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10_20 OBGYN
| Question | Answer |
|---|---|
| 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 |
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ehstephns
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