OBGYN UW & APGO

What is postpartum gestational diabetes protocol?

(btw 6-12wks after delivery) 2hr oral glucose tolerance test If negative, repeat screening every 3 yrs! (#18282)

If pt has endometrial hyperplasia, what is the txt option?

**without atypia→ Progesterine Therapy **with atypia, If they desire future fertility: Progesterine Therapy (ie. progestrine-releasing IUD)- which counteracts estrogen's effect by inhibiting endometrial proliferation & promotes differentiation -REPEAT endometrial Bx every 3mths ₀If it still had progressed to cancer→ require hysterectomy (#18564)

What is considered Reactive on NST?

*note: Non-reactive NST= may indicate hypoxemia & acidemia→ to Biophysical profile (#3110)

Name Uterotonics & tell me it's Contraindications

-Methylergonovine: CI is HTN (it causes constriction of smooth mm/ uterine/ vessel) serotonin-receptor agonist -Carboprost: CI is asthma (cause bronchoconstriction) Prostaglandin-F2a -Misoprostol: prostaglandin E1 analog Uterotonics: increase tonicity or induce contraction of uterus (#4809)

in preterm labor <32wks, what medications can you give and what do they do?

-Mg sulfate: provide fetal neuroprotection (ie. cerebral palsy) -tocolytics: (<32wks; indomethacin) -corticosteroid: (betamethasone) ↓risk of neonatal resp distress (#3269)

Causes of variable decelerations in FHR?

-cord compression: occlude umbilical vessels, esp during contractions→ ↑fetal SVR →reflex ↓FHR (aka. Nuchal cord) -oligohydramnios: ↓fluid can lead to cord compression Characteristic: -onset to nadir <30sec -doesn't have to be asso w/ contractions (but can be) (#12037) *Note: Cord prolapse: actually causes abrupt prolonged deceleration or bradycardia; as there is compression w/o decompression

Causes of Early deceleration in FHR?

-normal -fetal head compression Characteristics of Early decel: -mirrors contraction -onset to nadir ≥30sec (#12037)

Postpartum follow ups! 1. Routine (2) 2. gestational DM

1. -Intimate partner violence (3-6wks after delivery) -Postpartum Depression (4-6wks after) 2. 2hr 75g GTT - to screen for T2DM **No need to f/u: Pre-E, aSx UTI (#18280, 15949)

Name ovarian tumor types: 1. secrete LDH or b-hCG 2. may secrete thyroid hormone 3. virilization 4. high aFP 5.↑estrogen &↑ inhibin

1. Dysgerminomas 2. mature teratomas 3. Sertoli-leydig tumor 4. yolk sac tumors / ovarian germ cell tumor 5. Granulosa cell tumor -precocious puberty/ uterine bleeding -inhibin suppresses pituitary FSH release via neg feedback

If a pt is having abortion (ie. inevitable abortion), what management is appropriate for the following status? 1. Hemodynamically stable 2. Hemodynamically unstable 3. If persistent bleeding after initial treatment failed.

1. Expectant or medical (ie. misoprostol) 2. initially will do Suction Curettage: remove retained products of conception→ stops bleed 3. hysterectomy -if suction curettage, uterine tamponade, uterine artery embolization have failed! (#2541)

what is the evaluation needed for post-menopausal bleeding?

1. Pap test for cervical cancer: regardless of last pap test 2. TVUS look @endometrial thickness: >4mm →endometrial Bx ≤4mm→ May observe *BUT*, can go straight to Endometrial Bx bc this is gold standard Txt: hysterectomy w/ bilateral salpingo-oophorectomy (#12129)

1. Most common cause of puerperal(w/in 6wks postpartum) fever? 2. Treatment?

1. Postpartum endometritis: infx of uterine decidua. -due to inoculation of uterine cavity by vaginal flora during L&D (can also be from C/x!)= polymicrobial infx 2. Clindamycin &gentamicin -bc need broad-spectrum Abx -cont until >24hrs afebrile (#12297)

Tell me the Txt for the following urinary incontinence: 1. Stress 2. Overflow 3. Urgency 4. Mixed

1. Stress: Kegel ex, weightloss, Midurethral sling 2. Overflow: Cholinergic (bethanechol) 3. Urgency: Anti-Muscarinics & timed voiding 4. Mixed (Stress+Urgency): find which is more predominant by writing a voiding diary -Bladder Training w/ lifestyle changes (ie. weight loss, smoking cessation, ↓alcohol &caffeine intake) -pelvic floor ex (#15957, 2397, 2398)

Onset of Menses: 1. @ what Tanner stage? 2. how many yrs after initial breast bud dev? 3. avg age? 4. Until how old is it nl?

