PANCE review reproductive system
At what gestation age is suction or vacuum curettage used to terminate a pregnancy?
7 to 13 weeks
What would you expect on microscopic evaluation with saline and 10% KOH on a patient with BV?
"Clue cells" which are epithelial cells with bacilli attached to their surfaces. On saline wet mount adding 10% KOH to the dischrage produces a fishy odor
At what gestational age is suction or vaccum curettage used to terminate a pregnancy?
7 to 13 weeks
By which week of gestation can a mother feel fetal movement? What is the term used to discribe this?
18 to 20 weeks in primigravida and as early as 14 to 18 weeks in a multigravida. termed "quickening".
What percentage of patients with pelvic inflammatory disease become infertile?
10%
What is the average weight gain in pregnancy?
11 kg (25 lbs) 30% attributed to placenta and fetus. 30% attributed to blood, amniotic fluid, and extravascular fluid. 30% to maternal fat.
What is the normal fetal heart beat by the doppler?
120-160 bpm
What percentage of pregnancies result in spontaneous abortion? What is the number one etilogy for spontaneous abortion?
15% to 20%. generic defects account for 50% of spontaneous abortions
What WBC is expected during pregnancy?
15,000 to 20,000 are considered normal during pregnancy
When is an amniocentesis performed
15-18 weeks
How soon after implantation can B-hCG be detected?
2-3 days
By which week of gestation is the fundus at the umbilicus?
20 weeks
When should glucose challenge test for screening of gestational diabetes be performed?
24 to 28 weeks. In women at high risk can screen during first prenatal vist and repeat at 24 to 28 weeks.
What is the recommended treatment for massive intractable dysfunctional uterine bleeding?
25-mg IV conjugated estrogens
When shoudl Rhogam be administered in Rh-negative mothers for prophylactic protection?
28 to 29 weeks and again within 72 hours of delivery of an Rh-positive baby
If a woman has a positive screening glucose challenge test, what is the next step?
3 hour gtt
What is the normal pH of the vagina?
3.8 to 4.4 ( a vaginal pH > 4.9 indicates a bacterial or protazoal infection)
What are the most common causes of etiologies of endometrial cancer?
30% of these tumors are caused by exogenous estrogens, 30% are caused by atrophic endometriosis or vaginitis, 10% are caused by cervical polyps, and 5% are caused by endometrial hyperplasia
What is the standard dose of Rho-Gam?
300 mg
When should a vaginal-rectal culture for group B streptococci be conducted during pregnancy?
35 weeks
When and how does an ectopic pregnancy most commonly present?
6 to 8 weeks. Patients usually present with amneorrhea and sharp, generally unilateral abdominal or pelvic pain. Adnexal mas is not common ( found in < 50%)
What percentage of woman get morning sickness?
70% it generally occurs in the first trimester up to week 14 -16.
At what gestational age does B-hCG peak?
8 to 10 weeks
What is the most common type of cervical cancer
80% are squamous cells and arise from the squamocolumnar junction of the cervix
By how much is the incidence of functional cysts reduced by OCP use?
80% to 90%. Oral contraceptives suppress FSH and LH ovarian stimulation
After nonsurgical treatment for gestational trophoblastic disease and establishment of remission, what is the recommended duration of contraception use?
9 to 12 months
What is the cause of midcycle spotting or light bleeding?
A low or declined estradiol that occurs immediately prior to the LH surge
What is a nabothian cyst?
A mucous inclusion cyst of the cervix ( usually asymptomatic and benign)
What does a progestrone level of 25 ng/mL or higher indicate about a pregnancy?
A viable uterine pregnancy. Serum progestrone is produced by the corpus luteum in the pregnant patient and remains constant for the first 8 to 10 weeks.
What is Danazol and what are the side effects of it?
Danazol is a steroid used to treat endometrosis and fibrocystic breast disease. Side effects of it are Hirsutism, amenorrhea, deepening of the voice, acne, weight gain, hot flashes, labile emotions, and decreased vaginal secretions.
What is the most common sign of ectopic pregnancy or transvaginal ultrasound?
Absence of interuterine prgnancy or gestational sac with B-hCG level > 2000 mIU/mL. Adneal mass or gestational sac in adnexa is less reliable finding. Follow-up ultrasound always recommended in high-risk patients to ensure intrauterine pregnancy.
What is the purpose of the corpus luteum and its lifespan in the absence of pregnancy?
After ovulation, the expelled follicle is called the corpus luteum. the corpus luteum secretes esradiol and progestrone, which causes secretory ducts to develop in the endometerial lining in anticipation of implantation. In the absence of prengnacy the lifespan is approximately 14 days.
What are the risk factors for pelvic inflammatory disese?
Age < 25 years ( cervix not fully matured) Early onset of sexual activity Frequent sexual intercourse especially during menses nonbarrier contraception new, multiple or symptomatic sexual partners Douching Presence of IUD Bacterial vaginosis Women with one episode are at increased risk for a second episode
What foods put a patient at risk for mercury posioning?
All fish and shell fish contain some levels of mercury. However, the following contain the highest levels: predatory fish ( shark< sword fish, mackerel, tilefish) and to a lesser extent albacore tuna, pike and bass.
What is the criteria for the dx of Toxic shock syndrome (TSS)?
All of the following must be present: ( Temperature > 38.9 (102)) Rash ( blanching erythmatous rash X 3 days ), followed by full thickness desquamation of the palms and soles. Systolic BP < 90 mm Hg with orthostasis Involvement of three organ systems ( GI, renal, musculoskeletal, mucosal, hepatic, hematologic, of CNS) The patient must also have negative serologic tests for diagnoses such as RMSF, hepatitis B, measles, leptospirosis, and VDRL
What are the criteria for diagnosis of pelvic inflammatory disease (PID)?
