OB GYN OVERVIEW
What may occur if the infant presents other than vertex?
Slow labor
What is labor dystocia?
Slow labor progress. It can be characterized by 1) protraction or 2) arrest disorder.
What can be said about fetal accelerations and decelerations in a healthy baby?
They have + accelerations in response to fetal mov't and no decelerations
what is MOA for mirena:
Thickens cervical mucus Thins endometrial lining Inhibits sperm transport higher concentrations of hormone less systemic effect, local affect
velamentous insertion occurs more often with what factor:
# of babies present 1% singleton, 10% twin, 50% triplet
what does gravida mean:
# of pregnancies
SE cited for d/c of OCPs
#1 irregular bleeding - nausea - wt gain (depo has highest associated) - mood changes - breast tenderness - HA
H&P consistent with EP (+hCG, Low abd pain, bleeding) pt BP 98/62, P 140 What do you do?
#1 stabilize #2 STAT surgery - bc it is presumptive ruptured EP or hemorrhage
*What is the most common cause of abrupted placenta?* Name other causes of abruption
#1: Hypertension - Previous abruption - other: major trauma, Cocaine, polyhydramnios w/ rapid decompression
2 main types of cervical CA-->
#1: SCC (MC) - adenocarcinoma HPV 16, 18 responsible for 70%
What is the #1 most common cause of jaundice during pregnancy?#2?
#1: Viral hepatitis #2: intrahepatic cholestasis of pregnancy
MC types of lady part cancers
#1: endometrial ca #2: ovarian ca REMEMBER though that 2nd MC ca worldwide is cervical
what is perfect use failure rate
% of women who conceived in 1st year of use when they use method exactly as instructed
What are some elements of preterm labor management?
*Hydrate* Culture for infection (GBS, BV wet prep, UA) Ultrasound for abnormalities of uterus or baby EFW (macrosomia), cervical length, AFI, presentation Tocolytics Steroids
Ripening the cervix in PROM is associated with...
*Increased infection risk* SO DON'T DO IT Rely on oxytocin
S/S of intrahepatic cholestasis of pregnancy
*Intense pruritis* - hallmark Fatigue Jaundice Dark urine
Membrane rupture before 24 weeks leads to this pulmonary abnormality
*Lung hypoplasia*
What is advised for patients after recovery from a pregnancy in which they developed PPCM?
*NO MORE BABIES*
What is the presenting complaint of a placenta previa?
*Painless vaginal bleeding at about 30 weeks*
What are some risks for developing preeclampsia? *test*
*Prior hx of it* nulliparity pregestational DM (Not GDM) obesity chronic HTN FH of pre ecclampsia multiple gestation
What are the characteristics of "true" labor?
*REGULAR uterine contractions + Cervical changes* (effacement, dilation, station) +/- bloody show (mucous and blood)
what must you do after txt of atrophic vaginitis
*Repeat PAP in 2-4 months s/p topical estrogen tx.*
How is EP diagnosed?
*TVUS (diagnostic standard)* Quantitative hCG
US presentation of complete mole-->
*US snowstorm* Order CBC to exclude anemia
Most specific lab values for dx of PID
*US*, MRI, laparoscopic or endometrial bx only use MRI if you must know dx for sure, US is best
What is the best test for assessing abrupted placenta?
*Uterine contractions* on external fetal monitor looking for uterine irritability due to bleeding
What does a late deceleration indicate?
*Uteroplacental insufficiency* (if placenta was robust it would compensate after being smashed) BAD NEWS
The preferred anteroposterior diameter of the fetal vertex is the:
*a. Suboccipitobregmatic* b. Supraoccipitomental c. Occipitofrontal d. Biparietal e. Occipitoparietal
What is the MC GYV presenting complaint?
*abnormal uterine bleeding* - MC due to (75%) neuro*endocrine* (dysfunctional uterine bleeding) - 25% organic
avoid this med with stress incontinence
*alpha antagonists*
2nd MCC of 2' amenorrhea->
*anovulatory cycles* - Functional hypothalamic amenorrhea--> wt loss below 10% IBW and exercise, nutritional deficiencies, *leptin deficiency*
what is the severe criteria for pre-eclampsia:
*any of the following* BP >160/110, >5gm proteinuria, oliguria (<500cc/24 °), HA, scotomata, pulm edema, cyanosis, Plts<100K, RUQ/epigastric pn
classic presentation of cervical incompetence
*bulging amniotic sac* in ABSENCE of - UCs - VB - Infxn - amniorrhexis: PROM or PPROM
what is major difference btwn squamous cell hyperplasia/ Lichen simplex chronicus and lichen sclerosis?
*can resolve w/o treatement*
TOC choriocarcinoma
*chemo* --> highly responsive
how should endometriosis be viewed?
*chronic* dz, that requires life-long management - goal is maximizing medical treatment and *avoiding repeated surgical procedures*
what do variable decels (no pattern) indicate
*cord compression* - Reduced fluids: ogliohydramnios - Nuchal cord
unopposed estrogen increases the risk of
*endometrial Ca*
vulvar dz MC pressents as
*itching*
cytology result says limited endocervical cells what is your next best step?
*low risk repeat 12 months high risk repeat 6 months*
2nd MC type of vulvar ca
*malignant melanoma*
MC cause of polyhydramnios
*maternal dm*
lichen sclerosis is MC in
*menopausal* women & *prepubertal* girls
MC type of incontinence in women
*mixed incontinence* combo of urge and stress
MC presenting sx of cervical CA is?
*post-coital bleeding and AUB*
In a postmenopausal female what findings are predictive of malignancy?
*postmenopausal pelvic mass, >65 u/ml CA-125* is 75% predictive of malignancy
Hallmark for dx of PMDD-->
*regular ovulation*
Unsatisfactory > 75% of cells obscured on pap result: what is your next best step?
*repeat 2-4 months f/u* (if HPV + and > 30 colpo is an option)
usual approach toward molar pregnancy-->
*suction curettage* - confirm dx - relief of sx - prevention of complications
What establishes CIN level?
*tissue bx* NOT PAP smear
most preventable cause of LBW
*tobacco*
RF for endometrial CA-->
*unopposed estrogen* e.g. *anovulatory cycles* - obesity, T2DM, affluent, white - low parity, post-menopausal (esp ERT) - lynch syndrome (familial nonpolyp colorectal ca) *early menarche & late menopause also*
When are steroids typically used?
*use 24-34 wks EGA* Contraindicated if >34 weeks UNLESS evidence of immaturity (L/S ratio < 2, neg PG)
What is the station when the head is crowning?
+5
What labs indicate no RDS? suggests lungs are mature
+PG and L/S >2
Desire (libido) details define what modulates it it is excited via ___ suppressed via ___
- "appetite" usually accomp by fantasy - Modulated by testosterone *excited by dopamine and suppressed by serotonin*
PCOS on wu
- "string of pearls on US", progesterone challenge test will show withdrawl bleed - r/o neoplasm (DHEA-S >700 or testosterone > 150 think neoplasm) - PCOS: see mild elevation of DHeAS or total testosterone, LH:FSH ratio usually > 2:1
3 main causes of gonadotropin independent PP
- #1: fxnal ovarian cyst - CAH - adrenal tumors
Txt of severe preeclampsia
- #1: seizure proph: Mg Sulfate - txt BP: hydralazine, labetalol - < 34 wks: steroids - DELIVER (pref vag) is TOC regardless of EGA
*how is obstetric conjugate assessed*
- *1.5 to 2.0 cm Subtracted from obstetric conjugate* - actual space available to fetus - Fetal head engaged when BPD passes thru inlet (0 station)
RF ovarian ca
- *2nd MC gyn malignancy*, risk 1/70 in lifetime, mc cause of gyn ca death - RF: nulliparity, breast/ colon ca, TOB, Familial ovarian syndrome, FHx
Choriocarcinoma hx-->
- *50% have a preceding molar pregnancy* - 50% have *preceding SAB, induced AB, ectopic or nml pregnancy*
Endometrial hyperplasia: MC presentation MC epidemiology
- *AUB MC presentation* - MC in post menopausal women
what are some non-reassuring patterns:
- *Absent or minimal variability*(AMV) (0-5bpm) related to fetal acidosis/hypoxemia AMV with recurrent *late decelerations* AMV with recurrent variable decelerations Bradycardia (sustained) with AMV <100 sustained even w/o AMV
RF cervical cancer
- *HPV, Tob*, PMH cervical dz or fHM - STDs, early onset of sex, > 1 sexual partner - DES poor
Name a SERM what is MOI Pro/ Con
- *Raloxifene* - agonist at bone, antagonist at breast/ endometrium - worsen VM s/s, *prevent vertebral fx*
pathogenesis of endometriosis
- *Retrograde menstruation* (genetic or outlet) - muellerian dysplasia - lymphatic spread
MC physical finding of ovarian ca
- *ascites* or pelvic mass - also anorexia, wt loss, freq UTIs, constipation DO TVUS use Ca 125 to follow txt - *in postM pelvic mass + Ca 125 > 65 is predictive of malignancy*
Endometriosis is assoc w/
- *chronic pelvic pain (69%)* - dyspareunia - dysmenorrhea - infertility.
s/s endometriosis
- *cyclic or chronic pelvic pn* begin few days prior to menses and last first few days of cycle = PRE or POST menstrual spotting, *chocolate cysts on ovaries* - Triad: dysmenorrhea, dyspareunia, dyschezia - typically 30, nulliP, infertile
Partial hydatidiform mole:
- *fetal features* identifiable - FOCAL swelling chorionic villi - FOCAL trophoblastic hyperplasia - TRIPLOID 2/3 paternal most XXY - MAY detect fetal heart rate
overflow incontinence/ incomplete bladder emptying
- *freq, hesitation, nocturia, dribbling* - overdistention (impaired contractility) bladder outlet restrition
Impetigo morph causative agent TOC
- *honey-crusted lesions* - by s. aeurus or GABHS - tx: *dicloxicillin* or cephalexin, topical mupirocin, hydrogen peroxide cream
Stress incontinence-->
- *loss w/ cough, laugh, or sneeze* "dribble" - NO bladder contraction - Pelvic floor or urethral weakness: change in urethral angle (surg, hypoE, age)
Management of leiomyomata uteri-->
- *observe*: serial exams, H/H - COCPs--> reduced bleeding only - Hormone tx *Mirena* FDA approved - GnRH preop Myomectomy recurs with clones Myolysis--> laparoscopic thermal coag *Hysterectomy* Uterine arter embolization MRI directed focused US.
describe bacterial vaginosis
- *profuse, milky d/c, fishy odor especially after sex* - dx requires *3/4 Amsel's* 1- homogenous d/c 2- pH > 4.5 (blue nitrazine) 3- POS whiff test (10% KOH) 4- Clue cells on wet prep (NS)
COCPs have decreased efficacy w/ what meds
- *rifampin* - st. johns - anticonvulsants ABX use is not CI w/ COCPs
F/U after sexual assault
- 1 week if proph given to review labs, - 2 wks if no proph to repeat GC, & Trichomonas - Other- syphilis @ 6 wks - *HIV 6, 12, 24 weeks regardless of proph*
delay in patch wearing (ortho evra) rules
- 1 wk: reapply, back up 1 wk - delay 2nd/3rd wk: < 2d no back up, >2d use 1 wk back up
MC sexual dysfxn in women (3) these are MC if you > ___ yo
- 1. dyspareunia, 2. phyical issue (atrophy, endoM), 3. decreased desire - MC if > 50 yo
monitoring in pregnancy (genetic/ deformities)
- 10-12 weeks: bHcg, nuchal tranlucency, CVS, PAPP-A - 16-20 wks: quad screen, amniocentesis - 24-28 wks: 1 hr GTT, H&H - 3rd tri: strep B (35-37), hep b, syphilis, GC, HSV
describe the four stages of labor:
- 1: onset of true labor to full or complete dilatation - 2: complete dilation to parturition (2 hrs) - 3: parturition to placenta <30 mins - 4: following hour, risk of PPH
rules for missing pills: OCPs
- 1: take 2 following day, no back up - 2: take 2 pills for 2 days, use other contraception - 3+: d/c, menses, reinitiate on sunday after menses
maternal weight gain
- 1st tri: 3-6 lbs - after 20 wks approx 1 lb per weeks - 25-35 lbs is overall recommended wt gain - 300 cal per/d during prig, 500kcal d when breast feeding *don't skip breakfast become ketotic*
weight gain during pregnancy
- 1st tri: 3-6lbs, no need to increase calories - after 20 wks: 1 lbs per wk - 25-35 lbs of overall wt gain during preg
TOC hyperthyroidism pregnancy
- 1st tri: PTU - 2nd/ 3rd: Methimazole both cross placenta can cause fetal hypOthyroid/ goiter
US dating of pregnancy
- 1st tri: measure crown to rump length, +/- week - 2nd tri: measure BPD & femur length, accurate +/- 2 wks - 3rd tri: measure BPD & femur length, accurate +/- 3 wks
degrees of pelvic relaxation
- 1st: structure in upper 2/3 vagina - 2nd: structure descend to elvel of introitus - 3rd: structure protrudes out of vagina
describe fetal umbilical cord
- 2 arteries: arteries carry deoxygenated blood flaccid L side - 1 vein: vein carries highly oxygenated blood, still relatively low @ 28 mmHg pO2, pressurized R side
90% of immunocompetenet women clear HPV infxn over ___ yrs ____ HPV have higher likelihood of deveoping cervical ca
- 2 yrs - persistent HPV
describe CAH
- 21 a-OH deficiency = accumulation of 17-OHP - don't synthesize cortisol or mineralcorticoids at birth --> present w/ salt wasting or adrenal insufficiency - *ambigious genitalia* due to androgen excess, *clitoromegaly* - 46, XX
when do we screen for GDM
- 28 wks
which generation progestins have least SE
- 3rd and 4th
describe sperm count @ various times
- 40-300 million sperm (50-90% morph nml) on ejaculation deposited into vagina: majority lost in vagina due to acidity - volume ejaculation: 2-5 ml - some get stuck in cervical crypts (may ascend later) - fewer than 200 reach proximity to egg - 1 sperm fertilizes
folic acid supplementation in pregnancy
- 400 mcg daily or 0.4-0.8 mg po daily - 4.0 mg if taking anticonvulsants (esp valproate & carbs), hx of NTD, DM, BMI > 35, FH of NTD
which BC has risk of hyperK
- 4th generation progestins caution in people taking meds that increase K levels (NSAIDs, heparin, ACEIs, K sparing diuretics)
Peri-menarchal AUB think -->
- 5-7 yrs after menarche, usually immature HPO axis.
Long-term complications of rape: how can we mitigate this complication
- 50%: PTSD (persistence of sxs for at least 1 mos) - *mitigated by acute crisis counseling*
% of unintended vs intended pregnancies
- 51% intended, 49% unintended - 1/3 of those on BC @ time
what is cervical area sufficient for menstrual flow? what is associated with retrograde flow
- 5mm sufficient for flow *(<2mm assoc w/ retrograde flow)*
mean onset of thelarche
- 8.9/ 10.0 yrs - AA earlier than white
stages of puberty in years
- 9 yo: thelarche - 10 yo: adrenarche - 11 yo peak height velocity - 12.5-14: menarche - 14-16 yo: mature sexual hair & breasts
1st tri abortions majority done when
- 92% < 13 wks - 62% < 8wks
rules for detached patch (ortho evra)
- < 24hrs -- replace same patch, no back up - > 24 hrs -- new patch, new day, BU x 1 wk
what is back up for nuva ring if it falls out
- < 3hr, dust it off, no BU - > 3hr, rinse it off, BU x 1 wk
evaluating edema
- > 1+ after 12 hr bed rest or wt gain of 5 lbs in 1 wk is concerning - hx marker of preE should raise your suspicion - often happens due to IVC compression
relative CIs to COCPs
- > 35 hx of migrane w/ focal components - immobile - poorly controlled HTN - *> 35 yo w/ obesity* - anti convulsant use (dec efficacy) - hyperTG
what consistitutes Recurrent VVC what are RF for recurrent VVC
- > 4 episodes in 1 year - RF: OCP, diaphragm, DM, ABX, pregnancy, immunosuppression Consider Cx to identify *candida glabrata (resistant)*, text A1C for UL cause
you can stop PAP @ 65 yo if....
- @ least 3 or more consecutive neg cytology OR - 2 consecutive negative co-tests (pap/ hpv) in past 10 years w/ most recent w/i past 5 years
FDA drug classes-
- A: studies show risk of fetal harm is remote - B: no evidence of fetal risk - C: no controlled studies in humans or animals - D: positive evidence of fetal risk - X: clear evidence of fetal risk outweigh any possible benefit
androgen levels controlled by ___ from pituitary in ovaries whtat produces androgens
- ACTH stimulation - ovaries granulosa/ theca cells under influence of LH
AFLP vs HELLP
- AFLP: has elevated ammonia, BG < 50, reduced fibrinogen & antithrombin III levels treatment also is delivery
describe Lichen sclerosis-->
- AI: inflam in the dermis - SXS: pruritus, irritation, dysparuenia - Buzz words: *tissue paper* hypotrophic epithelium
ectopic pregnancy: ART or natural conception MC to have combined ectopic + pregnancy
- ART (more eggs coming down the pipe)
CI meds in pregnancy (6)
- ASA - sulfonymides (late): messes with bilirubin - tetracycline: grey baby - accutane - ACEI - coumadin
*Indication for surgical intervention in pt w/ uterine leiomyomoa* (7) *WORTHY SLIDE*
- AUB w/ anemia - severe pelvic pain or 2' dysmenorrhea - inability to evaluate adnexa (fibroid > 12 wks gestational size!) - urinary tract symptoms (frequency or retention, UTI) - growth of myoma following menopause - infertility - rapid increase in size
Virilization
- Acne, increased libido and strength, clitoromegaly, male pattern baldness, deepened voice DUE TO ANDROGENS
2 phases of rape trauma syndrome
- Acute/ disorganization phase - Integration/ resolution phase
describe menoP estrogen production
- Adrenal gland: androstenedione precursor converted to *estrone* in peripheral fat - women have lg amt despite lack of ovarian estradiol
PCOS txt/ meds
- Anovulation: fertility drugs, *DOC: OCP (reduces unopposed E) 4th gen is best*, cyclic P if CI for E - 5 alpha reductase inhibitor (finasteride) - hirsutism: shaving, cream - insulin resistance: WT loss, DM screen, metformin - DLP: statin
dx of ovarian mass
- BME, US - CA-125 only in POST menoP - definitive dx: TISSUE
IOM guidelines
- BMI < 18.5: 28-40 lbs - BMI 25-29.9: 15-25 lbs - BMI > 30: 11-20 lbs
Arousal/ Excitement Genital effects of estrogen Extragenital effects of E
- Genital: labial fullness, clit enlargement - Xtragenital: HR, BP, muscle tension, breast size, areolar engorgement, nipple erection, sex flush
WHO classification of hyperplasia
- Glandular (top)/ stromal (bottom): simple vs complex --> complex = higher potential malignancy - nuclear atypica: absent vs present --> present higher risk malignancy *malignant potential worst w/ *complex hyperplasia w/ atypia*, least w/ simple w/o atypia
hypothalamus hormones we care about
- GnRH (decapeptide) - PIF
hormones of spermatogenesis
- GnRH pulsatile, increases @ puberty - LH works on Leydig cells --> testosterone release - FSH stimulates sertoli cells to begin spermatogenesis - testosterone & FSH required @ puberty but testosterone only needed after that
3 classifications of precocious puberty
- Gonadotropin dependent PP - Gondadotropin independent PP - incomplete PP
RF for ovarian CA--> (3)
- HIGHEST: familial ovarian cancer syndrome (30-50%) - low/no parity - breast/colon CA - tobacco
CI to breastfeeding
- HIV - TB infxn - some meds: tetracyclines, anticonvulsants - chemical dependency
CI to breast feeding
- HIV - chemical dependency - meds (retinoids, tcns, phenytoid, nitrofurantoin - active TB
Ectopic pregnancy: natural conception implantation locations vs ART
- Natural: 1: tubal, 2: ampulla - ART: 1: ampulla, 2: tubal ART is more likely to implant in cervix or ovarian abdominal
scheduling of OB appointments
- New: @ 12 wks - Routine: 12-28wks monthly, 29-36wks q 2 wks, >36 wks weekly appt
Cons to OCPs
- No STI protection - increased risk for blood clots
RF for cord prolapse
- Non-vertex presentations (transverse and breech) - multiple gestation - PTL - polyhydramnios - Iatrogenic (esp AROM)
TOC intertrigo what are some predisposing circumstances
- Nystatin, clotrimazole - HIV, DM, steroids, incontinence, occlusive clothes, obesity
AUB 3rd tri
- OB: Placental: previa, *abruption* or circumvallate; Maternal: uterine rupture, clotting d/o; Fetal: fetal vessel rupture - nonOB: same as above
early decels are
- OK, normal finding
Describe the first stage of labor
- Onset of true labor (regular contractions + cervical change) thru complete dilation - 1st stage has 2 phases: latent & active phase
When is DELIVERY the TOC in PPROM?
- Overt maternal infection - non-reassuring fetal status - Fetal lung maturity + EGA 34 wks or greater
renal changes of pregnancy
- P relaxes smooth muscles -- higher risk UTI/ pyle - increased GFR and CrCl - dumping bicarb = alkalosis - decreased buffer predisposes to metabolic acidosis
boundaries of perineum
- Sup: pelvic diaphragm - Inf: skin - Ant: pubic symphysis - Post: coccyx - Lateral: ischial tuberosities - posterolateral: sacrotuberous ligaments
complications of COCPs
- TE - stroke - htn - post pill amenorrhea - *cholelithiasis* - benign hepatic tumors
6 complications of COCPs
- TE - stroke - htn - post pill amenorrhea - cholelithiasis - benign hepatic tumor
endometrial hyperplasia dx
- TVUS accepted in POSTmenopausal women. < 4mm thickness of stripe = low risk of CA - TVUS NOT ok in premenoP women
stages of puberty
- Thelarche: 8 - Adrenarche (pubic): 9 - Somatic growth: 9.5 - Menarche: 10.5 - adrenarche (axillary): 11.5
2 types of SAB where there is BLEEDING - what is difference
- Threatened: closed cervix, up to 50% cause pregnancy loss - Inevitable: open cervix, +/- ROM, all result in loss of pregnancy
RF for PP hemorrhage
- Tissue: POC retatined, placenta accreta, cord avulsion - Trauma: laceration, inversion, rupture - Thrombin: DIC - Tone: atony* (multiP), multiple gestation, macrosomic, prolonged labor w/ pit, rapid labor
3rd MCC of vaginal d/c--> 50% of trichomoniasis is ____ dx of trich
- Trichomoniasis - *50% asymptomatic* - Dx--> 1. *frothy* d/c (grn-ylw) 2. *strawberry* cervix 3. pH *>4.5* (musty odor) 4. wet prep: motile orgs
other causes of spontaneous abortion
- UL med conditions: DM, SLE, hypothyroid - ETOH, Tob
2' dysmenorrhea is usually caused by _________ and is not limited to menses. what is it usually associated with
- UL pathology (endometriosis, fibroids, adenomyosis, ovarian cysts) - assoc s/s dyspareunia, infertility, or AUB
What is caused by overstimulation of the uterus by oxytocin?
- Uterine fatigue -post delivery uterine Atony - Tachysystole - uterine Rupture - ADH like: water toxicity, coma
what is concerning about lichen planus? what is Txt
- Very resistant to txt - ToC: clobetasol
CI meds
- aCEI - ASA (high dose) - acne meds - tetracylines (yellows teeth) - sulfonamides (not in late preggo bc displaces bilirubin, causes jaundice) - coumadin (use LMWH)
what causes uterus didelphys
- absolute failure to merge of ullerian ducts 2 separate uteri
Sperm sample details-->
- abstain @ least 2d - nml at least 2 specimens a few weeks apart - abnml at least 3 specimens a few weeks apart
how does 2 day method work
- abstinence based on presence or absence of secretions - unprotected sex only if no secretions for last 2 days - typical abstinence req 10-14d
what is done @ new OB appointment
- accurate dating of pregnancy - Health: overall and past medical hx - maternal conditions, previous pregs - clinical pelvimetry - labs - domestic violence screening
psoriasis is characterized by What is inciting factor of psoriasis of vulva TOC
- adherent *silver scale* but in skin folds more red w/ fine scale - Trauma/ koebnerization is inciting factor - TOC: emollients, steroids, Dovenex after control obtained
clinical RF for osteoporotic fracture independent of BMD: 7
- advance age - CCS use - PHx: of fragility fx as adult - hx of fragility fx in 1' relative - low body weight - current smoker, ETOH - CCS use, RA
alarm BP in pregnancy? bp trend
- alarm: > 140/90 - trend: drop in bp in 2nd tri, return to baseline in 3rd tri
lack of estrogen effects the vagina leading to atrophy and ___ pH how will this present? TOC
- alkaline pH - s/s: dyspareunia, atrophic vaginitis, urinary symptoms - *Best: vaginal E cream or other topical estrogen therapy*
who gets screened for chlamydia? how often? why
- all females < 25 yo - because of PID probs
wu of cervical
- all visible cervical lesions refer for colposcopy - DRE for stage/ local invasion - image for mets - Stage I = confined to cervix
role of amniotic fluid
- allows fetus room for growth, mov't, & development - midpregnancy: pulmonary development due to mov't of amniotic fluid thru fetal lungs - antibacterial activity - labor: protective for fetus, aid cervical dilation - cmun for labor
symptoms of pregnancy
- amenorrhea - breast tenderness - N/V - fatigue
causes of high cardiac output that leads to polydydramnios
- anemia - twin to twin transfusion
s/s of ovarian ca
- anorexia, early satiety, wt loss - freq UTIs in menoP pt - pelvic mass/ ascites all found late
what does perimetrium form
- ant: vesicouterine pouch - post: rectouterine pouch (douglas)
describe sexual assault
- any sexual act w/o consent - use of or Threat of force - inability to consent: age or drug influence
when does the mom get Rho-gam:
- anytime during gestation if trauma/bleed/procedure - at 28 wks - w/in 72 hrs of delivery of an Rh-pos infant
gestational trophoblastic dz is unique bc maternal lesions arise from ___ tissue s/s
- arise from fetal (trophoblastic) tissue - bhCG is marker, pelvic pn, bleed, looks like "tapioca/ hydatid cyst"
what are theca lutein cysts associated with what would be a red flag in pt hx
- assoc w/ molar pregnancy/ choriocarcinoma - hx of ovulation induction therapy.
red lesions w/ vulvar itching
- atopic dermatitis - contact dermatitis - psoriasis - vestibulitis - lichen planus
what are advantages of transdermal BC methods
- avoid 1st pass, therapeutic effect @ lower dose - plasma hormone level constant - good compliance due to sustained delivery - drug stops immediately when removed
what indicates presence of functional androgen receptors
- axillary/ pubic hair
Follow- up directions for choriocarcinoma-->
- b-HCG followed monthly x 1 year, follow for 5 years if w/ METs - Recommend contraception for 6-12 months
which BC methods are garbage and have a higher failure rate
- barrier - behavioral - least effective: withdrawl, spermicide
ovulation tests--> (4)
- basal body temp (0.4F increase on 2 consecutive days) done in AM - EMB in late luteal phase - Serum progesterone >3ng/mL=80% chance of ovulation - Urinary kits detect LH in urine
when is surfactant produced how can we measure
- beginning @ 24 wks - measure by Sphingomyelin (S), PG, PI, lecithin
how does rhogam work
- bind to maternal cells - 30 cc, 3 wks half life - can't use if alloimmunized
SCJ @ birth. @ puberty
- birth @ endocervix - puberty migrate to ectocervix
complications of txt for CIN
- bleed, infxn - cervical stenosis - cervical impotence
absolute "no go's" for sex during pregnancy
- bleeding - discomfort
TOC hypothyroidism pregnancy
- continue synthroid, doesn't cross placenta - risks of hypoT: SAB, IUFD, congential malformations
Possible therapies for PMDD
- continuous OCPs (w/ *drospirenone*) - exercise, relaxation - Ca, Vit D, B6, light therapy
risks of multiple gestation
- cords (twist) - chromosome abnml - twin to twin tranfusion (donor anemic, recipient polycethemic) - hydramnios, PTL, IUGR - GDM, IUFD
back up for nuva ring
- day 1 start: no BU - days 2-5 start: BU x 1 wk
osteoporosis is a deterioration of trabecular bone tissue leading to decreased ____, ____, and increased ___ risk
- dec bone mass - fragility - inc fx risk
parts of decidua
- decidua basalis: part of endometrium into which the embryo implants - decidua capsularis: pt of endometrium that lies over implanted ovum/ embryo - decidua vera: open part of uterine cavity (endometrium) not yet in contact with the embryo - this will fuse with chorion laeve at 16 wks
describe Bohr effect
- decrease O2 affinity w/ decreasing pH - fetal enviro is acidotic, fetus has higher hgb - fetal blood has higher affinity for O2 @ PO2 of 30 - maternal hgb has lower affinity for O2 at PO2 of 30
how does EM contraception work
- delays fertilization, cannot affect implantation - if it implants = pregnancy
what will MRI show us with leiomyomata uteri/ fibroids
- delineate btwn fibroids & adenomysosis
events assoc w/ fetal maternal hemorrhage
- delivery, abortion, SAB, ectopic - molar, amniocentesis, ECV, abruptio placenta - maternal trauma (ab) - removal of placenta
describe bHCG
- detectable @ 7-10 d post fert - rise for 60 to 90d then declines to plateau - doubles q 2.2 days *higher in gestational trophoblastic neoplasia - marker to follow 1st trimester bleed
how is obstetric conjugate determined
- diagonal conjugate - 2.0 or 1.5 - usually if diagonal conjugate is >11.5 its adequate
describe binding of O2 by Hgb in the fetus
- diff in partial pressure of O2 (conc) of maternal (higher PO2) and fetal blood (lower PO2) - fetal Hgb has greater affinity for O2 than maternal Hgb - Double bohr effect
using the rape kit->
- disrobe on white sheet - wood's lamp for semen - Sperm: saline, pap, gram stain - STDs--> GC, BV, trichomonas, candidiasis, HIV, HEP B, syphilis. - ETOH and Tox screen.
what stimulates release of oxytocin
- distention of birth canal - mammary stimulation
GDM wu in *>24 wks preggo*
- do 75 g 2 hr challenge
meds used for pregnancy termination
- done either very early 7-9wks or late 13-15 wks - Mifepristone, Misoprostol (antiprogestins) - best effective if < 49d EGA
genital warts (6,11) how is it dx?
