 pubis to umbilicus for 16wk, at umbilicus for 20wk
causes of symmetric IUGR usu insult in 1st trimester, due to fetal problems, ie aneuploidy or early infxn
causes of asymmetric IUGR and when occur insult occurs >20wks, placental problems incl HTN and poor nutrition
reasons why fundal size may be too small 1) fetal (IUGR, fetal demise), 2) amniotic fluid (oligohydramios)
reasons for 2nd trimester loss usu maternal, 1) uterine duplication, septum or submucous leiomyoma, 2) incompetent cervix
placental causes for fetal demise abruptio placenta, infxn not allowing O2 xchg, macrosomia in DM outgrowing placenta
how dx antiphospholipid syndrome need 1 of history: venous thrombosis, PE, stroke, reptd preg losses, fetal demise, and 1 of labs: cardiolipin Abs, lupus anticoag, incrsd PTT
what labs indicate anti phospholipid syndrome cardiolipin Abs, lupus anticoag, incrsd PTT
if fetal demise in late 2nd tri--what do need to induce labor (earlier can do D&C in 1st tri, D&E in 2nd tri)
describe hydatiform mole types and cxns 1) Complete (MC): 2 sperms w egg w/o a nucleus=46XX all from dad. Grape like vesicles w/o a fetus. 20% malignancy; 2) Incomplete: 2 sperms w nml egg->69XXY. No vesicles, fetus present, 5% malignancy
which hydatiform mole is more concerning for cancer complete (46XX all from dad)
clinical findings suggestive of hydatiform mole bleeding <16wks (MC), pre eclampsia <20wks, severe hyperemesis, new onset hyperthyroid, very high bHCG
if uterus larger than dates and bHCG very high, think… hydatiform mole
US showing snowstorm pattern, unrecognizable detail of gestational sac…think hydatiform mole
what w/u needed for hydatiform mole bHCG for f/u, CXR to check for mets, D&C, need to make sure on contraception and follow bHCG ea mo for 1 yr if benign or good px malignant, 5 yrs if poor px malignant
when use chemo in hydatiform mole? Which agent? malignant dz or recurrent dz, use MTX or actinomycin
sites of ectopic preg MC is oviduct (95%), then uterine cornu, then abd
risk factors for ectopic preg salpingitis (MC), previous ectopic preg, tubal ligation/sx, IUD
clinical findings suggestive of ectopic preg amenorrhea, vaginal bleeding, abd pain incl cervical motion tenderness or adnexal tenderness
cut offs for bHCG and US=ectopic preg if bHCG>1500 and no gestational sac visualized
what are good px factors for gestationl tropho tumor low bCHG (<40000) and mets to lung or pelvis (not brain or liver)
what are screening tools for Downs 1st tri=PAPP, nuchal translucency, and mAFP, 2nd tri=triple screen/quad screen
causes of high MSAFP neural tube, ventral wall, renal…twins and placental bleeding gives false high
what quad screen would suggest Downs hi bHCG and inhibin, low MSAFP, estriol
what PAPP value suggests Downs low along w high bHCG
what constitutes a negative CST no late deccels w 3 cxns in 10min
what 5 parameters are measured in a BPP NST reactivity, gross mvmts, extremity tone (flexion/extension), breathing, AFI
if 4-6 on a BPP what should you do deliver if 36wks or grtr, rept in 24hr if <36wks
what constitutes a reactive NST accels (2 in 20min)
glucola amt and when can dx with frank GDM w/o 3hr 50g glucose, if blood glucose in 1hr >140 is cut off do 3hr; can dx w/o 3hr if single fasting 110 or grtr or was 200 on glucola
amt of glu given and cut offs for 3hr GTT 100g given, cut offs: 95/180/155/140 [only need 2 abnml]
management of mild PreE Mg during labor and 24 hr postpartum, keep DBP 90-100, give steroids <34wk, antenatal BPP/AFI and grwth q 3wks (need to check bc IUGR counts as sPreE), c linic q1 wk; once 37wk deliver
management of sPreE in patient, at 23-32wks can do expectant management as long as no end organ damage, >32 wks deliver
