question

What is Nagele's rule?

answer

due date = LMP + 9 months + seven days

question

What is developmental age?

answer

number of weeks and days since fertilization. typically used only in research, as the exact date of fertilization is not commonly known

question

What is gestational age?

answer

number of wks and days measured from the first day of the LMP.

question

How else can gestational age be determined?

answer

Fundal height: at 20wks, uterus is at the umbilicus and grows approx 1 cm/wk Quickening, or appreciation of fetal movt: typically occurs at 17-18 wks Fetal heart tones: can be heard at 10-12 wks by Doppler Ultrasound: measures fetal crown-rump length (CRL) at 5-12wks and measured biparietal diameter (BPD), femur length (FL), and abd circumference (AC) from 13 wks. U/S measurement of GA is most reliable during the first trimester

question

How does renal flow change in pregnancy?

answer

increases 25-50%

question

How does glomerular filtration rate change in pregnancy?

answer

increases early, then plateaus

question

How does uterine weight change in pregnancy?

answer

increases from about 60-70g to about 900-1200g

question

How does body weight change in pregnancy?

answer

average 11kg (25lb) increase

question

What is the standard for diagnosing pregnancy?

answer

B-hCG - produced by placenta; peaks at 100,000 mIU/mL by 10wks of gestation - decreases throughout the second trimester; levels off in the third trimester - hCG levels double approx every 48hrs during early pregnancy. This is often used to diagnose ectopic pregnancy when doubling is abnormal

question

What is a quantitative B-hCG used for?

answer

- to diagnose and follow ectopic pregnancy - to monitor trophoblastic disease - to screen for fetal aneuploidy

question

What is a quad screen?

answer

1) Maternal serum alpha-fetoprotein - produced by the fetus, crosses the placenta in small amounts and enters the maternal circulation - Elevated: assoc w/ open neural tube defects (anencephaly, spina bifida), abd wall defects (gastroschisis, omphalocele), multiple gestation, incorrect gestational dating, fetal death, and placental abnormalities (e.g. placental abruption) - Decreased: assoc w/ trisomy 21 and 18, fetal demise, and inaccurate gestational dating. 2) inhibin A 3) estriol 4) B-hCG

question

What quad screen results suggest Trisomy 18?

answer

ALL four decreased

question

What quad screen results suggest Trisomy 21

answer

decreased AFP and estriol Increased B-hCG and inhibin A

question

How does heart rate change in pregnancy?

answer

gradually increases 20%

question

How does blood pressure change in pregnancy?

answer

gradually decreases 10% by 34 wks, then increases to prepregnancy values

question

How does stroke volume change in pregnancy?

answer

increases to maximum at 19wks, then plateaus

question

How does cardiac output change in pregnancy?

answer

rises rapidly by 20%, then gradually increases an additional 10% by 28wks

question

How does peripheral venous distention change in pregnancy?

answer

progressive increase to term

question

How does peripheral vascular resistance change in pregnancy?

answer

progressive decrease to term

question

How does respiratory rate change in pregnancy?

answer

unchanged

question

How does tidal volume change in pregnancy?

answer

increases by 30-40%

question

How does expiratory reserve change in pregnancy?

answer

gradual decrease

question

How does vital capacity change in pregnancy?

answer

unchanged

question

How does respiratory minute volume change in pregnancy?

answer

increases by 40%

question

How does blood volume change in pregnancy?

answer

increases by 50% in second trimester

question

How does hematocrit change in pregnancy?

answer

decreases slightly

question

How does fibrinogen change in pregnancy?

answer

increases

question

How do electrolytes change in pregnancy?

answer

unchanged

question

How does sphincter tone change in pregnancy?

answer

decreases

question

How does gastric emptying time change in pregnancy?

answer

increases

question

What is the recommended amount of weight women should gain in pregnancy?

answer

an additional 100-300 kcal/day; 500 kcal/day during breastfeeding Excessive gain: >1.5kg/mo Inadequate gain: <1 kg/mo

question

What are the nutritional guidelines for pregnancy?

answer

folic acid supplements (decrease neural tube defects for all reproductive-age women): 0.4 mg/day Iron: 30mg/day of elemental iron Calcium: 1300 mg/day for women <19yo; 1000mg/day >19yo Vitamin D: 10ug or 400IU/day Vitamin B12: 2ug/day

question

What is PAPP-A?

answer

pregnancy-assoc plasma protein A recommended at wks 9-14 to detect Down Syndrome and Trisomy 18 risk combined with ultrasound-determined nuchal transparency (fluid in the fetal neck) + B-hCG

question

What is CVS?

answer

chorionic villus sampling recommended at wks 10-12 involves transcervical or transabd aspiration of placental (chorionic villi) tissue

question

What are the advantages and disadvantages of CVS?

answer

Ads - diagnostic accuracy comparable to that of amnio, available at 10-12wksDisads - carries risk of fetal loss (1-2%); cannot detect open neural tube defects

question

What are complications of CVS?

answer

limb defects have been assoc w/ CVS performed </= 9wks

question

How often should prenatal visits occur?

answer

Wks 0-28: every four wks Wks 29-35: every 2 wks Wks 36-birth: every wk

question

What kind of testing should be completed at the initial prenatal visit?