- dx- clinical, bx only if no response to txt
benign probs of vulva
- dystrophies (white lesion) - dermatoses (red lesion) - infestations - bartholin cyst
Incomplete PP-->
- early development of *2ndary sexual characteristics* - Check bone age (will be nml) - Premature thelarche (isolated, may progress to PP) --> 2 peaks 2 and 6-8 YO
congenital syphilis
- early: HSM, - late: hutchinson's teeth, mulberry molars, saddle nose deformity
If your patient c/o primary amenorrhea and has breast development what are the possible issues?
- either outlet obstruction: transverse vaginal septum, imperforate hymen - quasi-estrogen (XY, elevated testosterone, AIS) - cervical agenesis, mullerian agenesis
define mild preE
- elevated BP after 20 wks (previous bp norm) > 140/90 - proteinuria: >3 g but < 5 g in 24 hr
2 components of blastocyst
- embryoblast: gives rise to embryo - trophoblast (chorion): produces hCG, detactable 7-10 d post fertilization, preserves corpus luteum until placenta takes over
exercise suggestions for preggos
- encourage @ least 30 min/d - MHR 60% - avoid hot tubs
parts of cervix
- endocervix: columnar - ectocervix: squamous - portio: pt of cervix that extends into vaginal canal - fornix: recessed cavity of cervix, border ext os & portio
WU of adenomyosis
- endometrial bx: non dx BUT good for endoM hyperplasia - TVUS ok, MRI is best
milk doesn't get removed in timely manner and builds up --> what is this? what can it lead to
- engorgement - stasis may lead to mastitis
describe ductus arteriosus
- ensures improved O2 of brain & heart, limits flow to lungs - functionally closed w/in 24 hrs
Chlamydia what type of bacteria s/s dx what is txt
- intracellular bacteria - 70% asxs, urethritis, cervicitis - dx- culture, antigen tests, PCR - TOC: azithro 1g x 1d or doxy 100mg BID x 7d *txt all sexual contacts (60d), abstinence x 7d*
SE of OCPs
- irregular bleed - nausea - wt gain - mood change - breast tenderness, HA
SE of PO BC agents
- irregular spot/ bleed - amenorrhea - wt gain - increased follicular cysts - acne
SE of progesterone only agents
- irregular spot/ bleed - amenorrhea - wt gain (depo) - *increased follicular cysts* - acne flares
AUB wu
- is bleed uterine! - r/o organic cause - labs: hCG, TSH, PRL, coags - US, possible bx
what happens if there is a single umbilical artery
- it happens - often correlates with other fetal abnml like renal anomalies
who is P only agents best for
- lactating moms - smokers > 35 yo
most predominant microorganism is the normal vagina
- lactobacilli - secretes latic acid & hydrogen peroxide
Describe acute/ disorganization phase of rape trauma syndrome
- lasts hours to days - characterized by *distortion, paralysis of coping mechanisms - may have complete loss of emotional control or calm - Signs: generalized pn, HA, chronic pelvic pn, eat/sleep disturbances, vaginal sxs, emotional sxs (anxiety/ depression)
2 portions of 1st stage of labor (onset to dilation)
- latent: 6 hours (cervix 0-4/5 cm) - active: 3-7 hrs (cervix 4/5-10 cm)
anovulatory cycles leads to ____ menses has ___ estrogen effect (exacerbated by __) why is this bad
- leads to irregular menses - increased E effect (unopposed) - exacerbated by obesity - endoM stimulation can lead to hyperplasia or ca
what 3 uterine conditions are estrogen dependent
- leiomyomata - adenomyosis - endometrial hyperplasia
benign probs of uterus
- leiomyomata - adenomyosis - hyperplasia - polyps
MC pelvic tumor in women
- leiomyomata uteri/ fibroids
name 3rd generation progestins
- levonorgestrel - norgestrel - Desogestrel - norgestimate (so 3 end in *gestrel*
white lesions w/ vulvar itching think
- lichen sclerosis - squamous hyperplasia
leopold's maneuvers confirms
- lie - presentation (breech vs vertex) - estimated fetal weight
what does uterosacral ligament do
- lie on either side of rectum and anchor uterus posteriorly to sacrum
Stress incontinence
- loss w/ cough, laugh - etiology: weakness or change in urethral angle (surgical, hypoE, age) - Degrees: 1. w/ severe stress (jump, cough, sneeze) 2. mild stress (rapid movement, stairs) 3. mild stress (stand)
theories of endometriosis
- lymphatic system - metaplastic transformation of peritoneal tissue (muellerian dysplasia) - retrograde menstruation
3 RF of shoulder dystocia
- macrosomia - obesity - DM
labia majora and minora glands
- majora: both sebacous & sudoriferous - minora: sebacous only
signs of pregnancy
- majority of women have early bleeding related to implantation, this may get confused with LMP - 3 categories: presumptive, probable, positive
cause of olgiohydramnios
- making too little: renal atresia - leaking
who would be indicated as HR and you would suggest HIV proph for in rape case
- male on male - high HIV prevalence in pop - multiple assailants - anal rape - bleeding
s/s of dysfxn in social or economic performance for PMDD
- marital discord - parenting difficulties - school, work affected - increases social isolation - legal probs - suicidal ideation
what might happen to fetus with polyhydramnios
- maternal discomfort - cord prolapse - fetal malpresentation - cord prolapse
describe indirect Coombs test
- maternal plasma mixed w/ known Rh + RBCs - agglutination is positive test (1:16 titer = sensitization)
complications of DM
- maternal: HTN, PIH, UTI, preE, operative delivery - fetal: SAB, IUFD, polyH, macrosomia, IUGR, congenital anomalies
describe indirect Coombs test
- measure anti-Rh titers - maternal plasma mixed with Rh positive RBCs - if agglutinates, positive test - 1:16 is positive test
fundal ht assessment
- measured from top pubic symphysis to fundus - gross estimation of growth - 20-36 wks grows 1cm/wk and wk should equal ht in cm
how is diagonal conjugate assessed
- measuring from lower border of pubis to sacral promotory using tip of 2nd finger & where base of index finger meets the pubis - via digital exam
WU of incontinence
- med review - PE: cough/ valsalva w/ full bladder - UA & cx - in HR pt: *PVR*
heavy, irregular bleeding
- menometrrhagia
name some hypoestrogenized states
- menopause - high Progesterone relative to E --> preggo, hormonal contraception
Trichominiasis tx-->
- metronidazole 2g PO in single dose - *required tx of partner*
tx for bacterial vaginosis-->
- metronidazole 500mg BID x 7d OR - topical flagyl cream 5g/d x 5 d OR - Topical clindamycin 5g QD x 7d
relative CI in COCPs (ie exercise caution)
- migraine hx w focal components - HTN (uncontrolled, poorly controlled) - > 35, obese - anticonvulsant use - HLP
AUB treatment-->
- mild: observe & expectant management - Mod: *cyclic* estrogens plus progestin (HRT), *COCP* - Severe: *high dose estrogen* (premarin IV), *D&C* is the TOC in *unstable pt*
sxs of pregnancy
- missed period, amenorrhea - N/V - breast tenderness - fatigue
describe velamentous insertion
- missing whatnot's jelly, cord not protected from trauma
describe components of external genitalia
- mons pubis - labia majora, minora - clitoris - urethral orifice - vestibule (fourchette) - vestibule bulb - skene, bartholian glands
parts of vulva
- mons pubis (veneris) - labia maj/min - clitoris - vulvovaginal glands (bartholin) - fourchette - perineum
s/s of ovarian mass
- most asxs unless torsion or rupture - slow inc in ab girth - pressure on organs --> *constipation, UTI* - think malignant if: ascites, wt loss
combined therapy for menopause/ HRT is ___ txt for vasomotor sxs? - Decreases risk of? - Increases risk of?
- most effective txt for VM sx - Dec risk: Osteoporotic fx, colon ca - inc risk: CAD, CVA, blood clots, Breast ca (> 4yrs use)
what happens if L/S is <2 but PG is present
- most likely mature - only 5%probability of RDS
Protective factors against ovarian cancer
- multiparity - OCP - hx of breastfeeding
protective factors against ovarian ca
- multiparity - breast feed - OCP use - tubal ligation - don't smoke
Factors for persistent HPV infection
- multiple sex partners - early onset (<20) sex - high-risk partner - H/O STDs - cigarette smoking (4x) - immunosuppression - age
fibroids emerge from what structure
- myometrium
difference btw natural family planning and fertility awareness methods
- natural family planning: use abstinence to avoid pregnancy during times of fertility - fertility awareness: use other another method to avoid pregnancy during times of fertility
possible results of cervical cytology
- neg for intraepithelial lesion or malignancy - infxn: candida, trich, BV, HSV - non neoplastic: reactive (WBCs --> inflam or IUD), atrophic, hyperkeratosis
feedback of GnRH
- negative: LH/ FSH - positive: estradiol
allergens of contact derm
- neomycin - chlorhexidine (KY) - latex, dyes, lanolin - semen
elevated body temp in preggo's is associated with what bad things
- neural tube defects - miscarriage
why do we give Mg Sulfate for PTL if EGA is 24-32 wks
- neuroprotective - reduces incidence of cerebral palsy - also used for preeclampsia as well as PTL
who is indicated for PVR for incontinence wu
- new incontinence after surg or with POP - Neuro dx (parkinson) - failed med therapy - recurrent UTIs - previous urinary retention
2 forms of hydatidiform moles are complete vs partial: describe complete hydatidiform mole:
- no identifiable fetal features - *generalized* hydatidiform swelling of villi - *diffuse* trophoblastic hyperplasia - diploid *paternal* 46xx (90%) *HCG typically > 100K* nml prego peaks at < 100k
What is prolonged *active* phase in regards to nulliparous females vs multiparous?
- nulliparous: <1.2 cm/hr - multiparous: <1.5 cm/hr (overall: <1.5 - 1.2 cm/hr) (prolonged active phase must be @ 6cm)
GDM management
- nutrition consult, wt management - insulin if FG persistently > 95 - oral: some sulfonylureas, most not FDA approved most induced by 38 wks or CS for macrosomia
AUB 1st tri
- obstetric: SAB, ectopic, extrusion of molar pregnancy - nonOB: cervicitis, polyps, neoplasm, vaginal laceration
when is luteal/ secretory phase
- occurs after ovulation (day 14) - progesterone predominant
Integration and resolution phase: of rape trauma syndrome
- occurs mo to yrs after event - Characterized by *flashbacks, nightmares, phobias* - GYN or menstrual complaints.
describe umbilical vessels
- one vein: oxygenated, pressurized R side - 2 arteries: deoxygenated & flaccid L side *if see single artery think of renal anomalies*
what is bottom line use of tocolytics
- only a 48 hr delay - will fetus be better off where it is (location, lung maturity etc) or is it better off outside uterus
dx and txt of endometriosis
- only definitive is on lap/ direct visualization on bx - "barb on uterosacral ligament or dark lesions - NSAIDS, cyclic hormones, danazol or depo (pseudomenopause) - Ablation required for pt w/ infertility - Definitive: TAH/ BSO
3 main types of emergency contraception
- oral hormones: plan B, Yuzpe - Copper IUD inserted w/in 120 hrs - Antiprogestins
Bisphosphonates indications:
- osteoporosis prevention osteopenia + RF
BTL is associated with a decreased risk of what cancer what is recommended for post-partum BTL
- ovarian - wait until 6wks until tubes shrink
OCPs reduce which cancer risk
- ovarian - endometrial - colon
conditions that can elevate Ca-125
- ovarian Ca - endometriosis, leiomyomata, PID - hepatitis, cirrhosis - chf
physiology of perimenopause
- ovary fxn wax/ wane - irregular ovulation (use contraception until amen 1yr) - fluctuating hormone production: E/P ultimately cease, ovary produce sm amount of androgens
what is SE of IUD
- overall lower risk of ectopic pregnancy but if pregnancy does happen then it has a higher chance of being ectopic in IUD pt
changes in maternal blood chemistry
- pH more on alkaline side - less bicarb, compensating for hyperventilation - decreased CO2 - increased pO2
Primary syphilis how is it dx? what is TOC
- painLESS chancre @ site of inoculation - DX: 1. screen via RPR or VDRL 2. confirm with FTA-ABS - TOC: 2.4 mil units PCN IM
layers of endometrium
- perimetrium (extension of broad ligament) - myometrium (muscle layer that responds to oxytocin) - endometrium
what is surfactant composed of
- phospholipids - lipids - protein - carbs - salts
probable signs of pregnancy
- pisakeck sign: asymmetrical uterine enlargement - hegar's sign: ability to compress connection btw fundus & cervix
describe diaphragm use
- placed up to 6 hrs prior to intercourse, MUST be left IN PLACE for 6 hrs after - increases risk of UTI - increased efficacy if used w/ spermicidal - decreased STD if used w/ condoms
3 abmnl of Nitabuch's layer? why is this important
- placenta accreta: MC, adhere myometrium - placenta increta: invade myometrium - placenta percreta: perforate myometrium important in delivery - if placenta won't unattach from uterus may need hysterectomy
thyroid disease in pregnancy
- placenta produce hCG & hCT: weakly stimulate thyroid - MC: Graves, MC: hashimoto's
possible sequalae of trauma in pregnancy
- placental abruption - uterine rupture - fetal injury/ death - fetomaternal hemorrhage
describe physiological anemia
- plasma volume increases about 70% in 1st tri - RBC volume increases only about 30% in 2/3 tri - causes hemodilution - hct is 33-35% in 3rd trimester
why do we give pain meds
- pn causes hyperventilation, increased HR due to catecholamine release - happier mom, happier fetus
txt of RDS? what is complications?
- positive pressure which causes pneumothorax - these babies end up with chest tubes
AUB indications for biopsy
- postmenopausal* - age > 45 yo - obesity - DM - break through bleed on HT - infertility - Fhx endometrial or colon cancer
toxic shock syndrome again
- preformed toxin from s. aureus - assoc w/ super absorbent tampons - txt NOT for initial syndrome but to dec occurences
calories per day in pregnancy/ birth
- preg: 300 kcal - breastfeeding: 500 kcal
HRT/ERT therapy CI:
- pregnancy - AUB - estrogen sensitive CA - thrombosis - CVA and liver disease.
when is DVT risk highest in females
- pregnancy - post partum
what is PROM
- premature rupture of membranes (ROM < 37 weeks) - "prolonged" (PPROM) if 24+ hrs elapses before labor begins
4 ways in which OCPs work
- prevent ovulation: surpress LH surge - thicken cervical mucus - limit proliferation of endometrium - alteration of normal tubal motility
A high serus FSH concentration is indicative of ____ ___ failure what does it require for eval
- primary ovarian failures - karyotype
how does ovulation method work
- several times daily cervical mucus evaluation of color, consistency, elasticity, abundance - req 14-17d abstinence
PCOS
- severe: frontal balding, clit enlargement, deepen voice; hirsutism, AUB, PCOS, infertility, obesity - increased androgen and E levels - *clinical dx requires: hyperandrogenism (signs or labs), chronic oligo/ anovulation, r/o other dx
describe foramen ovale
- shunt of O2 from R atrium to systemic circa - MC fused by age 2
smaller glands on either side of *urethral* orifice, secrete mucous into urethral orifice
- skene's gland
what does ACOG say about HRT?
- smallest dose for shortest time *<4 years* - long term rx should stop in asxs pt (taper dose)
irritant causes of vulval contact derm
- soaps, nylon hose - talcum powder - douches - ETOH, perfume, tea tree oil
OCPs do NOT stop what?
- sperm capacitation, sperm acrosome can occur
who are IUDs suggested for
- stable, monogamous - low risk for STI - nulliparous - mirena - dysfunctional uterine bleeding
describe Rhogham
- standard dose 300 mcg - covers 30 cc fetal to maternal hemorrhage - T1/2 3 wks
benign probs of cervix
- stenosis - ectropion - nabothian cyst - polyps
describe nml vaginal mucosa
- stratified squamous epith - secretory - estrogen responsive - numberous aerobic/ anaerobes - low pH 3.504.5
contributing factors of functional amenorrhea-->
- stress, eating d/o, excessive exercise - wt loss or wt < 10% IBW - celiac disease - Can also be a source of 2' amenorrhea
types of incontinence
- stress: laugh, cough, sneeze - urge - overflow - fxn (mix of urge & stress)
describe hyperprolactinemia-->
- suppresses GnRH - often see galactorrhea - *pituitary adenoma* /craniopharyngioma, - PRL levels > 15-20 ng/ml (increased by stress, sleep, exercise)
how do we test for GBS
- swab of vagina & rectum bc colonizes columnar epithelium
Bartholin's abscess (sequela of Bartholin's cyst) s/s what does it have correlation w/
- sx: *severe pain*, unable to walk, sit or have intercourse - gonorrhea/ chlamydia
All BV symptomatic pt should be? who should be screened?
- sxs = *treated* - screen *asymptomatic pregnant women* at high risk for pre-term delivery.
describe the 2ndary oocyte once its been ejected (ovulation) from follicle
- takes some cells with it on its outer surrounding: called corona radiata - zona pellucida surrounds oocyte
Hirsutism
- terminal (thick) hair - Male distribution in a female DUE TO ANDROGENS
MOI of PO BC
- thicken cervical mucus - thin endometrium - reduce tubal motility
MOA of P only agents
- thickens cervical mucus - thins endometrium - reduces tubal motility *NO suppression of ovulation*
what does tocodynamometer measure/ show
- timing & duration of contraction (mom) - NOT STRENGTH
leading cause of low birth weight in infants
- tobacco: preventable
olgiohydramnios
- too little amniotic fluid, AFI < 5 - early in pregnancy: pulmonary defects, potter's - late in pregnancy: adhesions, meconium hypoxia, umbilical cord progression
polyhydramnios
- too much fluid, > 2L - make too much: high cardiac output, spinal covering anomalies - excrete too little: esophageal atresia, esotracheo fistula
how does cardiac output change in pregnancy
- total blood vol increases by 40% - physiologic anemia: disproportionate rise in plasma vol compared to RBC vol = hemodilution w decreased hct reading - CO 40% greater than non pregnant level @ wk 20 - O2 consumption higher, decrease exercise capacity/reserve - arterial bp falls during preggo (MAP, SBP, DBP) - HR, SV, & CO all increase during pregnancy
what does TORCH stand for:
- toxoplasmosis - other (syphilis, hepB, EBV, parvo, varicella) - Rubella - CMV - HSV
describe ortho evra
- transdermal patch (weekly admin), avoid >190lbs - 1 patch in different area ea wk for 3 wk, then 1 wk patch free
pregnancy counseling
- travel up to 37 wks - exercise encouraged, up to 60% of MHR, no impact, contact or straining after 1T - hottubs are assoc w/ neural tube defects avoid - sex ok unless vaginal bleed or discomfort
at what EGA is presentation important
36 wks
what tri is toxoplasmosis Higher infectivity but less fetal sequelae
3rd tri
How long would you monitor prolonged active labor if there are adequate contractions (>200 montevideos)?
4 hours
Para means:
4 parts full term birth preterm birth abortions (both spontaneous/induced) living children
What is the active phase of the first stage of labor?
4/5-10 cm dilation (complete)
how many ovulations could occur in a lifetime:
400
At what point would you induce someone with prolonged pregnancy?
41 weeks
when do we need to induce labor if post date:
41wks (prostaglandin E used or fetal membranes stripped)
describe androgen insensitivity
46xY - receptors not responding to androgens - undermasculinized genitalia - XO (turners),
at what station is when head is *crowning*:
5
What are the criteria for tachysystole?
5 contractions in 10 minutes (avg over 30 min) Contractions within 1 minute of eachother Any contraction over 2 minutes
how long do you have before hypoxia to baby on delivery
5 minutes
*Arrest of dilation* occurs after reaching ____cm with ruptured membranes
5-*6* cm
Define precipitous labor
5-10 cm per hour labor that lasts no longer than 3 hrs from contraction onset to delivery
nml afi
5-25 cm
what is the normal total amniotic fluid index:
5-25 cm normal index
the zygote adheres to endometrium by day s/p ovulation:
5-6
What is the ultrasound milestones noted at ~5 weeks ~5.5-6 weeks 6-7 wks
5wks: gestational sac 5.5-6: fetal pole, cardiac activity 6-7: yolk sac
How long would you monitor prolonged active labor if there are INadequate contractions (<200 montevideos)?
6 hours
mod-severe inflamm (50-75% cells obscured) on pap results: what is the next best step
6 month follow up
when is postpartum check up conducted
6 wks
how often do you follow up for GDM:
6-12 wks postpartum
What is the desired variability for the fetal heart rate?
6-25 bpm
Generally, EP occurs when?
6-8 weeks after LMP
Antiandrogenics and hirsutism
1st line COCP - req 6-12mos to work Androgen receptor blockers -- *spironlactone, flutamide* 5DHT inhibitor - *finasteride* Cosmetic tx: vaniqa (cream inhibit hair growth), shave, electrolysis/ laser
when is toxoplasmosis Low infectivity but severe fetal sequelae:
1st tri
what is the recommended wt. gain:
1st trimester 3-6 lbs ---no need to increase caloric intake now After 20 weeks approx 1 lb. per week 25-35 lbs overall weight gain recommended for women with a normal BMI (18.5-24.9)
describe amniotic fluid trends throughout pregnancy
1st trimester: up to 25cc 2nd trimester: up to 800 cc term: 500 cc (so decreases toward end of pregnancy) production: 700cc/d urine, 250cc/d lungs eliminated: 500cc/d swallowed, rest osmotic exchange
Tx for incomplete abortion
2 lg bore IV + *oxytocin* Consult OR: D&C Rhogam if necessary PPH tx
what is average return to fertility of pills, patch or ring
2 wks
Delayed puberty w/ low or nml FSH/LH-->
2' hypogonadism.
BP generally decreases till week ____ then goes back to normal
20 wks
what embryology wk does primordial germ cells in the ovary complete first meiotic division giving the primary oocytes
20 wks
preterm labor is....
20 wks to 37 weeks
Feundity __% per cycle __% in 3 mo __% in 1 yr
20% per cycle 50% in three months 85% in a year
Age to initiate PAP screening?
21 years old to the ripe old age of 65 - 21 to 29: cytology q 3 yrs - > 30 yo: co-test HPV + cytology q 5 yrs or cytology q 3 yrs
MC cause of CAH
21-OH def other is 11B OH def
best time to screen for DM in preg
24-28 wks
How quickly does hCG decrease?
25% per week
ASCUS HR HPV NEG age 25 age 21-24
25--> repeat co-test @ 36 months 21-24--> routine screening
Dose for Hemabate
250 mcg IM
what is dose for hemabate:
250 mcg IM
worldwide cervical Ca is ___ MC cancer in women
2nd MC worldwide in women
what is the normal change in LFTs during pregnancy:
2x increase in ALP due to fetal skeleton
Which degrees of laceration require repair?
3 & 4
how long should a pt stay on a pill before trying a new pill or dose due to irregular bleeding:
3 months
ex. G3P2012
3 pregnancies 2 full term 0 preterm births 1 abortion 2 living children
what BC methods are "very effective" what is that failure rate?
3-10% fail rate - Pill - Patch - ring
regular contractions
3-5 contractions per 10 mins
what is normal Hct in pregnancy:
30-38
What can be injected thru the foley to cause ripening to happen?
30-40cc of extra-amniotic saline
When does lecithin increase significantly?
35 weeks while spingo stays same
rules of lactational amenorrhea
<6mo post partum - BF is infant only source of nutrition - infant must feed @ least q 4 hrs during day, @ least q 6hr at night - infant < 6mo - mother can't have had a period after day 56 of PP
ASCUS HR HPV POS > 25 21-24
> 25--> colpo/ECC 21-24--> cytology in 12 months
post date pregnancy
> 42 weeks
evaluating edema in pregnancy
> 5lbs wt gain is concerning not dx of pre-ecclampsia but should raise suspicion
Montevideo units are measured by peak height of amplitude of contractions over 10 minutes. What is a good value for these Montevideo units?
>*200*-250
Osteopenia definition?
>1.0 but < 2.5 SD below the mean
Definition of PPH in C-section?
>1000cc
How is gestational HTN/PIH diagnosed?
>140/90 after 20 weeks *without proteinuria*. It resolves fewer than 12 weeks post delivery
When does placental abruption occur in pregnancy?
>20 weeks
Who gets HELLP?
>25 y/o Multiparous Last trimester (>36 wks gestation)
What are the criteria for diagnosing arrest of descent in the 2nd stage in a multiparous female?
>3 hours WITH epidural or >2 hours without it
What are the criteria for diagnosing arrest of *descent* in the 2nd stage in a nulliparous female?
>3.5 hours WITH epidural or >3 hours without it
Advanced maternal age is....
>35 at delivery
At what EGA is amniocentesis not required to assess fetal lung maturity
>36 weeks
At what cervical dilation would you NOT consider tocolytics?
>3cm
Definition of PPH in vaginal delivery?
>500cc
what is definition of PPH:
>500cc in vaginal delivery >1000cc in c section
What are the criteria for lamellar bodies?
>50k= :) mature <15k= :( not
Adverse outcomes with conception after previous birth are noted in what interpregnancy intervals?
>60 months <6 months
What are hCG discriminatory thresholds for ultrasound testing modalities
>6500 = TAUS > 1500 = TVUS
L/S ratio <2 w/ no PG, infant has what probability of RDS:
>90%
when does CO increase peak
@ 2nd trimester
describe oogenesis
@ 4wks primordial germ cells migrate to urogenital ridge - PGC/oogonia (46, 2n) undergo *mitosis* and proliferate into *primary oocyte* (23, n) - primary oocytes undergo *meiosis I* arresting in prophase until puberty - @ onset of puberty *meiosis I completes* creating a *secondary oocyte* and a polar body - secondary oocyte is arrested in meiosis II, metaphase until and only if fertilization occurs - dominant, largest follicle undergoes ovulation
women who previously had choriocarcinoma are at increased risk of ___ in future pregnancy? what about obstetric complications?
@ increased risk of subsequent GTN. ESP > 40 YO - NO increased risk of obstetric complications once prego :)
when are maternal blood tests done
@ initial OB appt @ 28 wks --> if negative, mother is given Rhogam
what are some noncontraceptive benefits of OCPs:
Acne/Hirsutism Irregular menstrual cycles Dysmenorrhea Menorrhagia Anemia Increased bone density
What is your patients disposition if they initially present in preterm labor <34 weeks, then it subsides?
Admit and treat
If your patient has contractions >1 every 10 min, vaginal bleeds, abd pain or tenderness, poor fetal HR (not 110-160), or bruising....what must you do?
Admit for at least 24 hours
3 risk factors for complicated preggers?
Advanced maternal age Adolescent Hx of complicated pregnancy
What is the downside of surgery for EP?
Affects fertility
describe spermiogenesis
Spermatid to spermatozoa (differentiation occurs) - acrosome forms - nuclear packing - mitochondria & centriole form flagellum - majority of cytoplasm & residual body is lost (streamlined) - cytoplasm pinches off (spermiation then occur)
External cephalic version (ECV-baby spinning) can endanger yo baby. How?
Spinning can disrupt the placenta
what tx of toxoplasmosis infection:
Spiramycin/pyrimethamine
What conditions must be present for MTX use?
Stable Desires continued fertility Must be small/early (*<3.5cm*) *NO fetal cardiac activity* hCG must be <5000 No renal or liver dz (1 pill of MTX causes renal failure or ARDS) a *good F/U candidate* - must rtn for serial hCGs No breastfeeding
Criteria for *mild preeclampsia*
Stage 1 HTN (>140/90) @ 20 wks Proteinuria 0.3-5g /24 hr UA
Criteria for *severe preeclampsia* (9)
Stage 2 HTN (>160/110) Proteinuria >5g /24 hrs oliguria (<500cc/24hr) HA Scotomata (spots in eyes) Pulmonary edema platelets <100 RUQ pain/ epigastric pn cyanosis
When are severe variable decelerations commonly seen?
Stage 2 pushing (10cm to delivery)
Breast feeding is the....
Standard of care/ best choice
When is surfactant produced?
Starting at 20 weeks
How is fetal head descent measured?
Station
How do you treat tachysystole?
Stop meds (oxytocin) Put on left side Check for cord entrapment Oxygenate Tocolytics (B agonist): terbutaline or ritodrine
What is a 2nd degree laceration?
Subcutaneous only extends into subepithelial tissues of the vagina or perineum with or without involvement of the muscles of the perineal body
Complications of vacuum delivery
Subglial hemorrhage Scalp edema
what parenteral narcotics has limited efficacy except early 1st stage. cross placenta
Sublimaze (Fentanyl) 20-60 min MSO4 1-2 hours Meperidine (Demerol) 4-6 hours
what are the mechanical effects of the gravid uterus:
Supine hypotensive syndrome IVC and iliac vein compression Decreased preload leads to decreased cardiac output—syncope Varicosities, hemorrhoids, edema Predisposition to DVT
Which will provide a quicker resolution of hCG levels to baseline?
Surgery
Type 1 IUGR is....
Symmetric
Which radical has the most morbidity for mom?
Symphysiotomy
Above what level would you not give the spinal anesthesia?
T-10
Treatment for PPCM
TOC in 3rd trimester: delivery via forceps or vacuum Salt restriction Digoxin Diuretics - NO ACEI Operative delivery
Grouped because of similar congenital syndromes: Chorioretinitis / cataracts Nonimmune hydrops Intrauterine growth restriction (IUGR) Hydrocephalus or microcephaly Rash Most neonates are asymptomatic at birth
TORCH syndrome
if pt is hypothyroid - how often is TSH measured during pregnancy
TSH is measure q 4 wks in pregnancy, used to guide increase in synthroid dosing
If hx of irregular menstrual cycles suggest anovulation get-->
TSH, prolactin, FSH, total testosterone, DHEA-S
what is the best imaging for diagnosis of placenta previa:
TVUS
what is the standard for diagnosing ectopic preg:
TVUS (transvaginal U/S)
How do you diagnose placenta previa?
TVUS has 100% accuracy, do it better than TAUS
Side effects of B agonists?
Tachycardia Tremor/anxiety Hyperglycemia from impaired glucose tolerance Tachyphylaxis
What significantly increases the risk of multiple gestation?