1. Tanner stage 4 2. 2-2.5 yrs after inital breast bud dev 3. avg 12.5 yo 4. <15yo is still ok if dev of 2ndary charac has been appropriate (#12477)

Based on the following chromosomal aberration, list what type of congenital anomalies you can see in the fetus 1. Trisomy 21 (down) 2. Trisomy 18 (edwards) 3. Trisomy 13 (patau) 4. Turner

1. Trisomy 21 (down): Endocardial cushion defect, Duodenal atresia, Tracheoesophageal fistula 2. Trisomy 18 (edwards): diaphragmatic hernia, rocker-bottom feet, clenched hands w/ overlapping fingers 3. Trisomy 13 (patau): holoprosencephaly, microcephaly, cleft lip, omphalocele 4. Turner: horseshoe kidneys, coarctation of aorta (#16965)

1.What are clinical features of PMS? 2.How to dx?

1. chart* 2. Sx diary over 2 menstrual cycle to see if Sx start during luteal phase (1-2wks b4 menses) & resolve during follicular phase (onset of menses or few days after) -Has to be severe enough (ie. miss work) to qualify as PMS (#8899)

Pap test shows "endometrial cells and no cervical intraepithelial lesions" what does this result mean for: 1. <45yo 2. >45yo

1. for <45yo, this is common and benign, esp during the first 10days of menstrual cycle 2. for >45yo, this is more concerning for abn, esp in postmeno pts -endometrial Bx is indicated (#14767)

Fundal height: 1. why do you measure? 2. what is normal?

1. indirect assessment of fetal growth & amniotic fluid volume (measured @ prenatal visits during 2nd &3rd trimesters) 2. After 20wks, Fundal height(cm) correlates to Gestational age(wks) ±3cm (i.e.: @29wks, fundal height should be 26-32cm) (#14166)

Septic abortion: 1. cause? 2. presentation? 3. pelvic exam finding 4. US finding? 5. Txt

1. non-sterile or incomplete abortion 2. fever, lower abd pain, heavy vag bleed, malodorous, purulent vaginal discharge 3. enlarged, boggy, tender uterus 4. intrauterine echogenic material w/ blood flow consistent w/ inflam 5. Broad-spectrum Abx & suction currettage (#2545)

pregnant pt has a migraine and acetaminophen did not work what can she take? tell me the steps of mgmt

1. nonpharm: rest/ hydration 2. Acetaminophen 3. Antiemetics or Codeine or caffeine/butalbital -can use w/ acetminophen 4. NSAID **only in 2nd semester 5. Opioids (#18967)

What's the cause of postpartum urinary retention?

1. regional epidural anesthesia→ ↓sensory & motor sacral spinal cord impulses → compress micturition reflex & ↓ detrusor tone→ bladder atony 2. Prolonged 2nd stage of labor→ perineal trauma→ pudendal nerve injury → ↓voiding sensation (#12034)

postpartum pt is bleeding from uterine atony. She is hemodynamically stable so far. What should be line of treatments?

1.Bimanual massage 2.infusion of Oxytocin 3.Uterotonics** 4. either: Intrauterine balloon tamponade, Uterine artery embolization 5. Hysterectomy (last resort) (#4809, 14774) **oxytocin is a first-line agent; then TXA; other agents, such as methylergonovine and carboprost may be administered if oxytocin fails

Preventive migraine therapy for pregnant pts?

1st line: -beta blockers (propranolol or metoprolol) -Ca⁺⁺ channel blockers: verapamil Note: -topiramate is avoided cuz teratogenic (cleft palate, low birth weight) (#18968)

Epidural can lengthen which part of labor?

2nd stage of labor: After 10cm dilation until fetal delivery! Note: Epidural can cause: -Postpartum Urinary retention - HoTN (Sympathetic that cause ↑vascular tone is blocked) (#15689, 4146)

pt @38wks gestation, ROM, contractions of 240MVU/10min. 8/90/0 4hrs later cervix is unchanged. next step? A. C-section B. Operative vaginal delivery

A. C-section -this is Arrest of Active phase; since no cervical change for ≥4hrs while adequate contractions ⊗Operative vaginal delivery: to expedite delivery for category III tracings or maternal exhaustion. -Can only do during 2nd stage of labor! (10cm dilation to fetal delivery) (#3116)

37yo woman comes to ED due to sudden onset, severe RLQ pain with vomiting. She is going through IVF, LMP 5wks ago. -Vitals: 100F, 140/70, HR92 -PE: RLQ tenderness w/ guarding & rebound -BME: tenderness in rt adnexa w/o mass or cervical motion tenderness -Lab: WBC16k, b-hCG2k -TVUS: singleton gestation w/in uterine cavity & nl bilateral adnexa w/ normal Doppler flow Dx?

