The Final Step: Ob/Gyn
What are four causes for postpartum hemorrhage?
*"4 Ts"* ⇢ *T*one: uterine atony ⇢ *T*rauma: hematoma, inversion, rupture ⇢ *T*issue: retained placenta ⇢ *T*hrombin: coagulopathy
What are four tocolytic medications you should be aware of?
*"It's Not My Time"* ⇢ *I*ndomethacin (NSAID) ⇢ *N*ifedipine (calcium channel blocker) ⇢ *M*agnesium sulfate ⇢ *T*erbutaline (adrenergic agonist)
What are two medications used to induce labor?
*dinoprostone (Cervidil)* ⇢ prostaglandin gel applied to cervix ⇢ encourages cervical rippening *oxytocin (Pitocin)* ⇢ encourages uterine contractions
At how many weeks of pregnancy can chorionic villus sampling be done?
10-13wks
What is the normal range of fetal heart rate?
120-160bpm
At approximately how many weeks pregnant is the uterus at the level of the symphysis pubis?
12wks
At how many weeks of pregnancy can an amniocentesis be done?
15-20wks
About how much weight should a woman gain during pregnancy?
20-35lbs
At approximately how many weeks pregnant is the uterus at the level of the umbilicus?
20wks
At what point during pregnancy is RhoGAM given if it is needed?
28wks
What is the karyotype for a patient with Turner syndrome?
45, XO ⇢ they are missing one sex chromosome
What is the average age of menopause?
51
What is the mean age for ovarian cancer?
63 ⇢ you will need to think of this in an older patient with vague abdominal SX
What is the most common endometrial cancer?
75% are adenocarcinomas
How many days after conception is a serum beta-HCG positive?
8
What age range is the HPV vaccination recommended for?
9-26 years
What is a cystocele?
A herniation of the bladder into the vagina
When is it recommended to begin pap smears?
Age 21 ⇢ regardless of sexual history
Clue cells should make you think of what diagnosis?
Bacterial vaginosis
Thin, sticky, malodorous vaginal discharge should make you think of what diagnosis?
Bacterial vaginosis
What medication is used to increase surfactant levels and help with lung maturity if you are worried about preterm labor?
Betamethasone ⇢ steroid
Are fibrocystic breast masses usually bilateral or unilateral?
Bilateral
What ethnic background is at an increased risk of fibroids?
Black women ⇢ black women are five times more likely than white women to have fibroids
Define metrorrhagia.
Bleeding between menstrual cycles
During what portion of the menstrual cycle does PMS occur?
By definition, it is the second half (luteal phase) and menstruation should relieve the symptoms
A patient believes she is pregnant. You notice that her cervix appears a little blue. What is the name of this sign?
Chadwick's sign
What is the most common sexually transmitted bacteria?
Chlamydia
What medications are used to treat postpartum metritis?
Clindamycin + gentamicin
If the pap smear results come back anything other than negative or ASCUS what is your next step?
Colposcopy and biopsy
Give the definition for preterm labor.
Contractions that open the cervix before 37wks
What is the treatment for Turner Syndrome?
Cyclical estrogen and progesterone
Define full term.
Delivery at 37-42wks
Define premature birth.
Delivery before 37wks
Define the third stage of labor.
Delivery of baby to delivery of placenta
Define abortion.
Delivery of uterine contents before 20wks
Postmenopausal bleeding is immediately believed to be what diagnosis?
Endometrial cancer until proven otherwise
If you see the term chocolate cyst, it should make you think of what diagnosis?
Endometrioma
A physical exam revealing a retroverted uterus or uterosacral ligament modularity should make you think of what diagnosis?
Endometriosis
The follicular phase of menstruation is dominated by what hormone?
Estrogen
Early on in pregnancy serial beta-hCG should double over what time period?
Every 48-72hrs
A cervical biopsy comes back as CIN2 or CIN3. What is your next step?
Excision ⇢ LEEP ⇢ cold knife (worry about incompetent cervix) ⇢ cryotherapy
How do you definitively diagnose endometriosis?
Exploratory laparoscopy
A unilateral, single, mobile, firm, nontender solid breast mass should make you think of what diagnosis?
Fibroadenoma
A rope-like breast mass should make you think of what diagnosis?
Fibrocystic breast mass
How is the first day of the menstrual cycle defined?
First day of menstrual bleeding is day one of the cycle
Define the second stage of labor.
Fully dilated to delivery
What is the most common type of ovarian cyst?
Functional cyst ⇢ no treatment needed
A woman presents to the ER concerned she is in preterm labor. What treatment should you begin before even getting any imaging or lab results?
Give IV fluids ⇢ dehydration is most common cause
Which four human papillomaviruses are linked to cervical cancer?
HPV 16, 18, 31, 33
Define menorrhagia.