answer

Heme: CBC, Rh factor, type and screen ID: UA and culture, rubella ab titer, HBsAg, RPR/VDRL, cervical gonorrhea and chlamydia, PPD, HIV, Pap smear (to check for dysplasia) If indicated: HbA1c, sickle cell screening Discuss genetic screening: Tay-Sachs, CF

question

What kind of prenatal testing should be completed at 9-14wks?

answer

offer Triple Screen - PAPP-A - nuchal transparency - free B-hCG +/- CVS

question

What kind of prenatal testing should be completed at 15-20wks?

answer

Offer Quad Screen - AFP - estriol - B-hCG - inhibin A +/- amniocentesis

question

What kind of prenatal testing should be completed at 18-20wks?

answer

ultrasound for full anatomic screen

question

What kind of prenatal testing should be completed at 24-28 wks?

answer

1hr glu challenge test for gestational diabetes screen

question

What kind of prenatal testing should be completed at 28-30 wks?

answer

RhoGAM for Rh (-) women (after ab screen)

question

What kind of prenatal testing should be completed at 32-36wks?

answer

GBS; repeat CBC

question

What kind of prenatal testing should be compeleted at 34-40wks?

answer

cervical chlamydia and gonorrhea cultures, HIV, RPR in high-risk pts

question

What is an amniocentesis?

answer

recommended 15-20wks consists of transabdominal aspiration of amniotic fluid using an ultrasound guided needle and eval of fetal cells for genetic studies

question

What are the advantages and disadvantages of an amniocentesis?

answer

Ads - detects ~80% of open neural tube defects, ~85% of cases of Down syndrome, and ~60% of cases of trisomy 18Disads - risks: premature rupture of membranes, chorioamnionitis, and fetal-maternal hemorrhage, which can result in fetal loss (0.5%)

question

When is an amniocentesis indicated?

answer

- women who will be >35yo at time of delivery - conjunction w/ an abnormal quad screen - Rh-sensitized pregnancy to obtain fetal blood type or to detect fetal hemolysis - to evaluate fetal lung maturity via a lecithin-to-sphingomyelin ratio >/=2.5 or to detect the presence of phosphatidylglycerol (done during the third trimester)

question

What does FDA Risk Category A suggest of drugs used during pregnancy?

answer

adequate and well-controlled studies in women fail to demonstrate a risk to the fetus in the 1st trimester (and there is no risk in later trimesters). Possibility of fetal harm seems remote. Ex) Vita B6, Vita E, folic acid (w/in recommended daily allowances)

question

What does FDA Risk Category B suggest of drugs used during pregnancy?

answer

either animal reproduction studies have not demonstrated risk to the fetus but no adequate and well-controlled studies in pregnant women have been reported, or animal reproduction studies have shown an adverse effect that was not confirmed in controlled studies in women in the 1st trimester (and there is no evidence of risk in later trimesters). Ex) ampicillin, acetaminophen, buproprion

question

What does FDA Risk Category C suggest of drugs used during pregnancy?

answer

either studies in animals have revealed adverse effects on the fetus but no controlled studies in women have been reported, or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus Ex) diphenhydramine, rifampin, AZT

question

What does FDA Risk category D suggest of drugs used during pregnancy?

answer

positive evidence of human fetal risk exists, but the benefits from use in pregnancy women may be acceptable despite risk Ex) alcohol, phenytoin, tetracycline

question

What does FDA Risk Category X suggest of drugs used during pregnancy/

answer

studies in animals or humans have demonstrated fetal abnormalities, or evidence exists of fetal risk based on human experience, or both, and the risk in pregnant women clearly outweighs any possible benefit Ex) isotretinoin, thalidomide, warfarin

question

What kinds of fetal defects are assoc w/ ACEIs?

answer

fetal renal tubular dysplasia and neonatal renal failure, oligohydramnios, IUGR, lack of cranial ossification

question

What kinds of fetal defects are assoc w/ alcohol?

answer

FAS - growth restriction before and after birth - MR - midfacial hypoplasia - renal and cardiac defects Consumption of >6 drinks per day is assoc w/ a 40% risk of FAS

question

What kinds of fetal defects are assoc w/ androgens?

answer

virilzation of females; advanced genital development in males

question

What kinds of fetal defects are assoc w/ carbamazepine?

answer

neural tube defects, fingernail hypoplasia, microcephaly, developmental delay, IUGR

question

what kinds of fetal defects are assoc w/ cocaine?

answer

bowel atresias, congenital malformations of the heart, limbs, face, and GU tract; microcephaly; IUGR, cerebral infarctions

question

What kinds of fetal defects are assoc w/ DES?

answer

clear cell adenocarcinoma of the vagina or cervix, vaginal adenosis, abnormalities of the cervix and uterus or testes, possible infertility

question

What kinds of fetal defects are assoc w/ lead?

answer

increased spontaneous abortion (SAB) rate; still births

question

What kinds of defects are assoc w/ lithium?

answer

congenital heart disease (Ebstein's anomaly)

question

What kinds of defects are assoc w/ methotrexate?

answer

increased SAB rate

question

What kinds of defects are assoc w/ organic mecury?

answer

cerebral atrophy, microcephaly, MR, spasticity, seizures, blindness

question

What kinds of fetal defects are assoc w/ phenytoin?