Acute Appendicitis -Imp to r/o ectopic pregnancy first! ("ring of fire" on doppler) -Her TVUS of nl adnexa &doppler flow= eliminate most ob emergencies *IF pt has enlarged uterus due to pregnancy, appendix can be displaced & pain can be in RUQ! (#16071, 16072)

pt @30wk gestation comes to ER w/ severe RUQ pain since last night. complains of n/vx7. vitals: 99F, HR112. PE: pale, scleral icterus. no rebound tenderness. uterine is nontender w/o contractions. Lab: -plt: 60k , WBC 24k -glucose 48 -cr nl -TBili 5.3, alk phos 170, AST87, ALT 99 Dx? next step in mgmt?

Acute fatty liver of pregnancy (AFLP) -Immediate delivery, regardless of gestational age! AFLP: intrinsic hepatic dz, likely due to defective maternal-fetal fatty acid metabolism ₀ cause hepatic inflam(pain, ↑WBC, ↑LFT) → fulminant liver failure(↑Tbili, thrombocytopenia, hypoglycemia) →dev multiorgan sys failure (ie. DIC) ₀As mother decompensates, placenta hypoperfuses THUS ↑↑ maternal & fetal mortality rates (#16218, 16137)

PPROM with FHR nl. what's the management?

Admin Prophylactic Abx + expectant mgmt ±corticosteroids *Abx= 1wk of ampicillin, erythromycin, amoxicillin (Note, PCN for GBS is only intrapartum!!) **Tocolytics is CONTRAINDICATED in PPROM bc it halts contractions, which often indicate a complication (ie. intra-amniotic infx, placental abruption) that requires delivery or intervention (#16233)

17yo female pt comes in w/ 2mths of colicky LLQ pain, which worsens w/ exercise & intercourse but resolves spontaneously. -neg b-hCG -neg STD -pelvic exam: tender left adnexal mass -US: 8cm left ovarian cyst with calcifications & hyperechoic nodules Next step? A. Ca-125 & CEA serum B. Laparoscopic ovarian cystectomy to reduce risk of ovarian torsion C. observe & repeat US in 6wks as Sx will resolve

Ans: B. remove ovaries! Dx: Mature Cystic Teratoma (Dermoid cyst) -many are aSx -some can dev partial adnexal rotation (=intermittent colicky pelvic pain), triggered by physical activity -Can dev persistent ovarian torsion Thus should remove it! (#15174)

34yo nulligravid woman w/ 3mths of intermittent abd cramping. no other Sx Which prompts further evaluation in this pt? A. 4cm right adnexal mass B. FHx of mother with hysterectomy for heavy mentraul bleed & gma w/ breast cancer@64 C. US: adnexal mass w/ multiple irreg, thickened internal septations

Ans: C. concern for Epithelial ovarian carcinoma -size alone ≠malignancy; bc benign mass can also be really big! (but rapidly enlarging mass can suggest cancer) -gma is 2ndary relative so doesn't warrant further eval (#16824)

6hr post-partum pt has involuntary dribbling of urine & can't empty her bladder. She had epidural during her uncomplicated vag labor. How to manage? A. reassurance as it is self-limited B. Urethral catheterization C. Suprapubic catheterization

Ans: urethral cath She has postpartum urinary retention= inability to void≥6hrs after vaginal delivery (if c/x, ≥6hrs after catheter removal) Urethral cath: req'd for both Dx & txt! -postvoid residual volum of ≥150ml suprapubic cath is invasive and done only if urethral cath can't be done (urethral injury) (#4225)

22yo woman here for well-womans visit. on vaginal exam, there is a mobile, soft, nontender, flesh-colored, 2cm cystic mass @ 4 o'clock position at the base of left labium majus. Dx? Txt?

Bartholin duct cyst -4 &8 o'clock position -soft, mobile, nontender cystic mass; aSx Txt: will drain spontaneously and resolve on their own! IF Symptomatic (bc it got so big/ infected) then incision &drain then place Word Catheter to ↓recurrence. (#12112)

If pregnant pt is worried about down syndrome, which test is most effective?

Cell-Free DNA test! -detects Down syndrome 99% of the time. -Better than quadruple test (AFP, unconjugated estradiol, hCGP, inhibin A) Can also tell you about other Aneuploidy as well (APGO; 50Qs Ob)

pt @33wk gestation has PPROM. pt vitals: 102F, 90/56, HR109. What other signs do you look for that will warrant immediate Delivery?