Artificial reproductive technology (also increases risk of ectopics)
overview in our wu for infertility
Assess if - anovulation: labs, hx of reg menses - abnml spermatogenesis: semen analysis - abnml female genital tract: US
What significantly increases the likelihood of a heterotopic pregnancy?
Assisted reproductive technology, specifically *IVF*
Who is Hemabate contraindicated in?
Asthmatics Seizure patients
Type 2 IUGR is...
Asymmetric, big head little body - head size is preserved
How would the head enter the inlet if CPD?
Asynclitic
When are anovulatory cycles more common?
At the extremes of menses.
Same DSM criteria 2-3 months duration Requires monitoring, protection, consultation
PP psychosis
This psych d/o persists for 2-3 months postpartum, and is an *emergency*. See hallucinations, delusions, dissociative behavior
PP psychosis
Which psych d/o requires monitoring, protection, and consultation? why?
PP psychosis increased risk infanticide & suicide
what are the maternal consequences of shoulder dystocia:
PPH d/t atony vag/cerv lacs
What are the maternal consequences of squeezing out a shoulder dystocia baby?
PPH from atony Lacerations
Rupture of membranes for *over 24 hours, before 37 weeks*, before onset of active labor.....
PPPROM (*Prolonged Preterm Premature* ROM) Basically PPROM that lasts > 24 hrs
Complications of previa
PPROM IUGR Anomalies Malpresentation
Rupture of membranes *< 37 weeks*, prior to onset of labor....
PPROM (*Preterm Premature* ROM
This is rupture of membranes before onset of active labor *>37 weeks*
PROM (*Premature* ROM)
What is the treatment for *hyperthyroid in the first trimester*?
PTU
Perinatal mortality increases 2-3x with prolonged preggers. Why?
Placental failure
What is the most common pathology associated with MVA?
Placental separation from uterine wall
what is least favorable pelvic shape
Platypelloid
What is the most reliable indicator for rupture?
Pooling/expulsion of fluid
When are prostaglandins used?
Poor Bishop scores - used to cause cervical ripening
what are the reassuring patterns of FHR:
Baseline FHR 110-160 Absence of late or variable decelerations Moderate FHR variability (BTB) (6-25bpm) Age-appropriate FHR accelerations -slower rate as gest. age increases)
Why might trauma to the placenta not be obvious?
Because the placenta may have centrally separated, occluding the bleeder because the periphery is still attached
why must extension occur
Because the vaginal outlet is directed upward and forward, extension must occur before the head can pass through it.
Germ cell neoplasms
Benign cystic teratoma (dermoid cyst) < 1% malignant (See teeth & stuff) *single MC ovarian neoplasm*--> risk of torsion 15-20% bilateral
What are the classes & drugs of tocolytics?
Beta blockers: Albuterol or terbutaline CCB: Nifedipine Mag sulfate Prostaglandin synthetase inhibitors: Indomethacin
What two steroids can be administered?
Betamethasone (2 dose) Dexamethasone (4 dose)
A bishop score >9 is _______ than a bishop score <4
Better! The higher the number, the riper the cervix > 9 cervix ripe, most likely commence spontaneously < 5 need ripening agents/ not ready
what are some late deceleration causes:
Beyond UC (nadir occurs/extends beyond peak) Uteroplacental insufficiency
How do you suppress breast milk production?
Binding Ice packs, painkillers Dopamine agonists? (not used unless necessary due to increased stroke risk) *No stimulation* or pumping
What is the most common result of PROM/PPROM?
Birth within 1 week Most give birth by week 36
What defines a complicated pregnancy history?
Recurrent abortion - > 2 consecutive losses IUFD (EGA>20wks but prior to labor) Big baby, small baby (SGA, LGA, lBW) PTL Grand multiparity - > 5 Pregnancy induced HTN Termination for a medical condition rapid succession, operative, atony, psych
What meds are used for the lumbar epidural?
Bupivicaine and fentanyl
What are some problems with adolescent pregnancy?
Poor nutrition poor edu Smoke Drugs STDs Poor prenatal care
Gestation exceeding 42 weeks=
Post-dates
renal atresia, clubbed feet, pulmonary hypoplasia, fetal face deformity
Potter's disease
What are the 4 main causes of dystocia?
Power Passage Passenger Psyche
What are some *maternal* indications for labor *induction*?
Pre-eclampsia DM Heart dz
Who is Methergine contraindicated in?
Pre-eclampsia HTN Raynauds
If your pregnant patient presents with a seizure, and has no history of seizures, what have you likely missed?
Pre-eclampsia (now becomes eclampsia)
Preeclampsia, abrupted placenta, preterm baby, and FGR are all complications of
Pre-existing HTN
TOC ecclampsia
PreE + seizure - ABCs - MS 4-6g bolus, IV2g/hr - DELIVER
If PIH develops proteinuria at any time, it is considered...
Preeclampsia
what are the CIs for induction of labor for fetoplacental causes:
Premature fetus without lung maturity Acute fetal distress Abnormal presentation
surgical management of *cystic* adnexal mass *know this slide*
Premenarchal age - if >2cm: ex-lap - if < 6cm: 6wks observe - if 6-8 cm: unilocular then observe, multilocular or soild then ex-lap - > 8cm: resect @ lap (surg) Postmenopausal age - if >4cm resect at lap (surg)
what are some prescribed meds given to pregnant pts:
Prenatal vitamins Folic acid Fe/colace
#1 cause of neonatal morbidity & mortality causes 75% of neonatal deaths not due to congenital anomalies
Preterm Labor Birth
What is the most common cause of neonatal morbidity and mortality?
Preterm labor
what are the risk factors for PPROM:
Previous PPROM---3X risk Genital infection—single most identifiable factor Antepartum bleeding—3-7X risk Smoking---2-4X risk
Primary amenorrhea definitions-->
Primary: never had menses - no menses by age *15* in the *presence* of nml 2' sexual characteristics - no menses by *age 13* in *absence* of 2' sexual characteristics - no menses w/i *2 years* of *thelarche*
What are some risks of DVT?
Prior PE or DVT Hereditary thrombophilia (Factor V Leiden) Mechanical heart valve A fibz Trauma, immobilized Antiphospholipid syndrome
What placental hormones cause diabetes/ insulin resistance in pregnancy?
Progesterone Placental lactogen CRH Growth hormone
What are some indications for a forceps or vacuum delivery? (4)
Prolonged 2nd stage (10cm to delivery) suspicion of fetal compromise (NOT fetus is compromised) Breech (FORCEPS ONLY) shorten 2nd stage for Maternal benefit (heart dz, DM)
What might lumbar epidural cause?
Prolonged 2nd stage (can't feel) Maternal fever Headache Backache
During delivery with a cord prolapse, what might you expect to see on the fetal heart monitor?
Prolonged bradycardia from impaired blood flow
what is considered complicated pregnancy hx:
Recurrent abortion - >2 consecutive losses Interurterine fetal demise- EGA >20wk but prior to labor Preterm labor, LBW, small for gestional age, interuterine growth retardation/restriction Macrosomia, large gestional age Grand multiparity - 5 or more Pregnancy-induced HTN Termination for a medical condition Rapid succession, operative, atony, psych
What would you recommend to your patient complaining of conditions such as cholecystitis or appendicitis that require surgery?
Recommend waiting till 2nd trimester, general anesthesia is teratogenic - use abx to curtail
What risks are associated with previa?
Multiparous, multiple gestation Old women *Hx of it*
PID treatments
Must cover: GC/Chlam/ anaerobes - Inpt: cefoxitin IV or cefotetan IV + doxy IV - Outpt: ceftriaxone IM, & doxy BID x 2 wks +/- metronidazole BID for 2 wks if Trich or recent instrumentation
are uterine polyp formations estrogen dependent
NO
are cervical polyps at a high risk for malignancy?
NO - low risk but still send to pathology regardless
does pelvimetry preclude a trial of labor
NO - still may allow for delivery of a small baby
Can you run wild during menopause?
NOPE, use contraception until amenorrhea x 1 yr.
describe pouch of douglas
NOT a uterovesical fold loweset point in retroperitoneal cavity for blood accumulation ONLY accessed thru posterior fornix
Primary dysmenorrea Starts w/i 48-72h of menses. What is the tx?
NSAIDS, OCPS (preferred)
What is associated with anti-epileptic use?
NTD (teratogenic effects) Folate deficiency Vitamin K deficiency
What is pulmonary immaturity characterized by *lack of surfactant*, leading to decreased oxygenation and ventilation?
Neonatal respiratory distress syndrome
What can happen if you give parenteral narcotics close to delivery?
Neonate respiratory depression (if close to delivery) Decreased FHR variability
Adrenal causes of hyperandrogenemia:
Neoplasm, Cushing's, CAH
What tocolytics are used from 32-34 weeks?
Nifedipine 1st line Terbutaline alternate
How do you prevent cracked nipples?
Nipple shield and lotion/ emollient Air dry after feeding
The region of fibrinoid degeneration where trophoblasts meet decidua is called ____? what is it's fxn
Nitabuch's layer prevent placental invasion into uterus
Do implants interfere with breast feeding?
No
Does PPROM imply labor is imminent?
No
can someone who has had PPCM have anymore pregnancies:
No
does synthroid cross the placenta:
No
is intrahepatic cholestasis of pregnancy an indication for delivery:
No
is well's criteria validated in pregnant pts?
No
is serum FSH necessary for dx of menopause
No (these levels vary throughout perimenoP) - clinical dx: no menses x 1yr
What lab indicates RDS?
No PG and L/S ratio <2
What are the types of fetal assessments?
Non-stress test Contraction stress test Biophysical profile
what is tx of rubella:
None *Avoid exposures to possible infection* Vaccination of non-immune women should occur in immediate post-partum period—do not vaccinate while pregnant—vaccine contains live virus
What are the scores for late decelerations in the contraction stress test?
None is good 1 is equivocal and requires monitoring 2+ is bad (decels occur in relation to contraction)
What tocolytic is administered after 34 weeks?
None, deliver that baby
*What are some contraindications to tocolytic therapy?* (8)
Nonreasurring fetal status Chorioamnionitis (won't work) SEVERE Eclampsia/preeclampsia IUFD- evacuate dead baby Fetal maturity Hemodynamic instability Cervix dilated >3 cm Severe IUGR
How likely are you to encounter a pregnant female with hypothyroid?
Not very likely. Hypothyroid causes infertility.
What do you do for dystocia if the fetal and maternal conditions are ok?
Nothing
What procedures can be used to extract products of conception?
ring Forceps Dilation and curettage
normal rise in hCG post fertilization
rises 2.2x every day
what are the types of testing available to families for prenatal genetic screening:
serum markers & 20 wk U/S for all pregnant women targeted screening in high risk ethnic groups
Failure of shoulders to deliver after vertex Incidence 0.6-1.4% "Turtle sign" Risk factors Macrosomia Obesity Diabetes
shoulder dystocia
Incomplete bladder emptying--> "overflow"
similar to SUI and urge Characteristics - Frequency, hesitation, nocturne and dribbling Cause - *overdistention (impaired detrusor contractility)* - bladder outlet restriction (prior surg/injury)
what happens to BP during pregnancy
slight drop @ week 24, then level out
phase 1 of menstrual cycle is:
slight raise in FSH that stimulates the growing follicle
THE most preventable cause of low birth weight (LBW) infants (<2500 gms)
smoking
if Ab titer is > 1:16 on an Rh neg mom, what are the tests performed to predict severity of the dz:
spectrophotometry U/S-standard test now Percutaneous Umbilical blood sampling
Physiologic process by which ejaculated sperm acquire the ability to fertilize ova Readies the sperm for the "acrosomal reaction" to occur once the head of the sperm contacts the ova May occur in-vivo or in-vitro
sperm capacitation
non motile, non round, non differentiated form of sperm
spermatid
what are the 23 single chromosomes found after second meiotic division:
spermatids
non motile, differentiated form of sperm, but not fully mature
spermatozoa
phase 3 of menstrual cycle is:
spike in LH in response to elevated estradiol as it reverts to positive feedback loop resulting in ovulation
phase 2 of menstrual cycle is:
spike in estradiol that causes proliferation with sharp drop once ovulation occurs
Incidence: 50% of all pregnancies 25% are recognized pregnancies *80% occur prior to 12 wks* Causes: 50% attributed to chromosomal abnormalities, ie increasing maternal age Medical conditions---DM,SLE,hypothyroidism EtOH Tobacco
spontaneous abortion
Where columnar cells meet squamous cells Position of the SCJ depends on a woman's age and her hormonal status
squamocolumnar junction
lichen sclerosis puts patient @ slight increase risk for
squamous cell CA of vulva
transformation from one cell type to another
squamous metaplasia
how do you manage an incomplete abortion:
stabilize pt (2 lg. bore IVs, NS or LR w/ oxytocin specialty care for products of conception Rhogam as indicated manage PPH
what is the first day start:
start the pill on the first day of period. *no back up needed*
2 layers of endometrium
statum basalis stratum functionalisis
>5 UCs in a 10 minute period (avg over 30 min) UCs occurring within one minute of one another Any UC lasting 2 minutes or more
tachysystole
if you miss 1 pill, what do you do:
take 2 on following day no back up needed
if you miss 2 pills, what do you do:
take 2 pills for 2 days, use other contraceptive method
What to tell your pt to prevent ovarian CA
take a birth control pill, stop and have a baby, breastfeed, go back on pills, have 3 more kids and breastfeed them all, get your tubes tied and don't smoke!
MOI of methotrexate as drug for EP
targets rapidly dividing cells - folic acid antagonist
what additional testing may be needed in chlamydia
test for other STIs must test for cure if pregnant rescreen in 3-4 months
produced by Leydig cells (acts locally on Wolffian ducts and peripherally on responsive tissues
testosterone
describe expulsion
the anterior shoulder delivers under the symphysis pubis, followed by the posterior shoulder over the perineal body and the body of the child.
A younger pt w/ abnml uterine bleeding may be treated with just progestin because ________.
they are more likely to have sufficient estrogen levels.
any pigmented lesion of the vulva-->
work it up, could be 2nd MC type of vulvar CA, malignant melanoma
SGA is
wt < 10th percentile for GA SGA may just be a "little" baby as opposed to IUGR
macrosomia is...
wt > 4.0 kg
can OCPs reduce risk of ovarian, endometrium, and colon and rectum cancer:
yes
is infertility common with hypothyroid:
yes
if women on enzyme inducing anticonvulsants, is progesterone only agents a good choice as a contraceptive?
yes,
are asthma meds ok for use in pregnancy/lactation:
yes, consult
primordial germ cells migrate to genital ridge. where do they come from:
yolk sac
About how long might MTX therapy for EP take?
~3 months
A BPS of 6 correlates with a pH of....
~7.2
stage -1 STRAW (transition):
≥ 2 missed cycles plus *amen ≥ 60d* (missed cycles, don't have to be continuous)
meds/ txt stress incontinence
● *Pelvic muscle exercises/Pessary* ● Periurethral collagen injections ● Surgery ● Topical estrogen if atrophic (not oral) ● *Duloxetine* AVOID: a-antagonists
meds/ txt of overflow incontinence
● Surgery ● Intermittent cath Avoid: Ca blockers, a-adrenergic agonists, anticholinergics
meds/ txt of urge incontinence
● Timed voids ● Anticholinergics (Detrol, Ditropan) ● PMEs (Pelvic Muscle Exercises)
wu of abnml pap
colposcopy is dx - cervix cleansed w/ 3% acetic acid, intraepithelial neoplastic areas turn white "ecetowhite" - bx of acetowhite + endocervical curretage performed colp unsatisfactory then - LEEP - cold knife cone
Women ages 25-29 should under go?
colposcopy regardless of HPV testing result.
which type of spontaneous abortion usually occurs < 12wks?
complete
what are the different types of breech presentations:
complete, footling, frank
describe Bohr affect
decreased affinity of Hgb for O2 due to fall in pH (acidity) - increased concentration of CO2 in maternal blood causes oxygen to unload - decreased concentration of CO2 in fetal blood causes oxygen to bind
Tx for AFLOP
definitive: *DELIVERY* (high fetal mortality) - IV glucose (hypoBG) and FFP (coags)
how do you manage chorioamnionitis:
delivery!! avg time from dx to delivery is 3-5 hrs Abx-Amp/Gent/clindamycin if LTCS
Good for excessive bleeding, for amenorrhea Good for carcinoma Decreased risk of PID, because of the increased cervical mucus Ovulation affect, only one that affects it SE-wt. gain, mood changes, *decreased bone mineral density w/long term use* for return to fertility, takes a long time. choose something else if pt may stop BC to become pregnant later
depo-provera
cardinal mov't: is brought about by the force of the uterine contractions, maternal bearing-down (Valsalva) efforts, and, if the patient is upright, gravity
descent
what are the 6 cardinal movements of labor:
descent, flexion, internal rotation, extension, external rotation, expulsion
Spinnbarkeit
describes stretchability of cervical mucus during or prior to ovulation - due to mucus change due to increased E
What does the pap report?
description of specimen type, description of adequacy, general category, interpretation/result, description of ancillary testing, educational notes.
phases of sexual response (3)-->
desire (libido) Excitement (arousal) Orgasm (done)
when is b-hCG detectable in blood:
detectable 6-8 days after implantation <5 IU/L = negative >25 IU/L = positive 6-24 = equivocal—repeat in 2 days By time of missed menses values >100 IU/L
Clinical estimation of obstetric conjugate Usually 1.5-2 cm bigger >11.5 cm is "adequate"
diagonal conjugate
this barrier method Can be placed up to 6 hours prior to intercourse but must be left in place for 6 hours after Increase UTI risk
diaphragm
what are the techniques to diagnose PTL:
digital cervical exam fetal fibronectin (trophoblast glue) cervical length
what are pregnant women at an increased risk for (higher than preeclampsia & diabetes):
domestic violence
pregnant women are at an increased risk for what? this risk is higher than risk for pre ecclampia & DM
domestic violence prevalence is 4-8%
define Leopald's maneuver's
done at 28 wks - 1st: determine what part of baby occupies fundus - 2nd: determine which side back is on - 3rd: determine which part of baby is presenting (near vajay) - 4th: is it brow or occiput
what is the best initial test for DVT in pregnancy:
doppler U/S
chances of prolapse ___ after first pregnancy
doubles after first pregnancy
describe 4th generation progestins
drospirenone - aldosterone antagonist - increases Na & H20 excretion, K retention - least androgen effect
Primary diversion that ensures improved oxygenation of brain and heart and limits flow to lungs Functionally closed in 50% of term infants within 24 hrs PDA risk inversely proportional to gestational age
ductus arteriosus
primary fetal diversion that ensures oxygenation of fetal brain & heart, and diverts blood away from fetal lungs
ductus arterious
Allows interstate-size bypass of hepatic circulation of oxygenated blood Functionally closed within minutes of delivery and structurally closed within 3-4 days Remnant is ligamentum venosum
ductus venosus
when are vasomotor sxs MC during menopause
during 1-5 yrs (56%) 2nd: > 5yrs
when are all anticonvulsants ok to use
during breast feeding
triad for endometriosis?
dysmenorrhea (pnful menses), dyspareunia (pnful sex), dyschezia (pooing hurts)
types of pain d/o--> (2)
dyspareunia, vaginismus
Intractable vomiting/oral (PO) intolerance Increased incidence with first pregnancy *Electrolyte and urinary abnormalities*
hyperemesis gravidarum
EMB results are hyperplasia w/ atypia, what do you do?
hysterectomy! IF refused tx w/ progesterone, then Q3 mos EMB is recommended.
what are the +'s of breast milk:
ideal nutrient balance, recommended as sole nutrient for first 6 mo, maternal bonding immunocompetence
results of TVUS in postmenoP women guides us in treatment for endoM ca how?
if < 4mm treat w/ HRT if > 4mm requires EMB +/- D&C
when is diagonal conjugate adequate?
if it is greater than or equal to 11.5 cm
when is Fe prescribed
if need 1.0 mg or greater - give with colace
what would you counsel a pregnant pt on meds/herbs:
if not prescribed or recommended, don't use it
for pregnancies less than 24 wks, what are the three pathways for diabetic testing:
if pt <92 FBG or A1C <6.5 or RBG <200, 75g 2hr OGTT at 24-28 wks if pt >92 FBG and <126 FBG, GDM - no further testing if pt >126 FBG or >6.5 A1C or RBG >200, overt diabetes - no further testing
Transport in fallopian tube may be fertility factor Estrogen facilitates "sticking" Progesterone inhibits sticking Prostaglandin E relaxes tube Prostaglandin F stimulates tubal motility
implantation
what types of contraceptives are highly effective <3% failure rate:
implants, IUD, inj
Non-contraception benefits of COCP
improve - acne/ hirsutism - irregular cycles - dysmenorrhea - anemia - increase bone density
What is feedback inhibitor of lactation protein?
in engorgement see build up of milk, initiating lactation inhibition factor which shuts down PRL
What is meant by dystocia caused by power?
inadequate strength or freq
which SAB is an EMERGENCY
incomplete - look for hx of passed clots but patient is still bleeding
normal pregnancy is characterized by what 3 cardiovascular things:
increase in CO, reduction in systemic vascular resistance, and modest decline in MAP
reaction—a febrile response within 24 hours of treatment of syphilis. Not prevented by anti-pyretics May cause preterm labor (PTL)
jarisch-herxheimer
all HTN meds cross placenta, what is preferred:
labetalol, hydrazine, methyldopa
define Delayed puberty-->
lack of thelarche by age 12 MCC constitutional delay
what are progesterone only agents useful for (demographics):
lactating mothers tobacco users >35 yo
what behavioral method Must do exclusive breastfeeding and have no menses Failure rate 5-10% Must use alternative contraception after 6 months
lactational amenorrhea
connect parietal bones to occiputal bones
lambdoid suture
rapid test for fetal lung maturity
lamellar bodies, good PPV
what are some types of mechanical dilation:
laminaria foley bulb dilation
describe normal menstrual period
lasts 21-35 days less than 80 cc typically </= 5 d
what does broad ligament do
laterally anchor uterus to pelvic walls, divides pelvis into anterior/ posterior compartments
what barrier method is the best for reducing STIs:
latex condom
The adrenal gland continues to produce andostenedione which is converted into estrone in peripheral fat, what is the problem with that?
leads to increased risk of endometrial and breast cancer.
MC indication for a hysterectomy
leiomyomata uteri
IUD will typically do what for abnml uterine bleeding
lengthen bleeding
Begin at 28 weeks Confirms: Lie Presentation (vtx,breech, shoulder) Estimated fetal weight (EFW)
leopold's maneuvers
Reproductive age AUB is what-->
less cycle variability, ages 20-40
Composed of 3 muscles Puborectalis Pubococcygeus Iliococcygeus provides dynamic floor for support of abdominopelvic organs Tonically contracted most of the time to provide fecal/urinary continence
levator ani
support structures of the pelvis--> how are these structures most often damaged
levator ani urogenital diaphragm perineum vagina ALL ASSOC w/ damage following pregnancy (inc intra ab prssure on pelvic contents)
produces testosterone in male embryo
leydig cells - acts locally and systemically (testosterone)
what do leopald manuevers confirm
lie fetal presentation estimated fetal weight
remnant of ductus venosus
ligamentum venosum
how does standard day method work
like counting beads on a rosary.... - start on day of menses: 1-7d infertile - days 8-19 fertile: don't have unprotected sex - day 20 until end of cycle: infertile
variability is the most reliable indicator of fetal well being. what are the two types:
long term (variations from baseline) and short term (beat to beat)
When you get the placenta out, what should you look for?
look at membranes to confirm no retained bits - one side slick, other side "hamburger" like - if retained membranes: side shows disruption - document completeness & # of umbilical vessels present
the midplane AP should extend from what to what:
lower pubic margin to jct of S4-5
what Rx are given to seizure pts that become pregnant:
lowest dose anticonvulsant monotherapy, folic acid and VitK supplements
1st Trimester US marker, earliest screening available Combined with serum markers has highest sensitivity Sensitivity 94-96%, Specificity 95%
nuchal translucency (NT)
2nd MC GYN malignancy? when does risk increase
ovarian CA risk is increased 40-60YO.
MCC of GYN CA *deaths*
ovarian cancer
what method Requires cervical mucus evaluation several times daily Evaluate consistency,color,elasticity, abundance Correct rate 2/100 women/yr Typical rate 23/100 women/yr Typically requires abstinence 14-17d/mo
ovulation method
what do behavioral methods of contraception depend on:
ovulation, cervical mucus, basal body temp
what respiratory changes occur during pregnancy:
oxygen consumption increases 15-20%
First line drug for post partum hemorrhage
oxytocin
First line drug for post-partum hemorrhage
oxytocin
what hormone influences the lobule (alveoli) of the breast:
oxytocin
what is the only FDA approved drug for induction/augmentation:
oxytocin
txt of prolonged active labor (summary)
oxytocin observe 4 hr if adequate contrax observation to 6 hrs in inadequate contrax fetal and maternal monitoring if contrax exceeds hrs of observation --> c-section
what is the procedure of choice for regional analgesia:
lumbar epidural -Vaginal or cesarean Continuous infusion adjacent to spinal canal Bupivicaine 10-12 cc/hr + Fentanyl 2-5 mcg/ml Associated with prolonged 2nd stage & maternal fever
begins with pre-ovulation, ends with 1st day of menses, typically 14 days---only portion with defined duration (life of corpus luteum 9-10 days)
luteal phase
What is meant by dystocia caused by passenger?
macrosomia=>4kg baby Malpresentation (brow or face) malposition (occiput post)
name that pelvis: pelvic angle <90 degrees, sacrum tilted fwd, and ilia closer together:
male
Pregnant w/ ASCUS-->
manage as if non-pregnant except no endocervical curette or EMB. May *defer colpo until 6 wks postpartum*. Bx only high grade lesions.
MC cause/ condition that highly predisposes fetus to polyhydramnios
maternal DM - think maternal DM if high AFI and BMI > 31%
describe rosette screen
maternal plasma mixed with IgM to bind with rh positive cells - if neg, no further testing needed - if pos, must quantify with KB test
Elevated in 90-100% of pregnancies with an open neural tube defect High false positive rate (1 in 20 women) only 2% are true positives, better positive predictive value in older patients
maternal serum a-fetoprotein
Z-score what is the deal?
measures BMD w/ same age & wt for risk of fracture Granny v. Granny
vestibule homolog
membranous urethra
NIH diagnostic criteria for PCOS
menstrual irregularity due to oligo or anovulation plus clinical and/or biochemical signs of hyperandrogenism
Dose by body surface area (BSA) (50mg/sqm) Hemodynamically stable Desires fertility "Small" "Early" <3.5cm No fetal cardiac activity <5000 IU HCG No med hx (liver, renal disease) No breast feeding Good follow-up candidate more complications from med tx than surgical
methotrexate
tx for non-ruptured EP:
methotrexate
once the placenta comes out, prolactin is dis-inhibited causing what:
milk production
Progesterone-only agents IUD and implantable
mirena (Levonorgestrel secretion for 5 yrs) implanon//nexplanon 1 implant for 3 yrs
what are the s/s of diagnosing a pregnancy:
missed period breast tenderness N/V fatigue bleeding - 30-40%
MC type of incontinence in women
mixed incontinence combo of urge and stress
grape like clusters
molar pregnancy
Combination OCPs ________-each active pill has same amount of hormones ________-dose of hormone varies among the pills in the package
monophasic:multiphasic
what is the therapy for abnormal bleeding from a female:
more estrogen causes proliferation of endometrium causing the bleeding to stop
what should be covered in the counseling for seizure pts that get pregnant:
pan-teratogenicity of anti-epileptics folate and Vit K deficiencies from phenytoin, phenobarbital, primidone safe in lactation
what type of pelvic side walls are usual and desired:
parallel
which placenta abruption has apparent hemorrhage:
partial partial (can as well) and complete have concealed hemorrhage
Which type of hydatidiform mole is most likely to be mistaken for incomplete AB?
partial, presents w/ vaginal bleeding, FHT.
what is used to track progression of cervical changes/ dilation
partogram chart
rule of heart disease in patient
patient must have had ZERO hx of heart problems prior to pregnancy to be dx with PPCM
what are the 4 P's of dystocia:
power, passage, passenger, psyche
what does cervical mucus identify
pre ovulation
Lacerations, fetal respiratory issues, and uterine atony are s/s of what type of labor:
precipitous labor 5-10 cm/hr
Opportunity to improve obstetric outcomes Should be provided to ALL women of reproductive age since 50% of pregnancies are unplanned
preconception care
what are some maternal conditions where we don't want a long labor:
preeclampsia, DM, heart dz
*MCC of 2' amenorrhea* -->
pregnancy
MC cause of 2ndary amenorrhea
pregnancy
Naturally produced in endometrium/myometrium Exogenously applied as a gel or pill Cause cervical ripening—induction
prostaglandins
skene's gland homolog
prostate
Hyperthecosis- severe PCOS--> describe
pt virilized - temporal balding - clitoral enlargement - deepening voice - remodeling of limb-shoulder girdle.
when both uterus and vaginal canal lie closer to the rectum than the bladder, what position is the uterus:
retrocession
MCC of delayed puberty
- constitutional delay
LSIL < 30 with NO HPV testing
colposcopy
LSIL w/ POS HPV
colposcopy
menopause is defined as?
Amenorrhea for 12 months after FMP
Patients at 43 weeks have 4x risk of
Baby mortality - don't let go above 43 wks
Which operative delivery method is associated with increased fetal morbidity?
