OB/GYN rotation

When is the 2nd trimester quad screen usually performed?

16-18 weeks (2nd trimester quad screen: combines AFP, bHCG, estriol, and inhibin A to screen for trisomy 21/18/neural tube defects --> detects Down syndrome with 81% sensitivity --> AFP: alpha fetoprotein that will be ELEVATED in neural tube defects and DECREASED in trisomy 21/18 --> bhCG: beta-hCG that will be ELEVATED in trisomy 21 and DECREASED in trisomy 18 --> uE3: estriol that will be DECREASED in both trisomy 21/18 --> inhibin A: will be INCREASED in trisomy 21)

When is the quadruple screen normally done in pregnant women?

16-20 weeks (quadruple screen: involves AFP + hCG + estriol + inhibin A --> has 80% detection rate for aneuploidy)

Which medication is shown to reduce risk of premature labor from all causes (including PPROM)?

17 alpha-hydroxyprogesterone (started between 16-20wks and administered weekly until 36wks)

When should a multiparous woman start to feel fetal movement?

18 weeks

Most accurate method of determining gestational age

1st trimester US with crown rump length (if done between 7-14wks, accuracy varies by 3-5 days)

Most reliable method of confirming gestational age

1st trimester ultrasound (accurate at 14-15 weeks gestation --> should be used to revise due date if there is >7 day discrepancy from menstrual dates or >10 day discrepancy if US performed between 16-21wks --> can give accurate estimated due date within 3-5 days)

At what point after delivery can a woman be diagnosed with postpartum depression?

2 weeks (signs/symptoms of depression <2wks is called postpartum blues, occurring in 40-85% of women in immediate postpartum period --> signs/symptoms of depression >2wks after delivery called postpartum depression, occurring in 10-15% of women)

How do you define a reactive NST?

2+ accelerations in 20mins (should be seen in fetuses >28wks)

At how many weeks gestation is the fundal height usually around the umbilicus?

20 weeks

When should a primigravid woman start to feel fetal movement?

20 weeks

At how many weeks is a miscarriage considered intrauterine fetal demise?

20 weeks (IUFD: fetal death >20wks, diagnosed by absence of fetal cardiac activity on US --> risk factors: fetal growth restriction, abnormal karyotype, and tobacco use --> need to remove fetus to avoid coagulopathy after several weeks of fetal retention --> if 20-23wks, treat with D&E or vaginal delivery --> if >24wks, treat with vaginal delivery)

Minimum weeks of gestation to diagnose pregnant woman with gestational HTN/pre-eclampsia

20 weeks (therefore pregnant women <20wks with SBP >140 and DBP >90 are considered to have CHRONIC HTN --> pregnant women >20wks with new-onset elevated BP are diagnosed with gestational HTN --> pregnant women >20wks with gestational HTN and proteinuria OR signs of end-organ damage such as thrombocytopenia/elevated AST and ALT/elevated Cr/pulmonary edema/CNS changes diagnosed with preeclampsia)

What is the cutoff of Montevideo units for adequate contractions?

200 (aka woman needs to have >200 MU in 10mins for adequate contractions)

Treatment of pathologic anemia in pregnancy

200mg iron (can obtain from ferrous sulfate, fumarate, or gluconate)

Two methods to diagnose proteinuria

24hr urine collection or urine P/C ratio (diagnosis of proteinuria: 24hr collection shows total urine protein excretion >300mg --> or urine protein/creatinine ratio of >0.3)

How many pounds should a woman with normal weight gain during pregnancy?

25-35 pounds (women with BMI 18.5-25 should gain about 25-35lbs total during pregnancy --> should gain 1.5-3lbs in 1st trimester --> then 0.8lb/wk in 2nd and 3rd trimesters)

When do women with no prior risk factors usually get screened for gestational diabetes?

26-28 weeks (use 1-hour glucose challenge test/1-GCT --> if positive >140, follow with 3-hour glucose tolerance test/3-GTT --> if fasting >95, 1-hour >180, 2-hour >155, or 3-hour >140 then diagnose with GDM)

At how many weeks gestation should you start to see a reactive NST?

28 weeks (by this point, fetus is neurologically mature and therefore autonomic nervous system should create constant push/pull of BTBV to show variability in FHR --> reactive NST diagnosed by at least 2 accelerations >15bpm above baseline lasting 15s over 20mins)

At how many weeks gestation should an NST become reactive?

28 weeks (this is when the fetal SNS is fully mature --> therefore, extremely premature fetuses <28wks do not demonstrate reactivity)

When is Rhogam given to Rh-negative moms?

28 weeks and delivery

When is the lowest Hgb value seen in a pregnant woman?

28-30 weeks (women usually have Hgb around 10 due to physiologic dilution --> if Hgb <10, need to do iron studies)

How many pounds should an underweight woman gain during pregnancy?

28-40 pounds (women with BMI <18 should gain >28lbs)

Which type of perineal laceration involves the fascia and perineal body, but NOT the anal sphincter?

2nd degree (involves fourchette, perineal skin, and vaginal mucosa, aka 1st degree --> further involves fascia and muscle of perineal body but NOT anal sphincter)

Average number of contractions in 10mins (for NORMAL labor)

3

Definition of preterm labor

3 contractions in 30mins and cervical change

When should you be able to detect b-hCG in maternal serum or urine?

3-3.5 weeks after LMP (aka 6-12 days after fertilization --> however, can diagnose pregnancy with 95% sensitivity by 1wk after first missed menstrual period)

Normal vaginal pH

3.8-4.5 (vagina is normally acidic due to flora --> causes of increased vaginal pH include bacterial vaginosis and trichomoniasis)

How much iron is recommended per day during 2nd and 3rd trimester?

30 mg/day

How much time should it take for delivery of placenta after the baby is born?

30 minutes (to help deliver placenta, perform uterine massage --> then oxytocin --> then reach into uterus and perform manual extraction)

What % of women with GDM develop diabetes later in life?

30%

How much additional calories should a pregnant women be consuming?

300 kcal/day

At how many weeks gestation should magnesium be given if pregnant pt presents with preterm labor?

32 weeks (aka preterm labor <32wks requires magnesium for neuroprotection of fetus, as well as betamethasone + indomethacin for tocolysis --> if labor begins between 32-34wks, only need to give betamethasone and nifedipine --> if labor begins >34wks, only need to give betamethasone)

When should pregnant women stop taking ibuprofen for pain?

32 weeks (due to risk of premature closure of DA)

At how many weeks should a patient with PPROM be delivered?

34 weeks (if PPROM occurs <34wks, then pt must receive betamethasone and latency antibiotics with possible magnesium sulfate if <32wks --> then delivered at 34wks when risk of complications outweights neonatal benefit of continuing pregnancy)

When do you recommend IOL in patients with PPROM?

34 weeks (in pt with PPROM <34wks, you need to give latency antibiotics + betamethasone + magnesium sulfate and do expectant management and fetal surveillance, then induce delivery at 34wks --> in pt with PPROM between 34-37wks, only need to do betamethasone + latency antibiotics and immediate delivery --> role of tocolytics is controversial and contraindicated >36wks)

When is it recommended for a pregnant woman to stop air travel?

35 weeks

When do women receive rectovaginal culture for GBS during pregnancy?

35-37 weeks (if positive GBS culture, women should receive intrapartum penicillin G or ampicillin)

Cutoff value of beta-hCG to detect IUP on US

3500 (able to identify IUP on US once beta-hCG reaches 3500 mIU/mL --> if patient presents with b-hCG >3500 with no IUP on US, can diagnose with ectopic pregnancy)

At how many weeks gestation do you check for fetal presentation/rule out breech?

36 weeks (perform 36wk US to check if baby is in breech --> if breech, can offer external cephalic version >37wks)

At how many weeks gestation is a fetus checked for breech presentation?

36 weeks (usually indicates persistent breech and indication for external cephalic version/ECV if patient >37wks --> malpresentation <34wks is common and not significant, as most babies spontaneously convert to vertex as term approaches)

At how many weeks is it recommended to offer ECV for breech presentation?

37 weeks (can attempt ECV >37wks without anesthesia, but 5-10% risk of reverting to breech --> if unsuccessful, can reschedule under epidural anesthesia at 39wks and can have IOL immediately after --> if fails second time, pt will have C-section)

Best method to diagnose gestational diabetes

3hr glucose tolerance test (3hr GTT: make pt fast and then give 100g of glucose, then check blood sugar every hour for 3hrs --> if 2+ values are above cutoff, diagnosis of GDM)

What is the cutoff value for abnormal nuchal translucency test on 1st trimester US?

3mm

Which type of perineal laceration involves the anal sphincter, but NOT the rectal mucosa?

3rd degree (involves fourchette, perineal skin, vaginal mucosa, fascia, and perineal body, aka 2nd degree --> further involves anal sphincter but NOT rectal mucosa)

How much folic acid should be given to a mom whose previous child has a neural tube defect?

4 mg/day (should start 4wks prior to conception and through 1st trimester)

How much should a fetus weigh to consider C-section?

4500g (any fetus with EFW >4500g should be considered for cesarean delivery)

Recommended dose of folic acid for pregnant patients with hx of previous pregnancies complicated by fetal neural tube defects

4mg/day (should be taking PRIOR to conception and through 1st trimester)

What size of endometrial lining is an indication for endometrial biopsy in women >45yrs?

4mm (any woman with postmenopausal bleeding and endometrial stripe >4mm on US should receive endometrial biopsy/EMBx)

Which type of perineal laceration involves the rectal mucosa?

4th degree (involves fourchette, perineal skin, vaginal mucosa, fascia, perineal body, and anal sphincter, aka 3rd degree --> further involves rectal mucosa to expose lumen of rectum)

How many days postpartum is colostrum secreted from breast?

5 days (colostrum: yellow-colored liquid secreted by breasts around day 2 postpartum and secreted until 5 days postpartum --> contains minerals, protein, fat, secretory IgA, memory T cells, IL-6, complement, macrophages, lymphocytes, lyzozymes, lactoferrin, and lactoperoxidase --> contains MORE minerals/protein and LESS fat/carbs compared to breastmilk, and contains secretory IgA that protect infant against enteric organisms)

How many late-term pregnancies are associated with uteroplacental insufficiency?

5-10% (uteroplacental insufficiency associated with post-term pregnancy will have US findings such as IUGR, oligohydramnios, placental calcifications, and IUFD)

12yo girl presents with 1yr hx of progressive facial hair growth and acne Development: breasts are Tanner stage 1, axillary and pubic hair are Tanner stage 3 PE: dark hair over upper lip/cheeks/chin, acne vulgaris over cheeks, 2cm vaginal canal, significant clitoromegaly, posterior labioscrotal fusion, and no cervix/palpable uterus Abdominal US: bilateral gonads without follicles and no uterus

5-alpha reductase deficiency (autosomal recessive condition in which 46XY males have impaired conversion of testosterone to DHT --> presents with male internal genitalia and ambiguous external genitalia until PUBERTY, in which elevated testosterone results in virilization and growth of male external genitalia --> labs: normal testosterone and estrogen levels, normal LH --> diagnose via elevated testosterone:DHT ratio >20)

13yo F presents with painful acne over face/chest and amenorrhea PE: normal weight/height, nodulocystic acne on face/upper chest, no breast bud development, clitoris protruding from clitoral hood, and bilateral masses in labia majora

5-alpha-reductase deficiency (5AR deficiency: impaired 5-alpha-reductase enzyme, causing lack of conversion of testosterone to DHT and impaired virilization during embryogenesis in patient with 46XY genotype --> presents in phenotypically female patients with blind-ending vagina, bilateral labial masses indicating testes, and virilization at puberty such as clitoromegaly/increased muscle mass/male-pattern hair development/nodulocystic acne and lack of breast bud development --> diagnose via elevated testosterone:DHT ratio)

43yo G6P5 at 39wks presents with brief generalized tonic-clonic seizure, disorientation, lightheadedness, breathlessness, and cyanosis 20mins after NSVD Vitals: BP 90/40, HR 110, RR 30, SaO2 75% PE: generalized purpuric rash and bleeding from IV line site

Amniotic fluid embolism (AFE: rare complication during pregnancy/after delivery in which amniotic fluid enters maternal circulation thru endocervical veins/placental insertion sites/areas of uterine trauma --> leads to inflammatory response causing vasospasm, cardiogenic shock, hypoxemic respiratory failure, and coagulopathy with DIC --> risk factors: AMA, >5 live births, previous cesarean delivery, placenta previa/abruption, preeclampsia --> presents with sudden postpartum cardiogenic shock and respiratory failure, DIC, coma/seizures --> treat with intubation/mechanical ventilation and vasopressors, with possible blood transfusions)

Absolute contraindications to exercise during pregnancy

Amniotic fluid leak, cervical incompetence, multiple gestation, placenta previa, risk of preterm delivery, preeclampsia, and severe heart or lung disease

1st line treatment for asymptomatic bacteriuria in pregnancy

Amoxicillin-clavulanate, nitrofurantoin, cephalexin, and fosfomycin (amoxicillin is 1st line --> can then try nitrofurantoin --> also used to treat cystitis)

18yo F presents with lack of menarche and nodulocystic acne over chest/back PMH: ambiguous external genitalia at birth, and laparotomy revealed normal uterus and Fallopian tubes PE: no breast development, normal pubic/axillary hair, marked cliteromegaly Labs: normal XX karyotype, normal glucose and serum electrolytes, absent estradiol/estrone, and elevated serum FSH/LH/testosterone/ androstenedione Pelvic US: multiple ovarian cysts

Aromatase deficiency (rare enzyme deficiency that causes MATERNAL virilization in utero due to inability of placenta to convert androgens into estrogens --> presents at birth with ambiguous external genitalia but normal internal genitalia --> presents in adolescence with delayed puberty, osteoporosis, cliteromegaly, undetectable estrogen levels, and polycystic ovaries --> treat with estrogen supplementation)

How much blood loss must occur to be diagnosed as PPH during vaginal delivery?

500 cc (any EBL >500cc during vaginal delivery is diagnosed as PPH --> treat with uterine massage, oxytocin/methergine, uterine/internal iliac artery embolization, or total abdominal hysterectomy)

How long does breastfeeding prevent ovulation if mother nurses >2-3x/night and every 4hrs during the day?

6 months

At how many weeks gestation does breast enlargement/tenderness and areolar enlargement occur?

6 weeks

At what age do you normally stop Pap testing?

65 years (women >65 can STOP Pap testing if they have no hx of CIN2 or higher, and 3 consecutive negative Pap tests OR 2 consecutive negative co-testing results)

How many cm is a woman dilated by the end of the prolonged latent phase (1st stage)?

6cm (prolonged latent phase of 1st stage of labor: should last <20hrs for 1st time mom, and <14hrs for 2nd time mom)

Until how many weeks can you offer manual vacuum aspiration for termination of pregnancy?

8 weeks (manual vacuum aspiration/MVA can be performed on pregnancies <8wks --> more than 99% effective)

At how many weeks gestation should fetal heart tones be heard?

8-12 weeks (fetal heart starts beating at 22-24 days --> electronic Doppler should hear FHTs by 8wks --> if not heard by 11wks, need to order US evaluation to confirm viable IUP)

What is the target FASTING blood glucose level for a pt with GDM?

95 (aka want pt with GDM to have fasting BG <95mg/dL)

Risk of isoimmunzation without Rhogam

<20% (risk is 2% antepartum, 7% after full term delivery, and 7% with subsequent pregnancy)

What is the normal finding for fetal breathing movements on BPP?

>1 breathing episode for 30 seconds

What is the normal finding for fetal tone on BPP?

>1 episode of flexion/extension of fetal limbs or spine

Normal progesterone levels for healthy pregnancy

>25 (pregnancy with progesterone >25 suggests healthy pregnancy --> progesterone levels <5 indicate abnormal/extrauterine pregnancy or fetal death)

What is the normal finding for fetal movements on BPP?

>3 general body movements

2nd trimester fetal US: edematous scalp and nuchal fold, fetal ascites, macrocephaly, and shortened femur length

Achondroplasia (caused by SPORADIC mutation in FGFR3 that causes constitutive action of FGFR3 and inhibition of chondrocyte proliferation, also inherited autosomal DOMINANT --> results in failure of LONGITUDINAL bone growth, while membranous ossification is not affected --> presents with large head, short limbs, and possible hydrops fetalis --> associated with increased paternal age)

Contraindications to breastfeeding

Active TB, HIV, herpetic breast lesions, active varicella, breast cancer, drug abuse, chemotherapy or radiation, and infant galactosemia (in addition, some meds are contraindicated during breastfeeding: bromocriptine, cyclophosphamide, cyclosporine, doxorubicin, ergotamine, lithium, methotrexate, and COCPs --> radiotherapy drugs contraindicated during breastfeeding: gallium, indium, iodine, radioactive sodium, technetium)

Which stage of labor begins at 6cm dilation and ends at 10cm dilation?

Active phase (second part of Stage 1: further divided into acceleration phase, phase of max slope, and deceleration phase --> fetal descent begins at 7-8cm dilation and becomes most rapid after 8cm --> duration depends on 3 P's including power/strength and frequency of contractions, passenger/size of baby, and pelvis/size and shape of mother's pelvis --> should progress by >1cm every 2 hrs --> if <1cm in 2hrs, diagnose with protracted active labor and place IUPC to measure strength of contractions and oxytocin if <200 Montevideo units --> if NO cervical change in 2hrs, diagnose with arrest of active labor and administer oxytocin + amniotomy)

25yo with hx of C-section 6 days ago presents with nausea, vomiting, and sharp right-sided abdominal pain PE: fever of 101°F, tenderness over RLQ with guarding and rebound tenderness, decreased bowel sounds, and 14wk-size non-tender uterus Labs: Hgb of 9.6 and elevated WBC

Acute appendicitis (obstruction of appendiceal lumen from fecalith/cancer/lymphoid follicular hyperplasia --> causes increased appendiceal intraluminal pressure, occluding blood flow and causing ischemia --> presents with fever, RLQ pain with rebound/guarding, McBurney point tenderness, psoas sign aka pain with right hip extension, obturator sign aka pain with right hip internal rotation, and Rovsing sign aka RLQ pain with LLQ palpation --> diagnose via CT scan or US --> treat with surgical appendectomy)

Which routine prenatal lab tests are done at 24-28wks?

CBC, Rh antibody screen, and 50g GCT

Two conditions that DECREASE risk of endometrial cancer

COCPs and smoking (COCPs: contain progestin that stimulates endometrial shedding --> smoking: tobacco stimulates estrogen metabolism in liver to decrease serum estrogen levels)

Which hormones are secreted by the decidualized endometrium?

CRH, cortisol, and prolactin

Ultrasound criteria for missed abortion

CRL >7 mm with no cardiac activity (aka crown rump length >7mm with inability to hear fetal heart tones)

Gold standard method for diagnosis of pulmonary embolism

CT pulmonary angiography

Long-term sequelae of IUGR

CV disease, HTN, stroke, COPD, T2DM, and obesity (IUGR fetuses also at risk for cognitive delay in childhood)

What is the best next step in management for a postpartum patient <24hrs since delivery presenting with asymptomatic fever?

CXR (lungs are most common source of fever on first postpartum day, especially if pt had general anesthesia --> need to rule out atelectasis and aspiration pneumonia, and start broad-spectrum antibiotics)

Best next step in management in patient presenting with molar pregnancy

CXR (need to do a CXR in a patient with suspected molar pregnancy due to high risk of metastasis to lungs)

What is the best next step in management for a pregnant woman with suspected pneumonia?

CXR with abdominal shield

Which food items are associated with increased pain of fibrocystic breast mass?

Caffeine, tea, and chocolate (can INCREASE cyclic pain associated with fibrocystic changes of breast --> also recommend pts to wear support bra and avoid breast trauma)

Complications of cervical conization (cold knife or LEEP)

Cervical stenosis, cervical insufficiency, preterm birth, and PPROM (cervical stenosis: abnormal stricture of cervical canal that can impede menstrual flow and cause secondary dysmenorrhea/amenorrhea and infertility --> cervical insufficiency: results in 2nd trimester pregnancy losses --> preterm birth and PPROM: due to weakened cervical stroma)

19yo presents with 2wk hx of abnormal yellow vaginal discharge and post-coital vaginal bleeding PE: yellow cervical discharge, and friable cervix that bleeds easily on cotton tip manipulation

Cervicitis (inflammation of cervix most commonly caused by Chlamydia trachomatis and Neisseria gonorrhea --> presents with mucopurulent vaginal discharge, postcoital bleeding, and edematous friable cervix that bleeds with manipulation --> diagnose via NAAT --> treat with ceftriaxone + azithromycin)

Diagnosis of cervical insufficiency

Cervix less than 2.5cm

Treatment for arrest of active phase

Cesarean delivery (required because no further cervical dilation is expected despite oxytocin infusion --> delayed delivery increases maternal-fetal morbidity due to intraamniotic infection/PPH)

What is the best next step in management after recognition of Cat3 FHT and no improvement with maternal reposition and O2 delivery?

Cesarean delivery (since there is persistent uteroplacental insufficiency, fetus is at high risk for hypoxia --> patients <10cm dilated who do not improve with maternal repositioning and intrauterine resuscitative interventions REQUIRE immediate C-section)

What is the term used to describe bluish discoloration of vagina and cervix due to congestion of pelvic vasculature?

Chadwick sign

24yo F presents with 1wk hx of single large painful ulcer on vulva with grayish exudate PE: 2cm genital ulcer with well-demarcated borders/soft friable base/gray exudate, and tenderness to palpation of inguinal lymph nodes

Chancroid (caused by Haemophilus ducreyi infection, an STD more common in developing countries --> presents with single large 1-2cm painful genital ulcer with gray/yellow exudate and tender, suppurative inguinal lymphadenopathy --> diagnose with culture showing organisms clumping into long parallel strands, aka "school of fish" pattern)

Which 2 factors contribute to pregnant women's increased risk of gallstones, cholecystitis, and biliary obstruction?

Cholestasis and increased lipids/cholesterol

24yo G1P0 at 39wks presents with active labor, fever of 102°F, and FHR of 180bpm with minimal variability Labs: blood type O+, negative RPR/HBsAg/HIV, GBS unknown

Chorioamnionitis (ASCENDING maternal infection that gets into uterus while fetus is still inside mom --> presents with maternal fever, maternal and/or fetal tachycardia, fundal/uterine tenderness, and purulent amniotic fluid --> treat with IV ampicillin + gentamicin + clindamycin --> if woman is undergoing preterm labor and presents with chorioamnionitis + reassuring FHTs, can induce labor)

32yo with hx of vaginal delivery 4mo ago presents with absent menses and increased fatigue. Started on OCPs but no vaginal bleeding/spotting during week of placebo pills. PMH: vaginal delivery with postpartum hemorrhage requiring blood transfusion, emergency suction, and sharp curretage PE: clear vaginal discharge, well-rugated vagina, small anteverted uterus, bilateral small non-tender ovaries Labs: negative bHCG, normal FSH/LH, normal TSH

Asherman syndrome (formation of intrauterine adhesions that causes injury to basalis layer of endometrium, creating denuded adherent intrauterine surface prone to synechiae and endometrial cavity obliteration --> risk factors: infection such as septic abortion/endometritis, or intrauterine surgery such as D&C/myomectomy --> presents with very light menses/secondary amenorrhea that does not respond to progesterone challenge, infertility, and cyclic pelvic pain --> treat with hysteroscopy to lyse adhesions)

24yo presents with 2mo hx of amenorrhea and persistent pelvic pain PMH: Hx of D&C abortion Labs: normal FSH/LH/prolactin/TSH, progesterone withdrawal test does not induce vaginal bleeding

Asherman syndrome (structural cause of secondary amenorrhea due to intrauterine adhesions/synechiae or fibrosis of endometrium --> caused by damage to endometrial basalis layer that creates inflamed denuded endometrium, resulting in uterus adhering to itself and obliteration of uterine cavity --> associated with endometritis and intrauterine surgery such as D&C/myomectomy --> presents with amenorrhea, decreased fertility/recurrent pregnancy loss, abnormal uterine bleeding/AUB, chronic pelvic pain, and negative progesterone withdrawal test --> diagnose via hysteroscopy, and treat via lysis of adhesions)

16yo G2P1 at 41wks presents with full dilation and fetal station at 2+ during pelvic exam 20mins ago, with FHR at 150bpm with no decels When pt is placed on fetal monitor now, FHR is 60bpm and maternal HR is 100bpm. Without pushing, fetal scalp is visible at introitus in occiput anterior position. Best next step in management?

Assisted operative vaginal delivery (recommended when patient cannot deliver infant with 1-2 pushes)

Major contraindication for carboprost

Asthma (carboprost is a synthetic prostaglandin that stimulates uterine contraction --> causes severe bronchoconstriction, so contraindicated in asthmatics)

Fetal US reveals abdominal circumference and fetal weight <10th percentile, but normal fetal head circumference

Asymmetric IUGR (asymmetric fetal growth restriction: fetal adaptation to chronic placental insufficiency results in INCREASED abdominal growth restriction relative to head, aka "head-sparing" IUGR --> caused by maternal malnutrition or uteroplacental insufficiency, resulting in fetal hypoxia --> as a result, fetal redistribution of blood flow occurs to vital organs such as brain/heart/placenta at the expense of less vital organs, such as abdominal viscera --> associated with cocaine, smoking, gestational diabetes, gestational HTN, and pre-eclampsia)

When should patients with risk factors for gestational DM be initially screened?

At first prenatal visit (risk factors for GDM: family hx of T2DM, BMI >30, hx of GDM in prior pregnancy, known impaired glucose metabolism)

How large does the embryo have to be to detect fetal cardiac motion?

At least 5mm

23yo G1P1 18hrs after uncomplicated C/S presents with fever of 100.4°F Vitals: BP 112/74, HR 94, RR 18 PE: decreased breath sounds heard bilaterally, non-tender fundus, incision site c/d/i, and lower extremities show 2+ pitting edema to midcalves bilaterally with no cyanosis/clubbing

Atelectasis (postpartum partial lung collapse, usually associated with general anesthesia causing an increase in intrapulmonary shunt --> common cause of postpartum fever 1-2 days postop --> presents with postpartum fever, decreased lung sounds, and hypoxemia on POD#2 --> diagnose via CXR --> treat with CPAP and chest physiotherapy/suctioning)

Which tocolytic agent is an oxytocin receptor antagonist that blocks intracytoplasmic Ca2+ release, and downregulates PG synthesis?

Atosiban (oxytocin receptor antagonist: not really used in the USA, but commonly used in Europe --> not many side effects, but shown to have little efficacy in slowing down labor)

36yo G1P0 at 36wks with hx of hypothyroidism currently undergoing labor due to preeclampsia with severe features, SROM 4hrs ago Meds: Mg sulfate, oxytocin, and epidural anesthesia PE: fever of 103°F, BP 150/90, HR 114 FHT: 170bpm

Chorioamnionitis (intraamniotic infection/triple I: caused by polymicrobial vaginal bacteria ascending into uterus during labor --> risk factors: prolonged ROM >18HRS, preterm/premature ROM, internal fetal/uterine monitoring devices, repetitive vaginal exams, and presence of genital tract pathogens--> presents with maternal fever >39°C, leukocytosis >15k, and purulent amniotic fluid --> diagnose with gram stain and culture of amniotic fluid --> treat with acetaminophen, ampicillin + gentamicin + clindamycin, and immediate delivery to prevent fetal sepsis/cerebral palsy)

What is the order of management of unresponsive uterine atony during exploratory laparotomy of atonic patient?

B-Lynch suture, uterine artery ligation, internal iliac artery ligation, and hysterectomy (B-Lynch suture: uterine compression suture should be 1st line --> uterine and internal iliac artery ligations: should be performed if B-Lynch suture fails --> hysterectomy: last resort option for PPH)

23yo G1P0 at 38wks presents with 1-day hx of lower abdominal pain and mild nausea. Normal fetal kicks. PE: afebrile, normal BP/HR/RR, fundal height 36cm, cervix is firm/long/ closed/posterior Tocometer: irregular contractions every 2-8mins Urine dipstick: 1+ glucose with negative ketones

Braxton-Hicks contractions (short, irregular, less intense contractions associated with discomfort in lower abdomen/groin areas --> associated with ABSENT cervical dilation/effacement)

Which imaging method should be used to evaluate the breast in patients that are BRCA carriers/first degree relative of BRCA carrier, genetic mutations, women with 20-25% lifetime risk of breast cancer, and women with hx of chest wall radiation?

Breast MRI (should be recommended IN ADDITION to mammography to women in high-risk groups)

Which imaging method should be used on a woman <30yrs with a breast mass?

Breast US (used to assess breast masses in women <30YRS OLD --> also used to assess whether >0.5cm mass is solid or cystic in any woman)

Safest method to suppress lactation

Breast binding, ice packs, and analgesics (avoidance of breast stimulation/other means of milk expression causes natural inhibition of prolactin secretion --> results in breast involution and suppression of lactation)

What is the best next step in management for a woman with a breast mass that drained clear fluid on FNA?

Breast exam in 2 months (breast mass with clear bloody fluid does NOT indicate breast cancer --> want to check in 2mo to make sure cyst did not recur)

Most common cause of endometritis

C-section

What is the best next step in management after diagnosis of umbilical cord prolapse?

C-section (after palpating umbilical cord in pt's vagina, you should elevate fetal head with hand in pt's vagina and call for assistance to perform cesarean delivery --> need to elevate fetal head to avoid compression of umbilical cord)

29yo with hx of NSVD 3mo ago presents with bilateral dull persistent chest pain, dyspnea, and frequent episodes of dark bloody vaginal discharge PE: bilaterally clear lungs, enlarged uterus with closed cervix and minimal dark blood in vagina CXR: multiple bilateral infiltrates of various shapes

Choriocarcinoma (gestational trophoblastic neoplasia arising from placental trophoblastic tissue that can occur after hydatitiform mole, normal gestation, or SAB --> presents <6mo after pregnancy with irregular vaginal bleeding, enlarged uterus, pelvic pain --> if pulmonary metastasis, presents with chest pain, hemoptysis, and dysnea --> diagnose via quantitative beta-hCG --> stage with CXR to show bilateral infiltrates --> treat with chemotherapy and methotrexate)

Causes of symmetric IUGR

Chromosomal abnormality and congenital infection (symmetric IUGR: occurs during 1ST TRIMESTER --> causes GLOBAL growth lag in which biparietal + abdominal circumference are BOTH <10th percentile --> manage with weekly BPP, serial umbilical artery Doppler, and serial growth US)

Which antibiotics are tested for sensitivity in pregnant women that are GBS positive and severely allergic to penicillin?