Chorioamnionitis Dx: maternal Fever +≥1 of the following - fetal tachycardia (>160) -maternal leukocytosis -purulent amniotic fluid Note: Need to deliver fetus REGARDLESS of gestational age (ie induction of labor) bc of maternal morbidity & mortality > benefit gained by prolonging pregnancy -C/x is warranted if breech, severe maternal hemorrhage, etc. (it needs to meet its own criteria. chorioamnionitis itself doesn't meet c/x) *Note: genital inflammation (ie. infx) can lead to PPROM (#13352, 16234)

pt @37wk gestation started contracting 1hr ago. no leakage of fluid. 4cm dilation 90% effaced. all prenatal visits and checkup has been nl. cervical exam: bulging bag is palpable w/ no presenting fetal part. What's the next step? A. Amniotomy B. C-section C. External cephalic version D. Transabdominal US

D. Transabdominal US -Since no fetal part is palpable. we do not know what Fetal Presentation is. Thus, 1st determine that baby is not in breech presentation! -If cephalic, go for vaginal delivery -If breech, do external cephalic version and if Failed, C-section ⊗Amniotomy: no longer performed in spontaneous labor bc it does NOT ↓duration of 1st stage of labor or reduce C-section rates (#15691)

20yo woman complains of worsening acne. PE shows: -Nodulocystic ance -Hirsutism -Androgenic alopecia What are the DDx?

DDx: -PCOS (hirsutism, acne/ not male pattern balding) -Androgen-secreting tumor -Cushing syndrome -Nonclassical CAH Her PE shows signs of Hyperandrogenism (#12303)

What method of management is used to confirm clinical suspicion of endometriosis or pelvic adhesions?

Diagnostic laparoscopy (#8948)

In Pre-Eclampsia, why is LDH elevated?

Due to Microangiopathic hemolysis (#12064) *Note: HELLP occurs in ~20% of severe pre-E

US of a fetus has these traits: 1. echolucent abd fluid 2. single deepest pocket >8cm 3. placental thickening w/ pleural and pericardial effusion. Dx? Possible Causes? (list what the traits mean)

Dx: Hydrops fetalis Causes: Parvo, Rh alloimmunization, α-Thalassemia major, Fetal aneuploidy, CV abn, etc 1. echolucent abd fluid= Ascites 2. single deepest pocket >8cm**= polyhydramnios 3. placental thickening= intravillous edema (#14709) **Deepest pocket <2: oligohydramnios 2-8: normal **Normal AFI: 5 to 25 cm -Amniotic Fluid Index (AFI) is different from deepest pocket!

2wk postpartum & breast-feeding pt wants contraception. What's the best option?

Either: -Copper IUD (not for anemic/heavy bleeders) -Progestin-only IUD (can ↓ protein content in breastmilk) *In <1mth postpartum & breastfeeding, estrogen-containing products are avoided bc ↑thromboembolism & (-) affect on breastfeeding (usually wait 6wks to give combined ocp) *technically, any iud, depot, combined ocp, progestin-ocp: none of these really interrupt breastfeeding. (#16587, 3339)

29yo woman @33wk gestation w/ known vasa previa is admitted for ROM w/ blood tinged-fluid within the last hr. She was conceived by IVF but pregnancy has been uncomplicated. uterus is nontender & no contractions. FHR is 100/min. Best next step? A. betamethasone & magnesium sulfate B. Emergency C-section

Emergent C/s! - vasa previa (fetal vessel overlying the cervix) most likely tore w/ ROM = blood tinged fluid -fetal bradycardia: sign of ruptured fetal vessel. ⊗Betamethasone: takes hrs to take effect. so in emergencies, offers min benefit ⊗Mg sulfate: NOT admin to pts ≥32wks gestation (#17182)

25yo with pelvic pain that is worse before her period. PE: tenderness in post vaginal fornix, decreased uterine mobility, and thickening of uterosacral ligaments. Dx? Sx? PE findings? Txt?

Endometriosis ₀Sx: before onset of menses, ↑in pelvic pain, dyspareunia, dysmenorrhea ₀PE: tenderness of recto-vaginal area & mvmt of uterus, thickening of uterosacral ligaments, cervix displaced ₀Txt: 1) empirically w/ NSAID & OCP, if Failed then 2) Laparoscopy: visualize, Bx, and remove endometriotic lesion **Definitive txt: hysterectomy & oophorectomy (#4473, 15708)

Why do pt have urgency incontinence post menopause?

Estrogen-sensitive tissues in bladder trigone & urethra (↓collagen, elasticity, and blood flow)→ urogenital atrophy & urgency incontinence (#12054)

30yo woman at 29wks gestation reports increasing fatigue, SOB w/ exertion, and bilateral leg swelling over last few wks. -Vitals: nl -PE: CV and pulm nl, bilateral LE edema 2+ up to knees. -Lab: platelets 118,000 (was 240,000 @10wk) Dx&management?

Gestational thrombocytopenia -mild (100,000-150,000) -aSx -Reassure! (plt # will return to nl w/in 6wks postpartum) *Her fatigue, SOB, and edema= NORMAL Sx of Pregnancy!! (#18481)

Which ovarian Tumor can cause precocious puberty in females?