Vacuum
where are the MC locations of ectopic pregnancy for ART:
ampullary 93% tubal 82%
What is involved in a 4th degree laceration?
anal sphincter and rectum A laceration involving the rectal mucosa
what does cardinal ligament do?
anchor cervix/ vagina (cardinal lady bits) to pelvic LATERAL wall - support uterus
46 XY baby with female phenotype
androgen insensitivity syndrome mullerian system is normal
What decreases SHBG levels?
androgens and insulin (obesity)
endocrine cause or dysfxn uterine bleed results from ____
anovulation - factors that affect HPO axis - systemic dz: celiac, thyroid
if mom has a risk of delivery, these are for For EGA 24-34 weeks in absence of chorioamnionitis Decrease Respiratory Distress Syndrome, NEC and Intraventricular hemorrhage Effects last for 7 days
antenatal CS (betamethasone, dexamethasone)
common causes of an upset vaginal microflora -->
antibiotics, douching, semen (alkaline), foreign bodies, HYPOestrogenized (atrophic)
What are some malpositions
anything that is transverse or occiput posterior - want occiput anterior presenation (R or L)
Precocious puberty defined-->
appearance of 2' female sex characteristics *prior to age 8*
MOST frequent non-obstetric indication for surgery Atypical presentation due to anatomic changes Increased risk of perforation in third trimester
appendicitis
Cervical Polyp when and where do they typically arise from? what is TXT what must we always do?
arise from endocervical canal during reproductive years - Txt: IF large, symptomatic or atypical Small and pedunculated--> grasp at base and twist off. Sessile--> remove w/ bx forceps, cauterize base - Send to path despite low malignancy potential
relationship of BPS with umbilical venous pH
as BPS gets lower so does fetal pH (acidotic from hypoxemia) - linear & inverse relationship
What is the definitive manner in which to dx endometriosis?
biopsy via laparoscopy.
what do you measure during 2nd tri for U/S dating:
biparietal diameter and femur length accurate +/- 2 wks
*Predicts success of vaginal delivery based on status of the cervix
bishop score
TOC for osteoporosis
bisphosphonates
(distance between ischial spines)
bispinous diameter
Protrusion of pelvic organs via vagina-->
bladder--> cystocele Rectum--> rectocele Bowel--> enterocele Uterus--> *procidentia*
OCPs have an increased risk of what SE
blood clots
way in which choronic villi drain nutrients & o2 from maternal blood
bohr effect
what are the fetal consequences:
brachial plexopathy clavicular fxs hypoxic injury
What are the baby consequences of squeezing out a shoulder dystocia baby?
brachial plexus injury - erb's palsy Clavicle fractures Hypoxia
continuous OCP has similar SEs/risks to other OCP except more what:
break through bleeding
using OCPs you are NOT at an increased risk for what cancer?
breast cancer
what would you counsel a pregnant pt on delivery planning:
breast feeding L&D - emergency indications
where do you not put the patch on the body:
breasts
what is anterior fontanele
bregma - jxn of saggital suture & coronal suture
What is the menopause window? when is menopause premature
btw ages 50-55. *avg 51* Occurrence before 40 YO *premature*
bartholin's gland homolog
bulbourethral gland
when do 50% of ductus arterious close
by 24 hours after birth of term infants
by what age do most foramen ovales have flap fusion
by age 2
how is uterine atony combated in general ans patients
by giving oxytocin in advance
elongates during pregnancy (after the 28th week) becoming lower uterine segment
isthmus
what is the MC abnormal uterine development:
uterus bicornis
What consult must be made if GDM is diagnosed?
- consult Nutrition US @ 20 wks looking for anomalies
why no PTU in 2/3rd trimester
- ↑risk of liver failure
What is the 3rd stage of labor?
"Baby launch to placenta dump" parturition to placenta < 30 mins
ways to date a pregnacy
- Naegels rule - OB wheel - early US
ddx of AUB
"PALM-COEIN" - polyp, pregnancy - adenomyosis - leiomyoma - malignancy - coagulopathy - ovulatory dysfunction - endometrial - iatrogenic, infection - Not yet classified
*what are favorable pelvic shapes*
*- #1 Gynecoid - #2 Anthropoid*
Dose for oxytocin in PPH
*10 units IM or 10-20 U/L @ 100cc/hr*
Post menopause stage +1 is
*1st 5 yrs* after menopause
prevalence of domestic violence
*4-8%* higher than preeclampsia & DM, need a screen - Problem oriented prenatal risk assessment
When must you follow up abnormal OGTT?
*6-12 weeks post partum* keep doing Q 3 yrs even if no longer pregnant
What are the criteria for diagnosing *arrest of dilation*?
*> 6 cm dilated + ROM with NO CERVICAL CHANGE* > 4 hours WITH adeq contractions OR > 6 hours with INADEQUATE contractions
Definition of osteoporosis?
*>2.5* SD below the mean
*Some contraindications for ECV* (6)
*ANYTHING THAT PRECLUDES VAGINAL DELIVERY! IF YOU KNOW YOU"RE GOING TO DO A C-SECTION, DONT SPIN* - Uteroplacental insufficiency - HTN - IUGR - Oligohydramnios-not enough juice to spin kid in - Uterine surgery: previous
A contracted pelvis is a _____ to induction
*Absolute contraindication*! You don't smash baby into the bones of the pelvis.
What are the operative deliveries?
*C-section MC* Forceps Vacuum
initial recommended tx of hirsutism what is MOI of this txt
*COCPs*, esp *drospirenone*/ 4th gen bc min androgen effect - inhibit LH secretion, reduce LH dependent ovarian androgen production - inc hepatic synthesis of SHBG (estrogen) - inhibit adrenal androgen secretion *add anti-androgenic AFTER 6 mos*
How is PPCM diagnosed?
*Echo (EF<40%)*
how do you manage PPROM:
*Empiric antibiotics prolong latency; use if <34 weeks (note difference with PTL) *Antenatal steroids if < 34 weeks Tocolytics only to allow for antibx/steroids Monitor for infection - induce if infected
What is HELLP syndrome?
*H*emolysis *E*levated *L*iver enzymes (transaminase) *L*ow *P*latelet (<100k) (already had PIH)
dating of pregnancy
- Naegle's - OB wheel - early US if uncertain LMP or irregular periods 1st tri most accurate (crown to rump) estimates +/- 1 wk
3 factors that influence emergency contraception
- BMI > 30 - Day of cycle: intercourse on the day before ovulation when conception probability is 30%) compared with intercourse when the risk of conception was theoretically nil (ie, intercourse more than 5d before ovulation or more than 1d after ovulation - further intercourse after use
define severe preE
- BP >160/110 - proteinuria > 5 g in 24 hr - oliguria < 500 cc/hr - plt < 100k (CNS s/s, RUQ or N/V (liver), IUGR, pulm edema, cyanosis
3 main hemodynamic changes in pregnancy
- BP stays normal - CO increases - SVR decreases this causes increase in HR
describe epithelium of cervix @ birth? @ puberty?
- Birth: No E --> columnar in endocervical canal, squamous in cervix/ va-j - puberty/ preggo: E increases --> 1. columnar epith proliferate & evert onto eCTOcervix, acidifies va-j forcing columnar epith to "transform" back into squamous epith
what are the benefits of mom and infant of breast feeding:
- Bonding - decrease postpartum hemorrhage - wt loss - *decreased ovarian and breast CA risk* - immune protective (IgA)
what is progression to cancer risk in CIN
- CIN I: < 1% - CIN II: 5% - CIN III: 22%
s/s of *incomplete* abortion
- CRAMPING (retained products) - vaginal bleeding - passage of tissue or clots - dilated os, soft uterus - HOTN
reversal agent for MS
- Ca gluconate or Ca chloride
Cervical stenosis causes: (3) what is TOC?
- Causes: txt for CIN (Leep), congenital, spontaneous in hypoestrogenic women - TOC: cervical dilators, vaginal estrogen for 4 weeks in hypoestrogenic women.
what does Bishop score measure
- Cervix: position, effacement, dilation, consistency - fetal head: station
which has a higher chance of metastasis: Choriocarcinoma or persistent/ invasive mole
- ChorioCa has HIGH likelihood of mets - mole has RARE chance of mets
Bartholins cyst is common in who be concerned if seen in who? where does cyst occur? what s/s?
- Common in reproductive age women - *concern for CA in women > 40 refer for bx* - cyst in duct, *NO PAIN* (unlike abscess)
what should you do in women w/ bartholin's abscess? what is TOC
- Consider GC, screen and treat, obtain MRSA culture d/t prevalence - Fluctuant: I&D immediate relief, follow w/ word. - ABX only if 1. recurrent or 2. high risk of complicated infection (pregnant, cellulitis, systemic infection, immunocompromised) *Augmentin + Clindamycin x 1 wk*
IUD mechanism of Cu IUD mechanism of Mirena
- Cu: functional spermicide, decreases sperm motility & ability to fertilize, inflammatory changes in endometrium spermicidal - Mirena: thicken cervical mucus, thins endoM, inhibit sperm transport *ovulation NOT inhibited*
operative window for pregnancy termination
- D&E < 16 wk (DE not usually done after 20 EGA) - induction labor: > 16 wk
describe androgens: where are they found what is their action
- DHEA: adrenal gland, weak - Androstenedione: adrenals, ovary, weak - Testosterone: adrenals, ovary, *adipose*, Potent - DHT: hair follicles, genital skin, MOST POTENT
Pros to OCPs
- Decreased: ovarian, colon, rectal & endometrial ca - very effective 3-10% failure
So if you have a post menoP women w/ AUB and suspect endoM hyperplasia you
- Do TVUS 1st - if > 4mm then do bx
PMDD is assoc w/
- Dx= *sx during luteal phase* and a sx free interval of at least *7d* in the 1st half cycle for at least *3 consecutive cylces* - physical/ behavioral sxs
Prognosis of sexual d/o from EASIEST to txt to RESISTANT
- Easiest: orgasmic - Challenge: Excitement/ libido - Resistant: Desire - Pain: (? depends)
Mag Sulfate treatment (doses)
- Eclampsia: 4-6g bolus, IV 2g/hr - After delivery for PPH: 20U IV
Rape kit contents
- Equip: microscope slides, saline, swabs, tubes, specimen containers - evidence collection: comb, nail scraper, pap setup & wood's lamp (SPERM)
Basic management of infertility after 12 mo of infertility--> when do we refer?
- Est. a calendar - confirm reg ovulation - coitus Q other day in ovulation window - document hx, examine, cx and assess semen *Refer if regular ovulation and normal sperm.*
hormones involved in implantation
- Estrogen facilitate sticking, - P inhibit sticking - prostaglandin E relax tube - prostaglandin F stimulate tubal motility
why gallbladder problems in pregnancy
- Estrogen stimulates gallbladder/ cholesterol - Progesterone decreases gallbladder emptying
Leiomyomata Uteri (fibroids) define what is its malignancy potential? what are 3 types
- Estrogen-dependent smooth muscle tumor - Low intrinsic malignant potential - 3 Types: intramural, submucosal, subserosal
parenteral narcotics that can be used in 1st stage
- Fentanyl - Morphine Sulfate - Demerol (longest T1/2)
TRIAD of toxic shock syndrome
- Fever - macular Rash - HOTN
what does preconception counseling consist of
- Folic acid supplementation: 400 mcg/ daily - nutritional status (over/under wt), 3mo prior - STI screen - med hx/ review - avoidance: tob, ETOH 3 mo prior to conception
Functional ovarian cyst
- Follicular or Lutein - hemorrhagic (either of those ^^) - benign neoplasm = solid
florida power and lights
- Full term - Preterm - abortion - living children
MC benign neoplasms
- GERM Cell (as group then epithelial)
pre - puberty pathophysiology
- HPA in young kids suppressed age 4-10, gonadostat is HPA system regulaing GnRH release - low levels of gonadotropins & sex steroids prepubertal: 1. max sensitivity of gonadostat to negative feedback effect of low, circulating levels of estradiol & 2. *intrinsic CNS inhibition of GnRH secretion* - late prepubertal: adrenal androgens rise: increase growth of axillary & pubic hair -- adrenarche
describe initiation of puberty
- HPO axis suppressed 4-10 yo = inhibition of gnrh - loss of gonadostat sensitivity @ 11 yo, less responsive (takes more estradiol to stop FSH/LH) - more FSH/ LH = increased sex steroid production
causative agent of genital warts transmission via
- HPV: 6, 11 - contact, inanimate objects, birth canal to laryngeal transmission can happen w/o presence of lesions
triad of preE
- HTN - edema - proteinuria
define gestational HTN
- HTN > 20 wks EGA w/o proteinuria and resolves prior to 12 wks post partum
chronic HTN
- HTN before conception, prior to 20 wks or post partum > 12 wks (140/90) - TOC: *labetolol* or nifedipine, consider *methyldopa*
3 major efficacy groups for contraception
- Highly effective - Very effective - all others
recap: txt of *prolonged latent* phase
- Hypertonic contrax: Morphine or Ambien - Hypotonic bc of sedatives: wait - Hypotonic (bc soft uterus during contrax): IV oxytocin +/- AROM if >4-5cm
HIGH risks for ectopic
- IUD - previous ectopic or tubal surg - tubal pathology - in utero DES exposure
Localized Provoked Vulvodynia MC cause who do you suspect it in? how is it dx?
- Idiopathic - suspect in new onset *insertional dyspareunia* (3-4mos) - Dx: light touch cotton applicator in the right area --> tenderness + redness
causes of DM in preggo
- Increased insulin resistance: GH, placental lactogen, CRH, progesterone - increased maternal adipose - decreased exercise, increased caloreis
describe Contact dermatitis (exogenous)
- Irritant (MC)--> trigger directly damages skin - Allergic--> trigger induces immune response leading to skin damage
2nd syphilis: s/s TOC
- LAD, *exanthem (palms, soles)*, *condylomata lata* - Rx- PCN 2.4 million units IM
txt of CIN
- LLETZ - surg - cervical conization: CKC, LEEP
components of pelvic diaphragm
- Levator ani: Puborectalis, pubococcygeus, iliococcygeus - coccygeus
Treatment of vasomotor symptoms?
- Lifestyle (hang out in the local meat locker) - HRT - Time (1-5yrs) - SSRIs/SNRIs
etiology of infertility
- MC abnml spermatogenesis (40%) - anovulation and anatomic defects of female genital tract are 30% each
MC causes of SAB
- MC in 1st tri: < 12 wk chromosomal abnl, infection
Persistent/invasive mole--> which type of molar preg is it MC in? happens in persistent mole? what is dx? what is REQ txt?
- MC in 20% of complete molar, only 3-4% of partial - INVADES myometrium - DX-->*persistent HCG levels following evacuation of molar pregnancy* - MUST do *hysterectomy*
what causes Jarisch Herxheimer rxn
- MC in 2ndary syph - due to release of endotoxin when lg # of orgs killed by abx - serum like illness
Lichen Planus is MC in who what is defining characteristics what type of AI is it how to distinguish LP from other dermatitis
- MC in older women (50-60) - Purple Pruritic Polygonal Papules and Plaques - AI of T-cell - Can involve vagina and gingiva *(VVG syndrome)* (no vag involvement in others)
Key points about burden of unintended pregnancy
- MC of those using active contraception - every method of BC is safer then preggo - large cost associated with unintended preggo
MC type of vulvar CA? etiology of vulvar ca in young pt vs older
- MC: *SCC* - in young think HPV 16, 18, 33/VIN, smoking - older--> chronic inflammation/lichen sclerosus
ways abortion is done less than 13 weeks
- MC: D&C - meds - uterine instillation
Epithelial benign neoplasms types & malignancy potential
- MC: Serous cystadenoma 20% malignant - Mucinous cystadenoma (largest) 15% malignant
What is the MC gynecological malignancy in US? what s/s do 90% of women w/ this ca exhibit? what does that mean?
- MC: endometrial CA - 90% exhibit AUB - Evaluate all women > 35 YO for EMCa
Gonorrhea s/s how is dx done what is TOC when is rescreen done?
- MOST women asxs, possible urethritis, cervicitis - Dx- gram stain, *Cx on thayer martin media*, NAAP - TOC: Ceftriaxone 250mg IM plus 1g azithro - *treat all sexual contacts, test for other STIs, abstinence x 7d, rescreen in 3-4 months.*
CMV causes this in newborns
- MR - vision/ hearing problems - developmental delay
txt of severe PreE
- MS for seizure prophylaxis - BP: hydralazine or labetalol - pulm immature: < 34 wks corticosteroids - definitive: deliver
What is the first line tx for HELLP? definitive tx?
- Mag Sulfate - delivery
SE IUD
- Menorrhagia/ dysmenorrhea (MC w/ Cu) - PID - if pregnancy, higher chance of ectopic
meds used for pregnancy termination
- Mifepristone or MTX on day one, Misoprostol on day 3 (antiprostiglandins) - best efficacy if < 49d EGA
HPV vaccine has greatest efficacy in who
- NAIVE pt from HPV 16, 18 cannot be used in pt who already has HPV
Squamous cell hyperplasia (lichen simplex chronicus)
- NONneoplastic morphologic alteration of vulvular skin related to *chronic irritation* - prolonged itch/ scratch cycle - epithelium is THICK vs lichen sclerosis is thin
describe HSV s/s how is it transmitted what is dx txt
- PAINful vesicles/ulcers - 1' infxn- fever, HA, malaise, inguinal LAD - Transmission- saliva, direct contact *70% during asxs shedding* - Dx- culture, PCR, serum Ab. - Rx- acyclovir, famciclovir, valacyclovir
Name PGEs
- PGE1: Cytotec - PGE2: Prepidil
RF preE
- PMH, FMH - nulliparity, multiple gestation - pregestational DM - HTN, obesity
describe atopic dermatitis (enDOgenous) what is TOC
- POS hx of *allergy* d/o - familial predisposition, Begins in childhood - TOC: w/ low potency topical CCS
what should you measure if FSH is low or nml, especially if there is galactorrhea
- PRL - thyrotropin
BV & pregnancy--> are associated with these adverse outcomes (4)
- PROM - Preterm delivery - intraamniotic infection - Post-partum endometritis
2nd line for osteoporosis
- PTH--> stimulates blasts>>clasts, only need 18-24mos of txt but $$$ *(Tscore >4.5 or 2.5 w/ frag fx)* - Calcitonin *reduce vertebral fx pain*, inhibits clasts $$$
describe HPV screening
- Paps: sample both endo & ectocervix - 2 types smears: conventional, liquid based - consider HPV DNA testing in ASCUS & women > 30
IUDs length of time
- Paraguard: Cu 10 yrs - Mirena: Progesterone, 5 yrs - Skyla: Progesterone 3 yrs
Endometrial polyps--> peak age is ___ MC sxs is ____ Dx via ____ when is it removed?
- Peak age 50 - MC sx--> metrorrhagia - DX--> TVUS - Removal if symptomatic (bleeding) or large
homologous pairs Clitoris Labia majora Labia minora Skene's Bartholin Round ligament
- Penis - Scrotum - Penile shaft - Prostatic utricle - Cowper's - Vas deferens
PLISSIT
- Permission: ok to engage in crazy sex acts - Limited info: provide pt w/ limited info needed to fxn sexually, dispel myths - Specific suggestions: so they can engage in activity @ desired level - intensive therapy: if req to address pt sexual concerns / REFER "meet in the middle situation"
*What are some complications of ECV?* (5)
- Placental abruption (main concern) - Uterine rupture - PTL - Fetomaternal hemorrhage - Fetal demise
How can you diagnose PPROM? Describe tests
- Pooling - Nitrazine (pH indicator turns blue w/ alkalinity) - Ferning - US looking for AFI < 5 or 2x1 pocke - Amnisure - Smurf test
describe HELLP
- PreE + liver issues - hemolysis (schistocytes, inc lactate deh, elevated total bilirubin) - elevated Liver enzymes - Low platelets (see anemia, increased transaminases, thrombocytopenia) *definitive txt is delivery regardless of EGA*
What are some *fetoplacental* indications for induction? (7)
- Prolonged preggers (placenta "expires") - IUGR - Abnormal non-stress test or BPS - Rh incompatible - Premature rupture of membranes (PROM) - Chorioamnionitis
define protraction disorder (labor dystocia). define arrest d/o (labor dystocia)
- Protraction: Takes longer than it should - Arrest: failure of labor to progress
tests for fetal-maternal hemorrhage
- Qualitative: erythrocyte rosette *screen* test - Quantitative: Kleihauer Betke
EM indications after 20 wks
- ROM, vaginal bleed, regular contractions - need 24 hr phone number of L&D
admin of rhogam
- Rh moms w/ neg ab screen -
who gets rhogam
- Rh negative moms with NEG antibody screen - given anytime if trauma/ bleed procedure - @ 28wks & @ 72hr post birth if rh pos baby
describe VCC
- S/S vaginal burning, irritation, postvoiding dysyria, *odorless* thick white *"cottage cheese"* d/c *itching* - Dx--> 1. vulvovaginal erythema 2. pH *< 4.5* 3. Cx (IF recurrent s/s but NEG KOH)
hyperglycemia increases risk of
- SAB - congenital anomalies
HTN goal in pregnancy
- SBP: 140-150 - DBP: 90-100
circulation of androgens 80% bound to ___ 20% bound to ___ 1-2% are ___
- SHBG - albumin - free
EB Treatment of PMS/ PMDD-->
- SSRIs (*fluoxetine*, sertraline, peroxetine, citalopram) - anovulator agents: GnRH agonist: *Leuprolide*, Danazol
rape treatment (medical)
- STD proph: GC, chlamydia, trichomonas - HBIG/HEP B vaccine if not vaccinated - HIV proph if HR - EM contraception
RF for cervical CA:
- STDs (HPV 16,18) - low socioeconomic status - >1 sexual partner - immunosuppression - tobacco - hx of prev. cervical dz - diethylstilbestrol (DES) exposure
how are tocolytics administered
- Sequentially NOT simultaneously - Start w/ B agonist first then work down list - if nothing's working BE VERY SUSPICIOUS of chorioamniotitis
name and describe 4th generation progestin
- Spironolactone: Drospirenone (aldosterone antagonist) - has less androgenic effects: helps in PMS, breast tenderness, bloating
6 behavioral/ natural family planning/ fertility awareness based methods of BC
- Standard Days method (cyycle-beads) - ovulation method: cervical mucus - 2 day: cervical mucus - symptothermal: BBT, mucus - lactational amenorrhea - coitus interruptus
WU of delayed puberty
- Start w/ FSH/ LH level - if primary hypogonadism: elevated levels - 2ndary hypoG: low or nml levels - do algorithm for primary amenorrhea
DON"T do this if baby has meconium aspirate
- Suction: suction tip can hit the vocal cords and decrease HR significantly via vagal response - intubate during resuscitation
which OCP start requires 7 days back up BC
- Sunday and Quick start
3 methods to begin OCPs
- Sunday start: 1st sunday post menses - Quick start: whatever day - First Day start: take on 1st day of menses
signs of pregnancy
- bleeding* - presumptive: skin change (chadwick's blue cervix, line nigra, chloasma mask) - probable: uterine change (piskacek's asymetric uterus, hegar's cervix and fundus compression) - positive: heartbeat (doppler @ 9 wks, fetoscope @ 20 wks), quickening (primi @ 18-20wk, multi @ 15-17 wks)
Leiomyomata symptoms and dx:
- bleeding, mass effect, pelvic pain, asx, *infertility* - Dx- bimanual exam, *US is preferred* MRI is really good but $$$
labs done @ new OB appointment
- blood type, Rh screen, antibody screen, h&h - RPR, rubella, varicella, chlamydia, HIV (opt out), HbSAg - urine culture & protein
benefits of breast feeding
- bonding, decreased PPH, wt loss, dec Ca risk - immune protection (IgA)
what aspect of fetal head has to pass through the pelvic inlet to be considered engaged
- bony presenting part is at level of ischial spines (0 station) @ plane of least diameter/ midplane when widest part of fetal head *(BPD) is engaged in pelvic inlet*
TOC tubo-ovarian abscess
- broad spectrum IV abx - if no improvement *24-48hrs-->surgical*
describe ductus venosus
- bypass of hepatic circ of O2 blood - functionally closes w/in minutes, structurally closes w/in 3-4d - remant is ligamentum venosum
Prolapse picture--> pt might complain of what worsens prolapse? what improves it?
- c/o of fullness, urinary issues (retention w/ systole), UTI, (constipation w/ rectocele) - Worsened by *posture and duration of day* - Improved by *supine position*
how is diaphragm used? what is suggested for barrier method use?
- can be placed 6 hr prior and left 6 hr after intercourse, increased risk UTI - use spermicide with barrier methods
peritoneal folds of pelvis - name
- cardinal - broad - round - uterosacral
AUB *< 1 pad/hr* treatment-->
- cascade of COCPs, 5 pills on day 1, 4 pills on day 2, 3 day 3... x 1 week. Should have w/d bleed when stopped. May require anti-emetics
describe Gonadotropin-dependent PP-->
- caused by early maturation of HPO axis - MC: idiopathic - isosexual (pheno = geno) - usual seq of development - pubertal levels of FSH/LH - Increased FSH/LH w/ GnRH
Preinvasive phase of cervical cancer what causes it
- cervical intraepithelial neoplasia - persitent HPV infxn in t-zone results in some cells progressing towards malignant change "CIN is a spectrum"
describe cervical mucus fern test
- cervical mucus has a fern pattern when under high influence of E (ovulation) - during high progesterone (mid-luteal) phase no fern pattern occurs - can be used to test if ovulating or if amniotic seal has been broken
presumptive signs of pregnancy
- chadwick sign: bluish hue of cervix - linea nigra: darkened skin pigmentation of this line on ab - choalsma: mask of pregnancy - hyperpigmented macules mc found on face
how does age affect FHR
- changes as fetus ages --> slower rate as GA increases due to parasympathetic maturity - 20 wks: 155 - 30 wks: 144
signs of endometriosis
- chocolate cyst: tender adnexal mass - retroverted uterus - rectovaginal septum nodules - "barb" on uterosacral ligament
risks of amniotomy
- chorioamnionitis if labor is prolonged - umbilical cord compression or cord prolapse if the presenting part is not engaged.
2 parts of placenta
- chorion frondosum (fetal) - decidua basalis (maternal)
areas of chorion
- chorion laeve: is smooth chorion, devoid of villi (faces out toward uterine cavity) - chorion frondosum: villus area of chorion that projects into decidua basalis (lines the part of embryo laying on the wall), derived from cytotrophoblast, forms umbilical vessels
2 other major sxs of endometriosis
- chronic pelvic pn - pre or postmenstrual spotting - infertility (often can be only sxs)
describe KB test
- citric acid dissolve maternal Hb - Eosin stains Fetal Hb, maternal ghost cells - manual count to determine % fetal cells - % of fetal cells x 50 determines extent of hemorrhage
breast feeding
- colostrum: 1-2 days post delivery composed of protein, fat & minerals, has IgA, natural laxative *accelerates meconium*, last 3 to 6 days - breast milk: reco for 6 mo, IgG provides protection of lactobacillus, stops shigella, e coli, yeast, lysozyme protect against staph
Nabothian cysts form when? what is typical presentation & txt
- columnar cells become trapped beneath squamous cells during metaplasia. Columnar cells continue to secrete mucus resulting in discrete cyst. - Usually asx and no tx --> if pn consult for cautery or excision
Ectropion exists when ___ epithelium is ___ to the vaginal milieu by ____ of the endocervix when is it observed? what what can it increase? what is TOC
- columnar epithelium is exposed to the vaginal milieu by eversion of the endocervix - Observed during high estrogen states CAN increase vaginal secretions/ POST-coital bleed - NO TX NEEDED
describe mechanical effects of gravid uterus
- compression of IVC & iliac veins which increases in supine position & decreased reflex tachy (supine HOTNive syndrome), relieved by sleeping on side - venous compression: elevates pressure in veins that drain leg & pelvic organs exacerbates varicose veins & cause hemorrhoids & predisposition to thrombosis (DVT)
what if your patient has syphilis and is allergic to PCN
- confirm real allergy w/ test - they must undergo desensitization - PCN is only txt that effective - erythro has 11% fail rate
Low or nml FSH concentration suggests what 3 problems
- congenital gonadotropin releasing hormone - functional hypothalamic amenorrhea - other d/o of hypothalamic pituitary axis
Functional cysts define s/s dx?
- considered fxnal when *> 3cm* - sxs: pelvic pain, dull sensation, *heaviness* - Dx- bimanual exam, US is better
describe sperm descent to egg
- enter vagina... RIP most here - those that make to cervix are aided by cervical mucus enviro - 2 waves of passage to uterus: contractions of uterus propel sperm to tubes (these reach tubes fast) other sperm must fight way to tubes - capacitation once in proximity of egg: acrosome lysome to desolve into ovum corona radiata, acrosin to help penetrate zona P. - 1 sperm then absorbed by oocyte, oocyte then membrane changes & zona P & corona bc an iron vault not letting any other sperm into egg
3 ways we provide regional analgesia during labor
- epidural - spinal: DIRECTLY into spinal fluid - pudendal: perineal pn (2nd stage): consider in tears or episiotomy
describe T-zone
- epithelium @ exto/endo cervix (SCJ) - OCPs, hormones, menarche can cause ectropion
hormones on breasts
- estrogen: fat deposition, ductal growth - progesterone: alveolar (ampullary) hypertrophy, secretory maturation - progesterone: secretory effect on endometrium (lush, nutrient friendly, increased surface area) - PRL works on lobe - Oxytocin work on alveoli - estrogen on mammary duct`
describe implant
- etonogestrel, 68 mg May be started at any time in the menstrual cycle once it is determined that the woman is not pregnant. Back-up contraception is not needed if started within 5 days of onset of menstruation. If started >5 days after the onset of menstruation or at any time in a woman experiencing amenorrhea (not postpartum), back-up contraception should be used for 7 days - complete return to normal serum after removal: 7d
what does the round ligament do
- extend anteriorly from uterine tubes to labia majora - maintain anteversion
PID admit criteria (6)
- failed PO txt - compliance is questionable - pregnancy - surgical EM not r/o - tubo-ovarian abscess - severely ill.
definition of infertility? what are types
- failure of couple to conceive w/i 12 months with regular coitus w/o contraception (6 mo if > 35) Types - 1' never had a baby - 2' had at least 1 baby
types of atypical gladular cells
- favor neoplastic - adenocarcinoma in situ - adenocarcinoma
describe how embryonic development ends up male
- fertilization w XY - Gonads @ 4 wks - Week 7 genital differentiation, see testis - SRY on Y chromosome codes for TDF which codes for testosterone and mullerian inhibiting factor - MIS inhibits mullerian - wolfian ducts develop into vas deferens, epidydimis, seminal vesicles
what does US transducer show
- fetal HR based on US cardiac cycle
positive signs of pregnancy
- fetal heartbeat: fetal doppler 9-12 wks or fetoscope - quickening: 18-20 wks primiG, 15-17 wks multiG
heaviest components that make up maternal wt
- fetus - maternal fat stores
Yeast tx-->
- fluconazole 150mg PO single dose OR - topical azole (only approved tx for *prego*)
Recurrent VVC tx-->
- fluconazole Q *3 d x 3 doses* PO, 7-14d for vaginal txt AND - maintenance regimen weekly Flu x 6 months, 2x wkly cream
TOC squamous cell hyperplasia
- fluorinated topical steroid
MOI Cu IUD
- functional spermicide - decreases sperm motility & ability to fertilize - inflammatory endometrial changes
3 pathogenesis of ovarian masses
- functional: follicular, lutein, PC sclerotic ovaries - inflammatory: neisserian, pyogenic, or granulomatous oophoritis - metaplastic: edometriosis, malignancy
benign probs of ovaries
- fxnal cysts - benign masses
causes of premature menopause
- genetic (turner's) - AI d/o - Iatrogenic: surg (BSO), chemo, radiation
factors that determine time of onset of puberty
- genetics - nutritional state - latitude, altitude, urban/ rural
US testing of pregnancy
- gestational sac @ 5 wks via transvaginal US - fetal pole @ 6 wks - fetal heart beat: 6 wks
Provider job in sexual assault case
- get SANE if available - Rape Kit - Consent for exam - Chaperone - we do NOT need law enforcement in Exam, only need to notify
What is the goal of treatment for EP? how do we determine if we have met treatment goal for EP?
