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USMLE OBGYN2

QuestionAnswer
cause of GDM, when onset due to human placental lactogen (hPL) and insulinase; last 1/2 preg
describe White classif DM A-D A1= GDM diet; A2=GDM insulin; B: onset <20 duration <10; C: 10-19, duration 10-19; D: <10, >20, vascular cxns
describe DM White classif F, R, T, H F=nephropathy, R=prolifer retino, T=renal tx, H=aterioscler heart dz
2 MC cxns of IDM, most specific MC are NTD and cardiac, most specific is caudal regression
risk factors GDM, 3 MC, 4 others MC: FMH, obesity, >30yo; maternal cxns during prev (still birth, traumatic delivery w shoulder dystocia, congenital anomaly, macrosomia) or poly, macrosomia or fetal anomaly in current
what are goals for glu while in preg fasting <90, 1hr <140, 2hr <120
what are doses of insulin for DM in preg by trimester 0.5U/kg for 1st tri, 0.6 for 2nd, 0.7 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
cut offs 3hr OGTT fasting ≥95/≥180/≥155≥140
management baby GDM/DM Monthly US&BPP for fetal grwth and well being; 32 wks do NST and AFI (amniotic fluid index) 2x/wk if using insulin, macrosomia, or h/o still birth. at 26wks if vasculopathy, HTN, or poor glu control
management DM (not GDM) before/beginning of preg 4mg folate 3mo before conception, check for end organ dz (24hr protein and Cr clr, fundoscopy, neuropathy, Kaplan says get HbA1c ea tri)
fetal screening for IDM 15-20wks triple marker for NTD, 16-18wk US for NTD, 18-20wks US for other structural anomalies, 22-24 fetal echo if glu hadn't been well controlled
during/after delivery and timing delivery IDM during keep glu 80-100, after watch for PPH from overdistension and rapid drop in insulin needs, deliver no later than 40wks [tend to be late mature, so don't want deliver too early]
4 types of pelvis Gynecoid-round oval 50%; Android-male 30%, inlet is triangular, restricted all lvls, arrest of descent common; Anthropoid (ape like) 20%, inlet is large A-P,head will engage A-P (occiput posterior); Platypelloid- squashed gynecoid, head engages transvers
what's presentation? 5 exs which part of baby is presenting over os, ie cephalic, also footling breech=legs/thigh extended; complete breech=legs/thigs flexed; freank breech=thighs flexed legs extended; compound
what's attitude? 4 types if chin of baby is flexed (vertex MC) or extended (partial=brow, max=face) (partial flex=military)
what's position? 3 types portion of baby ag pelvis, MC occiput anterior, also sacrum, mentum/chin/face presentation
only breech can be delivered vaginally frank breech
brady in baby and causes? Tachy? brady <110, tachy >160; Brady: b blockers, anesthetics, congenital heart block in baby (maternal SLE); b agonists (terbutaline, rinodrine), F, thyroxociosis, premie, fetal arrhythmia, baby moving a lot
cut offs for variability absnet, min 5 or less, moderate (nml) 6-25), marked >25
cut offs accel, prolonged accel, baseline change Abrupt incrs in FHR (<30sec) _15bpm and _15sec. [if <32 wks _10bpm and _10sec], unrelated to cxns; prolonged accel if 2-10min, baseline change if 10min
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 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
how resuscitate baby if bad FHT decrs ctx by d/c oxytocin, give terbutaline 0.25subQ, 500ml bolus NS, high O2, change position (sit up or L lateral to incrs CO, lateral also to help w cord compression); check for prolapsed cord and can do scalp stim
pathophys cervical effacement oxytocin and prostaglandins breaking disulfide links of collagen fibers leading to increased water content
pathophys of incrsing ctx formation of gap jxns bw uterine myometrial cells, correlated w incrsd oxytocin and prostaglandins and multiplcation of receptors
what are the 5 cardinal mvmts of labor EDFIEERE=engagement, descent, flexion, internal rotation, extension, external rotation, expulsion
4 stages of labor 1 latent=(Effacement), ends w accel of cervical dilation ~3-4; 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; 4=recovery