Granulosa Cell tumor *Precocious puberty= 2ndary sexual charac in girls <8yo (#4230)

What causes HELLP syndrome?

HELLP (Hemolysis, elevated LFG, Low Platelet) thought to result from abn placentation→ triggering systemic inflam w/ platlet consumption & activation of coagulation system and complement cascade (#4795)

How do you manage Hydatidiform mole? Why do pt need to be on contraception >6mths following Suction curettage of Hydatidiform mole?

Hydatidiform mole can dev into Gestational trophoblastic neoplasia (GTN), like choriocarcinoma. f/u suction curettage, surveillance of GTN is done by β-hCG levels. you follow β-hCG weekly until undetectable→ Then, monitor monthly for 6mths. IF levels plateau or increase, it is Dx for GTN! Since Pregnancy will make it hard to det levels, contraceptive is required during this time. (#12311)

pt @ 8wks gestation has persistent vomiting, signs of dehydration and lost 3 kg after pregnancy (current 55kg). What are some labs to diagnose her?

Hyperemesis gravidarum - This is different from normal "morning sickness" Labs: 1. ketones on UA 2. Hypokalemia 3. Hypochloremic metabolic alkalosis *Know the clinical features to Dx this! (#12234)

In women age 40-50s, Vasomotor Sx, insomnia, and irreg menses can be due to what?

Hyperthyroidism or Menopause -these can present w/ overlapping clinical manifestations (#4136)

32yo female w/ multiple submucosal fibroids come to clinic due to heavy menstrual bleeding & wanting to conceive. What's best management for this pt?

Hysteroscopic myomectomy -can remove submucosal fibroids, by accessing thru vagina -correct abn intrauterine anatomy→ ↓heavy menstrual bleeding & ↓infertility/pregnancy complications! (#14753)

pt @32 wk gestation has failed her 3hr GTT - no PMH, BMI 19 with healthy lifestyle which is the most likely mech of her gDM?

Increased insulin resistance 3rd Trimester pregnancy causes→ ↑human placental lactogen or hPL (placental somatomammotropin) production→ pancreatic β cell hyperplasia→ ↑insulin secretion & ↑peripheral insulin resistance Insulin antagonism by hPL is mediated by the increase in free fatty acid levels, which, in turn, directly interfere with insulin-directed entry of glucose into cells. (#12179)

What is the diff btw Threatened & Inevitable Abortion?

Inevitable has Dilated cervical os! (may see or feel product of conception above os) *Both have vaginal bleeding (#2544)

47yo woman w/ 2mths of worsening lower abd pain that is relieved w/ urination. Also has pain with intercourse. -PE: no cervical motion tenderness -valsalva(-) -UA &urine culture is (-) Dx?

Interstitial cystitis (bladder pain syndrome) -Sx: bladder pain w/ filling &relief w/ voiding, ↑urinary frequency & urgency, dyspareunia This is Dx of exclusion: r/o everything else! -valsalva is looking for Cystocele -overactive bladder will not have dyspareunia or relief w/ voiding (#4807)

pt who had c-section a few hrs ago has CC of extreme fatigue. BP 80/50, HR124. PE: pale w/ cold skin. fundus is firm at umbilicus. abd is tender but no bleeding from incision site. minimal lochia w/o clots. Dx? Txt?

Intraabdominal bleeding from uterine artery injury - post c/x delivery pts in shock without vaginal or incisional bleed or signs of uterine atony -bleed is likely collecting in retroperitoneal space Emergency lapartomy! (#16318)

37yo pt @8wks gestation comes to the clinic. -b-hCG: 25,659 IU/L. (was 27,325 last wk) -Pelvic exam: closed os & no discharge/bleed -TVUS: intrauterine gestational sac w/ yolk sac but no fetal pole. Dx?

Missed Abortion -no vaginal bleed -closed os -No fetal cardiac activity OR empty sac *Also ↓β-hCG = abn pregnancy/demise (#12318)

what are teratogenic effects of valproate?

Neural tube defects (spina bifida); minor craniofacial defects (APGO; 50Qs Ob)

63yo female at annual exam w/o any concerns. PE: on valsalva, there's a bulge of anterior vaginal wall to the introitus. Next step in management?