Clindamycin and erythromycin (clindamycin is 2nd line to patients with penicillin allergy --> if GBS is not sensitive to either clindamycin or erythromycin, can give vancomycin as 3rd line)

What is a contraindication to membrane stripping and AROM?

Closed cervix (need to FIRST ripen the cervix by using misoprostol/PGE1/cytotec or dinoprostone/PGE2/cervidil to get the cervix to dilate)

Which mammography finding is found in 90% of patients diagnosed with ductal carcinoma in situ (DCIS)?

Clustered microcalcifications

Treatment for severe vaginal prolapse + hydronephrosis

Colpocleisis (procedure in which vagina is surgically obliterated --> can be performed quickly w/o general anesthesia)

Best next step in management for abnormal Pap test result

Colposcopy (also recommended for women with HSIL cytology test results)

Best next step in management for patient with abnormal Pap test result of HSIL (high-grade squamous intraepithelial lesion)

Colposcopy (you can skip reflex HPV testing, since diagnostic excisional procedure recommended for women with HSIL regardless of HPV result)

Workup for women age >35yrs with abnormal Pap test showing atypical glandular cells

Colposcopy, endocervical curettage, and endometrial biopsy (abnormal Pap test showing atypical glandular cells can indicate endometrial hyperplasia/carcinoma or cervical adenocarcinoma)

Which blood gas abnormality is common in pregnant women?

Compensated respiratory alkalosis (occurs due to increased minute ventilation in pregnant women, which comes from increased tidal volume/TV --> causes "subjective SOB" during pregnancy --> causes more CO2 to be blown off, resulting in low CO2 --> metabolic compensation results in low HCO3)

22yo F presents with 4hr hx of severe lower abdominal cramping and heavy vaginal bleeding with passage of large clots PMH: LMP 7wks ago SH: hx of intermittent cocaine abuse and smokes 1 pack of cigs/day PE: mild tenderness over bilateral lower quadrants, closed cervix, small amount of blood pooled in vaginal vault Labs: positive urine b-hCG TVUS: normal uterus with empty endometrial cavity

Complete abortion (type of SAB in which products of conceptions are expelled --> presents with lower abdominal pain and heavy vaginal bleeding with passage of clots, expulsion of solid or sack-like bloody white mass with lessening of symptoms after, vaginal bleeding with closed cervical os, and pelvic US showing empty uterus and normal adnexa --> takes up to 6wks for b-hCG levels to become undetectable)

Which breech type is associated with both fetal knees and hips flexed?

Complete breech

34yo F presents with 3mo hx of worsening vulvar lesions PE: multiple non-tender fleshy verrucous growths clustered at vestibule of vulva and over labia majora, with few lesions friable and bleed on manipulation

Condyloma acuminata (genital warts: caused by infection with low-risk HPV6 and HPV11 --> risk factors: chronic tobacco use or immunosuppression --> present as clusters of soft, pink or skin-colored, exophytic, dry-appearing, verrucous/cauliflower-like lesions in internal or external vaginal/vulvar/anal regions --> can be asymptomatic and non-tender or pruritic/friable and bloody --> treat CHEMICALLY with topical trichloroacetic acid or podophyllin resin --> treat IMMUNOLOGICALLY with imiquimod and podofilox --> treat SURGICALLY with cryotherapy, laser therapy, and excision)

Fetal US: SGA, bilateral periventricular calcifications in brain, and enlarged liver with multiple intrahepatic calcifications

Congenital CMV (congenital cytomegalovirus infection acquired via maternal CMV infection from close contact with young children --> presents in MOTHERS with fever and pharyngitis, or asymptomatic --> presents on fetal US with periventricular calcifications, ventriculomegaly, microcephaly, intrahepatic calcifications, IUGR, and hydrops fetalis --> presents in NEONATES with petechiae, hepatosplenomegaly, chorioretinitis, and microcephaly --> diagnose via maternal serology and amniocentesis --> long-term sequelae: sensorineural hearing loss, seizures, and developmental delay)

Treatment for molar pregnancy

D&C, serial b-hCG, and contraception for 6 months

What is normal fibrinogen levels at delivery indicate?

DIC (fibrinogen should be ELEVATED in pregnancy, so low or "normal" levels is actually a sign of DIC)

What is the effect of increased GFR in pregnancy on lab values?

Decreased creatinine (pregnant women should have Cr around 0.4-0.8 --> anything above 0.8 should be considered pathologic)

Effect of progesterone on gallbladder

Decreases gallbladder motility and emptying

What is the indication for internal podalic version?

Delivery of breech 2nd twin (facilitates vaginal delivery of breech 2nd twin by placing hand inside uterus, grasping fetal foot, and delivering baby feet first)

Which contraceptive methods have <1% pregnancy rates?

Depo Provera, sterilization, and LARC

Which systemic diseases are most commonly associated with early pregnancy loss?

Diabetes, chronic renal disease, and lupus (all 3 increase risk of 1st trimester pregnancy loss)

Which test is used to confirm clinical suspicion of endometriosis or pelvic adhesions?

Diagnostic laparoscopy (both conditions not reliably diagnosable via radiologic imaging)

Which contraceptive method is the least effective?

Diaphragm with spermicide (has the highest pregnancy rate of 18% with typical use)

Pelvic US: 2 intrauterine gestations with thick intertwin membrane and lambda sign

Dichorionic diamniotic twins (twins with 2 placentas and 2 amniotic sacs due to cleavage at 0-4 days, aka division of embryos BEFORE differentiation of trophoblast --> 2nd most common twin gestation occurring 25% of the time --> can develop obscured intertwin membrane that causes separate placentas to have fused appearance on US, but identified by thick intertwin membrane and placental projection where intertwin membrane meets placenta aka LAMBDA SIGN)

Treatment of lactational mastitis

Dicloxacillin (narrow-spectrum penicillin that covers MSSA and group A strep --> if woman is at risk for MRSA such as recent antibiotic therapy/incarceration, treat with clindamycin, TMP-SMX, or vancomycin)

What are the 5 components of the cervical exam to evaluate labor?

Dilation, effacement, station, consistency, and position

Which uterotonic agent is given via vaginal/rectal suppository?

Dinoprost (Cervidil: PGE2 agonist used for cervical ripening/IOL and inserted into vagina until active labor/12 hrs, until which oxytocin can be started --> contraindicated in HYPOTENSIVE patients, and must be thawed to room temp prior to use)

US markers of dizygotic twins

Dividing membrane thickness >2mm, lamda sign (twin peak sign), different fetal genders, and separate placentas

36yo G1P0 with 2nd trimester triple screen presents with b-hCG: elevated Estriol: decreased AFP: decreased

Down syndrome (trisomy 21: can be detected via 2nd trimester triple screen with elevated b-HCG + decreased estriol/AFP --> has 68% detection rate)

Conditions associated with low MSAFP during 16-18wk triple screen

Down syndrome and Edward syndrome (trisomy 21 and trisomy 18)

Treatment of breast abscesses

Drainage and vancomycin (covers MRSA, which can cause breast abscesses)

Which condition is associated with green, sticky discharge from the breast?

Duct ectasia (subacute inflammation of ductal system that causes dilated mammary ducts, with infiltration of plasma cells and significant periductal inflammation --> occurs in PERIMENOPAUSAL or postmenopausal SMOKERS --> presents with bilateral sticky green nipple discharge, nipple retraction/inversion, and non-cyclic breast pain --> diagnose via mammogram and excisional biopsy --> treat with local excision of inflamed area)

What is the best next step in management for a woman >45yrs with benign endometrial cells on Pap smear?

Endometrial biopsy (benign endometrial cells on Pap smear for women >45yrs indicates abnormal endometrial shedding --> concerning for endometrial hyperplasia/cancer, even if pt is asymptomatic --> higher risk pts: obesity, prior chronic anovulation)

Pelvic US: small homogenous cystic masses with diffuse "ground glass" appearance on bilateral ovaries

Endometrioma (encapsulated collections of old blood from ectopic endometrial implants on ovaries --> seen in patients with endometriosis)

Which hormones decrease immediately after delivery, allowing breast milk to come in?

Estrogen and progesterone (drop in progesterone removes inhibition of progesterone on prolactin, thus allowing production of alpha-lactalbumin --> increased alpha-lactalbumin serves to stimulate lactose synthase, thus increasing milk lactose)

Which type of contraception can diminish lactation and cause issues with breastfeeding?

Estrogen-progesterone OCPs (not recommended for women in first 30 days postpartum)

How often should a woman >45yrs receive a colonoscopy?

Every 10 years

How often should the beta-hCG level double in the first 10wks of gestation?

Every 48 hours

How often should a woman >45yrs receive flexible sigmoidoscopy?

Every 5 years

How often should women age 30-65 receive combined Pap test + HPV testing?

Every 5 years (women age 30-65 can also get cytology alone every 3yrs)

How often should a woman >45yrs receive hemoccult testing?

Every year

What is the next best step in management for a woman with a breast mass with non-diagnostic FNA, that persisted after drainage?

Excisional biopsy (required if FNA does not obtain fluid/tissue, or if cytology/histology is non-diagnostic --> used to rule out breast cancer)

What is the best next step in management for a woman with a breast mass that drained bloody fluid on FNA?

Excisional biopsy (required to rule out breast cancer --> indicated if bloody fluid found on FNA, mass persists after fluid is removed, cyst persistent after 2 aspirations, or fluid re-accumulates within 2wks)

Best test to diagnose immaturity of HPG axis

Exogenous progesterone (if patient with immature hypothalamic-pituitary-gonadal axis takes progesterone, it should cause withdrawal bleeding --> used to confirm NORMAL endogenous estrogen production and proliferative endometrium)

Management of PPROM <34wks

Expectant management, latency antibiotics, betamethasone, and fetal surveillance (latency antibiotics: ampicillin and azithromycin to prevent chorioamnionitis and prolong latency period by 5-7 days --> betamethasone: to increase fetal lung maturity --> fetal surveillance: want to rule out oligohydramnios from amniotic fluid loss --> NOTE: if pt <34wks presents with PPROM and signs of infection or fetal compromise should be delivered immediately with IAI treatment and penicillin)

Definition of precipitous labor

Expulsion of fetus <3hrs from start of contractions

Which artery is at risk of injury during embolization of internal iliac artery?

External iliac artery (very close to internal iliac and can be confused --> damage to external iliacs causes death of gluteal muscles/legs)

Which pulmonary function test remains unchanged in a pregnant woman?

FEV1

What is the next best step in management for a woman with a breast mass, and mammogram showed no abnormalities?

FNA (fine needle aspiration: involves making multiple passes thru mass from diff angles while aspirating syringe on a 20-22 gauge needle --> required for any solid dominant breast mass to evaluate mass cytologically --> if FNA does not obtain fluid/tissue, need to do excisional biopsy)

Which pulmonary function tests are DECREASED in a pregnant woman?

FRC, ERC, and RV (occurs because functional residual capacity/FRC reduced by 80% in 3rd trimester due to fetus preventing diaphragm from moving up/down --> also results in decreased expiratory reserve capacity/ERC and residual volume/RV)

Risks to fetus during forceps delivery

Facial lacerations, facial nerve palsy, corneal abrasion, skull fracture, and intracranial hemorrhage

Which inherited coagulopathy is most commonly associated with stillbirth, preeclampsia, placental abruption, and IUGR?

Factor V Leiden (FVL: point mutation that alters factor 5, making it resistant to inactivation by protein C --> therefore you get INCREASED clotting and at higher risk of VTE --> affects 5% of Caucasian women in USA --> causes obstetrical complications such as stillbirth, preeclampsia, placental abruption, and IUGR)

Most common heritable coagulopathy in pregnancy

Factor V Leiden mutation (production of mutant factor V that is resistant to degradation by activated protein C, usually from guanine-to-adenine point mutation --> present in 5-8% of general population with heterozygous inheritance --> usually diagnosed when asymptomatic woman starts COCPs --> 4-8X increased risk of first VTE in pregnancy --> other complications: cerebral vein thrombosis and recurrent pregnancy loss)

25yo presents with lump in left breast without pain or nipple discharge SH: rear-ended 1wk ago PE: firm irregularly shaped mass in left breast

Fat necrosis of breast (local breast trauma/surgery causes necrosis of adipose tissue within breast --> presents as painless, firm, irregularly shaped breast without nipple discharge --> imaging with mammography shows calcified oil cyst, may be mistaken for DCIS --> biopsy shows necrotic fat and giant cells)

Major complication of McRoberts maneuver for shoulder dystocia

Femoral nerve damage (presents with numbness over ANTERIOR/MEDIAL thigh, inability to extend leg, inability to flex hip, and DECREASED PATELLAR reflexes)

Most appropriate method used for postmortem fetal dating

Femur length (long bones do not undergo soft tissue changes after death --> more reliable than head or abdominal measurements)

32yo G5P4 at 21wks presents with 4hr-hx of bright red vaginal bleeding. Denies contractions and LOF. She has not had any prenatal care. PE: bright red blood in posterior fornix of vagina, no bleeding from cervix FHT: 140bpm What is the best next step in management?

Fetal US (when you are concerned for placenta/vasa previa, you should FIRST to fetal US before digital exam as digital exam can increase bleeding and cause fetal distress)

What should you be concerned for if a FHT shows absent variability?

Fetal acidosis

What would be the most common finding on a FHT in a fetus with congenital fetal heart block?

Fetal bradycardia (FHR <110bpm: congenital fetal heart block usually a complication of maternal SLE or Sjogren syndrome due to anti-Ro/SSA antibodies crossing placenta)

22yo G1P1 woman with no prenatal care delivers 3100g female infant Neonatal PE: spontaneous cry on delivery, skin appears to be peeling and has green/yellow hue, long fingernails, and thin fragile appearance

Fetal dysmaturity (occurs in 10% of infants >43wks due to chronic intrauterine malnutrition --> presents in women with unknown LMP/unsure dating who deliver infants with long thin body, long nails, meconium-stained skin/nails, dry peeling skin, and small placenta --> fetal complications: oligohydramnios, cord compression, meconium passage, stillbirth)

PE of newborn: infant appears thin with loose skin and large anterior fontanel, placenta is meconium stained, umbilical cord is thin

Fetal growth restriction (FGR: weight <10th percentile for gestational age, usually detected on US --> presents at DELIVERY with thin loose peeling skin, thin umbilical cord, large anterior fontanel, minimal subcutaneous fat, and meconium-stained amniotic fluid --> diagnose via histopathologic exam of placenta and neonatal urine toxicology screen/serology to look for TORCH infection --> neonatal complications: polycythemia, hypoglycemia, hypocalcemia, and poor thermoregulation)

Diagnosis of arrest of fetal descent

Fetal head descends <1-2 cm/hr (arrest of fetal descent/arrest of 2nd stage of labor: occurs when there is no fetal descent after pushing for >3hrs in nulliparous, >2hrs in multiparous women --> risk factors: maternal obesity, excessive pregnancy weight gain, diabetes mellitus --> most common cause is fetal malposition, aka deviation from OA position, but other causes include CPD, inadequate contractions, and maternal exhaustion --> treat with operative vaginal delivery or C-section)

Causes of fetal tachycardia (>160bpm)

Fetal hypoxia, intrauterine infection, maternal fever, fetal hyperthyroidism, and terbutaline (most common cause: maternal fever from intraamniotic infection/chorioamnionitis --> temp elevation and increased metabolic demand create elevated fetal HR)

Which term is used to describe the orientation of the baby in the uterus?

Fetal lie (determined by Leopold maneuver or US --> only correct lie is longitudinal cephalic, aka baby is parallel to mom's axial skeleton and baby's head is facing DOWN --> any position other than longitudinal cephalic is called "breech")

Which term describes the relation of the long axis of fetus to that of mother?

Fetal lie (you want LONGITUDINAL LIE seen in 99% of term or near-term births, which can be vertex or breech --> can also have transverse or oblique lie)

Risk factors for shoulder dystocia

Fetal macrosomia, maternal obesity, excess pregnancy weight gain, GDM, and post-term pregnancy

Most common cause of arrest of fetal descent (arrest of 2nd stage of labor)

Fetal malposition (aka relationship of fetal presenting part to maternal pelvis --> any deviation from OCCIPUT ANTERIOR position can cause cephalopelvic disproportion and 2nd stage arrest)

Causes of decreased BTBV

Fetal or maternal acidemia, asphyxia, drugs, or neurologic abnormality

Which components are assessed by the prenatal US performed when a pt presents to L&D for possible delivery?

Fetal presentation, EFW, placental location, and MVP/AFI (fetal presentation: want to make sure its cephalic and rule out breech --> EFW: want to be between 10th-90th percentile --> placental location: want to rule out placenta previa --> MVP/AFI: determines max vertical pocket >2cm or amniotic fluid index >5cm)

16yo G1P0 at 39wks presents with gush of blood-tinged fluid 5hrs ago and onset of uterine contractions that have become stronger and closer together over past hour, recorded every 2-3mins FHR: 140bpm with accelerations and no decels PE: cervix is 4cm dilated and 100% effaced, fetal station is 0 You are unable to obtain FHR because pt cannot lie still. Best next step in management?

Fetal scalp electrode

What is the best way to measure fetal heart rate if the pt cannot tolerate external FHR monitoring?

Fetal scalp electrode (note: requires ROM for use)

What is the best next step in management in evaluating a fetus with no accelerations on FHR monitoring?

Fetal scalp stimulation (used to evaluate fetal acidosis)

Best next step in management for a patient in labor with ROM, and FHT shows minimal variability with no accelerations?

Fetal scalp stimulation (want to see 2+ accelerations 15bpm x 15s to indicate fetal pH >7.20--> when there is lack of acceleration, need to workup with fetal scalp pH or allis clamp pinching of fetal scalp)

Which term is used to describe how far out baby is/how close baby is to coming out?

Fetal station

Best method to evaluate thrombosis in pregnant woman

Fibrinogen (fibrinogen should be ELEVATED during pregnancy due to hypercoagulable state --> therefore, NORMAL or LOW FIBRINOGEN should indicate possible VTE)

33yo presenting with lump in right breast that becomes tender before menses. Denies nipple discharge. PE: well-demarcated, round, firm, mobile mass in right breast

Fibroadenoma (benign palpable breast mass most common in women <35yrs --> presents with small, well-defined, round, firm, mobile mass that increases in size/tenderness with high estrogen such as pregnancy/prior to menses --> no increased risk of breast cancer)

What is the most common breast pathology seen in women under 25?

Fibroadenoma (benign tumor of the breast with bond glandular and stromal components --> usually UNILATERAL and SOLITARY, but occur bilaterally in 25% of cases --> present as round, well-circumscribed, mobile, firm lesions that are rubbery and non-tender that changes in size during menstrual cycle/pregnancy/OCPs --> can be followed clinically if STABLE, but require FNA if suspicious of malignancy --> if >5cm, requires excisional biopsy)

Which tests are indicated during the 16-18wk prenatal visit?

First sonogram, amniocentesis, and triple screen (NOTE: amniocentesis and triple screen only done on high-risk mothers, such as AMA/maternal age >35yrs)

23yo G1P0 at 34wks with hx of pre-eclampsia with severe features presents with severe headache, nausea, muscle weakness and hypoventilation Meds: magnesium sulfate PE: low RR and DTRs 1+

Magnesium toxicity (caused by too high dose of magnesium sulfate, given to pts with pre-eclampsia for seizure prophylaxis, seen in patients with renal insufficiency/elevated serum Cr --> toxic doses can cause decreased ACh release from skeletal muscle, prolonged conduction time in cardiac muscle, respiratory compromise, and CNS symptoms --> presents with blurry vision/scotoma, muscle weakness with low DTRs, sleepiness, hypocalcemia, pulmonary edema, and cardiac arrest --> treat with cessation of Mg therapy and IV calcium gluconate)

22yo F presents with 5-day hx of lower abdominal pain that has progressed to worsening RUQ pain, fever, chills, and vomiting Menstrual hx: increasingly irregular period over last 3mo with occasional spotting Vitals: fever of 102°F, BP 100/70, HR 104, BMI 21 PE: RUQ tenderness and diffuse lower abdominal tenderness without guarding Labs: neg urine pregnancy test

Fitz-Hugh-Curtis disease (perihepatitis: liver capsule inflammation and "violin string" adhesions of peritoneum to liver resulting from chronic PID that extends from upper genital tract and spreads thru abdomen --> presents with fever >100.9°F, lower abdominal pain, intermenstrual spotting due to cervicitis, pleuritic RUQ pain that increases during inspiration, and N/V --> labs: slightly elevated AST/ALT --> treat with hospitalization and IV cefotetan + doxycycline, or IV clindamycin + gentamicin)

27yo G2P1 at 30wks presents with 2mo hx of chronic fatigue and 10lb weight loss SH: No prenatal care. Hx of alcoholism and drug abuse PE: appears chronically ill, skin pallor, fundal height 28cm FHT: 140bpm Labs: Hgb 6.0, MCV 101

Folic acid deficiency (lack of folate/vitamin B9 often seen in PREGNANCY and ALCOHOLISM --> also associated with medications such as phenytoin, valproic acid, sulfonamides, methotrexate --> presents with anemia, glossitis, and NO NEURO SYMPTOMS --> labs: macrocytic megaloblastic anemia, elevated homocysteine --> complications: risk of NTDs for fetus)

Pelvic US: unilateral, unilocular thin-walled cystic mass on ovary

Follicular cyst (simple ovarian cyst: caused by failed follicular rupture during ovulation --> presents with unilateral abdominal or pelvic pain and polymenorrhea/oligomenorrhea --> diagnose via US showing simple thin-walled cyst, aka granulosa cell-lined cyst with clear to yellow estrogen-rich fluid --> treat with OCPs)

Which breech type is associated with fetal hips extended?

Footling breech

Complications of shoulder dystocia

Fractured clavicle, fractured humerus, Erb-Duchenne palsy, Klumpke palsy, and perinatal asphyxia

Which types of breech can possibly delivered vaginally in select patients?

Frank and complete breech (frank breech: flexed hips and extended knees, thus feet are near fetal head --> complete breech: flexed hips AND flexed knees, with at least one foot near breech --> other favorable conditions include favorable pelvis, flexed head, and EFW between 2000-3800g --> NOTE: rare in the USA due to increased risk of neonatal morbidity/mortality due to cord prolapse, entrapment of fetal head, and fetal neurologic injury)

Which breech type is associated with fetal knees extended and hips flexed?

Frank breech

Most common type of breech presentation

Frank breech (occurs in 65% of cases: feet are in front of head or face --> thighs are flexed/bent forward and knees are extended/straight over anterior surfaces of body)

Which thyroid function test does not change during pregnancy?

Free thyroxine (during pregnancy, total T3/T4 increase and TBG increase due to estrogen effects, but free T3/T4 remains normal --> therefore mother remains EUTHYROID)

Contents of cryoprecipitate

Fresh frozen plasma plus fibrinogen, vWF, factors 8 and 13, and fibronectin

What is the one requirement for forceps-assisted vaginal delivery?

Full dilation of cervix

CC: Amenorrhea FSH: ↓ LH: ↓ Prolactin: normal TSH: normal

Functional hypothalamic amenorrhea (exercise-induced amenorrhea: severe caloric restriction/energy expenditure/stress causes increased cortisol and decreased fat mass, resulting in decreased leptin --> functional disruption of pulsatile GnRH secretion from hypothalamus --> results in low LH/FSH, which also causes low estrogen --> usually presents as "female athlete triad" aka excessive exercise + low bone mineral density + amenorrhea --> also associated with eating disorders)

Which routine prenatal lab tests are done at 35-37wks?

GBS culture

Potential complications of chronic Hep C in pregnancy

GDM, cholestasis of pregnancy, and preterm delivery (note: patients with chronic Hep C can still have vaginal delivery and can still breastfeed)

23yo G1P1 with hx of NSVD 3mo ago presents with right breast mass and yellow-tinged nipple discharge. She is currently breastfeeding. PE: soft, mobile, non-tender palpable mass in right breast

Galactocele (breast retention cyst containing milk/milky substance caused by obstructed lactiferous duct --> presents in BREASTFEEDING women with unilateral soft mobile non-tender mass and yellow-tinged nipple discharge --> usually resolves after breastfeeding --> can also treat with aspiration or excision of cyst)

What is the biggest risk of using NSAIDs during 1st trimester of pregnancy?

Gastroschisis (mostly associated with ASPIRIN use during 1st trimester)

24yo F presents with 2-day hx of vulvar pain and dysuria, as well as intermittent fever and malaise for the last week SH: sexually active with 3 new male partners over last 6mo PE: grouped shallow ulcers with surrounding erythema on left labia minora, and tender left inguinal lymph nodes UA: 5-10 leukocytes/hpf and 1-2 erythrocytes/hpf, negative culture

Genital herpes (caused by HSV that causes primary/recurrent infection --> presents with painful vesicles/ulcers on erythematous base that evolve into group of shallow ulcers with crust, painful urination, mild lymphadenopathy, and sterile pyuria --> treat with acyclovir to decrease symptom severity/duration)

24yo G0 woman presents with weeping/crusted painful vulvar ulcers, fever, and difficulty voiding due to pain SH: vaginal ring for contraception, multiple sexual partners with condom use PE: fever of 100.2°F, presence of multiple ulcers and erosions on perineum/labia minora/vestibule that are eroded and some with purulent eschar, diffuse swelling, exquisite tenderness to touch

Genital herpes (usually caused by HSV-2, transmitted perinatally and thru sexual contact --> causes primary herpes that presents with painful genital ulcerations, fever, and dysuria --> diagnose herpes culture AS EARLY AS POSSIBLE --> ALSO include STI testing for gonorrhea/chlamydia, syphilis, HIV and provide HBV vaccination --> can remain latent in sacral ganglia and become exacerbated during times of stress/infection)

24yo woman presents with dyspareunia and inability to use tampons due to pain SH: no previous sexual partners PE: no lesions and no pain during exam of external genitalia, unable to perform internal pelvic exam due to pain

Genito-pelvic pain disorder (penetration disorder/vaginismus: pain on and an aversion to attempted vaginal penetration --> can be idiopathic or caused by previous sexual trauma/hx of abuse --> presents with pain on vaginal penetration with inability to tolerate speculum insertion, distress/anxiety over symptoms, and no other medical causes --> treat with desensitization therapy and Kegel exercises to relax vaginal muscles)

Which type of uterine prolapse is associated with presence of cervix in vaginal canal?

Grade 1 (type of uterine prolapse in which uterus is in vaginal canal but NOT YET at vaginal opening)

Which type of uterine prolapse is associated with presence of cervix at vaginal opening?

Grade 2 (type of uterine prolapse in which uterus is at vaginal canal, but not yet out of vagina)

Which type of uterine prolapse is associated with a non-inverted uterus out of vagina?

Grade 3 (type of uterine prolapse in which uterus is outside of vagina, but not yet inverted)

Which type of uterine prolapse is associated with INVERTED uterus that is out of vagina?

Grade 4 (type of uterine prolapse in which uterus is INVERTED and outside of vagina --> worst type)

Method of diagnosis for suspected appendicitis in pregnancy

Graded compression US (sensitive and specific for appendicitis <35wks gestation)

24yo F who recently emigrated from New Guinea presents with multiple genital lesions that do not cause pain PE: multiple red ulcers that bleed readily on contact

Granuloma inguinale (Donovanosis: caused by Klebsiella granulomatis infection that is endemic to tropical/subtropical countries such as India, Guyana, New Guinea --> presents with painless "beefy red" ulcers that bleed readily on contact, and NO associated lymphadenopathy --> diagnose with culture showing deeply staining gram-negative intracytoplasic cysts, aka Donovan bodies)

What is the best next step in management of a woman diagnosed with protracted active labor?

IUPC placement (if pt is having contractions, need to measure strength of contractions to determine if they are adequate --> if IUPC reports inadequate contractions with <240 Montevideo units, then add oxytocin to augment labor)

Treatment of hypochloremic alkalosis in pregnant woman with hyperemesis gravidarum

IV 5% dextrose and anti-emetics (dextrose helps to decrease ketosis to disrupt cycle of nausea)

Antibiotic given as prophylaxis for C-sections

IV cefazolin (used to prevent surgical site infections)

Inpatient treatment of pelvic inflammatory disease (PID)

IV cefotetan and PO doxycycline (inpatient tx for PID recommended for pts with persistent N/V, dehydration, severe presentation, and adolescents --> can also give IV cefoxitin + PO doxycycline --> or can give IV clindamycin and gentamicin)

Treatment of pyelonephritis during pregnancy

IV ceftriaxone (3rd gen cephalosporin that covers the E. coli --> may also add IV gentamicin)

Empiric therapy for bacterial pneumonia during pregnancy

IV erythromycin (note: severe disease may require amoxicillin-clavulanate or ceftriaxone --> vancomycin added for community-acquired MRSA)

1st step in management for hypovolemic shock of a pregnant women

IV fluid resuscitation and repositioning to left lateral decubitus position (IV fluid resuscitation: with CRYSTALLOIDS, if unresponsive to fluids, then repeat CBC and if Hgb <7, perform emergency blood transfusion and add vasopressors --> repositioning to left lateral decubitus position: displaces uterus off aortocaval vessels and maximizes CO)

After receiving an epidural, a 40wks pregnant woman in labor presents immediately with tinnitus and metallic taste in her mounth Vitals: BP 140/100, HR 110

IV injection of anesthetic (misplacement of epidural catheter results in systemic toxicity from epidural test dose, usually lidocaine+epinephrine --> presents with immediate tinnitus, metallic taste, restlessness, convulsions, and systemic vasoconstriction --> treat by changing position of catheter into epidural space)

Treatment for baby born to Hep B (+) mom

IVIG and Hep B vaccine (give to baby on day of delivery)

Most common cause of preterm labor

Idiopathic (usually no cause can be identified for preterm labor --> dehydration and uterine distortion also associated with preterm labor)

20yo F presents with 3yr hx of mild-to-moderate hair growth over face, breasts, and lower abdomen that has become worse during past 2yrs Menstrual hx: regular menses every 28 days PE: excessive hair growth over upper lip, chin, lower abdomen, and pubic area Labs: normal FSH and LH, normal DHEAS, normal 17-alpha-hydroxyprogesterone, normal testosterone

Idiopathic hirsutism (increased male-pattern terminal hair that occurs in women with NORMAL LABS and no other symptoms, usually associated with 5-alpha-reductase activity in the skin causing increased sensitivity of hair follicles to androgens --> presents with increasing male-pattern hair growth on face/breasts/abdomen/ pubic area such as diamond esutcheon, and NORMAL FSH, LH, DHEAS, 17-hydroxyprogesterone, and testosterone levels --> can treat with 5-alpha-reductase inhibitors such as finasteride)

13yo F presents with hx of intermittent lower abdominal pain several times/yar that resolves after 2-3 days, and rectal pain with bowel movements SH: not reached menarche, and has never been sexually active PE: lower abdominal tenderness to deep palpation in midline, and smooth firm mass protruding between labia majora

Imperforate hymen (when hymen fails to fenestrate during embryonic development, which causes blood to collect in vagina behind hymenal membrane/hematocolpos during menstruation that causes pressure on surrounding pelvic oragns --> presents with cyclic lower abdominal pain with amenorrhea, pelvic pressure, defecatory rectal pain, and blue bulging vaginal mass/membrane that swells with Valsava --> treat with incision of hymen and drainage of hematocolpos)

Most common cause of abnormal triple screen

Inaccurate gestational age

How to calculate Montevideo units (strength of contraction)?