All of the following must be present: - Adnexal tenderness - Cervical and uterine tenderness - Abdominal tenderness In addition, One or the following must be present: - Temperature > 38 degrees celcius - Endocervix Gram stain positive for gram- negative intracellular diplococcic - Leukocytosis > 10,000/mm3 - inflammatory mass on ultrasound or pelvic examination - WBCs and bacteria in the peritoneal fluid.
What is the definition of an acceleration and is it normal?
An acceleration must be at least 15 bpm above baseline and last at least 15 secs. Rapid heart rate can indicate fetal distress, 2 acceleration every 20 mins are normal
What causes toxic shock syndrome (TSS)?
An exotoxin composed of certain strains of staphylococcus aureus. other organisms that cause toxic shock syndrome are group A streptococci, Pseudomonas aeruginosa, and Streptococcus pneumoniae
What is the definition of pregnancy - induced hypertension?
An increase in systolic pressure > 30 mm Hg and/or an increase in diastolic pressure > 15 mm Hg above baseline, measured on 2 seperate occasions at least 6 hours apart presenting after 20 weeks gestation with no other etiologies associated with elevation in blood pressure.
This type of pelvic has a heart shaped brim and is quite narrow in front. This type of pelvis is likely to occur in tall woman with narrow hips and is also found in african women. The pelvic cavity and outlet is often narrow, straight and long. The ischial spines are prominent.
Android
This type of pelvis has an oval brim and a slightly narrow pelvic cavity. The outlet is large, although some of the other diameters may be reduced. If the baby engages in the pelvis in an anterior position, labour would be expected to be straightforward in most cases.
Anthropoid
What laboratory study can be useful in the evaluation of suspicious vulvar lesions?
Application of acetic acid or staining with toluidine blue may help direct optimal biopsy location
What type of blood test is used to determine the occurance and degree of fetomaternal hemorrhage?
Apt or Kleinhauer-Betke test
What is meigs syndrome?
Ascites and hydrothorax in the presence of an ovarian tumor.
For a gestational sac to be visible on ultrasound, what must be the B-hCG level?
At least 6500 mlU/mL for a transabdominal ultrasound, and 2000 mIU/mL for a transvaginal ultrasound.
What is the single most useful laboratory test in the evaluation of gestational trophoblastic disease?
B-hCG. Both molar pregnancies and gestational choriocarcionomas produce B-hCG because of their trophoblastic origin. Complete molar pregnancies often have > 100,000 mU/mL. B-hCG can also be used as a tumor marker to correlate the volume of disease and response to therapy.
What is the treatment for syphillis?
Benzathine PCN G 2.4 million units IMX 1 dose. Additional dose if infection has been for > 1 year or if the patient is pregnant. If the patient is penicillin allergic treat with doxycycline
Besides hCG and ultrasound, what other laboratory tests are essential prior to treatment for elective or spontaneous surgery?
Blood type and Rh status. Immunoglobulin should be administered in Rh-negative women in the event of elective or spontaneous abortion.
Besides hCG and ultrasound, what other laboratory tests are essential prior to treatment for elective or spontaneous abortions?
Blood type and Rh status. Immunoglobulin should be administered in Rh-negative women in the event of elective or spontaneous abortion?
What effect does pregnancy have on BUN and Creatine?
Both are decreased. This is the result of increased renal blood flow and increased glomerular filtration rate.
What agents may be used to ripen the cervix?
Both chemical and physical agents. Oxytocics, prostaglandins ( especially PGE2), progestrone antagonists (RU-486), and dehydroepiandrosterone are such pharmacologic agents. Laminaria and Foley catheter ballons are examples of physical dilators
What is the recommended management of a woman with negative cytology reslts and HPV positive?
Both tests should be repeated in 12 months
What is the term used for sporadic uterine contractions that are most felt in the third trimester but are not accompanied by changes in the cervix?
Braxton-Hicks contractions
This presents on physical exam as a frothy, grayish white, fishy smelling vaginal discharge.
Bacterial vaginosis
A patient presents with pain in her eyes, canker sores in her mouth, and sores and scars in her genital area. What is the diagnosis?
Behcet disease. This is a rare disease involving ocular inflammation, oral aphthous ulcers, and destructive gential ulcers (generally on the vulva). No cure is known, but remission may occur with high estrogen levels.
What is the main opthalmalogic change that occurs during pregnancy?
Corneal thickening
This presents as downward displacement of the bladder into the vagina along the anterior wall...
Cystocele
What is the effect of estrogen on the endometrium, when it peaks and the effect of declining estrogen?
Estrogen causes growth of the endometrium. The endometrium glands lengthen and the glandular epithelium becomes pseudostratified. Mitotic acitivty is present in both the glands and the stroma. Serum estradiol levels are at their peak approximately 1 day prior to ovulation. When estrogen levels begin to decline, there is a loss of endometrial blood supply, endometrial sloughing and onset of menses.
What serum marker is associated with ovarina cancer?
CA-125 BRCA1 gene is associated with 5% of cases
What is the standard laboratory work-up for a perimenopausal woman presenting with dysfunctional uterine bleeding?
CBC, PT, PTT, hCG, TSH, progesterone, prolactin, FSH, LFTs
Which routine screenings should be performed at the first prenatal visit?
CBC, blood type and Rh, Coombs' test, Rubella titer, Hepatitis B and C, urine DNA probe for chlamydia and gonorrhea, serologic testing for syphillis, pap smear, and urinalysis. All offer all women HIV testing and couple screening for cystic fibrosis, sickle cell and other conditions per maternal/paternal history.
What are the recommended lifestyle modifications in the treatment of premenstrual syndrome?
Caffeine reduction, salt restriction, low-fat and high complex carbohydrate intake, emphasis on fresh/nonprocessed foods, increased exercise, relaxation measures and stress reduction.
What are the expected changes in volume of cardiovascular system of pregnancy patient?