answer

IUGR, MR, microcephaly, dysmorphic craniofacial features, cardiac defects, fingernail hypoplasia

question

What kinds of fetal defects are assoc w/ radiation?

answer

microcephaly, MR, medical dx radiation delivery <0.05 Gy to the fetus has no teratogenic risk

question

What kinds of fetal defects are assoc w/ streptomycin and kanamycin?

answer

hearing loss; CN VIII damage

question

what kinds of fetal defects are assoc w/ tetracycline?

answer

premanent yellow-brown discoloration of deciduous teeth; hypoplasia of tooth enamel

question

What kinds of fetal defects are assoc w/ thalidomide?

answer

bilateral limb deficiencies, anotia, microtia, cardiac and GI anomalies

question

What kinds of fetal defects are assoc w/ Trimethadione and paramethadione?

answer

cleft lip or clef palate, cardiac defects, microcephaly, MR

question

What kinds of fetal defects are assoc w/ valproic acid?

answer

neural tube defects (spinal bifida); minor cranial defects

question

What kinds of fetal defects are assoc w/ vitamin A and derivatives?

answer

increased SAB rate, thymic agenesis, cardiovascular defects, craniofacial dysmorphism, microphthalamia, cleft lip, or clef phrase, MR

question

What kinds of fetal defects are assoc w/ warfarin?

answer

nasal hypoplasia and stippled bone epiphyses, developmental delay, IUGR ophthalmologic abnormalities

question

What are common sequelae of maternal-fetal infxns?

answer

premature delivery, CNS abnormalities, anemia, jaundice, hepatosplenomegaly, growth retardation

question

What are the TORCH infxns?

answer

most common pathogens causing maternal-fetal infxns - Toxoplasmosis - Other (parvovirus, varicella, Listeria, TB, malaria, fungi) - Rubella - CMV - Herpes - HIV - Syphilis

question

What kinds of animals should pregnant women avoid?

answer

cats they shouldn't change a cat's litterbox

question

Which is more common, toxo during the first or third trimester?

answer

1st trimester: less common, more severe 3rd trimester: more common, less severe

question

How does toxoplasmosis affect pregnant women?

answer

transplacental transmission w/ primary infxn occuring via consumption of raw meat or contact w/ cat feces. Specific findings: hydrocephalus, intracranial calcifications, chorioretinitis, ring-enhancing lesions on head CT

question

How does rubella affect pregnant women?

answer

transplacental transmission in the 1st trimester. Specific findings: purpuric \"blueberry muffin\" rash, cataracts, MR, hearing loss, patent ductus arteriosus (PDA)

question

How does CMV affect pregnant women?

answer

most common congenital infxn primarily transmitted transplacentally specific findings: petechial rash (similar to \"blueberry muffin\" rash) and periventricular calcifications

question

How does herpes affect pregnant women?

answer

intrapartum transmission if the mother has active lesions Causes skin, eye, and mouth infxns or life-threatening CNS/systemic infxn

question

How does HIV affect pregnant women?

answer

Transmission can occur in utero, at the time of delivery, or via breast milk Occurs in 13-39% of births to infected mothers Combination of AZT tx (prenatally, intrapartum, and neonatally for the first six wks of life) and C-section can lower transmission to 2%. Newborns w/ congenitally acquired HIV are often ASx, failure to thrive, bacterial infxns w/ common organisms, and an increased incidence of upper and lower respiratory diseases may appear early or may be delayed for months to years. HIV + mothers should not breastfeed

question

How does syphilis affect pregnant women?

answer

Primarily intrapartum transmission Specific findings: maculopapular skin rash, lymphadenopathy, hepatomegaly, \"snuffles\" mucopurulent rhinitis, osteitis Childhood findings: saber shins, saddle nose, CNS involvement and Hutchinson's traid: peg-shaped upper central incisors, deafness, and interstitial keratitis (photophobia, lacrimation)

question

What is the definition of SAB?

answer

loss of products of conception prior to the 20th wk of pregnancy. Approx 60% of chemically evident pregnancies and 15-20% of clinically dx pregnancies terminate in a SAB. More than 80% occur in first trimester

question

What are the risk factors for an SAB?

answer

Chromosomal abnormalities Maternal factors - maternal trauma, increased maternal age, infxn, dietary deficiencies - inheritied thrombophilias: Factor V Leiden, prothrombin, antithrombin, proteins C and S, methylene tetrahydrofolate reductase (hyperhomocysteinemia) - immunologic issues: antiphospholipids abs, alloimmune factors - anatomic issues: uterine abnormalities, incompetent cervix, cervical conization, loop electrosurgical excision procedure, cervical injury, DES exposure, anatomical abnormalities of the cervix - endocrine issues: DM, hypothyroidism, progesterone deficiency Environmental factors: Tabacco, alcohol, caffeine, toxins, drugs, radiation Fetal factors: anatomic malformation

question

How is SAB dx?

answer

decreasing level of hCG U/S: identify the gestational sac 5-6 wks from LMP, a fetal pole at six wks, fetal cardiac activity 6-7wks; accurate dating, a small, irregular intrauterine sac w/o fetal pole on transvaginal U/S is diagnostic of abnormal pregnancy Maternal Rh type should be determined and RhoGAM given if the type is Rh neg

question

What is included in a normal obstetric exam?