Increase in IUP multiplied by contraction frequency over 10mins

What is the best next step in management for a hypothyroid woman with recent confirmation of pregnancy?

Increase levothyroxine dose (hypothyroid woman on stable dose of levothyroxine should increase dose by 30% at time pregnancy is detected --> should be adjusted in 4wk increments based on TSH, using pregnancy-specific norms)

Why does the CO increase in pregnant women?

Increased HR and SV

Why are adolescent/young adult females at higher susceptibility for STDs?

Increased cervical cell vulnerability to infections

Effect of estrogen on the gallbladder

Increases cholesterol excretion into bile

1st line tocolytic agent for preterm labor between 24-32wks

Indomethacin (NSAID that works as COX inhibitor, thus inhibiting PG production --> 1st line tocolytic agent <32wks, CANNOT use after 32wks due to risk of premature PDA closure --> contraindications: maternal platelet dysfunction or bleeding disorder, hepatic dysfunction, gastrointestinal ulcerative disease, renal dysfunction, or asthma)

Which tocolytic should NOT be used >32wks gestation?

Indomethacin (due to risk of premature PDA closure, so CONTRAINDICATED in use >32wks --> also related to oligohydramnios due to COX inhibition and reduced fetal urine output)

31yo G1P0 at 7wks presents with vaginal bleeding and lower abdominal pain PE: blood clots in vaginal vault, active bleeding from dilated cervix, and 6wk-size tender uterus Pelvic US: gestational sac in lower uterus with no fetal heartbeat

Inevitable abortion (type of SAB in which abortion of fetus is active occurring --> presents with abdominal pain, vaginal bleeding, dilated cervical os, and products of conception seen in lower uterine segment --> treat with expectant management, PG administration, or D&C for hemodynamically unstable pts)

Which types of spontaneous abortions are associated with open cervical os?

Inevitable and incomplete abortion (inevitable abortion: no tissue has passed yet but abortion is inevitable --> incomplete abortion: only some tissue has passed --> treat BOTH with D&C)

42yo G0 F presents with painful left breast with diffuse breast erythema and pain in axillary region PE: diffusely erythematous breast with "orange peel" appearance, nipple retraction, and enlarged axillary lymph nodes

Inflammatory breast cancer (invasion of cancer into dermal lymphatic spaces --> presents with painful breast with warm swollen erythematous skin, "orange peel" appearance, nipple retraction, and enlarged axillary lymph nodes --> poor prognosis with 50% survival at 5yrs)

Order of parts of the Fallopian tube, from lateral to medial

Infundibulum, ampulla, isthmus, and intramural part (infundibulum connected to fimbriae --> ampulla is widest section and site of ectopic pregnancy --> isthmus is narrowest part --> intramural part pierces uterine wall)

2nd line treatment for GDM (for pts who failed to achieve glycemic control with dietary modifications)

Insulin or metformin

Which arteries supply the vulva?

Internal and external pudendal arteries

Which artery does the uterine artery arise from?

Internal iliac artery

Which blood vessel gives rise to the uterine artery?

Internal iliac artery (branch off of common iliac artery)

Major SNS innervation to pelvis

Internal iliac plexus (arises from aortic plexus)

32yo F presents with 6mo hx of increasingly frequent pelvic cramps, pain with urination, and urinary urgency. Pain partially relieved with urination but must void every 30mins Menstrual hx: regular menses and does not aggravate symptoms PE: suprapubic tenderness, and tenderness of anterior vaginal wall

Interstitial cystitis (bladder pain syndrome: chronic bladder pain/inflammation with unknown cause --> presents with chronic pelvic pain not associated with menses, urinary urgency/dysuria, and SUPRAPUBIC + ANTERIOR VAGINAL tenderness --> labs: NEGATIVE urine culture --> diagnose via cystoscopy --> treat via diet/lifestyle modifications such as avoiding bladder irritants, physical therapy, amitryptilline, or surgery)

48yo presents with 1wk hx of "copper-colored" discharge from right nipple PE: 1mL of reddish brown fluid expressed from right breast, no masses, no lymphadenopathy

Intraductal papilloma (small fibroepithelial tumor within lactiferous ducts, usually occurring beneath areola --> presents with unilateral bloody nipple discharge and no associated mass/lymphadenopathy --> image with breast mammography and US to reveal single dilated breast duct --> diagnose with biopsy or duct excision)

18yo G1P0 at 32wks presents with 2wk hx of intense itching on arms/legs/soles of feet, with no improvement with OTC lotions and antihistamines PE: scattered excoriations over arms and legs Labs: elevated total bile acids, elevated AP, elevated AST and ALT

Intrahepatic cholestasis of pregnancy (retention of bile salt during pregnancy, causing increased serum bile that gets deposited into dermis/liver/fetal circulation --> presents in 3RD TRIMESTER with severe pruritus and excoriations worse on hands/feet, no associated rash, and RUQ pain --> labs: elevated total bile acids >10, elevated total bilirubin with high CB, elevated AST/ALT/AP --> treat with ursodeoxycholic acid to lower bile levels, naltrexon for pain relief, and delivery at 37wks --> complications: IUFD, preterm delivery, meconium-stained amniotic fluid, and neonatal RDS)

What landmark is used as the "0" when determining fetal station?

Ischial spine (considered station 0 --> fetal station is -1 to -5 if baby is going into UTERUS --> fetal station is +1 to +5 if baby is going into VAGINA)

Which test is used to determine dose of Rhogam required for Rh-negative moms?

KB test (Kleihauer-Betke test: should be done >28wks if woman suffers MVA, placental abruption, amniocentesis, CVS, or ECV --> uses RBCs from maternal circulation and fixes on slide --> slide then exposed to acidic solution and lyses maternal HbA and turning those into white "ghost cells," while fetal HbF remains bright pink --> dose of anti-D Ig calculated from % of remaining fetal Hgb)

Which test is used to evaluate fetomaternal hemorrhage?

KB test (Kleihauer-Betke test: usually performed on women with IUFD who are Rh-negative)

What is the best next step in management for a women <40yrs with amenorrhea and elevated FSH?

Karyotype analysis (woman <40yrs with amenorrhea and elevated FSH indicates primary ovarian insufficiency --> associated with chromosomal abnormalities such as Turner syndrome and fragile X syndrome premutation carriers)

32yo G2P1 at 26wks presents with 2-hour hx of left-sided back pain that radiated into left inguinal area and left labium, sweating, nausea, and several episodes of vomiting. She felt faint when attempting to urinate and could not completely empty her bladder. Only feels comfortable while ambulating. Vitals: afebrile, BP 110/65, HR 122, RR 12 PE: moderate tenderness in left back and flank, no gross hematuria

Kidney stone (nephrolithiasis/ ureterolithiasis: occurs in pregnancy due to urinary stasis from hydronephrosis, as well as increased urinary excretion of calcium/uric acid/sodium/oxalate from elevated GFR --> presents with severe flank pain radiating to groin, N/V, dysuria, and hematuria --> diagnose via trasabdominal US, or IVUG if results are inconclusive --> treat with expectant management or nifedipine)

Which maternal tests are performed after an IUFD?

Kleihauer Betke test, antiphospholipid antibodies, and coagulation studies

Newborn PE: unilateral forearm supination, wrist extension, MCP joint hyperextension, IP joint flexion Neuro exam: absent grasp reflex, intact Moro reflex, intact biceps reflex

Klumpke palsy ("claw hand": traction or tear of lower trunk/C8-T1 roots caused by upward force on arm during delivery --> causes damage to intrinsic hand muscles: lumbricals, interossei, thenar, hypothenar --> presents with total claw hand including wrist extension, MCP hyperextenion, DIP/PIP flexion, and absent grasp reflex --> also associated with Horner syndrome aka ipsilateral ptosis and miosis --> treat with gentle massage and PT to prevent contractures, and surgical intervention if no improvement by age 3-9mo)

At which level does the ovarian artery arise from the aorta?

L1

Tumor markers for dysgerminoma

LDH and hCG (dysgerminoma: MALIGNANT germ cell tumors that contain cells that differentiate into syncytiotrohpoblast cells of placenta --> most common type of germ cell tumor in ADOLESCENT GIRLS --> histo: sheets of uniform "fried egg" cells --> secrete hCG and LDH)

Which hormone is highly elevated in patients with PCOS?

LH (luteinizing hormone: hyperinsulinemia/insulin resistance alters hyopthalamic hormonal feedback response, resulting in excess LH release --> increased androgen production from theca cells without conversion into estrogen causes decreased follicular maturation and anovulation --> remnants of unruptured follicles then form cysts throughout ovary --> presents in OBESE WOMEN with amenorrhea, hirsutism, acne, and infertility --> treat with weight reduction, OCPs to prevent endometrial hyperplasia, clomiphene, and spironolactone/finasteride/ flutamide to treat hirsutism)

2yo girl presents with abnormality in genital area PMH: multiple diaper rashes over past 6mo PE: thin labia minora that is fused at midline and partially blocks urethral meatus, and multiple excoriations

Labial adhesions (seen in prepubertal girls due to LOW ESTROGEN + inflammation from poor hygiene, vaginitis, diaper rash, or trauma/saddler injury --> adhesions can cover urethral meatus and cause abnormal urinary stream/urine accumulation --> presents with thin fused labia minora, vaginal pain/pulling, and recurrent UTIs --> treat with topical estrogen)

Best treatment for bipolar disorder during pregnancy

Lamotrigine (mood-stabilizing and anti-epileptic drug that blocks voltage-gated Na+ channels, inhibiting the release of glutamate --> has favorable pregnancy safety profile therefore used to treat bipolar disorder and epilepsy in pregnancy --> side effects: SJS and hematophagocytic lymphohistiocytosis)

What is the best next step in management of a patient with adnexal mass, and TVUS shows complex cyst?

Laparoscopic removal

What is the best next step in management for a pt undergoing D&C that presents with "fatty appearing tissue" in curette, and increased bleeding?

Laparoscopy (fatty-appearing tissue in curette during D&C is concerning for uterine perforation with damage to omentum and/or bowel --> need to perform immediate laparoscopy to closer examine bowel/surrounding structures for damage, and repair damage immediately)

Two signs of uteroplacental insufficiency

Late decelerations and oligohydramnios (late decelerations: detect on NST --> oligohydramnios: detected on US by MVP <2cm or AFI <5cm)

How do you define a positive contraction stress test/CST?

Late decelerations following at least 50% of contractions

First step in management when patient presents with PPROM (<37wks)

Latency antibiotics (give ampicillin and erythromycin --> prolongs latency period by 5-7 days and reduce incidence of maternal chorioamnionitis/neonatal sepsis)

Which ovarian vein joins the renal vein before the IVC?

Left ovarian vein

How to determine cervical effacement?

Length from internal to external os (if length 3-4cm, then 0% effacement --> if length 2cm, then 50% effacement --> when cervix becomes as thin as adjacent lower uterine segment, it is 100% effaced)

Which two muscles form the pelvic diaphragm?

Levator ani complex and coccygeus (levator ani complex: formed from iliococcygeus, puborectalis, and pubococcygeus muscles --> pelvic diaphragm forms broad sling in pelvis to support internal organs)

Best method of contraception for postpartum woman

Levonorgestrel IUD (LARC that prevents pregnancy by releasing progestin analog into uterus, creating physical barrier by thickening cervical mucus and impairing implantation thru decidualization of endometrium --> side effects: amenorrhea, mood changes, breast tenderness, headaches)

What is the best next step in management for a women <40yrs with amenorrhea and elevated prolactin?

MRI of pituitary (woman <40yrs with amenorrhea and elevated prolactin indicates pituitary adenoma --> other symptoms include frequent headaches, bitemporal hemianopsia, and galactorrhea)

Which conditions in an Rh-negative mom would indicate KB test?

MVA, amniocentesis, CVS, ECV, and placental abruption

Fetal complications of late-term pregnancy

Macrosomia, dysmaturity syndroe, oligohydramnios, and fetal demise (late-term >41wks and post-term >42wks are at risk of uteroplacental insufficiency due to age-related placental infarcts/calcifications that cause increased placental vascular resistance --> uteroplacental insufficiency can lead to chronic fetal hypoxemia, causing CNS suppression and intrauterine fetal demise --> UPI can present with late decelerations and oligohydramnios, which requires delivery to prevent intrauterine fetal demise)

Which tocolytic agent is contraindicated in myasthenia gravis?

Magnesium sulfate

Which tocolytic agent competes with calcium entry into myometrial cells?

Magnesium sulfate (competes with calcium at plasma membrane voltage-gated channels, thus hyperpolarizing membrane and inhibits MLCK to reduce myometrial contractility --> CONTRAINDICATED in moms with myasthenia gravis, cardiac conduction defects, impaired renal function --> NEUROPROTECTIVE for fetus <32wks

27yo G1P0 at 36wks presents with IOL for preeclampsia with severe features Vitals: BP 180/120, HR 92, RR 20, FHR 144bpm Meds: 10hrs of oxytocin, IV magnesium sulfate 2g/hr Past 2hrs: UOP down to 20mL/hr, RR 10, pulse ox 88%

Magnesium toxicity

19yo G1P0 at 34wks presents with pre-eclampsia with severe features (BP 170/110), fetal bradycardia, rushed for emergency C-section PE: fever of 102.9°F, BP 180/110, HR 130, RR 30, patient is markedly rigid and difficult to ventilate

Malignant hyperthermia (rare but life-threatening condition caused by skeletal muscle receptor abnormality resulting in excessive intracellular Ca2+ accumulation upon exposure to volatile anesthetics, succinylcholine, or excessive heat --> presents in patients immediately after anesthesia induction with sudden-onset muscle rigidity, fever, tachycardia, tachypnea, difficulty ventilating, and rhabdomyolysis --> labs: elevated PCO2 due to increased minute ventilation, elevated K+, and myoglobinuria --> treat with immediate cessation of anesthetic and dantrolene)

Which imaging method should be used on a woman >30yrs with a breast mass?

Mammography

42yo G5P4 exclusively breastfeeding 2mo old baby presents with left breast pain and fever of 101°F PE: breast shows red, tender, wedge-shaped area on outer quadrant of left breast

Mastitis (usually seen in BREASTFEEDING mothers, caused by Strep bacteria from baby's mouth --> treat with antibiotics and continuation of breastfeeding--> complication: abscess)

Complications of short interpregnancy interval (<18mo from delivery to next pregnancy)

Maternal anemia, low birth weight, PPROM, and preterm delivery (maternal anemia and low birth weight: occurs from depleted maternal folate/iron stores for prior pregnancy/breastfeeding --> PPROM and preterm delivery: occurs from persistent uterus/genital tract inflammation)

Which test should be given to all women with vaginal bleeding during pregnancy?

Maternal blood type (want to determine whether mom is Rh-negative --> if Rh-neg, need to give Rhogam to prevent Rh sensitization)

Diagnosis of chorioamnionitis (intraamniotic infection/triple I)

Maternal fever, fetal tachycardia, maternal leukocytosis, and purulent amniotic fluid

Causes of fetal bradycardia (<110bpm)

Maternal hypothermia, labetalol, fetal hypothyroidism, and fetal heart block (caused by maternal SLE due to anti-Ro/SSA and anti-La/SSB)

Causes of asymmetric IUGR

Maternal malnutrition and uteroplacental insufficiency (caused by maternal vasculopathy, resulting in inadequate uteroplacental perfusion and chronic fetal hypoxia --> associated with cocaine, smoking, gestational diabetes, gestational HTN, and pre-eclampsia)

What is the next best step in management after recognition of Cat3 FHT?

Maternal repositioning, O2 administration, IV fluids, and discontinuing uterotonics (all of these should improve uteroplacental blood flow and fetal oxygenation --> patients remote from delivery who do not improve with initial intrauterine resuscitative interventions require immediate C-section)

Pelvic US: partially calcified unilateral ovarian mass with multiple thin echogenic bands

Mature cystic teratoma

What are the components of the biophysical profile (BPP)?

NST, breathing, movement, muscle tone, and MVP/AFI (non stress test/NST: determines appropriate variation of FHR --> breathing: detects >1 episode of rhythmic breathing movements of >30s within 30mins --> movement: >3 discrete body or limb movements within 30min --> muscle tone: >1 episode of extension with return to flexion or opening/closing of hand --> MVP/AFI: determines max vertical pocket >2cm or amniotic fluid index >5cm --> NOTE: need to score at least 8 points on BPP to be considered normal, while BPP score <4 suggests imminent risk of fetal demise)

Which tests are involved in the 1st trimester screen (performed at 11-13wks)?

NT, PAPPA, and b-hCG (NT: nuchal translucency measured via US that will be INCREASED in trisomy 21 --> PAPP-A: pregnancy associated plasma protein A that will be DECREASED in trisomies --> bhCG: beta-hCG that will be INCREASED in trisomy 21, DECREASED in trisomy 18/13 --> combined screen has 85% detection rate of Trisomy 21)

Which tests are involved in the sequential screen?

NT, PAPPA, and quad screen (combination of 1st trimester nuchal translucency/PAPP-A and 2nd trimester quad screen --> has 93% detection rate for trisomy 21)

Contraindication for tolterodine (Detrol: anticholinergic used to treat urge incontinence)

Narrow-angle glaucoma

Conditions associated with elevated MSAFP during 16-18wk triple screen

Neural tube defects, gastroschisis, omphalocele, fetal death, placental abnormalities, and multiple gestations

Which tocolytic agent blocks calcium ion transfer thru the myometrial cell membrane to decrease intracellular free Ca2+ concentration and induce myometrial relaxation?

Nifedipine (calcium channel blocker: 1st line tocolytic between 32-24wks --> maternal risks: hypotension --> neonatal risks: decreased uteroplacental blood flow and possible fetal hypoxia)

1st line tocolytic agent for preterm labor between 32-34wks

Nifedipine (calcium channel blocker: blocks calcium ion transfer thru the myometrial cell membrane to decrease intracellular free Ca2+ concentration and induce myometrial relaxation --> 1st line tocolytic agent between 32-34wks, 2nd line tocolytic agent between 24-32wks maternal risks: hypotension --> neonatal risks: decreased uteroplacental blood flow and possible fetal hypoxia)

Method to confirm rupture of membranes (ROM)

Nitrazine test (performed during speculum exam --> confirms leakage of amniotic fluid)

First step in diagnosing ROM

Nitrazine testing of vaginal fluid and microscopic exam for ferning

Antibiotic prophylaxis for recurrent UTIs during pregnancy

Nitrofurantoin (Macrobid: safe for treatment of UTIs during pregnancy --> can also give amoxicillin or cephalexin)

Diagnosis of arrest of active phase

No cervical change after 2 hours of adequate contractions, or 6 hours of inadequate contractions (if progress during active phase is slower than 1.2-1.5 cm/hr --> need to evaluate adequate of uterine contractions, fetal malposition, or cephalopelvic disproportion --> best next step is usually C-section)

What is the best step in management for a pregnant woman with prior hx of neonatal sepsis due to GBS?

No culture, just intrapartum penicillin (cultures for GBS at 35-37wks NOT required in women who have GBS bacteriuria during current pregnancy or who have previously given birth to neonate with early-onset GBS disease --> these women should automatically receive intrapartum penicillin prophylaxis)

Which 2 assumptions are involved in Nagele's rule?

Normal gestation of 280 days and 28-day menstrual cycle

3 layers of the myometrium

OL, MO, and IL (outer longitudinal layer --> then middle oblique layer --> then inner longitudinal layer)

Major risk factors for endometrial cancer/hyperplasia

Obesity, chronic anovulation, nulliparity, early menarche, late menopause, tamoxifen (all of these relate to unopposed estrogen exposure)

What are the indications for delivery in a patient with IUGR fetus (EFW <10th percentile)?

Oligohydramnios and abnormal umbilical artery Doppler (if fetus presents with BOTH of these conditions, need to deliver regardless of gestational age --> IUGR fetuses with reassuring fetal testing should be delivered at 37wks)

What is the best next step in management for a postpartum female after C-section presenting with incisional tenderness and serous bloody drainage?

Opening wound, checking for fascial dehiscence, drainage, and assessment of fluid

Treatment for uncomplicated varicella in pregnant women

Oral acyclovir (give 800mg 5X/day for 7 days)

Treatment for urgency incontinence

Oral antimuscarinics and timid (ex: oxybutynin, solifenacin, tolterodine)

45yo premenopausal F presents with large unilateral breast mass PE: warm erythematous shiny and engorged breast skin, and large 5cm smooth well-circumscribed breast mass

Phyllodes tumor (rare variant of fibroadenoma involving epithelial and stromal proliferation that forms large mass of CT and cysts with leaf-like lobulations --> occurs in PREMENOPAUSAL women between age 40-50yrs --> presents as 4-5cm large bulky smooth well-circumscribed mobile mass, warm red shiny and engorged overlying skin, and rapid growth --> treat small tumors with wide local excision with 1cm margin, and simple mastectomy for large lesions)

Best next step in management for a pregnant woman with protracted labor and contraction power <240 Montevideo units

Pitocin augmentation

Prenatal US: irregular placental-myometrial interface and intraplacental villous lakes

Placenta accreta (when uterine villi attach directly to myometrium instead of decidua --> risk factors: prior C/S, prior D&C, and AMA --> presents with cord avulsion/manual extraction of placenta during delivery and severe PPH --> diagnosed via ANTENATAL US --> manage with cesarean hysterectomy)

Woman with hx of multiple pregnancies presents with painless 3rd trimester bleeding US: fetus in breech position

Placenta previa (inappropriate implantation of placenta over the internal cervical os --> risk factors: prior C-section, multiple gestation, AMA --> presents with painless 3rd trimester bleeding and baby in transverse/breech lie, or asymptomatic --> diagnose via US, often seen in 2nd trimester US around 18-20wks with placental tissue covering internal os --> can resolve by 3rd trimester due to physiologic lower segment lengthening and/or placental growth toward fundus, but persistent placenta previa will stretch placenta/shear vessels as cervix opens --> loss of fetal blood supply and presents with fetal distress, and indication for C-section at 36-37wks--> treat with pelvic rest and abstinence from intercourse/digital cervical exam)

29yo G3P2 at 32wks presents with sudden-onset heavy vaginal bleeding and non-painful contractions PMH: LTCS 4yrs ago SH: smokes 1 pack of cigs/day Vitals: afebrile, BP 96/70, HR 118, RR 16 FHR: baseline of 150bpm, moderate variability, +accelerations, no decelerations Tocometer: irregular contractions every 10-15mins

Placenta previa (when placenta implants over the internal cervical os --> risk factors: multiple gestation, multiparity, prior C-section, smoking --> usually asymptomatic and diagnosed during 2nd trimester US, but can cause bleeding during uterine irritability/contractions as placenta is sheared off cervix --> symptomatic placenta previa presents with painless vaginal bleeding >20wks, irregular non-painful contractions, and reactive FHR --> treat with avoiding digital cervical exam and sexual intercourse, and inpatient admission for bleeding episodes)

Causes of painless 3rd trimester bleeding

Placenta previa and vasa previa

Main indications for C-section

Placenta previa, prior classical C-section, and breech presentation

26yo F who delivered her first child 6mo ago presents with excessive anxiety/worry about newborn daughter, fatigue, irritability, constipation, and 5.5lb weight gain Vitals: BP 130/90, HR 60 PE: mild bilateral lower extremity edema Labs: low Na+, high total cholesterol

Postpartum thyroiditis (occurs in 7-8% of women after childbirth within first 6mo --> can initial present with HYPERTHYROID phase with anxiety/palpitations, that progresses to HYPOTHYROID phase with fatigue, weight gain despite normal appetite, constipation, small non-tender goiter, bradycardia, diastolic HTN, lower extremity edema, coarse facies, and delayed DTR relaxation --> labs: elevated TSH, low free T4, hypercholesterolemia, and hyponatremia --> diagnose via positive anti-TPO/microsomal antibodies and low radioiodine uptake --> histo: lymphocytic infiltrate with occasional germinal center formation --> usually self-limited, and patients return to euthyroid state in several months)

32yo F presents with 2-day hx of pelvic pain that "feels like labor contractions" with no relief from ibuprofen Menstrual hx: LMP 2 days ago, hx of regular but heavy menstrual cycles and occasionally passes clots Vitals: BP 140/90, HR 113 PE: irregularly enlarged uterus, 5cm cervical dilation with firm smooth spherical mass visible thru external os with slight bleeding noted around it

Prolapsing uterine fibroid (aborting submucosal myoma: prolapse of intracavity submucosal fibroid thru cervical os during expulsion from uterus while hanging from pedicle attached to myometrium --> causes heavy vaginal bleeding followed by labor-like pain due to mechanical cervical dilation by solid mass, associated with elevated BP and pulse --> treat with surgical removal of aborting myoma)

Treatment of thyroid storm during pregnancy

Propranolol and PTU (propranolol: beta-blocker that will stop SNS symptoms --> PTU: blocks TPO and 5'-deiodinase to inhibit T3/T4 production --> can also add prednisone if necessary --> AVOID potassium iodide due to risk of fetal thyroid blockage)

39yo G1P0 at 38wks presents for induction of labor and delivers 9lb healthy boy via forceps-assisted vaginal delivery over midline episiotomy. During delivery of placenta, excessive traction is placed on cord causing it to avulse, and placenta is manually extracted in pieces. 60min after delivery, pt soaks her perineal pad. 300mL of clotted blood expressed from lower uterine segment during bimanual uterine exam. Uterus is firm, non-tender, and below umbilicus. Pelvic US: thickened endometrial stripe

Retained placenta (prevents uterus from contracting effectively and can lead to postpartum hemorrhage --> risk factors: cord avulsion during placental delivery/manual placental extraction --> diagnose via pelvic US showing echogenic mass or thickened endometrial stripe --> treat with D&C for removal)

26yo woman who gave birth 3wks ago presents with continued vaginal bleeding PE: firm uterus

Retained products of conception (parts of membranes/placenta left behind within uterus, associated with multiple pregnancies --> treat with D&C --> if bleeding continues, treat with hysterectomy)

Which test is performed on all Rh-negative moms?

Rh IgG antibody (if positive, then immediately give Rhogam at 28wks and delivery --> if negative and dad is Rh+ or unknown, also give Rhogam at 28wks and delivery)

Which routine prenatal lab tests are done at initial prenatal visit?