Cardiac output increased by 30% in the first trimester; increased by 50% ( second trimester) Stroke volume increases by 25% while Hct drops because of hemodilation Plasma volume increases by 50% Heart rate increased by 12 to 18 bpm Systolic and diastolic blood pressure decreased by 10 to 15 mm Hg during the second trimester, but gradually returns to baseline in the third trimester.
Define the five drug labeling categories for use during pregnancy?
Category A- safe for use in pregnancy Category B- Animal studies have demonstrated the drug's safety and human studies do not reveal any adverse fetal effects. Category C- The drug is a known animal tergaogen, but no data are avalible about human use, or there is no date on humans or animals Category D- There is positive evidence of fetal toxicity, but the benefits in selected situations make use of the drug acceptable despite the risks. Category X- The drug is definite human and animal teratogen and should NOT be used in pregnancy.
What is the recommended management of a 25+ y/o woman with ASC-US pap result and HPV positive?
Colposcopy
What are the other treatment options for polycystic ovarian syndrome?
Combined oral contraceptive pills for menstrual regulation and ovarian suppression; Biguanides (metformin) for menstural regulation, weight reduction, and to reestablish fertility, anti-androgen (spironolactone) for sex androgen suppression and hirsutism.
What is the treatment for neisseria gonorrheae?
Ceftriaxone 125 to 250 mg IM x 1 dose or cefixime 400 mg PO x 1 dose or Cefpodoxime 400 mg PO x 1 dose. Pluse include either azithromycin 1 g x 1 dose or doxycycline 100 mg BIDx 7 days since 50% of patients are also infected with Chlamydia trachomatis.
What is considered the most appropriate treatment for a chancroid?
Ceftriaxone 250 mg IM X 1 dose or azithromycin 1 g PO x 1 dose
What is the msot common cause for prolongation for the active phase labor?
Cephalopelvic disproportion caused by contraction of a narrowed midpelvis
What is the definition of CIN and how is it categorized?
Cervical intraepitheal neoplasia (CIN) refers to preinvasive dysplasia of cervical epithelial cells, the precursor of malignant disease. CIN is categorized according to the depth of involvement and the atypicality of the cell. CIN 1- considered a low-grade lesion, with mildly atypical cellular changes in the lower third of the epithelium CIN2- Considered a high-grade lesion, with changes affecting the basal two thirds of the epithelium. This is equivalent to moderate dysplasia. CIN 3- Also a high grade lesion, with cellular changes affecting more than two-thirds of the epithelium, including full thickness lesions. This was formerly called severe dysplasia or carcinoma in situ.
A 30 year old woman complains of a painful sore on her vulva that first resembled a pimple. On examination, you find an ulcer with vague borders, gray base, and foul smelling discharge. What is the probable diagnosis and causative agent?
Chancroid. Gram stain, culture, and biopsy ( used in combination because of the high false-negative rates) show the causative agent Haemophilus ducreyi
Cervical motion tenderness on physical examination in the presence of PID is known as.....
Chandelier sign
What is the most common sexually transmitted disease in the united states and sometimes asymptomatic in women?
Chlamydia trachomatis
How many times more likely is a woman with condyloma acuminatum (genital warts) to develop cervical cancer than a woman without this lesion?
Four times more likely
What are the three types of breech presentations?
Frank breech- Thighs flexed, legs extended ( most common) Complete Breech- At least one leg flexed Incomplete ( footling) breech- At least one foot below the buttocks with both thighs extended
What are the hormones and their source that are involved in maintainging a normal menstural cycle?
From the ovary: Estrogen and progesterone From the pituitary: Follicle-stimulationg hormone (FSH) and luteinizing hormone ( LH). In addition, prolactin- and thyroid-stimulating hormones are also vital in maintaining a normal menstrual cycle. From the Hypothalamus: Gonagoptophin-releasing hormone (GnRH)
What is the causative agent in bacterial vaginosis (BV)?
Gardnerella
What is the most common malignant gestational trophoblastic disease?
Gestational choriocarcinoma
What is a safe anticoagulant to use in pregnancy?
Heparin. Warfarin is contraindicated
A 22 year old patient presents with a complain of painful blisters on the vulva and vaginal introitus. She admits t a prodrme of buring, tingling, and/or pruritius prior to the appreance of lesions. Upon examination, you note vesicles on an erythematous base. What is the probable diagnosis?
Herpes simplex virus
What criteria are ncessary for the definitive diangosis of gestation diabetes.
If two or more of the 1-hour, 2 hour or 3 hour glucose values are abnormal on a 3 hour tolerance test, the patient is diagnosed with GDM. Glycosylated hemoglobin (Hbg A1c) is not recommended for screening or confirming diagnosis.
What is the squamocolumnar junction? describe its importance.
It is the junction between the columnar epithelium and the squamous epithelium of the cervix. This is known as the transformation zone. Throughout a woman's life, the squamous epithelium of the ectocervix ( and vagina) invades the columnar epithelium of the endocervix. It is important because it is the squamous epithelium in this transformation zone that is most likely to become dysplastic.
What is the function of FSH?
It stimulates the maturation of the follicules and the production of estradiol from the follicles.
What is the predominate change in the lung volumes during pregnancy?
Decrease in functional residual capacity by as much as 15% to 25%. Tidal volume increases by 40%
What are the main changes to the gastrointestinal system of a pregnant patient?
Decreased gastric emptying and GI motility leading to gerd and constipation
What is the definition of preterm delivery?
Delivery of a viable infant before 37 weeks gestation
What are the six movements of delivery?
Descent flexion internal rotation extension external rotation expulsion
In a woman who is Rh negative and a fetus that is Rh positive, what is the risk?
Development of Rh isoimmunization leading to fetal anemia, hydrops and/or fetal death
What is the most useful preventative measure for pelvic organ prolapse?