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, MC cause anesthesia; tx=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)
management prolonged 2nd stage if ctx adequate emergency c/s if head not engaged, otherwise vacuum extraction or forceps
management prolonged3rd stage oxytocin if ctx inadequate or manual delivery of placenta
management of prolapsed cord put pt in knee-chest, elevate presenting part, avoid palpating cord, immediate c/s
manage shoulder dystocia suprapubic pressure, maternal thigh flexion (McRobert’s maneuver), internal rotation of fetal shoulder into oblique plane (Wood’s corkscrew), manual delivery of P arm, and Zavanelli maneuver (cephalic replacement
perineal lacs 1=only perineal mucosa, 2=perineal mscl, 3=some of anal sphincter (external and/or internal), 4=rectal mucosa **careful prevent rectovaginal fistula
4 types forceps and how used Simpson-for traction only; Kjelland-rotation and traction; Piper-for the aftercoming head of a vaginal breech delivery; Barton-to deliver head in occiput transverse w a platypelloid pelvis
at what station forceps used outlet forceps=fetal head on pelvic floor; low forceps= +2 station but not on pelvic floor
MC indication forceps, 3 others prolonged 2nd stage, also nonreassuring FHT, avoid maternal pushing (cardiac dz), breech (shorten delivery of head)
3 reasons c/s, MC MC=cephalopelvic disproportion (doesn't follow nml dilation curve, prolonged/arrest labor); fetal malpresent (MC breech), nonreassuring FHT
risks assoc c/s relative to vaginal Blood loss 2x vaginal (~1L), risk of infxn, DVT incrsd, visceral injury can occur
required to be able to use low transverse incision longitudinal lie, formed lower uterine seg
rate of successful vag s/p c/s 80% in carefully selected
when cerclage placed/removed, 2 types placed 14wks, Shirodkar=suture is beneath cervical mucosa and left in place w delivery by c/s; McDonald=simple purse string, removed at 36wks to allow vaginal delivery
pain from uterine ctx and cervical dilation from what nerves? Perineal distention? T10-12, S2-4
describe paracervical block, pudendal block; what stages used Bilateral transvaginal local anesthetic blocking Frankenhauser ganglion lateral to cervix. active phase (watch transient fetal brady); Bilateral transvaginal injxn to block pudendal n as passes by ischial spines, stage 2;
describe epidural and spinal block Local anesthesia into epidural space blocking lumbosacral n roots during Stage 1&2; Injxn into subarachnoid to block lumbosacral. Saddle block for stage 2 and c/s.
SE epidural and tx hypotension from sympathetic blockade and spinal HA. Tx hypotension w fluids and ephedrine (sympathomimetic). Spinal HA w hydration, caffeine, or blood patch
describe lochia and progression Vaginal flow: bright red is not nml, lochia (shedding of decidual layers) seen, red (lochia rubra) in first few days, pink/yellow <2wks (lochia serosa), then white >2wks (lochia alba
tx perineal or episotomy pain ice packs, after 24hr that use heap lamp or sitz baths
define hypotonic bladder after delivery, tx postvoid residual vol (>250ml) from hypotonic bladder (might need a cholinergic agent, ie bethanechol
if mom was not rubella immune, what do after birth give live attenuated vaccine; breastfeeding is ok but prevent preg for 1mo
how long BF provide contraception 3mo
when refit vaginal diaphragm? IUD after 6wks
when use progestin only v combo OCPs, when start Progestin-only: USE IN LACTATING (milk yield is not affected); combo: don’t use if lactating. For nonlactating wait 3wks until not hypercoagable
definition PPH 500ml vagina, 1000ml c/s <24hr
MC cause PPH, risks for that uterine atony (50%), at risk rapid or protracted labor (MC), chorio, b adrenergic, halothane, Mg, overdistension
tx uterine atony and contraindications uterine massage, oxytocin, methylergonovine, PGF2/Hemabate/carboprost; **can’t use methergine in HTN or PreE (vasoconstrictor) and *can’t use PGF2 (hemabate/carboprost) in asthmatics (broncho-constrict)