answer

1) Leopold's maneuvers: determine fetal lie (longitudinal or transverse) and if possible, fetal presentation (breech or cephalic) 2) Cervical examination: evaluate dilation, effacement, station, cervical position, cervical consistency. Use Bishop score. Confirm or determine fetal presentation. Determine fetal position through palpation of the fetal sutures and fontanelles. Conduct a sterile speculum exam if rupture of membranes is suspected

question

What is the Bishop score?

answer

used to evaluate the favorability of delivery and the probability of succeeding w/ an induction. Scoring: 0-4: indicates 45-50% chance of failure. Give prostaglandins for induction 5-9: points to a 10% chance of failure. Give pitocin for induction 10-13: assoc w/ very high probability of success. There is no need for intervention for induction

question

What are the different types of SAB?

answer

- Complete - Incomplete - Threatened - Inevitable - Missed - Septic - Intrauterine fetal demise - Recurrent

question

What is a complete SAB?

answer

POC is expelled. Pain ceases, but spotting may persist. CLOSED OS U/S shows empty uterus POC should be sent to pathology to confirm fetal tissueNo further intervention needed

question

What is an incomplete SAB?

answer

some POC expelled, bleeding/mild cramping. Visible tissue on exam. OPEN OS U/S shows retained fetal tissueIntervention: manual uterine aspiration (MUA) or D&C

question

What is a threatened SAB?

answer

No POC expelled. Uterine bleeding +/- abd pain CLOSED OS intact membranes, fetal cardiac motion on U/SIntervention: pelvic rest for 24-48hrs and follow-up U/S to assess the viability of conceptus

question

What is an inevitable SAB?

answer

No POC expelled. Uterine bleeding and cramps OPEN OS +/- ROMIntervention: MUA, D&C, misoprostol, or expectant mgmt

question

What is a missed SAB?

answer

No POC expelled, No fetal cardiac motion, No uterine bleeding. Brownish vaginal discharge CLOSED OS No fetal cardiac activity, retianed fetal tissue on U/SIntervention: MUA, D&C, or misoprostol

question

What is a septic SAB?

answer

endometritis leading to septicemia. Maternal mortality is 10-15% Hypotension, hypothermia, increased WBC countIntervention: MUA, D&C, IV abx

question

What is an intrauterine fetal demise?

answer

absence of fetal cardiac activity Uterus is small for GA; no fetal heart tones or movt on U/SIntervention: induce labor; evacuate the uterus (D&E) to prevent DIC at GA >16wks

question

What is recurrent SAB?

answer

Early pregnancy: often due to chromosomal abnormalities Late pregnancy: due to hypercoagulable states (SLE, factor V Leiden, protein S deficiency) Incompetent cervix: should be suspected w/ hx of painless dilation of cervix and delivery of a normal fetus btw 8 and 32 wksKaryotype both parents. Hypercoagulability work-up in mom. Evaluate for uterine abnormalities Intervention: surgical cerclage procedures to suture the cervix closed until labor or ROM occurs w/ subsequent removal prior to delivery. Restrict activities

question

what is the medical procedures for a first trimester therapeutic abortion?

answer

1) oral mifepristone (low dose) + oral/vaginal misoprostol UP TO 49 days GA 2) IM/oral methotrexate + oral/vaginal misoprostol UP TO 49 days GA 3) vaginal or sublingual or buccal misoprostol (high dose), repeated up to three times UP TO 56 days GA

question

What is the surgical procedure for a first trimester therapeutic abortion?

answer

1) manual aspiration 2) D&C w/ vacuum aspirationBOTH UP TO 13 wks GA

question

What is the obstetric mgmt for a second trimester therapeutic abortion?

answer

induction of labor (typically w/ prostaglandins, amniotomy, and oxytocin) UP TO 13-24 wks GA (depending on state laws)

question

What is the surgical option for a second trimester therapeutic abortion?

answer

D&E UP TO 13-24 wks GA (depending on state laws)

question

What are the recommendations for FHR monitoring in pts w/o complications?

answer

Review FHR tracings every 30 min in the first stage of labor and every 15 min in the second stage of labor

question

What are the recommendations for FHR monitoring in pts w/ complications

answer

Review FHR tracings every 15 min in the first stage of labor and every 5 min in the second stage of labor

question

What are the components of reading FHR?

answer

Rate (normal = 110-160) - <110 = bradycardia ---caused by congenital heart malformations or severe hypoxia (secondary to uterine hyperstimulation, cord prolapse, or rapid fetal descent) - >160 = tachycardia ---can be caused by hypoxia, maternal fever, fetal anemiaVariability (normal beat to beat variability = 6-25 bpm) - undetectable variability indicates severe fetal distress - minimal variability (<6) indicates fetal distress or effects of opioids or mag - marked variability (>25) indicates fetal distress; or may occur before a decrease in variability - sinusoidal variability: points to serious fetal anemia; may also occur during maternal meperidine use - accelerations: onset of increase in FHR to a peak in <30sec. Reassuring b/c they indicate fetal ability to appropriately respond to the environment - decelerations: several types (early, late, variable)

question

What are the stages of labor?

answer

First stage - latent - active Second Third

question

What occurs during the first stage of labor?

