OB/GYN

Woman presents w/ ascites, R-sided pleural effusion, pulling sensation in groin LFTs are normal Mass found in ovary Biopsy shows bundles of spindle-shaped collagen-rich fibroblasts. Mass type? benign/malig?

Fibroma; benign sex cord stromal tumor Meigs syndrome

Contrast fibroids, adenomyosis, and endometrial hyperplasia in terms of presentation of AMB

Fibroids -heavy, long periods -may have bulk symptoms (constipation, urinary freq, fullness) -irregularly enlarged uterus Adenomyosis -heavy periods -dysmenorrhea, pelvic pain -globally enlarged, bulky, tender uterus Endometrial hyperplasia -irregular bleeding -hx obesity, nulliparity, chronic anovulation -nontender uterus, not palpably enlarged

Most common benign neoplasm of the breast. Usually seen in 20s-30s

Fibroadenoma

Tumors of breast stroma

Fibroadenoma Phyllodes

Woman in 20's/30's w/ solitary, well-defined/marble-like, non-tender, rubbery and mobile mass Notes that it becomes painful w/ periods/since starting OCPs/etc Mammography shows single well-defined mass w/ popcorn-like calcifications Biopsy shows proliferation of intralobular myxoid/fibrotic stroma; may compress ducts into slits

Fibroadenoma: hormone dependent tumor

25 yo w/ multiple lumps in L breast which are painful before period Discover acini and stromal fibrosis, calcification Dx? Risk of cancer

Fibrocystic change, specifically sclerosing adenosis. 2 x for invasive carcinoma in EITHER breast

Heavy periods, constipation, urinary frequency/incontinence, pelvic pain/heaviness, irregularly enlarged uterus 1st line tx?

Fibroids (Leiomyoma) OCP or prog IUD if wants kids

Why are symptoms of menopause milder in obese women?

Most estrogen is produced by peripheral adipose tissue in menopausal women; so more adipose = more estrogen = milder menopause

Distinguish Kallman and Klinefelters

No firm testes or gynecomastia in Kallman (LOW FSH & LH = low aromatase)

How do the following cross the placental barrier? -Oxygen, CO2 -Glucose -Amino acids -Which antibodies?

No mixing of maternal/fetal blood • Oxygen & carbon dioxide diffuse • Glucose= facilitated transport • Amino acids = active transport • Only IgG antibodies can cross

Endometrial stripe means

No retained placenta

Does HSV cross placenta?

No! Vaginal HSV is transmitted to infant during birth from contact

What does the quadrivalent HPV vax cover?

Types 6, 11 (genital warts), 16, 18 (dysplasia, carcinoma)

progesterone challenge -bleeding = (2) -no bleeding = (3)

test for cause of amenorrhea progesterone given for 5-10 days, then withdrawn. Bleeding should occur 2-7 days after w/drawl Withdrawal bleeding: anovulation (PCOS, premature ovarian failure) No withdrawal bleeding (mucosal: Asherman, endometritis; ↓estrogen: function hypothalamic amenorrhea)

Tx for chlamydia

1 dose of oral doxycycline or azithromycin (pregnancy)

Where should uterine fundus be at 12th week?

Just above the symphysis

When in the ovulatory cycle is body temp highest and what causes it?

Just after ovulation, caused by increased progesterone from corpus luteum

Central/2° hypogonadism + delayed puberty + lack of smell +/- cleft palate

Kallmann syndrome

Male worried about infertility. Tall, long limbs, no sense of smell. Small, soft testes Dx? Pathogenesis?

Kallmann syndrome: failed migration of GnRH neurons from olfactory placode to hypothalamus→↓GnRH→↓FSH, LH, T, E

Inhibits steroid synthesis via inhibition of 17,20 desmolase/17α-hydroxylase Drug? Use? AEs?

Ketoconazole Used in PCOS to reduce androgenic symptoms; systemic tinea corporis AEs: gynecomastia/ amenorrhea; liver dysfunction

65 year old postmenopausal woman w/ porcelain-white/parchment like plaques w/ red/violet borders on vulvar skin + serosanguinous vaginal discharge & oral lesions

Lichen planus (bc vaginal involvement) p = p

65 year old postmenopausal woman w/ porcelain-white/parchment like plaques w/ red/violet borders on vulvar skin Dx? Workup? Tx? Slightly increased risk of what cancer?

Lichen sclerosus: thinning of epidermis w/ fibrosis/sclerosis of dermis Punch biopsy if adult onset to r/o SCC Tx: topical steroid (betamethasone, clobetasol) tacrolimus (2nd line) Slightly elevated risk of squamous cell carcinoma of vulva

Woman presents w/ chronic vulvar itching. Vulva shows leathery, thick vulvar skin with enhanced skin markings. Dx?

Lichen simplex chronicus: Hyperplasia of vulvar squamous epithelium

Contrast main MoA of locally acting progestins (progestin-only OCs, levonorgestrel IUD) and systemic progestin (combination methods, progestin implant/injection)

Local thickens cervical mucus, impairing sperm penetration Systemic stops ovulation by inhibiting gonadotropin (LH/FSH) synthesis by anterior pituitary

Failed involution of paramesonephric ducts can result in

Longitudinal uterine septum/ septate uterus

Why are FSH/LH, and subsequently estradiol, high in Klinefelter's?

Loss of negative feedback from testosterone & inhibin, due to loss of Sertoli cells

Breakthrough bleeding is a side effect of which hormonal BC?

Progesterone

Tx for prepubertal girl w/ labial adhesions, itchiness

Topical estrogen cream

European woman 27 wks pregnant Hx of self-limiting fever and rash Ultrasound shows bilateral ventricular enlargement, intracranial basal ganglia calcifications, low weight, ascites

Toxo

Trichloracetic acid

treats vaginal/vulvar warts caused by low risk strains 6 & 11

Drugs that cause gynecomastia

"Some Hormones Create Funny Knockers" Spironolactone, Hormones, Cimetidine, Finasteride, Ketoconazole

When is tocolysis contraindicated (4)

(cervical dilation > 4 cm), chorioamnionitis, nonreassuring fetal signs, abruptio placentae, or risk of cord prolapse.

Describe the phases of the ovulatory cycle **follicular/proliferative phase (day 0-14)** GnRH (hypothal) → ↑ _____ (ante pituitary) FSH stimulates maturing follicles, which produce ________, which _______ FSH/LH release via ______ feedback on pituitary 1 follicle becomes dominant, estradiol levels continue to rise→ peak estradiol now induces _______ feedback on pituitary→ LH _____ → ovulation **secretory phase (day 15-28)** follicle forms _____ ______ & produces _______, inhibiting LH surge Falling LH causes regression of corpus luteum → fall in progesterone & estradiol→ period

**follicular/proliferative phase (day 0-14)** GnRH (hypothal) → ↑ FSH (ante pituitary) FSH stimulates maturing follicles to produce estradiol, which inhibits FSH/LH release via negative feedback on pituitary 1 follicle becomes dominant, estradiol levels continue to rise→ peak estradiol now induces positive feedback on pituitary→ LH surge → ovulation **secretory phase (day 15-28)** follicle forms corpus luteum & produces progesterone, inhibiting LH surge Falling LH causes regression of corpus luteum → fall in progesterone & estradiol→ period

preterm labor mgmt >34 wks

+/- betamethasone PCN if + or unknown

Proteinuria

+1 dipstick urinalysis → confirm w/ >300 mg/24 hrs Protein/Cr ratio >0.3

How many vessels does a normal umbilical cord contain? What anomaly can occur?

3: 2 arteries + 1 vein Single umbilical artery aka 2 vessel cord can result from congenital/chromosomal abnormalities

Causes of postpartum hemorrhage (4)?

4 T's Tone (uterine atony; most common) Trauma (lacerations, incisions, uterine rupture) Thrombin (coagulopathy) Tissue (retained placenta)

Threshold for endometrial hyperplasia in postmenopausal?

4 mm

Normal FSH in premenopausal woman

4-30 midcycle peak 10-90

How long after delivery does post partum depression arise?

4-6 wks, but can be up to 1 yr screen all women

Lynch syndrome risks + px

40% lifetime risk of endometrial cancer Hysterectomy with bilateral salpingo-oophorectomy at the end of childbearing age (∼ 40 years) is recommended for women with Lynch syndrome.

PPROM mgmt

<34 wks + reassuring = latency abx + steroids >34 wks or nonreassuring = delivery

preterm labor before

<37 weeks

How long postpartum is lochia normal

<8 wks

Prolonged latent phase

> 20 hours for primipara > 14 hours for multipara

positive urine culture

>100,000 colony forming units

Postpartum fever

>100.4 (38.0) 24 hrs after delivery

At what serum B-hcg levels should intrauterine pregnancy be detectable on TVU

>1500

Fetal station -3 0 +3

-3 = initial position prior to labor 0 = at level of narrowest point of ischial spines +3 = at vaginal opening

Etiology of acute mastitis? Tx?

-Bacterial infection of breast, usually due to Staph aureus -Assoc w/ breastfeeding -Tx: continued drainage via breastfeeding + antibiotics (dicloxacillin)

Mgmt of uncomplicated preterm labor 32-33 wks

-Betamethasone (steroids) -PCN if + or unknown -tocolytic (nifedipine) ---- + mag if <32; use indo - toco if >34

5 screening test categories at initial prenatal visit (10 wks)?

-CBC -Blood typing (ABO and rhesus) -Screen for proteinuria & bacteriuria -Rubella & varicella antibody testing Screening for STIs -HIV (ELISA), Syphilis (RPR), HBsAg -Chlamydia PCR (<25 or high risk) ^if STI + or <25, repeat screen @ 24-28 wks

Tx for UTI in pregnancy (3 options)

-Cefpodoxime -amoxicillin-clav 3-7 days -single dose fosfomycin -never fluoroquinolones -no TMP-SMX in 1st & 3rd

Tx for hydatidiform pregnancy?

-Dilation & curettage -Methotrexate (or Actinomycin D) Monitor β-hCG

Levonorgestrel and COCPs work as EC ______ hrs after unprotected sex?

0-72 hrs

Name 1st line pharm tx for uterine atony Name 3 2nd line options and any contraindications

-IV oxytocin (1st line) -IM carboprost tromethamine: if no asthma -IM methylergonovine: if no HTN -Tranexamic acid: given when initial therapies fail to stop the bleeding

Limitation of pap smear?

-Inadequate sampling of transformation zone (false negative screening) -limited efficacy screening for adenocarcinoma

Breast lobules & ducts are lined by 2 layers of epithelium

-Luminal cell layer-inner cell layer; responsible for milk production in the lobules -Myoepithelial cell layer-outer cell layer; contractile function propels milk towards the nipple.

Defects caused by seizure drugs (valproic acid, phenytoin, phenobarbital, carbamazepine) Onset of preventative therapy?

-Neural tube defects (meningocele, myelomeningocele) -Microcephaly -Cleft palate -Nail/digit hypoplasia High dose folic acid supplementation 1 month before pregnancy!

Woman in for prenatal check-up at 26 wks; Rh antibody screen at 10 wks was negative. What tests should be ordered?

-Repeat antibody screen + give rhogam if neg -CBC -50 g 1 hr GCT

Threshold for preeclampsia w/ severe features -BP -5 other sx

-SBP >160 or DBP >110 -Headaches or visual changes -Thrombocytopenia (platelets <100,000) -Cr > 1.1 -↑Transaminases -Pulmonary edema

Risk factors for ectopic pregnancy?

-Scarring of fallopian tubes, most commonly due to chronic salpingitis, PID -Abdominal surgery -Kartagener syndrome (1° ciliary dyskinesia)

Regulators of prolactin?

-Stimulated by: TRH, pregnancy (progesterone & estrogen), breastfeeding (via ↓dopamine), sleep, stress -Inhibited by: dopamine, prolactin, somatostatin -Prolactin itself downregulates GnRH to prevent conception during breastfeeding

Which vaccines are recommended in pregnancy (3)

-Tdap [3rd trimester] -Killed influenza -RhoGAM (if negative)

Isotretinoin (Accutane)

-Vit A derivative -Causes spontaneous abortions or severe birth defects -Birth control mandatory

6 contraindications to breastfeeding

-active substance use -chemo -HIV -varicella outbreak -herpetic breast lesion -active TB

Contraindications for tocolysis in premature rupture of membranes?

-advanced labor (cervical dilation > 4cm) -chorioamnionitis -nonreassuring fetal signs -abruptio placentae -risk of cord prolapse

3 risks for placenta previa

-c section or curettage -maternal age >35 -short interval b/w pregnancies

Mgmt PPROM >34 wks

-delivery -steroids -PCN (+ or unknown)

Order these events in the menstrual cycle chronologically -estradiol peak -progesterone peak -LH peak -ovulation

-estradiol peak -LH peak ----ovulation---- -progesterone peak

What 3 things would endometrial biopsy show during estrogen surge (end of follicular phase--day 12)?

-long, tortuous glands -numerous mitotic figures in glandular epithelium -stromal edema

Risk with insufficient weight gain during pregnancy

-low birth weight -preterm delivery

Tx for breech presentation (if no CIs to vaginal delivery) -offer ______ -if not, offer ______ at ___ wks -contraindication to 2nd line?

-offer c section -if not, external cephalic rotation @ 37 wks **never do in preterm labor

7 risk factors for preeclampsia?

-pre-existing hypertension -diabetes -obesity -CKD -SLE, antiphospholipid antibody syndrome -1st pregnancy or multiple gestation

3 risk factors for PPROM?

-prior PPROM -ASB, BV -antepartum bleeding

4 Contraindications to vaginal delivery

-prior classical c section -prior uterine myomectomy (cavity entered) -placenta previa -active HSV outbreak

Chronic hypertension risks to mother & fetus

-superimposed preeclampsia -postpartum hemorrhage -gestational diabetes -placental abruption -c section -fetal growth restriction -oligohydramnios -preterm labor -perinatal mortality

How many Barr bodies in Turner

0

Explain how the timing of cleavage determines chorionicity (# chorions) and amnionicity of monozygotic twins 0-13 days

0-4 days: Separate chorion & amnion (25%) 4-8: shared Chorion (most common; 75%) 8-12: shared Amnion (and Chorion) 13+: shared Body (conjoined) if amnion is shared, chorion is shared SCAB

Which form of CAH? 1)HYPOnatremia, severe HYPOtension, HYPERkalemia. Females virilized 2)HYPOkalemia, HYPERtension. Females virilized 3)HYPOkalemia, HYPERtension. Males feminized

1) HYPOnatremia, HYPOtension, HYPERkalemia, virilization = 21-hydroxylase 2) HYPERtension, HYPOkalemia, virilization = 11-hydroxylase 3) HYPERtension, HYPOkalemia, feminization = 17α-hydroxylase starts w/ 1 = HTN ends w/ 1 = virilization h before v

Workup for precocious puberty? (3 steps)

1) XR hands/wrists to determine bone age 2) if older→LH level (high = central) 3) GnRH stim test if LH low→ stays low = periph

Uses of magnesium sulfate in preterm labor

1) neuroprotection to fetus 2) weak, 2nd line tocolytic indicated if delivery before 32 wks is anticipated

Quad screen -when -what (4)

15-20 wks Maternal serum -HCG -Inhibin A -AFP -Estriol triple screen same minus inhibin

Name the high cancer risk subtype of HPV and explain what makes them so

16, 18, 31 All express these genes -E6: protein inhibits p53 (tumor suppressor; controls G1 to S phase) - E7: protein inhibits Rb (tumor suppressor; inactivates E2F transcription factor)

Labs for Turner syndrome

Low estrogen, progesterone High FSH/LH

Sequential integrated test -when -what

10-13 weeks gestation followed by 15-20 weeks gestation First trimester combined test plus Quad screen test

Apgar score

10-point scale, evaluated at 1 minute and 5 minutes after birth Score < 7 requires further evaluation

Common karyotypes of complete hydatidiform moles? Staining

100% paternal DNA due to empty egg 1 X sperm that duplicates → 46,XX 2 sperm → 46,XY No fetal parts (unlike partial mole) p57-negative: Only expressed by maternal chromosomes (imprinted)

First trimester screen -when -what

11-13 wks -Ultrasound to check for nuchal translucency (↑ in Downs) Blood test for -β-HCG -PAPP-A (pregnancy-associated protein A) (↓ in Downs)

Normal fetal heart rate

110-160 bpm

State how hCG, inhibin A, estriol, & AFP, levels would be in trisomy 21 vs trisomy 18 vs 13

13: only abnormality is ↓ hCG 18: ↓ hCG, estriol, & AFP, inhibin A normal 21: ↑ hCG & inhibin. ↓ estriol & AFP

What enzyme converts androstenedione to testosterone?

17β-hydroxysteroid dehydrogenase

Chemotherapy is safe after ___ trimester

1st

What heart defect is most strongly associated with maternal diabetes? Onset of maternal DM?

1st trimester Transposition of the great arteries (TGA) -Neural crest cells forming aorticopulmonary septum fail to spiral -Aorta arises from RV & pulmonary artery arises from LV, creating 2 completely disconnected circulatory systems

when can beta-hcg be used to measure fetal wellbeing

1st trimester (0-13 wks)

Most accurate estimate of gestational age? (When & What)

1st trimester US w/ crown-rump measurement

Workup for 2° amenorrhea (4)

1st: preg test (B-HCG) 2nd: prolactin, FSH, TSH

Contrast progesterone production in 1st vs 2nd/3rd trimesters

1st: produced by corpus luteum, stim'd by hCG 2nd/3rd: synthesized by placenta

Outline the process of oogenesis

1° oocytes (2N, 4C) begin meiosis I during fetal life & then remain arrested in prophase I until puberty/ovulation, at which time some complete Meiosis I, forming a 2° oocyte (1N, 2C) and 1st polar body 2° oocytes are then arrested in metaphase II until fertilization If fertilization does not occur w/in 1 day, 2° oocyte degenerates. If fertilization does occur, 2° oocytes complete meiosis II, yielding mature ova (1N, 1C) and 2nd polar body

1° oocytes are arrested in ____________ until puberty 2° oocytes are arrested in ____________ until fertilization

1° oocytes are arrested in prophase I until puberty 2° oocytes are arrested in metaphase II until fertilization (prophase till puberty, metaphase after sperm "met" egg)

35 year old woman w/ light/irregular periods. Low estrogen, high LH, extremely high FSH. Dx?

