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USMLE OBGYN2
| Question | Answer |
|---|---|
| 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 |
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ehstephns
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