answer

Latent: onset of labor to 3-4cm dilation - primiparous: 6-11hrs - multiparous: 4-8hrs - prolonged if excessive sedation and hypertonic uterine contractionsActive: 4cm to complete cervical dilation (10cm) - primiparous: 4-6hrs (1.2cm/hr) - multiparous: 2-3hrs (1.5cm/hr) - prolongation seen w/ cephalopelvic disproportion

question

what occurs during the second stage of labor?

answer

complete cervical dilation to delivery of infant - primparous: 0.5-3.0hrs - multiparous: 5-30min When baby goes through all cardinal mvts of delivery

question

What occurs during the third stage of labor?

answer

delivery of infant to delivery of placenta - primparous and multiparous: 0-0.5 hr uterus contracts and placenta separates to establish hemostasis

question

What is an early fetal deceleration?

answer

visually apparent, gradual (onset to nadir in >30sec) decrease in FHR w/ a return to baseline that mirrors the uterine contraction Etiology: head compression from uterine contraction (normal)

question

What is a late fetal deceleration?

answer

WORRISOME visually apparent, gradual (onset to nadir in >30 sec) decrease in FHR w/ return to baseline whose onset, nadir, and recovery occur after the beginning, peak, and end of uterine contraction, respectively Etiology: uteroplacental insufficiency and fetal hypoxemia

question

What is a variable fetal deceleration?

answer

an abrupt (onset to nadir in <30sec), visually apparent decrease in FHR below baseline lasting >/= 15 sec but <2 min Etiology: umbilical cord compression

question

What are the indications for antepartum fetal surveillance?

answer

used in pregnancies w/ increased risk for fetal demise. Begin 32-34wks for at risk pts 26-28 if there are multiple worrisome risks

question

What are the components of antepartum fetal surveillance?

answer

Fetal movt assessment: - # movts in an hr; assessed by mom - average is 10 movts q20min - if decreased movt...Nonstress Test (NST) - mom is resting in lateral tilt position (prevent supine hypotension) - FHR monitored externally by Doppler along w/ a tocodynamometer to detect uterine contractions - Acoustic stimulation can be used - Results: ---\"reactive\" (normal response): two accelerations of >/=15 bpm above baseline lasting for at least 15 sec over a 20min period ---\"nonreactive\": fewer than two accelerations over a 20 min period. Perform further tests (e.g. biophysical profile). Lack of FHR accelerations may occur w/ any of the following: -----GA<32 wks -----fetal sleping -----fetal CNS anomalies -----maternal sedative or narcotic administration Contraction Stress Test (CST) - mom in lateral recumbent position - FHR monitored during spontaneous or induced (via nipple stimulation or oxytocin) contractions - reactivity is determined from fetal heart monitoring, as w/ NST - procedure CI in women w/ preterm membrane rupture or known placenta previa; women w/ history of uterine surgery; women who are at high risk for preterm labor - Results: ---\"Positive\" CST: late decelerations following 50% or more of contractions in a 10min window; raises concerns about fetal compromise. DELIVERY NEEDED ---\"Negative\" CST: no late or significant variable decelerations w/in 10 min and at least 3 contractions. Highly predictive of fetal well-being in conjunction w/ a normal NST ---\"Equivocal\" CST: defined by intermittent late decelerations or significant variable decelerations Biophysical profile (BPP) - real-time U/S to assign a score of 2 (normal) or 0 (abnormal) to five parameters --fetal tone --breathing --movement --amniotic fluid volume --NST - Scoring: ---8-10: reassuring for fetal well-being ---6: considered equivocal. Term pregnancies delivered w/ this profile ---0-4: Extremely worrisome for fetal asphyxia; strong consideration should be given to immediate delivery if no other explanation is found Modified BPP (mBPP) - combines NST w/ amniotic fluid index (AFI). Normal if reactive NST and AFI>5cm Umbilical artery Doppler Velocimetry - IUGR: reduction and even reversal of umbilical artery diastolic flow. Test is of benefit only when IUGR is suspected Oligohydramnios (AFI <5 cm) ALWAYS warrants further work-up

question

Where is the pain in uterine contractions and cervical dilation?

answer

visceral pain at T10-L1

question

Where is the pain when the fetal head descends and pressure is placed on vagina and perineum?

answer

somatic pain at S2-S4

question

What are absolute CI to regional anesthesia during delivery?

answer

refractory maternal hypotension maternal coagulopathy maternal use of once-daily dose of LMW Heparin w/in 12hrs untreated maternal bacteremia skin infxn over the site of needle placement Increased ICP caused by mass lesion

question

What is hyperemesis gravidarum?

answer

persistent vomiting not related to other causes, acute starvation (usually large ketonuria), and weight loss Evaluate Severity: - ketonemia, ketonuria, hyponatremia, and hypokalemic, hypochloremic metabolic alkalosis - measure LFTs, serum bilirubin, serum amylase/lipase More common in first pregnancy, multiple gestations, and molar pregnancies. - check B-hCG and U/S to r/o molar pregnancy If \"morning sickness\" persists after the first trimester, think hyperemesis gravidarum Increased B-hCG and estradiol implicated R/O acid reflux, gastroenteritis, hyperthyroidism, neuro conditions

question

What are the different types of pain relief offered to delivery moms?

answer

Nonpharmacologic Opiods Local block (lidocaine) Epidural Spinal Combined spinal epidural General

question

What is included in nonpharmacologic pain relief and what are the advantages of this method?