management of HELLP stabilize pt and deliver--can't manage
management of preterm labor tocolytics (Mg, terbutaline), steroids if 24-34 (24-28wks decrs risk IVH, 28-34 decrs RDS and help lung maturation)
cut offs for UTI 100K CFU if midstream, 10K if cath
incidence of twin w spontaneous ovulation and fertility tx 1:90 spontaneous, 1:10 if clomiphene, 1:3 if gonadotropins
causes of 3rd tri bleeding (PainLESS and PainFUL) PainLESS: placenta previa, vasa previa; PainFUL: abruptio placenta, uterine rupture
what's MC OB cause of DIC abruptio placenta
ROM leading to VB and fetal brady cardia, diagnosis is? vasa previa
what features make preE severe? if BP 160/110, 5g protein in 24hr, Cr 1.2, plt <100K, hemolysis (ie incrsd LDH), incrsd ALT/AST or sympt of epigastric pain, persistent HA, visual disturbances
which preE/gHTN pts are most likely to develop HTN later? gHTN (NOT preE)
medical problems put at risk for preE? Demographics? DM, cHTN, renal dz, SLE (vascular or connective tissue dz); demographics: nullip, age<20 or >34
contraindications for expectant management or preE plts <100,000, DBP >100 on 2 anti-HTN, non reassuring fetal signs, LFTS>2x nml, eclampsia, CNS sympt, and oliguria
name criteria for DM B, C, D B: onset <20 duration <10; C: 10-19, duration 10-19; D: <10, >20, vascular cxns
what are the White cxns letters for end organ damage F=nephropathy, R=proliferative retinopathy, T=renal transplant, H=heart disease (Athero)
what electrolyte disturbances can see in neonate of DM mother hypoCa+ bc of immature parathyroid (+ hypogly)
what are goals for glu while in preg fasting <90, 1hr <140, 2hr <140
what are doses of insulin for DM in preg by trimester 0.8U/kg for 1st tri, 1.0 for 2nd, 1.2 for 3rd
how are insulin doses distributed 2/3 in am and 1/3 in eve, in am give 2/3 NPH and 1/3 regular, in eve 1/2 and 1/2
besides control of glu with Rx, what other Rx do DM need 4mg/d of folate bc incrsd risk of neural tube
at what EFW do c/s in DM? non DM? if baby EFW >4.5kg but >5kg in non DM
when do antenatal testing in DM if insulin dependent, macrosomia, or h/o still birth start testing at 32wk w NST and AFI 2x/wk
how tx pyelo in preg need IV Abx until afebrile and CVA tenderness resolves, then 14d of oral and need to retest urine. Rx: cefotetan or ceftriax OR amp and gent
what are lab findings for acute cholestasis of preg incrsd bile acids, +/- ALT/AST and pruritis
tx for acute cholestasis of preg ursodeoxycholic acid (helps bile flow) w cholestyramine (prevents bile reabsorption) and anti His
tx of Graves during preg use methimazole or PTU to make mom euthyroid--maternal IgG cross placenta
what syndrome can appear like acute cholestasis of preg PUPP=pruritic uriticarial papules and plaques of preg--but these appear perimbulical and don't affect preg
management of the preg if cholestasis is present if severe deliver 36wks if fetal lung matures, if not severe deliver by 38
tx PUPP steroids and anti His
what's presentation ? which part of baby is presenting over os, ie cephalic
what's attitude ? if chin of baby is flexed (MC) or extended
what's position ? portion of baby ag pelvis, MC occiput anterior
what parameters define sinusoidal tracing sinusoidal pattern w freq 3-5min and lasts >20min
what causes variable decels? Early decels? Late decels? variable=cord compression, early=head compression, late=uteroplacental insuffic
what makes cat I tracing FHR 110-160, moderate variability, no late or variable decels, may have early decels
cat III tracing absent variability AND ANY of : recurrent late or variable decels, bradycardia
what are indication for c/s nonreassuring FHT, prev c/s or myomectomy, arrest of labor, placental abnmlties, abnml presentation +/- mltpl gestations