- goal: Destruction of all trophoblastic tissue - do serial hCGs after EP txt (MTX specifically)
Workup of endometrial CA--> what is gold standard
- gold standard: EMB Premenopausal--> endometrial bx Postmenopausal--> initial test is TVUS
Stromal neoplasms types & what it hormone it affects
- granulosa-Theca cell: estrogen production - Sertoli-Leydig cell: testosterone production - Ovarian fibroma: no hormones
how is reproductive hx documented
- gravida (pregnancies) - para (births)
etiologies of prolapse
- gravity: erect, bipedal posture - congenital/ develop - prego, L&D via vag - inc intra-ab pressure - atrophy - iatrogenic - white >>> - inc parity - obesity
4 pelvic shapes and which are best for delivery?
- gynecoid: most favorable - anthroid: favorable for delivery - android: frontal plane > transverse plane, ichial TUBS prominent - platypelloid: transverse plane > frontal plane, sacral & coccyx more prominent
Who should be considered for surgery w/ AUB?
- has UL organic cause (polyps, fibroids, tumor) - failed medical therapy - completed childbearing desires--> endometrial ablation or hysterectomy.
describe testing for pregnancy
- hcG < 5 = negative, hcg > 25 = positive, inbtwn repeat in 2 days - US: sac @ 5 wks, fetal pole @ 6 wks, heartbeat @ 6 wks
describe cervical mucus
- high estrogen @ ovulation causes - increased quantity, more alkaline, decreased viscosity (spinnbarkheit) and ferning P makes cervical mucus thick and cellular
low vs high titers of HCG - what can this tell us
- high titers in non-pregnant woman: hCG producing tumor (hydatidiform mole) or carcinoma - low: usually ectopic or threatened abortion - use normal hCG patterns during pregnancy to track fetal development/ irregularities, track/eval 1st trimester bleeding
efficacy of birth control Highly Very
- highly < 3% failure: Implants, IUD, injectable - very 3-10% failure: pills, patch, rings - > 10%: barrier, behavioral
choriocarcinoma characteristics-->
- highly anaplastic - NO chorionic villi - *Necrosis and hemorrhage* - Rapidly INVASIVE. *Hematogenous METs to vagina and lungs (MC), CNS, GI/liver, kidny TX- chemotherapy.
what is management of PTL if EGA < 34 wks
- hospitalize initially, *hydrate* - betamethasone (lungs) - GBS proph (only if indicated) - tocolytic for 48 hr - abx if POS culture - *Mg Sulfate if 24-32 wks*
describe HCG
- human *chorionic* gonadotropin - secreted by (synctio)trophoblast, maintains pregnancy by stimulating release of progesterone - 2 subunits: a & b, a is shared by LH & TSH, b is specific which is why we test bHCG - hCG rise 8 days after ovulation in preggo person, detectable @ 7-10 post fert, peaks @ days 60-90 - first 6-8 days hCG maintains CL, which continues to secrete P until placenta can take over progesterone secretion
a hx of what strongly suggests regular ovulation
- hx of reg menstrual cycles
*absolute CIs to COCPs*
- hx thromboembolic dz, stroke or ischemic HD - undx genital bleeding - active hepatic dz - *hx of E dependent tumor* - *> 35 yo who smoke > 15 cigs/ d* - pregnancy
6 *absolute* contraindications of COCPS
- hx thromboembolitic dz, stroke or ischemic hd - undx genital bleeding - active hepatic dz - hx of estrogen dependent tumor - >35 who smoke >15 cig/day - preggo
assessed in routine OB visits
- hx: bleed, pre ecclampsia, fetal mov't - fundal ht, maternal wt, BP, fetal heart ausc, edema, fetal mov't counts - after 36 wks: assess fetal presentation (Leopalds maneuvers)
common fetal anomalies (anatomical)
- hydrocephalus - spina bifida - other structural anomalies
HAIR-AN-subgroup of PCOS what will you see - TRIAD...
- hyperandrogenism - *insulin resistance* - acanthuses nigricans *TRIAD*
s/s only seen ONLY with complete mole, NOT seen with parital mole
- hyperemesis - hyperthyroid - trophoblastic emboli - theca lutien cyst
severe PCOS
- hyperthecosis
when must you manually remove placenta
- if > 30 mins after birth of baby
Severe cervical stenosis causes these complications
- impeded menstrual flow (uterine distention) - impeded access for dx/tx - inc risk of cervical related dystocia - inc risk of infxn d/t retained products
3 most reliable forms of contraception
- implant - iud - dmpa
admin of bisphosphonates
- in AM w/ water ONLY - remain upright for 30 min
Intertrigo--> where does it occur what does it cause how is it dx
- in skin folds - maceration 2' to friction--> yeast infxn - Dx: clinical, diff from erythrasma
capitation can occur when/ where
- in-vivo: after ejaculation (when in close proximity to egg) - in-vitro: in culture media
renal changes in pregnancy
- increased CrCl, blood flow, GFR - collecting system dilates: due to mechanical obstruction, P relax smooth muscles, higher risk of UTI - homeostatic for Na & K, dumping of bicarb,
describe endocrine control of lactation
- increased E acts as inhibitory, like dopamine - PRL is higher during pregnancy but bc of E no milk is made, E&P upregulate recptors in breast - once birth, placenta is gone so decreased E now PRL is uninhibited = milk production - suckling produces oxytocin causing milk ejection
what contributes to diabetogenic state seen in pregnancy (4)
- increased insulin resistance due to placental horomones - increased maternal adipose depo (decreases insulin efficency) - decreased exercise - increased caloric intake (hyperBG)
Why do we want to avoid C-section in chorioamniotis
- increased risk maternal bactermia, infxn
what do germ cell ovarian neoplasms increase the risk of
- increased risk of torsion
what happens to mons pubis during puberty? menopause
- increased size during puberty - descreases in size menopause
absence or decreased sperm when--> (6)
- increased temperature - medications - infection (mumps) - varicocele - hypogandotropic-hypogonadism - smoking
components of urogenital diaphragm
- inferior fascia - sacrotuberous ligament - ischiorectal fossa
how do OCPs work
- inhibit LH surge - thicken cervical mucus - limits proliferation of endometrium (bc P dominant) - alters normal tubal motility
OB appointments
- initial @ 12 wks - monthly appt from 12-28 wks - q 2 wks from 28-36 wks - weekly > 36 wks
describe zygotes travel into uterine cavity
- initial fertilization in ampulla - 3 day transit to isthmus, endometrial cavity - hangs out for 2-3d to continue development before implanting
When do we suspect domestic violence?
- injury to torso, face or genitals - defensive injuries - injuries are bilateral, unexplained or inconsistent w/ hx - delay to ER or multiple ER visits - psychological symptoms - partner reluctant to leave the room.
how to measure diagonal conjugate
- insert 2 fingers into vaginal until reach sacral promontory - distance of sacral promontory to ext portion of symphysis is diagonal conjugate
PCOS is associated with? Txt
- insulin resistance - Metformin
describe ovarian cycle (development of follicle)
- primordial follicle: 1 oocyte surrounded by granulosa cells - primary follicle: follicular cells bc cubodial, zona pellucida forms - 2ndary follicle: atrum develops, theca apparent - (mature) Graafian follicle: single, large atrum
pros/ cons of IUDs
- pro: high efficacy, decreased menstrual bleeding (mirena), low user req's - con: uterine perforation, pelvic infxn (20d after insertion), must be inserted by physician, expulsion
prolapse
- procidentia is uterus into vagina (prolapse) - exacerbated by posture/ time of day, relieved by supine, *retention w/ cystocele* - *txt: estrogen if post-M & signs of atrophy, Kegel's, pessaries, surgery*
txts that do NOT work for PMS s/s
- progestin only OCP - conventional use OCPs - primrose, gingko - fatty acids - TCAs, Li
What are some *maternal* indications for labor *augmentation*? (3)
- prolonged latent or active phase - abnml labor (inadequate contrax strength)
benefits of using steroids from 24-34 wks EGA
- promote lung maturity - decreases incidence of necrotizing enterocolitis, RDS & intraventricular hemorrhage
What is expectant management in PPROM
- proph abx - steroids if lung immaturity OR < 34 wks - 48 hr tocolytics - surveillance of mom for infxn, fetus for demise
function of Nitabuch's layer
- prvents vili from going any further into endometrium (fibrinoid degeneration in decade basalis) - prevents placental invasion in uterus
describe Gonadotropin-independent PP-->
- pseudo or peripheral PP - cause: excess secretion of sex steroids - FSH/LH suppressed and don't respond to GnRH
decreased amniotic fluid during midpregnacy
- pulmonary hypoplasia @ birth
Neonatal respiratory distress syndrome
- pulmonary immaturity leading to poor oxygenation and ventilation - Sx/Si: grunting, flaring, retractions, hypoxia - due to lack of surfactant to decrease surface tension - TOC: surfactant
tests for maternal fetal hemorrhage
- qualitative: rosette - maternal serum ix w/ IgM to bind Rh+ cells - if rosette pos then do Kleihauer Betke test: citric acid dissolves maternal Hgb, manual count of fetal cells
How can you assess the baby viability following minor trauma?
- r/o abruption by *monitoring x 4-6 hours* - Assess membrane integrity, fetal mov't, viability of pregnancy - Kleihaur-Betke for fetomaternal hemorrhage - K-B, Rho-gam (proph)
what happens to LH/ FSH when you give a continuous infusion of GnRH
- rapid & reversible suppression of LH/ FSH
what do we do for PTL that ceases if EGA > 34 wks
- recommend abstinence, no PT/ work - *weekly f/u* - if it ceases send HOME if: no need for hospitalization, bedrest, maintenance tocolysis, or repeat steroids
what does compensated resp alk with chronic losses of bicarb predispose pregnant women to
- reduces renal buffering capacity - predispose to severe metabolic acidosis (esp if infxn)
what is plausible explanation for onset of pubertal changes
- reduction in GnRH sensitivity to estrogen levels
Excitement details: it is a reflex of ____ modulated by ____ enhanced by ___ which causes MCC of loss of arousal is
- reflex T11-L2, S2-S4 - Modulated by parasympathetics - *enhanced by estrogen--> genital effect (labial fullness, clitoral enlargement)* - Lack of estrogen is *MCC*
Orgasmic phase details: is a reflex of ____ modulated by ____ optimized by ____ how does masturbation affect it?
- reflex of T11-L2, S3-S4 - modulated by *sympathetics* - optimized by clitoral input (afferent concentration) - Masturbation leads to increased rate/intensity
monitoring for osteoporosis
- repeat DEXA Q 2 years OR - Bone metabolism markers @ 6 mos (serum CTX or urinary NTX)
who is suggested for surgical ablation or excision in endometriosis
- req txt for pt w/ infertility
describe respiratory changes during pregnancy
- rising uterus elevates position of diaphragm, cause less negative intrathoracicpressure, decreased FRC but no change in VC - total body O2 consumption increase 20% in pregnancyQ - rise in tidal volume --> hyperventilation - Co2 falls, rise in minute ventilation, rate stable, respiratory alkalosis, bicarb is excreted
risk of cystic fibrosis patient in pregnancy
- risk IUGR/ PTL&D
Tubo-ovarian abscess what happens if rupture? how is it dx?
- rupture: peritonitis, sepsis - Distinguished from endomtritis/salpingitis by presence of *tender inflammatory adnexal mass by US, CT, MRI, or laparscopy*
Pubic lice: s/s TOC
- s/s: Pruritis, excoriation, LAD. - Tx: permethrin, pyrethrins, lindane (not infant or preggo) - wash household linen and tx household contacts.
Scabies: s/s dx TOC
- s/s: pruritus, dermatitis, intertriginous, glans - dx: oil scrape - Same as lice, also add ivermectin: txt must be left on 10 hrs
s/s atrophic vaginitis how is it dx TOC for atrophic vaginitis
- s/s: vulvar irriation, clear, yellow or blood tinged d/c, urinary s/s. - Dx--> 1. friable vaginal epithelium 2. loss of rugae, 3. pale, PAP smear changes - Tx--> topical estrogen in cream, suppository or ring; PO estrogen, treat any concommitent infection.
2 indications for DEXA scan
- screening - monitor of therapy
continuous ocp drugs
- seasonale - seasonique - lybrel or skip placebo with regular ocp rx
describe corpus luteum
- secretes E&P after ovulation
what in hirsuitism labs would suggest NEOPLASTIC cause
- serum total Test: >150 (ovarian ca possible) - DHEA-S > 700 (adrenal tumor) - rapid onset sxs, virilization
What is the second stage of labor?
Complete (10 cm) dilation to delivery of the baby (parturition) "time to push"
describe placental development
- trophoblastic cells invade decidua basalis - this trophoblastic layer now called syncytiotrophoblast - part of trophoblast layer facing toward embryonic mesenchyme now called cytotrophoblast - day 9: lacunae appear w/in syncytioT, maternal blood then fills lacunae - day 12: primary villi form - membrane of embryonic mesenchyme (chorion) pushes out into syncytioT forming 2ndary villi - day 15: maternal venous sinuses tapped - day 17: both fetal & maternal blood vessels fxn, placental circ established - cytotrophoblastic shell forms - end of 3rd mo: amnion & chorion come in close contact - 16-18wks: chorion laeve contacts & fuse w/ decidua vera, obliterate uterine cavity
overview of incontinence txt
- txt transient cause - scheduled voids - kegels (3-4x/wk for 15 wks) - meds - surgery
tx of benign neoplasms is based on--> (3) types of surgical txt for benign neoplasms
- type of neoplasm - age of pt (prepubertal /peri vs postM) - desire for reproduction TYPES of surgical tx--> cystectomy, unilateral salpingo-oophorectomy, TAH/BSO if suspicion of malignancy
maternal blood tests
- typing: ABO/ Rh - antibody screen: indirect Coombs
Indications for D&C (6)
- unable to tolerate EMB - benign EMB w/ continued AUB - non-dx EMB in high risk pt - insufficient tissue on EMB - severe cervical stenosis - if laparoscopy also required.
Factors that play a role in unintended pregnancy
- underutilization of contraception (edu, lack access, barrier to product) - poor compliance (SE, inconvenience) - choice not to use
Tocolytics are used when? What do they do? what other things to we do when giving tocolytics
- up to 48 hours, not used if > 34 wks EGA or < 20wks - Delays contrax, doesn't stop --> allows us to assess for bad outcome & give steroids if needed (buys time) - O2, LLD position
urge incontinence
- urgency, large *vol loss* - etiology: detrusor instability (uninhibited contraction), no impairment of strength - precipitant "hear water"
how does symptothermal method work
- use BBT + cervical mucus eval + calendar method abstinence for 12-17d/mo
when can epidural be used during c section
- usually if scheduled: can do combine epidural + spinal
pregnancy termination
- usually prior to 13 weeks, MC via D&C or meds - D&E < 16wks, IOL if > 16wks
what is done to help delivery of placenta and facilitate uterine contractions to close down blood vessels
- uterine massage - 20 U oxytocin given after baby birth
EM indications for L&D after 20 wks
- vaginal bleeding - contractions q 3-5 min - rupture of membranes
late findings in cervical ca
- vaginal d/c, pelvic pn - *leg swelling* - urinary sxs
how to differentiate rectocele from enterocele
- vaginorectal exam
methods of sterilization
- vasectomy - BTL: post partum or interval - transcervical tubal occlusion (Essure)
What is the consequence of estrogen loss?
- vasomotor sxs/ mood sxs - vulvovaginal atrophy - osteoporosis - increased risk of CAD/CVA - increased risk of colon CA.
Hypertirchosis (non-sexual hair) what is hypertrichosis NOT due to?
- vellus (fine and short hair) - Lanugo (fine and long hair) - Normal genetic variant NOT DUE TO ANDROGENS
urogenital diaphragm function
- vesicourethral control, attachment of erectile body of clitoris contains ext genitalia and urethral orificeu
2 elongate masses of erectile tissue, deep to labia on both sides
- vestibule bulb
indications for HRT/ ERT in menopause
- vulvovaginal atrophy - vasomotor sxs - osteoporosis w/ vasomotor sxs (due to VM sxs not OP)
patient with congenital gnrh def will present how?
- w/ anosmia - low FSH
when does puberty typically occur? how is it measures
- w/in 3 yr period: breast buds, pubarche (axilla then pubis), vert growth, menarche - measured by tanner stage
TOC delayed puberty
- watchful waiting +/- gonadal steroids
Potential treatment for endometriosis-->
- watchful waiting - NSAIDS - cyclic hormones (P, OCP) - Danazol (inhibits FSH/LH) - GnRH agonist (pseudomenopause), - surgical ablation or excision.
what is pipelle method
- way to perform EMB 1. minimal to no dilation req 2. little to know ans req 3. way mo cheaper than D&C
what is done for sensitized rh neg moms
- weekly titers - 18-28 wks: US Of MCA - possible intrauterine transfusion if fetal hct < 30%
what happens if you stop premarin & provera
- withdrawl bleed
who is endometriosis common in?
- women in 30s - typically: nulliparous, infertile
Erythrasma (corynebacterium) appearance TOC
- woodslamp--> coral red *kissing lesion* - TOC: *Erythro* x 14d if widespread - if Localized topical Clindamycin AAA x 1 week
what is working dx for vulvar dz what must you do
- working dx: Cancer - always bx suspicious lesions
describe implantation
- zona P sheds, blastocyst adheres to endometrium - amniotic cavity forms inbtwn embryonic disk & trophoblast - under P, endometrium cell enlarge & thickens, now known as decidua. basalis is area right underneath site implantation - decidua capsularis overlies developing ovum, separates from rest of uterine cavity
overview of embryonic stages
- zygote: fertilization restores diploid #, 46n, sex is determined - cleavage: rapid mitotic division, 16 cell stage - morula: outer cells secrete fluid which form blastocyst cavity - blastocyst: zona P disappears, 2 layers: outer layer called trophoblast, inner layer is embryonic disk
why no methimazole in 1st trimester
- ↑risk TE fistula, scalp defects
What is cervical effacement? Describe cervical changes seen in labor
-*Progressive thinning of cervix* - cervix fans out (thins), and retracts upward into lower uterine segment - initial cervical plug gets dislodged "bloody show"
SEQUELLAE OF PID
-->*infertility, ectopic pregnancy, preterm birth
what is domestic violence prevalance what about sexual assault
-50% in ED sample (lifetime) - 41% all women, 75% know victim
21-24 YO w/ ASCUS or LSIL-->
1. repeat cytology @ 12 months preferred or 2. reflex HPV testing (ASCUS only) IF HPV positive then repeat cytology in 12 months. IF ASC-H, AGC, HSIL then colpo, all others get repeat cytology. IF negative routine is resumed, if ASC then colpo at this point.
Preterm labor is defined as....
<37wks EGA Uterine contractions (4/20 or 8/60) *AND* Cervical change, or 80% effaced, or 2+ cm dilated (+/- ROM)
describe flexion
-change of the presenting diameter from the occipitofrontal to the smaller suboccipitobregmatic (chin to chest)
At what station is the head engaged?
0
at what station is when fetal vertex at *ischial spines*:
0
What is the latent phase of the first stage of labor?
0-4/5 cm dilated
what is the dose for methergien:
0.2 mg IM
Dose for Methergine
0.2mg IM
What are the abnormal results for OGTT at 24-28 weeks for GDM? 1 hour: 2 hour:
1 hour: ≥180 2 hour: ≥153 (if they do FPG: ≥ 92)
Delayed puberty w/ elevated FSH/LH-->
1' hypogonadism
Degrees of stress incontinence
1- only w/ severe stress (jump, sneeze, cough) 2- mild stress, jog & pee your pants, *stairs, rapid mov't* 3- mild stress, *stand* and pee your pants
UCSD criteria for dx of PMDD-->
1. self report of at least one somatic and affective symptom during the 5d prior to menses in each of the three menstrual cycles. 2. Relief of sxs w/i 4d of the onset of menses, w/o recurrence until at least cycle day 12 3. no other cause 4. *Identifiable dysfunction in social or economic performance*
*Women who should undergo evaluation for endometrial hyperplasia or endometrial cancer* --> these women get BX (7) *WORTHY SLIDE*
1. > 40 YO w/ AUB 2. < 40 YO w/ AUB + risk factors (chronic anovulation, obesity, tamoxifen, DM, famhx of endometrial/ovarian/colon CA) 3. fail to respond to tx of AUB 4. women w/ uterus in situ receiving unopposed estrogen replacement 5. presence of atypical glandular cells 6. presence of endoM cells on cervical cytology in a women > 40 YO 7. women w/ hereditary nonpolyposis colorectal CA.
What is the most common non-obstetric indication for surgery? What is the second most frequent non-obstetric indication for surgery?
1. Appendicitis 2. Cholecystitis
describe fetal circulation
1. Blood from placenta enters umbilical vein 2. Enters liver --> fetal shortcut is *Ductus Venosus* 3. DV enters IVC (oxy blood mix w deoxy blood) enter R atrium 4. In R atrium some blood go to R vent/ pulm circ, most take shortcut to L atrium via *foramen ovale* 5. FO to L vent to aorta 6. blood from pulmonary artery goes into aorta via *ductus arterious* due to high SVR from fetal lungs 7. Aorta to iliac arteries to umbilical arteries to placenta
phases of menstrual cycle
1. Follicular: begin 1st day menstruation, ends w/ LH surge 2. Luteal: starts on *LH surge*, ends w/ 1st day of menses (14 days)
How do you diagnose PTL?
1. Initial assess: digital cervical exam: note effacement/ dilation 2. Cervical length: done via US 3. Fibronectin: measured when cervical length 20-30mm
2 mc types of BC methods used by women
1. OCP 2. condoms
requirements of lactational amenorrhea
1. She is less than six months postpartum 2. She is breastfeeding exclusively (ie, not providing food or other liquid to the infant) 3. She is amenorrheic
Stages of Reproductive Aging Workshop (STRAW)
1. Transition: stage -2, -1 2. Menopause: 12 mo amen. after FMP 3. Post menopause: stage +1, +2
4 causes of preterm labor U AIM
1. Uterine overdistention (stretch): polyhydro, twins 2. Anatomy abnml-bicornate, didelphys, cervical incompetence/ shortening, previa, abruption, fetal anomalies 3. *Infection MC*-UTI, BV, cervix. 4. Medical problems-trauma, preeclampsia, HTN
3 MC fx seen in osteoporosis
1. Vertebrae 2. hip 3. distal radius
Types of gestational trophoblastic disease:
1. benign hydatiform mole (noninvasive) 2. persistent/invasive gestational neoplasia 3. Choriocarcinoma: HIGHLY malignant, highly CURABLE
best approach to evaluation of primary amenorrhea (3)
1. by focusing on presence or absence of breast development --> marker of estrogen action & ovarian fxn 2. presence or absence of uterus via US 3. FSH level
5 main changes that occur to fetus after birth
1. elimination of placental circ - interruption & obliteration of umbilical vessels 2. closure of ductus venosus 3. closure of foramen ovale 4. gradual constriction & eventual obliteration of ductus arteriosus 5. dilation of pulmonary vessels & establisment of pulm circulation
in IUGR why hasn't fetus reached its growth potential
1. environmental factors or 2. genetic factors
2 indications for high risk HPV DNA test
1. follow-up for atypical squamous cells of undetermined significance to determine if need for colpo 2. *ALL WOMEN > 30* in addition to PAP
Signs of onset of 3rd stage of labor (4)
1. fresh show of blood from vagina 2. umbilical cord lengths outside of vagina 3. fundus of uterus rises up 4. uterus becomes firm and globular
dx of PCOS requires?
1. hyperandrogenism 2. chronic oligo/anovulation 3. r/o other dx
2 d/o of libido/ desire
1. hypoactivity: MC 2. Aversion: think prior sexual trauma
PPROM.... 1. Baby > 34 wks but lungs are immature - course of action 2. Baby < 34 wks but lung are Mature - course of action
1. if > 34 but lungs immature, try to hold out for delivery @ 36 wks 1. if < 34 but lungs mature, try to hold out for delivery @ 34 wks *34 wks is cut off for delivery llung maturity decides if you hold out longer*
Idiopathic hirsutism--> what is req for dx
1. normal serum androgens 2. NO menstrual irregularity 3. no identifiable cause of hirsutism pathogenesis: inc activity of 5-a reductase, mild PCOS
To detect anatomical problems that may be contributing to anovulation/ infertility 1. order 2. looking for
1. order: US, HSG, hyseroscope, laparoscope 2. looking for: congenital or anatomic deformity, scarred tubes (2' PID or endometriosis), endometriosis, leiomyomata
COCPs decrease risk of which 4 cancers
1. ovarian 2. colon 3. endometrial 4. rectal & colon *CORE*
abnml OGTT
1hr > 180 or 2hr > 153 f/u 6-12 wks post partum
naegels rule
1st day of LMP + 7d + 9mo = Estimated Date of Delivery
Transdermal advantages
1.Therapeutic effect achieved at lower peak dose since 1st pass metabolism avoided 2.Plasma hormone levels remain constant—no peaks, troughs 3.Sustained delivery= increased compliance 4.Good for non-swallowers 5.Drug stops immediately when removed
when is fertility halved
1/2 if btw 37-45 YO
what is the dose for pitocin:
10 U IM or 10-20 U/L @ 100cc/hr
return to fertility DMPA
10 mo
what age range does menarche take place:
10.5-16
expected hcg concentration on the day of expected menses
100 iu/L
what is tx for variable deceleration:
100% O2 Elevate presenting part or assume Trendelenburg LLD position Stop pit if in use Try amnioinfusion
What is the normal fetal HR range (baseline)?
110-160 (tachy > 160, brady < 110)
At what point would you stop Mag Sulfate administration?
12 hours past the last contraction, or till steroids are administered
normal fetal heart tone range
120-160
what is considered prolonged latent:
14-20 hr, mutip, and nullip
how many veins and arteries in umbilical cord:
1:2
What is a severe variable deceleration?
60 x 60 (BPM 60 x Decel > 60 seconds) decel last 60 sec, pulse is 60 --> BAD, don't sit on this
how long does it take to change spermatids into mobile spermatozoa:
64 days
spermatogenesis timeline
74 days total, together w transportation about 3 mo - 64 days for spermatids to spermatozoa
pregnancies >24 wks have what testing done for diabetes:
75g 2hr OGTT
If things look good at ___ weeks, over the next 20 weeks the fetal loss rate is only about 3%.
8 weeks
what age range does thelarche take place:
8-15
what embryology wk does a Undifferentiated embryo begins to respond to gene effects of Y chromosome
8-9 wks
pubarche mean onset
8.8/ 10.5 yo
Dose for Cytotec/Misoprostol
800-1000 PR
what is dose for misoprostol:
800-1000 mcg PR
what is tx of TB:
9 mo of INH and rifampin INH prophylaxis of infant
what age range does adrenarche (pubic) and (axillary):
9-15 : 11.5-14.5
Hemodynamically stable but *> 1 pad/hr* AUB treatment-->
: DOC: Premarin until bleeding subsides then add Provera daily for last 10d of cycle
when should gestational HTN subside
< 12 wks post partum - if it doesn't now *chronic HTN* (majority BP normalizes in 1st wk PP)
BMI guide to wt gain during pregnancy
< 18.5 : 28-40lbs 18.5-24.9 : 25-35 lbs 25-29.9 : 15-25 >30 : 11-20
low birth weight
< 2.5 kg
hx signs of AUB-->
< 3 hours btw pad/tampons >21 pads/tampons per cycle change during the night clots > 1 inch in diameter possibly anemic
which BC methods have highest efficacy
< 3% fail - Implant - Injectable (depo) - IUD
what is considered prolonged active:
<1.5-1.2 cm/hr
When do the majority of spontaneous abortions occur?
<12 weeks
if there is a delay in the 2nd/3rd week when using transdermal, what do you do:
<2 days—no back up needed >2 days—back up for 1 week
Define adolescent delivery
<20 at delivery date
when is the risk high for the child to get infected with varicella:
<20 wks gestation w/in 1 wk of delivery (5 days prior-2 days after)
if a patch becomes detached when using transdermal, what do you do:
<24 hrs—replace same patch—no BU >24 hrs—new patch, new day, BU X 1 wk
fill in the blank: ___ Controlled studies show risk of fetal harm is remote ___ No evidence of fetal risk ___ No controlled studies in humans or animals ___ Positive evidence of fetal risk ___ Clear evidence of fetal risk outweigh any possible benefit
A B C D X
What is the basic premise of the labor velocity curves?
A nulliparous female will have a longer latent and active phase of labor than a multiparous female. The labor velocity curves are rough estimates of what to expect. - curve difference begins in active phase, this when multiP women dilate faster They are used with singleton mothers, not multiple gestators.
About how long does it take from dx of chorioamnionitis to delivery?
About 3-5 hours
ruptured uterus is likely associated with...
A previous uterine scar/ surgery (think vertical C section)
A non-stress test is characterized by administration of glucose or wiggling the fetus and assessing accelerations. What is a positive non-stress test?