answer

social support, massages, breathing, aromatherapy, ambulation, and repositioning - no known neg side effects - works by increasing coping w/ pain rather than eliminating painBUT offers limited pain relief

question

What are the advantages/disadvantages of using opiods for obstetric analgesia/anesthesia?

answer

ADS: provide an adequate level of pain relief for some women w/o risks assoc w/ regional anesthesia DISADS: sedative effect of opiods decreases FHR variability and increases the possible need for neonatal naloxone admin and five-min APGAR scores <7

question

What are the advantages/disadvantages of using local blocks for obstetric analgesia/anesthesia?

answer

ADS: excellent anesthesia before episiotomy and during repair of lacerations; can be used to perform a pudendal block DISADS: rarely, may cause seizures, hypotension, and cardiac arrhythmias

question

What are the advantages/disadvantages of using epidural for obstetric analgesia/anesthesia?

answer

ADS: MOST effective form of pain relief; can also be used for C-section or postpartum tubal ligation DISADS: can result in pruritis, fever, hypotension, and transient FHR deceleration

question

What are the advantages/disadvantages of using spinal for obstetric analgesia/anesthesia?

answer

ADS: rapid onset analgesia that provides excellent pain relief for procedures of limited duration (30-250min) DISADS: Limited duration. Puts pts at risk for hypotension, postdural puncture headache, and transient neuro sx

question

What are the advantages/disadvantages of using combined spinal epidural for obstetric analgesia/anesthesia?

answer

ADS: offers rapid onset of spinal analgesia combined w/ ability to prolong duration of analgesia w/ continuous epidural infusion DISADS: carries risk of both procedures; may increase risk of bradycardia and emergent cesarean delivery over epidural analgesia alone

question

What are the advantages/disadvantages of using general anesthesia for obstetric analgesia/anesthesia?

answer

ADS: used in emergent c-section and indicated in some cases of FHR abnormality; can be useful in cases where regional anesthesia is absolutely CI or fails DISADS: requires airway control; carries significant risk of maternal aspiration and neonatal depression (inhaled anesthetic agents readily cross placenta); assoc w/ higher maternal morbidity rates than epidural anesthesia

question

How is hyperemesis gravidum tx?

answer

1) Admin Vitamin B6 2) doxylamine (antihistamine) PO 3) Promethazine or deminhydrinate PO/PR 4) If severe: metoclopramide, ondansetron, prochlorperazine, or promethazine IM/PO 5) If dehydrated: IV fluids, IV nutritional supplementation, dimenhydrinate IV

question

What is the difference btw gestational diabetes and pregestational diabetes?

answer

gestational = onset occurs during pregnancy

question

What classification system is used to risk stratify women with diabetes assoc w/ pregnancy?

answer

White Classification A1: gestational; insulin not required A2: gestational; insulin required B: age of onset 20yrs or older or duration <10yrs C: age of onset 10-19yrs or duration 10-19yrs D: age of onset<10yrs or duration >20yrs F: nephropathy H: cardiomyopathy R: proliferating retinopathy RF: proliferating retinopathy T: renal transplant

question

How does gestational diabetes present?

answer

typically ASx Edema, polyhydramnios, or a large-for-GA infant (>90th percentile) may be warning signsoccurs in 3-5% of all pregnancies, usually in late pregnancy

question

How is gestational diabetes dx?

answer

1) One hr 50g glu challenge test; venous plasma glucose is measured one hr later (at 24-48wks). Values >/=140mg/dL are considered abnormal 2) Confirm w/ an oral three hr 100g glu tolerance test showing any two of the following: fasting >95mg/dL; one hr>180mg/dL; two hr>155mg/dL, three hrs >140mg/dL

question

How is gestational diabetes tx?

answer

Mom: 1) start on ADA diet, regular exercise, strict glu monitoring (4x/day). Tight maternal glu control (fasting glu <100; one to two hr postprandial glu <150) improves outcomes 2) add insulin if dietary control is insufficient Give intrapartum insulin and dextrose to maintain tight control during deliveryFetus: - Obtain periodic U/S and NSTs to assess fetal growth and well being (30-32wks) - may be necessary to induce labor at 39-40wks

question

What are complications of gestational diabetes?

answer

more than 50% pts go on to develop glucose intolerance and/or type 2DM later in life

question

What are risks of pregestational diabetes?

answer

poorly controlled DM is assoc w/ increased risk of congenital malformations, fetal loss, and maternal/fetal morbidity during labor and delivery

question

How is pregestational diabetes tx?

answer

Mother: - renal, ophthalmologic, and cardiac evaluation to assess for end-organ damage. - strict glu control (w/ diet, exercise, insulin tx, and frequent self-monitoring for type 1 and type 2 DM) to minimize fetal defects --Fasting AM<90mg/dL --two-hr postprandial<120mg/dL Fetus: - 18-20wks: u/s to determine fetal age and growth: evaluate for cardiac anomalies and polyhydramnios; quad screen to screen for developmental anomalies - 32-4wks: close fetal surveillance (NST, CST, BPP). Admit if maternal DM has been poorly controlled for fetal parameters are a concern. Serial U/S for fetal growth Delivery and postpartum - maintain normoglycemia (80-100mg/dL) during labor w/ an IV insulin drip and hourly glu measurements - consider early delivery in the setting of poor maternal glu control, preeclampsia, macrosomia, evidence of fetal lung maturity - c-section should be considered for EFW> 4500g - encourage breastfeeding w/ appropriate increase in caloric intake - continue glu monitoring postpartum. Insulin needs rapidly decrease after delivery

question

What lab tests in mom suggest pregestational diabetes?