Kegel exercises
What predisposes women to vaginal candidias infections?
Diabetes, oral contraceptives and antibiotics
What is the recommended clinical intervention in the setting of incomplete abortion?
Dilation and curettage is necessary to remove the remainder of tissue
What is the preferred means of establishing a diagnosis of endometriosis?
Direct visualization during diagnostic laparoscopy or laparotomy. Clinical presentation, laboratory evaluation, and/or pelvic ultrasound are considered inadequate to make a definitive diagnosis.
What condition is indicated by a low-alpha fetoprotein?
Down syndrome
In general, what time during the pregnancy is the fetus most susceptible to teratogens?
During the embryonic peroid which lasts from 2 to 8 weeks postconception. This is the time of organogenesis.
What are the risk factors for ectopic pregnancy using the mnemonic Ectopic?
E-endometriosis C- Congenital anomaly of tubes T- Tubal or abdominal surgery O- Other ectopic pregnancy P- Pelvic inflammatory disease I- IUD C- Clinician- assisted reproduction
How do B-hCG levels differ in women with ectopic pregnancy versus intrauterine pregnancy?
Lower in ectopic pregnancy
What are the risk factors for elevated maternal serum alpha-fetoprotein? Explain using the mneumonic MSAFP..
M- multiple gestation S- Spina bifida ( or other neural tube defect) A- Abdominal wall defects ( omphalocele, gastrochisis) F- Fetal death P- Placental anomalies
What agents can be used in an attempt to stop contractions in preterm labor?
Magnesium sulfate, calcium channel blockers, B-mimetric adrenergic agents (ritodrine or terbutaline)
What are the four physiologic actions of hCG?
Maintenance of corpus luteum and continued progestrone production. Stimulation of fetal testicular testosterone secretion promoting male sexual differentiation Stimulation of the maternal thyroid by binding to TSH receptors Promotes relaxin secretion by the corpus luteum
What is the four main etiologies of secondary dysmenorrhea?
Endometerosis pelvic inflammatory disease Uterine Fibroids Pelvic Congestion ( typically occurs in multiparous women with pelvic vein varicosities and congested pelvic organs OR s/p C section.
What is the gold standard test for definitive diagnosis of endometerial cancer?
Endometrial biopsy
What is the most common gynecologic malignancy?
Endometrial carcinoma
The decline in which hormone heralds the onset of menses?
Endometrial shedding ( onset of menses) occurs because of progesterone withdrawal
What are chocolate cysts?
Endometriomas ( cystic forms of endometerosis on the ovary)
What are the normal changes heard during heart ausculation during pregnancy?
Exaggerated Split S1, systolic ejection murmur heart at the left sternal border (90%), soft/transient diastolic murmurs (20%). All harsh murmurs should be taken seriously and worked up before attributing to pregnancy.
What is hyperemesis gravidarum?
Excessive vomiting during pregnancy that results in starvation (ketonuria), dehydration, and acidosis
What are the degrees of perineal tears associated with vaginal delivery?
First degree: perineal skin or vaginal mucosa Second degree: Submucosa of vaina or perineum Third degree: Extends into the anal sphincter Fourth degree: Extends into rectal mucosa
A patient with suspected PID presents with marked tenderness in the right upper quadrant, what condition is most likely present?
Fitz-Hughes Curtis syndrome
What are the most common physical symptoms of premenstrual syndromes?
Fluid retention, breast pain, bloating, constipation, backache.
What is the known effect of folic acid deficiency in pregnancy?
Folic acid deficiency is associated with nueral tube defects ( spina bifida, ancephaly)
What is the most common type of ovarian cyst?
Follicular. The other types are corpus luteum and theca lutein cysts.
What finding on Gram stain is indicative of neisseria gonorrhea?
Gram Negative diplococci
What is the classic ultrasound finding in the presence of a complete hydatiform mole?
Grape-like vesicles or "snowstorm patten"
This type of pelvis has an almost round brim and will permit the passage of an average-sized baby with the least amount of trauma to the mother and baby in normal circumstances. The pelvic cavity( the inside of the pelvis) is usually shallow, with straight side walls and with the ischial spines not so prominent as to cause a problem as the baby moves through.
Gynecoid
What are the known risk factors for vulvar/vaginal carcinoma?
HPV infection Smoking Coexisting cervical carcinoma In utero exposure to DES
What are the known subtypes of HPV associated with cervical cancer?
HPV type 16, 18 and 31 are risk factors for cervical dysplasia, which can lead to cervical cancer.
Who is eligible for methotrexate treatment of an ectopic pregnancy?
Hemodynamically stable patients with unruptured gestations < 3.5 cm in diameter on ultrasound and B-hCG < 5000 mU.
What virus causes condylomata acuminata?
Human papiloma virus types 6 and 11
What is the most likely dianosis in a patient whose uterus is larger than expected from the history of gestation, has vaginal bleeding and passes grape like tissue from the vagina?
Hydatidiform mole
What have endocrine abnormalities are moles and other gestational teophoblastic neoplasms associated?
Hyperthyroidism
What diagnostic tests in the evaluation of secondary dysmenorrhea can be both diagnostic and therapeutic?
Hysteroscopy, dilation and curettage (D&C) and laparoscopy
What is the recommended management of women with preterm premature rupture of membranes (PROM)?
If no sign of maternal or fetal distress/infection, expectant management with bed rest and prophylactic antibiotics is preferred. PPROM is defined as rupture between 20 and 36 weeks.
When can an intrauterine gestational sac be identified by an abdominal ultrasound?
In the fifth week. A fetal pole can be identified in the sixth week and an embryonic mass with cardiac motion in the seventh week.
Of the two types of hydatidiform mole, Which has a nonviable fetus present?
Incomplete
What are the laboratory findings seen with polycystic ovarian syndrome?