what are the 5 cardinal mvmts of labor EDFIEERE=engagement, descent, flexion, internal rotation, extension, external rotation, expulsion
3 stages of labor 1 latent=(Effacement), ends w accel of cervical dilation ~4-5; 1 active=cardinal mvmts of labor begin, ends w complete dilation; Stage 2=descent (ends w delivery of baby); Stage 3=expulsion, delivery of placenta
times for ea stage of labor 1 latent=14 for multipara, 20 for primi; 1 active=1.2cm/hr for primi, 1.5 for multi; 2=2 hr primi, 1 hr for multi +1hr if epidural; 3=30min
tx of prolonged latent phase ambulation or sedation, avoid oxytocin or c/s
tx of prolonged active oxytocin if ctx inadequate
w/o IUPC how can tell if ctx are inadequate if last less than 45 sec and <3 in 10min
how define prolonged 2nd stage (from complete dilation to delivery of baby=descent), >2hrs of active pushing if primi or 1 hr multip (+1 epidural)
criteria for PTL 20-37wks GA, ctxs (3 lasting 30 sec in 20min), resulting in cervical change (dilation or effacement) **have to have all of these, can't just be having ctxs
when deliver someone w PROM deliver right away: lungs mature (ie lecithin: sphingo >2 or + phosphatidylglycerol), chorio (ie maternal F unexplained), non reassuring FHT/BPP
if PROM and >36 wks deliver, may need to ripen cervix before IOL
if PROM and <36wks how manage goal prolong preg: bed rest w DVT prophylaxis, steroid for lung maturity if <32 wks, Abx after swab for GBS (they give even if GBS -); monitor w NST/BPP and deliver immed if non reassuring
tocolytic agents and who you CAN't use them in Mg (don't use in myasthenia gravis), b adrenergic (terbutaline, ritodrine, don't use in DM bc incrs glu), indomethacin (don't use >32wks bc close PDA), CCB (nifedipine)
tx uterine atony, when can't use certain agents uterine massage, oxytocin, methylergonovine (methergine), PGF2/carboprost **can't use methergine in HTN or PreE, can't use carboprost in asthmatics
etiology of fever after c/s depending on POD POD 0=wind (atelectasis), 1-2=water UTI, 2-3=womb endometriosis, 4-5=wound, 5-6 walk incl septic pelvic thrombophlebitis
2 MC cause of painful genital ulcers HSV (MC) and chancroid (H Ducreyi)
tx for chancroid azithro or ceftriax (same as for gonorrhea)
MC painless genital ulcers syphillis, lymphogranuloma venereum (from C trachomatis L type--rare in US), granuloma inguinale (donovanosis-rare in US)
describe lymphogranuloma venereum (from C trachomatis L type) painless vulvar ulcer that heals, then painful inguinal LAD, these LN rupture become draining abscesses or fistulas ( groove sign =depression bw groops of inguinal LAD)
treatment of lymophogranuloma venereum doxy 21d or erythro 3-6wks, drain fluctulant LN so don't burst
beefy red painless vulvar ulcer--think what? granuloma inguinale (donovanosis)
tx for granuloma inguinale (donovanosis) doxycycline or bactrim 21 d
tx for condyloma acuminatum podophyllin, TCA, imiquimod (no systemic tx available)
tx for chlamydia, gonorrhea chlamydia: azithro 1 dose PO or doxy 7d; gonorrhea: ceftriaxone IM 1x or azithro 1 dose + NEED TX chlamydia
tx of PID if outpatient 14 d of ceftriax or cefoxitin and add metronidazole if suspect anaerobes [I've also seen ceftriax + doxy]
3 causes of vaginal discharge and how to differentiate bac vaginosis, candida, trichomonas vaginitis
tx trichomonas vaginitis metronidazole (same as bac vaginosis but need to treat sex partner)
types of abnml placenta attachment previa=att is near or covering os, accreta=attach to myometrium, increta=goes through myometrium, percreta=to uterine serosa
tx for stress incontinence kegel exercises, urethroplexy (move urethra up back into pelvic cavity)