1° ovarian insufficiency/ premature ovarian failure-menopause before 40

1°, 2°, 3° prevention

1°= prevent disease (prophylactic, HPV vax) 2°= catch early, before symptoms (mammography) 3°= treat to prevent M&M

50% cervical effacement

2 cm (baseline = 4 cm)

Criteria (2), risk factors (4), and tx (including when) for cervical insufficiency

2 or more consecutive painless, 2nd trimester (13-28 wk) pregnancy losses risks -collagen defect -cervical conization -obstetric surgery -uterine abnormalities tx = cerclage at 12-14 wks gestation

How many wks along for delivery if premature ROM?

34 wks

When should GBS test be performed?

36-38 wks

When is fetal malposition an issue?

37 wks

Threshold for spontaneous abortion/miscarriage vs fetal demise/stillbirth?

20 weeks

adequate contraction strength =

200-250 MVU

When does cervical cancer screening begin and end in most cases?

21-65

Pt @ high risk for preeclampsia should have what additional screen at 1st prenatal?

24 hr urine protein

When should screening for gestational diabetes occur? How?

24-28 wk 50g 1 hr glucose challenge test

When in pregnancy should 50 g 1 hr GCT be performed?

24-28 wks

Mgmt of gestational diabetes -time of initial test ? FU test if initial abnormal? -3 meds -post-partum mgmt

24-28 wks w/ 1 hr GCT or 3 hr GTT *If BGL >140 of 1 hr GCT > 3 hr GTT Insulin, metformin, glyburide 2 hr GTT 6-12 wks postpartum

beta-hcg @ 9-12 wks

26,000-290,000 mIU/mL

Causes of prolonged active phase labor (3)

3 p's Pelvis Passenger Power

how often depo provera given ?

3 yrs

Pathogenesis of Klinefelter's syndrome 4__ XXY resulting from __________ or translocation (1 X chromosome becomes a Barr body) Dysgenesis of __________ tubules/loss of ______ cells→ ↓ _____→↑ ______ (which upregulates aromatase) →↑ estrogens _____ cell dysfunction→↓ ________→↑↑LH (no neg feedback from T)

47 XXY resulting from nondisjunction during meiosis 1 or translocation (1 X chromosome becomes a Barr body) Dysgenesis of seminiferous tubules/loss of Sertoli cells→ ↓ inhibin→↑ FSH (which upregulates aromatase) →↑ estrogens Leydig cell dysfunction→↓ testosterone→↑↑LH (no neg feedback from T)

Woman 2 days post c-section w/ pain on deep inspiration, bilateral decreased breath sounds over lung bases, low grade fever & leukocytosis

5 W's of post-op fever • Wind (atelectasis) = POD 1-2 • Water (UTI) = POD 3-5 • Walking (DVT) = POD 4-6 • Wound (infection) = POD 5-7 • Wonder (anything) = POD 7+ pain on deep inspiration → shallow breathing → underutilization of lung bases → atelectasis

Risk factors for spontaneous abortion (4)

50% due to congenital abnormalities Other: -Maternal smoking, alcohol, cocaine -Maternal infection (TORCH) -Maternal lupus/antiphospholipid syndrome

How is DHT produced?

5α-reductase converts testosterone into DHT

12 yo girl w/ enlarging clitoris, no menarche. Karyotype shows XY. Dx?

5α-reductase deficiency Normal male internal genitalia, ambiguous or female external genitalia until puberty (↑testosterone)

XY neonate w/ small/feminized genitalia, hypospadias, undescended testes Normal testosterone & estrogen levels (for boy) Normal BP

5α-reductase deficiency; converts testosterone→ DHT (more potent androgen, also contributes to MPD/BPH) -External genitalia = female/ambiguous until puberty (low T→ no virilization) -Internal = male (DHT) -Normal or ↑ LH

Stress UI is normal up to ____ wks postpartum

6

Postpartum urinary retention = X hrs tx?

6 hrs cath

Which HPV strains cause warts?

6, 11

Which subtypes of HPV cause genital warts?

6, 11

2 pathways to endometrial carcinoma? State risk factors and describe histology for each 75% from ______________ -Avg age ______ -Risk factors: estrogen exposure (early menarche/late menopause, nulliparity, infertility w/ anovulatory cycles, obesity) -Histology is ___________ 25% is _______ -Avg age ______ -Risk factor: _______ mutation -Histology: serous w/ _______ structures & _______ bodies -aggressive tumor

75% from endometrial hyperplasia (esp simple architecture w/ atypia) -Avg age 50 -Risk factors: estrogen exposure (early menarche/late menopause, nulliparity, infertility w/ anovulatory cycles, obesity) -Histology is endometrioid 25% is sporadic -Avg age 70 -Risk factor: p53 mutation -Histology: serous w/ papillary structures & psammoma bodies -aggressive tumor

How often should newborn be fed

8-14 times per day

Normal 1 hr glucose challenge

< 140 If higher, do 3 hr GTT

Low birth weight

< 2500 g (5.5 lbs)

Uncomplicated preterm labor <32 wks vs 32-33 vs 34-36 Preterm labor = regular contractions + cervical change or ROM

<32 -Betamethasone -PCN if status + or unknown -Tocolytics (indomethacin) -Magnesium sulfate 32-33 -Betamethasone -PCN if status + or unknown -Tocolytics (nifedpine) 34-36 -Betamethasone -PCN if status + or unknown

Threshold for magnesium sulfate in preterm labor (GA)

<32 wks

Acceleration (CTG) A normal temporal increase in the FHR from the baseline by >__ bpm for a maximum duration of ___ minutes

A normal temporal increase in the FHR from the baseline by >15 bpm for a maximum duration of 10 minutes

Decelerations (CTG) A temporary decline in the FHR of > __bpm for a maximum duration of ___ minutes

A temporary decline in the FHR of > 15 bpm for a maximum duration of 3 minutes

Primary ovarian insufficiency -WU after dx confirmed (3)

AKA premature ovarian failure. Premature atresia of ovarian follicles in women of reproductive age. Patients present w/ signs of menopause after puberty but before age 40.↓estrogen, ↑LH,↑↑FSH Can be idiopathic or due to chromosomal abnormalities (esp if <30) or chemotherapy WU = adrenal antibodies, TSH, and karyotype analysis

Indications for intrapartum PCN if GBS status unknown (4)

ANY OF THE FOLLOWING -maternal fever -<37 wk gestation -rupture of membranes for >18 hrs -previous neonate w/ GBS infxn (neonatal sepsis)

5α-reductase deficiency -Genetics -Presentation

AR; Affects genetic males (46,XY DSD); often raised/present female 5α-reductase (converts testosterone→ DHT) Ambiguous genitalia until puberty, when ↑testosterone causes masculinization/growth of external genitalia. Normal testosterone/estrogen levels Normal or ↑ LH Normal internal genitalia

Neonate w/ mild jaundice, ↑reticulocytes, hyperbilirubinemia, + indirect coombs test no Rh incompatibility Type O mothers; type A or B fetus. Dx? Tx?

ABO hemolytic disease Mild Responds to phototherapy

Mode of delivery for HIV+ pregnant people

ART ASAP in prenatal care determined by viral load <1000 = ART + vaginal delivery >1000 = ART + zidovudine + C section

Indications for endometrial biopsy in 45 or greater

AUB Postmenopausal bleeding Atypical glandular cells on pap (>35)

Indications for endometrial biopsy in person under 45

AUB PLUS -high risk endometrial hyperplasia (obese, PCOS) -failed medical mgmt of AUB -Lynch syndrome Any above + Atypical glandular cells on pap

Placental abruption presents w/ __________ bleeding in 3rd trimester Placenta Previa presents w/ ____________bleeding in 3rd trimester

Abruption = painful Previa = painless

Teratogenic effects of tetracyclines

Accumulate in teeth, long bones Permanently discolor teeth (hint: teethtracyclines)

Fever, uterine fundal tenderness >24 hrs after delivery/miscarriage Dx + pathophys? 4 risk factors? Tx?

Acute endometritis: polymicrobial infection of decidua RF: C-section, forceps-assisted, prolonged ROM, GBS colonization Tx: IV gentamicin & clindamycin +/ ampicillin (ECG = endometritis → genta & clinda)

Pregnant w/ RUQ pain, scleral icterus, hypoglycemia, coagulopathy. BP 120/80 ↑AST & ALT ↑Bilirubin Platelets <100,000 Tx?

Acute fatty liver of pregnancy immediate delivery

HSV mgmt in pregnancy

Acyclovir from 36 wks C section only if outbreak at time of labor

Heavy, painful period + uniformly enlarged, globular, tender uterus

Adenomyosis- endometrial tissue in myometrium

Middle-aged, parous woman w/ dysmenorrhea, menorrhagia, uniformly enlarged, soft, globular uterus Dx? Pathogenesis? Tx?

Adenomyosis-extension of glandular endometrial tissue into myometrium Caused by hyperplasia of basal endometrium Tx: Pharmacologic: NSAIDs (first-line); OCPs, progestins Surgical: hysteroscopy → endometrial ablation/resection Definitive: hysterectomy

Patient is Rh ⊖ and unsensitized (⊖ antibody test). She is pregnant. Mgmt?

Administration of Rh (D) immune globulin This patient should be given Rhogam every time she comes into contact with fetal blood to keep her unsensitized

Tx of pylo in pregnancy

Admit + IV CTX

Fundal height

After wk 20, correlates to gestation age in wks +/- 3

When does pap screening start?

Age 21 regardless of sexual activity

Neonate w/ small head, low-set ears, widely spaced eyes, and a thin upper lip. The rest of the newborn exam is notable for a wide and fixed split S2 heart sound on auscultation. Likely teratogen?

Alcohol

Which chemotherapies are most teratogenic? What do they cause?

Alkylating agents and antimetabolites Spont abortion; missing digits; etc

Distinguish b/w the 3 types of morbidly adherent placenta

All will cause excessive postpartum hemorrhage if vaginal delivery is attempted Placenta accreta—placenta attaches to myometrium without penetrating it; most common type Placenta increta—placenta infiltrates myometrium Placenta percreta—placenta perforates myometrium and invades entire uterine wall; can attach to rectum or bladder→hematuria

irregular periods /menorrhagia in 2 years after menarche caused by

Alternating ovulatory & anovulatory cycles due to inadequate gonadotropin production

When are amnio, chorio, and cordocentesis done?

Amnio: 10-13 Chorio: 15 Cordo: 17 **give rhoGAM

Describe the amnion and chorion membranes of the placenta

Amnion = inner membrane that covers/protects fetus and holds amniotic fluid (hint: "am in") Chorion = outer membrane that surrounds amnion; derived from trophoblast

38 yo woman G5P5 develops sudden breathlessness, confusion, cyanosis 20 min after giving birth and then has TC seizure Exam shows unconscious woman with purpuric rash and bleeding from puncture sites Dx? 5 risk factors

Amniotic fluid embolism Risks = advanced maternal age, gravida >5, c-section or assisted delivery, placental previa or abruption, preeclampsia Tx w/ vent & hemodynamic support

12 weeks pregnant with UCx growing GBS Tx?

Amoxicillin now + PCN ppx at labor

Genetic abnormalities in breast cancer?

Amplification/ overexpression of estrogen/progesterone receptors or c-erbB2 (HER-2, EGF receptor) is common Triple negative (ER ⊝, PR ⊝, Her2/Neu ⊝) = more aggressive (more common in black women, women <40)

What enzymes convert androstenedione to estrogen? Androstenedione converted to Testosterone by ___________ Testosterone converted to 17-β-Estradiol by _____________

Androstenedione converted to Testosterone by 17-β-Hydroxysteroid dehydrogenase Testosterone converted to 17-β-Estradiol by Aromatase

15 year old w/ neg pregnancy test but no period for 2 months. Meses began 6 months ago. Progesterone is low

Anovulatory cycles; normal for months after menarche due to immaturity of hypothalamic-pituitary-gonadal axis

4 AEs of synthetic oxytocin?

Anti-diuretic properties similar to ADH, can cause hyponatremia, seizure, subarachnoid hemorrhage; uterine rupture

Teenager presents after fracturing wrist from minor fall. She was noted to have clitoromegaly at birth, but laparotomy showed normal internal sexual organs She is noted to have virilization, and has never menstruated US shows polycystic ovaries LH and estrogen is undetectable, FSH, LH, T are high

Aromatase deficiency

Anastrozole, letrozole, exemestane -Class/MoA -Use

Aromatase inhibitors; Inhibit peripheral conversion of androgens to estrogen Used in ER ⊕ breast cancer in postmenopausal women; letrozole also 1st line to induce ovulation in PCOS

Common cause of premature rupture of membranes (membrane rupture before contractions but at term) Complications?

Ascending infection Umbilical cord prolapse (cord before baby) Placental abruption Chorioamnionitis

Px for thrombosis in pregnancy in woman w/ Antiphospholipid Antibody Syndrome?

Aspirin and LMW heparin (ex: enoxaparin)

Pregnant w/ ≥ 100,000 CFU/mL in 2+ voided urine samples Tx (3 options)?

Asymptomatic bacteriuria Tx: amoxicillin-clauv, cephalosporin, fosfomycin get f/u culture

Tx polyhydramnios 3 complications?

Asymptomatic: expectant management Symptomatic: amniocentesis Premature (ROM, labor, birth)

What is placenta previa? 3 risk factors ? Workup (1)?

Attachment of placenta to uterus over internal cervical os Risk factors: prior C-section, older age, multiple gestation Presents w/ painless 3rd-trimester bleeding Workup: transvaginal ultrasound (Hint: "preview" of placenta seen thru cervix)

Grey-white, fishy smelling vaginal discharge, vaginal epithelial cells covered in gram-variable rods w/ stippling, pH >4.5, positive whiff test (amine odor with KOH) Tx?

Bacterial vaginosis; gardnerella Tx patient w/ metronidazole (free radicals), clindamycin (binds 50s) "Grey/white fish in the garden" "clinda looks for clues"

Gestational hypertension: definition & tx

BP > 140/90 mm Hg after 20th week No pre-existing hypertension No proteinuria or end-organ damage (after 20th & + ^ = preeclampsia) Antihypertensives (Hydralazine, α-Methyldopa, Labetalol, Nifedipine/procardia), deliver at 37-39 weeks "Hypertensive Moms Love Nifedipine"

Assoc for male breast cancer (2)

BRCA2 Klinefelter

What reflex is this & when should it stop? What does it mean in adults? An upward moving great toe with fanning of the other toes when the bottom of the foot is stroked

Babinski sign (indicates corticospinal pathways not fully myelinated) Normal in babies <1 yo In adults indicates UMN lesion

Gubernaculum

Band of fibrous tissue Male remnant-Anchors testes w/ scrotum Female remnant-Ovarian lig + round lig of uterus

Unilateral, mobile, cystic lesion at base of labia/vestibule Dx? Etiology? Tx?

Bartholin cyst: most commonly d/t E coli or staph aureus Tx is incision & drainage only glands at 4 & 8 o'clock

Soft, mobile, nontender mass located behind labia majora; may extend into vagina

Bartholin duct cyst

Pap testing in HIV⊕

Baseline, then yearly until 3 consec normal, then every 3

Breast cancer most commonly metastasizes to (3)

Bones Lungs Liver

Pregnant woman w/ ovarian torsion @ wk 8 receives oophorectomy. prenatal care?

Before wk 10, corpus luteum is primary source of progesterone, so if removed before wk 10, progesterone supp is needed to maintain pregnancy

Early deceleration -describe -1 cause

Beginning & end of deceleration correspond w/ progression of contraction; deceleration reaches nadir (most deceleration) @ peak contraction Onset to nadir is gradual (≥ 30 sec) Occur during active labor; usually normal Caused head compression during contraction triggers vagus nerve stimulation & reflex bradycardia

Mature cystic teratoma (dermoid cyst)

Benign germ cell tumor Cystic ovarian mass containing elements from all 3 germ layers (eg, teeth, hair, sebum). May cause pain from ovarian enlargement / torsion

Abnormalities leading to bicornuate vs uterus didelphys

Bicornuate: partial lateral fusion; uterus w/ two lumens ("horns"), entering a common vagina Characterized by indentation in center of fundus Uterus didelphys: complete lack of lateral fusion of paramesonephric; double uterus, cervix, vagina

Complications of uterine prolapse?

Bilateral hydronephrosis, pyelonephritis

Contrast histology of intraductal papilloma and papillary carcinoma

Both have fibrovascular projections lined by epithelial cells Intraductal: + myoepithelial cells ("my introduction") Papillary carcinoma: without underlying myoepithelial cells

Distinguish between Alvarez-waves & Braxton-Hicks

Both normal Alvarez: occurs after 20 weeks; Low intensity, high frequency Braxton-Hicks: high intensity; last 1 min or less; usually ≤2/hr; may increase near term

LH and T levels in defective androgen receptor?

Both would be high

Unilateral nipple discharge over vs under 30 yo 1st & 2nd step

Both: ultrasound Over: mammography (& US)

In mom: asymptomatic or febrile/sore throat illness (mono-like illness) Sensorineural deafness, periventricular calcifications, seizures, hepatosplenomegaly, petechial rash/blueberry muffin, chorioretinitis TORCH? Family?