Rh antibody screen, CBC, HIV, syphilis, Hep B, rubella, varicella, chlamydia PCR, urine culture, and urine dipstick

23yo G2P1 with LMP 10wks ago and 2 days s/p elective termination of pregnancy presents with lower abdominal pain and vaginal bleeding PE: fever of 102°F, cervix 1xm dilated, uterus is 8wk size and tender

Septic abortion (infection of the placenta and fetus of previable pregnancy that has potential to spread to uterus, cause pelvic infection, or become systemic and cause sepsis --> usually caused by retained POC from elective abortion with nonsterile technique, also associated with missed/incomplete abortion --> presents with high fever >101°F, prolonged lower abdominal pain, vaginal bleeding, dilated cervix, and malodorous purulent vaginal discharge --> diagnose via enlarged boggy tender uterus + pelvic US showing intauterine echogenic material with blood flow --> treat with IV fluids, broad-spectrum antibiotics, and D&C to clean uterus of residual tissue)

29yo G1P1 with hx of cesarean delivery 5 days ago presents with recurrent fevers despite gentamicin+ clindamycin+ ampicillin therapy PE: fever of 102.2°F, mild bilateral lower quadrant tenderness to deep palpation, incision with serosanguineous drainage, and non-tender uterus CT scan of abdomen/pelvis: no abscess or fluid collection

Septic thrombophlebitis (SPT: complication associated with pelvic surgery or postpartum after C-section caused by thrombosis of deep pelvic or ovarian veins that becomes infected --> presents with persistent fever unresponsive to broad-spectrum antibiotics, and negative blood/urine cultures --> treat with anticoagulation and more antibiotics)

Pelvic US: complex mass with solid components on unilateral ovary

Serous ovarian cystadenocarcinoma

22yo G0 presents with 6mo hx of worsening acne on face and body and 15lb weight loss in last 3mo PE: BMI 42, coarse hair on chin and upper lip, nodulocystic acne on face/chest/back, pelvic exam shows enlarged clitoris but otherwise normal genitalia Labs: elevated testosterone, normal DHEAS

Sertoli-Leydig cell tumor (type of sex cord stromal tumor arising from ovaries that results in markedly elevated testosterone levels >150ng/dL --> presents with unilateral solid adnexal mass, rapid-onset virilization <1yr such as clitoromegaly/increased muscle mass/male-pattern balding/voice deepening, oligomenorrhea, and estrogen deficiency such as breast/vulvovaginal atrophy, dyspareunia, and oligomenorrhea --> diagnose via pelvic US to visualize complex adnexal mass --> treat with surgical excision of tumor and cancer staging)

Pregnant woman with gestational hyperandrogenism Pelvic US: intrauterine gestation and unilateral solid complex ovarian mass

Sertoli-Leydig tumor (MALIGNANT ovarian tumor caused by proliferation of Sertoli-Leydig cells, which secrete testosterone --> presents with HIGH maternal virilization and HIGH risk of fetal virilization --> treat with ovarian biopsy/oophorectomy in 2nd trimester or postpartum)

Contraindications to Mirabegron (beta-3 agonist used to treat urge incontinence)

Severe HTN, ESRD, and liver disease

Which condition is associated with sinusoidal FHR (smooth, wave-like oscillation with fixed amplitude and frequency)

Severe fetal anemia (sinusoidal FHR considered category III tracing, usually associated with VASA PREVIA or PLACENTAL ABRUPTION --> presents with SROM with bright-red fluid --> due to rapid fetal exsanguination and deterioration, requires urgent C-section)

21yo G1P1 woman presents with 1yr hx of amenorrhea, inability to breastfeed, fatigue, hair loss under arms/pubic area, forgetfulness, and depression after birth of her daughter (age 1) OB hx: delivery complicated by PPH and hypovolemic shock, requiring aggressive resuscitation PE: afebrile, BP 90/50, HR 84, tired appearance, dry skin Labs: (-) b-hCG

Sheehan syndrome (ischemic infarct of anterior pituitary following postpartum hemorrhage --> caused by pregnancy-induced pituitary growth, which makes it susceptible to hypoperfusion --> leads to loss of LH/FSH, TSH, ACTH, and prolactin production --> presents with failure to lactate, amenorrhea, hypotension, cold intolerance, fatigue, weight gain, slow mental function --> treat with estrogen and progesterone replacement, with supplementation with thyroid/adrenal hormones)

What is the best next step immediately after delivery of healthy newborn?

Skin to skin contact (should immediately place infant with the mother --> if needed, then clear airway by suctioning mouth/nose to avoid aspiration with first breaths --> then dry newborn off with towel --> 30-60s after birth, clamp and cut umbilical cord to allow increased Hgb levels at birth and improve iron stores)

Major modifiable risk factors for osteoporosis

Smoking, alcohol, sedentary lifestyle, corticosteroids, anticonvulsants, vitamin D deficiency, inadequate calcium intake, and estrogen deficiency

What is the best position for application of positive pressure ventilation in a newborn infant?

Sniffing position (tilting neonate's head back and lifting chin --> also need to secure mask to infant's mouth/nose and observe initial chest rise --> recommended rate of O2 flow is 10L/min)

Which cardiac sounds are considered normal in a pregnant woman?

Split S2, S3 gallop, and systolic ejection murmur along LUSB

37yo G8P8 presents with increasing vaginal bleeding for past 5hrs PE: 8cm mass of upper cervix and right parametrium, and no palpable ovary CT scan: right hydroureter above level of mass

Squamous cell carcinoma of cervix (SCC of cervix: accounts for 80% of all cervical cancers, caused by infection with HPV16/18 --> risk factors: cigarette smoking, high # of sexual partners, early age of onset of sexual activity, immunosuppression, and poorly controlled HIV --> presents with postcoital bleeding, abnormal vaginal bleeding/watery discharge, pelvic pain/pressure, and friable bleeding cervical lesion or mass --> staged CLINICALLY by no invasion/stage 1, invasion into parametrium/stage 2, invasion into pelvic wall/lower third of vagina/hydronephrosis with stage 3, and invasion into bladder or rectal mucosa/stage 4 --> treat invasive disease with cisplatin-based chemotherapy)

Which stage of labor starts from onset of contractions to 10cm dilation of cervix?

Stage 1 (split up into 2 phases: latent phase is early part of labor where cervix dilates more slowly to 6cm, can take 14-20hrs --> active phase is where cervix dilates faster to 10cm, should take 2-3.5hrs)

Which stage of labor can be lengthened by neuraxial anesthesia?

Stage 2 (involves period of time from 10cm cervical dilation to fetal delivery --> usually increases duration by <1hr)

Which stage of labor starts when cervix is dilated at 10cm and ends with baby being delivered?

Stage 2 (should take 2-3hrs of pushing in 1st time mom, and 1-2hrs of pushing in repeat delivery --> longer with epidural)

Diagnosis of urethral hypermobility

Straining Q tip angle >30 degrees (helpful to diagnose urethral hypermobility, which is the most common cause of stress incontinence)

25yo with hx of C-section 2 days ago presents with nausea, abdominal pain, and copious serosanguinous discharge from incision site PE: bulging mass at incision site

Strangulated incisional hernia

58yo G2P2 presents with 2yr hx of frequent involuntary loss of urine. Denies burning, frequency, or urgency with urination. PSH: 2 term vaginal deliveries in her 30s PE: leakage of urine with Valsava Labs: normal post-void residual

Stress incontinence (outlet incompetence: involuntary leakage of urine caused by pelvic floor muscle weakness, resulting in urethral hypermobility in which urethra abnormally moves DOWNWARD with increased intra-abdominal pressure and is unable to fully close --> risk factors: multiple vaginal deliveries, obesity, chronic high-impact exercise such as jogging --> presents with urinary leakage with increased abdominal pressure, such as coughing/sneezing/lifting/ Valsava, normal PVR <150mL --> complication: cystocele due to inadequate bladder support --> treat with pelvic floor muscle strengthening exercises/Kegels, weight loss, pessaries, or midurethral sling surgery)

PE: normal sized uterus and ovaries, and downward mobility of urethral vesical junction with Valsava maneuver

Stress incontinence (outlet incompetence: involuntary leakage of urine caused by pelvic floor muscle weakness, resulting in urethral hypermobility in which urethra abnormally moves DOWNWARD with increased intra-abdominal pressure and is unable to fully close --> risk factors: multiple vaginal deliveries, obesity, chronic high-impact exercise such as jogging --> presents with urinary leakage with increased abdominal pressure, such as coughing/sneezing/lifting/ Valsava, normal PVR <150mL --> complication: cystocele due to inadequate bladder support, possible urethrocele --> treat with pelvic floor muscle strengthening exercises/Kegels, weight loss, pessaries, or midurethral sling surgery)

Young female presents with hypothyroidism following flu-like illness Neck exam: jaw pain and very tender thyroid gland

Subacute thyroiditis (granulomatous/de Quervain thyroiditis: autoimmune inflammation of thyroid gland following viral infection and flu-like illness --> presents with goiter, JAW PAIN, and HYPOTHYROIDISM aka cold intolerance, weight gain, coarse brittle hair/nails, puffy facies and generalized non-pitting edema, constipation, proximal muscle weakness, AUB/amenorrhea, fatigue, delayed DTR relaxation, and bradycardia --> diagnose via elevated ESR/CRP and low radioiodine uptake --> histo: granulomatous inflammation --> permanent in 15% of cases)

Type of uterine fibroid that will most likely cause heavy menstrual bleeding

Submucosal fibroid

Which maneuver for shoulder dystocia involves dislodging the anterior shoulder of the fetus?

Suprapubic pressure (combined with McRoberts maneuver, should relieve 50% of all shoulder dystocias)

Which ligament contains the ovarian artery and vein?

Suspensory ligament of ovary (infundibulopelvic ligament: connects ovaries to lateral pelvic wall, and contains ovarian artery/vein --> needs to be ligated during oophorectomy to avoid bleeding --> runs ABOVE ureter, thus risk of ureter injury during ligation of ovarian vessels)

Fetal US reveals fetal head circumference, abdominal circumference, and estimated fetal weight <10th percentile

Symmetric IUGR (symmetric fetal growth restriction: global proportionate growth lag that begins during 1st trimester and affects fetal organs uniformly --> caused by fetal chromosomal abnormalities or 1st trimester congenital TORCH infection --> diagnose with US --> manage with weekly biophysical profiles, serial umbilical artery Dopper sonography, and serial growth US)

Where does the pain from Stage 1 of labor come from?

T10-T12 (visceral pain)

39yo G1P0 at 37wks presents for IOL secondary to polyhydramnios. She received cervical ripening with PGE2 and is now on oxytocin. After her water broke, pt reports contractions every minute and large amount of bleeding. Vitals: BP 100/80, HR 100, temp 100.0°F FHT: Cat2 reactive SVE: 10/100%/+2

Placental abruption (abruptio placentae: premature separation of placenta from uterine wall before delivery of infant, associated with maternal HTN/MVA/cocaine abuse/smoking/pre-eclampsia --> also seen during DELIVERY in pts with polyhydramnios, in which placenta separates due to rapid decompression of intrauterine cavity --> presents with ABRUPT ONSET of painful 3rd trimester bleeding, tender distended uterus, with possible maternal shock/DIC --> requires US to confirm placenta no longer attached, and non-stress test/NST to help evaluate baby --> FHT: fetal bradycardia and/or late decelerations --> usually requires C-section)

26yo G1P0 woman 34wks pregnant presents with sudden onset of severe abdominal pain, vaginal bleeding, and contractions OB hx: pre-eclampsia PE: uterine tenderness FHT: uterine tachysystole and fetal bradycardia with late decelerations

Placental abruption (abruptio placentae: premature separation of placenta from uterine wall before delivery of infant, associated with maternal HTN/MVA/cocaine abuse/smoking/pre-eclampsia --> presents with ABRUPT ONSET of lower abdominal and/or back pain, 3rd trimester vaginal bleeding, firm tender uterus, and high frequency/low amplitude uterine contractions --> requires US to confirm placenta no longer attached, and non-stress test/NST to help evaluate baby --> FHT: fetal bradycardia and/or late decelerations --> usually requires C-section --> complications: maternal DIC due to tissue factor release by decidual bleeding, leading to hypovolemic shock)

Most common complication of PPROM

Placental abruption (premature separation of placenta from uterus due to decreasing amniotic fluid volumes, aka AFI <5cm or MVP <2cm --> leads to uterine decompression, causing maternal decidual vessels to shear --> results in bleeding and separation of placenta from uterus)

Causes of painful 3rd trimester bleeding

Placental abruption and uterine rupture

Pregnant woman with gestational hyperandrogenism Pelvic US: intrauterine gestation and no ovarian masses

Placental aromatase deficiency (caused by aromatase deficiency in fetus, thus preventing placenta from converting androgens into estrogen --> excess androgens enter maternal serum and cause MATERNAL virilization --> presents with hyperandrogenism in PREGNANT MOM --> in female infants, presents with ambiguous genitalia at birth and progressive virilization during puberty)

Which causes of gestational hyperandrogenism are at high risk of FETAL virilization?

Placental aromatase deficiency, luteoma, and Sertoli-Leydig tumor

Causes of gestational hyperandrogenism

Placental aromatase deficiency, luteoma, theca lutein cyst, and Sertoli Leydig tumor (placental aromatase deficiency: NO ovarian mass --> luteoma: bilateral SOLID ovarian masses --> theca-lutein cyst: bilateral CYSTIC ovarian masses --> Seroli-Leydig tumor: UNILATERAL solid complex ovarian mass)

Components of a DIC panel

Platelets, INR, fibrinogen

Obstetric risk factors of PPROM

Polyhydramnios, genital tract infection, and antepartum bleeding

Which tests can be used to determine whether patient has actually ruptured membranes?

Pooling, valsava, ferning, and nitrazine (pooling: presence of fluid collection in posterior fornix --> valsava: fluid seen coming thru cervical os during Valsava maneuver --> ferning: viewing thin layer of fluid on microscope slide for characteristic ferning pattern made by crystallized NaCl in amniotic fluid --> nitrazine: placing vaginal fluid on nitrazine paper to assess pH, positive if it turns blue indicating basic pH)

What is the major risk of 3rd trimester maternal use of SSRIs?

Poor neonatal adaptation (presents with agitation, abnormally increased/decreased muscle tone, tremor, temp instability, insomnia/somnolescence, and difficulty feeding --> symptoms should subside within hours-days)

21yo G1P1 who had NSVD 2 days ago presents with 1-day hx of severe headache that started after getting out of bed and has not improved with acetaminophen or ibuprofen. Now developed N/V whenever she gets out of bed. Vitals: afebrile, BP 136/88, HR 108 PE: neck stiffness, unable to sit up due to severe nausea, and bilateral pitting edema to knees

Postdural puncture headache (caused by unintentional dural puncture during LP or epidural anesthesia, which causes CSF leakage and low CSF pressure that results in slight herniation of brain and brainstem --> presents within 72hrs of LP/epidural with POSITIONAL HEADACHE that worsens when sitting/standing, N/V, neck stiffness, photophobia, diplopia, hearing loss, tinnitus --> usually self-limited, but pts with severe symptoms can be treated with epidural blood patch)

What is the presenting part for a fetus in vertex presentation?

Posterior fontanel (aka small triangular fontanel --> want baby to be in occiput anterior/OA position for easiest delivery --> NOTE: 90% of babies presenting in OP position spontaneously rotate to OA position)

48yo with recent hysterectomy/salpingo-oophorectomy presents with 2wk hx of clear, watery vaginal discharge PMH: endometriosis treated with surgery PE: well-rugated vaginal mucosa with pool of clear fluid in vaginal canal Wet mount microscopy: few squamous epithelial cells and rare WBCs

Vesicovaginal fistula (formation of inappropriate connection between bladder and vagina, usually associated with pelvic surgeries complicated by endometriosis/pelvic adhesions, pelvic irradiation, prolonged labor/childbirth trauma, or GU malignancy --> presents with persistent, painless, uncontrolled clear watery vaginal discharge --> diagnose via visible vaginal defect/pooling of clear fluid into vagina, bladder dye tests, or cystoscopy to identify small fistulas --> treat with surgical correction)

27yo G0 F presents with 3yr hx of dyspareunia with worsening severe pain on penile insertion, and inability to use tampons because of pain PE: palpation of vestibule with Q-tip elicits marked tenderness and slight erythema

Vestibulodynia (syndrome consisting of severe pain on vestibular touch/attempted vaginal entry, tenderness to pressure, and vulvar erythema of varying degree --> presents as SHARP PAIN with tampon insertion/intercourse, exquisite tenderness to light touch of vestibule, and possible erythematous vulvar macules --> treat with TCAs, pelvic floor rehab, biofeedback, and topical anesthetics)

What is the best next step in management of a fetus with non-reactive NST for 40mins?

Vibroacoustic stimulation

What determines the risk of HIV transmission from mom to baby?

Viral load (HIV transmitted via blood-to-blood, NOT via placenta)

Best treatment for osteoporosis prevention (for high-risk women)

Vitamin D, calcium, and alendronate (vitamin D and calcium: required vitamins for bone growth --> alendronate: bisphosphonate that inhibits osteoclastic activity and 1st line med for osteoporosis --> if persistent osteopenia, can add teriparatide and/or raloxifene)

Most common cause of delayed postpartum hemorrhage (>24hrs after delivery)

Von Willebrand disease (autosomal dominant mild coagulopathy caused by intrinsic defect of vWF resulting in defective platelet plug formation, and also decreased factor 8 --> presents with heavy menorrhagia at early age, delayed PPH starting at 48-72hrs after delivery, and increased bleeding time/BT --> diagnose via failure of platelet aggregation with ristocetin assay that CORRECTS with FFP --> treat with desmopressin/DDAVP to stimulate vWF release from endothelium)

18yo F presents with 1-day hx of fever, N/V, and diarrhea with associated diffuse rash Vitals: fever of 102.2°F, BP 90/60, HR 96, RR 22 PE: diffuse erythematous maculopapular rash over perineum/thighs, and cervical motion/uterine/bilateral adnexal tenderness with no masses

Toxic shock syndrome (TSS: colonization/infection with Staph aureus from tampons/vaginal infections/endometritis, causing production of epidermal toxin TSST-1 --> presents with high fever >102°F, hypotension, diffuse erythematous macular rash, desquamation of palms/soles, and involvement of 3+ organ systems: GI with abdominal pain/N and V/diarrhea, myalgias, mucous membrane hyperemia, increased BUN/Cr, platelets <100k, and alterations in consciousness --> labs: often NEGATIVE blood culture due to exotoxin absorption thru vaginal mucosa --> treat with hospitalization and IV clindamycin + vancomycin for 10-14 days)

Treatment for heavy menstrual bleeding in pt with hx of VTE

Tranexamic acid (AA lysine analog that serves as anti-fibrinolytic and prevents fibrin breakdown --> used to treat heavy menstrual bleeding in pts in which COCPs are contraindicated)

Best method to diagnose IUFD

Transabdominal US (confirms absence of fetal cardiac activity --> pregnant women with IUFD present with decreased or absent fetal movement and absent FHR on fetal Doppler --> if IUFD occurs between 20-23wks, can manage via D&C or vaginal delivery --> if IUFD occurs >24wks, can manage via vaginal delivery)

Which two congenital heart defects are associated with maternal diabetes?

Transposition of great vessels and VSD

Treatment of vulvar/vaginal warts (condylomata acuminata)

Trichloroacetic acid therapy (treats low-risk HPV types 6 and 11)

38yo G0 woman presents with 3mo hx of persistent yellow frothy vaginal discharge associated with mild vulvar irritation with no improvement with anti-fungals PE: mild erythema at introitus, copious yellow frothy discharge filling vagina, and erythematous patches on ectocervix

Trichomoniasis (STD infection with Trichomonas vaginalis, aka unicellular protozoans transmitted via sexual contact --> causes VAGINITIS and presents with malodorous frothy yellow-green vaginal discharge, itching/burning vulva, vulvovaginal erythema, dyspareunia, elevated vaginal pH >4.5, and "strawberry cervicitis" aka erythematous patches on cervix --> diagnose via wet mount microscopy that will show motile ovid protozoa with flagella --> treat with metronidazole for BOTH patient and partner)

Vaginal discharge: yellow/gray/green frothy discharge with unpleasant odor

Trichomoniasis (caused by Trichomonas vaginalis, a unicellular anaerobic flagellated protozoan --> presents with profuse yellow/gray/green frothy discharge and foul odor, vulvar erythema/edema, pruritus, and erythematous punctate epithelial papillae/"strawberry" cervix --> diagnose via wet mount showing motile flagellated protozoa --> treat with metronidazole for both patient and partner)

Causes of false-positive nitrazine test

Trichomoniasis, blood, and semen

What are the precursor cells for the placenta and membranes?

Trophoblasts (aka trophoectoderm: forms trophoblastic shell to separate embryo form endometrium --> trophoblast CLOSEST to myometrium forms placental disk, while other trophoblasts form chorionic membrane --> secretes hCG, hPL, and ACTH)

Pelvic US: unilateral multiloculated cystic mass on ovary, with distortion of normal adnexal structure

Tubo-ovarian abscess (TOA: caused by persistent PID --> presents with fever, abdominal and/or pelvic pain, adnexal mass/fullness, leukocytosis with left shift, and elevated ESR --> diagnose with US that shows complex, thick-walled mass with air-fluid levels --> treat with ampicillin + gentamicin + clindamycin --> can also surgically drainage TOA if pt does not respond within 48hrs)

Term to describe retraction of fetal head into maternal perineum

Turtle sign (warning sign of shoulder dystocia --> indication for McRoberts maneuver with hyperflexing mother's legs to abdomen to widen pelvis/flatten lumbar spine)

How do you manage a pregnancy diagnosed with IUGR?

Twice weekly antenatal testing (includes twice weekly NST, weekly AFI, and/or weekly BPP --> want to rule out fetal acidosis and overall FWB)

Stillborn male fetus delivered at 36wks to a 26yo G5P1031 woman who received no prenatal care Fetal autopsy: delivered via NSVD at 4.9lbs, has short bent extremities, multiple limb fractures, and hypoplastic thoracic cavity

Type 2 osteogenesis imperfecta (T2OI: autosomal dominant disorder caused by defective type 1 collagen synthesis resulting in decreased bone density and increased skeletal fragility --> type 2 associated with fatal perinatal disease and diagnosed via ANTENATAL US with multiple fractures, shortened femur, hypoplastic thoracic cafe, and growth restriction --> most fetuses die in utero, during delivery, or shortly after delivery due to pulmonary hyoplasia)

Which pelvic muscle maintains urinary continence?

UG diaphragm (urogenital diaphragm: external to the pelvic diaphragm and is com- posed of deep transverse perineal muscles, urethral constrictor, and internal/external fascial coverings --> helps maintain urinary continence)

What is the best next step in management if a woman presents with an abnormal 2nd trimester quad screen?

US to confirm gestational age (most common cause of abnormal quad screen is inaccurate dating of fetus --> if US confirms dates, then recommend genetic counseling + targeted US --> amniocentesis + karyotype analysis required for final diagnosis of trisomy 21)

Which test is used to monitor growth-restricted babies?

Umbilical artery Doppler (measures the systolic and diastolic blood flow to placenta --> in growth-restricted babies, increased resistance in placenta decreases end diastolic flow relative to systolic flow --> INCREASED S/D ratio is ABNORMAL)

Which condition is associated with variable decelerations (onset/peak not associated with contraction)?

Umbilical cord compression (variable decelerations: abrupt decelerations with V-shape not associated with contractions --> can be mild, moderate, or severe --> commonly seen during labor, but highly associated with premature ROM, oligohydramnios, and nuchal cord --> treat RECURRENT variable decelerations with >50% contractions with maternal reposition such as left lateral decubitus/all fours --> if no improvement, treat with amnioinfusion by infusing normal saline into uterus thru IUPC to alleviate cord compression and plan delivery of fetus if worsening)

What is the biggest risk for vaginal delivery of complete/incomplete breeches?

Umbilical cord prolapse

35yo G2P1 at 40wks admitted for active labor 2hrs ago with recent SROM PE: cervix is 9cm dilated and fetal head is OA at 1+ station, palpation of 5cm long section of umbilical cord in patient's vagina FHR: 150bpm with multiple accelerations and no decels, regular uterine contractions every 2-3mins

Umbilical cord prolapse (when umbilical cord drops thru open cervix into the vagina ahead of baby --> can become trapped against baby's body during delivery, with risk of fetal hypoxia --> treat by elevating fetal head with hand in vagina + emergent C-section)

Most common cause of elevated MSAFP

Underestimation of gestational age (therefore women with elevated MSAFP should receive workup with US to assess gestational age, viability, and rule out multiple gestation/fetal structural abnormality)

Most common cause of proteinuria in pregnancy <20wks gestation

Underlying renal disease (usually associated with diabetic nephropathy: chronic hyperglycemia causes dilation of renal AFFERENT arterioles + constriction of EFFERENT arterioles, resulting in glomerular hyperfiltration --> causes structural/functional changes in GBM and podocytes --> during pregnancy, renal perfusion and glomerular filtration rates increase by 50% causing acceleration of renal disease --> presents with worsening albuminuria/proteinuria, elevated creatinine, and HTN --> treat with insulin)

Treatment for intrinsic sphincter deficiency

Urethral debulking (minimally invasive procedure with 80% success rate)

33yo G3P3 presents with 2wk hx of vaginal mass and dyspareunia OB hx: 3 term vaginal deliveries PE: 3cm mass on anterior aspect of vaginal wall that does not change in size with Valsava, tender to palpation and expresses purulent urethral discharge

Urethral diverticulum (abnormal localized outpouching of urethral mucosa into surrounding tissues caused by recurrent periurethral gland infections, which can develop into abscess that eventually branches urethral mucosa --> results in chronic infection/inflammation/ increased tissue tension on diverticulum, and also collection of urine/debris within diverticulum --> presents with tender anterior vaginal wall mass, dyspareunia, purulent discharge, dysuria, and postvoid dribbling --> diagnose via MRI --> treat via surgical excision)

54yo G2P2 presents with 2yr hx of frequent involuntary loss of urine and 1wk hx of burning with urination. Denies frequency/urgency. PMH: 3 UTIs in past year PSH: 2 term vaginal deliveries in her 30s PE: no leakage of urine with Valsava, vaginal dryness and atrophy, and 2cm tender anterior vaginal mass that is palpable and causes expression of bloody discharge at urethral meatus Labs: normal post-void residual

Urethral diverticulum (abnormal localized urethral mucosa that outpouches into surrounding tissue, caused by recurrent periurethral gland infection along anterior vaginal wall --> outpouching can collect and store urine, and can also get infected --> presents with dysuria, postvoid dribbling, dyspareunia, and tender anterior vaginal wall mass with purulent or bloody urethral discharge --> diagnose via pelvic MRI --> treat with surgical excision of diverticulum)

Causes of urinary stress incontinence

Urethral hypermobility and intrinsic sphincter deficiency (urethral hypermobility: usually caused by weak pelvic stress muscles, diagnosed by straining Q-tip angle >30° from horizon --> intrinsic sphincter deficiency/IDS: cause of 10% of stress incontinent cases, diagnose via clinical findings + negative Q-tip test + cystourethroscopy showing "drain pipe" urethra)

50yo G3P2012 presents with 9yr-hx of loss of urine with coughing/straining/lifting that has worsened over past 2yrs PE: well-supported anterior and posterior vaginal wall, loses urine in small spurts with coughing, and Q-tip angle of 45° during Valsava

Urethrocele (urethral prolapse into vagina, causing urinary stress incontinence --> pelvic floor muscle weakness results in urethral hypermobility, in which urethra abnormally moves with increased intra-abdominal pressure and is unable to fully close --> allows urine to leak with increased intra-abdominal pressure such as sneezing/coughing/tennis --> cervical exam shows Q-tip sign WITHOUT anterior prolapse --> treat with pelvic floor muscle exercises and lifestyle modifications)

37yo F who underwent laprascopic hysterectomy for severe endometriosis 1wk ago presents with 2-day hx of increasing diffuse abdominal pain, abdominal bloating, increasing vaginal discharge, and new onset N/V Vitals: fever of 100.4°F, BP 128/72, HR 88 PE: moderately distended abdomen, watery vaginal discharge in vagina, closed vaginal cuff Abdominal US: large amount of intraabdominal fluid with no internal echoes

Uroperitoneum (urine within peritoneal cavity, usually caused by unilateral ureteral laceration during recent GYN surgery --> urine drains directly into abdomen, causing large volume of intra-abdominal fluid and peritoneal inflammation --> can present within 2wks post-op with abdominal distension/pain, watery vaginal discharge, fever, nausea/vomiting, and NORMAL voiding with NORMAL serum Cr/UA --> diagnose via CT urography --> treat via surgical repair)

Most common cause of post-partum bleeding

Uterine atony (the uterus is tired and fails to contract down to stop bleeding --> uterus feels boggy and large --> treat with uterine massage, then misoprostol/methergine/ oxytocin/carboprost, then mechanical tamponade with Bakri balloon, then surgery)

PE: irregularly enlarged anteverted and anteflexed uterus

Uterine fibroids (leiomyomata uteri: usually subserosal and pedunculated fibroids cause compression of adjacent organs such as bladder --> can result in stress incontinence or fecal incontinence)

Woman presenting with post-partum hemorrhage and non-palpable uterus

Uterine inversion (caused by excessive traction during treatment of uterine atony --> treat with uterine packing, then tocolytics and/or uterotonics)

Consequences of DES exposure in utero

Vaginal clear cell adenocarcinoma and congenital Mullerian abnormalities (vaginal clear cell adenocarcinoma: rare form of vaginal cancer --> congenital Mullerian abnormalities: include cervical incompetence, vaginal adenosis, T-shaped uterus, hypoplastic uterine cavity, shortened upper uterine segment, and transverse septa)

Best treatment for non-viable fetus (acardia, anencephaly, bilateral renal agenesis, holoprosencephaly, IUFD, pulmonary hypoplasia, and thanatophoric dwarifms)

Vaginal delivery

5yo girl presents with 1-day hx of blood in underpants, 5-day hx of rubbing/scratching of genital areas, and foul-smelling discharge/itching/burning in that area that worsens during urination PE: green vaginal discharge and diffuse inflammation of vulva Wet mount: occasional RBCs and numerous WBCs Culture of discharge: polymicrobial infection

Vaginal foreign body (occurs when a young girl inserts a foreign object into vagina, often simultaneously with inserting foreign bodies in ears/nose, that results in pediatric vaginitis --> presents with vaginal bleeding, purulent or foul-smelling vaginal discharge, diffuse inflammation of vulva with itching/burning pain, and dysuria --> wet mount shows numerous WBCs, while culture of discharge shows polymicrobial infection --> treat with antibiotics)

30yo G1P0 who delivered 9.3lb infant via forceps-assisted vaginal delivery 1hr ago presents with dizziness and lightheadedness Vitals: afebrile, BP 90/50, HR 120 PE: pt appears pale and diaphoretic, sinus tachycardia, clear lungs, minimal blood on perineal pad, and large purple mass protruding into vagina

Vaginal hematoma (stretching of vaginal canal causes injury to uterine artery, resulting in massive postpartum bleeding that collects in paravaginal space --> risk factors: operative vaginal delivery, infant >4000g/8.8lbs, nulliparity, prolonged 2nd stage of labor --> presents with massive OCCULT bleeding with hypovolemic shock, protruding purple vaginal mass, and rectal/vaginal pressure --> manage non-expanding hematomas via observation, while expanding hematomas treated with arterial embolization and surgery)

52yo postmenopausal woman presents with vulvar irritation, streaks of blood on sanitary pads, and pain with sexual intercourse PE: multiple vulvar excoriations with surrounding erythema, and erythematous friable plaque on left labia majora

Vulvar cancer (vulvar squamous cell carcinoma: caused by persistent infection with HPV16 or HPV18 and chronic inflammation --> risk factors; smoking, immunodeficiency, vulvar lichen sclerosus, prior abnormal Pap tests, and vulvar/cervical intraepithelial neoplasia --> presents with vulvar pruritus and/or pain, unifocal friable plaque or ulcer on labia majora, intermittent bleeding, and dyspareunia --> diagnose via vulvar biopsy to evaluate depth of invasion/determine management options)

Most serious side effect of pitocin infusion

Water intoxication (oxytocin is structurally/functionally related to ADH --> therefore has potent antidiuretic effects and can cause fluid overload/hyponatremia --> leads to convulsions, coma, and death)

Management of fetal IUGR

Weekly biophysical profiles, serial umbilical artery Doppler sonography, and serial growth US

What is the most important contraindication to transdermal contraceptive patch?