MC cause retained placenta, look for accessory lobe, missing placental cotyledons in the presence of contracted uterus
MC cause genital lacs uncontrolled vaginal delivery, also macrosomia, forceps, vacuum
MC causes of postpartum F MC endometritis, then UTI
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
MC time for mastitis and how treat 7-21d 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
s/s septic pelvic thrmobophlebitis, what day occurs, tx POD 5-6; persistent wide F swings despite Abx “picket fence F”, normal pelvic and physical exam. Feels fine; tx IV hep 7-10d
risks endometritis, phys exam emergency c-section, PROM, prolonged labor, mltpl vaginal exam. See moderate F w uterine tenderness
when does portpartum blues occur, how freq, sympt, tx 20%; <2wks; tearfulness, mood swings, feeling of inadequacy in caring for self and infant. But pt is still taking care of self and infant. No tx
when does portpartum depression occur, freq, sympt, tx 10% <6wks): absence of tearfulness but feelings of despair, hopelessness, anxiety, neglect of child and self. Need psychotherapy and Rx
when does postpartum psychosis occur, sympt, risks for first few wks,Loss of reality and hallucinations. Need hospitalization, psych meds and psychotherapy, often h/o mental illnes ie bipolar, recurrence 50-80%
what are good px factors for gestationl tropho tumor low bCHG (<40000) and mets to lung or pelvis (not brain or liver), <4mo since preg and wasn't full term preg
describe hydatiform mole and risk malig 1) Complete (MC): 2 sperms fertilize an egg w/o a nucleus=46XX all from dad. Grape like vesicles w/o a fetus. 20% progress to malignancy; 2) Incomplete mole: 2 sperms fertilize nml egg->69XXY. No vesicles, fetus present, only 5% progress to 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, fundus larger than dates, bilateral theca lutein cysts
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 and tx (exc chemo details) needed for hydatiform mole/gestational tropho dz bHCG for f/u, CXR to check for mets, D&C, need to make sure on contraception and chemo
f/u benign hydatiform mole follow bHCG q1wk until negx3wk, then f/u q1mo for 1yr. If bHCG plateaus/persists need do CT and w/u for met
chemo tx in gestational tropho dz? nonmet or good px: MTX or actinomycin D until bHCG negativex3wks, then follow qmo for 1 yr; poor px: mltpl agents (MTX, actinomycin D, cytoxan) until bHCG negativex3wks, then follow qmo for 2 yr and q3mo for another 3yrs
sites of ectopic preg MC is oviduct (95%, MC distal ampulla), then uterine cornu, then abd
risk factors for ectopic preg salpingitis (MC), previous ectopic preg, tubal ligation/sx, IUD, DES (pretty much any reason for abd scarring)
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
tx for ectopic preg if unruptured and bHCG<6000, no fetal heart motion, <3.5cm, no h/o folate suppl give IM MTX, otherwise need surgical
lab test/value most predictive of chorioamniotis IL6
components of bishops score dilation, effacement, station, cervical consistency, position of the cervix (ie anterior higher than posterior)
high Bishops score >5-8 (varies)
components favorabl cervix dilated, effaced, soft, anterior to mid
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
describe early onset GBS, late. Mortality? Early onset-(MC) few hrs-days: fulminant PNA and sepsis. 50% mortality; Late onset- <1wk. meningitis, usu hospital acquired, 25% mortality
when give intrapartum GBS prophyl? Which Rx? if + GBS urine or prev baby w GBS sepsis, if 28wk vag GBS cx +, if no 28wk test give if preterm, ROM>18h, maternal F; IV PCN (erythro if allergy)
how toxo acquired, likelihood transmitting to baby cat feces, raw goat milk, uncooked meat; only acquired if 1ry infxn (lifelong immunity), 1st tri low risk transmission but bad dz; 2nd tri high risk but mild dz
key features toxo baby symm IUGR, microcephaly, scattered intracranial Ca++, chorio, sz, HSP, thrombocytopenia