CMV Also microcephaly Herpes: Enveloped, dsDNA

Most common cause of ID sensorineural deafness in newborns?

CMV (TORCHeS) Congenital deafness = CMV

Is extramammary/vulvar paget or paget of breast assoc w/ underlying carcinoma

Breast Extramammary is usually not

A well-circumscribed, anechoic mass with posterior acoustic enhancement in a premenopausal woman tx?

Breast cyst; if asymptomatic no further workup, if symptomatic FNA

Breast mass on exam or abnormal calcification on mammography (saponification) Biopsy shows necrotic fat with associated calcifications and giant cells Hx of trauma may not be known/mentioned

Breast fat necrosis

Unilateral blood-tinged breast milk in new mother + firm mass. NBS?

Breast imaging d/t cf cancer

Solid ovarian tumor; pale yellow-tan & appears encapsulated. Resembles bladder epithelium (transitional cell tumor)."Coffee bean" nuclei on H&E stain Dx? Benign or metastatic

Brenner's tumor; Usually benign

4 complications of supplemental O2 therapy in infants

Bronchopulmonary dysplasia Intraventricular Hemorrhage Retinopathy of prematurity PDA (O2 makes u BIHRP)

Threshold for oligo and poly menorrhea ?

Oligomenorrhea = periods @ intervals >35 days Polymenorrhea < 21 days

Soft, tan, cauliflower-like lesions on genital/anal skin Due to HPV type 6 or 11 Histology shows koilocytic change (Peri-nuclear clear vacuolization) Does not lead to cancer

CONDYLOMA ACUMINATUM

How is cervical dysplasia graded? CIN I-III + carcinoma in situ

CIN I < 1/3 thickness of epithelium. CIN II < 2/3 thickness of epithelium. CIN III almost full thickness Carcinoma in situ (CIS)= full thickness (penetrates BM and full epithelium)

Distinguish b/w low and high grade CIN

CIN in high grade (II-III) once atypical cells have invaded past lower 1/3 of cervical epithelium

Teratogenic effects of fluoroquinolones

Cartilage damage (fluoro's make you floppy)

What marker is used to monitor for the recurrence of ovarian neoplasms?

CA-125

Ovarian mass in postmenopausal woman; next step?

CA-125; if elevated→laparoscopy more specific in postmeno bc lower likelihood of confounders like leiomas, endometriomas **never needle biopsy due to risk of seeding

Amnio showed 46 XX but baby born w/ scrotum & phallus

CAH→virilization

Pregnant woman w/ sx of pulmonary embolism. V/Q scan shows low probability PE NBS?

CTA

Workup for pregnant w/ HIV + ⊕ PPD

CXR

Tx for prolactinoma?

Cabergoline; shrinks tumor, suppresses prolactin

atypical glandular cells on pap in woman >35 or w/ ↑risk of endometrial hyperplasia

Can be due to cervical or endometrial adenocarcinoma so -endometrial biopsy -colposcopy w/ endocervical curettage

Presents w/ thick/cottage-cheese vaginal discharge, vulvar inflammation/itching. Microscopy reveals pseudohyphae budding cells. 5 Risk factors? Tx

Candida albicans Risks: antibiotic or corticosteroid use, high estrogen, unmanaged diabetes, immuno comp/supp Tx: fluconazole

Which STIs cause vulvovaginal erythema

Candida albicans (normal pH), Trich (high pH)

What ligament contains the uterine vessels & connect cervix to pelvis? What other structures may be injured ligation of uterine vessels?

Cardinal aka transverse cervical ligament Ureters may be damaged during hysterectomy (run under vessels "water under bridge"): presents w/ fever, flank pain, normal urination (uterus makes you bleed cardinal red)

What effect does testosterone have on growth?

Causes growth spurts but also can stunt growth bc closes epiphyseal plates

Teratogenic effects of nicotine

Causes vasoconstriction IUGR/low birth weight Premature delivery ADHD, SIDs

Tx for PID

Cef + doxy +/- metro

Postpartum + hx DVT + seizure and/or signs ICP. Normal head CT Probably dx? NBS?

Cerebral vein thrombosis Cerebral venography MRI

Difference b/w threatened and inevitable abortion?

Cervical dilation → inevitable

Pregnant woman @ 14 wks w/ light vaginal bleeding. PMH of LEEP. Exam shows funneled internal os Dx?

Cervical incompetence

Top 3 RF for endometritis

Cesarean delivery Prolonged labor or ROM

Which 2 forms of EC are effective 120 hrs after unprotected sex?

Copper IUD (>99%) Ulipristal

Lung masses & testicular mass. Gynecomastia, weight loss, palpitations Elevated β-hCG, low TSH

Choriocarcinoma

Malignant tumor of syncytiotrophoblasts and cytotrophoblasts (placenta-like tissue, but no villi) ↑β-hCG Hematogenous metastases to lungs & brain. Gynecomastia, HYPERthyroidism (α-subunit of hCG same as LH/FSH, TSH)

Choriocarcinoma

Pregnant/peripartum/miscarriage pt w/ vaginal bleeding, friable vaginal mass, abnormally high hCG, SOB, hemoptysis. CXR shows "cannonball" opacities. Cancer of ___________ Lacks ________ Spreads how? May cause what cysts?

Choriocarcinoma: malignancy of trophoblastic tissue (cytotrophoblasts & syncytiotrophoblasts); mimics placental tissue, but lacks chorionic villi Early hematogenous spread to lungs High hCG (made by syncytiotrophoblasts) may cause bilateral theca-lutein cysts

Chronic inflammation of the endometrium Presents w/ pelvic pain, heavy menses Biopsy shows lymphocytes & plasma cells w/in endometrial stroma (+granulomas if TB infection) Dx? Causes?

Chronic endometritis Causes: retained products of conception, PID (Chlamydia, Gonorrhoeae), IUD (Actinomyces israelii), TB

3 signs of placental separation during stage 3 labor?

Cord lengthening Gush of vaginal blood Uterine fundal rebound

Structural characteristics of HPV?

Circular, naked, dsDNA

Selective Estrogen Receptor Modulator (SERM) Blocks estrogen negative feedbacking hypothalamus, resulting in ↑GnRH→ ↑FSH/LH → ovulation Used to induce ovulation in PCOS

Clomiphene

Complications of Turner syndrome? 2 heart 1 hormone 1 renal

Coarctation of the aorta (femoral < brachial pulse aka higher BP in upper extremity) Bicuspid aortic valve HYPOthyroidism Horseshoe kidney

What layer is defective in morbidly adherent placenta? Name 4 risk factors

Defective decidual layer→abnormal attachment and separation after delivery Risk factors -prior C-section -placenta previa -advanced maternal age -multiparity

Pap shows HSIL in pt >25. NBS? Monitoring?

Colposcopy -No CIN 2/3 → cotesting @ 12, 24 mo OR LEEP

Suspected cervical cancer during pregnancy

Colposcopy & cervical biopsy is safe in pregnancy Cervical excision only if invasive cancer found due to risk of preterm delivery

Triphasic bc =

Combined OCP w/ diff doses throughout month

Comedo subtype of DCIS

Comedo type is characterized by high-grade cells w/ central necrosis & dystrophic calcification

Female comes in w/ concerns about infertility. External genitalia look normal, normal breast development, scant axillary & pubic hair, rudimentary/blind vagina; no uterus or fallopian tubes. Testes found in labia majora Labs? Dx? Karyotype?

Complete androgen insensitivity syndrome (CAIS) due to X-linked defect in androgen receptor 46, XY Labs show elevated testosterone, estrogen, LH

When is urodynamic testing recommended

Complicated urinary incontinence + candidate for surgery

What is the vitelline/omphalomesenteric duct, when should it obliterate, and what results from partial or total failure to obliterate/close?

Connects yolk sac to midgut lumen, should obliterate by 7th week Partial closure→Meckel diverticulum: true diverticulum; may contain ectopic acid-secreting gastric and/or pancreatic tissue→ melena, hematochezia, RLQ pain, ↑tech-99 uptake in RLQ Total failure to close→ vitelline fistula: meconium discharge from umbilicus

Round ligament of the uterus -connects -derived from -travels through

Connects: uterine horn to labia majora Derivative of gubernaculum Travels through round inguinal canal; above the artery of Sampson

Neonate w/ microcephaly, high-pitched crying/ epicanthal folds, cardiac abnormalities (VSD) Will develop intellectual disability

Cri du chat; Congenital deletion on short arm of chromosome 5 (46,XX or XY, 5p−).

Fibroadenoma is assoc w/ what drug?

Cyclosporin A usage (renal transplant) (Half of women receiving cyclosporine (renal transplantation) develop fibroadenomas and often present with multiple, bilateral tumors)

Pt presents w/ pelvic pain Ultrasound shows complex mass w/ multiple echogenic bands and partial calcification Doppler shows decreased blood flow

Cystic teratoma causing ovarian torsion

What layers does the trophoblast form and what are their functions?

Cytotrophoblast: inner layer; proliferates → cells migrate into syncytiotrophoblast Syncytiotrophoblast = outer layer; makes hCG, other hormones. Lacks MHC-I so less likely to be attacked by maternal immune system.

Low testosterone, low LH suggests

Hypogonadotropic hypogonadism (2°) ex: CNS lesion, Kallmann

What drug causes this phenotype? Flat nasal bridge, short nose Far apart eyes Malformed ears Microcephaly Cleft lip/palate Nail hypoplasia

Fetal hydantoin syndrome; caused by Phenytoin (anti-seizure drug)

Pt w/ heavy vaginal bleeding and abdominal pain confirmed to have ectopic pregnancy How would her endometrium appear?

Decidualized; like secretory/luteal phase or normal pregnancy: dilated, coiled endometrial glands, vascularized stroma no chorionic villi 334

Normal breast exam. Screening mammogram reveals microcalcifications. Biopsy shows ducts distended by pleomorphic cells w/ central necrosis and no invasion of basement membrane

DCIS

Rank androgen potency

DHT > testosterone > androstenedione

How should BP be affected by pregnancy?

Decreased peripheral resistance should cause lower BP

Synthetic androgen; partial agonist at androgen receptors. Uses: Endometriosis, hereditary angioedema. AEs: weight gain, edema, acne, hirsutism,↓HDL levels (good cholesterol), hepatotoxicity, pseudotumor cerebri.

Danazol

Pregnant pt w/ right sided low abdominal pain, leukocytosis, fever, uterine contractions Cervix closed; no signs of fetal distress Uterus had fundal tenderness and firm mass

Degenerating leiomyoma myometrial blood flow goes to fetus→ fibroid infarction & necrosis→ degeneration→ uterine contractions, fundal tenderness, tender mass, and leukocytosis (due to inflammatory cytokine release)

When can HCG be detected? What could abnormally high or low levels mean?

Detected in blood @ day 8, in urine @ day 10 ↓ hCG: ectopic pregnancy /spontaneous abortion, trisomy 13, 18 ↑ hCG: multiparity, hydatidiform mole, gestational cancer, Down syndrome

Phenotype for 22q11 deletion→ no 3rd & 4th branchial pouches→

DiGeorge No 3rd & 4th branchial pouches→ thymus or parathyroids (CATCH-22: Cardiac defects, Abnormal facies, Thymic/paraThyroid hypoplasia, Cleft palate, Hypocalcemia→ 22q11 deletions)

Dx? Pathogenesis? -Long, narrow face, cleft palate -Tetany (HYPOcalcemia) -Recurrent viral/fungal infections (T-cell deficiency) -Tetralogy of Fallot, truncus arteriosus Findings: ↓T cells, ↓PTH, ↓Ca2+. Thymic shadow absent on CXR

DiGeorge syndrome; autosomal dom 22q11 deletion→ no 3rd & 4th branchial pouches→no thymus or parathyroids (CATCH-22: Cardiac defects, Abnormal facies, Thymic hypoplasia, Cleft palate, Hypocalcemia→ 22q11 deletions)

What med causes these birth defects: vaginal clear cell adenocarcinoma, congenital Müllerian anomalies ?

Diethylstilbestrol (DES)

Tx of acute AUB in hemodynamically unstable, >45, or risk factors for endometrial cancer (>35, obesity/PCOS, nulliparity, early menarche, diabetes, tamoxifen)

Dilation and uterine curettage (D&C) + hysteroscopy/endometrial biopsy It is both diagnostic and therapeutic

PGE2 analog that softens cervix and induces contractions AEs?

Dinoprostone (Cervidil) GI distress Postpartum DIC Fever (Dinosaur movie rated PG)

Risk to fetus if mom has ITP

Disorder of decreased platelet survival, due to anti-GPIIB/IIIA IgG antibodies→ consumption by splenic macrophages antibodies are IgG, cross placenta and attack fetal platelets too

Teratogenic effects of sulfonamides (TMP-SMX aka bactrim)

Displace bilirubin from albumin Causes kernicterus (Unconj bilirubin enters placenta, acts as neurotoxin in basal ganglia & brain stem)

Distal vagina, vulva, distal anus are drained by ________ inguinal nodes

Distal vagina, vulva/scrotum, distal anus →superficial inguinal nodes

Name the 3 malignant ovarian germ cell tumors

Dysgerminoma Immature teratoma Yolk sac tumor

Very tall teenage boy w/ severe acne and ASD. Phenotypically normal; normal fertility Dx? Pathogenesis?

Double Y, 47 XYY paternal nondisjunction during anaphase II 2 Ys = anaphase 2

Ovarian tumor; Large polygonal/round cells in lobules with clear, watery cytoplasm hCG, LDH = tumor markers

Dysgerminoma (Germ cell tumor mimicking oocytes)

Endometrial glands and stroma outside of the uterine endometrial lining (gun-powder nodules), most likely due to retrograde menstruation w/ ectopic implantation Presents w/ extreme dysmenorrhea, pelvic pain; may cause infertility

Endometriosis

Polycythemia of the newborn

Excessively elevated Hct at birth (>65) -Newborns normally have ↑ RBC mass (uterus is relatively hypoxic) -May cause HYPOglycemia (excessive RBC glucose utilization), HYPERbilirubinemia

Fetal ultrasound shows double bubble + AFI >24. Dx + assoc abnormalities?

Duodenal atresia Assoc w/ trisomy 21 + VACTERL Vertebral Anal atresia Cardiac Tracheoesophageal fistula Esophageal atresia Renal Limb

Teen w/ ovarian mass, elevated β-hCG & LDH. Biopsy shows fried egg cells w/ watery/clear cytoplasm

Dysgerminoma

What is the most common malignant ovarian germ cell tumor in teens? Describe histology + markers

Dysgerminoma Equiv to male seminoma but rarer. Sheets of uniform "fried egg" cells w/ watery cytoplasm LDH, hCG = tumor markers (Fry eggs dysgerm them)

Teenager w/ ovarian mass, ↑LDH, large cells in lobules with watery cytoplasm Dx? What is male equiv & what marker?

Dysgerminoma Male equiv = seminoma (same histo, but ↑ placental ALP)

Preeclampsia + maternal seizures = ? Feared outcomes? Tx?

Eclampsia Can result in maternal death due to stroke, intracranial hemorrhage, or ARDS Tx: anti-HTNs, IV magnesium sulfate, immediate delivery

How can GTD (esp complete mole) cause HYPERthyroidism ?

Excess Beta-hCG, which shares α subunit w/ TSH, can cause release of T3/T4 Labs will show low TSH, High T3/T4

What type of breast cancers/pts respond to aromatase inhibitors (anastrozole, exemestane)?

ER⊕ in post-menopausal women

Mgmt of preterm labor 32-37 wks EVERYONE GETS: (2) <____ gets magnesium sulfate <____ gets tocolytics

EVERYONE GETS: steroids + PCN if GBS unknown <32 gets magnesium sulfate <34 gets tocolytics

What birth defects can lithium cause?

Ebstein anomaly -Downwardly displaced tricuspid valve causes atrialized R ventricle → severe tricuspid regurg (holosystolic murmur @ R LSB) -Associated with WPW syndrome (delta wave on EKG) Rarely: nephrogenic DI, HYPOthyroidism

Low AFP, estriol, β-HCG normal inhibin A

Edwards (trisomy 18) (Microcephaly, prominent occiput, rocker-bottom feet, clenched hands, heart defects)

For each population state type of urinary incontinence they are @ risk for and its etiology -Elderly/UTI -BPH, MS -Pregnant, obese, prostate surgery + Tx

Elderly/UTI/EARLY MS/UMN: urge incontinence - detrusor overactivity -M3 ANTAGonists: (Oxybutynin, tolterodine, solifenacin); Mirabegron (β-3 AGONIST) BPH/LATE MS/LMN: overflow incontinence -detrusor underactivity or outlet obstruction: causes dribbling, retention -Tx CNS w/ intermittent cath Pregnant, etc: stress incontinence -↑intra-abdominal pressure + urethral sphincter hypermobility -urinate w/ sneezing, lifting -Kegels 10962

Embryonic vc gestational age

Embryonic age= time since fertilization Gestational age= time since last period (embryonic age + 2 weeks)

Hours after delivery woman has hypotension, paleness, cool skin, dizziness. No abdominal pain or incisional bleeding, no vaginal bleeding, no signs of uterine atony

Emergency lap for suspected retroperitoneal hematoma from damaged uterine artery

Abdominal pain, ovarian mass, high AFP, Schiller-Duval bodies (glomeruloid) in child

Endodermal sinus / yolk sac tumor (SAC = Schiller-Duval, ↑AFP, Children (<3))

HRT increases risk of which 2 cancers?

Endometrial & breast

Irregular / postmenopausal bleeding. Hx of obesity, nulliparity, chronic anovulation. Nontender uterus

Endometrial hyperplasia/cancer

Postmenopausal uterine bleeding. Histology shows hyperplasia of endometrial glands relative to stroma Dx? Pathogenesis?