tx for urge incontinence antichol (oxybutinin, ie ditropan and tolterodine (detrol)), propantheline ( Pro-Bantheline ), B adrenergic (Ursipas)
contrast sympt for difft types of incontinence stress: small amts urine w cough/sneeze, not at night, cystometry nml; urge: detrusor ctx involuntarily w larger amts urine, incl at night but can occur cough/sneeze, cystometry hypertonic bladder; hypotonic: constantly lose small amts day and night
tx of hypotonic cholinergic (bethanecol), a adrenergic blocker (phenoxybenzamine)
3 common sympt of endometriosis dysmenorrhea, dyspareunia, constipation
tx of endometriosis progestin, OCPs
describe adneomyosis, sympt, treatment endometrial glands and stroma in myometrial wall (ie type of endometriosis) w cyclic bleeding (dysmenorrhea or menorrhagia), tx=hysterectomy
risks for endometrial hyperplasia and cancer unopposed estrogen (nulliparity, late menopause), DM, HTN, obesity
tx endometrial hyperplasia if w/o atypia cyclic progestins may reverse it, would need f/u bx 3-6mos; if done w childbearing do hysterectomy
what can lead to pseudomyxoma peritonei mucinous cystadenoma of ovary
risks for ovarian cancer BRCA gene, fam hx, grtr
tx for fibrocystic breast reduce caffeine, vit E, OCPs, bromocriptine, tamoxifen
4 types of malignant breast tumors infiltrating ductal (MC 80%), infiltrating lobular (more often bilateral and better px), inflammatory, Pagets
what's the diff simple mastectomy v modified radical modified radical also take axillary nodes [radical is when also remove chest wall mscl, don't do that anymore]
what tx if hormone receptor + (ie estrogen, progesterone) tx w tamoxifen (selective estrogen receptor modulator)
absolute contraindication to OCPs CVS: any thromboembolic event, CAD; Cancer: breast, endomet, melanoma; Liver: abnml LFTs, liver tumor; undiagnosed uterine bleeding
relative contraindication to OCPs DM, SC, HTN, hyperlipidemia, migraines, depression, smoking, >35yo
how OCPs effect risks for cancers decrsd risk of endometrial and ovarian and colon, incrsd cervical and maybe breast cancer as well as CAD and thromboembolic dz
subQ progestin names, advantages Jadelle/Implanon/Norplant, rapid return of fertility s/p removal
what are signs/sympt of placental abruption uterine tachysystole, VB, FHR very high w sinusoidal pattern (fetal anemia)
if PTL and mom has F look for source of infxn, incl intramnionic--so don't give steroids until r/o intramniotic infxn
when is fetal fibronectin helpful 24-34wk, in sympt women >95% that won't deliver in next 14d
smoking puts at risk for placenta abruption, placenta previa, fetal grwth restriction, preE, infxn
when is cerclage usu placed 12-16wks
when is cerclage usu removed 37wks
tx of mastitis dicloxacillin
paper thin, bluish vulva, most likely dx? How dx? Tx? most likely lichen sclerosis seen in post menopause w itching, dx w bx, tx w clobestrol
what differentiate lichen sclerosis from, how tx the two? squamos hyperplasia which has more white, firm, cartilaginous lesion and tx w steroids (v high dose clobestrol for lichen sclerosis)
tx PCOS? What if want to be preg? OCPs, progestin (also wgt loss and if want preg use clomphene +/- metformin)
what ovarian tumors can cause elevated androgens Sertoli-Leydig and hilar cell
Cushing's disease: how respond to dexamethasone test suppressed by low doses but not high doses
how tx hereditary hirsutism, how does it work spironolactone; inhibits 5alpha reductase in hair follicle which causes terminal differentiation of the hair follicle
pale areola and blind pouch vagina--dx? Tx? androgen insensitivity; need to remove intra-abdominal testicles
irreg VB PP continues for >4-6wks, think? Test for? gestational troph neoplasia, test bHCG if above nml its choriocarcinoma or trophoblastic tumor