Weight (transdermal contraceptive patch: releases ethinyl estradiol and norelgestromin slowly into dermis, which establishes steady serum levels for 7 days --> woman should apply 1 patch in a diff area for 3wks, then have a patch-free week for withdrawal bleeding --> has a much higher failure rate in women >198lbs, and has higher risk of VTE compared to COCPs)

Major side effect of medroxyprogesterone injections

Weight gain

32yo G1P0 at 18wks presents with unsteady gait and frequent falls, increasing confusion, and incoherence PMH: persistent N/V during pregnancy and 7lb weight loss PE: nystagmus, epigastric pain without rebound/guarding, trace pedal edema over bilateral lower extremities, and bilateral absent ankle reflexes Labs: low Na+, low K+, low Cl, high HCO3-, low glucose, high AST/ALT

Wernicke encephalopathy (neurologic disease caused by thiamine deficiency, usually associated with chronic alcoholism/malnutrition/ hyperemesis gravidarum --> presents with altered mental status, horizontal nystagmus and/or bilateral abducens palsy, and postural/gait ataxia --> labs: hypochloremic metabolic acidosis, hypokalemia, hypoglycemia, and elevated AST/ALT --> treat with IV thiamine followed by glucose infusion, as well as anti-emetics and fluids)

What is the next best step in management for a woman with NO palpable breast mass, but a mammogram finding suspicious of malignancy?

Wire-guided excisional biopsy (goal is to excise abnormal tissue along with 1cm rim of normal tissue --> findings on mammogram that are most suggestive of malignancy: spiculated mass, architectural distortion with retraction, asymmetric localized fibrosis, microcalcifications with linear branched patterns, increased vascularity, or altered subareolar duct pattern)

25yo G2P1 at 38wks presented to L&D 2hrs ago with spontaneous onset of labor and SROM, with 5cm cervical dilation + 90% effacement + fetal station 0 Presently, the pt is uncomfortable and notes strong contractions with unchanged cervical exam. Placement of IUPC causes 300cc of frank blood and amniotic fluid to flow out of vagina. Best next step in management?

Withdraw IUPC and monitor fetus (when IUPC placement causes vaginal bleeding, need to consider placental separation or uterine perforation --> need to withdraw IUPC and monitor fetus for any signs of fetal compromise --> if fetal status is reassuring, then attempt to place another IUPC)

Which maneuver for shoulder dystocia involves replacing fetal head into maternal pelvis for emergency C-section?

Zavanelli maneuver (performed ONLY if all other dystocia maneuvers fail)

Which supplements should be given to a pregnant woman with a vegan diet?

Zinc, vitamin B12, and iron

63yo F presents with daily vaginal spotting, dyspareunia, and post-coital bleeding SH: sexually active for 6mo, smokes pack of cigs/day PE: BMI of 30, atrophic vagina with minimal rugation, 1cm ulcerated lesion in upper 1/3 of posterior wall, malodorous watery discharge in vagina Wet mount: numerous squamous epithelial cells with rare WBCs, negative KOH test Pelvic US: anteverted uterus with 3mm endometrial stripe

Vaginal squamous cell carcinoma (squamous cell carcinoma of vagina seen in women >60, persistent HPV infection, chronic tobacco use, and in utero DES exposure --> presents with vaginal bleeding, malodorous vaginal discharge, and irregular plaque/ulcer located in upper 1/3 of posterior vagina --> diagnose with vaginal biopsy to differentiate between VIN and vaginal cancer --> treat non-invasive disease with topical therapy or wide local excision --> treat invasive disease with surgery and/or chemoradiation)

Prophylactic treatment for herpes-positive pregnant woman

Valacyclovir (should be given from 36wks to delivery to prevent active lesions --> if active lesions present during labor, need to perform C-section to avoid fetal exposure)

24yo G1P0 woman 34wks pregnant presents with regular painful contractions over past 3hrs and SROM with bright-red amniotic fluid FHTs: sinusoidal pattern

Vasa previa (caused by velamentous cord insertion, aka umbilical cord inserting into chorioamniotic membranes causing fetal vessels to travel to placenta unprotected by Wharton jelly --> causes fetal vessels to run over internal cervical os --> presents with TRIAD of membrane rupture + painless 3rd trimester bleeding + fetal bradycardia <110 beats/min OR sinusoidal FHR --> treat with emergency C-section)

40yo F presents with 2wk hx of abdominal pain not relieved by ibuprofen that has gotten progressive worse, and fever of 102°F PE: tenderness to deep palpation in RLQ without rebound/guarding, small mobile tender uterus, enlarged tender right adnexal mass Labs: elevated WBCs, CRP, and CA-125 Pelvic US: large, thick-walled multiloculated mass filled with debris obliterating right adnexa

TOA (tubo-ovarian abscess: complication of PID causing polymicrobial infection of upper genital tract that extends to Fallopian tubes and creates inflammatory exudate/purulent fluid/and wall thickening --> conglomerates into complex mass to create pyosalpinx/infected Fallopian tube and TOA --> presents in YOUNG ADULT WOMEN with fever, abdominal pain, and pelvic US showing complex multiloculated adnexal mass with thick walls and internal debris --> labs: leukocytosis, elevated CRP/CA-125 --> diagnosed via pelvic US --> treat with ampicillin + gentamicin + clindamycin)

Which thyroid function test decreases during pregnancy?

TSH (since b-hCG shares common alpha subunit with TSH, it directly stimulates TSH receptors --> this results in mildly increased T3/T4 production with more negative feedback on pituitary --> DECREASED TSH release)

Evaluation of amenorrhea in >13yo girl without secondary sex characteristics (or girl >15 with secondary sex characteristics)

TSH and pelvic US (to evaluate hypothyroidism and confirm presence of uterus/ovaries)

Which thyroid-related substances CANNOT cross the placenta?

TSH, T3, T4 and thyroglobulin (while TRH, iodine, and thyrostimulating immunoglobins can cross placenta)

24yo G1P0 has just delivered 37wk male twins Twin A is large and plethoric, while twin B is small and pale

TTTS (twin-twin transfusion syndrome: complication of MONOCHORIONIC pregnancies caused by imbalance of blood flow thru communicating vessels across shared placenta --> leads to underperfusion of donor twin and overperfusion of recipient --> results in donor twin developing anemia/IUGR/ oligohydramnios, while recipient twin develops volume overload/ polyhydramnios that can lead to heart failure and hydrops fetalis)

Best imaging test to diagnose uterine fibroids

TVUS

What is the best next step in management for an asymptomatic adnexal mass found on physical exam?

TVUS (for simple cyst, want to see <10cm smooth anechoic unilocular mass, aka single fluid-filled homogenous cyst --> if <3cm no need to re-evaluate --> if 3-10cm, need to reimage within 12wks)

1st step in evaluating risk of preterm labor

TVUS (used to measure cervical length in 2nd trimester --> short cervix <2.5cm indicates high risk of preterm labor --> treat with vaginal or IM progesterone, placement of cerclage at 12-14wks, and serial TVUS-CL measurements until 24wks)

Which test is required for women >45yrs with abnormal uterine bleeding?

TVUS or endometrial biopsy (TVUS: look to see if endometrial stripe >4mm --> if stripe >4mm, then endometrial biopsy required to look for endometrial atypia/neoplasia)

When is menarche expected?

Tanner stage 4 (around 2-2.5yrs after initial breast bud development --> around 6mo after growth spurt --> occurs at age 10-15yo with average age at 12.5yrs)

Pregnant woman with gestational hyperandrogenism Pelvic US: intrauterine gestation and bilateral cystic masses in ovaries

Theca lutein cysts (caused by elevated b-hCG that results in ovarian hyperstimulation --> presents asymptomatically OR moderate virilization in mom, with low risk of fetal virilization --> spontaneously regresses after delivery)

Pelvic US: large, multiloculated, cystic masses on bilateral ovaries

Theca lutein cysts (caused by ovarian hyperstimulation from abnormally high b-hCG from molar pregnancy/choriocarcinoma/ multifetal gestation, or GnRH stimulation from ovulation induction therapy --> present as large, bilateral cysts filled with clear straw-colored fluid that feel firm/solid on palpation --> diagnose with pelvic US --> treat underlying pathology)

29yo G1P0 at 7wks presents with lower abdominal pain and vaginal bleeding PE: closed cervix and 6wk-size tender uterus Pelvic US: intrauterine gestational sac with normal fetal heartbeat

Threatened abortion (pregnant woman with abdominal pain/vaginal bleeding but has viable fetus --> also associated with subchorionic hematoma, aka abnormal collection of blood between placenta and uterus --> about 50% of these patients will end up having abortion)

19yo G1P1 presents with continuous vaginal discharge after vaginal delivery 6wks ago PE: well-healed 3rd degree perineal laceration, small red area of granulation tissue on anterior vaginal wall, and pool of clear fluid in vaginal with pH of 6

Vesicovaginal fistula (VVF: complication of obstructed labor in which excessive fetal head compression causes injury and necrosis to maternal vagina/bladder, leading to erosion and fistula development between vagina and bladder --> presents with continuous vaginal discharge with elevated pH >4.5, vaginal pooling of urine, and visible defect or area of raised red granulation tissue on anterior wall --> diagnose via bladder dye testing --> treat with surgical repair)

34yo G4P3 at 19wks gestation presents 3hr hx of chest pain, palpitations, and sweating SH: lost 40lbs this year without trying PE: BP 162/84, HR 132, pt appears diaphoretic and anxious, eyes are wide open and prominent with easily visible sclera surrounding pupil, enlarged thyroid with audible bruit EKG: sinus tachycardia

Thyroid storm (occurs in patients with untreated hyperthyroidism who develop infection/trauma/pregnancy, usually in setting of Graves disease --> presents with agitation, delirium, fever, diarrhea, coma, and tachyarrythmia with increased LFTs --> treat with PTU and propranolol, AVOID potassium iodide due to risk of fetal thyroid blockage --> CONTRAINDICATED in pregnancy: radioactive iodine due to congenital hypothyroidism)

1st line treatment for genital warts (condyloma acuminata)

Topical trichloroacetic acid, topical podophyllin, and 5-fluorouracil cream (these medical treatments chemically injure lesion and are repeated weekly by clinician until all lesions are gone --> for motivated patients with uncomplicated condyloma that can be reached, can give topical imiquimod used 3x/week and podofilox used 2x/day for 3 days that stimulate immune response --> larger lesions require cryotherapy, laser therapy, or excision)

Which thyroid function tests increase normally during pregnancy?

Total T3 and T4 (pregnancy causes increased estrogen levels, which increases TBG synthesis in the liver --> increased TBG allows more T3/T4 to be bound, but does NOT affect amount of free T3/T4 --> therefore pregnant woman only have increased TOTAL T3/T4 but normal levels of free T3/T4 --> since there may be less free T3/T4, there may be an increase in TSH which can increase the size of thyroid gland by up to 10%)

Which thyroid function tests increase during pregnancy?

Total thyroxine and TBG (total T3/T4 increase and TBG increase due to estrogen effects, but free T3/T4 remains normal --> therefore mother remains EUTHYROID)

Fetal head is just past the ischial spines What is the fetal station?

+1 (fetal head not yet ready to be delivered)

Fetal head present at level of introitus What is the fetal station?

+3 (aka fetus about to be delivered)

How much folic acid should be given to a first time mom with no risk factors?

0.4 mg/day (or 400ug/day --> ideal if started 3mo before pregnancy to prevent neural tube defects)

Recommended dose of folic acid for non-high risk pregnant patients

0.4mg/day

Which test should be done annually to sexually active women age <25?

NAAT (screening for chlamydia and gonorrhea --> can be obtained by either vaginal or cervical swab)

Which components are found in the modified BPP (mBPP)?

NST and AFI (non-stress test: determines appropriate variation in FHR --> AFI: should be >5cm to rule out oligohydramnios, and <25cm to rule out polyhydramnios)

Management of PPROM between 34-37wks

Betamethasone, latency antibiotics, and immediate delivery (betamethasone: decrease risk of RDS --> latency antibiotics: ampicillin and azithromycin to treat subclinical chorioamnionitis --> immediate delivery: should NOT wait for expectant management because >34wks is safe for delivery, and delivery decreases incidence of chorioamnionitis)

Medications required for pregnant women presenting with preterm labor (without yet ROM)

Betamethasone, nifedipine, and ampicillin (betamethasone: used to promote fetal lung maturity --> nifedipine: tocolytic used to delay progression of labor to allow betamethasone to work --> ampicillin: used as GBS prophylaxis since she has unknown GBS status, should be continued until culture is negative or labor stops)

Causes of DKA in pregnant mothers with T1DM

Betamethasone, terbutaline, hyperemesis gravidarum, and infections

When can you offer amniocentesis to a high-risk pregnant woman?

15-20 weeks (amniocentesis: transabdominal aspiration of amniotic fluid using US-guided needle --> should ONLY be used for genetic testing/evaluate chromosomal abnormalities --> indicated if AMA/mother >35yrs at time of delivery --> complications: pain/cramping, vaginal spotting, 1-2% amniotic fluid leakage, symptomatic amnionitis, and lower risk of fetal loss than CVS at <0.5%)

How many pounds should an overweight woman gain during pregnancy?

15-25 pounds (women with BMI 25-30 should gain about 15-25lbs)

How often does PPROM occur between 16-26wks gestation?

1% (however PPROM occurs in 1/3 of all preterm deliveries --> recurrence rate is 32% in subsequent pregnancies --> can reduce risk by giving 17 alpha-hydroxyprogesterone weekly from 16-36wks)

What changes should be seen in a 1st time mom in active phase (1st stage of labor)?

1.2 cm/hour

What changes should be seen in a 2nd time mom in active phase (1st stage of labor)?

1.5 cm/hour

Normal fetal movement

10 movements in 2 hours (indicates normal fetal acid-base status and low risk of fetal demise)

When can you offer cell-free fetal DNA test to pregnant women?

10 weeks (cell-free DNA: uses maternal serum to obtain fetal DNA and screen for aneuploidy, can be performed >10wks --> most effective SCREENING test for Down syndrome with 99% detection rate --> still need to CONFIRM diagnosis of aneuploidy with amniocentesis)

When is chorionic villus sampling (CVS) generally performed?

10-12 weeks (CVS: involves transvaginal or transabdominal aspiration of precursor cells in intrauterine cavity --> samples chorionic frondosum that contains most mitotically active villin in placenta that can be analyzed for fetal chromosomal abnormalities, biochemical, or DNA-based studies to test for mutations --> recommended for AMA >35yrs, hx of IUFD, or hx of infant with birth defects/intellectual disability --> complications: preterm delivery, PROM, fetal injury/limb defects especially if performed <9wks, and higher risk of fetal loss at 1%)

How often does PROM occur in pregnancies?

10-15%

What is the cutoff for hemoglobin to diagnose anemia in 2nd trimester?

10.5 (aka pregnant women need to have Hgb <10.5g/dL for diagnosis of anemia)

How much blood loss must occur to be diagnosed as PPH during C-section?

1000 cc (any EBL >1000cc during C-section is diagnosed as PPH --> treat with uterine massage, oxytocin/methergine, uterine/internal iliac artery embolization, or total abdominal hysterectomy)

How many cm is a woman dilated at the end of prolonged active phase (end of 1st stage of labor)?

10cm (aka cervix is fully/completely dilated --> allows her to transition to 2nd stage of labor)

What is the cutoff for hemoglobin to diagnose anemia in 1st and 3rd trimesters?

11 (aka pregnant women need to have Hgb <11g/dL for diagnosis for anemia)

When is the 1st trimester screen normally performed?

11-13 weeks (first trimester screen/FTS: combines NT, PAPP-A, and b-hCG to screen for trisomy 21/18/13 --> detects Down syndrome with 85% sensitivity --> NT: nuchal translucency measured via US that will be INCREASED in trisomy 21 --> PAPP-A: pregnancy associated plasma protein A that will be DECREASED in trisomies --> bhCG: beta-hCG that will be INCREASED in trisomy 21, DECREASED in trisomy 18/13)

How many pounds should an obese woman gain during pregnancy?

11-20 pounds (for any woman with BMI >30, should only gain 11-20lbs)

At how many weeks gestation is the fundal height usually around the pubic symphysis?

12 weeks (uterus should now be size of grapefruit)

What is the target 2-hour postprandial blood glucose level for a pt with GDM?

120 (aka want pt with GDM to have 2hr postprandial BG <120mg/dL)

What is the target 1-hour postprandial blood glucose level for a pt with GDM?

140 (aka want pt with GDM to have 1hr postprandial BG <140mg/dL)

At how many weeks gestation can you determine the sex of the baby?

16 weeks (around the time when the formation of external genitalia is complete)

Definition of menopause

Absent menses for 12 months (diagnose via clinical symptoms + elevated FSH --> also need to order TSH to rule out hypothyroidism)

What defines abnormal cells in colposcopy?

Acetowhite changes (occurs in abnormal lesions after application of acetic acid)

Which substance is measured in amniotic fluid measurement for a fetus with suspected Rh hemolytic disease?

Bilirubin (in severely erythroblastic fetus, amniotic fluid stained yellow due to bilirubin --> quantify bilirubin by spectrophotometric measurements of optical density between 420-460nm, aka wavelength absorbed by bilirubin --> deviation from linearity of optical density reading at 450nm/delta-OD 450 due to presence of heme pigment and indicates SEVERE HEMOLYSIS)

Which medications are contraindicated in pregnancy due to risk of renal failure, oligohydramnios, and hypocalvaria?

ACE inhibitors

What is the best next step in management when prenatal visit US reveals IUGR?

AFI, umbilical artery Doppler, and NST (AFI: used to assess for oligohydramnios which is common in IUGR due to chronic hypoxia, resulting in reduced fetal blood volume/RBF/UOP --> umbilical artery Doppler: will show INCREASED S/D ratio in IUGR fetuses due to increased vascular resistance, resulting in absence/reversal of end-diastolic flow --> NST: should be use to detect fetal asphyxia and assess FWB, could also use CST/BPP)

Tumor marker for yolk sac tumor

AFP (yolk sac tumor: ovarian endodermal sinus tumor that presents in sacrococcygeal area in YOUNG CHILDREN as yellow, friable, solid mass --> histo: Schiller-Duval bodies)

Which tests are involved in the 2nd trimester triple screen?

AFP, bhCG, and estriol (AFP: alpha fetoprotein that will be ELEVATED in neural tube defects and DECREASED in trisomy 21/18 --> bhCG: beta-hCG that will be ELEVATED in trisomy 21 and DECREASED in trisomy 18 --> uE3: estriol that will be DECREASED in both trisomy 21/18 --> has 68% detection rate for trisomy 21)

Which tests are involved in the 2nd trimester quad screen (performed between 16-18wks)?

AFP, bhCG, estriol, and inhibin A (AFP: alpha fetoprotein that will be ELEVATED in neural tube defects and DECREASED in trisomy 21/18 --> bhCG: beta-hCG that will be ELEVATED in trisomy 21 and DECREASED in trisomy 18 --> uE3: estriol that will be DECREASED in both trisomy 21/18 --> inhibin A: will be INCREASED in trisomy 21 --> has 81% detection rate for trisomy 21)

Intrapartum management for HIV(+) mom with viral load <1000 copies/mL

ART and vaginal delivery (infant still needs to take zidovudine/AZT for >6wks)

Intrapartum management for HIV(+) mom with viral load >1000 copies/mL

ART, zidovudine, and C-section (in addition, infant needs to take multi-drug ART for >6wks)

32yo G1P0 at 34wks presents with constant, severe, stabbing RUQ that suddenly started yesterday, as well as rigors and chills Vitals: fever of 101.7°F, BP 136/84, HR 105, RR 22, BMI 38, FHR 170bpm with moderate variability PE: scleral icterus, tenderness to palpation in RUQ with no rebound or guarding, bilateral 1+ pedal edema to midcalf Labs: high WBCs, high total bilirubin, high CB, normal AST/ALT

Acute cholangitis (ascending infection of the biliary tree caused by biliary obstruction, common in pregnant women due to increased risk for cholesterol gallstone formation --> caused by elevated levels of progesterone/estrogen that promote gallbladder stasis and cholesterol supersaturation, which become impacted in common bile duct and result in biliary obstruction --> presents with CHARCOT'S TRIAD of fever, jaundice, and RUQ pain --> labs: elevated total bilirubin, CB, and AP --> diagnose via abdominal US showing dilated common bile duct or choledocholithiasis --> treat with broad-spectrum antibiotics and biliary drainage via ERCP within 24-48hrs --> complications: Reynolds pentad with fever, jaundice, RUQ pain, hypotension, and altered mental status)

24yo G1P0 with twin pregnancy at 30wks presents with 1-day hx of severe epigastric and RUQ stabbing pain, nausea, and 7 episodes of vomiting PE: BP 136/86, HR 108, pale and scleral icterus, tenderness to palpation over RUQ and epigastric region with no rebound, and non-tender uterus with no palpable contractions Labs: low platelets, high WBCs, low glucose, high AP, high AST, high ALT

Acute fatty liver of pregnancy (AFLP: rare but life-threatening condition in 3rd trimester caused by defective maternal-fetal fatty acid metabolism resulting in microvesicular fatty infiltration of hepatocytes, usually in moms with multiple gestation --> results in hepatic inflammation that can lead to fulminant liver failure --> presents with nausea, vomiting, RUQ/epigastric pain, scleral icterus, and profound hypoglycemia --> labs: elevated WBCs, thrombocytopenia, AST/ALT, AP, bilirubin --> treat with IMMEDIATE DELIVERY --> complications: DIC, acute kidney injury, and fetal hypoxemia due to placental hypoperfusion)

Most common cause of sepsis in pregnancy

Acute pyelonephritis (ASCENDING infection from urinary tract to kidneys, usually cased by E. coli, and has increased rates in pregnancy due to kidneys increasing in size/ureter dilation in pregnancy --> presents with back pain, back tenderness, elevated WBCs, and urinalysis showing multiple WBCs --> treat with IV ceftriaxone + gentamicin)

46yo F presents with 1-year hx of increasingly heavy menses with 5 days of heavy bleeding, increasingly painful menses unrelieved by ibuprofen, and constant dull pelvic pain between menses PSH: three C/S deliveries and bilateral tubal ligation PE: soft tender globular uterus that measures 11wks Labs: neg urine pregnancy test, Hgb 9.8, platelets 180K

Adenomyosis (abnormal collection of endometrial glands and stroma within uterine myometrium --> risk factors: multiparous women age >40yrs, and prior uterine surgery such as myomectomy/C-sections --> presents with new onset of dysmenorrhea, heavy menstrual bleeding, chronic dull pelvic pain, and symmetrically enlarged/globular soft tender uterus <12wks size --> screen via MRI/US showing thickened myometrium --> definitively diagnose via histology after hysterectomy --> treat with OCPs and hysterectomy)

When can you start to offer PUBS for a pregnant women with fetus at risk of fetal anemia?

After 17 weeks (usually performed between 20-32 weeks after positive MCA doppler in setting of alloimmunization --> if MCA doppler is positive >32wks, just deliver baby)

At what age should a woman start receiving yearly screening mammograms?

Age 40 (all women should receive yearly mammogram --> women with >20% risk of developing breast cancer should also get breast MRI)

At what age should you begin colonoscopy screening if someone has a 1st-degree relative with colon cancer before age 60?

Age 40 (or 10yrs before youngest relative diagnosis --> these patients then need repeat colonoscopy every FIVE YEARS instead of every 10yrs)

When should women be offered colorectal cancer screening?

Age 45 (have the option of yearly hemoccult testing, flexible sigmoidoscopy every 5yrs, or colonoscopy every 10yrs)

Major non-modifiable osteoporosis risk factors

Age, menopause, low body weight, malabsorption disorder, hypercortisolism, hyperthyroidism, hyperparathyroidism, autoimmune disorders, liver disease, and renal disease

2nd trimester fetal US: edematous scalp and nuchal fold, fetal abdomen with large amount of echolucent fluid, normal biparietal diameter, MVP 12cm, and placenta thickened to 6cm

Alpha thalassemia major (caused by both parents having "cis" aa/-- genotype of alpha-thalassemia minor --> fetus inherits loss of all 4 alpha-globin genes, leading to no alpha-globin production --> fetuses form gamma tetramers/Y4 known as Hb Barts, which has extreme affinity for O2 and does not release O2 to tissues --> results in severe fetal hypoxemia, causing high-output cardiac failure and hydrops fetalis --> presents in fetuses with hydrops fetalis and NORMAL biparietal diameter/femur length)

Best method to DIAGNOSE chromosomal abnormality in pregnant woman

Amniocentesis (only way to DIAGNOSE chromosomal abnormalities, can be done at 15-20wks --> cell-free DNA is best SCREENING method and detects >99% of cases of Down syndrome, can be performed >10wks)

Best treatment for FHTs showing persistent variable decelerations

Amnioinfusion (infusion of normal saline into uterus through IUPC to alleviate cord compression --> usually only used for severe variable decelerations occurring with >50% of contractions)

Male fetus delivered at 36wks presents with cleft lip/palate, congenital amputation of digits, clubfoot, and constriction rings around arms/legs

Amniotic band sequence (congenital disorder caused by entrapment of fetal parts in fibrous amniotic bands while in utero --> presents with congenital amputations, constriction rings around digits/arms/legs, clubfoot, cleft lip/palate, congenital lymphadema, and hemangiomas --> usually non-fatal, and infants are treated with plastic and reconstructive surgery)

Which anti-Rhesus antibodies can cause hemolytic disease of the newborn?

Anti-D, anti-Kell, and anti-Duffy antibodies (need to be at critical titer level, usually >1:16)

Which anti-Rhesus antibody poses NO harm to fetus?

Anti-Lewis antibodies

Treatment of septic pelvic thrombophlebitis

Antibiotics and anticoagulation (antibiotics: should use broad-spectrum such as Ampicillin + Gentamicin + Clindamycin --> anticoagulation: should use short-term heparin/Lovenox postpartum)

35yo G4P1021 at 7wks presents for recent episode of vaginal bleeding/cramping and nausea that has since subsided 6mo ago pt had sudden right arm weakness and slurred speech, which resolved spontaneously in 2hrs PMH: 1 normal-term delivery and 2 early 1st-trimester pregnancy losses Vitals: BP 140/80, BMI 30 PE: closed cervix and no vaginal bleeding Pelvic US: empty uterus Labs: b-hCG 23

Antiphospholipid syndrome (APS: autoimmune condition caused by autoantibodies that mediate hypercoagulable state that result in recurrent vascular thrombosis and pregnancy complications from placental thrombosis --> presents with recurrent transient ischemic attacks/strokes or DVTs, recurrent 1st trimester losses/IUFD/preeclampsia/ IUGR, and presence of >1 anti-cardiolipin antibody, lupus anticoagulant, and anti-B2 glycoprotein antibody --> treat with HEPARIN to prevent VTE during pregnancy, and treat non-pregnant women with long-term warfarin --> other fun facts: anti-cardiolipin antibody causes false positive VDRL/RPR, and lupus anticoagulant causes prolonged PTT not corrected by normal platelet-free plasma)

Which condition is the most "thrombogenic" of all heritable coagulopathies?

Antithrombin III deficiency (inherited deficiency of ATIII: loss of antithrombin causes unopposed actions of factors 2a and 10a --> no effect on PT/PTT/thrombin time but diminishes increase in PTT following heparin administration --> highest risk of VTE during pregnancy --> can also be acquired from renal failure/nephrotic syndrome due to antithrombin loss in urine)

Management of pregnant women with history of HSV infection

Antiviral prophylaxis at 36 weeks (acyclovir or valacyclovir given to ALL pregnant women beginning at 36wks with hx of HSV regardless of symptoms --> reduces asymptomatic viral shedding and risk of vertical transmission to fetus --> if lesion/prodromal sx present during labor, requires C-section)

Which blood vessel gives rise to the ovarian artery?

Aorta

27yo G2P1 woman at 18wks presents with 24hr hx of fever, nausea, vomiting, loss of appetite, and mid-abdominal pain PE: fever of 102°F, decreased bowel sounds, and RLQ tenderness with rebound and guarding

Appendicitis (most common indication for surgical abdominal exploration during pregnancy --> presents with fever, anorexia, nausea, vomiting, and right-sided pain not always in RLQ due to enlarged uterus shifting appendix upward and outward toward flank --> diagnose with graded compression US --> treat with immediate surgery)

Which test is indicated for pregnant women with non-reactive non-stress test OR who are at risk for placental dysfunction (gestational HTN or pre-eclampsia)?

Biophysical profile

55yo postmenopausal woman presents with several week hx of occasional bloody spotting on her toilet paper PE: BMI 32, spare pubic hair and fissures along vestibule, vaginal with multiple areas of petechiae, cervix flush with vaginal wall, minimal clear vaginal discharge UA: normal FOBT: negative Pelvic US: small anteverted uterus with 3mm endometrial stripe

Atrophic vaginitis (genitourinary syndrome of menopause: physiologic decline in estrogen production from depleted ovarian follicles --> causes diminished blood flow and decreased collagen/glycogen production in vulvovaginal tissue, resulting in loss of vaginal epithelial elasticity + vaginal atrophy + reduced normal vaginal lactobacilli activity --> atrophic urogenital epithelium becomes thin/dry/easily denuded, resulting in vesitbular fissures and vaginal petechiae --> presents with vulvar/vaginal bleeding, dryness/irritation/ pruritus, dyspareunia, recurrent UTIs, and pelvic pressure --> PE: sparse pubic hair, loss of vaginal rugae with pale mucosa, vaginal petechiae/fissures, loss of labial volume, narrowed introitus, and shortened vaginal making cervix flush with vaginal wall --> diagnose via elevated vaginal ph >5 --> treat with vaginal moisturizers/lubricant and topical vaginal estrogen)

Most common abnormal karyotype encountered in spontaneous abortuses

Autosomal trisomy (accounts for 40-50% of SABs --> most common is trisomy 16)

Most common abnormal karyotype causing spontaneous abortion

Autosomal trisomy (accounts for 40-50% of spontaneous abortions --> monosomy X accounts for 15-25% of losses --> triploidy accounts for 15% --> tetraploidy accounts for 5%)

Treatment of chlamydia ONLY

Azithromycin (preferred because it only requires single dose and safe in pregnancy --> can also use doxycycline)

Treatment of gonorrhea ONLY

Azithromycin and ceftriaxone (require BOTH meds due to increasing cephalosporin resistance of gonococcal infections)

Which measurement system is used to determine the status of cervix for successful vaginal delivery?