Observation -pt has Cystocele but no Sx!! so no need to do anything ₀aSx: Just observe! ₀Sx: 1. kegel exercises, then 2. Vaginal pessary, then 3. surgical repair (#18973)

27yo pt has seizure 30hrs postpartum. Prior to labor: She had received oxytocin infusion for 48hrs for induction of labor bc she had pre-E w/ severe features. & She also received magnesium sulfate for seizure prophylaxis. During labor: PPH txt w/ bimanual massage & oxytocin bolus Now: -vitals: nl -labs: Hb 10 / K+, Cl-, Mg2+: nl / Na+ 112 What's the cause of seizure? A. Mg sulfate toxicity B. Seizure from Eclampsi C. Oxytocin side effect

Oxytocin side effect Oxytocin has similar structure as ADH/vasopressin: can ↑free water absorption Thus ↑↑oxytocin→ acute hyponatremia→ cerebral edema→ seizure (#3117)

pt has PPROM @33wk of gestation. Managment?

PPROM (preterm premature rupture of membrane) <34wks, expectant management: -corticosteroid for fetal lung maturity -prophylactic broad-spectrum Abx: to prevent chorioamnionitis ₀For prevention of infx: 1wk of ampicillin, erythromycin, amoxicillin ₀If pt gets chorioamnionitis, give clinda, erythro (+ usually also warrants immediate delivery) ₀If pt has fever &/or have unk GBS status, give intrapartum PCN (#13352)

What's initial Diagnostic imaging for Fibroids?

Pelvic US (#8948)

33yo @39 gestation is having contractions every 4min with ROM 2hrs ago. she is 5cm/80%/-1. FHR is Category I. 4hrs later, she continues to have contractions w/ same FHR But her cervical exam is unchanged. What to do?

Place Intrauterine pressure catheter! Arrest is defined as: ≥4hrs of no change of cervix w/ adequate contractions Thus, we need to place a pressure catheter to see if contraction is >200MVUs -IF >200MVUs, C/x -IF <200MVUs, observe for 2 more hrs then det if it is Arrest (APGO obj26 #1)

26yo women comes to clinic for routine visit after 6mths postpartum w/ uneventful delivery. -she had excessive anxiety first 2-3mths -fatigues & irritable last several wks -also constipated -gained 5lbs in last 3mths Vitals: 130/90, HR60 PE: bilateral LE edema Lab: hyponatremia Dx?

Postpartum thyroiditis -brief hyperthyroid phase→ self-limited hypothyroid phase→ euthyroid. -Dx w/in first 6mths postpartum Pt is in hypothyroid phase: -note low HR, bilateral LE edema and hyponatremia How does hypothyroidism cause hyponatremia? - hypothyroidism→ ↓Cardiac output → ↑ADH→ decreased capacity of free water excretion (#12398)

44yo pt w/ light intermenstual bleeding over 3mths. Her menstrual cycle is regular and normal in duration, amt, cramping. -no PMH or meds -multiparous all vaginal delivery -BMI 22 -uterus is small, mobile, and nontender w/o adnexal mass Dx?

Pre-meno pt w/ reg monthly menses & inter-menstrual bleeding most likely has an Endometrial polyp -painless, light intermenstrual bleed -small, nontender uterus w/no visible cervical or vaginal lesions NOT endometrial hyperplasia: presents w/ irreg anovulatory menses w/ unopposed estrogen. =this pt has nl BMI & reg ovulation (#14752)

Secondary Amenorrhea w/ -nl TSH & prolactin -high FSH -low estradiol Dx?

Primary ovarian insufficiency hypothalamus (GnRH) & ant pituitary (TSH, prolactin, FSH) are working fine! but ovaries are not working since it's not producing enough estradiol thus, (one level up) ant pituitary is ↑↑ release of FSH due to lack of neg inhibition (#15167)

For Adolescent girls who have irregular, heavy menstrual bleed due to immature hypothalamic-pituitary axis, which txt helps?

Progesterone PO therapy -stabilizes unregulated endometrial proliferation (#12524) *Note: -Primary dysmenorrhea is crampy abdominal/back pain beginning 1or 2 days prior to menses & resolving w/in the first few days of menses with a normal physical examination= NSAID or OCP -PMS is bloating, irritability, mood swings that makes pt miss work= SSRI -Endometriosis: pain few days before onset of cycle & dysmenorrhea, dyspareunia, dyschezia

what test can confirm low estrogen levels? What is this test used for?

Progestin challenge test (ie. medroxyprogesterone acetate) -If pt have enough estrogen, their endometrium would be adequately proliferated→ thus once progesterone 10-day challenge is done, her endometrium should slough off -pt w/o adequate estrogen: NONE to MIN bleeding (no endometrial lining to shed) Good way to test for secondary amenorrhea caused by: -functional hypothalamic amenorrhea -Compromised outflow tract: either Asherman's syndrome (adhesions) or cervical stenosis (scarring) -Premature ovarian failure (#4480)

G5P4 women @ 39wks is in labor. -BMI: 33, gained 40lbs this pregnancy -She had 1cm of cervical dilation in 4hrs w/ 200MVUs What is the problem here?