answer

HgbA1c>8% UA before 20wks reveals glycosuria Hyperglycemia in 1st trimester

question

What is the difference btw gestational and chronic HTN?

answer

Gestational HTN: - aka PIH - idiopathic HTN w/o significant proteinuria (<300mg/L) that develops at >20wks' gestation. 25% will develop preeclampsiaChronic HTN: - present before conception and at <20wks gestation, may persist >12wks postpartum - 1/3 may develop superimposed preeclampsia

question

How are gestational and chronic HTN tx?

answer

Monitor BP closely and tx w/ appropriate anti-HTN (methyldopa, labetalol, nifedipine). DO NOT give ACEIs or diuretics

question

What are complications that can occur if pregnant pts receive ACEIs or diuretics?

answer

ACEIs: uterine ischemia Diuretics: low plasma volume to point of uterine ischemia

question

What are complications of gestational and chronic HTN?

answer

similar to preeclampsia

question

What is preeclampsia?

answer

new onset HTN (SBP>140 or DBP> 90) and proteinuria (>300mg in 24hrs) occuring at >20wks gestation

question

What is eclampsia?

answer

new onset grand mal seizures in women w/ preeclampsia

question

What is HELLP syndrome?

answer

Hemolytic anemia Elevated liver enzymes Low plateletVariant of preeclampsia w/ poor prognosis Clinical manifestations explained by vasospasm leading to hemorrhage and organ necrosis

question

What are maternal complications of pregestational DM?

answer

DKA (type 1) HHNK (type 2) preeclampsia/eclampsia cephalopelvic disproportion (from macrosomia) and need for C-section preterm labor infxn polyhydramnios postpartum hemorrhage maternal mortality

question

What are fetal complications of pregestational DM?

answer

macrosomia or IUGR cardiac and renal defects neural tube defects (sacral agenesis) hypocalcemia polycythemia hyperbilirubinemia IUGR hypoglycemia from hyperinsulinemia respiratory distress syndrome birth injury (shoulder dystocia) perinatal mortality

question

What are risk factors for preeclampsia/eclampsia?

answer

nulliparity, African-American ethnicity, extremes of age (<20 or >35), multiple gestation, molar pregnancy, renal disease (due to SLE or type I DM), FHx of preeclampsia, chronic HTN

question

What are the s/sx of mild preeclampsia?

answer

usually ASx BP>/= 140/90 on 2 occasions >6hrs apart Proteinuria (>300mg/24hrs or 1-2 + urine dipsticks) Edema

question

What are the s/sx of severe preeclampsia?

answer

BP>160/110 on two occasions >6hrs apart Renal: proteinuria (>5g/24hrs or 3-4+urine dipsticks) or oliguria (<500 mL/24hrs). Cerebral changes: headache, somnolence Visual changes: blurred vision, scotoma Hyperactive reflexes/clonus RUQ pain Hemolysis, elevated liver enzymes, thrombocytopenia (HELLP)

question

What are the s/sx of eclampsia?

answer

signs preceding eclamptic attack - HA, visual changes, RUQ/epigastric pain Seizures are severe if not controlled w/ anticonvulsant tx

question

What is the classic triad for preeclampsia?

answer

HTN proteinuria edema

question

What is the ONLY cure for preeclampsia/eclampsia?

answer

delivery of fetus

question

How is preeclampsia tx?

answer

if pts is close to term or preeclampsia worsens, induce delivery w/ IV oxytocin, prostaglandin, amniotomy if far from term, tx w/ modified bed rest and expectant mgmt

question

How is severe preeclampsia tx?

answer

1) Control BP w/ labetalol and/or hydralazine (goal <160/110, DBP btw 90-110 to maintain fetal blood flow). 2) Prevent seizures w/ continuous MgSO4 drip - watch for signs of mg toxicity (Loss of DTRs, respiratory paralysis, coma). Continue seizure prophy for 24hrs postpartum. Tx mg toxicity w/ IV calcium gluconate 3) Delivery by induction of C-section when mother is stable

question

How is eclampsia tx?

answer

1) ABCs w/ O2 2) seizure control/prophy w/ mg. If seizures recur, give IV diazepam. Monitor mg blood levels and mag toxicity; monitor fetus status. Control BP (labetalol and/or hydralazine). Limit fluids; Foley for strict I/Os. 3) Initiate delivery if pt is stable and convulsions are controlled. Postpartum mgmt is the same as that for preeclampsia. Seizures may occur antepartum, intrapartum, or postpartum. Most w/in 48hrs after delivery

question

What are complications of preeclampsia?

answer

prematurity fetal distress stillbirth placental abruption seizure DIC cerebral hemorrhage serous retinal detachment fetal/maternal death

question

What are complications of eclampsia?

answer

cerebral hemorrhage aspiration pneumonia hypoxic encephalopathy thromboembolic events fetal/maternal death

question

What are possible causes of third trimester bleeding?

answer

Vagina: bloody show, trauma Cervix: cervical cancer, cervical/vaginal lesion Placenta: placental abruption, placenta previa Fetus: fetal bleeding

question

What is antepartum bleeding?