A rise of 15 bpm for at least 15 seconds, twice in 20 minutes - "reactive = healthy" This gives you 2 points in the BPS
what are some CI meds:
ACEI, high dose ASA, accutane, Tetracyclines, sulfonamides-late preg, Coumadin
which BPS assessment is a chronic marker
AFI
polyhydramnios
AFI > - decreased elimination (swallow): esophageal atresia or tracheo esophageal fistula - increased production: high cardiac output (fetal hydrops, fetal anemia, tw tw transfusion, spinal covering anomalies - Lead to premature labor, maternal discomfort, cord prolapse, fetal malpresentation
What are some non-reassuring patterns of fetal heart patterns? (5)
AMV (absent or minimal variability) 0-5bpm (e.g. fetal HR is 110 but never moves, loss of beat 2 beat variability) AMV + Late decelerations AMV + Recurrent variable decelerations sustained bradycardia + AMV *Bradycardia < 100*
CF is what type of inheritance?
AR
If the baby is "ballottable" he is probably not engaged, right? So what would be contraindicated?
AROM/amniotomy This would allow the cord to prolapse and squeeze into the canal, cutting off blood supply to baby
what meds must you AVOID in overflow/ incomplete bladder emptying pts
AVOID CCB and a-adernergic agonists
What are some S/S of EP?
Ab pn, amenorrhea, vaginal bleed Ab TTP Adnexa TTP Adnexa mass *shoulder pn or defecatory urge*
What are some risks of general anesthesia?
Airway compromise Uterine atony from halogenated gases
What LFT increases naturally during pregnancy?
Alk phos-due to fetal skeleton
what are the emergency indications for L&D >20wks:
All patients should be provided a 24 hour phone number Regular contractions q 3-5 minutes, rupture of membranes or vaginal bleeding
What is a 3rd degree laceration?
Anal sphincter A laceration involving the anal sphincter
PCOS treatment
Anovulation - fertility drugs - COCP to reduce unopposed estrogen - cyclic progestins if CI to estrogens Hirsutism - Insulin resistance: wt loss, DM screen, metformin - HLP: lipids screen, statin
what is the test where Maternal plasma mixed with known Rh+ RBCs Agglutination is positive test (dilution = titers)
Anti-Rh Ab titers (indirect Coombs test)
What is a high risk pregnancy?
Any pregnancy that is not routine
what is an indicator in primary amenorrhea that the ovaries are working
Are there BREASTS? if there are, then ovaries are functioning
Which of the placenta abruptions will most likely lead to a dead baby?
Complete and concealed
What maneuver increases the likelihood of humeral fracture?
Barnums/ removal of posterior arm
post-menopausal AUB think
BAD -- malignant until proven otherwise
again BV turns nitrazine litmus paper....
BLUE :PH > 4.5
what are the IOM guidelines for wt.gain vs. BMI:
BMI <18.5------28-40 lbs BMI 25-29.9---15-25 lbs BMI >30--------11-20 lbs
what are some things that decrease efficacy of emergency contraception:
BMI >30, if the pt is ovulating, if pt cont. intercourse after taking emergency contraception
How do you diagnose chronic HTN in pregnancy?
BP >140/90 before 20 weeks or BP >140/90 lasting > 12 weeks post delivery
what do you measure during 3rd tri for U/S dating:
BPD + femur length accurate +/- 3 wks
S/S of abruption
Bleed Contract Uterus tender and irritable fetal heart rate (*tachy, late decels, demise*)
False positives of fern test
Blood decreases yield saline, cervical mucus cause false positives
How is MTX dosed?
Body surface area (50mg/sq m)
PTU (1st tri) or methimazole (blocks T3T4, 2nd, 3rd tri) are the meds for hyperthyroid dz during pregnancy. can they both cross the placenta? and if so, what's the SEs?
Both cross placenta Fetal hypothyroid/goiter Brow/face presentation/cephalopelvic dysproportion/LTCS
These contractions are irregular, may or may not cause cervical change, usually are painless, and appear in the last 4 weeks of pregnancy.
Braxton-Hicks
When would you give sedatives?
Braxton-Hicks false labor
What are the radical maneuvers associated with shoulder dystocia?
Breaking clavicles Zavanelli (push head back in and hold it flexed) & C-Section combo Symphysiotomy
OCPs show NO increased risk of which cancer
Breast
What should you get before inducing a patient with chorioamnionitis?
Cultures
Why would you put a preggers under general anesthesia?
C section urgency Contraindication to regional (lumbar, spinal, pudendal) Failure of regional
What would you do if your active labor patient was having adequate contractions (>200 mvus) for 5 hours?
C section. The cutoff for active labor with adequate contractions is 4 hours.
name the d/o from the ethnic groups: North American Caucasians, offered to ALL women in the US
CF 1/25
what does the anemia (from sensitization of RBCs) in a fetus cause to happen:
CHF (hydrops fetalis)
*CI to bisphosphonates* Complications of BPs
CIs 1. eso dysmotility 2. inability to be upright x 30 min 3. hypersensitivity 4. hypoCa Comps: *erosive esophagitis, jaw osteonecrosis*
TOC adenomysosis
CLASSIC treatement --> hysterectomy Can buy time w/ medical therapies (GnRH agonists, danazol, progestins)
MC congenital viral infxn.
CMV
What is the most common cause of dystocia and subsequent C-section?
CPD (cephalopelvic disproportion [nugget wont fit])
done at 10-12 wks <1% pregnancy loss Earlier diagnosis/quicker results once performed Less precise than amnio secondary to mosaicism Cannot give amniotic fluid AFP levels=no info about NTD If done <9 wks=jaw/limb abnormalities
CVS
Prevention of osteoporosis?
Calcium 1000-1500 Vitamin D 800 Wt. bearing exercise 20-30m, 3x/wk *AVOID ETOH and TOB*
*What medication is given to reverse Mag Sulfate toxicity?*
Calcium gluconate
What can we do when the baby aspirates meconium?
Call pediatrics stat Amnioinfusion to dilute uterus (saline)
what would you counsel a pregnant pt on travel:
Can safely travel up to 37 weeks pressurized commercial airplane presents no problems High altitudes (>8K ft) can cause problems in complicated pregnancies Car travel should include correct seatbelt wear Biggest risk DVT Max 6 hrs/day driving, stop q 2 hrs, walk for 10 minutes Carry copy of medical records
*Infants born at 23-27 weeks are 80x more likely to suffer from...*
Cerebral palsy
What is characterized by painless 2nd trimester dilation > 4 cm?
Cervical incompetence
what leads to false +'s on pH paper:
Cervical mucus, urine, and blood Also soap and semen
Urge incontinence-->
Characteristics - urinary urgency, lg vol of loss Cause - detrusor instability (uninhibited/ invol contrxn) - NO impairment of detrusor contractile strength.
How do you confirm prolonged active labor?
Check out that cervix. It has to be *at least 6 cm dilated*
MCC of PID (4)
Chlamydia Neissiria bacterial vaginosis genital mycoplasmas.
Tx of ICOP
Cholestyramine (bile acid sequestor) and anti histamine
Antenatal steroids administered at 24-32 weeks decrease RDS, NEC, and intraventricular hemorrhage. What is a contraindication for administration?
Chorioamnionitis --> induce if chorioamniotitis
What is the cause of the vast majority (50%) of spontaneous abortions?
Chromosomal abnormalities, most linked with maternal age
What are the hypertensive disorders
Chronic HTN Gestational HTN Preeclamps/ Eclamps HELLP
What ABX can be given for chorioamnionitis C-Section?
Clindamycin
What is the best diagnostic tool for DVT?
Compressing ultrasound/ doppler
What is the sequence of PPROM assessment?
Confirm rupture Confirm EGA Assess maternal & fetal well-being via tracings
what are some causes of early decelerations of FHR:
Consistent with UC (nadir of FHR = peak of contraction) Vagal response to cephalic pressure Normal finding! Not related to fetal distress
What test is performed when a non-stress test is negative?
Contraction stress test
how does copper prevent pregnancy:
Copper ions decrease sperm motility and ability to fertilize Inflammatory changes in endometrium spermicidal
Small baby and lots of amniotic fluid in PROM or PPROM can lead to....
Cord prolapse Abrupted placenta
What anticoagulant crosses the placenta and causes big problems? what is fetus at risk for
Coumadin risk intracranial hemorrhage
If your patient has an AFI <5, but BPS is 8, what is the best course of action?
Deliver, low AFI trumps everything else
Tx for chorioamnionitis
Delivery - INDUCE - not an indication for EM C-section - give empiric broad spec abx: *amp/gent*
what is the window for operative elective pregnancy termination in between meds
D&E (< 16 wks EGA) induction of labor (>16 wks EGA)
what makes up the placenta from the above structures:
D.basalis and chorion frondosum
screening guidelines for osteoporosis
DEXA for - postmenopausal women < 65 w/ 1 or more RF - *all women ≥ 65
Incontinence etiology
DIAPPERS - Delirium - Infection: get UA/ culture - Atrophic vaginitis/ urethritis (*give topical estrogen, repeat 2-4 mo) - psych, pharm - endo dz (DM) - restricted mobility - stool impaction
Transient etiology of incontinence:
DIAPPERS delerium/dementia, infection, atrophic vaginitis/urethritis, psychiatric d/o, pharmacological agents, endocrine dz, restricted mobility, stool impaction
Abruption is the most common cause of this coagulopathy in pregnancy
DIC
preferred BC method of women on anticonvulsants or meds that increase hepatic clearance of sex steroids
DMPA
2 widely used dx criteria for pMDD
DSM V UCSD (requires physical sx)
MC etiology of 2' amenorrhea after pregnancy is r/o
DUB or amenorrhea
Increased risk in pregnancy and PP #1 cause of pregnancy deaths History of same Hereditary thrombophilia (Factor V Leiden) Mechanical heart valve A fib Trauma, immobilization, surgery Antiphospholipid syndrome what is it:
DVT
When does mature milk start being produced?
Day 3-6
what needs to be checked and rechecked when giving Mg Sulfate IV for preeclampsia:
Deep tendon reflexes, if they go away getting close to Mg toxicity calcium gluconate is reversal agent only given if life threatening
out of the progesterone only agents which one is the only one that really affects ovulation:
Depo
only BC that inhibits ovulation
Depo provera bc large dose 150 mg, blocks for 14 weeks decreases risk of PID, germs cannot survive
Progesterone-only agents inj
Depo-provera (medroxyprogesterone)
What are the 6 cardinal movements of labor?
Descent Flexion Internal rotation Extension External rotation (restitution) Expulsion
when is b-hCG detectable in urine:
Detects levels >25 IU/L
What is our involvement with multiple gestation?
Diagnose. Refer. these pt CLOSELY monitored
how do you diagnose HTN in pregnancy:
Diagnosed if >140/90 anytime prior to 20wk EGA or persistent >12 weeks PP
which is longer: diagonal or obstetric conjugate
Diagonal
Shoulder pain in an ectopic pregnancy can be related to...
Diaphragmatic irritation (blood in diaphragm)
What ABX can be given with mastitis?
Diclox Cephalex Clinda
what are tx's for mastitis:
Dicloxicillin /cephalexin /clindamycin x 7-10 days Surgical I&D if abscess
What is difficult about diagnosing complete abortions?
Differentiating clots from conception products
Labor is defined as:
Documented uterine contractions(4/20min or 8/60min) AND Documented cervical change or Effacement of 80% or Dilation 2 cm or more
this OCP binds to aldosterone receptors and blocks aldosterone action in the kidneys It increases: Sodium and water excretion Potassium retention significant reduction in androgen activity:
Drospirenone
what are the normal cardiovasculature abnormalities during pregnancy:
Ductus venosus, ductus arteriosus, and foramen ovale
When is meconium generally passed?
During the 1st trimester, or if the baby is stressed
What are the indications for C-section?
Dystocia Repeat c section Breech Fetal distress placenta Previa previous Uterine incision (vaginal delivery would cause uterine blowout) active genital herpes
what would you use for cesarean delivery:
Dystocia Repeat cesarean Breech Fetal distress Placenta previa-placenta hanging down low Previous uterine incision Active genital herpes
#1 cause of bacteriuria:
E.coli GBS is number 2
endometrial cells or age > 40 & AUB-->
EMB & ECC (endocervical curretage)
WU for endometrial hyperplasia? what is GOLD STANDARD for dx
EMB is gold standard for dx, can use TVUS in post menopausal pt only bx to look for glandular & nuclear atypia
Lower abdominal pain, + hCG, tachycardia, and HOTN are ____ until proven otherwise
EP
What stage of labor sees benefit from parenteral narcotics?
Early 1st stage
Screening tool for post-partum depression
Edinburgh postnatal depression scale (EPDS)
If your previa patient has non-reassuring fetal status, what should you do?
Emergent C-Section
How much colostrum do normal breasts make?
Enough for 2 babies
how does baby enter inlet?
Enters inlet transverse
What will decrease oxygen demand in a pregnant asthmatic?
Epidural
What might a brachial plexus injury during the birth of a shoulder dystocia baby cause?
Erbs palsy (hands cupped outwards)
Leopolds maneuvers, beginning at 28 weeks, can estimate what?
Estimated Fetal Weight (EFW) Lie (fetal to maternal axis) Presentation (position presenting to maternal pelvis)
What is the goal of blood sugar during organogenesis in the first trimester?
Euglycemia
How often are vaginal exams completed during the active phase of labor?
Every 2 hours
How often are regular contractions encountered?
Every 3-5 minutes, last 30-60 sec
Self-limited resolution within two weeks Weeping, forgetful, labile, negativity Support and observation
PP blues (unique to pregnancy)
What type of monitoring must be done when the membranes haven't ruptured?
External monitoring only
What cardinal movement is characterized by head popping out and aligning with shoulders?
External rotation (restitution)
Pregnancies <24 weeks get these diabetes tests
FBG A1C Random
GDM wu in *<24 wks preggo*
FG, random BG or A1C in women @ high risk preggo - if FBG < 92 or A1C < 6.5 or random < 200: do 75g 2 hr GTT @ 24-28 wks - if FBG > 92 AND < 126: they have GDM no further testing - if FBG > 126 or A1C > 6.5 or random > 200 confirm with 2nd test, if both positive: overt diabetes
What parameters indicate GDM?
FPG 92-126 No more testing is needed - you have GDM
What parameters indicate no DM?
FPG <92 or A1C <6.5% or Random <200 *Must retest at 24-28 weeks*
what counts as an abnormal 2hr OGTT:
FPG > 92 or 1 hr > 180 or 2 hr > 153
what is criteria for GDM:
FPG >92 and <126 Abnormal 75 g 2hr OGTT at 24-28 wks
What parameters indicate overt DM?
FPG ≥126 or A1c ≥6.5% or Random ≥200 Random must be confirmed by 1 of the other 2. No more testing, u got (overt) DM.
what hormone works on the seminiferous tubules to produce androgens and *spermatogenesis*:
FSH
once puberty begins which hormone goes away:
FSH just need testosterone then
what is required to start puberty:
FSH and testosterone
What is a falling hCG indicative of?
Failing pregnancy or EP
Where do 98% of ectopics occur?
Fallopian tube
Irregular uterine contractions May or may not cause cervical change Last 4 weeks of pregnancy "usually" painless Some may be regular, but infrqt (q 10-20/min)
False labor "braxton hicks"
False positives of nitrazine?
False positives with cervical mucus, urine, blood, soap, sperm
What narcotic is best for analgesia with baby?
Fentanyl: shortest 1/2 life, 20-60 min efficacy
1/3 of all pregnancies bleed in the first trimester, but not 1/3 of mothers have abortions. What is a good predictor of a normal pregnancy in these first trimester bleeders?
Fetal cardiac activity at 7-11 weeks
What does tachysystole cause?
Fetal distress. Decreased fetal recovery time. maternal discomfort
fetal advantage is three fold to gain advantage over materal Hgb, what are they:
Fetal hemoglobin has higher affinity for O2 Bohr effect—decreasing O2 affinity with decreasing pH Fetus has higher Hgb (15-18 gm)
What must you assess before induction?
Fetal maturity! Lungs most important assessment
While administering Oxytocin, what must be in place?
Fetal scalp monitor Internal uterine pressure cathether
*What are the criteria for diagnosing chorioamnionitis?*
Fever >100.4 and 2/4 of the following: Tachycardia >100/>160 ab or fundal tenderness WBC >15k foul or culture pos amniotic fluid
What cardinal movement is characterized by cervical resistance?
Flexion
SE of Mag Sulfate
Flushing Resp depression Conduction defects
Which operative delivery method is associated with increased maternal morbidity?
Forceps
mastitis may occur due to stasis, what are some tx's:
Frequent breastfeeding with complete emptying Massage may facilitate latching Cool compresses/ice Analgesics Avoid breast pumps for more than 10 min Often inefficient at removing milk May promote excess milk production
What are the two labor velocity curves?
Friedman and Zhang
What is the most identifiable factor of PPROM?
Genital infection
U/S Milestones (calculated from LMP):
Gestational Sac (5 weeks) Fetal pole (6-7 weeks) Cardiac activity (5 weeks)
what is the tx of newborns of HbsAg pos moms:
HBIG + Hep B vaccine w/in 12 hrs prevents 95% of transmission
How do you stop vertical transmission of HBV?
HBIg and vaccine
Although oral medications aren't FDA approved for GDM, some folks use...
Glyburide if insulin isn't an option (sulfonylureas) Metformin in 2-3 trimester
Decapeptide synthesized in arcuate nucleus Causes production and release of LH and FSH Secreted in pulsatile fashion throughout menstrual cycle Inhibited by gonadotropins (LH, FSH) Estradiol enhances release
GnRH
#1 cause of neonatal sepsis in US:
Group B strep
S/S of RDS
Grunt Flare Retract Hypoxia
What is the shoulder dystocia management acronym?
HELPERR - Help - Episiotomy, Empty bladder (foley) - Legs back (McRoberts) - Pressure (suprapubic) - Enter (wood's screw/ internal rotation) - Rotate posterior shoulder (Rubin) - Remove posterior arm (Barnum's)
All women at new OB; repeat 3rd trimester in high risk "Opt-out" voluntary testing recommended ELISA with western blot confirmatory
HIV screening
what virus targets specifically transformation cells that can cause cancer:
HPV
Prime etiologic factor in the development of cervical dysplasia is? what are high risk strains
HPV High risk 16, 18, 31, 33, 35
ASCUS on PAP-->
HPV HR DNA reflex testing OR repeat pap @ 12 months
LSIL HSIL
HPV, mild dysplasia, CIN I mod/severe dysplasia, CIN II/III, CIS
What is the most reliable indicator of fetal well-being?
HR variability - long term: variation from baseline (accel or decel) - short term: beat 2 beat (R-R interval variations)
what is done after women sterilization procedure
HSG 12 weeks after to confirm (hysterosalpingogram)
*most prevalent STI*
HSV
What risk factors are associated with PPCM (peripartum cardiomyopathy)?
HTN PIH (>140/90) Pre-eclampsia malnourishment age > 30
what is the mild criteria for pre-eclampsia:
HTN p 20 wks (>140/90) (prev. nl BP) Proteinuria (>0.3g but <5gm in 24° UA)
what are good screening questions to ask:
Have you been hit, kicked or otherwise hurt by someone within the past 1 year? Do you feel safe in your current relationship? Is there a partner from a previous relationship who is making you feel unsafe now?
when do you screen for Hep B:
HbsAg in all women, rescreen for high risk 3rd tri
Side effects of CCB
Headache, dizzy, nausea *Decreased uterine/ umbilical blood flow*, doesn't preclude administration (may see oliguria, decreased amniotic fluid production)
PPH Tx
Help! Bimanual compression of the fornix & uterus Don't pack - try uterine balloons IV fluids for vol replacement Surgery
What is the term for coexisting IUP and EP simultaneously?
Heterotopic pregnancy
what is the bohr effect:
Hgb carries more oxygen at an alkalotic environment so the environment in the planceta is acidotic and when HgbF comes close to maternal blood, it changes to alkalotic and snags more oxygen
Would you use high or low dose Nifedipine?
High dose
Although steroids are Cat B or C, what should be avoided during pregnancy?
High dose *oral steroids* They cause cleft palate, PTL and LBW
Electronic (External) fetal monitoring is used during prenatal care for....
High risk pregnancies to assess fetal well being
what are some absolute CI for OCPs:
Hx of thromboembolic disease, stroke or ischemic heart disease Undiagnosed genital bleeding Active hepatic disease Hx of estrogen-dependent tumor >35 who smoke >15 cigs/day Pregnancy
What predicts poor fetal outcome in seizure management?
Hyperthermia
What does maternal death seen in ectopic pregnancy MC result from?
Hypovolemic shock
What is the last line surgical procedure for PPH?
Hysterectomy
What should you do if breast abscesses develop?
I & D
Same DSM criteria—10% incidence, 50-100% recur >two weeks...consider bonding, nutrition, safety SSRI
PP depression
Rho immune globulin (describe Rhogam)
IM dose 300 mcg *covers 30 cc fetal to maternal hemorrhage binds to fetal cells in maternal circulation UNEFFECTIVE if alloimunized
what are the contributing factors for pregnancy <20 yo:
INADEQUATE NUTRITION Poor education Cigarette smoking Drug abuse STD's Deficient prenatal care
what is a common factor of cervical ca
INFXN - MC in women 20-49 yo
What are the fetal complications of maternal diabetes?
IUFD or SAB Polyhydro macrosomnia IUGR (pre gestational DM) 2x risk of congenital abnormalities
What is the benefit of using internal fetal monitors over external?
IUPC can measure timing, duration, and *strength* of contraction. Fetal scalp electrode can show rate based on R-R interval.
What are some of the things included in early labor management?
IV fluids >>PO (pt may need C section so less in stomach, better) *Labs-H&H, dipstick, HBV, Rh status* Monitors (maternal and fetal) Uterus activity (IUPC for HR, oxytocin induced) Vaginal exams (every 2 hours during active [4/5-10 cm]) Amniotomy
how do you manage hypotonic contractions
IV oxytocin +/- AROM if >4-5cm
What is the most common cause of preterm labor?
Idiopathic (UK)
Describe cervical length assessment done in PTL patient
If >30mm, labor isn't imminent If <20mm, high risk of preterm birth If 20-30mm, get the fetal fibronectin (trophoblast glue)
At what point can you release a preggers who experienced abdominal trauma?
If after 4-6 hours, there is NO: Contractions >1 every 10 min Vaginal bleeds Abd pain or tenderness Poor FHR (decels, brady, tachy) Bruising
which screening test is for rubella:
IgG titer
what is the timeline for post partum vascular changes:
Immediate elimination of placental circulation and obliteration of umbilical vessels Umbilical arteries close after 45-60 sec Umbilical vein closes after 3-5 min Closure of ductus venosus—w/i 1 wk Closure of f. ovale—w/i 3 months Gradual constriction and obliteration of PDA---usually 4-10 days Dilitation of pulmonary vessels and development of pulmonary circulation
what is the most reliable of all forms of contraception for progesterone only agents
Implants, injections, IUD (Mirena)
rate of fetal monitoring in high risk pregnancies
In patients with obstetric risk factors, the fetal heart rate should be auscultated or the electronic monitoring tracing evaluated at least every 15 minutes during the active phase of the first stage of labor (immediately following a uterine contraction), and at least every 5 minutes during the second stage.
describe spermatogenesis
In sertoli cells, diploid to haploid - Spermatogonia (germ cell) 46, 2n under goes mitosis - Primary spermatocyte, 46, 2n (2 cells, 1 stays a spermatogonia, other becomes primary spermatocyte) PS undergoes meiosis I - 2ndary spermatocyte (2 haploid cells, 23, n) which then undergo meiosis II - Spermatids (4 daughter cells, 23, n ea)
what are some things that describe cervical mucus at ovulation:
Increase in quantity Becomes more alkaline Decrease in viscosity (spinnbarkheit) Ferning Favorable electrolyte content
Complications of c-section
Increased infection Increased embolism Increased hemorrhage
How does breastfeeding help treat PPH?
Increased oxytocin levels cause uterine contraction in response to suckling reflex
*What tocolytic is used from 24-32 weeks?*
Indomethacin: must use less than 72hr, prior 32 wks Mag sulfate
the process whereby labor is initiated by artificial means
Induction
What are some causes of PROM/PPROM? (5)
Infection: UTI, STI Chorioamnionitis Cervix incompetent (>4cm in 2nd tri) Polyhydro Multiple gestation
How does Ig A in breastmilk help prevent NEC?
Inhibits E. coli adherence to the guts
What is the best medication for controlling GDM glucose?
Insulin
what happens to glucose metabolism during late pregnancy:
Insulin resistance emerges - impaired glucose tolerance Placenta secretes diabetogenic substances: Human Placental Lactogen (hPL) Increased unbound cortisol Progesterone Reason for gestational diabetes screen at 28 weeks
Would you use fibronectin with intact or ruptured membranes? Rules of getting fibronectin
Intact ONLY membranes done PRIOR to digital exam so usually done right before exam
How can you measure pressure of contractions to call them adequate or inadequate?
Intra-uterine catheter
what are the adolescent risk factors for pregnancy:
Iron deficiency anemia Preeclampsia-eclampsia Prematurity Low Birth Weight SGA infants Operative delivery
what are the SEs for progesterone only agents:
Irregular spotting and bleeding Amenorrhea Weight gain (Depo-provera) Increased follicular cysts Acne flares
This psych d/o doesn't resolve in 2 weeks postpartum, and may require SSRI therapy
PP depression
How long is the 4th stage of labor, and what is the inherent risk?
It's an hour after placenta delivery, - highest risk of post-partum hemorrhage
What can prostaglandins be used for in a baby with cardiac abnormalities?
Keep PDA open
What is paramount when assessing PPROM?
Keep ur fingers outta there -- do sterile speculum exam, consider measurement of AFI
test where Citric acid (pH 3.2) dissolves maternal Hb Eosin stains remaining fetal Hb—mom's cells "ghost" Manual count of 2000 total cells to calculate % fetal cells
Kleihauer-betke test
when measuring lung profile, this can only be measured via amniocentesis:
L/S ratio
Which fetal lung maturity tests are measured via amniocentesis
L/S ratio Lamellar body PG
what pain pathways supply innervation to the vagina and deep pelvic structures:
L1-S4
what hormone stimulates leydig cells to produce testosterone:
LH
What are some of the methods for assessing fetal maturity - must do prior to induction?
LMP Size based on fundal height EGA with heart tones @ 8-12 weeks Quickening (mom feels baby kick) *1st trimester US*
If a patient has had a PE before, what will she receive throughout pregnancy?
LMWH - lovenox
surgical therapy for genital warts
LN2, excision, electrocautery, laser, intralesional interferon
What surgery increases the risk of DVT by 3-16x?
LTCS
What are the increased risks associated with post-dates?
LTCS (low transverse c-section) Birth trauma Oligohydramnios Meconium aspiration (think macrosomia, fetal intolerance of labor, shoulder dystocia, brachial plexus injury)
what are the risks of post-dates:
LTCS rate doubles macrosomia, fetal intolerance of labor) Birth trauma (shoulder dystocia, brachial plexus injury) Oligohydramnios/meconium aspiration syndrome
What are the preferred HTN meds in pregnancy?
Labetalol Methyldopa
What pathologies are associated with a precipitous delivery?
Lacerations to cervix, vagina, etc (no time to expand tissue) Fetal respiratory issues (less time compressed in BC, more secretions) Uterine atony
What are some non-pharm methods for analgesia?
Lamaze The "doula" (emotional support guru) Warm bath Sterile water subQ: back pn Efflurage (tummy tickles)
What is the compound that surfactant is packaged in?
Lamellar bodies
What phase of labor would you NOT strip membranes?
Latent phase
What are the components of surfactant? (4)
Lecithin Sphingomyelin PI PG
Where are DVTs most common in pregnancy?
Left leg ( L iliac vein smushed by nugget) MC proximal (iliac or femoral)
What is a marker for post-partum endometritis?
Lochia (fluid produced after delivery) if malodorous suspect endometritis Do a culture!
What are some of the causes of the most common cause of uterine atony?
Long labor or Precipitous labor Halogenated gases Oxytocin Grand multiparity (>5 kids) Multiple gestation
What happens at 9-12 mg Mag sulfate?
Loss of DTRs = toxicity > 10.5 very bad see cardiac conduction problems
What coincides with the peak of the uterine contraction?
Low point of fetal heart rate
Maternal infections that we are concerned with are concentrated primarily in the....
Lower genital tract
What is prescribed for patients with seizure disorders that can't stop their meds?
Lowest dose anticonvulsant *monotherapy* Vitamin K supplements Folate (phenytoin, phenobarb, primidone are enzyme inducers)
What is the procedure of choice for regional anesthesia? What is prolonged epidural contractions again...
Lumbar epidural next to spinal canal. This will affect moms ability to contract the uterus as hard, so.... Nulliparous >3.5 Multiparous >3 Are considered prolonged with epidurals.
Primary amenorrhea is MC due to?
MC d/t genetic or anatomic abnml - 50% chromosomal (gonadal fail) e.g. Turners - 20% hypothalamic hypogonadism - other: absence of female junk, transverse vag/septum/imperf hymen, pituitary dz, or a combo of--> PCOS, CAH, androgen insensitivity syndrome = excess androgen production
RF endometrial ca
MC gyn maligancy in US - *unnopposed E* (see ectropion) - obese, affluent, white - post menoP - DM2 - lynch syndrome "fat white rich tricks eating their faces off on postM rampage"
What are the causes of PPH? (4 T's)
MC: *Tone* - uterine atony Tissue: retained placenta/ accreta Trauma: laceration Thrombin: coagulopathy
What are some morbidities associated with laceration of the birth canal?
MC: chronic pain & Dyspareunia Incontinence
test of choice for hypothalamic pituitary axis
MRI
what makes up the quad screen:
MSAFP, hCG, unconjugated estradiol, inhibin A (increased )
TOC for *non-ruptured* EP? Ruptured?
MTX if rupture - surgery is indicated
What is the #1 cause of non-obstetric dead baby?
MVA
Tx for eclampsia
Mag Sulfate
What is given from 24-32 weeks to stop preeclampsia?
Mag Sulfate
What might occur as a result of severe preeclampsia? SEQUELAE
Maternal - cerebral hemorrhage, seizure - hepatic rupture, bleeding d/t thrombocytopenia - renal fail - pulm edema Fetal - Growth restriction - Placenta abruption
What are some relative contraindications for induction/augmentation? *test*
Maternal Prior uterus surgery Prior C section Distended uterus Fetoplacental Premature fetus (lung immature) Fetal distress Abnormal presentation
what are some causes of PROM/PPROM:
Maternal *Infection* UTI, chlamydia, gonorrhea *Chorioamnionitis* Cervical incompetence Polyhydramnios Multiple gestation
what are known causes of preterm labor:
Maternal medical problems (Trauma, preeclampsia, hypertension) Infection (increased phospholipase A activity UTI, bacterial vaginosis, cervical infections) Anatomic abnormalities (Cervical incompetence or shortening, bicornate uterus, didelphys, Placental abruption, placenta previa, Fetal anomalies) Uterine overdistension (Multiple gestation, polyhydramnios)
Where is the anterior shoulder of the fetus?