Increased LH/FSH ratio (2:1) Elevated serum glucose Elevated fasting insulin Elevated sex androgens (DHEA-S and/or testosterone)
What are the benefits of antepartum corticosteroids in premature babies?
Increased lung compliance Increased surfactant production Less respiratory distress syndrome Less intraventricular hemorrhage Less necrotizing enterocolitis Less neonatal mortality
What is the most frequent complication of hysterectomy?
Infection. The most common organisms are those found in normal vaginal flora. Because the vagina is difficult to cleanse, most experts recommend antibiotic prophylaxis for all patients undergoing vaginal hysterectomy.
A 27 year old woman presents with secondary amenorrhea for 6 months. What is the appropriate initial evaluation?
Pelvic examination, pap smear, pregnancy test. If pregnancy test is negative, additional laboratory studies to include prolactin, FSH, LH and TSH.
What is the function of the LH?
It causes follicular rupture, ovulation, and establishment of the corpus luteum
What is the modified ritgen maneuver?
It describes the elevation of the fetal chin acheived by placement of the delivering hand between the maternal coccyx and perineal body, whereas the other hand guides the crowning vertex. This technique assists in extension of the fetal head and allows the clinican to control delivery.
What is the function of prolactin?
It initiates and sustains lactation by the breast glands and it may influence synthesis and release of progesterone by the ovary and testosterone
What is oxytocin and its action?
It is a powerful uterotonic agent that stimulates uterine contractions during labor and elicits milk ejection by myoepithelial cells of the mammary ducts.
What is menorrhagia?
It is excessive amount of vaginal bleeding during the course of the period
What is the effacement of the cervix?
It is the foreshortening and thinning of the cervix as it is drawn upward (intra-abdominally)
A woman presenting with pelvic pain and pressure when standing, the feeling of something protruding from the vaginal opening, and occasional urinary incontinence or constipation is likely to have what?
Pelvic organ prolapse
When does labor begin?
Labor beings with the onset of regular, rhythmic contractions leading to serial dilatation and effacement of the cervix. Thus, contractions alone do not qualify for onset of labor.
What is the recommended fish consumption for a pregnant woman to avoid mercury posioning?
Limit fish consumption to 350 grams per week
What immunizations are contraindicated during pregnancy?
Live viruses are contraindicated. Including MMR, Oral polio, Varicella
What is the definition of spontaneous abortion?
Loss of fetus before the 20th week of gestation
What is the treatment of choice for a batholin gland abcess?
Marsupialization with the placement of a ward catheter
What are the independent risks for spontaneous abortion?
Maternal or paternal age smoking infection maternal systemic disease Immunologic parameters Drug use
In pregnant patients with underlying asthma, what is the main focus of management?
Medication should be used sparingly. However, uncontrolled asthma causes more fetal harm than medications therefore, use if necessary.
This excessive amount of blood at irregular frequencies.
Menometrorrhagia
This is a an excessive amount of vaginal bleeding or duration of bleeding during menses.
Menorrhagia
What is the pharmacologic treatment of choice for chronic hypertension or pregnancy-induced hypertension?
Methyldopa is first line. Labetalol is an alternative
What is the recommended treatment for BV?
Metronidazole (flagyl) either orally or vaginally
Which type of episiotimy is associated with the lowest amount of blood loss, improved healing time and cometic result, and less subsequent dyspareunia?
Midline ( median) episiotomy
What is percocious puberty?
Percocious puberty is when a child's body begins changing into an adults to soon. Puberty that begins before age 8 in females and age 9 in males is to soon.
What is considered the hallmark examination finding in 20% of trichomonas infections?
Petechiae in the cervix ( also known as "strawberry cervix")
What is the recommended treatment for uncomplicated follicular cysts?
Most resolve spontaneously within a few menstrual cycles (60 days) without treatment. Combined oral contraceptive agents can be used if recurrent.
What are considered protective factors for the risk of ovarian cancer?
Multiparity, combined oral contraceptive use, and breast feeding.
What is the recommended pharmacotherapeutic interventions for primary dysmenorrhea?
NSAIDs or combined oral contraceptive agents. If nonresponsive to the above interventions, tocolytic agents (salbutamol) or calcium channel blockers (nifedipine) or progestins (medroxyprogestrone) have been shown to be effective.
Which two organisms cause most cases of pelvic inflammatory disese?
Neisseria gonorrhoeae and Chlamydia trachomatis
What is the presenting feature of tertiary syphillis?
Neurosyphillis ( neuro deficits including difficulty with coordination, memory loss, paralysis, gradual blindness, or dementia)
If fetal bradycardia is detected during labor and delivery, what is the recommended course of action?
Place mother in left lateral decubitus position, administer oxygen, give IV fluid bolus.
What antibiotics are safe to use in pregnancy?
Nitrofurantoin Amoxicillin Amocillin-Clavulante Third-generation cephalosporins ( Cephalexin, Ceftriaxone, Cefpodoxime) Macrolides ( Erythromycin, Azithromycin) Trimethoprim-sulfamethaxazole ( avoid in first trimester or near term)
What are the ACOG recommendations for discontinuation of pap smear screening?
No cytology screening after total hysterectomy if surgery for benign condition. If surgery for CIN I, II, or III, then annually three times before discontinuing. Discontinue screening at age 65 for women who have had adequate recent screening. Adequate screening is defined as three consecutive negative cytology tests or two consectutive negative HPV/PAP co tests in the 10 years before stopping with the most recent test within 5 years.
What is the definition of missed abortion?
No uterine growth, no cervical dilation, no passage of fetal tissue, and minimal cramping or bleeding. Diagnosis is made by the absence of fetal heart tones and an empty gestation sac on ultrasound.
Can iodinated radiodiagnostic agents be used in pregnant patients?
No. They should be avoided because concentration in the fetal thyroid can cause permanent loss of thyroid function.