Bishop score (gives a score of 0-3 points for each of the five factors of cervical exam --> Bishop score >6 indicates probability of vaginal delivery with induction of labor is similar to that of spontaneous labor)

Management of shoulder dystocia

BE CALM (breathe/do not push --> elevate legs and flex hips/thighs against abdomen, aka McRoberts --> call for help --> apply suprapubic pressure --> enLarge vaginal opening with episiotomy --> MANEUVERS: deliver posterior arm, rotate posterior shoulder/Woods screw, adduct posterior fetal shoulder/Rubin, all fours position/Gaskin, and replace fetal head into pelvis for C-section/Zavanelli)

Which four findings are always recorded during prenatal visits?

BP, urine dip, fundal height, and fetal HR

What is the best next step in management of a fetus with non-reactive NST for 40mins, and non-reactive vibroacoustic stimulation?

BPP (biophysical profile: combines NST and US to look at 5 factors --> NST, breathing, body movement, tone, and amniotic fluid --> each factor worth 2 points, want to score at least 8-10pts for normal --> abnormal BPP score <6pts indicates fetal hypoxia due to placental dysfunction --> risk factors: AMA, tobacco use, HTN, diabetes --> abnormal BPP <36wks indicates contraction stress test, while abnormal BPP >36wks indicates immediate delivery)

Most important characteristic of baseline FHR

BTBV (beat-to-beat variability: variation of successive beats in FHR controlled by ANS --> ↑FHR due to activation of SNS, while ↓FHR due to activation of the PSNS --> constant push and pull of SNS and PSNS creates the BTBV, which indicates intact fetal CNS that should be seen >28wks)

Which renal function tests DECREASE during pregnancy?

BUN and creatinine (BUN: should be <13 during pregnancy --> creatinine: should be between 0.4-0.8 during pregnancy)

Vaginal discharge: thin white discharge with foul "fishy" odor

BV (bacterial vaginosis: caused by Gardnerella vaginalis --> risk factors: multiple sex partners, douching, lack of vaginal lactobacilli, and cig smoking --> presents with thin white vaginal discharge with foul odor --> diagnose via wet mount with clue cells and positive KOH whiff test --> treat with metronidazole or clindamycin)

21yo presents with thin gray vaginal discharge with "strange smell." Denies pain/itching or burning during urination. Wet mount microscopy: multiple squamous epithelial cells with stippled appearance along outer margin

Bacterial vaginosis (BV: infection with Gardnerella vaginalis, a pleomorphic gram-variable rod that infects vagina via sexual activity or overgrowth of anaerobic bacteria in vagina --> presents with thin gray vaginal discharge with "fishy" smell, NO PAIN, and urine pH >4.5 --> diagnose via wet mount microscopy showing clue cells aka vaginal epithelial cells covered with Gardnerella, OR amine whiff test when mixing discharge with 10% KOH to enhance fishy odor --> treat with metronidazole or clindamycin)

Which types of vaginitis are associated with increasing vaginal pH (pH >4.5)?

Bacterial vaginosis and trichomoniasis

Methods to augment labor

Balloon, misoprostol, dinoprostone, oxytocin, or amniotomy (balloon used for cervical ripening --> misoprostol/cytotec is PGE1 agonist while dinoprostone is PGE2 agonist, also used for cervical ripening but CONTRAINDICATED in pts with prior uterine surgery --> oxytocin helps stimulate contractions --> amniotomy is AROM and performed AS LAST RESORT)

22yo presents with discomfort during sitting and sexual intercourse SH: gymnast with balance beam, sexually active with 2 male partners, uses IUD for contraception PE: mobile, soft, non-tender, flesh-colored, 2cm cystic mass at 4 o'clock position at base of left labium majus

Bartholin duct cyst (obstruction of Bartholin ducts, which are located at 4 and 8 o'clock positions in POSTERIOR vulvar vestibule and drain Bartholin glands to provide vulvovaginal lubrication --> obstruction due to accumulation of mucus or 2° to edema/trauma --> causes proximal duct distension, resulting in cyst formation --> presents with soft mobile non-tender cystic mass at base of labia majora, and can be ASYMPTOMATIC or cause discomfort during walking/sitting/sexual intercourse --> no treatment if asymptomatic, treat with incision and drainage + Word catheter if symptomatic or abscess)

Which structures are located bilaterally at posterior vaginal introitus?

Bartholin glands (located bilaterally at posterior vaginal introitus --> Bartholin ducts then drain gland into vulvar vestibule at 4 and 8 o'clock positions to provide vulvovaginal lubrication)

Which pattern should the cervical mucus have during pregnancy?

Beaded pattern (should look like cells, due to PROGESTERONE --> decreased sodium chloride in mucus --> no crystallization --> BEADING instead of ferning)

2nd trimester fetal US: EFW at 99th percentile, abdominal wall defect, and MVP 12cm

Beckwith Wiedemann syndrome (caused by WT2 mutation --> presents in FETUSES with polyhydramnios, macrosomia, and omphalocele --> presents in INFANTS with Wilms tumor, macroglossia, organomegaly, and hemihyperplasia)

Best position for lactation

Belly to belly (baby's belly needs to be touching mother's belly for infant to be in good position for latch)

Treatment for patients in preterm labor <32wks

Betamethasone, indomethacin, magnesium sulfate, and penicillin (betamethasone: increases fetal lung maturity --> indomethacin: tocolytic to decrease labor to buy time for betamethasone --> magnesium sulfate: provides fetal neuroprotection to prevent cerebral palsy --> penicillin: if GBS status unknown)

Treatment for stress incontinence

Bladder training, Kegels, and surgery with midurethral sling

52yo postmenopausal woman presents with 2wk hx of pruritic rash on inguinal region and vulva that worsens with tight clothing PMH: asthma, recently hospitalized with exacerbation and treated with inhaled bronchodilators and systemic steroids PE: BMI 32, erythematous plaques within inguinal folds symmetrically, and multiple small lesions on groin

Candida intertrigo (candida vulvitis: dermatitis caused by Candida albicans that typically occurs within inguinal, axillary, gluteal, and inframammary folds --> most common cause of vulvar pruritus and associated with diabetes mellitus and immunocompromised pts, associated with increased skin moisture or friction from obesity/tight-fitting clothing that causes skin maceration/trauma --> presents with erythematous "beefy red" plaque within inguinal folds, vulvar erythema and pruritus, and small satellite lesions on groin and inner thigh --> diagnose via microscopic exam of skin scrapins that show hyphae or pseudohyphae --> treat with topical clotrimazole or ketoconazole)

22yo G2P1 who has been exclusively breastfeeding 3mo-old daughter presents with sore nipples and burning pain in breasts that is worse on breastfeeding PE: tips of nipples are pink and shiny with peeling at periphery

Candida of the nipple (mammary candidosis: caused by candida of baby's oral cavity transmitted to mother's nipple --> presents with severe discomfort/nipple pain and "shiny" pink nipples with peeling --> treat mother with topical antifungal such as clotrimazole or miconazole, with addition of topical antibiotic due to concurrent Staph aureus infection --> treat baby with oral nystatin, followed by oral fluconazole)

Vaginal discharge: thick white/yellow discharge and mucosal erythema

Candidasis (vaginal yeast infection: caused by infection with Candida albicans --> risk factors: use of broad-spectrum antibiotics, diabetes, immunodeficiency --> presents with vulvar/vaginal pruritus, burning, dysuria, dyspareunia, vulvar edema/erythema, and white/yellow cottage cheese-like discharge --> diagnose via microscopic exam of 10% KOH prep: branching hyphae and spores --> treat with topical or vaginal suppository miconazole/terconazole, nystatin suppository, or oral fluconazole)

Which uterotonic agent is administered as an IM injection?

Carboprost (Hemabate: PGF2-alpha: used to contract down uterus during uterine atony if oxytocin fails, injected via IM --> contraindicated in ASTHMATICS due to potent bronchoconstrictor effects --> side effects: diarrhea, fever, tachycardia)

Which ligament contains the uterine artery and vein?

Cardinal ligament (transverse ligament: connects cervix to side wall of pelvis, and also attaches uterus to bladder and rectum --> contains uterine artery and vein --> needs to be ligated during hysterectomy --> runs ABOVE ureter, thus risk of ureter injury during ligation of uterine vessels)

Two indications for operative vaginal delivery during 2nd stage of labor

Category 3 FHT and maternal exhaustion

Treatment for GBS patients in pregnant women mildly allergic to penicillin

Cefazolin (1st gen cephalopsorin: can be given due to lower risk of cross-reactivity but can achieve same high bactericidal concentrations in amniotic fluid without fetal toxicity)

Which prenatal screening test has the highest Trisomy 12 detection rate?

Cell-free DNA (most effective SCREENING test for Down syndrome with 99% detection rate --> can be performed from >10wks --> note: only way to DIAGNOSE Down syndrome is amniocentesis)

Intrapartum pelvic exam: molding and caput on fetal head

Cephalopelvic disproportion (molding: change in fetal skull shape as maternal expulsive efforts sculpt fetal head into shape of pelvis to facilitate delivery --> caput: scalp edema due to prolonged pressure)

53yo postmenopausal F presents with dark brown vaginal spotting yesterday, that has increased to now soaking thru thick menstrual pad every 2hrs PE: dark red blood in posterior vaginal vault, and 3cm friable mass on ectocervix extending laterally and actively bleeding Labs: Hgb 10.2 Pelvic US: thin endometrial stripe and no adnexal masses

Cervical cancer (squamous cell cervical carcinoma: caused by persistent infection with high-risk HPV16 and HPV18 --> risk factors: hx of STDs, early onset sexual activity, multiple or high-risk sexual partners, immunosuppression, OCP use, low SES, and tobacco use --> presents with heavy bleeding and laterally extending, friable cervical mass --> diagnose via direct biopsy --> treat with excision, radiation, or chemo)

Diagnosis of protracted active labor

Cervical dilation less than 1cm every 2 hours (active phase protraction: commonly caused by cephalopelvic disproportion --> more common in pregnancies >41wks, fetal anomaly, fetal malposition such as occiput posterior, maternal obesity/excessive weight gain during pregnancy, nulliparity, AMA, and inadequate contractions --> requires immediate IUPC to determine strength of contractions)

29yo G3P0 with hx of two prior 2nd trimester pregnancy losses presents for prenatal are at 8wks gestation Gyn hx: both losses associated with uncomplicated gestation, and then pink-tinged discharge with complete cervical dilation and amniotic sac bulging into vagina on evening of losses with spontaneous delivery of fetus/placenta

Cervical insufficiency (incompetent cervix: painless dilation and effacement of cervix in 2nd trimester of pregnancy, exposing fetal membranes to vaginal flora and causing PPROM, and causes 15% of all 2nd trimester losses --> associated with hx of cervical surgery such as cone biopsy/LEEP, hx of cervical lacerations, uterine anomalies, and hx of DES exposure in utero --> presents with mild abdominal cramping, excessive cervical dilation, and amniotic sac bulging thru cervix/PPROM --> treat with cerclage, aka suture placed vaginally around cervix at cervical-vaginal junction or at internal os to close cervix, around 12-14wks gestation that is removed around 36-38wks)

27yo F presents with 4mo hx of increasingly severe pain during menstrual periods Menstrual hx: regular every 28d, last 5-7d, light flow PSH: LEEP for cervical dysplasia 6mo ago PE: normal vagina, small scarred cervical os, slightly enlarged and tender uterus

Cervical stenosis (scarring of cervical os from surgical/obstetric trauma resulting in partial or complete closure of endocervical canal --> in premenopausal patients, causes blood to buildup inside uterus during menses --> associated with cold-knife conization and LEEP procedures for CIN2/3 --> presents with secondary amenorrhea, dysmenorrhea, and infertility --> treat with cervical dilators, laser ablation of scarring, or hysteroscopic shaving of cervical tissue)

Two major complications of cervical cone biopsy/LEEP

Cervical stenosis and cervical insufficiency

26yo G1P1 with no prenatal care delivers an SGA male infant via NSVD Newborn PE: microcephaly, closed anterior fontanelle, partially collapsed skull, multiple contractures and right clubfoot, and marked hypertonia Newborn imaging: thin cerebral cortices and multiple intracranial calcifications within cerebral cortex

Congenital Zika syndrome (caused by maternal infection with Zika virus from Aedes mosquito bite or sexual transmission, resulting in asymptomatic maternal infection with ssRNA Flavivirus that is then transmitted placentally to fetus --> Zika virus preferentially destroys fetal neural progenitor cells, resulting in abnormal brain development and neuronal destruction --> presents with SEVERE MICROCEPHALY >3 std deviations below mean, closed anterior fontanelle/craniosynostosis, skull collapse, multiple contractures, hypertonicity, spasticity, seizures, and ocular abnormalities --> neuroimaging: thin cerebral cortices/cortical thinning, multiple intracranial calcifications, and ventriculomegaly --> diagnose via RT-PCR Zika RNA detection in newborn serum/urine/CSF --> no treatment, prevention is avoiding travel to tropical mosquito-infected regions during pregnancy)

Presence of anti-Ro (anti-SSA) and anti-La (anti-SSB) are associated with which fetal anomaly?

Congenital heart block (often seen in babies born to mothers with SLE/Sjogren syndrome that are positive for anti-Ro and anti-La)

Fetal US: hydrocephalus, ventriculomegaly, and intracranial calcifications

Congenital toxoplasmosis (congenital Toxoplasma gondii parasitic infection from acquired from MATERNAL infection, transmitted via cat feces/cysts in soil/undercooked meat --> presents in MOTHERS with mono-like illness OR mild fever + diffuse nonpruritic maculopapular rash that resolves spontaneously in a few days --> presents in FETAL US with intracranial calcifications within basal ganglia, bilateral ventriculomegaly, and hydrocephalus --> presents in NEONATES with chorioretinitis, hydrocephalus, intracranial calcifications, and SEIZURES --> also associated with blueberry muffin rash, hearing loss, visual disturbances, developmental delay --> diagnose via amniocentesis for T. gondii PCR testing --> treat with prenatal spiramycin or pyrimethamine/sulfadiazine/ folinic acid)

What is the best next step in management of a baby <36wks with non-reactive NST for 40mins, non-reactive vibroacoustic stimulation, and BPP <8pts?

Contraction stress test (basically NST but while mom is having regular contractions, aka 3-4 contractions/10 mins --> performed by administering oxytocin or using nipple stimulation until 3 contractions occur every 10mins --> contraindications to CST: placenta previa and prior uterine surgery)

Gold standard for diagnosis of lower extremity DVT

Contrast venography (aka duplex venous ultrasonography: however due to complications and time consuming nature of venography, most doctors use compression US --> impedence pthysmography better for larger veins)

What is the best method of contraception for a patient with breast cancer?

Copper IUD (non-hormonal IUD that creates chronic cytotoxic inflammatory response to inhibit sperm entry --> 99% effective and works for up to 10yrs --> preferred for patients with breast/ovarian/endometrial cancer because it is non-hormonal and will NOT cause proliferation of breast/ovarian/endometrial tissue --> side effects: heavy menstrual bleeding, CONTRAINDICATED in women with hypermenorrhea or anemia)

Which type of contraception should a patient with heavy menstrual bleeding avoid?

Copper IUD (non-hormonal IUD that works for up to 10yrs --> can cause heavy menstrual bleeding and should not be placed in women with hypermenorrhea or anemia)

What is the next best step in management for a woman >30yrs with a solid palpable mass and mammogram finding suspicious of malignancy?

Core needle biopsy (findings on mammogram that are most suggestive of malignancy: spiculated mass, architectural distortion with retraction, asymmetric localized fibrosis, microcalcifications with linear branched patterns, increased vascularity, or altered subareolar duct pattern)

Pelvic US: gestational sac at upper left uterine cornu and free fluid in posterior cul-de-sac

Cornual ectopic pregnancy (interstitial ectopic pregnancy: abnormal implantation of embryo in OUTER quadrants/cornual areas of uterus, with high risk of intra-abdominal bleeding and hemoperitoneum if cornu ruptures --> risk factors: uterine anomalies such as bicornuate uterus, and IVF --> presents with acute abdomen aka diffuse abdominal pain with guarding and decreased bowel sounds, vaginal bleeding with passage of clots, and hypovolemic shock --> diagnose via TVUS showing fluid in posterior cul-de-sac and gestational sac in uterine cornu --> manage with emergency surgical exploration)

Treatment for dermoid cyst of ovary (teratoma/germ cell tumor of ovary)

Cystectomy without oophorectomy

Cervical exam shows anterior prolpase

Cystocele (bladder prolapse into vagina, causing urinary stress incontinence --> combo of inadequate bladder support and pelvic floor muscle weakness results in urethral hypermobility, in which urethra abnormally moves with increased intra-abdominal pressure and is unable to fully close --> allows urine to leak with increased intra-abdominal pressure such as sneezing/coughing/tennis --> cervical exam shows Q-tip sign or anterior prolapse --> treat with pelvic floor muscle exercises and lifestyle modifications)

Tumor markers for granulosa cell tumor

Estradiol and inhibin (elevated in granulosa cell tumors due to proliferation of granulosa cells, which convert testosterone into estradiol and secrete inhibin to block FSH release --> presents with breast tenderness and diffuse fibrocystic changes, and postmenopausal thickened endometrium)

Which hormone is associated with physiologic leukorrhea?

Estrogen (leukorrhea: white odorless cervical discharge composed of cervical mucus + normal vaginal flora + vaginal squamous epithelium --> increased leukorrhea occurs during estrogen increase prior to menses at mid-cycle/10-14 days after menses, then regresses)

What does an increased S/D ratio from umbilical artery doppler indicate?

IUGR (in growth-restricted babies, increased resistance in placenta which SLOWS DOWN/DECREASES end diastolic flow --> INCREASED S/D in umbilical artery is ABNORMAL --> may also be associated with DECREASED S/D ratio in MCA doppler)

25yo G0 presents with pelvic and lower sacral back pain that has worsened over past year, intensifies a few days before menses, and improves toward end of period. Minimal improvement with ibuprofen. Gyn hx: sexually active with 1 male partner for past 4yrs, taking OCPs 6mo ago PE: tenderness in posterior vaginal fornix, decreased uterine mobility, and thickening of uterosacral ligaments Labs: normal Hgb and WBC

Endometriosis (ectopic implantation of endometrial glands/stroma that cause pain, cyclic hemorrhage, and accumulating fibrosis --> presents with chronic pelvic pain that worsens before menses, dysmenorrhea, dyspareunia, constipation/pain on defecation, and infertility --> PE: tenderness/nodularity of rectovaginal area, tenderness with movement of uterus, immobile uterus, and thickening of uterosacral ligaments --> treat with NSAIDs and/or OCPs --> if failure, treat with laparoscopy for direct visualization, biopsy, and removal of endometriotic lesions)

30yo F presents with heavy menstrual bleeding, severe pelvic pain occurring before menses, dyspareunia, and significant pain on BMs PE: adherent immobile uterus

Endometriosis (presence of ectopic endometrial tissue outside of endometrial cavity, usually in ovary and pelvic peritoneum --> presents with severe cyclic pelvic pain beginning 1-2wks before menses that subsides at onset of flow, abnormal bleeding, dyspareunia, and infertility --> PE: uterosacral nodularity on rectovaginal exam, and fixed immobile uterus --> diagnose via laparoscopy or laparotomy to see rust-colored/brown implants in pelvis and chocolate cysts in ovary --> treat with OCPs, danazol, lupron, or nafarelin to suppress FSH/LH --> can also treat with laparascopic cystectomy)

Most common cause of postpartum fever

Endometritis (ASCENDING infection of endometrium caused by childbirth --> most common caused by C-section, seen in 10-15% of cases --> also seen in 3% of vaginal births, associated with prolonged labor, prolonged ROM, multiple vaginal exams, internal fetal monitoring, manual removal of placenta, and low SES)

23yo G1P1 presents with fever on 3rd day after uncomplicated C-section performed 2° to arrest of descent PE: moderate breast engorgement and mild uterine fundal tenderness

Endometritis (ASCENDING maternal infection of endometrium after delivery, usually caused by mix of aerobes/anaerobes in genital tract --> most commonly seen after C-sections, also associated with prolonged labor/prolonged ROM/multiple vaginal exams/internal fetal monitoring/manual removal of placenta/low SES --> presents with postpartum fever and uterine/fundal tenderness --> treat with IV ampicillin + gentamicin + clindamycin)

Differential diagnosis for postpartum fever

Endometritis, UTI, lower genital tract infection, wound infection, pulmonary infection, thrombophlebitis, and mastitis (note: endometritis most common cause)

What are the cardinal movements of labor?

Engagement, descent, flexion, internal rotation, extension, and external rotation (1. Engagement: descent of biparietal diameter/fetal head thru plane of pelvic inlet, determined by palpation of presenting part of occiput --> 2. Descent: occurs when fetal head passes down into pelvis, occurring in active phase of stage 1/stage 2 of labor --> 3. Flexion: occurs when chin is passively brought close to fetal thorax --> 4. Internal rotation: turning of head that moves occiput gradually toward pubic symphysis --> 5. Extension: moves occiput toward fetal back, occurring after fetus has descending to level of maternal vulva and completing delivery of fetal head --> 6. External rotation/restitution: fetus resumes normal "face forward" position with occiput and spine lying in same plane --> after external rotation/restitution, can begin delivery of anterior shoulder)

57yo F presents with pelvic pressure and a feeling of a mass in vaginal for 2mo, symptoms worse while standing for long periods of time and relieved by lying down PSH: vaginal hysterectomy 10yrs ago PE: no anterior vaginal relaxation, and Valsava produces bulging posterior vaginal mass with origin high in vaginal vault

Enterocele (prolapse of the small intestine that occurs in women after hysterectomy --> presents with pelvic pressure/pain, heaviness in lower abdomen, and vaginal bulge that worsens at night or aggravated by prolonged standing/vigorous activity/lifting heavy objects --> diagnose via split-speculum exam showing UPWARD bulging of posterior vaginal vault during Valsava --> treat with Kegels, pessaries, or posterior colporrhapy with reinforcement of rectovaginal fascia/posterior vaginal vault)

Pelvic US: solid adnexal mass with thick septations, and moderate amount of peritoneal fluid

Epithelial ovarian carcinoma (malignancy of ovary, Fallopian tube, and peritoneum arising from surface epithelium --> most common is serous cystadenocarcinoma --> risk factors: ELDERLY women, infertility, endometriosis, PCOS, BRCA1/2 mutation, Lynch syndrome, family history --> presents with pelvic/abdominal pain, bloating, heaviness/early satiety --> diagnose via pelvic US showing large ovarian mass with thick septations, solid components, and peritoneal flee fluid/ascites --> labs: elevated CA-125 --> treat with exploratory laparotomy and surgical resection)

Newborn PE: unilateral upper arm adducted/internally rotated, elbow extended, forearm pronated, and wrist/fingers flexed Neuro exam: intact grasp reflex, absent Moro reflex, absent biceps reflex

Erb Duchenne palsy ("waiter's tip": traction or tear of upper trunk/C5-C6 roots caused by lateral traction on neck during delivery --> causes damage to deltoid, supraspinatus, infraspinatus, and biceps brachii --> presents with forearm pronated, arm adducted and medially rotated at shoulder, elbow extended, absent Moro reflex, and absent biceps reflex --> treat with gentle massage and PT to prevent contractures, and surgical intervention if no improvement by age 3-9mo)

24yo G1P0 at 10wks presents with severe N/V, inability to keep down fluids, and worsening chest discomfort that radiates to back PMH: obesity and appendectomy PE: dry mucous membranes and decreased skin turgor, mildly tender epigastrium, equal breath sounds, and retrosternal crunching sound with each heartbeat

Esophageal perforation (repeated vomiting episodes causes an effort rupture of esophagus, aka Boerhaave syndrome --> results in efflux of air into mediastinum, aka pneumomediastinum --> presents in mothers with REPEATED VOMITING with retrosternal chest pain radiating to back, epigastric pain, neck/precordial crepitus aka subcutaneous emphysema, crunching sound with each heartbeat aka Hamman sign, and pleural effusion with atypical/green fluid --> diagnose via esophagography or CT scan with water-soluble contrast showing leaking from esophagus, esophageal wall thickening, and mediastinal air/fluid collection --> treat with NPO, IV antibiotics, PPIs, and surgical debridement/repair --> complications: mediastinitis, septic shock, and death)

Causes of polyhydramnios

Esophageal/duodenal atresia, anencephaly, maternal diabetes, fetal anemia, and multiple gestations

60yo postmenopausal woman presents with postcoital bleeding that has progressed to daily vaginal spotting PE: small amount of blood in vaginal vault, normal cervix, right adnexal fullness and slightly enlarged uterus Labs: low Hgb Pelvic US: 11cm solid ovarian mass and no free fluid in pelvis Endometrial biopsy: complex hyperplasia without atypia

Granulosa cell tumor (ovarian sex cord-stromal tumor arising from granulosa cells that secrete high levels of estradiol and inhibin --> high estradiol levels then bind to ER receptors on breast causing breast proliferation, and ER receptors on endometrium resulting in endometrial hyperplasia/carcinoma --> presents with increasing abdominal girth, early satiety, AUB, postmenopausal bleeding, and possible breast tenderness and bilateral diffuse fibrocystic changes --> pelvic US: complex ovarian mass with solid components/septations and thickened endometrial stripe >4mm --> histo: Call-Exner bodies, aka cells in rosette pattern --> treat with surgery and also endometrial biopsy to rule out endometrial cancer --> monitor disease progression/recurrence with serum inhibin)

Pelvic US: complex ovarian mass with solid components and multiple septations, slightly enlarged uterus, and thickened endometrial stripe

Granulosa cell tumor (ovarian sex cord-stromal tumor arising from granulosa cells that secrete high levels of estradiol and inhibin --> high estradiol levels then bind to ER receptors on breast causing breast proliferation, and ER receptors on endometrium resulting in endometrial hyperplasia/carcinoma --> presents with increasing abdominal girth, early satiety, breast tenderness and bilateral diffuse fibrocystic changes, AUB, and postmenopausal bleeding --> pelvic US: complex ovarian mass with solid components/septations and thickened endometrial stripe >4mm --> histo: Call-Exner bodies, aka cells in rosette pattern --> treat with surgery and also endometrial biopsy to rule out endometrial cancer --> monitor disease progression/recurrence with serum inhibin)

3 signs of placental separation

Gush of blood, lengthening of cord and rise of uterine fundus with firmness

What is the best pelvic shape for vaginal delivery?

Gynecoid shape (has round to slightly oval pelvic inlet --> pelvic inlet diagonal conjugate >12.5cm --> distance between ischial spines >10cm --> pelvic outlet intertuberous diameter >8cm --> pubic arch >90°)

What is the best next step in management for a woman with possible exposure to Hep B via sexual contact, who has not been vaccinated?

HBIG and start HBV vaccination series (HBIG: post-exposure prophylaxis for Hep B initiated within 7 days after blood contact, and within 14 days after sexual exposure --> HBV vaccine: should be started immediately in non-vaccinated individuals)

35yo G2P1 at 31wks presents with several episodes of N/V, severe heartburn, and RUQ pain PE: BP 160/90, HR 86, tenderness to palpation in midline and RUQ with absence of rebound/guarding Labs: low platelets, low Hgb, elevated total bilirubin with normal CB, elevated AP/AST/ALT Urine dipstick: 2+ protein

HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count syndrome: affects 10-20% of woman with pre-eclampsia and caused by abnormal placentation triggering systemic inflammation and activation of coagulation system/complement cascade --> results in rapid consumption of platelets and MAHA, which leads to serious liver problems such as centrilobular necrosis/subscapular hematoma/thrombi in portal capillary system --> cause liver swelling with distension of hepatic/Glisson's capsule --> presents with N/V, RUQ pain, and severe HTN --> labs: anemia with elevated UCB, elevated AST/ALT, and thrombocytopenia --> peripheral blood smear: RBC fragments/schistocytes --> treat with immediate delivery, magnesium sulfate, and anti-HTN drugs)

In which patient population is routine screening for Trichomonas vaginalis done during pregnancy?

HIV-positive women

Which two factors increase during pregnancy to increase overall cardiac output?

HR and preload (increasing BOTH HR and SV causes increased CO --> elevated CO + reduced SVR results in overall decreased MAP)

Which complications are associated with obesity in pregnancy?

HTN, gestational diabetes, pre-eclampsia, and fetal macrosomia

Young female presents with hypothyroidism Neck exam: diffusely enlarged, non-tender thyroid gland

Hashimoto thyroiditis (autoimmune disorder caused by anti-TPO/anti-microsomal antibodies and anti-thyroglobulin antibodies --> associated with HLA-DR3 and HLA-DR5 --> presents with DIFFUSELY enlarged non-tender goiter and HYPOTHYROIDISM aka cold intolerance, weight gain, coarse brittle hair/nails, puffy facies and generalized non-pitting edema, constipation, proximal muscle weakness, AUB/amenorrhea, fatigue, delayed DTR relaxation, and bradycardia --> labs: elevated TSH, low free T4, hypocholesterolemia, and hyponatremia,--> diagnose via positive anti-TPO/microsomal antibody and variable radioiodine uptake --> histo: Hurthle cells, aka lymphoid aggregates with germinal centers --> complications: infertility, primary biliary cholangitis, marginal zone lymphoma)

Which condition is associated with early decelerations (onset/peak occurs BEFORE contraction)?