Endometrial hyperplasia: consequence of unopposed estrogen (obesity, PCOS, and estrogen replacement therapy)

-Benign -Project from endometrium ("exophytic mass") -Often asymptomatic; may cause painless uterine bleeding -Assoc w/ tamoxifen (SERM; anti-estrogen in breast, pro-estrogen in bone & endometrium)

Endometrial polyp

Pelvic pain, dysmenorrhea, dyspareunia; symptoms vary w/ cycle. "Chocolate cyst"—endometrioma filled w/ blood. Complex mass on ultrasound. Dx test? Tx?

Endometrioma; Endometriosis within ovary with cyst formation; benign -Transvaginal ultrasound; laparoscopy to confirm -OCPs = 1st line; GnRH analogs, danazol, NSAIDs, progestins; surgery

Painful periods, pain with intercourse, fixed, retroverted uterus of normal size

Endometriosis: ectopic endometrium

Varicella Zoster Virus (TORCHeS) -2 symptoms -PEP

Enveloped, dsDNA virus Must be PRIMARY in 1st trimester to cause fetal infection Infant symptoms: Scars in a dermatomal pattern, microcephaly, hydrocephalus, seizures, cataracts, nystagmus, limb atrophy Long term: intellectual disability Non-immune exposed mothers & neonates (if mother has active infection during delivery) = VZV Ig Tx of disseminated infection in infants = IV acyclovir x 10 days

Polyhydramnios -define -risk factors

Excess amniotic fluid -single deepest >8cm -AFI >24 Risk factors -fetal esophageal/duodenal atresia (TEF) -anencephaly -maternal diabetes→ fetal hyperglycemia → polyuria -fetal anemia →↑ urine production; can be caused by parvovirus -multiples

Major placental estrogen?

Estriol; key indicator of fetal well being

Receptor positivity commonly found in lobular carcinoma in situ (LCIS)?

Estrogen Progesterone

What are estrogen and progesterone's overall roles in menstrual cycle

Estrogen = stimulates endometrial growth Progesterone = stimulates secretory activity

Pregnant thyroid changes

Estrogen increases TBG levels, leading to increased overall T4/T3 but low TSH & normal free (active) T3/T4

Why are gallstones more common in women who are pregnant or taking OCs?

Estrogen induces cholesterol HYPERsecretion Progesterone induces gallbladder HYPOmotility

Dx? -erythematous, pruritic, ulcerated vulvar skin -malignant epithelial cells w/ pale cytoplasm (halo) & hyperchromatic nuclei -PAS ⊕, keratin ⊕, S100 negative Underlying carcinoma?

Extramammary Paget's: carcinoma in-situ, w/o underlying carcinoma (unlike Paget of breast)

Breast abscess in postpartum woman tx

FNA + cephalexin / dicloxacillin (MRSA)

Irregular, mild contractions + no cervix change or rupture of membranes

False labor

Mutated SRY in XY individual would result in what phenotype

Female external and internal (but underdeveloped) Lack of SRY means the gonads go down "default" path, which is female

Why do pregnant women not lactate?

Progesterone & estradiol are high, down-reg prolactin receptors

Where/when do fertilization and implantation occur?

Fertilization occurs in ampulla of fallopian tube w/in 1 day of ovulation. Implantation occurs in the posterior superior wall of the uterus 6 days after fertilization

Germ cell tumor subtypes mimic tissues that are normally produced by germ cells. Dx based on the type of tissue Fetal Tissue Oocytes Yolk Sac Placental Tissue

Fetal Tissue: cystic teratoma, embryonal carcinoma Oocytes: dysgerminoma Yolk Sac: endodermal sinus tumor Placental Tissue: choriocarcinoma

Developmental retardation, microcephaly, smooth philtrum, thin vermillion border [upper lip], small palpebral fissures, limb dislocation, heart defects. Heart-lung fistulas & holoprosencephaly in most severe form

Fetal alcohol syndrome

NBS if fetus <10th percentile for gestational age? Onset in 1st trimester vs 2nd/3rd?

Fetal growth restriction: Doppler of umbilical artery to assess for uteroplacental insufficiency Onset in 1st trimester = TORCH or aneuploidy

What fibrocystic-related changes are assoc w/ increased risk of breast cancer? -Fibrosis, cysts, & apocrine metaplasia -Ductal hyperplasia & sclerosing adenosis -Atypical hyperplasia

Fibrosis, cysts, & apocrine metaplasia -no increased risk Ductal hyperplasia & sclerosing adenosis-2x greater risk for INVASIVE carcinoma in EITHER breast Atypical hyperplasia-5x greater risk for INVASIVE carcinoma in EITHER breast

Ovarian cysts resulting from distention of unruptured graafian follicle Assoc w/ hyperestrogenism, endometrial hyperplasia Most common ovarian mass in young women; monitor w/ follow up; does not require tx

Follicular cyst; type of functional cyst

Presents w/ postpubertal macroorchidism, long face with large jaw, & large everted ears. Auscultation reveals mid systolic click w/ high freq crescendo murmur, made worse w/ Valsalva maneuver. Dx? Pathogenesis?

Fragile X syndrome (murmur is MVP, common complication) FMR1 gene silenced/hypermethylated due to trinucleotide CGG repeats promoter region

Antibiotic GBS prophylaxis is recommended in which 3 cases?

GBS bacteriuria or rectovaginal cx in current pregnancy Unknown GBS + any of the following: <37 weeks gestation Intrapartum fever Rupture of membranes for ≥18 hours Prior infant with early-onset neonatal GBS infection

Absent fetal heart sounds in 2nd trimester + 'snowstorm/swiss cheese' appearance on ultrasound. +/- passage of grape-like mass through vaginal canal. Dx?

GTD; most likely complete hydatidiform mole

Presents w/ irregular/postmenopausal menstrual bleeding + breast tenderness & ovary mass ↑↑ estrogen and inhibin Grossly appears large, yellow Histo: cells arranged haphazardly around collections of eosinophilic fluid; resembling primordial follicles) and coffee bean nuclei Dx? Demographics? Workup (2)?

Granulosa cell tumor (malignant sex cord/stromal tumor) Mostly affects women in 50's/60's; can be seen in pre-adolescents w/ precocious puberty Endometrial biopsy Surgery (tumor staging) Histo = call-exner bodies (hint: "it's grand to call-exes from whom you're estranged w/o inhibition" "call in granny's estrogen")

Pregnant pt with mild anemia, plt 80,000, not sx

Gestational thrombocytopenia

Ovarian mass, postmenopausal bleeding, high estrogen and inhibin, thickened endometrial stripe. Cells w/ coffee bean nuclei arranged haphazardly arranged around follicle which may contain eosinophilic fluid*

Granulosa cell (sex cord/stromal tumor) *Call-Exner bodies

Leuprolide -MoA -Use -AEs

GnRH analog -agonist when pulsatile -antagonist when continuous (downregs GnRH R in pituitary→↓FSH/LH) Uses: -Pulsatile: infertility -Continuous: endometriosis, precocious puberty, prostate cancer, premenopausal breast canser AEs: Hypogonadism, ↓libido, ED, nausea, vomiting (Hint: in "leu" of GnRH)

When is methotrexate appropriate mgmt for ectopic pregnancy?

HDS + no fetal cardiac activity + BHCG <5,000 + no maternal contraindications (liver, kidney, lung dz, thrombocytopenia, breastfeeding)

Pap shows ASC-US in pt >25. NBS?

HPV testing if +→ colposcopy - → normal screening intervals

Pap shows ASC-US in pt <25.

HPV testing now or in 1 yr

Why is HPV cotesting not recommended w/ paps for 21-29?

HPV will usually be spontaneously cleared

Intraventricular Hemorrhage in newborn: -bleeding into what ventricle? -caused by premature infants having poor autoregulation of blood flow to what area?

Hemorrhage into lateral ventricle of brain Seen in premature infants bc they have poor autoregulation of blood flow to germinal matrix Presents w/ hypotonia, loss of spont movements, seizures, coma

Pharm tc for gestational diabetes? 1st line? If pt declines 1st line?

Insulin If declines can offer metformin or glyburide

What effect does insulin have on surfactant synthesis in utero?

Insulin inhibits surfactant synthesis (↑NRDS risk if diabetic mother)

What is HELLP syndrome?

Hemolysis, Elevated Liver enzymes, Low Platelets Manifestation of severe preeclampsia Blood smear shows schistocytes Can lead to DIC & hepatic swelling→ subcapsular hematomas which can rupture→ life-threatening HYPOtension

Pt given heparin, develops DVT or PE symptoms

Heparin-induced thrombocytopenia (HIT) Type 2 Heparin binds to PF4 IgG antibodies form against heparin-bound PF4 Antibody-heparin-PF4 complex activates platelets→ thrombosis & thrombocytopenia (<100,000) due to

Pt already pregnant and has been taking VPA. Mgmt?

High dose folate + AFP screening Don't change AED during preg dt risk of maternal sz

What causes the LH surge?

High estradiol

Tx for renal abscess / severe pylo in pregnancy?

IV ceftriaxone, possible US guided drainage 17777

Tx for pylo if pregnant

IV ceftriaxone→ sx improvement→ oral cephalexin or fosfomycin for 5-14 days → prophylactic oral abx for remainder of pregnancy

What is Human placental lactogen (hPL)

Hormone made by syncytiotrophoblast; similar structure/function to HGH -decreases maternal insulin-sensitivity (causes gestational diabetes) & glucose utilization -increases maternal lipolysis

Name 4 antihypertensives safe in pregnancy & briefly summarize MoAs

Hydralazine (↑cGMP→smooth mus relaxes) *α-Methyldopa (α2-agonist) Labetalol (β1,β2,α1 blocker) Nifedipine (procardia; CCB) "Hypertensive Moms Love Nifedipine" *methyldopa CANNOT treat acute

Ultrasound shows fetus with edematous scalp & nuchal fold & echolucent abdominal fluid. Single deepest pocket of amniotic fluid is 12 cm (normal >8) and placenta is thickened to 6 cm (normal >4)

Hydrops fetalis -amniotic fluid pocket >8 cm = polyhydramnios -abdominal fluid = ascites -edema if RH pos mom or indirect coombs/antibody neg, prob parvo B19

Low testosterone, high LH suggests

Hypergonadotropic hypogonadism (1°)

Polycystic ovarian syndrome (PCOS) _______ resistance alters hypothalamic hormonal feedback response, causes increase in ___: ____ ratio →↑testosterone from _______ cells causes hirsutism and gets converted to estrone in fat→↓_____→↓follicle maturation/rupture (anovulation) + unruptured follicles form bilateral cysts Presentation: amenorrhea/oligomenorrhea, hirsutism, acne, male-pattern hair loss, infertility Assoc w/ _______ ↑risk of ________ cancer 2° to unopposed estrogen

Hyperinsulinemia /insulin resistance alters hypothalamic hormonal feedback response, causing an increase is LH: FSH ratio (LH 2x FSH) →↑testosterone from theca cells causes hirsutism and gets converted to estrogen→↓FSH→↓follicle maturation/rupture (anovulation) + unruptured follicles form bilateral cysts Presentation: amenorrhea/oligomenorrhea, hirsutism, acne, infertility Assoc w/ obesity ↑risk of endometrial cancer 2° to unopposed estrogen --------- in depth: ↑LH causes ↑androgens from theca cells. Bc pts are obese, an abnormal amount of this gets converted to estrone in the fat instead of going to granulosa cells. the estrone inhibits FSH, meaning that granulosa cells can't make estradiol, so the follicles can't mature/ruptured. Unruptured follicles form bilateral cysts

Pt w/ hx limited scleroderma & 6-month history of menstrual cramps, heavy menstrual flow, and fatigue; she has gained 5 kg (11 lb) during this period. Examination shows a puffy face with telangiectasias and thinning of the eyebrows. Deep tendon reflexes are 1+ bilaterally with delayed relaxation. Pelvic examination shows a normal appearing vagina, cervix, uterus, and adnexa

Hypothyroidism

Woman w/ normal periods but infertility. Initial workup?

Hysterosalpingography No need for FSH bc HPA intact (normal periods)

Outpatient tx for endometritis?

IM ceftriaxone (single dose) + PO doxycycline (for 14 days)

Pt w/ uterine atony + hypertension; what tx should be avoided?

IM methylergonovine

Biopsy of breast mass -Gross: gray-white tumor with stellate morphology; reactive fibroplasia (desmoplasia) causes gritty induration -Histology: pleomorphic cells forming duct-like structures in desmoplastic stroma

INVASIVE ductal carcinoma stars invade the sky

Which antibodies can cross placental barrier?

IgG "IgG can GO"

In women, are mature or immature teratomas malignant?

Immature

Ovarian mass contains fetal tissue, neuroectoderm; embryonic like neural tissue. Commonly diagnosed before age 20

Immature teratoma; malignant potential

Urachus In the ______ week, yolk sac forms _______, which becomes urachus (and umbilical vessels) Connects fetal ______ and umbilicus _________ umbilical ligament = vestige of urachus

In the 3rd week, yolk sac forms allantois, which becomes urachus (and umbilical vessels) Connects fetal bladder and umbilicus mediAN umbilical ligament = vestige of urachus

Persistent fetal circulation

In utero: PVR > SVR; blood shunted right → left via foramen ovale & ductus arteriosus (skipping pulm circulation) At birth → oxygen to lungs → PVR should fall→blood should flow through pulmonary circulation Persistent high PVR → shunting continues → hypoxemia

Rank cervical, endometrial, and ovarian cancer in terms of incidence in US and best to worst prognosis

Incidence: endometrial > ovarian > cervical Prognosis: cervical > endometrial > ovarian *related to age of dx

Mgmt of hashimotos in pregnancy

Increase levothyroxine at + pregnancy test, TSH q4 wks

Cell free DNA sampling -when -what -tests for

Indicated if high risk or 35 and over done at or after 10 wks Tests for aneuploidies

+ leukocyte esterase on urinalysis

Indicates presence of WBCs in bladder; probable UTI

Indirect vs direct Coombs test

Indirect detects presence of unbound antibodies in the serum Direct Coombs test detects antibodies attached directly to the RBC surface

Woman w/ preterm labor <32 weeks gets tocolytic name the drug used and 2 risks to mom + 2 to fetus

Indomethacin Mom: gastritis, plt dysfunction Fetus: closure of PDA, oligohydramnios

How does p53 lead to growth arrest?

Induces p21, which inhibits CDKs →hypophosphorylation (activation) of Rb →inhibition of G1-S progression

Aromatase inhibitor; Inhibits peripheral conversion of androgens to estrogen; 1st line to induced ovulation in PCOS

Letrozole

What subtype of invasive ductal carcinoma is this? Prog? inflamed, swollen breast (tumor cells have no lymphatic drainage) w/ dimpling no discrete mass; can be mistaken for acute mastitis

Inflammatory; poorest prognosis of subtypes

How do combined ethinyl estradiol/progesterone contraceptive methods work?

Inhibit LH/FSH thus prevent estrogen surge. No estrogen surge= no LH surge =no ovulation Progestin also thickens cervical mucus & inhibits endometrial proliferation

How does estradiol regulate the release of LH/FSH from anterior pituitary?

Initial rise exerts negative feedback, suppresses LH/FSH Peak estradiol reverse and exerts positive feedback, leading to LH surge

bilateral ligation of which vessels can stop postpartum hemorrhage but preserve fertility?

Internal iliac (collat supply to uterus maintained thru ovarian vessels)

State the lymphatic drainage for prostate, corpus cavernosum, cervix, proximal vagina

Internal iliac nodes

Tumor of lactiferous duct

Intraductal papilloma

DfDx for bloody/straw colored nipple discharge WITHOUT accompanying breast mass

Intraductal papilloma (most common cause in premenopausal) Papillary carcinoma

Bloody nipple discharge in premenopausal woman under 50. No mass is felt on palpation Histology shows branching fibrovascular projections extending into dilated duct lined by epithelial and myoepithelial cells. Dx?

Intraductal papilloma; benign papillary growth

Woman in 3rd trimester with pruritus worst on hands and feet + RUQ pain ↑Bilirubin ↑Transaminases (2x normal but <1000 U/L) ↑Total bile acid (>10) No scleral icterus, plt >100,000 Dx AND tx?

Intrahepatic cholestasis of pregnancy ↑estrogen & progesterone cause hepatobiliary stasis and ↓bile acid excretion bile acid collects in liver & skin Tx w/ Ursodeoxycholic acid & delivery at 37 wks

most common post-menopausal breast carcinoma?

Invasive ductal carcinoma

Premenopausal woman w/ unilateral bloody nipple discharge, ill defined mass, and retraction of overlying skin

Invasive ductal carcinoma -mass (so not intraductal) -retraction

Breast tumor cells lack E-cadherin , grow in single-file linear or bulls-eye/signet-ring arrangement

Invasive/infiltrating lobular carcinoma

Tx for migraine in pregnancy

Isolated: Acetaminophen Severe, recurrent: Propranolol, metoprolol for px

47,XYY

Klinefelters

Testicular atrophy (small, firm), eunuchoid body shape (tall, long extremities, wide hips), gynecomastia, female hair distribution, developmental delay/retardation Elevated aromatase, estradiol, FSH/LH. Low testosterone

Klinefelters syndrome 47 XXY

Pap shows cells w/ dense, irregularly staining cytoplasm, perinuclear halo clearing, enlarged/pyknotic "raisinoid" nucleus

Koilocytes= Epithelial cell infected by HPV

Abnormal pap test findings?

Koilocytic atypia Nuclear enlargement ("raisinoid" appearance) Nuclear hyperchromasia Coarse chromatin granules Perinuclear halo

Bilateral ovarian masses; mucin-secreting signet cell adenocarcinoma Dx? Stomach findings?