Protraction of labor caused by Cephalopelvic disproportion common in late-term preg, fetal anomaly, or malposition. (#15689,12213)

33yo woman with 3mth dyspareunia and vaginal dryness. -no postcoital bleeding, change in libido, discharge -PE: bilateral atrophic breasts, pale &thin vulva, clitoris protrudes from the clitoral hood. minimal vaginal rugation & large, mildly tender adnexal mass -TVUS: 9cm solid adnexal mass Dx?

Sertoli-Leydig Cell tumor: testosterone-secreting sex cord stromal tumor 1. Rapid-onset virilization: clitoromegaly, male-pattern balding, voice-deepening,etc 2. Signs of Estrogen deficiency: ↑↑Testosterone→ inhibits hypothalamic GnRH & pituitary FSH/LH release→ ↓Estrogen (#14529)

pt @35wks gestation comes to ER w/ contractions. after eval you see: - closed cervix - reassuring NST - Toco w/ irreg uterine contractions. Next step?

She has false labor "Braxton Hicks contractions" Reassure & d/c w/ labor precaution (#3271)

38yo female pt comes to the office with CC of fatigue. "been beyond exhausted" for the past 5 mths since birth of her twins. she's having difficulty keeping track of new responsibilities and forgets to eat. she feels "disappointed" that she was unable to breastfeed. her delivery was complicated by PPH. PMH: MDD, not taking meds BMI 18 (pre-preg weight) Vitals: 85/55, HR65 What is the cause of her Sx?

Sheehan Syndrome -I was focused more on the "" and thought maybe cause was nutritional deficiency OR psych But all her Sx points to Sheehan: -↓TSH: fatigue/ bradycardia -↓ACTH: anorexia, weight loss, HoTN -↓prolactin: lactation failure -&her Hx of PHH (#4245)

pt conceived her 2nd baby after 6mths of birthing her 1st child. What are some possible complications & why?

Short interpregnancy interval (<6-18mths from delivery to next preg) Mother depletes iron, FA, and other nutrition for 1st child's pregnancy, delivery, and breastfeeding.→ Mother has worse anemia, low birthweight, preterm labor. *Also, PPROM can occur due to persistent genital tract inflam. (#16235)

Female pt w/ Bipolar 1 well controlled on Valproate is planning to conceive. Due to teratogenic properties of valproate, valproate is switched to which medication?

Switch to Lamotrigine Mood Stabilizers (options) 1. Lithium: Ebstein anomaly 2. Valproate: Neural tube defect 3. Lamotrigine: safer pregnancy profile (#15103)

If pregnant pt has prior Hx of HSV infx but current doesn't have any sign of active outbreak, what's the management?

Take Prophylactic antiviral (acyclovir, valacyclovir) from 36wks until labor. during labor, if she has lesions or prodromal Sx, do C/x (#15409)

6wk postpartum pt complains of light vaginal bleeding of brown blood. What do you advise her?

This is normal Lochia, a gradual process of endometrial shedding & regeneration. Can last up to 8wks after delivery. (#18282)

Which medication is an antifibrinolytic that can prevent blood clot breakdown & significantly decrease blood loss in labor & delivery? indication for its use? what's the time frame of use?

Tranexamic acid (TXA) can be used for ANY PPH! Within 3 hrs of delivery (use with caution in pt w/ hypercoagulability) (#16489)

pt with Hx of Grave's but surgically removed it 6mths before pregnancy gives birth to a baby after 40wks. Since thyroid removal, she had to be txt w/ levothyroxine due to being hypothyroid during pregnancy. Her new born has signs of neonatal thyrotoxicosis. How is this occurring?

Transplacental TSH-receptor Ab -In Grave's there are Ab being made by the body that stimulates TSH. -So even if pt removes the thyroid, the Ab(IgG) can still be around & cross the placenta. "elevated anti-TSH receptor Ab levels can occur despite maternal txt for Grave's disease and euthyroidism or hypothyroidism during preg" TxT: methimazole & β-blocker

33yo woman with 2wk mass in the anterior aspect of vaginal wall. causes dyspareunia. no postcoital bleed or irreg menstrual bleed. PE: tender to palpation & expresses purulent and bloody urethral discharge. does not change with valsalva. Dx?

Urethral diverticulum -due to recurrent periurethral gland infx→ abscess that breaches urethral mucosa. -diverticulum collects urine/debris→ purulent/bloody discharge, dysuria, postvoid dribbling *Anterior vaginal wall mass that is tender; can have dyspareunia. -Dx with MRI -txt with surgical excision (#15926, 15802)

pt @38wks gestation in labor. last preg was c-sec due to breech. -initial presentation: 6cm/60%/0. reassuring FHR -2hrs later: 6cm/60%/-3. sudden intense lower abd pain. FHR with recurrent late decelerations. moderate vaginal bleeding. Dx?