Head compression (early decelerations: result of increased vagal tone 2° to head compression during contractions, usually at cervical dilation of 4-7cm --> considered NORMAL during uterine contractions and indicate impending delivery)

Diagnosis of anemia in pregnant woman

Hemoglobin <10 or hematocrit <30%

Which test should be given to pregnant women with Hgb <11 and MCV <80?

Hemoglobin electrophoresis (pregnant women with microcytic anemia need to be screened for hemoglobinopathies such as thalassemia or sickle cell)

Multiple gestation with at least one IUP and one ectopic pregnancy

Heterotopic pregnancy (usually seen in IVF pregnancies when 1+ embryo was utilized)

What is the recommended treatment for a pregnant pt with hx of preterm labor and short cervix <2cm diagnosed on TVUS?

IM progesterone, cerclage, and serial TVUS (IM progesterone injections start in 2nd trimester --> cerclage placed at 12-14wks and removed at 36-38wks --> serial TVUS used to measure cervix length until 24wks)

Which major complication is most commonly associated with T1DM in moms?

IUGR (fetal growth restriction: related to degree of metabolic control in 1st trimester --> also have increased risk of polyhydramnios and congenital malformations such as VSD, transposition of great vessels, caudal regression syndrome, neural tube defects --> at birth, can be SGA/hypoglycemic/ polycythemic)

24yo F presents with painful bumps in her groin that cause sitting to become painful PMH: had these bumps previously but typically resolve within a few weeks and drain spontaneously PE: BMI 35, groin shows fibrotic bands/keloid formation, thickened plaques, and pitted acneiform scars

Hidradenitis suppurativa (chronic inflammatory condition that involves recurrent occlusion of hair follicles in intertriginous regions such as groin/axilla --> risk factors: obesity, tobacco use, family history --> initially presents as solitary painful nodule surrounding follicle that can persist for up to several months and develop into spontaneously draining abscess, and recurrences with multiple lesions/inflammation/abscess drainage eventually develops into sinus tract and scar formation --> presents in OBESE YOUNG WOMAN age 20-40yrs with hx of spontaneously draining abscess on groin, fibrotic bands and keloid formation, thickened plaques, and pitted acneiform scars --> treat with doxycycline --> complications: contractures, lymphatic obstruction, fistulas)

Why is fetal fibronectin test useful for screening in preterm labor?

High negative predictive value (fetal fibronectin test: checking for presence of fetal fibronectin in cervical mucus between 22-34wks, if positive indicates disruption/injury to maternal-fetal interface --> has NPV of 99.2% in symptomatic women, aka 99/100 pts with single negative test will NOT deliver in next 14 days --> has NPV of 96.7% in asymptomatic women <35wks --> however has low PPV and low sensitivity, aka pts with positive fetal fibronetic test may not necessarily go into delivery)

Treatment for lupus flare during pregnancy

High-dose methylprednisone

Side effects of tamoxifen

Hot flashes, VTE, and endometrial hyperplasia (tamoxifen is a selective estrogen receptor modulator/SERM: direct ANTAGONIST to estrogen in breast tissue, but AGONIST to estrogen in endometrium --> used as adjuvant therapy for ER-positive breast cancer and reduces risk of recurrence/development of new cancer in opposite breast --> also exhibits anti-estrogen activity in CNS to cause thermoregulatory dysfunction in anterior hypothalamus, resulting in hot flashes --> direct agonist activity in endometrium causes hyperplasia/polyps --> increased estrogen in bloodstream also increases protein C resistance, resulting in increased risk of VTE --> ALSO decreases blood lipid levels to prevent hypercholesterolemia, and decreases risk of ovarian cancer)

41yo F presents with 4mo hx of irregular spotting, 3wk hx of hot flashes/night sweats/palpitations, and 1-day hx of increasingly heavy vaginal bleeding with passage of small clots OB hx: LMP 4mo ago PMH: gastric bypass 7yrs ago and lost 99lbs since PE: BP 150/90, BMI 35, tachycardia, moderate amount of blood in vaginal vault and closed cervix, and enlarged uterus Pelvic US: enlarged uterus filled with a heterogenous mass composed of small cystic structures Labs: low TSH and elevated b-hCG

Hydatidiform mole (non-viable abnormal gestation composed of hypertrophic and hydropic placental trophoblastic villi --> risk factors: vitamin A deficiency caused by malabsorption, extremes of maternal age, and prior hx of HM --> presents with hyperemesis gravidarum, heavy vaginal bleeding with passage of clots, enlarged uterus, hyperthryoidism with hot flashes/tachycardia/smooth warm skin, and theca lutein cysts --> labs: SUPER HIGH hCG levels and low TSH --> diagnose via pelvic US: heterogenous cystic mass of cystic spaces, aka "snowstorm" --> treat with D&C, serial b-hCG post evacuation, and contraception for 6mo)

1st line drugs for maternal hypertensive crisis

Hydralazine, labetalol, or nifedipine (hydralazine: vasodilator given IV --> labetalol: non-selective alpha and beta blocker given IV --> nifedipine: calcium channel blocker given PO)

37yo G2P1 at 24wks presents with painful contractions and LOF, and delivers male fetus with no cardiac activity Newborn PE: edematous peeling skin, edematous scalp with normal palate and no dysmorphic facial features, tense and fluid-filled fetal abdomen, and thickened edematous placenta Maternal labs: O NEG, antibody negative, HIV-1 negative

Hydrops fetalis (caused by severe fetal anemia in which fetal heart compensates by increasing CO, resulting in high-output fetal heart failure and excessive fluid accumulation into interstitial spaces, aka third spacing --> most commonly caused by parvovirus B19 infection but also associated with Rh alloimmunization, fetal aneuploidy, CV abnormalities, and alpha-thalassemia major/Hb Barts disease --> presents with generalized skin edema and skin peeling, ascites/tense fluid-filled abdomen, pleural/pericardial effusions, and placental edema --> workup includes serial US and early delivery)

31yo G1P0 at 8wks presents with persistent N/V, epigastric pain, dizziness, and inability to tolerate oral intake for past day PMH: hx of GERD Vitals: afebrile, BP 90/50, HR 114, 6.6lb weight loss from pre-pregnancy weight PE: tachycardia and epigastric tenderness with deep palpation without rebound/guarding TVUS: 8wk twin intrauterine gestation with 2 normal fetal heartbeats

Hyperemesis gravidarum (HG: excess N/V during pregnancy caused by multiple gestation, hydatidiform mole, and hx of GERD --> presents with severe persistent N/V, epigastric pain, >5% weight loss of prepregnancy weight, signs of dehydration, and orthostatic hypotension --> labs: hypochloremic metabolic alkalosis, hypokalemia, elevated AST/ALT, and hemoconcentration --> diagnose via KETONURIA ON UA, which occurs due to prolonged hypoglycemia and resultant ketoacidosis --> treat with inpatient admission, IV antiemetics, rehydration, and electrolyte repletion)

Major contraindication for methylergonovine

Hypertension (methergine is a uterotonic drug that causes smooth muscle constriction, uterine contraction, and vasoconstriction --> rapidly increases BP, so contraindicated in HTN)

25yo presenting with increased fatigue, patchy hair loss, muscle weakness, and amenorrhea FSH: ↓ LH: ↓ Prolactin: ↑ TSH: ↑

Hypothyroidism (low T3/T4 levels cause loss of negative feedback, resulting in increased TRH secretion from hypothalamus --> TRH stimulates prolactin release from pituitary, which INHIBITS GnRH production --> results in low FSH/LH --> presents with fatigue, hair changes, amenorrhea, and enlarged thyroid gland)

Which pulmonary function tests are INCREASED in a pregnant woman?

IC, TV, and minute ventilation (occurs because of increased tidal volume in 3rd trimester of pregnancy, which increases minute ventilation but does NOT increase RR --> results in 15% increase in inspiratory capacity/IC)

Outpatient treatment of pelvic inflammatory disease (PID)

IM ceftriaxone and PO doxycycline (candidates for outpatient tx include stable vitals and tolerating oral antibiotic regimens)

Best method to measure strength and frequency of uterine contractions

IUPC (intrauterine pressure catheter)

58yo postmenopausal woman presents with several month hx of worsening vulvar pain, odorless pink-tinged vaginal discharge/pruritis, and few painful oral lesions PE: gingivae with lace-like reticular appearance with multiple white plaques on tongue/palate, diffusely erythematous vulva, labia minora with glazed brightly erythematous erosions with white striae along margin, and friable erythematous vaginal epithelium with serosanguinous discharge

Lichen planus (chronic inflammatory condition typically occurring in postmenopausal women age 50-60yrs/associated with hepatitis C characterized by inflammatory mucocutaneous eruptions with remissions/flares--> causes desquamation and erosion of mucosal surfaces including vulva/vagina/oral cavity, as well as scalp and nails --> presents with 6 P'S: pruritic purple polygonal planar papules/plaques on vulva, dyspareunia, glazed brightly erythematous vulvar lesions with Wickham striae/serpentine-appearing white striae, friable vaginal mucosa and serosanginous vaginal discharge, associated ORAL ULCERS with lace-like reticular erosions on gingiva/palate that cause painful oral ulcers and plaque formation on tongue AND/OR alopecia/extragenital rashes --> diagnose via vulvar punch biopsy that shows sawtooth infiltrate of lymphocytes at dermal/epidermal junction --> treat with high-potency topical corticosteroids)

54yo postmenopausal F presents with 1-year hx of increasing vulvar pruritus and burning, increasingly painful defecation, and vulvar bleeding after intense scratching PE: bilateral labia majora with excoriated pale thin skin, not visible labia minora, severe narrowing of introitus, and pale white wrinkled perianal skin with small anal fissure

Lichen sclerosus (chronic benign inflammatory disease common in postmenopausal women with autoimmune diseases such as alopecia areata --> presents with thin white wrinkled vulvar skin with PAPER-THIN appearance, waxy shiny sheen on labia minora/clitoris, increased skin sensitivity with intense vulvar pruritus and excoriations, perianal skin involvement in figure-8 pattern with painful defecation/anal fissures, and atrophy of labia minora and/or clitoral hood causing narrowing of vaginal introitus and dyspareunia --> workup includes punch biopsy of vulvar lesions to exclude malignancy --> diagnose via microscopic exam showing epithelial thinning with layer of homogenization, loss of rete ridges, and inflammatory cells --> treat with high-potency topical corticosteroids --> complication: non-HPV vulvar carcinoma seen in females >70yrs)

54yo postmenopausal F presents with 1-year hx of severe vulvar pruritus that causes inability to sleep PE: raised white thickened lesions with leathery appearance on vulva, and diffuse vulvar edema/erythema

Lichen simplex chronicus (LSC: hypertrophic dystrophy of vulvar squamous epithelium caused by chronic irritation, usually by rubbing/scratching --> presents with severe vulvar pruritus that worsens at night, leathery thick vulvar skin with erythema, and enhanced skin markings --> diagnose via vulvar biopsy showing acanthosis and hyperkeratosis --> associated with "itch-scratch" cycle --> treat with high-potency topical corticosteroids, antihistamines, and UV light)

Fetal US: dilated loops of bowel and ascites

Listeria infection (typically occurs in MOTHERS after consumption of unpasteurized dairy product, and vertically transmitted to fetus --> presents on fetal US with dilated loops of bowel/ascites --> presents in NEONATES with preterm delivery with multiple abscesses and granulomas, aka granulomatous infantiseptica)

Tenderness to touch on external genital exam

Localized provoked vulvodynia (vestibulodynia: pain to superficial touch on vestibule --> presents with area of tenderness to touch on external genital exam)

Order of symptom presentation in magnesium toxicity

Loss of DTRs, respiratory depression, and cardiac arrest (loss of DTRs occurs at Mag level of 7-10 --> respiratory depression occurs at Mag level 11-15 --> cardiac arrest occurs at Mag level of >15)

Which clinical sign is pathognomonic for uterine rupture?

Loss of fetal station (presenting fetal part RETRACTS back into pelvis)

What is the main cause of edema in pregnancy?

Loss of plasma proteins (by 20wks gestation, peak decrease in albumin levels --> causes low plasma protein, resulting in decreased plasma oncotic pressure --> edema in pregnancy)

Which type of C-section cut has the best potential outcome for a VBAC?

Low transverse cut

Most common congenital defect associated with valproic acid use during pregnancy

Lumbar myelomeningocele (valproic acid decreases amount of folate in body, thus associated with neural tube defects if taken during pregnancy --> fetal valproate syndrome includes spina bifida, cleft lip/palate, hypospadius, craniosynostosis, and limb defects such as radial aplasia)

Which tests are performed on patients with recurrent 1st trimester losses?

Lupus anticoagulant, anticardiolipin antibodies, diabetes, and thyroid disease (should also obtain maternal and paternal karyotypes --> can also do hysteroscopy or hysterography to exclude septum or other uterine anomaly)

Which lab findings should be seen in a patient with antiphospholipid syndrome?

Lupus anticoagulant, anticardiolipin antibody, and anti-B2 glycoprotein (each of these 3 findings must be present in plasma on at least two occasions >12wks apart)

Pregnant woman with gestational hyperandrogenism Pelvic US: intrauterine gestation and bilateral solid masses in ovaries

Luteomas of pregnancy (caused by elevated b-hCG that stimulates formation of luteoma from large lutein cells, as well as secretion of androgens --> presents asymptomatically OR moderate virilization in mom with high risk of fetal virilization --> pelvic US: bilateral SOLID ovarian masses --> spontaneously regresses after delivery)

24yo F presents with painful nodes above the vulva PE: large suppurative inguinal lymphdanenopathy

Lymphogranuloma venereum (genital ulcer disease caused by serovars L1-L3 of Chlamydia trachomatis, common in tropical and subtropical areas such as Caribbean --> presents initially with PAINLESS small shallow genital ulcers, followed weeks later by large, painful, suppurative lymphadenopathy aka buboes --> diagnose with Giemsa or fluorescent antibody-stained smear showing intracytoplasmic chlamydial inclusion bodies in epithelial cells/WBCs)

What is the best method to SCREEN for fetal anemia?

MCA doppler (can give >20wks to measure blood flow to fetal brain, especially in patients with alloimmunization --> INCREASED flow by intracranial doppler is indicative of fetal anemia --> only used as SCREENING, need to do PUBS/cordocentesis for diagnosis of fetal anemia)

Which vaccines are contraindicated in pregnant women?

MMR and varicella

21yo F presents with 3wk hx of dull intermittent RLQ pain that has progressed to constant severe pain, nausea, vomiting, and fever of 100°F PE: BP 140/70, HR 93, RLQ tenderness with rebound and guarding, palpable tender right adnexal mass Labs: negative bhCG Pelvic US: 6cm partially calcified right ovarian mass with multiple thin echogenic bands and decreased Doppler flow to right ovary

Mature cystic teratoma (dermoid cyst: benign ovarian germ cell tumor arising from embryonal endoderm/mesoderm/ ectoderm tissue --> most common ovarian tumor in young females age 10-30yo --> presents in YOUNG WOMEN with unilateral adnexal mass and pain 2° to ovarian enlargement/torsion due to heterogenous CYSTIC composition and variable density that creates unstable mass prone to rotation --> can also be struma ovarii/hyperthyroidism --> pelvic US shows partially calcified mass due to teeeth, with multiple thin echogenic bands due to hair --> diagnose and treat with ovarian cystectomy or oophorectomy)

Which maneuver for shoulder dystocia involves flexing the hips back against the abdomen?

McRoberts maneuver (involves elevating legs and flexing hips/thighs against abdomen --> allows rotation of pelvis, flattening of sacral promontory to align sacrum, and decreases obstruction thru bony pelvis to open birth canal --> used INITIALLY to prevent shoulder dystocia)

Which maneuvers should be performed FIRST and relieve about 50% of all shoulder dystocias?

McRoberts maneuver and suprapubic pressure (McRoberts maneuver: involves flexing hips/thighs against abdomen to rotate pelvis, align sacrum, and open birth canal --> suprapubic pressure: allows dislodging of fetal anterior shoulder)

Which condition is 3-4x more likely in post-term pregnancies?

Meconium-stained amniotic fluid (caused by greater length of time in utero for activation of more mature vagal system, AND fetal hypoxia --> nothing you can really do to treat)

Which type of episiotomy is most highly associated with 3rd/4th degree lacerations?

Median episiotomy

Treatment of neonatal thyrotoxicosis

Methimazole and beta-blocker

Medications used for medical abortions (can be done with pregnancies <9wks)

Mifepristone and misoprostol (mifepristone: anti-progestin given FIRST as abortifacient --> misoprostol: PGE1 analog given after to induce uterine contractions to expel the products of conception --> side effects: higher blood loss than surgical abortion)

Which uterotonic agent is usually given bucally?

Misoprostol (Cytotec: PGE1 agonist used for cervical ripening and labor induction, also used for uterine atony --> given ORALLY, vaginally, or bucally --> contraindications: PRIOR UTERINE SURGERY such as C/S, and >2 contractions/10mins)

Which medication is used for cervical ripening during induction of labor?

Misoprostol (synthetic PGE1 analog that can be administered intravaginally or orally)

30yo G1P0 at 7wks presents for routine prenatal visit PE: closed cervix and 6wk-size uterus Pelvic US: gestational sac in lower uterus with no fetal heartbeat

Missed abortion (type of SAB that occurs in ASYMPTOMATIC patients, pts that have loss of pregnancy symptoms such as N/V --> presents with closed cervical os and US showing fetus with no heartbeat or empty sac --> treat with expectant management, PG administration, or D&C)

Which pregestational heart conditions are the most concerning in pregnant women?

Mitral and aortic stenosis (cause increased PRELOAD that results in pulmonary HTN --> tachycardia associated with L&D exacerbates pulmonary HTN due to decreased filling time, resulting in pulmonary edema and heart failure --> fetus also at risk for FGR --> consider intrapartum endocarditis prophylaxis)

19yo G1P0 at 18wks presents with 3mo hx of palpitations and intermittent chest pain PE: HR 96 and grade 2/6 systolic ejection murmur with a click EKG: normal rate and rhythm

Mitral valve prolapse (floppy mitral valve that gets pushed into LV, resulting in sudden tensing of chordae tendinae during systole that causes murmur --> caused by myxomatous degeneration from Marfan/Ehlers-Danlos, rheumatic fever, chordae rupture --> presents with anxiety, palpitations, atypical chest pain, syncope, and late systolic crescendo murmur with midsystolic click --> complication: infective endocarditis and fatal arrhythmias--> treat with beta-blockers to decrease SNS tone, relieve chest pain/palpitations, and prevent arrhythmias)

18yo nulligravid F presents with unilateral, brief, sharp adnexal pain during days 13-14 of menstrual cycle Menstrual hx: menarche at age 13, occur regularly with moderate flow for first 2 days SH: never been sexually active

Mittelschmerz (ovulation/midcycle pain: peritoneal inflammation caused by ovarian follicle rupture that occurs during midcycle/during day 13-14 of menstrual cycle --> presents with acute onset of unilateral lower abdominal/pelvic pain during midcycle that lasts <2 days, with normal pelvic exam --> no definitive treatment besides NSAIDs for pain, and OCPs to stop ovulation)

Pelvic US: 2 intrauterine gestations with thin intertwin membrane and T-sign

Monochorionic diamniotic twins (twins with single placenta and 2 amniotic sacs due to cleavage at 4-8 days, aka division AFTER trophoblast differentiation but BEFORE amnion formation --> most common type of twin gestation occurring 75% of the time --> pelvic US shows thin intertwin membrane that meets placenta at 90° angle, aka T-sign)

Which type of twin pregnancy has highest pregnancy-related complication rate?

Monochorionic monoamniotic twins (single placenta and single amniotic sac due to cleavage between 8-12 days, aka division of embryos AFTER both trophoblast differentiation and amnion formation --> risk of twin-twin transfusion syndrome due to single placenta, and risk of umbilical cord entanglement and IUFD due to single amniotic sac --> managed inpatient at 28wks gestation with frequent fetal monitoring and antenatal corticosteroid admin --> then delivered preterm at 32-34wks gestation via C-section)

51yo F presents for routine health maintenance exam PMH: T1DM, last HbA1c 7.6% Gyn hx: LMP 2wks ago, sexually active and no dyspareunia Vitals: BMI 26 PE: normal vulvar architecture with flat hypopigmented macules with distinct borders

Mucosal vitiligo (acquired depigmentation disorder that occurs due to melanocyte destruction that is limited to genital/oral mucosa --> seen in patients with autoimmune disease such as T1DM and thyroid disorders --> presents ASYMPTOMATICALLY with flat hypopigmented macules with distinct borders that can expand/coalesce, normal vulvar architecture, and no surrounding inflammation --> treat with corticosteroids and phototherapy)

37yo woman undergoing Clomid ovulation induction presents with 2mo-hx of abdominal bloating, N/V, diarrhea, and dry skin Vitals: BMI 29 (weight gain of 15lbs in last 2mo) PE: large abdominal girth, very dry skin with peeling, and bilateral adnexal fullness

Ovarian hyperstimulation syndrome (exaggerated abnormal response to ovulation induction with clomiphone/recombinant GnRH that results in overexpression of VEGF in ovarries --> causes increased vascular permeability, resulting in leakage of fluid from vascular space to interstitial space aka "3rd spacing" --> presents with bilaterally enlarged ovaries, ascites with abdominal bloating/weight gain/girth, vomiting, diarrhea, dry skin/hair, and decreased UOP with darker urine/excessive thirst --> diagnose via pelvic US showing enlarged cystic ovaries with increased Doppler flow --> treat with aspiration of accumulated fluid, bed rest, and monitoring --> complications: pulmonary edema, pleural effusion, arterial TE, renal failure)

60yo postmenopausal F presents with coarse male-pattern facial hair and cliteromegaly PE: facial hair present on upper lip and chin, clitoris protruding from clitoral hood, and acanthosis nigricans on posterior neck Labs: low LH and FSH, high testosterone Pelvic US: enlarged, solid-appearing ovaries without cysts

Ovarian hyperthecosis (stromal hyperthecosis: hyperplasia of theca cells in ovary resulting in large testosterone production --> presents in POSTMENOPAUSAL women with gradual onset of hirsutism and insulin resistance --> pelvic US: bilaterally enlarged, solid-appearing ovaries up to 5-7cm in diameter)

Which ligament connects ovary to lateral uterus?

Ovarian ligament (connects the MEDIAL pole of the ovary to the LATERAL uterine horn)

30yo G0 female with hx of PCOS presents with abrupt onset of suprapubic pain not relieved by NSAIDs, and 3 episodes of vomiting PE: diffuse lower abdominal tenderness with left greater than right, without guarding or rebound Pelvic US: right-sided mass with cystic and solid components

Ovarian torsion (adnexal torsion: twisting of ovary and Fallopian tube around suspensory ligament of ovary/ovarian ligament --> causes compression of ovarian vessels + blockage of lymphatic and venous flow --> continued arterial perfusion WITHOUT venous outflow causes ovarian edema, which can block arterial inflow and cause necrosis/local hemorrhage --> presents with acute onset of unilateral pelvic pain, nausea/vom, and presence of adnexal mass/cyst --> diagnose via pelvic US showing unilateral complex adnexal mass without Doppler flow --> treat with exploratory laparotomy with untwisting of ovary, if it pinks up then leave it in but if it remains gray then take it out)

Pelvic US: complex adnexal mass (both solid and cystic components) with absent Doppler flow

Ovarian torsion (adnexal torsion: twisting of ovary and Fallopian tube around suspensory ligament of ovary/ovarian ligament --> causes compression of ovarian vessels + blockage of lymphatic and venous flow --> continued arterial perfusion WITHOUT venous outflow causes ovarian edema, which can block arterial inflow and cause necrosis/local hemorrhage --> presents with acute onset of unilateral pelvic pain, nausea/vomiting, and presence of adnexal mass/cyst --> diagnose via pelvic US --> treat with exploratory laparotomy with untwisting of ovary, if it pinks up then leave it in but if it remains gray then take it out)

68yo presents with 2yr hx of frequent involuntary loss of urine. Denies burning, frequency, or urgency with urination. PE: no leakage of urine on Valsava, vaginal dryness and atrophy Labs: post-void residual of 150mL

Overflow incontinence (incomplete emptying: involuntary leakage of urine caused by impaired bladder detrusor contractility or outlet obstruction, usually seen in postmenopausal women/diabetics/MS patients --> results in incomplete bladder emptying and chronic urinary retention, leading to overflow --> presents with constant dribbling of urine and increased post-void residual >100mL on catheterization or US --> treat with catheterization)

Vaginal discharge: clear elastic thin mucus (similar to uncooked egg white)

Ovulation (caused by LH surge --> results in increased cervical mucus secretion with clear thin elastic mucus present at cervical os)

Which hormone is responsible for milk letdown?

Oxytocin (released by nipple stimulation and infant crying, and also causes uterine contractions --> stimulates milk RELEASE from nipples)

27yo G2P2 presents with generalized tonic-clonic seizure that occurred 30hrs after vaginal delivery PMH: preeclampsia with severe features treated with magnesium for 24hrs after delivery, T1DM controlled with insulin, and postpartum hemorrhage treated with bimanual massage and oxytocin bolus/infusion Vitals: afebrile, BP 128/82, HR 78, RR 18 PE: lethargic pt with no focal neurologic deficits Labs: low Hgb and low Na+

Oxytocin toxicity (caused by excessive oxytocin use during induction of labor/management of postpartum hemorrhage --> since oxytocin similar to ADH, causes water retention and HYPONATREMIA --> presents with headaches, abdominal pain, N/V, lethargy, and tonic-clonic seizures --> treat with gradual administration of hypertonic saline/3% saline)

Which medications are used to treat PPH due to uterine atony?

Oxytocin, carboprost, methergine, and misoprostol (oxytocin: used 1st line via IV --> carboprost/Hemabate: PGF2-alpha agonist given IM used if oxytocin does not stop bleeding, contraindicated in ASTHMATICS --> methergine: smooth muscle constrictor given IM used if oxytocin and hemabate fail, contraindicated in patients with HTN or PRE-ECLAMPSIA --> misoprostol/Cytotec: PGE1 agonist given bucally/rectally, contraindicated in MATERNAL FEVER)

Which tests are involved in the serum integrated screen?

PAPPA and quad screen (only done when unable to obtain nuchal translucency --> combination of 1st trimester PAPP-A and 2nd trimester quad screen --> has 85-88% detection rate for trisomy 21)

32yo presents with difficulty conceiving over last 3yrs PMH: menses started at age 12 and are irregular, hx of recurrent vaginal candidiasis PE: thick dark velvety plaques under axillae and bilaterally enlarged ovaries Labs: normal LH, TSH, and prolactin

PCOS (polycystic ovarian syndrome: OBESE WOMEN with insulin resistance causes excess adipose tissue and increased conversion of androgens into estrogens --> continuously high estrogen INHIBITS HP axis, resulting in anovulation --> presents in OBESE WOMEN with irregular menses, infertility, hirsutism, acne, and bilaterally enlarged ovaries --> labs: can be normal or have high LH/testosterone/ estrogen --> diagnose via polycystic ovaries on US --> treat with weight loss, OCPs for menstrual regulation/prevention of endometrial hyperplasia, or clomiphene citrate for ovulation induction)

45yo F presents with irregular menstrual bleeding and intermenstrual spotting that has become progressively prolonged and heavy, now bleeds daily Meds: no OCP use PE: BMI is 38, dark-red blood seen at cervical os EMB: endometrial hyperplasia

PCOS (polycystic ovarian syndrome: hyperinsulinemia and/or insulin resistance alters hypothalamic hormonal feedback response --> increased LH secretion stimulates androgen production from theca cells relative to estrogen, causing decreased follicular maturation and formation of unruptured follicles/cysts --> also increased adipose tissue causes increased peripheral conversion of androgen to estrone via aromatase --> presents in OBESE WOMEN with abnormal uterine bleeding and/or amenorrhea, hirsutism, acne, infertility, and acanthosis nigricans --> increased risk of endometrial hyperplasia/cancer due to unopposed estrogen from repeated anovulatory cycles --> treat with weight reduction for cycle regulation, OCPs for prevention of endometrial hyperplasia, and clomid/spironolactone/ finasteride/flutamide for hirsutism)

Best method to diagnose HSV1/2 in pregnant mom

PCR of active lesions (need to take scraping of vesicle and send for HSV PCR --> Tzanck smear no longer recommended)

What is the best next step in management after finishing a D&C?

PO doxycycline (guidelines say that pts undergoing D&C should be given 100mg doxycycline 1hr BEFORE procedure

Preferred treatment of hyperthyroidism during pregnancy

PTU (inhibits conversion of T4 to T3 --> although hepatotoxic, only small amount transfers across placenta so considered safer than methimazole --> LOWER risk of aplasia cutis)

Which method is the best for treating fetal anemia?

PUBS (percutaneous umbilical blood sampling/cordocentesis: spinal needle advanced transabdominally under US guidance into cord vessel to sample fetal fluid, usually performed between 20-32wks --> mostly used to assess fetal anemia/fetal HCT in setting of alloimmunzation or positive MCA doppler --> also used to determine fetal karyotype, assay fetal platelet counts, acid-base status, Ab levels, and blood chemistries)

Most common pruritic dermatosis during pregnancy

PUPP (pruritic urticarial papules and plaques of pregnancy: intensely pruritic cutaneous eruption that begins on abdomen and spreads to arms/legs, but SPARES PALMS/SOLES --> can see erythema, vesicles, and eczematous target lesions --> usually appears LATE in pregnancy --> treat with oral antihistamines and topical steroids, can add systemic steroids for severe pruritus --> rash disappears shortly before or a few days after delivery)

Diagnosis of overflow incontinence

PVR >300cc (post-void residual: amount of fluid left in bladder after emptying --> normally 50-60cc, but ELEVATED >300cc in overflow incontinence due to hypoactive detrusor muscle OR bladder outlet obstruction)

53yo post-menopausal F presents with 1mo hx of "strange, itchy rash" on left breast that does not improve with OTC corticosteroid ointment PE: eczematous plaque on left nipple and areola

Paget disease of breast (caused by extension of underlying DCIS/invasive breast cancer up lactiferous ducts and into contiguous skin of nipple --> presents with eczematous and/or ulcerating patches over nipple and areolar skin, as well as pain/itching/burning of affected nipple with no resolution with topical steroids --> 85% associated with underlying breast cancer, usually adenocarcinoma --> further workup should include mammography and biopsy, which would show Paget cells aka intraepithelial adenocarcinoma cells)

Followup after cervical conization (cold knife or LEEP) for CIN3

Pap test with HPV 1 and 2 years after procedure

Which SSRI is contraindicated in pregnant women?