Maternal pubis
which prostaglandin can cause uterine contractions and lead to 2nd tri termination:
PGF2 alpha
Which maneuver for shoulder dystocia is the most successful and is usually all that is needed?
McRoberts
Treatment performed for a ruptured uterus?
Median laparotomy Usually hysterectomy also *give rho-gam if indicated*
who gets med txt in osteoporosis
Meds for - menoP women w/ T score > 2.5 SD - menoP women w/ T score -2.0 to -2.5 SD + 1 RF for fx
What other technique does a laminaria mimic?
Membrane stripping (PGE release)
What are some methods of induction/augmentation/ripening? (5)
Membrane stripping @ 37 weeks to release PGE AROM (Amniotomy) in active phase only Mechanical dilation via laminaria or foley bulb (balloon) PGE (Cytotec, Cervidil, Prepidel) Oxytocin-FDA approved
what are the SEs of IUD:
Menorrhagia/dysmenorrhea with copper-T esp. PID IF pregnancy occurs, higher chance of ectopic
What is the treatment for *hyperthyroid in the 2nd or 3rd trimester*?
Methimazole
What is used to treat unruptured ectopics?
Methotrexate (folate antagonist & anti-mitotic)
Progesterone-only agents Oral—the "mini-pill"
Micronor® (Norethindrone 0.35 mg) Nor-QD® (Norethindrone 0.35 mg) Ovrette® (dl-Norgestrel 0.075 mg) (No longer available in US)
what are the meds that are basically anti-progestins that are used for elective pregnancy termination:
Mifepristone (RU-486) on day one Misoprostol (Cytotec) on day three 90% effective if <49 days EGA
most potent prostaglandin
PGF2a - can be used as abortant in 2nd trimester
MINIMUM *diagnostic criteria for PID*
Minimum - uterine/adnexal or CMT in sexually active young women or women w/ RF (*prev. PID, sex during menses, douching, IUD, BV*)
Which IUD is associated with a higher risk of ectopic?
Mirena
which type of IUD can be used up to 5 yrs:
Mirena
What med *can* be used in hypertensive or asthmatics?
Misoprostol (Cytotec) PGE1
what constitutes as an arrest of descent or rotation 2nd stage:
Nulliparous-->3.5hrs with or >3 hrs w/o epidural Multiparous -->3 hrs with or >2 hrs w/o epidural
what should this counseling include:
Nutritional status—begin counseling 3 months prior Overweight/Underweight Medical history/Medication review Screening for sexually transmitted infections Folic Acid supplementation (neural tube closes 18-26 dac) 400 mcg daily Avoidance of alcohol, tobacco within 3 months of conception
Monthly intravaginal device ( 3wks in, 1 wk out) Plastic, not latex Etonogestrel/ethinyl estradiol Day 1 start—no back up: Days 2-5 require back up for 1 week If falls out can be replaced within 3 hours without backup If out for >3 hrs, may rinse, replace but use back up for 1 wk Rapid return to ovulation when discontinued
NuvaRing
Pregnancies >24 weeks get this kind of DM test
OGTT
txt of stress incontinence-->
PME/pessary peri-urethral collagen injections surgery topical estrogen if atrophic duloxetine (cymbalta)
This psych d/o resolves within 2 weeks postpartum, and is characterized by weepy, lability, being sad, etc
PP blues
What is the last resort in dystocia management?
Operative (C-section, forceps, vacuum)
What does failed induction usually result in?
Operative delivery
What cancer risks are reduced by breastfeeding?
Ovarian Breast
The problem with menopause and androgens?
Ovary still produces small amounts of androgens during menopause which can lead to hair chin syndrome.
GDM predisposes patients to getting...
Overt DM
What can you augment mom in active labor with?
Oxytocin
What is the only FDA approved method of inducing/augmenting labor?
Oxytocin
What meds can be used for PPH? (4)
Oxytocin Methergine Hemabate PGF2a Misoprostol (Cytotec) PGE1
What is the most commonly prescribed drug in the US?
Oxytocin (Pitocin)
Describe the contraction stress test
Oxytocin is administered, and you expect at least 3 contractions in 10 minutes.
string of pearl ovaries
PCOS
What is possible fetal complications associated with use of Indomethacin?
PDA closure NEC Intracranial bleed Oligohydramnios
What is the leading cause of pregnant female death?
PE
when measuring lung profile, this can only be measured in vaginal pool of amniotic fluid or amniocentesis:
PG
which fetal lung maturity test can be meausred by vaginal pool of amniotic fluid or amniocentesis
PG
Which surfactant component is most important?
PG-phosphatidylglycerol
what prostangladins can be used when unfavorable bishops score:
PGEI and PGE2
Tx for placenta previa
Pelvic rest Serial ultrasounds to assess fetal status/ maturity *C-Section* Rho-gam if Rh- mom
What might the atypical presentation of appendicitis cause in the 3rd trimester and will increase the risk of perinatal mortality?
Perforation
What does the pudendal analgesia provide? what spinal level is it given?
Perineal pain relief during the 2nd stage only S2-S4 supply pudendal nerve
Unique to pregnancy and puerpurium (20wk) RFs: HTN/PIH/Pre-E, malnourishment,age>30 DDx: viral myocarditis, chronic HTN, valve dz Dx: echo, bx (exclusion) Rx: supportive, Na restrict, digoxin, diuretics Deliver via forceps, vacuum
Peripartum cardiomyopathy
What is the heart condition associated with pregnancy?
Peripartum cardiomyopathy PPCM (Pregnancy CHF)
What sedatives can you give for Braxton Hicks?
Phenergan Hydroxyzine Zolpidem (ambien)
what sedative are helpful only in false labor:
Phenergan Vistaril Zolpidem
What enzyme is responsible for infection complications?
Phospholipse A --> causes PG release
In regards to fetal heart decelerations, what causes them?
Vagal response from uterus squashing the nugget
What is another name for cyclooxygenase?
Prostaglandin synthetase
This biolipid has receptors in the myometrium that interact with and cause efflux of calcium. Basically the opposite of CCBs.
Prostaglandins
What would you use to ripen that 41 week old cervix?
Prostaglandins Stripping would have to have been done 4 weeks ago (stripping done @ 37 weeks)
benign skin lesions. 3rd tri. resolve w/parturition. tx w/ topical CS. oral antihistamines not efficacious.
Pruritic urticarial papules and plaques of pregnancy
Intrauterine pregnancy noted on TVUS Next?
Pursue other treatment, it's not an EP
What is a SE of Misoprostol (Cytotec) administration?
Pyrexia
Non-diagnostic TVUS Next assessment?
Quantitative hCG levels
RF for gestational trophoblastic dz
RF >35 or < 20, prev. hx
S/S of acute fatty liver of pregnancy (AFLOP)
RUQ EPIgastric pain, N/V, Jaundice *Low glucose, Elevated transaminase, Ammonia Urate, prolonged coags* - LIVER BE SICK (unlike ICOP)
How often is tachysystole caused by natural causes?
Rarely, if ever. It is generally iatrogenic administration of pitocin
what makes up the biophysical profile for fetal assessment:
Reactive non-stress test *Adequate AFI (5cm total or any 2cm pocket)*-*most important need it or others don't matter* Mvmt ---at least 3 body or limb Tone ----at least1ext/flex of extremity Breathing --- at least 1 episode of 30sec last 3 must be w/in 30 mins
Which of the following is currently accepted as a plausible explanation for the onset of pubertal changes? Migration of primordial germ cells to the genital ridges Activation of the adrenal cortex Reduction in GnRH sensitivity to estrogen levels Rising FSH and LH levels caused by ovarian maturation Loss of GnRH pulsatile activity
Reduction in GnRH sensitivity to estrogen levels
What does membrane stripping cause?
Release of PGE
LSIL > 30 w/ NEG HPV test-->
Repeat contesting @ *1 year* IF both negative then repeat cotesting @ 3 years. IF POS then Colpo.
reversal rates of sterilization efficacy rates of sterilization
Reversal - Vasectomy 50-75%, BTL 30-75% (75% is as good as it gets) Efficacy - Vasectomy: > 99%, BTL > 98%
so who gets Rho-gam:
Rh neg moms w/ neg Ab screen
what med is the only one to reduce effectiveness of OCPs:
Rifampin
With reference to the menstrual cycle, which of the following is correct? The proliferative phase ends with menstruation Rising FSH levels at the end of the luteal phase signal the impending onset of menses The endometrium is stimulated to regenerate by progesterone secreted by the corpus luteum Each month 15 graffian follicles are created, one of which will undergo ovulation The duration of the follicular phase is the most constant and typically lasts for 14 days
Rising FSH levels at the end of the luteal phase signal the impending onset of menses c. is close but estrogen does this
what are the risk factors for chorioamnionitis (infection of amniotic fluid):
Risk factors Prolonged rupture of membranes (>18hr) Multiple digital examinations Instrumentation (FSE/IUPC)
Sharp groin pain usually during early second trimester usually due to Stretching & spasm of_______ ligament Often R>L reassurance, activity mod, analgesics rarely indicated
Round ligament pain
maneuver: anterior should is pushed towards baby's chest, posterior shoulder pushed towards baby's back - baby moved to face more sacral
Rubins: mov't of ant shoulder wood's screw: mov't of post shoulder
TOC for lichen sclerosis
Rx: topical CCS (clobetasol) chronic dz req long term therapy
What is the dividing line for determining whether a dead baby is a SAB(miscarriage) or IUFD is.....
SAB < 20 weeks IUFD 20 wks - before delivery
abortion definitions (SAB)
SAB: ends < 20 wks EGA - complete: complete of POC - incomplete: partial expulsion of POC - inevitable: no expulsion but bleeding & dilation of cervix - threatened: any IUB < 20 wks w/o dilation of cervix or expulsion of POC - missed: complete retention of POC but death < 20wks ega
so PTH txt is indicated for who?
SEVERE osteoporosis T-score > 3.5 or > 2.5 w/ fragility fx
Complications of adolescent pregnancy? SLOPPI
SGA LBW Premature (infxn risk) Preeclampsia/ Ecclampsia Iron deficient anemia (nutrition) Operative delivery (use of vaccum or forceps greater)
more specific dx criteria of PID
SPECIFIC 1. PO temp of 101 2. mucopurulent cervical or vaginal d/c 3. elevated CRP 4. lab dx of G or C
what is the specific gene region that codes for TDF:
SRY gene
What is a decent alternative to HRT?
SSRIs (venlafaxine, paroxetine) Gabapentin QHS clonidine is a QHS option as well
what continuous OCP has 4 menses/yr:
Seasonique
When does fetal evaluation occur in trauma?
Secondary survey - mother is priority
How do you monitor for Mag Sulfate toxicity?
Serial DTRs, usually patellar Mg acts @ NMJ
Your patient is dilated 3cm and has hypertonic contractions. What phase of labor is she in and what can you give her?
She's in latent phase (0-4/5 cm) Morphine 15-20 SQ inpatient Ambien (Zolpidem) 5mg if outpatient
Your nulliparous patient has been is 2cm dilated at 22 hours. You feel her uterus and she's having very soft contractions that you think are inadequate. What stage is she in? What can you give her?
She's in prolonged latency (0-4/5 cm and nulliparous >20 hrs) Give her some IV Oxytocin. Maybe rupture them membranes. He says not do do this later.
Where is loss of HR variability most bad?
Short term (beat to beat)
Failure of shoulders to deliver after vertex is called......
Shoulder dystocia
How do you treat severe variable decelerations?
Similar to tachysystole: Oxygenate Elevate uterus (trendelenburg) Left lateral decubitus Stop oxytocin Amnioinfusion if low AFI
What is a 1st degree laceration? *test*
Skin only involving the vaginal epithelium or perineal skin
which type of IUD can be used up to 3 yrs:
Skyla
When is the most bone loss experienced during menopause?
The first 2 years following menopause. *sentinel event--> vertebral fx 15 yrs before hip fx*
How do anti-inflammatories inhibit uterine contraction?
They block production of prostaglandins, which inhibits uterine contractions
how do you manage hypertonic contractions in prolonged latent phase:
Therapeutic rest (MS 15-20 mg subcut or Zolpidem 1 mg if allowed to go home) 85%--awake in active labor 10-15%--not in labor 5% continued dysfunctional labor
What is true about the majority of patients with prolonged latency who are knocked out with morphine or ambien?
They awake in active labor (4/5-10 cm)
what are the types of spontaneous Abortion:
Threatened =closed cervix but bleeding (before 20 wks) Inevitable =open cervix +ROM or bleeding Complete =documented pregnancy that spontaneously passes all products of conception (usually <12 wks) Incomplete =partial passage of products of conception THIS IS THE EMERGENCY Missed =retention of a failed pregnancy for extended period(>6 wks) <20 wks—fetus has died but is retained Recurrent =2 or more consecutive spont. Ab or 3 total Ab
What is the goal of fetal heart monitoring?
To identify hypoxemic and acidotic fetuses in a timely manner and provide intervention to avert death.
Tx for cord prolapse
Tocolytics C-Section
2 Points are awarded for each criteria in the biophysical profile. What are the 5 criteria? *TAN BM*
Tone- 1 flexion or extension of extremity AFI of 5cm or any 2x1cm pocket Non-stress test (US) Breathing- 1 episode of 30 seconds Movement 3x, body or limb
How often do post-dates patients get BPS?
Twice a week
How often should you BPS, Nonstress test, and motion assess these folks past due?
Twice weekly
_____ is the area between the original and new squamocolumnar junctions
Transformation zone
Causes of uterine rupture inlcude:
Trauma Labor Spontaneous
again only vaginal infxn that requires txt of partner
Trichomoniasis
t or f prostaglandins can maintain the patency of ductus arteriosus in fetus:
True
What are the 3 possibilities of the natural progression of an ectopic pregnancy?
Tubal rupture Natural resolving Tubal abortion into abdominal cavity (abdominal pregnancy on omentum [non-viable=abort])
common chromosomal abnml seen with primary amenorrhea
Turner (45, X)
What is the unique sign associated with shoulder dystocia?
Turtle sign- pull on head, it retracts
TOC localized provoked vulvodynia
Tx: Gabapentin, TCAs, Topical lidocaine
TOC bartholins cysts
Tx: none if asx. Word catheter placement for both cyst and abscess. IF FAILS--> marsupialization
What makes surfactant?
Type 2 pneumatocytes
required if uncertain LMP or irregular periods when trying to date a pregnancy:
U/S
management of prolapse
UL issue - Estrogen: atrophy - Kegels: incontinence, after delivery - Pessaries - Surgery
what modality is NOT sensivite for abruptio placentae but IS for placenta previa?
US
how is AFI attained? what are ranges
US separates abdomen into 4 quadrants and measures pockets of fluids, then this is added up - AFI should be btw 5-25
What is used to differentiate EP from threatened abortion?
Ultrasound - TVUS
What provides definitive diagnosis for EP when hCG levels are above the threshold?
Ultrasound - TVUS
What are the 7 risk factors associated with advanced maternal age? *USE CLP P*lease
Underlying condition-DM, HTN Spontaneous abortions-GDM, aneuploid Ectopic preggers - 4-8x risk C-section LBW (esp if >40 yo) Previa Preterm delivery
what are some factors that lead to unintended pregnancies:
Underutilization of contraception Poor patient education Lack of access to care Barriers to availability of product Ethical constraints Poor compliance with contraceptive method Adverse side-effects Inconvenience of regimen Choice not to use
What are some indications for EP surgery?
Unstable pt or rupture CI to MTX or failed MTX txt Heterotopic pregnancy (viable in uterus) desire permanent sterilization Poor F/U candidate
IF uterus is present and no obstruction a low or normal FSH indicates?
Upstream issue which can be functional or structural.
Manual extraction of the placenta carries what risk?
Uterine eversion
What may be the characteristics of the uterus in a complete abortion?
Uterus firm and contracted
What are some possible sites of bleeding after the baby has been delivered?
Vaginal walls Urethral tears Cervical laceration (especially precipitous)
What antiepileptic basically causes NTDs? Black box warning and is NO GO.
Valproate
what is the tx for varicella:
VariZIG to infant within 96hrs and contact isolation if infant is exposed to varicella infection Exposed susceptible mom: VariZIG within 6 days of exposure if neg IgG
What is the most common abnormal fetal heart pattern?
Variable decelerations
What is the second best diagnostic tool for DVT?
Venogram
What is the most common presentation for infants?
Vertex
Emergency contraception (timeline)
W/in 72 hrs - hormones: Plan B or Yuzpe (want 1.5 mg of progesterone), delays ovulation/ fertilization W/in 120 hrs - Cu IUD: inhibits fertilization by affecting sperm Antiprogestins: Ella/ Ulipristal
Why is cervical Ca relatively uncommon in developed countries?
We do PAP screening.
How often do high riskers get BPS?
Weekly
which maternal antibodies cross placenta
When Rh negative mothers are exposed to Rh antigen, they become sensitized producing first IgM antibodies (acute response) followed by IgG IgG antibodies can cross the placenta and attack fetal red blood cells
When is the fibronectin test most helpful?
When it's negative --> has high NPV
What is an "anterior lip"?
When the cervix gets caught between the baby and the pubis
who would be a good candidate for IUD:
Women in stable, monogamous relationships Low risk for STIs Can be used in nulliparous women Mirena can be used for dysfunctional uterine bleeding
amniocentesis or chorionic villi sampling should be offered to all women at increased risk of aneuploidy. what women specifically:
Women who will be older than 35 when they deliver (32 if pregnant with twins) Women with abnormal ultrasound including nuchal translucency Women with a previously affected pregnancy Couples with a known genetic translocation or other chromosomal abnormality Women with positive serum markers
What is meant by dystocia caused by psyche?
Worn out moms in the 2nd stage of labor (10cm dilated, waiting for baby to come out)
Are early fetal heart decelerations normal? why or why not?
Yes - we worry about LATE and variable decels - decels consistent with UC is vagal response to cephalic pressure
What might the station be with arrest of descent?
ZERO STATION Mom's with arrest of descent are in STAGE 2 of labor
the zygote is at the endometrial cavity how many days s/p ovulation:
`3
describe semen
alkaline environment in which sperm travel contains prostaglandins that cause uterine contractions (propel sperm)
pregnancy is a state of respiratory ____
alkalosis tidal vol rises, Co2 falls, increased inspirational capacity, fall in functional residual capacity
In normal females Muellerian duct development occurs due to:
a. Estrogen stimulation of the genital tubercle b. Ovarian development *c. The absence of MIF* d. Dissolution of Wolffian structures e. Sinovaginal bulbs
where does fertilization take place
ampulla
A 15-year-old female arrives at your clinic with her mother. She has recently experienced increasing abdominal pain. Her mother is concerned that her daughter has not begun to menstruate. General examination reveals age-appropriate thelarche and adrenarche. Gynecologic examination reveals a bulging vaginal introitus. The appropriate treatment for this patient is:
a. Oral contraception, which will also estrogenize her vulva and promote maturation. b. Reassurance. Lack of menarche prior to age 16 is within normal limits. *c. Referral to a gynecologic surgeon.* d. Incision and drainage as an outpatient procedure. e. Diflucan 150mg po as a single dose.
During labor, an arrest of fetal descent may occur, most commonly in the plane of least diameter (the midplane) of the pelvis. Which of the following is a component of the midplane?
a. The bituberous diameter *b. The anterior-posterior diameter from the inferior pubis to S4-S5. * c. The diagonal conjugate d. The posterior sagittal diameter from the bispinous midpoint to the middle of the sacral promontory e. The obstetric conjugate
what is velamentous insertion
abml cord insertion normally umbilical cord inserts into middle of placenta in this condition it inserts in chorioamniotic (fetal) membrane cords are exposed and not protected by wharton's jelly making them at risk for rupture
what lab findings will you see in Functional amenorrhea
abnml GnRH secretion--> - low gonadotropin levels - absent surges (no ovulations, no menses) - FSH is usually low/nml
Most common cause---HTN (chronic or pre-E) At >20 wks gestation Associated with: 50% major trauma 5% minor trauma also assoc. w/ cocaine abuse:
abruptio placentae
s/s are vaginal bleeding, contractions, significant uterine tenderness or irritability. nonreassuring fetal heart rate pattern (fetal tachy, late decelerations, demise)
abruptio placentae
Secondary amenorrhea defined-->
absence of menses for at least *6 mos* in women who were previously menstruating
What are some of the *maternal* complications of diabetes?
accelerated chronic HTN PIH UTI from glycosuria Preeclampsia Operative delivery
what are important elements of the new OB visit:
accurate dating of pregnancy Hx - overall health, reproductive hx Labs
what does RDS lead to
acidosis & death
enzymes digest the zona pellucida until sperm cell membrane can fuse with egg cell membrane
acrosomal rxn
what is true (anatomic) conjugate
actual entrance to true pelvis
Rare: maternal mortality<10%:fetal mortality 90% Occurs 3rd trimester/early postpartum period Associations: Preeclampsia or twin gestation Sx: abdominal pain, N/V, jaundice Labs Elevated transaminases, bilirubin, ammonia, uric acid *Low glucose*, prolonged coags Tx: DELIVERY
acute fatty liver of pregnancy
fetal movement assessment
after 28 wks lie on side and should detect 10 mov't in 2 hr can be given glucose to try and spark mov't from fetus if DFM assessed by L&D
when is it normal to resume intercourse after birth
after 6 wks
what would constitute for there to be an arrest of dilation:
after reaching 5-6 w/ rupture of membranes No change after 4 hrs with adequate contrax No change after 6 hrs with inadequate contrax
HPV vaccine indication age range which vaccines protect against which types
age 9-26 YO, target of 11-12 YO. Gardasil 16, 18, 6, 11 Cervarix 16, 18 only
RF for dyspareunia-
age < 50 hx of sexual abuse hx of PID depression, anxiety
types of SAB and describe
all before 20 wks - Threatened: closed cervix, *bleeding* - Inevitable: open (dilated) cervix + bleeding, +/- ROM - Complete: documented preg, all products of conception passed - Incomplete: partial passage of products of conception - Missed: retention failed pregnancy for > 6wks - recurrent: 2+ consecutive SAB OR 3+ total SAB
what is screening for chlamydia/gonorrhea:
all women get chlamydia GC in high risk initial and at 3rd tri
who should preconception care/ counseling be given to?
all women of reproductive age bc 50% of pregnancies unplanned
what effects does progesterone have on the breasts:
alveolar hypertrophy secretory maturation
when to head to c-section during active phase of labor
always after 6 hours
Allows growth, movement and development Physiologic buffer and antibacterial barrier Vol: 1st tri: 5-25cc; 32 wk: 250-800cc; Term: 500cc Production: ~700cc urine and 250cc lungs/day Elimination: 500cc/day swallowed, remainder osmotic exchange
amniotic fluid
if you admin indomethacin what must you monitor
amniotic fluid & ductus blood flow in fetus via US
why would pH paper turn blue when testing for PROM:
amniotic fluid neutralizes acidic environment
what is the tx of chlamydia:
amoxicillin for 7 days azithromycin/clindamycin alts for PCN allergry
*what is longest portion of the fallopian tube*
ampulla
Ectopic pregnancies from both ART and natural conception both MC implant where?
ampulla
where does fertilization occur at:
ampulla
MC encountered condition during pregnancy:
asthma
MC UL medical condition see in pregnancy
asthma (1/3 rule: better, same, worse)
head engages "cock-eyed". should raise your suspicion of cephalopelvic disproportion:
asynclitic
MCC of vaginal irritation after menopause-->
atrophic vaginitis
ASC ASCUS ASC-H
atypical squamous cells - unknown significance - cannot r/o HSIL
the artificial stimulation of labor that has begun spontaneously
augmentation
travel advice for preggos
avoid travel after 37 wks, usually req dr note for airplane - airplane altitudes can be detrimental - @ higher risk for DVT
describe internal rotation
baby rotates from transverse to AP diameter usually occurs as the fetal head meets the muscular sling of the pelvic floor
MCC vaginal discharge-->
bacterial vaginosis
greater vestibule glands, both sides of vaginal orifice - provide lubrication during intercourse
bartholin's gland
what is the sunday start:
begin first sunday post-menses, take one pill a day
Value doubles every 2.2 days (average) Rises for 60-90 days, then declines to plateau *Abnormally low in ectopic and spontaneous abortion* *higher in gestational trophoblastic neoplasia (GTN)* Proposed etiology of N/V of pregnancy & hyperemesis gravidarum Useful marker to follow in 1st trimester bleeding
beta hCG
Absence of Y chromosome gene products (testosterone) causes involution of Wolffian ducts Remaining bilateral paramesonephric ducts are allowed to develop what structures will develop:
bilateral fallopian tubes, fusion in midline to form uterus & upper 1/3 of vagina
what can be done to reduce neonatal transmission if viral load >1000 copies/mL:
c section
what is tx for an active genital infection of HSV during labor (or prodromal sx):
c section
which candida is resistant to azole txt
candida glabrata
what are the 4 major ligaments of the pelvis:
cardinal, round, broad, and uterosacral
what is tx of gonorrhea:
cefixime or ceftriaxone
Most common cause of dystocia and subsequent c-section
cephalopelvic disproportion
those babies with PTL are at greater risk for which condition
cerebral palsy risk of infants born 23-27 wks 80X that of term births
Passive painless 2nd trimester dilation Classically > 4 cm Classic: bulging amniotic sac in absence of: Uterine contractions (UCs) Vaginal bleeding (VB) Infection Amniorrhexis...PROM or PPROM
cervical incompetence
Measured by ultrasound >30mm very low risk of PTB <20mm significant risk of PTB—manage pt actively
cervical length
contraction of scar tissue or adhesions w/i the endocervical canal blocks OS
cervical stenosis
HPV positive and > 30 YO next step with unsatisfactory cytology, next step?
colpo or repeat cytology in 2-4 months. IF unsat then you should get the colpo.