Krukenberg tumor Diffuse subtype of gastric adenocarcinoma (gross thickening of stomach wall; appears leathery (linitis plastica; signet cells)

Venous drainage of left vs right ovary/testes

L ovary/testis→L gonadal vein→L renal vein→IVC R ovary/testis→right gonadal vein→IVC "L takes the Long way through renaL"

How is estradiol synthesized LH stimulates ______ ______ cells to make progesterone and androgens Androgens then migrate to _________ cells, where ______ stimulates ________ to convert them to _________

LH stimulates theca interna cells to make progesterone and androgens Androgens then migrate to granulosa cells, where FSH stimulates aromatase to convert them to estradiol

3 antihypertensives to acutely lower BP in pregnant woman w/ hypertensive crisis

Labetalol Hydralazine Nifedipine "Lower hypertension now" N= PO, other 2 are IV

Normal vaginal flora? Benefits?

Lactobacilli (gram⊕ facultative anaerobes) colonized by E coli & group B strep Maintain low pH (3.5-4.2) Loss due to antibiotics can cause overgrowth of C. albicans→vulvovaginitis (pruritus + white discharge)

RUQ, vomiting fever, pelvic pain, vaginal discharge What will laparoscopy show? Dx?

Laparoscopy shows "violin-string" adhesions in the peritoneal cavity Fitz-Hugh-Curtis syndrome; Perihepatitis: infection of liver capsule 2° to PID

Premenopausal woman w/ irregular uterine contour, heavy periods NBS?

Leiomyoma (fibroid) NBS: saline infusion ultrasound aka sonohysterography Estrogen sensitive; grows w/ pregnancy/cycle, shrinks w/ menopause Benign smooth muscle tumor may have abnormal uterine bleeding, miscarriage DOES NOT LEAD TO LEIOMYOSARCOMA

Postmenopausal woman Bulk symptoms, PMB Single uterine mass arising from myometrium, has hemorrhage + necrosis Dx? Pathogenesis? Risk factors? Tx?

Leiomyosarcoma: malignant proliferation of smooth muscle arising from myometrium Arises de novo; NOT from leiomyomas Risk factors = tamoxifen, pelvic radiation Tx is hysterectomy

Incidental finding on breast biopsy of cells lacking E-cadherin adhesion protein. Bilateral Dx? Definition? Tx?

Lobular carcinoma in situ (LCIS): malignant proliferation of cells in lobules with no invasion of the basement membrane Tx: tamoxifen + close monitoring (low risk of progression to invasive carcinoma)

Postterm pregnancy complications

Low weight for gestation age (dysmaturity syndrome) Oligohydramnios Demise Macrosomia (8 lbs, 13 oz (4,000 grams))

Low vs high AFP in pregnancy

Low: aneuploidies 18 & 21 High: neural tube defects (anencephaly, SB), ventral wall defects (gastroschisis, omphalocele), multiples

Hx chronic lymphedema from axillary lymph node dissection + weight loss & mass

Lymphangiosarcoma

Multiparous postmenopausal women w/ periareolar mass & green-brown nipple discharge Biopsy shows chronic inflammation w/ plasma cells

MAMMARY DUCT ECTASIA; Inflammation with dilation (ectasia) of the subareolar ducts Rare

Which vaccines are contraindicated in pregnancy (4)

MMR (vaccinate in immediate postpartum period) Varicella (give Ig if exposed/nonimmune) HPV Live attenuated flu (flu-mist)

25 yo woman 8 wks postpartum w/ increasing weakness and fatigue, asymmetric lower extremity weakness, increased knee reflexes

MS pregnancy is protective, but increased risk in postpartum period

hCG Made by __________ -Similar structure/function to ____ -Identical α subunit to ___, ____, ____ (states of ↑hCG can cause _____thyroidism). β subunit is unique -Maintains _____ ______ + stimulates it to produce _______ in 1st trimester

Made by syncytiotrophoblast -similar structure/function to LH -identical α subunit to LH, FSH, TSH (states of ↑hCG can cause hyperthyroidism). β subunit is unique -maintains corpus luteum + stimulates it to produce progesterone in 1st trimester

Workup for palpable breast mass >30

Mammogram→ core biopsy

3 complications of short interpregnancy interval (<6-18 mo)?

Maternal anemia PPROM/Preterm labor Low birth weight

Maternal complications of abrupted placenta

Maternal hemorrhage, DIC

Guidelines for neonate born to HIV+ person (2)

Maternal viral load <1000→ zidovudine >1000 → ART

Most common ovarian tumor in ppl 10-30? Presentation?

Mature cystic teratoma (dermoid cyst) Cystic ovarian mass containing all 3 germ layers (eg, teeth, hair, sebum). Unilateral ovarian mass w/ heterogeneous composition + calcification May cause pain from ovarian enlargement / torsion

Maneuver for shoulder dystocia?

McRoberts Knees bent, legs on belly, hips flexed

Baby w/ painless hematochezia, NTND abdomen, technetium-99 scan shows ↑ uptake on RLQ & periumbilical areas. Dx? Pathogenesis?

Meckel's Diverticulum

What kind of anemia is seen in HELLP syndrome? 3 Labs?

Microangiopathic hemolytic anemia • Schistocytes • Elevated bilirubin • Low haptoglobin

What subtype of invasive ductal carcinoma is this? Large, high-grade cells growing in sheets w/ associated lymphocytes & plasma cells. Can resemble a fibroadenoma on mammography. Assoc w/ BRCA1

Medullary carcinoma

Tx for choriocarcinoma as complication of pregnancy?

Methotrexate or Actinomycin D Most patients cured

Distinguish b/w presentations of non-classical 21-hydroxylase deficiency and 17α-hydroxylase deficiency in a teen girl

Mild 21-hydroxylase deficiency = hirsutism, +/- clitoromegaly AND Lack of 2° sex characteristics + oligomenorrhea 17α-hydroxylase deficiency = HYPERtension & HYPOkalemia. Lack of 2° sex characteristics, but no virilization

Goal of hyperthyroid tx in pregnancy?

Mild hyperthyroid state; overcorrection is more dangerous

Misoprostol vs dinoprostone

Misoprostol = Prostaglandin E1 analog; mostly used for prevention of gastric ulcers; off-label abortifacient (induces labor) Dinoprostone = PGE2 analog; induces labor

Misoprostol, mifepristone, and MTX (in small/no heartbeat ectopic) are used for abortion. Summarize the MoA of each

Misoprostol = prostaglandin E1 agonist; induces "labor" Mifepristone = progesterone & glucocorticoid antagonist MTX = folic acid antagonist

During ovulation, blood from ruptured follicle or follicular swelling can cause peritoneal irritation, mimicking appendicitis (umbilical/RLQ pain) Occurs in middle of cycle (period 2 wks ago)

Mittelschmerz; reassurance

Monozygotic twins w/ cleavage b/w day 4-8 will have how many chorion/amnion ? What about before day 4 or after day 8?

Monochorionic, diamniotic before day 4 = both separate 4-8 = chorion shared after 8 = both shared

A 4.5-lb female newborn and a 6.3-lb female newborn are delivered at 37 weeks' gestation to a 23-year-old, gravida 2, para 1 woman. The mother had no prenatal care. Examination of the smaller newborn shows a flattened nose and left-sided clubfoot. The hematocrit is 42% for the smaller newborn and 71% for the larger newborn. This pregnancy was most likely which of the following? CHORI-AMNIO?

Monochorionic-diamniotic monozygotic twin transfusion; 1 has poly and other oligohydramnios

How does multiparity affect gestation?

More fetuses = shorter pregnancy • 1 fetus ~ 40 weeks • Twins ~ 37 weeks • Triplets ~ 33 weeks

When do these primitive reflexes disappear? Moro (arms out when startled) rooting (move head to side when cheek is stroked) palmar Babinski

Moro- 3 months Rooting- 4 months Palmar- 6 months Babinski- 12 months

Hydatidiform mole

Most common form of GTD; growth of trophoblast tissue (placenta) • False pregnancy • Swollen chorionic villi • Villi form clusters - "clusters of grapes" • Ultrasound: "snowstorm or swiss cheese"

What subtype of invasive ductal carcinoma is this? clusters of tumor cells floating in mucin; avg age 70

Mucinous (colloid) carcinoma

Pseudomyxoma peritonei (aka mucinous ascites) + Ovarian mass w/ mucin-producing epithelial cells

Mucinous cystadenocarcinoma (epithelial)

Woman w/ abdominal pain, mucinous ascites, ovarian mass

Mucinous cystadenocarcinoma due to met to ovaries from tumor in appendix or elsewhere in GI may cause bowel obstruction

Pt presents w/ 1° amenorrhea. Physical exam shows normal 2SCs. Ultrasound shows shortened vagina, normal ovaries, rudimentary/absent uterus, and unilateral renal agenesis. Dx?

Mullerian aplasia (MRKH syndrome)

Absolute contraindications to breast conserving surgery for breast cancer? (3)

Multifocal disease Inflammatory breast cancer Prior therapeutic chest wall radiation therapy

Greatest risk factor for PID?

Multiple sexual partners

Doppler sonography fails to detect fetal heart tones; confirmatory test for IUFD?

No cardiac activity on Ultrasound

1° amenorrhea in female with fully developed 2° sexual characteristics (normal breast devel + pubic hair) -ovaries? -uterus?

Müllerian/paramesonephric agenesis (Mayer-Rokitansky- Küster-Hauser syndrome) No period bc no uterus, but 2° sexual characteristics bc functional ovaries

Does endometriosis cause uterus enlargement?

NO Adenomyosis- endometrial tissue in myometrium

Do premenopausal women w/o risks for endometrial hyperplasia or AUB req endometrial biopsy if endometrial cells are found on pap?

NO routine pap

Is prior c section a risk factor for placental abruption? Name 4 risks.

NO risks are -prior abruption -cocaine or tobacco use -abdominal trauma -hypertension

is holoprosencephaly a neural tube defect?

NO!! it is not!!! No forebrain

Criteria for active phase arrest? Tx?

No cervical change for 4 hrs w/ adequate contractions (>200 MVUs) or for 6 hrs w/o adequate contractions C-section

CXR of neonate shows bilateral ground glass appearance. Dx?

NRDs

Tx for endometriosis?

NSAIDs, continuous OCPs, progestins, GnRH agonists, danazol, laparoscopic removal

Premature, formula-fed infant w/ necrosis of terminal ileum/colon Can perf →pneumatosis intestinalis (free air in bowel wall, shows as lucent area parallel to bowel), portal venous gas, rectal bleeding

Necrotizing enterocolitis

Is HCV a contraindication to breastfeeding?

No

Elevated AFP in pregnant woman may indicate? NBS?

Neural tube defect (meningocele, anencephaly, spina bifida(+↑ACh esterase)) Underestimation of gestational age, multiparity (+↑hCG) Abdominal wall defects (omphalocele, gastroschisis) NBS is transabdominal ultrasound aka amniotic ultrasound

Preeclampsia -definition -pathogenesis -tx?

New-onset hypertension w/ EITHER proteinuria or end-organ dysfunction after 20th week (< 20 weeks suggests molar pregnancy). Caused by faulty placental spiral artery development (extravillous trophoblast fails to penetrate myometrium), leading to under-perfused placenta, vasospasm, coagulation Px: low dose aspirin @ 12 wks if hx Tx: -antihypertensives (Hydralazine, α-Methyldopa, Labetalol, Nifedipine) -IV magnesium sulfate (to prevent seizure) -deliver fetus if possible (37 wks or 34 w/ severe features)

Pap shows HSIL or ASC-H. NBS?

Next do colposcopy → If premalignant cervical changes (leukoplakia, punctated/mosaic capillaries, irregular surface contour, ulceration, regions that don't stain w/ acetic acid)→directed surface biopsy or if >24 & not pregnant, LEEP

Woman gets tachycardia, nausea, flushing, headache after being given tocolytic for preterm labor which drug? MoA

Nifedipine (CCB)

Name 3 tocolytics used to slow contractions in preterm labor

Nifedipine/procardia (CCB) Terbutaline (β2-agonist action) Indomethacin (NSAID)

Does neg RPR rule out syphilis?

No

Parvovirus B19 (TORCHeS)

Non-enveloped, ssDNA virus -transmitted thru respiratory secretions or vertically -replicates in RBC progenitors causing anemia, mild in healthy ppl; severe in chronic anemia (sickle cell) -fifth disease in children; "slapped cheek" appearance -adults develop arthritis In fetus: miscarriage/fetal death/hydrops fetalis

Dyspnea, mid-systolic murmur, +1 pitting edema in pregnant woman

Normal

Asymptomatic pregnant pt w/ Hgb 11.2 & Plt 100,000-140,000

Normal dilutional

Partial hydatidiform mole -Pathogenesis -Karyotype -Presentation

Normal egg fertilized by two sperm: 69,XXX, 69,XXY, 69,XYY (rare) Fetal parts present→villi drainage = less swollen villi (non-enlarged uterus) hCG less elevated than complete mole p57⊕ (maternal genetic material)

Describe external & internal genitalia in individual w/ Turner syndrome

Normal external Streak/atrophic ovaries Uterus present

4 days postpartum w/ continuous, dark red vaginal bleeding, small clots. Changing pad 7 times per day BP normal Mild anemia

Normal lochia

Oligo vs poly hydramnios -Normal single deepest pocket? -Normal AFI?

Normal single deepest pocket = 2-8 cm Normal AFI: 8-24

5 risk factors for cervical cancer

OCP use Tobacco use Early sex/many partners Lower SES Prior STI

Which forms of birth control should be avoided until after 6 weeks postpartum? If breastfeeding?

OCPs should not be given before 6 weeks postpartum • OCPs given before 3 weeks postpartum → ↑ risk of DVT • OCPs given before 6 weeks postpartum → ↓ protein content of breast milk (progesterone inhibits α-lactalbumin, the major protein found in breast milk) Give progestin patch, IUD (copper or progestin)

Biggest modifiable risk factor for endometrial cancer?

Obesity (weight loss decreases risk)

Fetal risks of preeclampsia

Oligohydramnios Low birthweight both due to placental insufficiency

Potter's sequence

Oligohydramnios = less cushioning from external forces -Compression causes limb abnormalities & flat face -Abnormal lung liquid movement causes pulmonary hypoplasia

Most common fetal malposition?

Occiput posterior

Meperidine aka Demerol

Opioid analgesic given during stage 1 of labor

Women who are fragile X syndrome carriers are at greater risk of

POI

Newborn w/ mild jaundice, mild unconjugated hyperbilirubinemia (< 15 mg/dL ) otherwise healthy

Physiologic neonatal jaundice due to ↑RBC breakdown

Ovarian vs Infundibular/Suspensory ligament

Ovarian = derived from gubernaculum; contains ovarian BRANCHES of UTERINE vessels Infundib & suspensory = SAME THING; contain ovarian vessels

Woman undergoing tx for infertility presents w/ ascites, respiratory distress, abdominal distension ↑Hct Bilateral pleural effusions bilaterally enlarged, multicystic ovaries

Ovarian Hyperstimulation Syndrome: multiple follicles mature, ↑VEGF 14775

Post-menopausal woman w/ pelvic pain and unilateral adnexal mass Ultrasound reveals large, solid mass with thick septations, & ascites

Ovarian cancer (epithelial)

Woman ORA w/ sudden-onset, unilateral pelvic pain, nausea, and vomiting. Dx? What will doppler show?

Ovarian torsion Dilated ovary, ↓blood flow to ovary

46,XX DSD

Ovaries present, but external genitalia are virilized or ambiguous Due to excessive / inappropriate exposure to androgenic steroids during early gestation (CAH or exogenous androgens during pregnancy)

State the lymphatic drainage for ovaries/testes

Ovaries/testes→ para-aortic nodes

Name the sources of 17β-estradiol, estriol, and estrone (via aromatization)

Ovary: 17β-estradiol Adipose tissue: estrone (via aromatization) Placenta: estriol

Hyperinsulinemia/insulin resistance increases LH:FSH ratio

PCOS

Woman w/ hyperandrogenism, irregular periods, obesity. Dx? Increased risk of what cancer?

PCOS; ↑ risk for endometrial hyperplasia/carcinoma due to anovulatory cycles (unopposed estrogen)

Woman w/ 1 pack/day habit presents w/ Inflammation of subareolar ducts; subareolar mass w/ nipple retraction -Dx -Demographics -Pathogenesis

PERIDUCTAL MASTITIS Seen in smokers Vit A deficiency causes squamous metaplasia of lactiferous ducts, resulting in blockages/inflammation

Dinoprostone is an analog of...

PGE2 (hint: dino movie 2 rated PG)

What causes period cramps?

PGs causes vasoconstriction and high freq myometrial contractions

Tx for hyperthyroidism in 1st trimester? Why?

PTU in 1st trimester, then methimazole (not used in 1st trimester bc can cause aplasia cutis (absence of epidermis on scalp)) PregMent

How can extramammary paget disease be distinguished from melanoma?

Paget cells: PAS & keratin positive, S100 negative "paket" Melanoma: PAS negative, keratin negative, S100 positive

45 yo woman comes w/ 2-week history of an itchy rash on her left nipple. The rash began as small vesicles on the nipple and spread to the areola. It has become a painful ulcer with yellow, watery discharge that is occasionally blood-tinged Examination shows a weeping, ulcerated lesion involving the entire left nipple-areolar complex. There are no breast masses, dimpling, or axillary lymphadenopathy. The remainder of the examination shows no abnormalities.