which TORCHes can cause chorioretinitis? Cataracts? chorio=toxo, varicella, CMV; cataracts=varicella, rubella
tx of toxo in preg pyrimethamine and sulfadiazine
risk of transplacental transmission varicells, highest risk when 25-40%, greatest if rash 5d before partum to 2 d post partum
key features congenital varicella zigzag scarring skin, hypoplasia limbs, chorioretinitis or cataracts
risk of transmission rubella >90% in 1st Tri, only 5% 3rd tri (opposite of Toxo)
key features of congenital rubella, MC feature congenital deaf (MC), CHD (VSD), cataracts, MR, HSP, thrombocytopenia, blueberry muffin rash
risk of transmission CMV 50% in 1ry regardless of tri, <1% w reactivation
congenital CMV causes, of babies + what % show dz 10% show dz: petechial rash, periventricular Ca++, meningoencephalitis, HSP, thrombocytopenia, jaundice(MC congenital infxn)
newborn w hearing loss and jaundice--TORCH? CMV (intracranial Ca++ periventricular), rubella (hepatomegaly, cataracts) [[syph also has hearing loss]]
newborn w purpural type rash CMV and rubella
which congenital TORCH can cause non immune hydrops CMV, toxo, syph
which TORCHEs have low plts and HSP CMV, toxo, rubella, syph
which TORCHes assoc w jaundice rubella, CMV, Syph
risk of infxn HSV 50% w 1ry infxn, <5% reactivation; mortality 50%
risk transmission HIV, greatest help c/s 30% w/o AZT, 10% wAZT, <5% if c/s. C/s most helps those w low CD4 and high viral load.
when start mom on AZT 14wks, continue through delivery
describe early congenital syph, late **watch for large edematous placenta; early=skin, anemia, thrombocytopenia, HSP. Later: Hutchinson teeth, mulberry molars, saber shins, saddle nose, 8th n deafness
risk of HepB transmission. Risk infected child will get chronic. % Chronic HepB from vertical transmission 10% if HepBsAg, 80% if also HepBeAg…once infected 80% wil get chronic. Overall 40% chronic HepB is vertical transmission
neonate of HepB mom gets what. Susceptible mom's should get what HepB Ig and HepB vaccine. Preg mom's at risk should get HepBIg, active immuniz safe bc it's a killed virus
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, estrogen in post menopause, urethroplexy (move urethra up back into pelvic cavity)
tx for urge incontinence antichol (oxybutinin, propantheline), B adrenergic (flavoxate), NSAIDs (also TCA antichol and CCB)
contrast sympt for difft types of incontinence stress: small amts urine lost w cough or sneeze, not at night, cystometry is nml; urge: detrusor ctx invol larger amts of urine, incl at night, cystometry hypertonic bladder; hypotonic: constantly lose small amts of urine day and night
tx of hypotonic cholinergic (bethanecol), a adrenergic blocker (phenoxybenzamine)
name degrees of uterine prolapse 1st degree if in vagina, 2nd degree if at introitus, 3rd degree if both vagina and cervix out of introitus, 4th if whole uterus is out
name types of vaginal prolapse cystocele (bladder, so anterior), rectocele (rectum, posterior), enterocele (small bowel upper posterior)
tx trichomonas vaginitis, if preg metronidazole (same as bac vaginosis but need to treat sex partner), if 3rd tri need vaginal betadine
3 common sympt of endometriosis dysmenorrhea, dyspareunia, constipation
4 tx of endometriosis progestin, OCPs, danazol, GnRH (for short time) (also surgery)
describe adenomyosis, sympt, treatment endometrial glands and stroma in myometrial wall (ie type of endometriosis) w cyclic bleeding (dysmenorrhea or menorrhagia), tx=hysterectomy
physical exam for fibromas v adenomyosis fibromas=enlarged, firm, nontender and asymmet uterus; adenomyosis=tender, symmetric enlarged uterus
risks for endometrial hyperplasia and cancer unopposed estrogen (nulliparity, late menopause, chronic anovulation, PCOS), DM, HTN, obesity
types of endometrial hyperplasia simple, cystic & complex w/o atypia rarely progress to cancer; complex w atypia 1/3 progress to cancer
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