ASC-H on pap-->
colpo, ECC
SECOND most frequent non-obstetric indication for surgery
cholecystitis
Maternal fever (>100.4) + at least 2 of these: Tachycardia (maternal (>100 or fetal >160) Abdominal/fundal tenderness Leukocytosis (>15K) Foul or culture-positive amniotic fluid
chorioamnionitis
Rapid number of mitoses Morula-16 cell stage Blastocyst (embryoblast, trophoblast) what stage:
cleavage
what are the qualitative/screening tests for fetal maternal hemorrhage:
clinical evidence or *erythrocyte rosette screen*
what is performed at new OB appt and during labor to assess fetal descent:
clinical pelvimetry
estradiols effect on bone
closes epiphysis
what are the changes to the renal system:
collecting system dilates, blood flow and GFR increase to 140%, tubular function (dump bicarb)
1-2 days post delivery Composed of protein, fat, minerals Contains the secretory IgA Laxative Approximately 40cc/day for 3-6 days
colostrum
HSIL, AGC, AIS on pap-->
colpo, ECC
16/18 POS > 30 YO
colpo/ECC
how do you manage prolonged active phase:
confirm dilatation of 6 cm. augment w/oxytocin. Maternal/fetal monitoring for 4 hours with adequate contrax (>200 Montevideo units) Extend observation period to 6 hours if less than adequate contrax
What should you do when BPS is <6?
consider deliver/ induce
what are some advantages of a transdermal patch:
continuous delivery of hormones no peak and trough
what is an absolute CI for induction of labor from a maternal cause:
contracted pelvis
which emergency contraception is good for obese women:
copper T IUD
which type of IUD can be used up to 10 yrs:
copper-T
connect parietal bone to frontal bones
coronal suture
phase 4 of menstrual cycle is:
corpus lutem secretes progesterone but once it goes away progesterone drops and menses begins
vestibule bulb homolog
corpus spongiosum
Women > 30 w/ NEG HPV preferred is?
cotesting at 12 months. Colpo is an option but not preferred.
what do you measure during 1st tri for U/S dating:
crown-rump accurate +/- 1 wk
this forms both the chorion frondosum-forms fetal villi which coalesce into umbilical vessels and chorion laeve (smooth, ie non-villus---was villus on d.capsularis, but atrophies in favor of villi on d. basalis
cytotrophoblast
how do you manage tachysystole:
d/c augmentation med *position L side* examine to r/o cord entrapment oxygen Beta agonist-(tocolytic,terbutaline)
if you miss 3 pills or more, what do you do:
d/c pills, wait for menses, and re-initiate sunday post menses
when is follicular proliferative phase
day 1-14 estrogen predominant begins w/ first day of menses
colostrum yields to mature milk by what day:
day 3-6
once implantation has occured, the endometrium is called what:
decidua basalis decidua capsularis
Peri-menopausal AUB think-->
declining ovarian function (fibroids, polyps, endometrial CA).
facts of OCP: Most popular reversible contraceptive in U.S. Increased/Decreased ovarian and endometrial cancer No increased/decrease risk of breast cancer ______ STI protection Increased/decreased risk for blood clots
decreased increased No increased
Provides direct shunt of oxygenated blood from R atrium to systemic circulation Flap fusion complete by age 2 in 75% of children --- ie prevalence 25-30%
foramen ovale
symptoms abd. pain, amenorrhea, vaginal bleeding, pregnancy sx signs abd. TTP, adnexal TTP, adnexal mass:
ectopic
younger female, abd. pain, who is pregnant, think:
ectopic pregnancy *33% have 1st tri bleeding*
When columnar cells are visible on the ectocervix Common near menarche, during pregnancy or when using estrogen-containing oral contraceptives May notice more vaginal secretions or postcoital spotting No treatment required once other causes have been ruled out
ectropion
Culmination of a three-month process 2-5cc Alkaline 40-300 million sperm
ejaculation
what would you counsel a pregnant pt on exercise :
encouraged safely exercise to 60% of MHR consider body temp - avoid hot tubs (assoc w/ neural tube defects) no impact, contact, straining after 1st tri
endometrial hyperplasia is a stepping stone to who is at higher risk for endoM hyperplasia
endometrial Ca obese women @ higher risk
Adenomyosis define typical presentation
endometrial glands and stroma embedded w/i muscular uterine wall. - Present w/ *heavy AUB/dysmenorrhea* in parous women ages 40-50
overgrowth of endometrial lining in the proliferative phase this occurs as a result of ____
endometrial hyperplasia - result of anovulation
hyperplastic overgrowth of endometrial lining on a stalk
endometrial polyps
chocolate cysts-->
endometriomas. Tender adnexal mass.
presence of endometrial tissue in an extra-uterine location
endometriosis
Pt presents w/ pain and pre/post menstrual spotting what should be in your ddx?
endometriosis.
if you feel the head at the ischial spines, the baby is:
engaged for delivery bipartial diameter has come through the pelvic inlet
Maternal serum mix with IgM to bind Rh+ cells Stain and assess
erythrocyte rosette screen
what hormone causes the *proliferation* of the endometrium:
estrogen
what hormone endorses follicular development
estrogen
what hormone has direct effect on Prolactin not mediated thru hypothalamus:
estrogen
what hormone influences mammary ducts:
estrogen
what is the bottom line from the high levels of estrogen and progesterone that are produced by the placenta during pregnancy:
estrogen causes high levels of prolactin. however, it inhibits the ability to make and release milk.
describe cervix during ovulation
estrogen is high - increased quantity, decreased viscosity, and favorable electrolyte content of cervical mucus - becomes alkaline, ferning pattern - ideal for sperm penetration
ovarian transmitter: Secreted by theca interna cells/granulosa cells of the follicle Secreted by corpus luteum after ovulation
estrogens
what increases SHBG levels?
estrogens
menorrhagia defined-->
excessive bleeding *>80ml or prolonged >7d* regular bleeding
due to higher ventilation, a fall in CO2, what do the kidneys do to off set respiratory alkalosis:
excrete bicarb. pregnant women will have low bicarb
what effect does the McRoberts position have relative to lithotomy position:
exit is more horizontal, more favorable for impacted shoulder
The urogenital triangle contains what:
external genitalia and urethral orifice
Post-evacuation monitoring of molar pregnancy-->
f/u weekly until 3 consecutive nml *Monthly for 6 months after 3 normals* Chemotherapy if levels persist
what effects does estrogen have on the breasts:
fat deposition ductal growth stimulates melantoncytes (pigmentation of cheeks, areola, and linea alba)
Top sxs of PMDD-->
fatigue and bloating for PE and labile mood for BH.
function of pelvic diaphragm
fecal continence supports ab/ pelvic organs
probability of conception/ probability of achieving a live birth in a single menstrual cycle
fecundity
name that pelvis: pelvic angle >90 degrees, sacrum tilted back, and ilia spread wider:
female
which sex is more likely to have precocious puberty
females 20x greater predominance
the maturation of oocytes is arrested in meiosis I (46 chromosome pairs) until when:
fertilization
Most frequent recognizable cause of mental retardation May affect 1% of US population Incidence 4% among "heavy" drinkers
fetal alcohol syndrome
IUFD is...
fetal demise where fetus EGA>20wks but prior to labor
Technique to assess fetal well being after 28 weeks Mother lays on her left side Mother should recognize 10 fetal movements in 2 hours If <10 some have mom drink glucose containing fluid and repeat for another hour If still <10 should come to L&D for assessment of "decreased fetal movement"
fetal movement counts (fetal kick counts)
internal fetal monitors must have ruptured membranes to use. which one shows fetal heart rate based on R-R interval:
fetal scalp electrode
US presentation of partial mole-->
focal placental cysts/gestational sac +/- fetus *detected after tissue examination of a SAB*
Best if pre-conception (NT closure 28 days) 0.4-0.8mg po daily (USPTF—all women of CB age) 4.0mg if: Anticonvulsants, to thwart deficiency, esp valproate and carbamazepine---val now with additional alert re decreased cognitive development History of NTD Type I diabetes, BMI>35, FH of NTD
folic acid
what makes up the HELLP syndrome:
form of severe preeclampsia as manifested by hemolysis, elevated liver enzymes and low plts
The recessed vagina that borders the lateral cervix
fornix
opening between labia minora, contains external urethral orfice, vaginal orfice and opening to the glands, may contain hymen
fourchette/ vestibule
How do you treat breast engorgement?
freq breast feeding w/ COMPLETE emptying (this done via baby not pump) Cool compresses and ice (not too much, may stop lactation) Tylenol *Avoid breast pumps >10 minutes* (can promote excessive milk production & not as efficient in removing milk)
Familial ovarian CA syndrome plan-->
frequent pelvic exams, TVUS, serum markers (CA-125) remember there is no real good screening for this.
26 YO G1P1 presents to your clinic with a chief complaint of post-coital bleeding for the past month. She denies painful intercourse or vaginal discharge and reports her LMP as 2 weeks ago. Her last Pap was last year and was normal. She is currently taking OrthoTricyclen
friable surface on cervix. most likely ectropion
Post menopause stage +2
from *stage +1 until death* do you part.
what is puerpurium
from delivery to up to 6 wks post delivery
connects the frontal bones
frontal suture
MCC of gonadotropin independent PP
functional ovarian cyst
when does ductus venosus close
functional stops within minutes of birth structurally closes within 3-4 days
what are the methods to asses amniotic fluid:
fundal height U/S (amniotic fluid index, single deepest pocket, 2x1 or 2x2 cm pocket, two diameter pocket)
Measured from top of symphysis pubis to top of fundus in cm Gross estimation of fetal growth from 20-36 wks:
fundal ht.
Formerly referred to as Pregnancy Induced Hypertension (PIH) New HTN (>140/90) after 20 wk EGA w/o proteinuria that resolves prior to 12 weeks postpartum-usually w/in 1st wk Will be changed to Preeclampsia if proteinuria develops Chronic HTN if persists >12 weeks postpartum
gestational HTN
what can you see on U/S at the following times: _______ at 4.5-5 wks _______ at 6-7 wks _______ at 5.5-6 wks
gestational sac fetal pole heartbeat
*RECALL* bimanual exam is not the most effective way to detect an adnexal mass, what is?
get that TVUS!!!
clitoris homolog
glans penis
what allows for the esinophillic bacteria to proliferate:
glycogenation of the squamous cells
IF uterus is present and no vaginal obstruction an elevated FSH indicates?
gonadal failure
the genital system is derived from 3 separate components:
gonads, genital ducts, and external genitalia
MC UL thyroid condition seen in pregnancy
graves
based on the %, what are the basic bony pelvic shape: 50%- <30% 20%- 3%-
gynecoid android anthropoid platypelloid
what two types of bony pelvic shapes are favorable for vaginal delivery:
gynecoid and anthropoid
What 2 hormones secreted by the placenta stimulate the thyroid and cause symmetric thyroid enlargement?
hCG hCT
how do you manage pt <34 wks, that goes into labor:
hospitalize initially - 20% will stop spontaneously Betamethasone to reduce fetal morbidity/mortality GBS prophylaxis if indicated Tocolytic therapy up to 48 hrs Antibiotics for positive cultures Magnesium sulfate if 24-32 weeks—neuroprotective effect
toxoplasmosis triad
hydrocephalus crorioretinitis coreocalcification
Luteal phase symptoms-->
heaviness of breasts, decreased vaginal secretions, abdominal bloating, mild peripheral edema
what is the management of shoulder dystocia (you got 5 mins, HELPERR):
help episiotomy, empty bladder legs back (McRoberts) pressure (suprapubic) enter (woods screw) rotate posterior shoulder (Rubins maneuver) remove posterior arm
is a medical condition in which the vagina fills with menstrual blood. It is often caused by the combination of menstruation with an imperforate hymen.
hematocolpos
remains most common cause of jaundice during pregnancy Diagnosed with viral antigen/antibody panel Treatment is supportive
hepatitis
Coexistance of an IUP and an ectopic pregnancy
heterotopic pregnancy 1:100 in IVF
pregnant ASCUS-H -->
higher FP rate, *do not defer colpo until postpartum*.
MC clinical presentation of PCOS (4)
hirsutism (90%) AUB (90%) polycystic ovaries (80-100%) Infertility (75%) Obesity (65%)
Hyperandrogenemia: - what is cause? - how?
increased production of androgens due to - neoplastic or functional cause OR - ovarian (neoplasm, PCOS) or adrenal cause (neoplasm, cushing, CAH)
the stimulus of sucking triggers a neuroendocrine reflex that results in:
increased secretion of oxytocin and prolactin
what results in 2ndary sexual characteristics
increased sex steroids: - estradiaol - androgens
what is the most important contraceptive factor of progesterone only agents:
increases amount and viscosity of cervix mucus preventing pregnancy
what are the CO changes during pregnancy:
increases to peak at 2nd tri (+40%)
if AFI < 5 or non stress test shows late decels in a baby >42 wks...
induce
how do you manage PROM >37 wks:
induce w/ pitocin FHR monitor to assess status Can wait up to 24 hrs before inducing labor Ripening associated with increased infection risk *Assess need for GBS prophylaxis*
L/S ratio >2 PG present, infant has what probability of RDS:
infant <5%
What 4 risk factors are associated with PPROM? iPAS
infection Previous PPROM Antepartum bleeds Smoking
what are the mod. degree risk factors for ectopic pregnancy:
infertility, previous cervicitis, hx of PID, multi. sex partners, smoking
3 key diameters to assess for fetal descent during labor:
inlet, midplane, and outlet
oligiohydramnios
insufficent *AFI <5* - 1st trimester leads to pulmonary hypoplasia (potter's renal agenesis) - late: meconium hypoxia, adhesions, umbilical cord compression
what are the meds for GDM:
insulin - for FBG levels persistently >95 oral- not FDA approved, some use SU
describe glucose metabolism
insulin resistance emerges, glucose tolerance impaired anti-insulin environment: diabetogenic environment in latter pt of pregnancy --> release of Human placenta lactogen, increase in unbound cortisol, increased progesterone
how do you manage PTL:
insure adequate hydration r/o infection and fetal/uterine anomalies w/U/S determine EFW, presentation cerv length, AFI tocolytic therapy-upt to 48 hrs steroids if 24-34 wks--none after 34 wks unless lungs immature
in what condition are tocolytics INEFFECTIVE
intra amniotic infection / chorioamniotitis
Second most common cause of jaundice during pregnancy Usually occurs in 3rd trimester Sx: intense pruritis, fatigue, jaundice, dark urine Labs: Elevated bile acids, bilirubin, extremely high alk phos Rarely prolonged PT/PTT due to malabsorption of Vit K
intrahepatic cholestasis of pregnancy
internal fetal monitors must have ruptured membranes to use. which one shows not only timing and duration of contraction but STRENGTH. measured in montevideo units-avg amplitude x # in 10 mins
intrauterine pressure catheter
what is vaginismus?
involuntary spasm of *outer 1/3 of vaginal muscles*
metrorrhagia defined
irregular bleeding
Symptoms of menopause?
irregular menses, endometrial hyperplasia, mood/emotional changes, hot flashes, night sweats.
#1 cause of non-obstetric fetal demise
motor vehicle accident
according to labor curves who (multiP or nulliP) would you want to do more frequent cervical checks on
multiP women bc traditionally dilate fast once in active phase
What is a prolonged *latent* phase in regards to a nulliparous vs multiparous? (protraction d/o)
multiparous: 14 hr nulliparrous: 20 hours (overall: 14-20 hrs)
1st day of the last menstrual period (LMP) + 7 days+ 9 months =estimated delivery date (EDD) or estimated date of confinement (EDC)
naegle's rule
the drugs mentioned above have what SEs:
neonatal respiratory depression if close to delivery decreased FHR variability
folic acid intake in pregnancy
neural tubes close wk 28, so good to do preconception - 0.4-0.8 mg in all CB age women - 4.0 mg/d if: hx NTD, anticonvulsants, DM, BmI > 35%
what is the regular prenatal care schedule:
new OB appt during 1st tri (10-12) 12-28 wks (appt monthly) 28-36 wks (appt Q2wks) >36 wks (wkly)
Zone of fibrinoid degeneration in the decidua basalis Prevents placental invasion into the uterus: Placenta accreta - adheres to myometrium (79%) Placenta increta - invades myometrium (14%) Placenta percreta - perforates through myometrium (7%)
nitabuch's layer
can an HIV pos woman breastfeed:
no
is herpes zoster a risk to pregnancy:
no
is mastitis a CI to breast feed?
no, continue to breast feed, source of S.aureus is from infants mouth
Actual space available to the fetus Fetal head engaged when biparietal diameter passes through inlet
obstetric conjugate
actual space available to fetus
obstetrical conjugate
posterior fontanele what is it
occiput - jxn of lambdoid suture & saggital suture
Oligomenorrhea defined
occurring at *intervals > 35d*
polymenorrhea defined-->
occurring at *intervals of < 24d*
describe primary dysmenorrhea
occurs during ovulatory cycles. - Starts *w/i 6mos menarche* or w/i 48-72 hrs of menses - Related to uterine *ischemia*/contractions - *increased PG* levels.
Insufficient production Early in pregnancy leads to pulmonary hypoplasia Late in pregnancy associated with meconium, hypoxia, adhesions, umbilical cord compression
oligohydramnios
proliferative phase is when:
once menses stops to when ovulation occurs
secretory phase is when:
once ovulation has occured and corpus lutem begins to secrete progesterone. once corpus lutem goes away and progesterone drops, it ends starting menses
what is the only asthma med with any SEs:
oral CS
what are some emergency contraception:
oral hormones-plan B and Yuzpe regimen-w/in 72 hrs copper-T IUD-w/in 120 hrs antiprogestins-Ella
most treatable sexual phase d/o
orgasmic phase (primary >> 2ndary in treatability)
this newer combo delivery system is a: Weekly transdermal patch Slight increased risk of VTE in comparison with OCPs Warning for online counterfeit products Caution in women >190lb Back up requirements same as OCPs
ortho Evra
Entrance to true pelvis Boundaries: Superior border of pubis Linea terminalis (iliopectineal line) Sacral promontory Fetal head enters in transverse position
pelvic inlet
MC physical finding for ovarian CA?
pelvic mass and ascites, advanced disease on discovery:(
Clinically significant esp with low arrests Boundaries: Sacrotuberous ligaments and sacrococcygeal joint posteriorly Inferior margins of pubic rami anteriorly Ischial tuberosities laterally
pelvic outlet
labia minora homolog
penile shaft
A diamond-shaped area medial to the thighs and buttocks in males and females Contains the external genitalia and anus
perineum
what does the increase in plasma volume cause:
physiologic anemia of pregnancy
this progesterone only agent delievery system: Require strict dosing due to fluctuation in hormone Delay of dose >3 hrs requires back-up contraception
pills
what types of contraceptives are very effective 3-10% failure rate:
pills, patches, rings
what are the meds for PPH:
pitocin methergine-NOT for pre-eclampsia/HTN hemabate-NOT for asthma, seizure pts misoprostol- can be used for HTN/asthma; beware of pyrexia
how do you tx gravid uterus:
place pt in LLD to take pressure off veins. important during birth of child
hCG is secreted by trophoblast cells during the 1st tri, and maintains the mothers corpus luteum for first 5 and 1/2 wks. after that time, what takes over as the major sex producing gland, increasing progesterone and estrogen:
placenta
Painless vaginal bleed (unless in labor) 1 in 200 pregnancies Mean GA 30 weeks will have recurrent bleeding and usually delivery early Management Pelvic rest Maturity LTCS Rho-gam prn
placenta previa
Little clinical significance Boundaries: Posterior pubis at maximum convexity Superior border of obturator formina 2nd/3rd sacral vertebral junction Anterior fetal head orientation through this plane
plane of greatest diameter
Clinically most important Boundaries: Lower posterior pubic edge anteriorly Ischial spines and sacrospinous ligaments laterally Sacrum posteriorly Frequent site of arrests
plane of least diameter
describe midplane
plane of least diameter AP diameter from inferior pubis to S4-S5 - ant: lower post pubic edge - lat: ischial *spines* - post: sacrum
what are the total volume increases during pregnancy:
plasma volume (1st tri) RBC mass (2nd-3rd tri)
what is nuva ring made of
plastic
pt applied therapy for genital warts
podofilox or imiquimod (not if prego)
provider applied therapy for genital warts
podophyllin or TCA *pt must come back on weekly basis to check progress*
moms on insulin during pregnancy, 5x the risk of:
polyhydramnios
"Too much" fluid (~2L) *Decreased elimination (swallowing)*(MC) ex. is Esophageal atresia or tracheo-esophageal fistula Increased production ex. High cardiac output—fetal anemia, tw-tw trans Spinal covering anomalies May lead to premature labor, maternal discomfort, cord prolapse, fetal malpresentation 14% d/t maternal DM
polyhydramnios (hydramnios)
defecatory urge in ectopic suggests
pooling in pouch of douglas
what are some techniques to diagnosis PPROM:
pooling, nitrazine, ferning, amnisure
Most reliable indicator for rupture
pooling/expulsion
What are some risks for ectopics? (8)
poor motility - PID (previous STD or salpingitis) - PHx Tubal ligation or ectopic - Progestin use - douching: ↑risk PD - IUD - Smoking - ↑ age or early coitus - Fertility (ART)
Portion of the cervix extending into the vagina. Includes parts of endocervix and exocervix
portio
hcg testing for pregnancy
positive 6-8 d after ovulation - Blood: <5 is negative, >25 is positive, anything in btwn buys them a repeat test - Urine: > 25 is positive, first morning sample preferred
Detect a heartbeat Fetal Doppler 9-12 weeks Fetoscope 20 weeks "Quickening" mom feels the baby move Primigravida 18-20 weeks Multigravida 15-17 weeks
positive signs of pregnancy
what does BTT identify
post ovulation
Retained placental fragments can cause....
post partum hemorrhage because risk uterine won't contract and shut down those vessels
oxytocin is made where and causes what:
posterior pituitary: milk ejection
What is a RF for PCOS?
premature adrenarche
what are the 7 risks for pregnancy >35 yo:
presence of underlying med problems, spontaneous abortion, ectopic pregnancy, placenta previa, c section rate, LBW, preterm delivery
Chadwick's sign - bluish hue of the cervix/vagina Linea nigra (d/t melanocyte stim. by estrogen) Chloasma = "Mask of pregnancy"
presumptive skin changes of pregnancy
what is the mechanism of action of OCP:
prevention of ovulation by suppressing LH surge thickens cervical mucus limits proliferation of endometrium alteration of normal tubal motility
what are the high degree risk factors for ectopic pregnancy:
previous ectopic pregnancy, previous tubal surg., tubal ligation, tubal pathology, current IUD use
what are the low degree risk factors for ectopic pregnancy:
previous pelvic/abd. surgery vaginal douching early age intercourse <18yo
what is the #1 factor to have pre-eclampsia:
prior hx
what are the risk factors for having a post date pregnancy:
prior hx of post date first pregnancy
what is an relative CI for induction of labor from a maternal cause:
prior uterine surgery classic cesarean section overdistended uterus
Piskacek's sign - asymmetric uterine enlargement Hegar's sign - ability to compress connection b/ cervix & fundus
probable signs of uterine changes of pregnacy
what does MIF act on
produced by sertoli, acts locally (paracrine) mullerian duct regression = no female organs
ovarian transmitter secreted by corpus luteum after ovulation:
progesterone
what hormone influences lactiferous duct (sinus):
progesterone
what hormone makes mucus thick & cellular:
progesterone
what hormone stimulates the secretory phase of the endometrium:
progesterone
what causes the tidal volume to rise 40% at term:
progesterone due to rise in inspiratory capacity fall in functional residual capacity-from rise in hemidiaphragms
Thickens cervical mucus, thins endometrium, reduces tubal motility No reliable supression of ovulation
progesterone only agents
EMB results are hyperplasia w/o atypia what do you do?
progesterone treatment and EMB Q 3-6 mos
what hormone influences the lobe of the breast:
prolactin
Most likely will be determined to be dopamine
prolactin inhibiting factor
what do tocolytics do what make up the tocolytics:
prolong onset of labor Beta agonists, CCB, Mg sulfate, prostaglandin synthetase inhibitors
*What increases the likelihood of getting chorioamnionitis?*
prolonged ROM >18 hours Multiple digitial exams Instruments (fetal scalp electrode/IUPC)
puberty pathop
pubertal onset: @ 11 yo 1. gradual loss of sensitivity by gonadostat to neg feedback of sex steroids -- GnRH pulse increases in amp & freq 2. loss of intrinsic central nervous system inhibition of hypothalamic FnRH release, heralded by sleep associated increases in GnRH secretion
Development of secondary sexual characteristics and reproductive capability
puberty
what are the borders of the perineum:
pubic symphysis anteriorly ischial tuberosities laterally sacrotuberous ligaments posterolaterally coccyx posteriorly
Workup of hirsutism
r/o neoplasm 1. serum total T 2. DHEA-S 3. pelvic US/CT look for functional d/o 1. PCOS (oligo/amenorrhea, hirsutism, acne, obesity) - see mild elevation of DHEA-s or Test 2. CAH or Cushings - consider if: reg menses - 17 hydroxyprogesterone stim test and 24h urine free cortisol/dexamethasone
when is a man considered sterile after a vasectomy
reached azoospermia after 6-10 ejaculations post procedure
if there is a delay in the 1st week when using transdermal, what do you do:
reapply and back up for 1 week
pregnant HIV pos women should receive what standard tx:
receive standard antiretroviral therapy Reduces vertical transmission to 1-2% if viral load <1000 (can opt for V delivery)
AKA the pouch of Douglas The is the lowest point in the abdominal cavity for fluid accumulation
rectouterine pouch
How do you ddx rectocele from enterocoele?
rectovaginal exam
How do we prevent fractures?
reduce risk of falls via - vision assessment - lighting - clean, well marked stairs and floors - footwear
describe spermiation
release of spermatozoa into seminiferous tubules - mature, but non-motile sperm - travel to epididymis and acquire motility
potter's syndrome is associated with what:
renal agenesis
Single artery cord abnormalities occur in 1:500 deliveries Aplasia or atrophy of the missing vessel 30% of affected infants with other structural defects particularly what:
renal anomalies
16/18 negative next step? > 30 YO
repeat both PAP & HR HPV @ 12 months. Both neg routine screen in 3 years. Otherwise they get a colpo
HPV HR DNA POS/pap NEG in pt > 30-->
repeat both tests in 12 months. ALT genotype test 16/18
> 30 who are cytology NEG but HPV POS-->
repeat cotesting @ 36 1 year or HPV DNA typing IF POS cytology or HPV positive then colpo otherwise repeat cotesting 1 year v. 3 years
ASCUS and > 25-->
repeat cytology @ 1 year, or HPV testing (preferred). IF HPV is POS--> colpo, IF repeat cytology has increased ASC--> colpo. NEG cytology return to routine screening. HPV NEG-> repeat contesting @ 3 years.
Unsatisfactory cytology and HPV negative next step if > 30 YO
repeat cytology in 2-4 months. IF negative return to nml screening or cotesting @ 1 year (HPV +)
Endometrial hyperplasia w/ atypia tx-->
requires either hysterectomy (post menopausal/post child bearing) or hormonal therapy in premenopausal pt.
intense pain with change in contour of abd. can be result of trauma, labor, or spontaneous:
ruptured uterus
what is reference point if baby is breech
sacrum (instead of occiput)
connects parietal bones
saggital suture
homolog to labia majora
scrotum
what are the 23 double structured chromosomes found after the first meiotic division:
secondary spermatocytes
If after 30 minutes of medicating PPH nothing is happening, what do you do next?
send to surgery
which type of SAB is frequently associated with INDUCED abortions
septic
Muellerian inhibiting substance is produced by
sertoli cells
what produces MIS in male embryo
sertoli cells
what do you do for a cord prolapse:
stop contractions and c section
hair-an
subgroup of PCOS: hyperandrogenism, insulin resistance, acanthosis nigricans
preferred AP diameter of fetal vertex is
suboccipitobregmatic
what two methods need back up contraceptives when starting OCP:
sunday start and quick start
how do you tx hyperemesis gravidarum:
support, hydration, small bland foods, sleep positioning, ginger *Vit B6/unisom (doxylamine)* anti-emetics/antihistamines/anticholinergics admission w/IV supportive care
Labs seen with hyperprolactinemia?
suppresses GnRH --> low/nl LH/FSH
txt of overflow incontinence & fxnal incontinence
surgery intermittent cath *avoid-alpha agnostic, anticholinergics, CCB*
what is tx for ruptured EPs:
surgery - linear salpingotomy or salpingectomy faster times to acceptable hCG levels
what method involves the basal body temp and cervical mucous method:
symptothermal
this method typically requires abstinence for 12-17 days/mo.
symptothermal method
Head engages parallel to pelvic plane
synclitic
Erodes into decidua basalis forming lacunae *Nitabuch's layer (fibrinoid degeneration*
syncytiotrophoblast
once implantation occurs, the trophoblast splits into what:
syncytiotrophoblast cytotrophoblast
Pre-pubertal AUB think-->
think of bleeding defects
how long does BP slightly drop during pregnancy:
till 24wk, then normal
txt of urge incontinence-->
timed voids anticholinergics (Detrol, ditropan) PMEs (pelvic mm exercises)
most preventable cause of low birth weight infants
tobacco use during pregnancy nicotine 15% higher in fetus
this external fetal monitor shows timing and duration of contraction. CANNOT measure strength of contraction:
tocodynamometer
what kind of U/S would you need if hCG is >6500:
transabdominal U/S
95% cervical neoplasia occurs here
transformation zone
Area of the ecto/endocervix where cells transition from squamous to columnar epithelial cells May be visible depending on the female's age AKA the squamocolumnar junction or T-zone
transformation zone
babies delievered by c section are at risk for:
transient tachypnea of the newborn
what are the risk factors for group B strep:
treat those w/ GBS bacteriuria, previously affected infant, delivery <37 wks, intrapartum fever, prolonged rupture of membranes >18hrs
Atrophy on pap smear result--> what is f/u & TOC
treat w/ topical estrogen and repeat in 2 months.
what meds do you avoid in treating bacteriuria:
trimethoprim 1st/ sulfa 3rd tri
what serum markers are used to discover aneuploidy (trisomy 18 & 21)
triple screen (MSAFP, hCG, unconjugated estriol)
Produces hCG Detectable 7-10 days post-fertilization Preserves corpus luteum until placenta takes over Menses deferred Pregnancy testing & component of "triple screen"
trophoblast (Chorion)
REGULAR uterine contractions + cervical change (+ "bloody show" (not always seen))
true labor
where are the MC locations of ectopic pregnancy for natural conception:
tubal 98% ampullary 80% isthmic 12%
complication of PID
tubo-ovarian abscess
What is a biochemical pregnancy?
women pregnant, has spontaneous loss w/o ever realizing she was pregnant bc...no missed period, no implantation, body absorbs conception products
what method requires Abstinence based on presence or absence of secretions Unprotected intercourse only allowed if no secretions noted for last 2 days Usually twice daily checks for secretions Usually requires abstinence for 10-14d/mo Correct use: 3.5/ 100 wmyr Typical use: 14/100 wmyr
two day method
describe how regional blood flow increases during pregnancy
two major increases: to kidney & skin, uterus - increase in renal blood flow: cause increased CrCl and lower serum Cr - uterine blood flow increases: accounts for 17% CO during pregnancy, if maternal CO falls blood shunted away from uteroplacental circ, uterine vessels maximally dilated during pregnancy little auto regulation to increase uterine blood flow if it drops
TOC gonadotropin dependent PP
tx w/ GnRH
what is vasa previa
umbilical vessels transverse fetal membrane and cross @ internal os at risk for rupture when membrane ruptures - fast fetal exsanguination
where is the fungal ht. at 20 wks:
umbilicus
PRL release
under tonic inhibition by hypothalamus
T-score what is the deal?
unfairly measures granny BMD to a normal young adult
What is meant by dystocia caused by passage?
unfavorable pelvic shape (android or platypelloid)
Fibromuscular sheet that stretches across the pubic arch Provides framework for attachment of erectile body of clitoris Major source of vesicourethral control
urogenital diaphragm
What is the main use of CA-125?
useful in *following* cancer *treatment*.
what is Yuzpe method
using a bunch of normal OCP rx as EC - must take so equal 1.5 mg progestin
when do menses return for continuous OCPs upon d/c and when do most women become pregnant:
usually day 32: usually by day 90
what is MC etiology of PPH:
uterine atony
for diagnosis of abruptio placentae, VB is not reliable, U/S is not sensitive, so how do we know:
uterine contractions on ext. monitor monitor 4-6 hrs - release if: contracting <1 Q 10 mins No VB, no abd. pain or tenderness, FHR reassuring
CI for external cephalic version:
utero insufficiency, HTN, oligohydramnios, prev. uterine surgery, anything that precludes vaginal deliver
uterine malformation where the uterus is present as a paired organ as the embryogenetic fusion of the mullerian ducts failed to occur. As a result there is a double uterus with two separate cervices, and often a double vagina as well.
uterus didelphys
common s/s of complete mole
vag bleed *increased uterine size* pre eclampsia hyperemesis ELEVATED hCG
what type of delivery is still preferred if pre-eclampsia:
vaginal
best test for SUI
valsalva
stage -2 of STRAW (transition):
variable cycle length *>7d*
Most frequent abnormal pattern Graded by severity "Severe"—60X60 Often seen in Stage 2 with pushing Tx as for tachysystole
variable deceleration
velamentous vessels over internal os 1:5000 50% perinatal mortality, 75% if membranes rupture
vasa previa
what are some sterilization methods of contraception:
vasectomy, bilateral tubal ligation, transcervical tubal occlusion
vein or arterial, which one is oxygenated and pressurized R side: which one is deoxygenated and flaccid L side:
vein: arteries
describe CAH
virilization of female - 21 hydroxylase deficiency - s/s: ambigious genitalia, precocious puberty, clitomegaly
2nd MCC vaginitis
vulvovaginal candidiasis
when is EC recommended to be initiated
w/in 1st 72 hrs - best w/in 1st 12 hrs
when do we screen for maternal diabetes
week 28
when is cervix at 100% effacement
when @ 10 cm
fetal engagement
when BPD enters pelvic inlet - 0 station when fetal head @ level of ischial spine
Amenorrhea is a pathological symptom (Not a dx) except when -->
when pre-pubertal, gravid, lactating, post-menopausal
when is ova usually fertilized in relation to ovulation
within 12 hours
How do you treat cervical incompetence?
women get serial US if shortening: Cerclage or Progesterone
explain post pill amenorrhea:
women on long term OCPs did not have menses once they stopped to get pregnant. better now with better meds