Paroxetine (Paxil: changed to category D drug because of increased risk of fetal cardiac malformations and persistent pulmonary HTN)

What is the 1st line test for evaluation of a palpable adnexal mass?

Pelvic US (shows uterus/endometrium, ovaries, and cul-de-sac --> epithelial ovarian carcinoma would show solid mass, thick septations, and possible ascites)

What is the next best step in management for a postmenopausal women presenting with an adnexal mass on pelvic exam?

Pelvic US and CA-125 (pelvic US: benign features include small size/simple cyst, while malignant features include large mass/solid components/septations --> CA-125: biomarker for epithelial ovarian cancer, and also elevated in common gyn conditions such as fibroids/endometriosis but these are usually seen in PREMENOPAUSAL women --> if there are suspicions features on US AND/OR CA-125 is elevated, pt should undergo MRI/CT scan to assess extent of disease)

19yo G0 woman presents with lower abdominal cramping starting with menses and persisting despite resolution of bleeding, nausea, and yellow blood-tinged vaginal discharge preceding menses SH: sexually active, uses condoms inconsistently PE: fever of 100.2°F, no flank pain, tender abdomen with guarding in lower quadrants, thick yellow discharge from vagina but no pruritus/odor, friable cervix with yellow discharge at os, (+) cervical motion tenderness, (+) uterus and adnexal tenderness without masses Labs: (-) urine pregnancy and (-) urinary nitrates

Pelvic inflammatory disease (PID: caused by gonorrhea or chlamydia infecting cervix/uterus/Fallopian tubes --> presents with fever, lower abdominal pain, mucopurulent vaginal discharge, cervical motion tenderness, and adnexal tenderness --> GONORRHEA more associated with mucupurulent cervicitis during/after menstruation)

26yo G1P0 at 35wks presents with recurrent SOB at rest and at night, requiring 3-4 pillows at night to elevate her head PE: tachycardia, lung crackles heard bilaterally, and mild bilateral lower extremity edema

Peripartum cardiomyopathy (PPCM: systolic heart failure secondary to dilated cardiomoypathy/DCM that occurs in 3rd trimester or first month after delivery --> presents with SOB, orthopnea, edema, tachycardia, and lung crackles --> diagnose via ECHO that shows dilated heart with low EF around 20-40% --> treat <34wks with betamethasone, diuretics, digoxin, vasodilators --> treat >34wks with immediate delivery)

1st line treatment for pelvic organ prolapse

Pessary fitting (least invasive intervention and recommended for pts with many comorbidities that can complicate surgery)

What is the next best step in management for a patient with a BPP of 6/10?

Repeat BPP in 24 hours (BPP score of 6/10 indicates "equivocal" aka non-diagnostic --> need to repeat in 24hrs: if BPP <4/10, indicates fetal hypoxia and requires urgent delivery --> if BPP >8/10, indicates normal fetus)

22yo G1P1 who is 6hrs postpartum presents with lower abdominal pressure and pain, inability to void, and persistent urine dribbling while lying in bed Op course: IOL at 41wks with forceps-assisted vaginal delivery due to prolonged 2nd stage, 2nd degree perineal laceration repair, and PPH resolving with uterotonic medications PE: firm uterine fundus and diffuse lower abdominal tenderness to palpation, intact perineal repair, moderate lochia, and normal DTRs

Postpartum urinary retention (inability to void >6hrs after vaginal delivery or >6hrs after urinary catheter removal following C-section --> caused by pudendal nerve injury from perineal trauma OR bladder atony from epidural anesthesia --> pts with acute urinary retention can develop concomitant OVERFLOW incontinence --> risk factors: primiparity, epidural anesthesia, operative vaginal delivery, perineal injury, or C-section --> presents with inability to void/incomplete bladder emptying, urinary dribbling, and lower abdominal pressure --> treat with intermittent urethral catheterization --> usually self-limited and resolves in <1wk)

What is the initial evaluation for a premenopausal woman with >3mo of amenorrhea?

Pregnancy test, prolactin, TSH, and FSH (prolactin: used to evaluate pituitary adenoma --> TSH: used to evaluate hypothyroidism --> FSH: used to evaluate primary ovarian insufficiency)

Risk factors for gestational diabetes (GDM)

Previous GDM, obesity, excessive weight gain during pregnancy, family history of diabetes, and previous macrosomic infant (patients with these risk factors should be screened EARLY in pregnancy at initial prenatal visit with HbA1c or glucose tolerance test --> if negative, should be re-screened at 24-28wks with 1-hour 50g GCT)

34yo with hx of lymphoma treated with chemotherapy 5yrs ago presents with 3mo of amenorrhea PMH: normal Pap smears, no hx of STDs PE: normal thyroid gland, dry vaginal mucosa, and small anteverted mobile uterus with no adnexal masses b-hCG: negative FSH: ↑ LH: ↑ Prolactin: normal TSH: normal

Primary ovarian insufficiency (hypergonadotropic hypogonadism in women age <40 that occurs due to absence of developing follicles, usually associated with chemotherapy/radiation, fragile X syndrome premutation carriers with FMR1 gene CGG repeats, Turner syndrome, autoimmune oophoritis, and galactosemia --> affects proliferating granulosa and theca cells of ovary, causing ovarian failure and decreased estrogen --> loss of negative feedback results in increased FSH/LH production --> presents with amenorrhea, vaginal dryness/hot flashes, and elevated FSH --> workup includes FMR1 gene mutation testing --> treat with HRT to provide menopausal relief and bone loss protection)

26yo F presents with 2-day hx of vulvar lesion with small ulcer in center and mild burning with urination SH: sexually active with 5 male partners over past 5yrs, uses tobacco/alcohol/illicit drugs PE: 2cm ulcer with non-exudative base with a raised indurated margin, no tenderness with palpation, and moderate painless bilateral inguinal lymphadenopathy

Primary syphilis (caused by Treponema pallidum infection, an STD common in patients with multiple sexual partners and substance abuse --> presents with painless bilateral inguinal lymphadenopathy and painless genital chancre, aka single shallow painless nonexudative ulcer with indurated edges and clean base --> diagnose with non-tremponemal RPR/VDRL that can cause false negative in early infection, or treponemal FTA-ABS/TP-EIA with greater sensitivity in early infection and can be positive even after treatment --> treat with IM benzathine penicillin G and repeat RPR/VDRL 2-4wks after)

Risk factors for PPROM (preterm prelabor rupture of membranes)

Prior PPROM, polyhydramnios, antepartum bleeding, genital tract infection, and asymptomatic bacteriuria (prior PPROM: increases risk --> polyhydramnios: overdistends the membranes --> antepartum bleeding, genital tract infection such as BV/gonorrhea, and asymptomatic bacteriuria: conditions that inflame or weaken membrane)

In which patients is trial of labor (TOL) contraindicated?

Prior classical cesarean delivery and prior abdominal myomectomy with uterine cavity entry

Most significant risk factor for postpartum depression

Prior history of depression

Major risk factors for preterm delivery

Prior history of preterm labor or PPROM (confers 20% risk for future spontaneous preterm birth --> manage prophylactically with IM progesterone during 2nd and 3rd trimesters, and serial TVUS cervical length measurements during 2nd trimester)

Most important risk factor for ectopic pregnancy

Prior hx of ectopic pregnancy (other risk factors: prior abdominal surgery, history of STIs, sterilization failures, endometriosis, and congenital uterine malformations)

Greatest risk factor for placenta accreta

Prior uterine surgery (usually prior C-section --> causes placental villi to attach to uterine myometrium)

Contraindications to PGE1/PGE2 for IOL

Prior uterine surgery and >2 contractions/10mins (prior uterine surgery: includes prior C/S or myomectomy, due to risk of uterine rupture --> >2 contractions/10mins: can cause uterine tachysystole)

Which hormone is associated with reflux esophagitis and constipation during pregnancy?

Progesterone (causes relative relaxation of esophageal sphincter to contribute to heartburn --> also relaxes intestinal smooth muscle and slows peristalsis to cause constipation)

Which hormone is associated with hyperventilation of pregnancy?

Progesterone (reduces CO2 threshold at which maternal respiratory center is stimulated --> increases respiratory center sensitivity --> causes pregnant women to have increased TV and VC)

26yo presenting with persistent headaches, loss of vision near the edges, and amenorrhea FSH: ↓ LH: ↓ Prolactin: ↑ TSH: normal

Prolactinoma (type of pituitary adenoma associated with increased prolactin release --> elevated prolactin INHIBITS GnRH secretion causing low FSH/LH --> presents with headaches, bitemporal hemianopsia, galactorrhea/milk from nipples, and amenorrhea --> complication: osteoporosis)

What is the initial evaluation performed for a couple with >12mo of infertility?

Semen analysis (because 25% of infertility is associated with male factor --> SA evaluates sperm concentration, motility, morphology, and identification of azoospermia/severe oligospermia --> can treat male factor infertility with artificial insemination techniques and use of donor sperm)

Cause of false-positive nitrazine test

Semen and blood (therefore any patient with vaginal bleeding OR recent intercourse needs to confirm ROM via microscopic exam of vaginal FLUID --> if no ferning, then rule out ROM and give expectant management)

38yo G5P5 who received epidural anesthesia during labor 24hrs ago presents with sharp lower midline abdominal pain that radiates down legs while ambulating, but no pain while lying down ROS: voided twice without difficulty, passed flatus but no BM, no numbness/foot drop PSH: SVD of 9lb infant complicated by shoulder dystocia relieved by McRoberts maneuver and suprapubic pressure PE: focal tenderness to palpation just inferior to bladder, moderate edema in LE b/l, and intact strength/sensation/reflexes of LE

Pubic symphysis diastasis (widening/diastasis of the pubic symphysis without fracture, physiologically due to progesterone/relaxin during pregnancy but can become symptomatic after traumatic delivery --> risk factors: fetal macrosomia, operative vaginal delivery, precipitous labor, multiparity --> presents with suprapubic pain that radiates to back/hips/thighs/legs exacerbated by walking, pubic symphysis tenderness, and intact neuro exam --> supportive care via pelvic support/PT, NSAIDs, and recovery within 4wks postpartum)

Major PSNS innervation to pelvis

Pudendal nerve (formed from S2-S4)

Which cardiac disease has the highest risk for mortality during pregnancy?

Pulmonary HTN (25-50% risk of mortality during pregnancy due to massive blood loss during delivery --> diminished venous return and RV filling causes maternal death)

24yo G1PO woman at 28wks admitted for preterm labor 24hrs ago presents with difficulty breathing, cough, and frothy sputum Meds: 6L of lactated Ringer's, magnesium sulfate, and nifedipine Vitals: afebrile, RR 24, pulse 110bpm, BP 132/85, pulse ox 97% PE: appears in distress, lung exam shows bibasilar crackles, uterine contractions regular every 3mins FHR: 140bpm Labs: 12K WBCs, normal K+, normal Na+

Pulmonary edema (caused by decreased plasma osmolality + tocolytic use, cardiac disease, fluid overload/isotonic fluids, pre-eclampsia, and Mg use --> presents with SOB, chest pain, cough, frothy sputum, and crackles on lung exam --> treat with furosemide)

35yo G2P1 at 31wks with hx of preeclampsia presents with sudden onset of dyspnea Vitals: BP 150/80, HR 112, RR 24, O2 sat 91% on RA PE: bibasilar crackles, use of accessory muscles for breathing, and 2+ pitting edema of lower extremities

Pulmonary edema (caused by pre-eclampsia due to generalized arterial vasospasm from systemic HTN, leading to increased SVR and high cardiac afterload that causes increased pulmonary capillary pressure --> combines with increased capillary permeability to result in pulmonary edema --> presents in PRE-ECLAMPTIC PTS with sudden-onset dyspnea, decreased O2 sat, and bibasilar crackles --> diagnose via presence of hemosiderin-laden macrophages/HF cells in lungs --> treat with supplemental O2, fluid restriction, and diuresis with furosemide)

42yo G1P1 3 days after C-section is found unconscious. Vitals: temp 100.4°F, BP 60/40, HR 120, RR 26, BMI 31 PE: bilateral wheezing, pleural friction rub Labs: respiratory alkalosis CXR: atelecatasis ECG: tachycardia with cor pulmonale

Pulmonary embolism (caused by hypercoagulable state in pregnancy/postpartum that results in DVT embolizing to pulmonary arteries --> presents with acute onset of SOB, simultaneous onset of pleuritic chest pain, cough/hemoptysis, and/or concomitant signs of DVT --> PE: TACHYPNEA, tachycardia, and wheezing/rales heard on lung exam --> labs: HYPOXEMIC RESPIRATORY ALKALOSIS --> EKG: sinus tachycardia, S1Q3T3 indicating right heart strain, or cor pulmonale indicating pleural effusion --> imaging: CLEAR CXR or atelectasis --> diagnose via CT angiogram --> treat with intra-arterial TPA/streptokinase and heparin/Lovenox)

Which conditions are LESS LIKELY when betamethasone is used from 24-34wks gestation?

RDS, intracerebral hemorrhage, and necrotizing enterocolitis (betamethasone is given in 2 doses, 24hrs apart, in women undergoing preterm labor <34wks --> increases fetal lung maturity to reduce risk of RDS --> also decreases risk of intracerebral hemorrhage and necrotizing enterocolitis in newborn)

Which renal function tests INCREASE during pregnancy?

RPF, GFR, and urine protein (RPF: should be >600 --> GFR: should be 130-180 --> urine protein: <185)

Recommended treatment for postmenopausal osteoporosis in women with high risk for breast cancer

Raloxifene (SERM: non-steroidal drug that exhibits estrogen AGONIST activity on bone, and estrogen ANTAGONIST activity on breast and uterus --> also decreases total cholesterol and LDL levels, but does NOT affect risk of CHD --> side effects: hot flashes and VTE)

Cervical exam shows posterior prolapse

Rectocele (rectum falls forward into space occupied by vagina, causing constipation --> patient can relieve

34yo G3P2 at 30wks presents with 2wk hx of abdominal bulge seen when straining to defecate or picking up toddler PMH: chronic constipation PSH: 2 prior C/S PE: non-tender abdominal mass protruding between rectus abdominis muscles during Valsava

Rectus abdominis diastasis (weakening of the linea alba that causes abdominal contents to bulge between RA muscles --> NO associated fascial defect and no associated pain, acute GI symptoms, or risk of bowel strangulation/incarceration --> risk factors: pregnancy, multiparity, surgical weakening from prior C/S, and increased intraabdominal pressure from constipation --> presents with non-tender midline bulge that increases with Valsava --> manage with observation and reassurance, as it usually resolves postpartum)

Which FHT patterns, in addition to absent variability, indicate a Cat3 FHT?

Recurrent late decelerations, recurrent variable decelerations, and bradycardia

FHT: variable decelerations with >50% of contractions

Recurrent variable decelerations (associated with prolonged umbilical cord compressions, oligohydramnios, or cord prolapse --> can result in lack of fetal-placental blood flow that the fetus cannot tolerate --> treat with maternal repositioning to left lateral decubitus position or all fours, and then amnioinfusion --> complications: hypoxemia and acidosis)

Best next step in management for patient with abnormal Pap test of ASC-US (atypical squamous cells of undetermined significance)

Reflex HPV testing (should look for high-risk DNA types, aka HPV16 and 18 --> if negative, then co-testing with cytology + HPV can be repeated in 3yrs)

Workup for a patient with Mullerian agenesis

Renal US and vaginal dilation (renal US: need to evaluate renal system abnormalities such as duplicated ureters, as kidneys associated with development of paramesonephric duct and uterus/cervix/upper 1/3 of vagina --> vagina dilation: opens up blind vaginal pouch to create a functional vagina for sexual intercourse)

23yo G1P0 at 29wks presents with sudden-onset of severe SOB. She woke up today with fluttering sensation in chest that progressed to dyspnea, dry cough, and inability to lie flat. Recently, patient had some exercise intolerance and tiredness. PMH: recurrent sore throat requiring tonsillectomy as a child SH: immigrated from India 5yrs ago ECG: AFib with rapid ventricular response

Rheumatic mitral stenosis (insidious progressive disease caused by early strep infection that resulted in rheumatic heart disease --> during pregnancy, physiologic increases in HR/blood volume raise transmitral gradient and LA pressure, resulting in loss of effective "atrial kick" and decrease in diastolic filling times resulting in AFib with RVR, aka pulse >100min --> this further increases LA pressure, with dramatic worsening of pulmonary congestion and pulmonary edema --> presents with pulmonary edema with rapid decompensation, aka cough/progressive SOB/orthopnea with new-onset AFib with RVR)

Young female presents with hypothyroidism following flu-like illness Neck exam: fixed, rock-like, non-tender thyroid gland

Riedel thyroiditis (thyroid gland replaced by fibrous tissue with inflammatory infiltrate, with fibrosis extending to local structures such as trachea/esophagus and mimics anaplastic carcinoma --> considered manifestation of IgG4-related systemic disease with autoimmune pancreatitis, retroperitoneal fibrosis, non-infectious aortitis --> presents with fixed, rock-hard, non-tender goiter and 1/3 present with hypothyroidism)

Which ureter is often compressed during pregnancy?

Right ureter (enlarging uterus compresses ureters at pelvic brim, which are already dilated around 6wks gestation --> usually on right side due to dextrorotation of uterus)

Which ureter/renal pelvis is usually more dilated in the pregnant woman?

Right ureter and renal pelvis (MORE dilated than the left due to cushioning of sigmoid colon on left ureter --> also dextrorotation and dilation of right ovarian complex-which lies over right ureter- contributes to right ureteral dilation)

Which tocolytic agent increases cAMP concentration to facilitate myometral relaxation?

Ritodrine (beta-2 agonist: increases cAMP within myometrial cells, which causes decrease in intracellular free Ca2+ and interferes with MLCK to cause myometrial relaxation --> maternal side effects: tachycardia, palpitations, hypotension, hypokalemia, hyperglycemia --> fetal risks: similar to maternal, with possible neonatal hypoglycemia)

Which ligament causes pain in the vulva during pregnancy?

Round ligament of uterus (connects uterine horn to labia majora: derivative of gubernaculum, thus travels thru inguinal canal --> runs ABOVE artery of Sampson, aka anastamosis of ovarian and uterine artery)

22yo G2P1001 at 32wks presents with sharp lower abdominal pain that worsens upon walking and improves with rest PE: fetal movement present, reassuring NST, no contractions recorded, and closed cervix UA: negative

Round ligament pain (round ligament is remnant of gubernaculum and extends from corpus of uterus down and laterally thru inguinal canal to terminate in labia majora --> contains artery of Sampson)

Order of lochia

Rubra, serosa, alba (lochia rubra: seen in first few days after delivery as red or reddish-brown vaginal discharge caused by normal shedding of uterine decidua --> lochia serosa: seen 3-4 days after delivery as thin and pink/brown colored vaginal discharge --> lochia alba: seen 2-3wks after delivery as white/yellow discharge)

27yo G3P3 woman presents with sudden onset of severe sharp pain in RLQ, pain in right shoulder, lightheadedness, nausea, and rectal pressure 6hrs ago Menstrual hx: LMP 24 days ago PE: moderate tenderness of RLQ without guarding/rebound, active bowel sounds Culdocentesis: 15mL of nonclotting, serosanguineous fluid with a hematocrit of 5%

Ruptured corpus luteum cyst (corpus luteum cysts: common functional cysts occurring in LUTEAL phase of menstrual cycle and form when corpus luteum fails to regress after 14 days, becomes enlarged >3cm, or hemorrhagic --> non-ruptured cysts present with delayed menses and dull lower abdominal pain --> ruptured cysts present with acute LLQ/RLQ pain and signs of hemoperitoneum late in luteal phase)

17yo G2P0 presents with 1-day hx of suprapubic pain radiating to RLQ and acute onset of severe RLQ pain Gyn hx: LMP 7wks ago, two 1st trimester elective abortions, hx of chlamydia treated twice Vitals: BP 90/60, HR 99, RR 22, temp 98.6°F PE: curled in fetal position due to pain, rebound and voluntary guarding, cervical motion tenderness, and rectal tenderness Labs: hCG 2500, HCT 24%, negative urinalysis US: no intrauterine pregnancy, 6cm x 2cm right adnexal mass, and moderate amount of free fluid in cul de sac

Ruptured ectopic pregnancy (implantation of embryo outside uterine cavity, usually Fallopian tube, and associated with assisted fertility/STDs/PID/previous pelvic or abdominal surgery/endometriosis/use of IUD for birth control --> presents with unilateral pelvic/lower abdominal pain, vaginal bleeding, tender adnexal mass, SGA uterus, bleeding from cervix, positive hCG, signs of hypovolemia such as hypotension/tachycardia, and signs of intra-abdominal bleeding such as rebound and voluntary guarding --> treat with IV fluids, blood products, pressors, and exploratory laparotomy with salpingectomy --> NOTE: if unruptured ectopic pregnancy with <4cm embryo without fetal heartbeat, can treat with methotrexate)

Where does the pain from Stage 2 of labor come from?

S2-S4 (somatic pain)

26yo G1P0 at 20wks presents with joint pain and swelling in her hands/feet PMH: hx of SLE PE: BP 150/95, red macular eruption on cheeks, and bilateral 2+ pitting edema of legs UA: 2+ proteins, RBC casts Labs: 24hr urine protein 1.5g, BUN 28, Cr 2.1

SLE nephritis (flare-up of SLE caused by pregnancy and postpartum period --> presents with edema, joint pain, malar rash, HTN, and proteinuria + hematuria with RBC casts --> labs: low complement levels, elevated ANA --> diagnose via renal biopsy --> OB complications: preterm birth, C-section, pre-eclampsia, FGR, and fetal demise)

Which fetal testing method is used to rule out metabolic acidosis in fetus with decelerations?

Scalp stimulation (done between decelerations to elicit reactive acceleration --> used to rule out metabolic acidosis)

39yo G0 woman presents with non-tender lesions on vulva and brownish rash on palms/soles SH: HIV(+) 2yrs ago, hx of IV drug abuse PE: 3 non-tender elevated plaques with rolled edges on vulva, and brown macular rash on palms/soles

Secondary syphilis (disseminated disease caused by bloodstream infection with spirochete Treponema pallidum --> presents with "copper penny lesions" on palms/soles, condylomata lata aka smooth painless wart-like white lesions on genitals, lymphadenopathy, and patchy hair loss --> screen via VDRL/RPR or dark-field microscopy, diagnose with FTA-ABS --> treat with penicillin G)

34yo G3P2 at 39wks has a precipitous NSVD and delivers 9lb5oz boy, but after 20mins placenta does not deliver. During traction/fundal massage, umbilical cord avulses and patient develops severe abdominal pain, SOB, and copious vaginal bleeding. Vitals: BP 70/40, HR 62 PE: smooth round pale mass protruding from vagina, and uterine fundus no longer palpable at umbilicus

Uterine inversion (uncommon but potentially fatal cause of postpartum hemorrhage due to excessive fundal pressure/traction on umbilical cord before placental separation --> fundus collapses into endometrial cavity and prolapses thru cervix --> risk factors: nulliparity, fetal macrosomia, placenta accreta, and rapid L&D --> presents with hemorrhagic shock, lower abdominal pain, smooth round mass protruding from cervix/vagina, and inability to palpate uterine fundus transabdominally --> treat with aggressive fluid replacement, manual replacement of uterus, and then placental removal/uterotonic drugs)

27yo G2P1 POD#2 s/p suction D&C for incomplete abortion presents with lower abdominal pain, nausea, scant bleeding, and fever of 100.4°F PE: rebound tenderness and abdominal guarding, soft and slightly tender uterus Pelvic US: 8mm endometrial stripe and normal ovaries

Uterine perforation (injury to surrounding blood vessels or viscera of uterus, usually due to intrauterine procedure such as D&C --> presents with fever, scant vaginal bleeding, lower abdominal pain with rebound tenderness/guarding, and slightly tender uterus)

74yo G5P5 woman presents with several month hx of vaginal spotting, discharge, difficulty defecating, and mass coming out of vagina that increases in size during straining PMH: HTN, T2DM, and heart failure SH: 40-pack-year smoking history PE: BP 150/90, HR 84, RR 16, BMI 42, cervix at level of vaginal introitus, thin vaginal mucosa with multiple areas of excoriations and erosion Pelvic US: thin endometrial stripe

Uterine procidentia (full uterine prolapse: type of pelvic organ prolapse in which uterus and anterior/posterior vaginal walls herniate thru vagina --> caused by weakened pelvic support and increased intra-abdominal pressure, risk factors include multiparity/obesity/aging --> presents with vaginal/pelvic pressure, bulging mass in vagina that increases with Valsava, bowel/bladder dysfunction, sexual dysfunction, or tissue damage such as erosions --> treat with vaginal pessary or surgical repair)

Biggest risk associated with TOLAC (trial of labor after cesarean)

Uterine rupture (10% risk with classical uterine incision and 1% risk with low transverse incision)

39yo G4P0030 at 35wks with IVF pregnancy presents with intense constant lower abdominal pain PMH: hx of uterine fibroids PSH: abdominal myomectomy for intracavitary fibroids PE: cervical dilation of 4cm, contractions every 2-3mins that last for 45s FHT: 140bpm, moderate variability, and persistent variable decels

Uterine rupture (caused by prior uterine surgery such as classical/vertical C-section or prior intracavitary myomectomy + onset of labor/contractions --> presents with intense constant abdominal pain and abnormal FHT in pts with prior uterine surgery --> also associated with vaginal bleeding, abdominally palpable fetal parts, loss of fetal station, and cessation of contractions --> treat with urgent laparotomy and delivery thru ruptured site, then uterine repair)

28yo G2P1 at 37wks presents with severe abdominal and back pain PE: BP 90/60, HR 120, palpable irregular protuberance in lower abdomen, and moderate vaginal bleeding SVE: 3cm dilated cervix with 80% effacement, bulging bag palpable at cervical os but no presenting fetal part FHT: fetal tachycardia, minimal variability, and late decelerations

Uterine rupture (occurs in woman attempting vaginal delivery after C-section/VBAC or myomectomy, prolonged labor, congenital uterine anomalies, or fetal macrosomia --> presents in MOTHER with abrupt onset of excruciating abdominal pain, vaginal or intra-abdominal bleeding resulting in hypotension/tachycarda, and loss of intrauterine pressure --> presents in FETUS with loss of fetal station, presence of abdominally palpable fetal parts, and FHT showing late decelerations --> treat with laparotomy for delivery and uterine repair)

30yo woman currently in labor presents with sudden abdominal pain, vaginal bleeding, and loss of contractions FHTs: sharp decline in fetal HR PE: loss of fetal station on manual vaginal exam

Uterine rupture (rupture of uterus under its own force, causing baby to be pushed into peritoneum and resulting in abdominal pregnancy with high risk of intra-abdominal bleeding --> risk factors: vaginal birth after C section/VBAC, uterine scars, trauma --> presents with increased PAIN and sometimes vaginal bleeding, sudden fetal distress followed by loss of contractions, and LOSS OF FETAL STATION --> treat with emergency C-section)

Which condition is associated with late decelerations (onset/peak occurs AFTER contraction)?

Uteroplacental insufficiency (late decelerations are ALWAYS WORRISOME and associated with fetal hypoxemia, as placental blood flow DECREASES during contractions but compromised fetus cannot compensate --> 2 major causes --> 1. Decreased uterine blood flow: associated with maternal hypotension from epidural and uterine hyperstimulation --> 2. Placental dysfunction: associated with postdate gestation, preeclampsia, chronic HTN, and GDM --> treat with having mom in left lateral recumbent position/turn mom on left side to maximize O2 to fetus, administer O2 to mother, turn off Pitocin and consider tocolysis, and introduce fetal scalp electrode and IUPC)

Most common causes of fetal growth restriction (FGR)

Uteroplacental insufficiency and poor fetal growth

Which ligament connects the uterus to the sacrum?

Uterosacral ligament (keeps uterus contained in pelvis --> need to be cut to remove uterus out of pelvis, but look very similar to URETERS)

Treatment for neonate born to mother with active chickenpox (VZV infection)

VZIG (varicella zoster immune globulin: post-exposure prophylaxis given to pregnant women with no varicella immunity who are exposed to varicella --> ALSO given to neonate if mother develops chickenpox within 5 days before delivery, or within 2 days after delivery)

25yo G2P1 at 24wks presents for routine prenatal care and reports that her 5yo son was diagnosed with varicella. Denies fever, malaise, rash. PE: no rash or lymphadenopathy, normal FH, normal FHR Labs: negative varicella-zoster IgG and IgM What is the next best step in management?

VZIG (varicella zoster immune globulin: post-exposure prophylaxis given to pregnant women with no varicella immunity who are exposed to varicella within 96hrs of exposure --> ALSO given to neonate if mother develops chickenpox within 5 days before delivery, or within 2 days after delivery)

2 methods to help mom that is fully dilated/completely effaced and fetus is below 2+ station

Vacuum delivery and forceps

Which two components should be ELEVATED in the 2nd trimester quad screen if a mother is carrying a fetus with Down syndrome?

bhCG and inhibin A (should be ELEVATED --> while estriol and AFP should be DECREASED)

Which two hormones are produced by the fetoplacental unit?

hCG and hPL (human chorionic gonadotropin: stimulates adrenal/placental steroidogenesis, stimulates fetal testes to secrete testosterone, and possesses thyrotrophic activity --> human placental lactogen: anti-insulin and GH-like effects causing impaired maternal glucose/FFA release from cells)

Which hormones are secreted by the trophoblast?

hCG, hPL, and ACTH