Uterine rupture Look for: - loss of fetal station (0 to -3 station) -palpable fetal parts in abd (irreg protuberance in abd) -abn FHR (recurrent variable & late decel; due to umbilical cord compression and ↓blood flow) (#2532)

pt @ 41wk gestation w/ CC of less fetal mvmt. -FHR: decreased from 140 to 130 after peak contraction & lasted for a min. -single deepest pocket 1cm -BPP4 What is causing this finding?

Uteroplacental insufficiency -late deceleration -oligohydramnios (#3112, 9985)

19yo comes to the office due to few wks of Continuous vaginal discharge. -6wks ago had vaginal birth to stillborn after 3 days of labor. -vaginal exam: small, red area of granulation tissue on anterior vaginal wall. No cervical lesion. Vaginal pooling of malodorous, clear fluid with pH6. Dx? Dx test?

Vesicovaginal Fistula -complication of obstructed labor (excessive fetal head compression →injury & necrosis to maternal vagina, rectum, bladder) -continuous d/c is urine. odor due to surrounding necrotic tissue. Test: Bladder dye test Txt: surgical repair (#15946)

52 yo post-meno pt w/ vulvar irritation. She noticed streaks of blood. PSH: hysterectomy & bilateral salpingo-oophorectomy for adenomyosis PE: multiple vulvar excoriations, red/friable plaque on left labium majus. Dx? A. Lichen sclerosis B. Vulvar cancer C. Contact dermatitis

Vulvar cancer Sx: Vulvar pruiritus, plaqu/ulcer & abn bleeding (#14197)

62 nulligravid woman with 5cm right ovarian cyst on pelvic US. menopause @52 w/o any postmeno bleed. what is next action? A. CA-125 level B. needle aspiration for cytology

ans: CA-125 (biomarker for epithelial ovarian cancer) -If pelvic US had benign charac & nl CA-125→ observe w/ periodic US -If US malignant features &/or ↑CA-125→ MRI or CT scan ⊗Needle aspiration is CONTRAINDICATED: risk of spreading potentially malig cells (#8903)

what causes fetal sinusoidal tracing?

asso. w/ severe fetal anemia, such as blood loss (ie. ruptured vasa previa) Category III tracing: Urgent C-section! (#15547)

45yo woman with fatigue, 10lb weight gain w/o hair loss, changes in BM, or mood. period became irregular over the last 2 yrs; last was 3mths ago. sexually active. PE are unremarkable bimanual exam: uterus is symmetrically enlarged w/o palpable adnexal masses. next step in management?

hCG level. -she is pregnant! I assumed she was hitting menopause due to irreg menstrual cycle. -Even though perimenopause Sx can overlap, ALL women of Reproductive age w/ Amenorrhea + Sx of preg = hCG test -enlarged uterus is also a clue for pregnancy (#12439)

How does HELLP cause RUQ or epigastric pain?

liver problems (centrilobular necrosis, hematoma formation, thrombi in portal capillary system)→ liver swelling→ distends hepatic (Glisson's) capsule→ RUQ/epigastric pain (#4781)

pt has Hx of prior preterm delivery and shortened cervix. what medication can you give to prevent preterm delivery?

progesterone (#3269)

20yo woman with days of vaginal bleed &RLQ pain. last period was 7wks ago & sexually active. -Vitals: unremarkable -PE: no active vaginal bleed &closed cervical os -lab: Hb 11 & b-hCG 1000 IU/L -TVUS: no intrauterine or extrauterine pregnancy. Next step in mgmt?

repeat b-hCG in 2 days -Since she is hemodynamically stable w/o Adnexal mass or TVUS showing pregnancy, -look @ b-hCG level: <1500 IU/L → repeat in 2 days (bc it will ↑ every 2 days in viable pregnancies; but slower in ectopic & nonviable) *Abd US is much less sensitive than TVUS so if TVUS didnt show preg, you won't find anything (#4759)

29yo female has not had menses after stopping OCP 6mths ago. she had irreg & heavy menses since 14yo. Since stopping OCP, she had frequent headaches & increasing acne. neg UPT & pelvic US is nl. BMI 22 next step in eval?

serum prolactin level -She has 2ndary Amenorrhea. (after stopping OCP, menses shud return in 1-3mths) 1. Pregnancy test (UPT) 2. serum: FSH, TSH, prolactin *Note: Headache is nonspecific & may be due to estrogen fluctuation after OCP d/c. *Even if you think of pituitary MRI, need to get ↑prolactin levels to do so (#4220)

Why do pt have recurrent UTI and dysuria post menopause?

↓glycogen content → loss of vaginal lactobacilli & ↑pH→ ↑risk of recurrent UTI thin, easily denuded vulvovaginal epithelium causes dyuria (#12054)