how is tx of breast cancer different for preg woman same exc no radiation at all during preg and no chemo during 1st tri, can undergo surgery
order of puberty thelarche (breast), adrenarche (pubic/axillary hair), then hgt wgt and then menarche
treatments for osteoporosis alendronate (fosamax, a biphosphanate), or raloxifene (SERM where estrogen agonist in bone but antagonist in breast and endometrium)
what's the diff bw true and pseduo precocious puberty true or central=gonadotropin, just the hypothal-pituit-ovarian axis is activated early; pseudo or peripheral=estrogen comes from ovaries but not from gonadotropins
ex of pseudo precocious puberty McCune Albright, granulosa cell tumor of ovary
what type of tumor has high AFP yolk sac
if abnml pap, when do need to do colpo in preg? What can't do? CIN1 can be deferred till PP, HGSIL or smthg like that should have colpo--can do everything exc ECC
what progesterone level indicates nml IUP >25, if <5 then nonviable preg
cytotec aka misprostol
tx for shoulder dystocia try McRoberts where flex mom's thighs ag abdomen w suprapubic pressure, also corkscrew 180 degrees
painLESS 3rd tri bleeding think placenta previa
amenorrhea PP and low thyroid, think Sheehan's=infarct of pit leading to low thyr, FSH/LH, cortisol (ACTH is from pituitary along w TSH)
tx of PE in preg IV heparin 5-7 days, then 3mos subQ and low dose heparin for remainder of preg and up to 4wk PP
when steroids given for pts going into labor? What does it help w at difft GA? steroids if 24-34 (24-28wks decrs risk IVH, 28-34 decrs RDS and help lung maturation)
what need to check while preg pt on Mg UOP (since excreted by kidney), pul edema/respir depression, loss of DTR
which ovarian tumors secrete estrogen? Androgen? estrogen=granulosa cell; androgen=Sertoli-Leydig
how differentiate mullerian agenesis and androgen insensitivity both have absent uterus, blind vagina, & nml breast, but mullerian often has renal abnmlties, should have nml testosterone and nml pubic hair (androgen insensitiv has decrsd)
1ry amenorrhea think Turner but be sure to check preg test
MC time for mastitis and how treat 3-4wks PP, tx w dicloxacillin
tx endometritis gent and clinda [I've also seen amp and gent listed]
how difft HELLP and acute fatty liver of preg if have renal damage w elevated Cr and coag then its acute fatty liver of preg
what do if bHCG isn't rising properly do a D&C, if see chorionic villi then it was a miscarriage, if don't see chorionic villi then likely ectopic and consider MTX
what do if bHCG is high enough that should see gestational sac, and yet don't very likely ectopic preg, consider laparoscopy
in woman w prev c/s, what would be most worrisome for placenta accreta if 3x c/s and placenta previa, ~40% will have placenta accreta and tx is hysterectomy!
hormones altered in Sheehans low TSH, low prolactin, low FSH and LH [remember GnRH is from hypothal]
how do OCPs help endometriosis suppresses hypothal axis so less estrogen is produced
when must treat PID as inpatient Temp >38.5, nulliparity, IUD, HIV, preg, poor f/u, teenager,e tc
w/u if ASCUS and no HPV testing rept pap q4-6mos until 2x nml, if 2nd abnml then colpo
what screen for in Ashkenazi jew Fanconi anemia, Tay-Sachs, CF, and Niemann-Pick (all AR, Tay Sach MC)
how OCPs help w PMS endometrial atrophy leads to less prostaglandins
how manage ASCUS depending on HPV if HPV - do 1 yr f/u pap, if + do colpo
ASCUS-H management do colpo, ECC
AGCUS management colpo, ECC, EMB
LGIS management colpo, if CIN2 can wait if CIN3 LEEP
when use cryo in cervical dysplasia persistent CIN1 (2yrs)
when use CKC CIS, adeno in situ
Created by: ehstephns on 2010-10-20



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