What are the presenting signs associated with secondary syphillis?
Nonpruritus maculopapular rash that includes the palms and soles ( Condyloma latum), lymphadenopathy, and constitutional symptoms ( fatigue/malaise). These symptoms present 4 to 6 weeks after the hallmark syphilitic chancre and presist for 2 to 6 weeks before the infection enters the latent phase.
What does a biphasic curve on a basal body temperature (BBT) chart of a 25 year-old woman indicate?
Normal ovulation caused by the effects of progestrone, A monophasic BBT curve indicates an anovulatory cycle. A temperature remaining elevated following a normal biphasic curve would indicate pregnancy.
What are the clinical manifestations of polycystic ovarian disease (PCOS)? Use the mnemonic OVARIAN:
O-obesity V-Virilization A-Anovulation R-Resistance to insulin I-Increased hair growth A-Androgen excess N-No period/Amenorrhea
What are the risk factors for endometrial cancer?
Obesity Nulliparity Early Menarche Late menopause Unopposed estrogen stimulation Hypertension Gallbladder disease Diabetes mellitus Prior ovarian, endometrial, or breast cancer
What is the recommended treatment for leiomyomas?
Observation in most cases. GnRH agnonists and mifepristone may reduce tumor size. Surgical intervention ( myomectomy, hysterectomy). Arterial embolization is becoming increasingly popular.
What is the most common cause of an ectopic pregnancy?
Occlusion of the fallopian tube secondary to adhesions
If a woman has ascites what is the most likely tumor to be found?
Ovarian carcinoma
What is the most common cause of pelvic pain in an adolescent girl?
Ovarian cyst
What are the advantages of radical hysterectomy relative to radiation therapy for stage I cervical cancer?
Ovarian preservation is possible Unimpaired vaginal function Extent of disease can be estabilished by pathology
In the normal menstural cycle when does ovulation typically occur
Ovulation in a 28 day cycle typically occurs on day 14 and is triggered by a surg of luteinizing hormone ( LH) from the pituitary.
How is prementrual dysphoric disorder diagnosed? (PMDD)
PMDD is diagnosed when at least five of the following symptoms occur seven to 10 days before menstruation and go away within a few days of the start of the menstrual period: Mood swings Marked anger Irritability Tension Decreased interest in usual activities Fatigue Change in appetite Sleep problems Physical problems, such as bloating Before a doctor makes a diagnosis of PMDD, he or she will rule out other emotional disorders—such as major depression or panic disorder—as the cause of the symptoms. In addition, underlying medical or gynecological conditions (such as endometriosis, fibroids, menopause, and hormonal problems) that could account for symptoms must be ruled out.
How common is Premenstrual dysphoric disorder?
PMDD occurs in 3 to 5 percent of menstruating women. Women with a personal or family history of mood disorders—including major depression or postpartum depression—are at greater risk for developing PMDD.
What is the definition of secondary dysmenorrhea?
Painful menstruation caused by an identifiable clinical condition, usually a disease of the uterus or pelvis. It usually affects women older than 25 years.
What is a Leopold's maneuver?
Palpation of the abdomen in the evaluation of a fetus in transverse lie
What secretes B-hCG?
Placenta trophoblasts secrete B-hCG to maintain the corpus luteum, which in turn maintains the uterine lining. The corpus luteum is maintained though the sixth to eigth week of pregnancy, by which time the placenta begins to produce its own progesterone to maintain the endometrium.
What is the most common clinical condition associated with the development of endometrial hyperplasia?
Polycystic ovarian syndrome
What is the number one cause of secondary amonorrhea? What can be the second cause?
Pregnancy. The second most common cause is hypothalamic hypogonadism, which can be because of weight loss, anorexia nervosa, stress, excessive exercise, or hypothalamic disease.
What are the two major differential diagnoses in a patient with secondary amenorrhea who fails a progestin challenge?
Premature ovarian failure and hypothalamic dysfunction, premature ovarian failure can be diagnosed if the serum FSH level is high, hypothalamic dysfunction can be diagnosed in setting of low FSH and LH.
What is the largest risk for breech presentation?
Prematurity. At 28 weeks a majority of fetuses are breech but correct by term. 95% of fetuses at term are in vertex presentation.
What is premenstrual dysphoric disorder?
Premenstrual dysphoric disorder (PMDD) is a severe form of PMS. The symptoms of PMDD are similar to those of PMS, but are severe enough to interfere with work, social activities and relationships.
A pregnant female at 32 weeks gestation, presents with uterine contractions over the past 5 hours. Upon examination you note cervical dilation of 2 cm an effacement of > 80%, what is the diagnosis?
Preterm labor
What is the typical rate of cervical dilation during active phase of labor in primiparous and multiparous women?
Primiparous- 1 cm/hr Multiparous- 1.5 cm/hr
What is the recommended management of women with the term PROM?
Prompt induction of labor
What is the most common cause of postabortal pain, bleeding and low-grade fever?
Retained gestational tissue or clot
What is thought to the be most common etiology of endometeriosis?
Retrograde menstruation is when the womb lining (endometrium) flows backwards through the fallopian tubes and into the abdomen (tummy) instead of leaving the body as a period. This tissue then embeds itself on the organs of the pelvis and grows.
What blood tests would be appropriate in the evaluation of a female child with precocious puberty?
Serum Levels of FSH, LH and prolactin, TSH, Estradiol, testosterone, dehydroepiandosterone sulfate (DHEAS) and HCG.
A 26 year old woman with secondary amenorrhea and an essentially normal work-up is given progestin 10mg for 7 days ( or IM injection of progestrone 100 mg). She responds with a normal menstrual period. What does this tell you?
She has a functional endometrium and a normal production of estrogen to proliferate the endometrial lining. This is called the progestrone challenge.
What is the difference between a simple and a radical hysterectomy?