2 key abnml bleeding endometriosis the bleeding isn't bw cycles, just dysmenorrhea (MC location ovaries); if bleeding bw cycles its anovulatory or endometrial hyperplasia/cancer
how dx anovulatory bleeding if don't have reg cycles then give progestin and see if wdrawal bleeding…if get wdrawal bleeding its anovulatory and tx w cyclic progestin
if ovulatory and still bleeding bw cycles usu structural ie polyps
MC causes of dysmenorrhea endometriosis (incl adenomyosis), fibroids
menorrhagia in ovulatory usu due to fibroids
staging for endometrial cancer I limited to uterus (a if <1/2, b if >1/2 myometrium), II cervix, III a=ovary or tube, vagina, pelvic nodes, cytology +; IV=bladder, bowel, distant (MC lungs)
tx for difft stages of endometrial cancer (after know surgical staging) Radiation need post-op (they already got TAH-BSO) if poor px: met to LN, >50% into myometrium, + surgical margins, poorly difftd; chemo is for metastatic dz
describe surgical staging treatment for encomet cancer TAH-BSO, pelvic and para-aortic LN, peritoneal washings
MC uterine tumor fibroid (leiomyomas)
fibroids more common in AA, usu in 40s
types fibroids, MC intramural (MC), subserous, submucosa
tx fibroids GnRH (used preop bc rapidly grow back), myomectomy, embolization, hysterectomy
name 2 main types of fxnl benign ovarian masses follicular/corpus luteum cysts; theca lutein cysts
compare follicular/corpus luteum cyst and theca lutein cyst follicular/corpus lutein cysts=unilateral and resolve ~2cycles, theca lutein cyst=bilateral due to high bHCG or overstimulation, ie see in preg [note an early IUP will always present w corpus luteum cyst]
what's a choc ovarian cyst endometrioma (non fxnl ovarian cyst)
types of nonfxnl ovarian masses endometriomas and PCOS
benign ovarian neoplasms serous and mucinous cystadenomas, cystic teratoma
how differentiate serous and mucinous ovarian cystadenomas serous=unilocular, mucinous=multilocular, if rupture can lead to pseudomyxoma peritonei
MC benign ovarian neoplasm <30yo cystic teratoma, any combo of germ layers, often on long pedicle
risks for ovarian cancer BRCA gene, fam hx, grtr
staging ovarian cancer I=ovaries; II tubes/uterus, + cytology; III=beyond pelvis w peritoneal implants; IV=distant mets, bladder, rectum
surgical staging tx for malignant ovarian cancer cytoreductive debulking surgery: TAH-BSO, omentectomy, bowel resxn as nec
after surgical stagin/cytoreduction what else do ovarian cancer get? f/u? post op chemo (carboplatin&Taxol). F/u q3mo for 2 yrs, then q6mo for 2 yrs and follow CA1
management of simple cystic ovarian mass likely fxnl. f/u 6-8 wks, should have resolved. Be aware of torsion. OCP can help prevent further fxnl cysts from forming; laparoscopy if: >7cm or if had been on OCP for at least 2mos
management of complex ovarian mass needs surgery (laparoscopy or laparotomy), try to preserve ovary (ovarial cystectomy) ** but be careful 10-15% dermoid cysts are bilateral
prepubertal adnexal mass is likely, features/markers? germ cell tumor, LDH=dysgerminoma, bHCG=chorio, AFP=endodermal sinus
management adnexal mass perpuberty simple mass=laparoscopy, complex needs laparotomy; if germ cell need unilateral salpingo-oophorectomy and surgical staging (peritoneal and diaphragmatic dx, peritoneal cytology, pelvic and para-aortic LN, omentectomy
tx germ cell cancer, f/u, px salpingo oopherectomy, post op chemo (vinblastin, bleomycin, cisplatin), f/u q3mo w marker measurements and pelvic exam, px 95%
dx of PID clinical, needs following: mucopurulent cervical discharge, cervical motion tenderness, bilateral adnexal tenderness, WBC and ESR incrsd
when tx PID in patient T>39C, nulligravida, adolescent, IUD, pelvic abscess, preg, outpt tx failure
tx PID in patient: IV cefox or ceftriax + doxy or amp + gent; outpt: cephalo and doxy
tx tubulovarian abscess in pt clinda and gent, if F doesn't resolve 72hrs may need explor lap or drainage
how dx chronic PID by lap showing adhesions
Created by: ehstephns on 2011-01-13



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