Paget disease of breast DCIS that extends up the ducts to the skin of the nipple Almost always assoc w/ underlying carcinoma

Woman presents w/ nipple ulceration, retraction, erythema Histology shows large epithelial cells w/ pale, clear cytoplasm & eccentric, hyperchromatic nuclei

Paget disease of the breast: DCIS that extends up the ducts to the skin of the nipple Almost always assoc w/ underlying carcinoma

Paget vs inflammatory breast cancer

Paget: nipple ulceration, retraction, erythema, no mass Inflammatory: inflamed, swollen breast w/ dimpling, +/- mass

hidradenitis suppurativa

Painful draining boils on groin

Workup for postmenopausal bleeding

Pap for HPV (no matter when last pap was done) Biopsy +/- TVUS

What causes bicornuate uterus?

Partial lateral fusion of paramesonephric ducts Bicornuate uterus: uterus w/ two lumens ("horns"), entering a common vagina Characterized by indentation in center of fundus ↑risk of complicated pregnancy, early pregnancy loss, malpresentation, prematurity

69,XXX or 69,XXY

Partial mole Ovum fertilized by 2 sperm

Pt w/ intermittent extreme unilateral adnexal pain, but no symptoms b/w episodes. US shows ovarian mass w/ normal flow during a pain free period

Partial ovarian torsion dx lap

Describe patent urachus, urachal cyst, and vesicourachal diverticulum

Patent urachus: total failure of urachus to obliterate→ urine comes from umbilicus Urachal cyst: partial failure of urachus to obliterate; fluid-filled cavity b/w umbilicus and bladder. Gets infected, presents as painful mass below umbilicus Vesicourachal diverticulum: slight failure of urachus to obliterate→outpouching of bladder

Membranes suddenly rupture + fetal HR decreases workup?

Pelvic exam to check for fetal position & cord prolapse; immediate c section if cord prolapse ----- If the baby is not in the correct position (ie, fetal station of at least 0) and there is sudden rupture of membrane (SROM), there is risk of cord prolapse (there is space for it to fall out; if baby is in correct position, the head would prevent cord prolapse) • Cord prolapse presents with rapid decrease in fetal HR • Pelvic examination will allow you to feel/see the cord to confirm your dx • Tx: Immediate cesarean section

Indications for vacuum assisted vaginal delivery?

Performed during stage 2 of labor in case of category 3 tracings or maternal exhaustion

37 wk pregnant + S3, III/VI murmur, significant edema, and limiting dyspnea -normal or peripartum cardiomyopathy

Peripartum cardiomyopathy

Teratogenic effects of aminoglycosides (Gentamicin, Neomycin, Amikacin, Tobramycin, Streptomycin)

Permanent deafness (I lost mycins of hearing)

In Meckel's Diverticulum, what causes blood in stool? What vessel supplies Meckel's diverticulum?

Persistent vitelline/omphalomesenteric duct containing ectopic acid-secreting gastric mucosa (parietal cells) Supplied by SMA

Pelvic organ prolapse 1st line tx

Pessary

Nail hypoplasia is a teratogenic effect of what drug?

Phenytoin (anti-seizure)

Postmenopausal woman w/ large painless, multinodular, smooth breast lump Biopsy shows Fibroadenoma-like tumor arising from stroma with overgrowth of fibrous component/hypercellular connective tissue and 'leaf-like' papillary projections/cystic spaces

Phyllodes tumors Larger/faster growing than fibroadenoma May become malignant

Pseudocyesis

Physical signs of pregnancy (breast tenderness, abdominal distension) and belief in pregnancy but no evidence on ultrasound/in-office test risks: infertility, pregnancy loss

Postpartum hemorrhage and Sheehan syndrome are associated with what placental pathology?

Placenta accreta/increta/percreta

Woman w/o prenatal care goes into labor. Umbilical cord avulses and the placenta is delivered in pieces. Persistent postpartum bleeding, unresponsive to tocolytics Dx? Tx?

Placenta accreta: defective decidual layer bleeding due to retained placental tissue Hysterectomy w/ placenta in situ

46,XX infant w/ ambiguous/masculinized external genitalia and normal internal genitalia. ↑androgens, ↓estrogen Mother notes virilization during pregnancy. Dx?

Placental aromatase deficiency

How do the following change during pregnancy? -Plasma volume -RBC mass -Hct & Hgb -Clotting factors -Acid/base (

Plasma and RBC mass expands, but plasma moreso, leading to dilutional anemia (↓Hct/Hgb) Pregnancy is hypercoagulable state (↑ fibrinogen, ↓ protein S, fetus may compress venous return) Mild respiratory alkalosis, ↑PaO2, ↓PCO2, ↑HCO3 excretion

Copper IUD -MoA -Use -AE

Produces local inflammatory reaction toxic to sperm and ova, preventing fertilization & implantation; hormone free. BC or EC (most effective EC) Heavier/longer menses, dysmenorrhea. Risk of PID w/ insertion (contraindicated in active pelvic infection)

Mifepristone, ulipristal -Class -Uses

Progesterone ANTAGonists -Abortion (mifepristone) -Emergency contraception (ulipristal)

Contraindications to epidural

Plt <70,000

afebrile breastfeeding mother, tender edematous area

Plugged duct ○ Tx: warm compress

norethindrone

Progestin

Tx for endometrial hyperplasia w/o atypia in woman who may desire future fertility

Progestin IUD + repeat endometrial biopsy every 3 months

Pregnant in 3rd trimester with pruritic, erythematous rash originating in abdominal striae Dx? Tx?

Polymorphic eruption of pregnancy Tx: topic steroids

Spastic bladder →urinary retention tx?

Prazosin; α1-blocker

Vulvar SCC -Presentation -Etiology in pre vs postmenopausal women

Presents w/ leukoplakia, vaginal irritation & sometimes bleeding, and a unilateral, friable mass often on labia majora Middle age: HPV-related vulvar carcinoma >70: Non-HPV vulvar carcinoma: long-standing lichen sclerosus May develop into vaginal SCC

Name 3 risk factors for NRDs

Premature Diabetic mother C-section (nrds are pretty damn cool)

What fetal heart problem can NSAIDs cause

Premature closure of ductus arteriosus

Placental abruption -Risk factors (5) -Presentation (sensation, contractions type, PE finding)

Premature separation of placenta from uterine wall before delivery of infant Risk factors: trauma, smoking, cocaine, hypertension, preeclampsia, uterine abnormalities (bicornate) Presentation: abrupt, painful bleeding (from maternal vessels) in 3rd trimester + high-frequency low-intensity contractions, and hypertonic/tender uterus possible DIC, maternal shock, fetal distress *Normal ultrasound doesn't rule out! Life threatening for mother and fetus.

Risk factor for cryptorchidism

Prematurity

Name 5 things other than SIDs and LBW that maternal age <19 is RF for

Preterm Gastrosciz/omphalocele Preeclampsia Hydatidiform Anemia (mother)

3 complications of PPROM?

Preterm labor Placental abruption IAI Umbilical cord prolapse

RF for morbidly adherent placenta (2)

Prior uterine surgery Placenta previa

Levonorgestrel, etonogestrel, norethindrone, megestrol -Class -Effect

Progestins; bind progesterone receptor causing ↓growth & ↑vascularization of endometrium, thicken cervical mucus

What is the major complication of endometrial hyperplasia, and what predicts it?

Progression to carcinoma; predicted by presence of atypical nuclei Simple hyperplasia w/ atypia often progresses to cancer (30%); Complex w/o atypia rarely does (endometrial cancer is simply atypical)

Woman who is too far in labor for epidural can have what nerve blocked? Spinal origin? 2 Important landmarks? Avoid (2)?

Pudendal nerve (sensory to perineum & genitals; motor to external urethral & anal sphincters + levator ani) S2-S4 origin Through sacrospinous ligament, medial to ischial spines. Avoid injecting internal pudendal or inf. gluteal arteries

Postpartum w/ perineal lac & inability to void bladder + dribbling how long postpartum is not peeing pathological?

Pudendal nerve injury→↓decreased voiding sensation postpartum urinary retention = no pee after 6 or more hours

Protraction vs arrest of active phase -criteria -tx

Protraction ◦<1 cm/2 hrs; +/- inadequate contractions ◦ tx = oxytocin Arrest ◦ no cervical change for 4 hrs w/ adequate contractions (>200 MVUs) or for 6 hrs w/o adequate contractions ◦ tx = c-section

Pt post delivery of large infant w/ difficulty ambulating/waddling gait, radiating suprapubic pain, pain on palpation of pubic symphysis no numbness/paresthesia

Pubic symphysis diastasis

How can the presentation of appendicitis change in pregnancy?

RUQ pain bc appendix displaced up

Pt w/ weight loss, high BP/HR, low TSH & high T3 & T4. 2 months postpartum Exam shows symmetrically enlarged & nontender thyroid How can you distinguish b/w Graves vs Painless Autoimmune Thyroiditis postpartum type?

Radioactive iodine uptake -Graves = stimm'd by autoantibodies to produce thyroid hormone → ↑uptake -Autoimmune thyroiditis = thyroid destroyed, releasing pre-formed hormone, but unable to take up iodine→↓uptake

What stimulates lactation after delivery?

Rapid fall in progesterone disinhibits & initiates lactation

Non-Gestational Choriocarcinoma

Rare germ cell tumor; may arise in the ovary or testes; does not arise in post-menopausal Germ cells differentiate into trophoblasts; Histologically same as gestational choriocarcinoma & produces β-hCG, but NOT easy to treat

Teratogenic effects of thalidomide

Rarely used to tx multiple myeloma, used to be used as sedative in pregnancy Causes limb deformities (hint: thalimbdomide)

Retinoblastoma and HPV strains expressing E7 (16, 18, 31) both inactivate what regulatory protein?

Rb

Pregnant pt w/ high ALT/AST, normal ALP. Hx STI but prior Hep screen neg

Recreen for hepatitis C

What causes DIC in obstetric emergencies?

Release of TF / thromboplastin into bloodstream activates coag cascade

Teratogenic effects of ACE-Is?

Renal damage→potter syndrome

Mgmt of suspected ectopic pregnancy in hemodynamically STABLE pt w/ TVUS showing no intrauterine or extrauterine pregnancy?

Repeat bHCG + TVUS in 2 days

Placenta not delivered 30+ minutes after fetus + bleeding Tx?

Retained placenta Manual extraction or D&C

RhoGAM is given to Rh (D) neg mothers (with/without) ____antibodies at _____ wks & ______ postpartum if Rh (D)____ baby What test determines postpartum dose?

RhoGAM is given to Rh (D) NEG mothers WITHOUT antibodies at 28 wks for all & 72 hrs postpartum if Rh (D) POSITIVE baby Use Kleihauer-Betke test to determine postpartum dose

Immigrant mother w/ maculopapular rash spreading down from face/chest to trunk/extremities, fever, posterior-auricular/suboccipital lymphadenopathy. Dx? Risk to fetus?

Rubella (TORCH) Fetus at risk of deafness, cataracts, PDA, blueberry muffin syndrome (I <3 pding on Ruby earrings in my cataract)

Causes mild, self-limited illness in mother: maculopapular rash, lymphadenopathy, joint pain In fetus/infant: sensorineural deafness; cataracts; PDA (+ other heart deformities); Blueberry muffin baby

Rubella: Enveloped, ss(+)RNA virus Droplet/vertical transmission (hint: eye pd for Ruby earrings) (Ruby = RNA)

Pt w/ symptoms of perimenopause but also weight loss; dfdx?

Rule out hyperthyroidism, which can also cause mood swings, anxiety, hot flashes, and is more likely to cause weight loss (perimenopause more often causes weight gain)

SRY gene (Y chromosome) produces ************→testes gives rise to Sertoli cells: produces *************, suppressing the development of *********** ducts Leydig cells: produces *********, stimulating development of *****************

SRY gene (Y chromosome) produces testis-determining factor→testes gives rise to Sertoli cells: produces Müllerian inhibitory factor, suppressing the development of paramesonephric ducts Leydig cells: produces testosterone, stimulating development of mesonephric/wolffian ducts (hint= leydig leyds to male, sertoli shuts down female)

1st line for severe PMDD

SSRIs

Tx of menopause sx in pt with contraindication to HRT?

SSRIs or SNRIs

Tamoxifen -Class/MoA -Use -AEs

SERM; Block estrogen binding to ER ⊕ cells - estrogen antagonist in breast - estrogen agonist in bone and endometrium Indications: estrogen-receptor ⊕ breast cancer (prevention and treatment); also used to prevent gynecomastia in men on GnRH agonists (11657) AEs -DVT/PE -Partial agonist in endometrium: ↑ risk endometrial cancer (+ polyps) -Induces menopause→hot flashes

Pregnant pt w/ hypertension, joint pain, malar rash, red casts + proteinuria on urinalysis

SLE nephritis

No Sertoli cells in XY embryo w/ SRY would cause

SRY = Male external genitalia No Sertoli = no Müllerian inhibitory factor = male and female internal, bc no suppression of paramesonephric duct

Girl under 4 years old presents with clear, grape-like, polypoid mass emerging from vagina. Spindle-shaped cells; desmin ⊕ Dx?

Sarcoma botryoides embryonal rhabdomyosarcoma variant (develops from immature muscle cells) (botryoid: having the appearance of a bunch of grapes)

Labs for DIC?

Schistocytes ↑FDPs (D-dimers) ↓fibrinogen ↓factors 5 & 8 ↓platelets ↑BT, PT, PTT

Caudal Regression Syndrome

Seen in maternal diabetes (1st trimester, ie not gestational) Sacral agenesis, "mermaid syndrome", may have neural tube defects

State class/MoA for tamoxifen, raloxifene

Selective estrogen receptor modulators (SERMs) Block estrogen binding to ER ⊕ cells - estrogen antagonists in breast - estrogen agonists in bone (and endometrium for tamoxifen)

postpartum woman w/ fevers unresponsive to abx, no localizable symptoms

Septic pelvic thrombophlebitis Approx. 90% of cases involve right ovarian vein tx w/ anticoagulation & broad-spectrum abx

Bilateral ovarian masses w/ psammoma bodies

Serous cystadenocarcinoma

Most common malignant ovarian neoplasm, frequently bilateral. Psammoma bodies

Serous cystadenocarcinoma (type of epithelial) ^risk w/ BRCA

Ovarian neoplasm lined with fallopian tube-like (columnar) epithelium. Psammoma bodies Often bilateral

Serous cystadenoma; benign ovarian tumor of surface epithelium **Most common ovarian neoplasm

Young woman with ovarian mass, recent onset hirsutism, clitoromegaly, voice deepening Reinke crystals on histology

Sertoli-Leydig cell tumor; sex cord-stromal tumor

Antidepressants safe in breastfeeding?

Sertraline (zoloft) and paroxetine (paxil)

What does a sinusoidal FHR tracing

Severe fetal anemia, blood loss, hypoxia (vasa previa, Rh disease) category 3 Get percutaneous umbilical blood sampling to check Hct/simultaneous transfusion

What is the broad ligament?

Sheet of peritoneum assoc w/ uterus & ovaries, contains ovarian, infundib/ suspensory, round ligament

Postmenopausal obese woman w/ vaginal bleeding how did obesity contribute to her condition?

She has endometrial hyperplasia or cancer due to excess unopposed estrogen Aromatase, found in adipose tissue, converts androesterone into estrogens 18654

Difference b/w simple & complex breast cyst

Simple = fluid filled, no solid component, will disappear after FNA Complex = solid, persists after FNA, reqs core needle biopsy

Normal histology of endocervix, uterus, and fallopian tubes?

Simple columnar epithelium -uterus w/ glands (donut in prolif phase, long/wavy in secretory) -fallopian tubes ciliated

Epithelium of ovaries?

Simple cuboidal

Contraindications for combined contraceptives?

Smokers > 35 years old ↑ risk of cardiovascular disease Migraine (especially with aura) Breast cancer Liver disease

Inhibits steroid binding Drug? Use? AEs?

Spironolactone Used in PCOS as anti-androgen. K+ sparing diuretic; hyperaldosteronism AEs: gynecomastia / amenorrhea; Hyperkalemia (peaked T waves, arrhythmias)

Teratogenic effects of folate inhibitors (MTX, aminopterin)?

Spont abortion (MTX is abortifacient for ectopic) Neural tube defects

Histology of transformation zone?

Squamocolumnar junction (most common area for cervical cancer)

What Tanner stage is this: downy pubic hair, breast buds

Stage 2

Top causative agents of septic abortion

Staph aureus E. coli Group B strep

Woman taking drug for PCOS notices patches of darkened skin. Explain

Taking ketoconazole, which inhibits steroid synthesis→↑MSH

Normal histology of vagina and ectocervix?

Stratified squamous epithelium, nonkeratinized

Causes of neonatal meningitis

Strep agalactiae (Group B strep) E coli Listeria monocytogenes

Why does urinary incontinence develop in pregnancy? Tx?

Stress incontinence (leakage w/ sneezing/coughing, lifting Due to ↑intraabdominal pressure, ↓urethral sphincter tone (pregnancy hormones) aka urethral hypermobility Kegel exercises strengthen levator ani

Indication for mid-urethral sling?

Stress urinary incontinence

Causes of AUB?

Structural causes: polyps, adenomyosis, leiomyomas, malignancy/hyperplasia (PALM) Non-structural causes: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified (COEIN)

Monodermal form of mature cystic teratoma; made of thyroid tissue; presents with HYPERthyroidism

Struma ovarii

What is the most effective form of BC?

Subdermal progestin

Dimpling of the breast is caused by cancer infiltrating the...

Suspensory ligamaent

What ligament contains the ovarian vessels? What structures are at risk of injury during ligation of the ovarian vessels?

Suspensory/Infundibulopelvic ligament Ureters at risk of injury during ligation of ovarian vessels

Why do epidurals cause hypotension?