Simple= used to denote whether vaginal tissue and pelvic lymph node are removed. Radical= includes the removal of uterus, cervix, vaginal and pelvic lymph nodes.
What are the known risk factors for preterm labor and delivery?
Smoking cocaine use uterine malformation cervical incomeptence infection ( vaginal or UTI) Low pregnancy weight
What are the nonpharmacologic options for treatment of chronic hypertension or pregnancy-induced hypertension?
Sodium restriction to 2 to 3 g per day Abstaining from alcohol and tobacco Weight reduction More frequent prenatal visits and ultrasound surveillance
What are the normal physical changes in the cervix during pregnancy ( signs in early pregnancy?)
Softening and cyanosis. ( chadwick sign - bluish discoloration of the vagina and cervix during pregnancy) Softening of the lower uterine isthmus- Hegar's sign
What diagnostic evaluation is recommended in suspected premature rupture of membranes (PROM)?
Speculum examination to look for pooling of amniotic fluid in the posterior fronix. And nitrazine paper test. In the presence of amniotic fluid, the paper will turn blue and exhibit a ferning pattern under the microscope.
What is the most common cell type in vulvar and/or vaginal carcinoma?
Squamous cell ( 90% in vulvar carcinoma; 85% in vaginal carcinoma)
What is the treatment for ovarian cancer?
Stage 1A and 1B- Surgical excision alone ( abdominal hysterectomy and bilateral salpingo-oophorectomy). Other stages -- Surgical resection followed by adjunctive chemotherapy or radiation.
What are the 4 stages of labor and delivery?
Stage I: onset of labor to complete dilation of the cervix Stage II: Cervical dilation to birth Stage III: Birth to delivery of placenta Stage IV: Placenta delivery to stability of the mother ( ~ 6 hours)
Does epidural analgesia affect the course of labor?
Studies show no effect in the first stage. The second stage appears to be prolonged an average of 20 to 25 mins. No evidence that this prolongation is harmful to the fetus.
What type of leiomyoma is symptomatic?
Submucosal myomas, though small, can cause profuse bleeding. Most other myomas are asymptomatic until grown large enough to cause obstruction or significantly distort the endometrial cavity.
What is the main physiological stimulus for prolactin release?
Suckling of the breast
What are the known risk factors for the development of toxic shock syndrome?
Tampons, IUDs, septic abortions, sponges, soft tissue abscesses, osteomyelitis, nasal packing and postpartum infections can all house these organisms.
How can fetal lung maturity be assessed?
The Lecithin to Sphinomyelin ratio. At more than 2:1 (L:S) the fetal lungs are mature
This type of pelvis has a kidney- shaped brim and the pelvic cavity is usually shallow and may be narrow in the antero-posterior ( front to back ) diameter. The outlet is usually roomy. During labour the baby may have difficulty entering the pelvis, but once in there should be no further difficulty.
The Platypelloid pelvis
What is the most common site of implantation in an ectopic pregnancy?
The ampulla of the fallopian tube (95%). Less common sites are abdomen, uterine cornua, cervix and ovary.
What is the cardinal symptom of endometrial cancer?
The cardinal symptom is inappropriate uterine bleeding (90%)
What is the definition of mittelschmerz?
The cyclic abdominal pain located on either side of the abdomen, which can be felt during ovulation and may persist for approximately 2 days after.
What are the pharamceutical treatment options for dysfunctional uterine bleeding?
Treatment depends on severity of bleeding. Options include observation, iron therapy, volume replacement, oral contraceptive, and cyclic progestins.
What defines the normal menstural cycle in terms of frequency, length and phases?
The normal menstrual cycle is 28 days, with a flow lasting 2 to 7 days. The variation in cycle length is set at 24 to 35 days. The luteal phase of the cycle is normally 14 days with the follicular phase being 14 to 21 days.
When is the typical onset of primary dysmenorrhea?
The onset is usually 3 to 6 months of menarche
Where is the most common site of endometriosis?
The ovaries. Other sites include the cul-de-sac, uterosacral ligaments, broad ligaments, fallopian tubes, uterovesical fold, round ligaments, vermiform appendix, vagina, rectosigmoid colon, cecum and ileum.
What is the microscopic findings of trichomonas infections?
The prescence of mobile and pear shaped protazoa with flagella is indicative of trichomonas
What is a oophorectomy?
The removal of the ovaries and is seperate from a hysterectomy. oophorectomy can be unilateral or bilateral.
What is the most common location for vaginal carcinoma?
The upper one-third of the posterior vaginal wall
What are the three events that occur in the normal course of female puberty in order of occurance?
Thelarche- the development of the breast Pubarche- The development of axiallary and pubic hair Menarche- The first menstrual cycle
At what rate do B-hCG levels rise?
They double every 48 hours
What is metorrhagia?
This is bleeding in between peroids
What is menometorhagia?
This is excessive amount of blood during infrequent periods
What oligomenorrhea?
This is menstrual periods greater than 35 days apart.
With is polymenorrhea?
This is menstrual periods less than 21 days apart
Which classification of abortion presents with vaginal bleeding but the cervical os is closed?
Threatened abortion. It is defined as uterine cramping or bleeding in the first 20 weeks of gestation without the passage of products of conception or cervical dilation.
What viral or protozoal infections require extensive work-up during pregnancy? Define ToRCH
To-Toxoplasma gondii R-rubella C-Cytomegalovirus H- Herpes genitalis
What are the recommended forms of treatment for vaginal candidiasis infections?
Topical clotrimazole ( Gyne-lotrimin) Topical tioconazole (monistat) Oral fluconazole (Difulcan). It has been reported that a one-time dose of fluconazole (Difulcan) is 90% effective. In severe infections ( generally in hospitalized patients), amphotericin B, caspofungin, or voriconazole may be used.
What is the most common complication of an ovarian cyst?