Heavy prolonged menstrual flow
Is FSH high or low in Turner syndrome?
High ⇢ there are no ovaries to respond to FSH and therefore no negative feedback
A snowstorm appearance on ultrasound should make you think of what diagnosis?
Hydatidiform mole ⇢ gestational trophoblastic disease
Grape-like vesicles or a sack of grapes on ultrasound should make you think of what diagnosis?
Hydatidiform mole ⇢ gestational trophoblastic disease
A patient with primary amenorrhea and a low FSH should make you think of what diagnosis?
Hypothalamic pituitary insufficiency
What endocrine issue is associated with PCOS?
Insulin insensitivity
Since a genetic cause is the number one reason for primary amenorrhea, what is one very important test?
Karotype
What is the most common uterine tumor?
Leiomyoma (Fibroid)
What organism causes us to warn pregnant patients to stay away from deli meats and soft cheeses?
Listeria
Why is folic acid given as a prenatal vitamin?
Low folic acid can lead to neural tube defects
A surge in what hormone leads to ovulation?
Luteinizing hormone (LH)
What is the medical treatment for an early ectopic pregnancy?
Methotrexate
List two medications commonly used for hypertension in pregnancy.
Methyldopa and Labetalol
What is the most common infection following a C-section?
Metritis
How do you treat a Trichomonas infection?
Metronidazole
How do you treat bacterial vaginosis?
Metronidazole x 7 days
What is the formula for calculating estimated date of confinement or due date?
Naegele's rule ⇢ first day of last menstrual period *plus* 1yr *minus* 3mos *plus* 7 days
Purulent cervical discharge should make you think of what diagnosis?
Neisseria gonorrhoeae
What is the #1 cause of septic arthritis in sexually active young adults?
Neisseria gonorrhoeae
What lab test is the gold standard for chlamydia?
Nucleic acid amplification test (NAAT)
Is a nulliparous or multiparous woman more likely to get preeclampsia?
Nulliparous woman ⇢ nulliparity is a risk factor preeclampsia
What location within the pelvis is endometriosis most commonly found?
On an ovary
Should a breast feeding mother stop breast feeding is she develops mastitis?
Only if she develops an abscess
Define the first stage of labor.
Onset of contractions to full dilation of the cervix
A 66-year-old female patient presents with bouts of nausea, weight loss, and vague abdominal pain. What is the most likely diagnosis?
Ovarian cancer
Which reproductive cancer carries the highest rates of death in women?
Ovarian cancer
What medication can be used to control bleeding due to uterine atony?
Oxytocin (Pitocin)
What is the term for when the placenta has implanted directly over the cervical os?
Placenta previa
Which is associated with painful third trimester bleeding: placental abruption or placenta previa?
Placental abruption
The baby was delivered several minutes ago. Suddenly, there is an increase in blood flow from the vagina and the cord noticeably lengthens. What is the most likely cause of these signs?
Placental separation
A patient presents with irregular menses, hirsutism and infertility. What is the most likely diagnosis?
PolyCystic Ovarian Syndrome (PCOS)
What is the more popular term for Stein-Leventhal syndrome?
PolyCystic Ovarian Syndrome (PCOS)
What is the most common cause of secondary amenorrhea?
Pregnancy
Interference with work or school is part of which diagnosis, premenstrual syndrome or premenstrual dysphoric disorder?
Premenstrual dysphoric disorder
The secretory phase of the menstrual cycle (day 14-28) is dominated by what hormone?
Progesterone
What would you expect to see on a KOH prep if the patient had vaginal candidiasis?
Pseudohyphae
When does quickening occur?
Quickening (fluttering fetal movements) ⇢ nulliparous: 18-20wks ⇢ multiparous: 14-16wks
What Rh combination for mom and dad might cause the mother to create antibodies against the baby's red blood cells?
Rh-negative mom + Rh-positive dad
What is the most common organism that causes mastitis?
Staphylococcus aureus
An ovarian cyst that contains hair and teeth should make you think of what diagnosis?
Teratoma (dermoid cysts)
What medium do you need to grow out Neisseria gonorrhoeae?
Thayer-Martin agar
Why is ovarian cancer so hard to diagnose?
There are no good markers and the symptoms are very vague
As part of the antepartum testing a baby has a positive stress test. What does that mean?
They have had two heart rate accelerations in a 20 minute period of 15 beats above baseline for at least 15 seconds ⇢ this is a good thing (reactive)
What is the first step of treatment for endometrial cancer?
Total hysterectomy and bilateral salpingo-oophorectomy
A strawberry cervix with copious yellow/green discharge should make you think of what diagnosis?
Trichomonas vaginitis
Vaginal infection with motile flagellated protozoa should make you think of what diagnosis?
Trichomonas vaginitis
What is the hallmark physical exam finding for placenta previa?