Sympathetics regulating vascular tone disrupted→venous pooling

Mom w/ chancre or maculopapular rash on palms/soles Rhinorrhea Skeletal/tooth anomalies (notched teeth, bowed legs) Desquamating rash (palms/soles) Scars at corners of mouth Saddle nose Deafness Dx?

Syphilis; Treponema pallidum; Spirochete bacteria TORCHeS

T or F: vaginal pH above 4.5 can be caused by low estrogen

T 3744

Sources of testosterone, DHT, androstenedione?

T, DHT = testes Andro = adrenal

Oligohydramnios -define (2) -risk factors (4) -complication

TOO LITTLE amniotic fluid -single deepest pocket <2 cm -AFI <8 cm Risk factors: placental insufficiency, bilateral renal agenesis (no/misplaced ureteric buds), posterior urethral valves (males), post-term preg (>41 wks) Can cause Potter sequence

T or F: breast cancer risk is NOT increased by fibroadenoma or non-hyperplastic cysts

TRUE

T or F: mature teratomas may be malignant in men

TRUE

T or F: variability of menstrual cycle is due to proliferative phase, which secretory is consistently 14 days

TRUE

Woman 10 days postpartum presents w/ diffuse macular rash, high fever, leukocytosis, hypotension, tachycardia, crackles over both lungs CBC shows Leukocyte count is 20,400/mm3 with 95% neutrophils Dx? Tx?

TSS (staph aureus); vanco + clindamycin

Contrast tamoxifen, raloxifene -uses -endometrial effects

Tamoxifen -use: prevent & treat ER+ breast cancer -estrogen agonist in endometrium, so ↑ risk cancer Raloxifene -use: osteoporosis & breast cancer prevention -estrogen antagonist in endometrium, so no ↑ risk cancer

ER+ & PR+ breast tumors may respond to

Tamoxifen (SERM)

Woman gets hypotension & pulmonary edema after being given tocolytic for preterm labor which drug? MoA?

Terbutaline (beta agonist)

Patient is Rh ⊖ but ⊕ anti-D antibody test NBS?

Test dads blood type. If he is neg, baby must be, do nothing. If Dad is +, check fetus Hct

46,XY DSD

Testes present, but external genitalia are female or ambiguous. Most common form is complete androgen insensitivity syndrome (testicular feminization).

Testosterone controls differentiation of ______ genitalia DHT controls differentiation of ______ genitalia

Testosterone = internal DHT = external

High testosterone w/ low LH suggests

Testosterone-secreting tumor, exogenous steroids

Protozoa; assoc w/ cats or infected meat Newborn w/ • Hydrocephalus • Chorioretinitis • Intracranial calcifications

Toxo

2 teratogenic effects of Chlorothiazide

Thiazide diuretic/antihypertensive Causes fetal jaundice, thrombocytopenia

Why are theca cells said to be analogous to male Leydig cells, and granulosa cells to male Sertoli cells?

Theca & Leydig stimulated by LH Granulosa & Sertoli stimd by FSH (hitn: Granulosa & Sertoli FSHo have more letters)

What hormones do theca vs granulosa cells respond to

Theca cells respond to LH Granulosa cells respond to FSH

Bilateral/multiple ovarian cysts Arise due to gonadotropin stimulation Assoc w/ choriocarcinoma & hydatidiform moles, but also can arise in normal pregnancy Can be assoc w/ virilization

Theca-lutein cyst

first-line therapy in women with AUB due to uterine arteriovenous malformation (AVM)?

Transcatheter uterine artery embolization

List TORCHeS infections; how are they transmitted

Transmitted vertically (across placenta, contact during birth, breast milk) • Toxoplasmosis • Other (syphilis, varicella-zoster, parvovirus B19) • Rubella • CMV • Herpes

Chorionic villus sampling -when -indication

To confirm abnormalities found on screen (cell free DNA) 10-13 wks

NBS to evaluate preterm labor

Transvaginal ultrasound to measure cervical length

HER2+ breast tumors may respond to

Trastuzumab (Herceptin) Monoclonal antibody against HER2 (hint Tras2zumab)

Which have vaginal inflammation & increased pH -BV (gardnerella) -Trich -Candidiasis

Trich & candidiasis - inflammation Trich & BV - increased pH (>4.5)

T or F: post-term pregnancy ↑risk of oligohydramnios

True

What subtype of invasive ductal carcinoma is this? well-differentiated tubules that lack myoepithelial cells; may be bilateral

Tubular good prognosis

Describe the karyotype, internal, and external genitalia of those w/ -Turner -Mullerian agenesis -CAIS -5α-reductase deficiency

Turner (45, X) -External = female -Internal = streak ovary, present uterus Mullerian/parames agenesis (46, XX) -External = female -Internal = ovaries, but no uterus -low testosterone CAIS (46, XY) -External = female (testes may be palpated in labia) -Internal = male -high testosterone 5α-reducatse deficiency (46, XY) -External = female/ambig -Internal = male -low DHT

Neonate w/ diminished femoral pulses, posterior neck mass composed of cystic spaces/connective tissue, and edema in hands and feet Dx? Pathogenesis?

Turner syndrome (45, X) Loss of paternal X chromosome Weak femoral pulses = coarctation of aorta Neck mass/edema = cystic hygroma

-Short stature -Streak gonads -Infertility & menopause before menarche (premature follicular apoptosis) -Shield chest w/ widely-spaced nipples -Cystic hygroma → webbed neck/neck mass; lymphedema in hands & feet -Abnormal development of female 2° sex characteristics -Coarctation of aorta (weak femoral pulses) Labs? Uterus?

Turner syndrome (45, XO) ↓ estrogen & progesterone ↑ FSH & LH Uterus present; can become pregnant thru in vitro

Order these thelarche menarche pubarche

T→P→M

Pregnant woman w/ intermittent loose, bloody stools, fecal urgency and then straining/inability to defecate (tenesmus). Hx of same years ago. Fetus is small for gestational age

UC

Breast carcinomas occurs most frequently what quadrant of the breast?

Upper outer

Function/supply/drainage of umbilical arteries and umbilical vein? From what primitive structure are they derived?

Umbilical arteries (2)—return deoxygenated blood from fetal internal iliac arteries to placenta Umbilical vein (1)—supplies fetus w/ oxygenated blood from placenta; drains into IVC via liver or ductus venosus Derived from allantois

IUFD < vs > 24 wks tx

Under 20-24 wks: D&C or vaginal delivery Past 24 wks: Induction when ready, vaginal delivery preferred

Pt has abdominal guarding, decreased bowel sounds, vaginal bleeding BP 90/50 Found to have cornual ectopic pregnancy Free fluid in cul-de-sac Dx? Tx

Unstable vitals + free fluid in cul-de-sac in setting of ectopic = hemoperitoneum Laparoscopy (emergency surgical exploration)

From what embryonic structure do these arise? Urinary bladder Prostatic, membranous, prox penile urethra Prostate Bulbourethral glands of Cowper

Urogenital sinus (following DHT exposure)

Tranexamic acid (TXA)

Used for menorrhagia, 2nd line for acute AUB AVOID in women at a high risk of thrombosis

Kleihauer-Betke test -Indication? -What Rh type needs it?

Used in Rh- mother after trauma. Evaluates the amount of fetal blood present in maternal blood to calculate dose of RhoGAM maternal blood smear is exposed to acid, and stained afterwards. Adult hemoglobin is removed by the acid, whereas fetal hemoglobin (HbF) is not, resulting in pink color cells that indicate fetal hemoglobin on a positive test

Teratogenic effects of cocaine

Vasoconstriction Placental abruption Premature delivery Low birth weight

Pathogenesis of Turner syndrome

Usually meiotic nondisjunction Sometimes mitotic error→mosaicism (45,XO/46,XX)

Woman w/ hx surgical abortion presents w/ ↓fertility, recurrent pregnancy loss, abnormal uterine bleeding/amenorrhea, pelvic pain normal FSH & estrogen (no symptoms of low estrogen) Dx? Pathogenesis?

Uterine adhesions/fibrosis of endometrium due to loss of basalis/stem cells Asherman Syndrome aka uterine synechiae; 90% assoc w/ over-aggressive D&C

Postpartum bleeding w/ soft uterus + palpated 4 cm above umbilicus ultrasound shows thin endometrial stripe

Uterine atony endometrial stripe = no retained placenta

Woman w/ hx c-section experiences abdominal pain and extreme vaginal bleeding during attempted vaginal delivery. Contractions cease Dx?

Uterine rupture + loss fetal station

Sudden abdominal pain during labor + progressively decreasing amplitude (staircase sign) on tocodynamometry

Uterine rupture +loss of fetal station

Which vessel is involved in thrombosis leading to recurrent pregnancy loss in antiphospholipid antibody syndrome

Uteroplacental artery • From mother to fetus: uteroplacental artery → placenta → umbilical vein • Mothers blood doesn't cross the placenta, therefore thrombosis must occur before the placenta

Decidual basalis

Uterus at site of implantation Derived from endometrium Interacts with trophoblast Maternal blood in lacunae

Complete mole presentation, complications, karyotype

Uterus enlarged, extremely elevated hCG (may be >100,000) Hyperemesis gravidarum, Ovarian theca lutein cysts "Honeycombed" uterus or "clusters of grapes" "snowstorm/swiss cheese" on ultrasound. No fetal parts Increased risk of malignant gestational trophoblastic disease, choriocarcinoma empty egg fertilized by 1 X sperm that duplicates → 46,XX 2 sperm → 46,XY

State the lymphatic drainage for uterus, superior bladder

Uterus/superior bladder→ external iliac nodes

Heavy periods, normal PT & PTT, ↑BT

VWF disease

Woman has postpartum bleeding with no evidence of uterine atony, retained placenta, or infection. ↑bleeding time, may have normal or ↑PTT normal PT, platelets,

VWF disease

Watery, malodorous vaginal discharge, postmenopausal bleeding, and ulcerated vaginal lesion in person >60

Vaginal SCC; get biopsy

After delivery of 9 lb infant woman has hypovolemic shock, purple mass protruding into vagina uterus firm and palpable above umbilicus, minimal vaginal bleeding

Vaginal hematoma 13849

Vaginal vs IM progesterone for prevention of preterm delivery

Vaginal if short cervix (<2.5 cm) IM 17-hydroxyprogesterone if hx preterm labor (painful contractions)/ rupture of membranes

Woman >24 wks pregnant w/ cervix <2.5 cm. No hx preterm delivery. Mgmt?

Vaginal progesterone

Differentiate b/w the presentations & treatments/parties treated for bacterial vaginosis (gardnerella) and trichomoniasis (trichomonas)

Vaginosis (gardnerella) -grey/white fishy smelling discharge; no inflammation -epithelial cells w/ stippling/fuzzy edges due to gram-variable rods (clue cells). ↑pH. -⊕ whiff test w/ KOH -Metro or clinda (clinda looks for clues) for pt only Trichomoniasis -thin, frothy, yellow/green, malodorous discharge & inflammation. ↑pH; inflammation -motile protozoa; visualize on saline microscopy (wet mount) -Metro for pt + partner(s) [if its motile give it to her man]

painless vaginal bleeding followed by fetal bradycardia (< 110 beats/min) or demise Dx? Tx? Risk factors?

Vasa previa: Fetal vessels run over cervical os May rupture leading to fetal exsanguination Tx: Emergency C-section Strong assoc w/ velamentous umbilical cord

Cord inserts in chorioamniotic membrane rather than placenta→fetal vessels travel to placenta unprotected by Wharton jelly Increased risk of vasa previa (fetal vessels over os)

Velamentous umbilical cord

5 AEs for estrogen

Venous thromboembolism (VTE) Hypertension Hepatic adenoma development Cardiovascular events Headaches

Painless clear fluid leakage after pelvic surgery or protracted labor (esp in young mother) Fluid has high pH +/- vaginal granulation tissue

Vesicovaginal fistula

Newborn presents after home birth w/ persistent bleeding from umbilical stump. Labs show ↑PT/PTT. Dx?

Vit K deficiency ↓γ-carboxylation of vit K-dependent factors (prothrombin, 7, 9, 10)→↓hepatic synth of these factors→bleeding

What supplements do exclusively breastfed infants need?

Vitamin D & K supplementation; iron after 4 moths

What drug has these teratogenic effects? -epiphyseal stippling -nasal ridge hypoplasia -fetal hemorrhage/ death

Warfarin

Is pregnancy possible for someone w Turner syndrome?

Yes via in vitro fertilization using egg donor, exogenous estradiol-17beta, and progesterone

Blueberry muffin baby -Pathogenesis -Most commonly assoc w/ which TORCH? -Other 2 torches?

Widespread purpura due to extramedullary hematopoiesis -normal in utero, should stop at birth; persists in congenital Rubella -rarely congenital toxo, CMV

When is the embryo most susceptible to teratogens?

Wks 3-8

Is anencephaly a neural tube defect?

YES

Can you breastfeed of anti-epileptic drugs?

Yep

Tumor in ovaries, tests or sacrococcygeal area of young child Yellow, friable/hemorrhagic, solid mass. Schiller-Duval bodies (resemble glomeruli) Elevated AFP

Yolk sac tumor (SAC = Schiller-Duval, ↑AFP, Children (<3))

State the tumor markers for -Yolk sac tumor -Dysgerminoma -Seminoma

Yolk sac: AFP Dysgerminoma: LDH Seminoma: placental ALP

Neonate w/ microcephaly, intracranial calcifications, thin cerebral cortex, closed anterior fontanelle, club feet

Zika; aedes

Pt at 34 wks has BP 140/90 & +1 proteinuria on dipstick how to confirm diagnosis of preeclampsia?

either protein/cr ratio >0.3 or 24 hr urine protein >300

RUQ pain + hypoglycemia + low platelets 2 other abnormal labs? dx?

acute fatty liver of pregnancy ↑AST & ALT ↑Bilirubin

Failure of urachus to involute is associated w/ increased risk of what cancer?

adenocarcinoma of bladder

oligohydramnios with consistent variable decels (suspected cord compression) tx

amnioinfusion

Pt has DIC + frothy pink sputum after emergency c section for abruption

amniotic fluid embolism

most common site of ectopic pregnancy?

ampulla of fallopian tube

Free fluid from ruptured appendix vs theca lutein cyst

appy = paracolic gutter cyst = cul de sac

Threshold for gestational vs chronic hypertension?

before 20 weeks = chronic/pre-existing after = gestational (assuming no proteinuria/end organ damage)

Late decelerations

begins after uterine contraction has started associated with uteroplacental insufficiency; dangerous repetitive late decelerations require intervention -Intrauterine resuscitation→ emergency c-section

1st stage of labor begins w/ ? ends when ? what are the 2 phases?

begins w/ reg contractions ends when cervix is 10 cm dilated latent phase = gradual dilation, up to 6 cm active phase = 6 cm - 10 cm (should progress 1cm/2 hrs)

Bloody show

benign bleeding during active labor due to rapid cervical dilation

Woman w/ hyperemesis gravidarum, 12 wk uterus w/ no embryo but multiple cysts, bilateral ovarian cysts, positive pregnancy test

complete hydatidiform mole 100% paternal DNA due to empty egg 1 X sperm that duplicates → 46,XX 2 sperm → 46,XY No fetal parts (unlike partial mole) p57-negative: no maternal DNA

Placental biopsy shows abnormally narrow spiral arteries and fibrinoid necrosis of vessels Dx?

preeclampsia (normal = A, preeclampsia = B)

contents of inguinal canal in F

both = genital branch of genitofemoral nerve) + ilioinguinal nerve F: round ligament

embryonal carcinoma vs hydatidiform mass

both can have ↑bHCG + abdominal mass (mass is enlarged uterus in case of mole) -embryonal + ascites -hydatidiform + hypertension; neuro sx (preeclampsia basically, but before 20 wks)

1st sign of puberty in girls?

breast bud

CA-15/3 and CA-27/29 are markers for

breast cancer

Delivery plan if prior classical (vertical) c section or uterine myomectomy?

c section at 36-37 wks

Anemia of prematurity -cause -labs

can't make enough EPO low hemoglobin normal MCV (80-100) low-normal reticulocyte count (normal = .5-1.5)

Contrast preeclampsia and eclampsia

preeclampsia = hypertension after 20th week + proteinuria OR organ dysfunction eclampsia = ^ + seizures

Pt w/ uterine atony + asthma; what tx should be avoided?

carboprost tromethamine

Advanced _______ often invades through the anterior uterine wall into the bladder, blocking the ureters → obstructive uropathy (hydroureter)

cervical adenocarcinoma

Maternal fever, tachycardia, uterine tenderness, malodorous and purulent amniotic fluid, vaginal discharge, and fetal tachycardia indicates ....

chorioamnionitis aka IAI Tx: delivery + -vaginal: IV ampicillin plus gentamicin -Csec: ^ + clindamycin (CAG = chorio → amp + gent)

What cancer affects women who were exposed to DES in utero?

clear cell adenocarcinoma of vagina

Contraindications to contraction stress test (CST)

contraindications to labor

Ovarian mass contains teeth, epithelium; squamous cell carcinoma

cystic teratoma w/ malignant potential

protrusion of the bladder behind the anterior vaginal wall and into the vaginal introitus

cystocele

postpartum woman w/ fecal incontinence since birth of child

damage to anal sphincter

Older woman w/ hx childbirth presents w/ constipation + pelvic prolapse What muscle is damaged?

damaged levator ani

Cause of short stature in Turners? Treatment?

deletion of second SHOX gene on the X chromosome Treat w/ growth hormone→↑JAK/STAT

1st ultrasound shows INCREASED nuchal translucency and hypoplastic nasal bone DECREASED pregnancy-associated plasma protein

downs

When is follicular growth fastest?

during 2nd week of follicular phase

Tumor if ↑estrogen signs? Tumor if ↑testosterone signs?

e = granulosa ("a grain of estrogen") t = serToli-leydig (sirtoli)

Contrast causes of early, variable, late and decelerations

early = pressure on fetal head (reflex bradycardia via vagus firing) variable = umbilical cord compression late = uteroPlacental insufficiency; hyPoxia VEAL CHOP

endometrial biopsy shows thin surface epithelium with short, straight glands and few mitotic figures phase of menstrual cycle?

early follicular phase; ~day 6

persistent rise in β-hCG level after dilation and curettage is diagnostic for

ectopic pregnancy

Abnormally low hCG in pregnancy may indicate

ectopic/failing pregnancy, Edwards syndrome, Patau syndrome.