Torsion of the ovary. Torison is more common in small- to - medium sized cyst and tumors. Emergency surgery is requried.
What is the difference between between a total and subtotal hysterectomy?
Total= removal of the entire uterus and cervix Subtotal= uterus removal while the cervix remains intact
What causes variable decelerations?
Transient umbilical cord compression. These often change with maternal position.
What are the pharmacotherapeutic options for treating endometrosis?
Treatment is based on severity of symptoms, location, and desire for child bearing. Pharmacotherapeutic options include NSAIDs, prostaglandin synthetase inhibitors, combined oral contraceptive agents, progestin-only contraceptives, GnRH agonists, danazol (a 17-alpha-ethinyl testosterone derivative)
What is the causative bacterium in syphilis?
Treponema pallidum
What other sexually transmitted disease is commonly seen in combination with condyloma acuminata?
Trichomonas
What causes a greenish gray frothy vaginal discharge with mild itching?
Trichomonas vaginitis
What is the classification system commonly used to define the progression of breast and pubic hair development in puberty and how many stages does it have?
Tunner classification, It has five stages
What is the average gestational age at delivery of twins, triplets, and quadruplets?
Twins: 36 to 37 weeks Triplets: 33 to 34 weeks Quadruplets: 30 to 31 weeks
What is the most common type of benign gynecologic pelvic neoplasm?
Uterine leiomyoma ( or uterine fibroids)
Which week of gestation can the fetal heart be auscultated or detected by the following?.... Ultrasound- Doppler- Stethoscope-
Ultrasound- 6 weeks Doppler- 10 to 12 weeks Stethoscope- 18 to 20 weeks
What clinical triad is strongly indicative of cervical cancer extension to the pelvic wall?
Unilateral leg edema, sciatic pain, urethral obstruction
What are the indications for lapartomy for the treatment of ectopic pregnancy?
Unstable patient Large hemoperitoneum Cornual pregnancy Large ectopic ( >6 cm) Fetal heart sounds
This presents as descent of the uterus and cervix down the vaginal canal toward the introitus secondary to broken uterosacral ligaments or relaxation of the musculature of the pelvic floor. Most likely the occur in women with a retroverted uterus.
Uterine prolapse
This presents as downward displacement of the vaginal apex also caused by loss of muscle and ligamental support.
Vaginal prolapse
What is the typical clinical presentation of lymphogranuloma venerum (LGV)? Causative agent?
Vesicopustular eruption, unilateral inguinal bubo, possible anal discharge, and rectal bleeding. The causeative organism is a serotype of chlamydia trachomatis.
How does age influence the incidence of hydatidiform mole?
Women aged 50 years or older have 300 -400 fold increase in risk. Women younger than 15 years have 6-fold increased risk
In a woman of reproductive age, what is the first step in the evaluation of abnormal uterine bleeding following the history and physical examination?
a pregnancy test.
What is primary amenorrhea?
absence of menstrual period by age 16
a 37-year-old woman, G2 P2 presents with a history of lengthening menses and secondary dysmenorrhea. This problem had been subtly going on for 2 years and now is a quality-of-life issue. Examination reveals an irregular, globular-shaped uterus. What is the most likely diagnosis?
adenomyosis
Which patients with PID should be admitted?
admit patients who are pregnant, have a temp > 38 ( 100.4), are nauseated or vomitting ( which prohibits oral antibiotics), have pyosalpinx or tubo-ovarian abscess, have peritoneal signs, have an IUD, show no response to oral antibiotics, or for whom diagnosis is uncertain.
What is a teratogen?
an agent or factor that causes malformation of an embryo.
What is the most common cause of vaginitis?
candidia albicans
What is the treatment for gestational DM?
diet, exercise, insulin. Do not give patient oral hypoglycemic because they can cross the blood brain barrier
What criteria are used for assuring the success of methotrexate?
following single-dose therapy, the B-hCG levels should fall by 15% between days 4 to 7 and continue to call weekly until undetectable
How should morning sickness be treated?
frequent small meals, carbohydrates, IV hydration, and antiemetics as a last resort
What are the different pelvic types? Which type is the most common?
gynecoid anthropoid android platypelloid The gynecoid is the most common type of pelvis in women. It is estimated that approximately 50% of women have gynecoid pelvis. ( it should be noted that in reality most women have intermediate pelvic shaped rather than true gynecoid, anthropoidm android or playtpelloid pelvis)
What is the definitive treatment for adenomyosis?
hysterectomy
What is the predominant organism in a healthy woman's vaginal discharge?
lactobaccilli ( 95%) ( this organism can be found in yogurt)
What are the recommended treatment options for condylomata acuminata?
liquid nitrogen, podophyllin resin, Aldara (topical imiquimod); not necessarily curative but treatment is focused on destruction of warts
Which type of episiotomy is associated with lesser propensity to extend into the external anal sphincter or rectum?
mediolateral episiotomy
This is bleeding between menstural periods
metorrhagia
This is menstrual periods greater than 35 days apart
oligomenorrhea
What is the hallmark presenting sign of primary syphillis?
painless ulcer ( chancre)
This is menstrual periods less than 21 days apart.
polymenorrhea
This presents as displacement of the rectum into the posterior wall of the vagina
rectocele
What are the indications for performing a dilation and curettage?
releif of profuse uterine hemorrhage Removal of endometerial polyp or hydatid mole termination of pregnancy/incomplete abortion Removal of retained placental tissue
What is the most common presenting symptom for patients with cervical cancer?
up to 80% of patients present with abnormal vaginal bleeding, most commonly postmenopausal. Only 10% note postcoital bleeding. Less frequent symptoms include vaginal discharge and pain.
What is the most common presentation of twins?
vertex-vertex
What is the most frequent gynecologic disease of children?
vulvovaginitis ( the cause of which is poor perineal hygeine)
What is the first line treatment for PCOS?
weight loss