Trick question ⇢ *never* do a physical exam on someone with presumed placenta prevue
A description of a young girl with a web neck or wide shield chest should make you think of what diagnosis?
Turner syndrome
Dose mastitis tend to be unilateral or bilateral?
Typically unilateral and only one quadrant
What is the most common cause of postpartum hemorrhage?
Uterine atony
Define procidentia.
Uterine prolapse beyond the introitus (4th degree)
Cottage cheese discharge should make you think of what diagnosis?
Vaginal candidiasis
What is the most common site of an ectopic pregnancy?
Within a fallopian tube
List 5 risk factors for ovarian cancer
⇢ BRCA1 ⇢ family history ⇢ nulliparity ⇢ late menopause ⇢ white or asian
List five risk factors for breast cancer.
⇢ BRCA1, BRCA2 positive ⇢ unopposed estrogen ⇢ nulliparity ⇢ early menarche ⇢ late menopause
List five risk factors for placental abruption.
⇢ HTN ⇢ smoking ⇢ advanced maternal age (AMA) ⇢ cocaine use ⇢ PROM
What characteristic of pelvic inflammatory disease will help to differentiate it in a question stem from ectopic pregnancy, appendicitis, ovarian torsion and ovarian cyst?
⇢ PID: bilateral pain ⇢ all others: unilateral pain
At what age is primary amenorrhea diagnosed?
⇢ age 13, if no secondary sex characteristics ⇢ age 16, if some secondary development
A patient presents with mucopurulent discharge and cervical motion tenderness. What is the most likely diagnosis?
⇢ cervicitis (Chlamydia) ⇢ pelvic inflammatory disease
List risk factors for endometrial cancer.
⇢ chronic unopposed estrogen ⇢ nulliparity ⇢ early menarche ⇢ late menopause ⇢ tamoxifen ⇢ diabetes, hypertension, obesity ⇢ breast or ovarian cancer
What is the first line treatment for mastitis?
⇢ dicloxacillin (first line) ⇢ cephalexin or erythromycin (second line)
What are three ways you can check for ruptured membranes?
⇢ ferning pattern on a slide ⇢ visualize leakage from the cervix ⇢ pooling in the vagina
How do you treat vaginal candida?
⇢ fluconazole (Diflucan) PO 1 dose ⇢ -azole cream x 1 week
What is the classic triad of pre-eclampsia?
⇢ hypertension ⇢ edema ⇢ proteinuria
How much time needs to pass before diagnosing secondary amenorrhea?
⇢ if cycles have been regular, then 3mos ⇢ if cycles have been irregular, then 6mos
You have a patient with PCOS who would like to get pregnant. What are two medications you may start her on?
⇢ metformin ⇢ clomiphene (Clomid)
List two risk factors for cervical cancer.
⇢ multiple sex partners ⇢ smoking
Define missed abortion.
⇢ no vaginal bleeding ⇢ cervix is closed ⇢ products of conception are still inside
What are the five components of the biophysical profile as part of antepartum testing?
⇢ non-stress test ⇢ fetal breathing ⇢ two gross body movements ⇢ fetal tone (heart rate) ⇢ amniotic fluid index
What are three treatments for uterine prolapse?
⇢ pessary ⇢ Kegel's maneuvers ⇢ surgical repair
Gestational diabetes puts mom and baby at increased risk for what three things?
⇢ preeclampsia ⇢ macrosomia (traumatic birth) ⇢ slowing in fetal lung development
List three risk factors for an ectopic pregnancy.
⇢ previous ectopic ⇢ scarred tubes (history of PID or salpingitis) ⇢ IUD
The pap smear results on a 23-year-old patient come back as atypical squamous cell uncertain significance (ASCUS). What is your next step?
⇢ repeat pap smear in 12mos ⇢ HPV test is also acceptable
A cervical biopsy comes back as CIN1. What is the next step?
⇢ repeat pap smear in 6mos ⇢ repeat colposcopy in 12mos
What are two important things you need to tell your patients before putting them on metronidazole?
⇢ stay out of the sun ⇢ avoid alcohol
What is the treatment for ovarian cancer?
⇢ total hysterectomy and bilateral salpingo-oophorectomy ⇢ adjuvant chemo + radiation
Define complete abortion.
⇢ vaginal bleeding ⇢ cervix closed ⇢ products of conception have passed
Define inevitable abortion.
⇢ vaginal bleeding ⇢ cervix is open ⇢ products of conception are still inside
Define incomplete abortion.
⇢ vaginal bleeding ⇢ cervix is open ⇢ products of conception partially passed
Define threatened abortion.
⇢ vaginal bleeding ⇢ closed cervix ⇢ products on conception are still inside
What three labs should you order if you are considering secondary amenorrhea?
⇢ β-hCG ⇢ TSH ⇢ prolactin