1-2 wk old neonate w/ blood-tinged, mucoid vaginal discharge, breast bud development, and labial swelling nontender greyish blue patches on back and buttox

effects of intrauterine estrogen exposure + congenital dermal melanocytosis (Mongolian spots)

Tx for hemodynamically unstable pt w/ ruptured ectopic preg

emergency exploratory surgery and repair

Endometrial cells on pap in postmenopausal woman

endometrial biopsy

Pain w/ sex, laterally displaced cervix

endometriosis

Granulosa cell tumors secrete

estrogen

Mammography guidelines -age, q

every 2 years in women 50-75

Prolonged/arrested 2nd stage of labor -definition -RF (3)

failed delivery 3 hours after 10 cm dilation (2 for multip) (+ 1 hr for each if epidural given) risks = cephalopelvic disproportion (fetal malposition, macrosomia, narrow pelvis), maternal obesity/excessive pregnancy weight gain, DM

Labs for Kallmann syndrome?

failed migration of GnRH neurons from olfactory placode to hypothalamus→ ↓GnRH→↓FSH, LH, T, E

Neonatal lupus complication + transmission

fetal AV block (bradycardia) maternal anti-Ro/SSA and anti-La/SSB (assoc w/ sjogrens but also present in 30% SLE)

Fibroadenoma vs fibrocystic changes

fibroadenoma: single, small, mobile well circumcised mass; nontender fibrocystic change: multiple, diffuse nodulocystic masses; tender both vary w/ cycle and are common in young woman and benign However, if over 18, palp breast mass reqs ultrasound to rule out cancer

Fetal fibronectin (fFN) test

fibronectin =protein produced at the boundary between the amniotic sac (which surrounds the baby) and the lining of the mother's uterus (the decidua) + = fFN in vaginal fluid = delivery soon

afebrile breastfeeding mother with a non-tender mass

galactocele; resolves w/o intervention

Immediately prior to delivery, estrogen upregulates expression of ___ ________ to increase excitability of myometrium

gap junctions

Complications of indomethacin tocolysis after 32 wks?

premature closure of DA oligohydramnios

1st line tx of acute AUB in hemodynamically stable woman under 45 w/o risks for endometrial cancer

high-dose oral conjugated estrogen High levels of estrogen trigger rapid growth of the endometrium and thereby stop sudden, heavy bleeding from the uterine surface

Athlete/low BMI w/ no period due to

hypothalamic amenorrhea

Endometrial hyperplasia treatment (1 surgical, 1 pharm)

hysterectomy or progestin

Benign appearing endometrial cells on pap in premenopausal woman. NBS (2)?

if AUB or ↑risk endometrial hyperplasia→ endometrial biopsy if not, routine pap screening

Mgmt of menopause w/ vs w/o hysterectomy

if uterus → estrogen & progesterone (p decreases risk of endometrial cancer) if no uterus → estrogen only

women on COCPs before menopause have an increased risk of ______ carcinoma decreased risk of ______ and ______ carcinoma.

increased risk of cervical carcinoma decreased risk of endometrial and ovarian carcinoma

6 yo boy w/ precocious puberty, normal BP, high DHEAS, and low deoxycorticosterone (DOC) and cortisol

late onset 21-hydroxylase deficiency

Postpartum + weakness that improves w/ rest / varies throughout the day + blurry vision

myasthenia gravis

20 min after placing an epidural for bupivacaine anesthesia, woman develops perioral numbness, metallic taste, palpitations, and tinnitus BP is 150/80 She then has TC seizure

local anesthetic systemic toxicity occurs when epidural cath is placed in epidural vasculature instead of epidural space, so delivers systemic instead of local anesthesia blocks inhibitory pathways→symptoms of CNS overactivity

Normal fetal position

longitudinal lie, cephalic presentation, occiput anterior

Hx C section + sudden intense ab pain & loss of fetal station during labor + late decels

loss of fetal station + sudden intense lower abdominal pain +/- protruding fetal parts in abdomen + abnormal FHT = uterine rupture Perform emergency laparotomy + C section

GBS px if pcn allergy (2)

low risk of anaphylaxis: cefazolin high risk: culture for clindamycin/erythromycin sensitivity -sensitive to both→clindamycin -resistant to either→ vanco

Woman develops flushing, resp distress, somnolence, hypocalcemia after preeclampsia Treatment?

magnesium sulfate toxicity: IV calcium gluconate bolus

Define ductal carcinoma in situ (DCIS)

malignant proliferation of cells in ducts, with no invasion of the basement membrane.

risk for umbilical cord prolapse

malpresentation (breech)

Erythema of breast + fever w/ vs w/o fluctuant area

mastitis w/ fluc = could be abscess

Caudal regression syndrome, TGA, and NRDs are all associated w/ what maternal condition?

maternal diabetes CDA & TGA w/ non-gestational NRDs w/ both

IntraAmniotic Infection (IAI) def (4) AND tx?

maternal fever w/o source + either -maternal leukocytosis -maternal OR fetal tachycardia -purulent amniotic fluid patients usually have vomiting, uterine fundal tenderness immediate induction regardless of gestational age + amp/gent 16234

Aneuploidy most commonly due to

meiotic nondisjunction

Explain how GnRH/menotropin and hCG are used to treat infertility

menotropin mimics FSH, causes follicle maturation once follicle is mature, hCG mimics LH, causes ovulation

Pregnant woman w/ exaggerated lordosis, numbness/tingling in lateral thigh, pain on hip flexion. Leg strength is 5/5 bilaterally

meralgia paresthetica- compression of lateral femoral cutaneous nerve at inguinal ligament no motor symptoms!

The most important prognostic factor in breast cancer is...

metastasis to axillary nodes; assessed via sentinel node biopsy

endometrial biopsy shows stromal edema and glycogen-rich vacuoles at the cellular apex phase of menstrual cycle?

middle secretory/luteal phase

How to distinguish b/w monochorionic and fused dichorionic twin gestations

monochorionic = intertwin membrane makes T sign dichorionic = intertwin membrane makes lambDa sign (2 lambs)

Elevated hCG in pregnancy may indicate (4)

multiparity, hydatidiform moles, choriocarcinomas, Down syndrome

Contraindications to magnesium sulfate?

myasthenia gravis

Uterus at level of umbilicus post-delivery =

no uterine atony (normal)

Rank the potency of estrogen released from the placenta, ovaries, adipose tissue

o: estradiol > a: estrone > p: estriol

tx idiopathic hirsutism?

oral contraceptives

In ovarian/adnexal torsion, the ovary twists around which 2 structures? Biggest risk factor?

ovarian ligament (contains ovarian branches of uterine vessels) & infundib/suspensory ligament (containing ovarian vessels): disrupts blood flow to/from ovary risk factor: enlarged ovary (greater than 5 cm)

Para-aortic lymph nodes drain the...

ovaries/testes

Most common site of endometriosis?

ovary (endometrioma; chocolate cyst)

Tx for postpartum atony?

oxytocin (stims gq); uterine massage

Pregnant + rash of urticarial papules and plaques that eventually form tense bullae develops around the umbilicus and trunk

pemphigoid gestationis

Recurrent pregnancy loss in woman w/ enlarged thyroid, TSH 7, normal T4, no hypothyroid sx. Likely cause?

subclinical hashi anti-thyroid peroxidase ab still cause preg loss give levothyroxine

Persistent nipple pain b/w feedings, bilateral abrasions, bloody appearing nipple discharge may have engorgement due to inability to tolerate breast feeding

poor latch on/ infant positioning

Ultrasound shows potters syndrome, bilaterally enlarged kidneys w/ thin renal cortices, distended bladder

posterior urethral valves

midline episiotomy to expedite delivery involves what structures?

posterior vagina to perianal body

Spasmodic, crampy pain in the lower abdominal and/or pelvic midline around or before menstruation

primary dysmenorrhea tx: NSAIDs, OCP (combo), IUD w/ progesterone

Who gets low dose aspirin for preeclampsia ppx? (4)

prior preeclampsia, chronic HTN, DM, CKD

Decreased % free-PSA

prostate cancer

The internal iliac nodes drain the...

proximal vagina, cervix

Hyperemesis gravidarum tx

pyridoxine + doxylamine (B6 + H1 blocker)

Antagonist at breast, uterus; agonist at bone;↑risk of thromboembolic events but no increased risk of endometrial cancer; used primarily to treat osteoporosis.

raloxifene

Variable decelerations -describe -3 causes -mgmt intermittent vs persistent

rapid ↓ in FHR (often < 100/min) with variable recovery; may not coincide w/ contractions reflex mechanism due to umbilical cord compression or prolapse; oligohydramnios If intermittent (occur with less than 50% of contractions in a 20-minute period), no intervention needed If persistent, correct by 1st shifting maternal position then amnioinfusion if membranes ruptured

Rh (D) antibody screen is negative at 10 wk appointment

recheck at 28 + give RhoGAM if neg to prevent alloimmunization

desmin ⊕

rhabdomyosarcoma Desmin = Muscle filament; Part of Z-disks in sarcomeres

Pregnant woman w/ unilateral MILD lower abdominal pain radiating to ipsilateral labia

round lig syndrome If severe consider nephrolithiasis

Lichen sclerosis vs vulvar cancer

sclerosis = multiple nonpigmented plaques cancer = 1 pigmented, raised plaque Always biopsy adult onset lesions to RO malignancy

BRCA1 mutation carriers have an increased risk for _______ carcinoma of the ovary and fallopian tube.

serous carcinoma of the ovary and fallopian tube "BRCA1 is ser1ous"

Stages of labor

stage 1: 0-10 cm -latent: 0-6 -active: 6-10 ◦protraction if <1cm/2 hr→oxytocin ◦arrest if no change for 4 hrs w/ good ctx, 6 w/o →c-section stage 2: 10 cm-delivery of baby ◦takes <3 hrs if nulliparous, <2 if multi (+ 1 for epidural) stage 3: placental delivery 30 min stage 4: 2-hour postpartum period Monitor to rule out hemorrhage or preeclampsia

Breast tissue is modified _____ gland

sweat gland

pregnant + virilization + b/l ovarian cysts

theca-lutein cysts Do nothing! They will go away

3 risks of estrogen containing OCPs

thromboembolism hypertension hepatic adenoma

Mgmt of PPROM LESS THAN 34 wks

uncomp -steroids -expectant -latency abx (azithromycin, ampicillin) comp -steroids -delivery -IAI tx (ampicillin, gentamicin) -magnesium sulfate if <32 wks

tender mass in anterior vaginal wall, dyspareunia, purulent urethral discharge, freq UTIs

urethral diverticulum

Pt 1 week after delivery w/ epidural presents w/ low back pain, fever, and weakness/tingling in lower legs

urgent MRI to confirm spinal epidural abscess

Oxytocin stimulates

uterine contraction + milk production

After delivering baby, placenta has yet to be delivered, pressure on umbilical cord leads to sudden avulsion, onset of severe pain, and vaginal bleeding. fundus cannot be palpated. a firm, rounded mass is seen protruding from the vagina

uterine inversion tx w/ fluids, manual replacement; discontinue uterotonics

At what B-HCG can transabdominal vs transvaginal ultrasound detect gestational sac?

vaginal: >2000 abdominal: >6500

Indications for delivery in preeclampsia w/o vs w/ severe features

w/o = 37 wks w/ = 34

Threshold for induction for preeclampsia w/ vs w/o severe features

w/o severe features = 37 wks w/ = 34

Rectus abdominis diastasis

weakening of linea alba b/w rectus abdominis muscles during or after pregnancy

Tx for PCOS?

weight reduction (↓peripheral estrone formation) OCPs (prevent endometrial hyperplasia due to unopposed estrogen) letrozole, clomiphene, metformin to induce ovulation spironolactone, ketoconazole (antiandrogens) for hirsutism

Binding of terbutaline to ______ receptors on the uterus leads to

β2 receptors ("terbu-2-line"); GCPRs w/ Gs subunit Activates cAMP/PKA cascade→ inhibits myosin light-chain kinases→ relaxes uterus (stops contractions)

Pap indications after total hysterectomy for CIN 3?

• CIN 3 requires 1 and 2 years post-procedural pap testing to rule out vaginal recurrence ● If patient had CIN 2 or greater, pap smear should be done annually for 20 years after diagnosis, regardless of hysterectomy

Normal weird during pregnancy

• CO rises • Afterload decreases due to fall in SVR -mild chronic respiratory alkalosis (↓Co2, ↓HCO3, ↑pH) • Preload rises due to ↑blood volume -this dilutes blood*, ↓ oncotic pressure→edema -lower Hgb -lower platelets (down 100,000) -mild leukocytosis -low Cr (0.4-0.8) -low BUN -urine protein (( up to 300 )↑GBM permeability) -↑GFR, RBF -bilateral hydronephrosis -Mid-systolic murmur -edema Uworld: 4148, 15698

How are CO, Preload, and afterload affected by pregnancy? What accounts for edema?

• CO rises • Preload rises due to ↑blood volume -this dilutes blood*, ↓ oncotic pressure→edema • Afterload decreases due to fall in SVR *somehow, dilutes blood =/= ↓osmolality. ↓oncotic pressure bc of lost albumin, but other things must make up for it bc osmolality is the same (am230077)

Risk factors for SIDS

• Infant stomach sleeping • Maternal smoking during pregnancy • Very young maternal age (<20) • Bed sharing (infant/parent) • Prematurity/low birth weight

Type of urinary incontinence w/ MS affecting UMNs vs LMNs

• UMNs→ loss of inhibitory control over bladder → urge incontinence -low postvoid residual volume <150 ml - detrusor overactivity -M3 ANTAGonists: (Oxybutynin, tolterodine, solifenacin); Mirabegron (β-3 AGONIST) • LMNs → hypotonic bladder → overflow incontinence -detrusor underactivity; dribbling/retention -higher postvoid volume (>150 mL) -intermittent cath

• Young women are more prone to cervicitis bc they have ↑ _______ epithelium (↑ susceptibility to Gonorrhea and Chlamydia infections) • Over time this ______ epithelium is replaced with ______ epithelium → ↑ microbial resistance • ↑ _________ → thickening of cervical mucus plug → ↓ risk of infection

• Young women have ↑ columnar epithelium lining their cervix • Overtime this columnar epithelium is replaced with squamous epithelium → ↑ microbial resistance • ↑ progesterone → thickening of cervical mucus plug → ↓ risk of infection

Endometriosis cancer risk?

↑ risk of carcinoma at site of endometriosis, especially in ovary

Summarize ovulation

↑estradiol, ↑GnRH receptors on anterior pituitary→↑↑LH surge → ovulation (rupture of follicle) ↑temperature (↑progesterone induced)

Postpartum woman with vaginal dryness, min rugation, pain with sex currently breastfeeding

↑prolactin→↓GnRH→↓FSH, LH, estrogen

AEs/contraindications for estrogens (Ethinyl estradiol, DES, mestranol)

↑risk of endometrial cancer (when given w/o progesterone), bleeding in postmenopausal women, clear cell adenocarcinoma of vagina in females exposed to DES in utero,↑risk of thrombi. Contraindications—ER ⊕ breast cancer, history of DVTs, tobacco use in women > 35 years old.

Hormonal changes in menopause

↓Estrogen, ↑↑FSH, ↑LH, ↑GnRH

Menopause Amenorrhea for 1 yr ↓______ production due to age-linked ↓ # ________ __________ Average age: ______ (earlier in smokers); considered premature before _________ Source of estrogen (estrone) after menopause becomes peripheral conversion of androgens ↑↑_______ is specific for menopause (loss of negative feedback on _____ from estrogen)

↓estrogen production due to age-linked ↓ # ovarian follicles due to atresia (apoptosis) Average age: 50 years (earlier in smokers); premature before 40 Source of estrogen (estrone) after menopause becomes peripheral conversion of androgens in adipose tissue (↓ symptoms in obese) ↑↑FSH is specific for menopause (loss of negative feedback on FSH from estrogen) "you have menopause FSH'o"

Klinefelters labs

↓testosterone, inhibin B, absent sperm ↑FSH, LH, estrogen

Criteria for short cervical length during pregnancy ? WHEN & HOW is it measured to assess risk of preterm labor?

≤ 2.5 cm measured by TVUS in 2nd tmester (16-24 weeks)

tachysystole definition & tx

≤2 minutes apart or >5/10 minutes may cause late decels discont uterotonics (oxytocin) + reposition; tocolysis

Contraction freq over 20 min vs 1 hr to hospitalize?

≥ 4 / 20 minutes ≥ 8 / 60 minutes

For preterm labor after ____ wks you don't use tocolytics

≥34

Woman w/ stress incontinence Small amount of urine leaks with valsalva, but anterior & posterior vagina appear well supported Q tip in urethra tilts on 45° arc upon valsalva

⊕ Q-tip test = stress incontinence >30° of movement = urethral hypermobility (urethrocele) (Well supported posterior and anterior vagina rule out cystocele and enterocele)

Tests for rupture of membranes

⊕ pool: amniotic fluid exiting the cervix and pooling in the vaginal fornix ⊕ nitrazine test: test strips turn blue (higher pH) ⊕ fern test: fern pattern on glass slide