answer

bleeding that occurs after 20wks gestation (bleeding before 20wks = threatened abortion) most common causes: placental abruption, placenta previa other causes: abnormal placentation (placenta accreta), ruptured uterus, genital tract lesions, and trauma

question

What is placental abruption?

answer

premature (before delivery) separation of normally implanted placenta

question

What are risk factors for placental abruption?

answer

HTN abd/pelvic trauma tobacco or cocaine use previous abruption rapid decompression of an overdistended uterus excessive stimulation

question

What are sx of placental abruption?

answer

PAINFUL Dark vaginal bleeding that does not spontaneously cease Abd pain, uterine hypertonicity Fetal distress

question

How is placental abruption dx?

answer

Clinical dx Transabdominal/transvaginal U/S sensitivity : 50% Look for retroplacental clot; most useful for ruling out previa

question

How is placental abruption tx?

answer

Stabilize pt w/ mild abruption and a premature fetus-->manage expectantly --hospitalize --start IV and fetal monitoring --type and cross blood --bed restModerate to severe abruption-->IMMEDIATE delivery -- vaginal delivery w/ amniotomy if mother and fetus are stable and delivery is expected soon --C-section for maternal or fetal distress

question

What are complications of placental abruption?

answer

Hemorrhagic shock Coagulopathy: DIC in 10% Recurrence risk is 5-16% and rises to 25% after 2 previous abruptions Fetal hypoxia

question

What is placenta previa?

answer

Abnormal placental implantation - total: covers cervical os - marginal: placenta extends to margin of the os - low-lying: placenta is in close proximity to os

question

What are risk factors for placenta previa?

answer

prior C-sections, grand multiparity, advanced maternal age, multiple gestation, prior placenta previa

question

How does placenta previa present?

answer

PAINLESS bright red blood that often ceases in 1-2 hrs w/ or w/o uterine contractions Usually no fetal distress

question

How is placenta previa dx?

answer

transabdominal/transvaginal U/S sensitivity is >95% Look for an abnormally positioned placenta

question

How is placenta previa tx?

answer

NO VAGINAL EXAMS! stabilize pts w/ a premature fetus-->mgmt expectantly Give tocolytics Serial U/S to assess fetal growth; resolution of partial previa Give betamethasone to help w/ fetal lung maturity Delivery by C-section --Indications for delivery ---labor ---life-threatening bleeding ---fetal distress ---documented fetal lung maturity ---36wks GA

question

What are complications of placenta previa?

answer

increased risk of placenta accreta vasa previa (fetal vessels crossing the internal os preterm delivery, PROM, IUGR, congenital anomalies recurrence risk is 4-8%

question

What is an ectopic pregnancy?

answer

tubal, but can be abd, ovarian, or cervical pregnancy

question

How does ectopic pregnancy typically present?

answer

abd pain and vaginal spotting/bleeding although some pts are ASx Assoc w/ etiologies that cause scarring to the fallopian tubes (Hx of PID, pelvic surgery, DES use, or endometriosis)

question

What is the DDx for ectopic pregnancy?

answer

surgical abd abortion ovarian torsion PID rupture ovarian cyst

question

How is ectopic pregnancy dx?

answer

RUPTURED ECOPTIC PREGNANCY UNTIL PROVEN OTHERWISE 1) + pregnancy test and transvaginal u/s showing an empty uterus 2) confirm w/ serial hCG w/o appropriate hCG doubling

question

How is ectopic pregnancy tx?

answer

Medical tx: methotrexate for small, unruptured tubal pregnancies Surgical tx: salpingectomy or salpingostomy w/ evacuation (laparoscopy vs. laparotomy)

question

What are complications of ecoptic pregnancy?

answer

tubal rupture and hemoperitoneum (obstetric emergency)

question

What is IUGR?

answer

EFW less than 10th percentile for GA

question

How does IUGR present?

answer

affected infants are commonly born to women w/ systemic diseases that lead to uteroplacental insufficiency (intrauterine infxn, HTN, anemia) other risk factors: maternal substance, placenta previa, multiple gestations

question

How is IUGR dx?

answer

1) Confirm serial fundal height measurements w/ U/S 2) U/S the fetus for EFW (although as pregnancy advances, ultrasound fetal weight estimates become increasingly unreliable)

question

How is IUGR tx?

answer

1) explore underlying etiology and correct if possible 2) if near due date, admin steroids (betamethasone) to accelerate fetal lung maturity 3) perform fetal monitoring w/ NST, CST, BPP, and umbilical artery Doppler velocimetry. A nonreassuring status near term may prompt delivery

question

What are complications of IUGR?

answer

increase perinatal morbidity and mortality

question

What is fetal macrosomia?

answer

birth weight> 90th percentile. Common sequela of gestational diabetes

question

How is fetal macrosomia dx?

answer

dx by weighing newborn at birth (prenatal dx is imprecise)

question

How is fetal macrosomia tx?

answer

planned C-section delivery may be considered if EFW>5000g in women w/o diabetes and EFW >4500g in women w/ diabetes

question

What are complications of fetal macrosomia?

answer

increased risk of shoulder dystocia (leading to brachial plexus injury and Erb-Duchenne palsy) as birth weight increases

question

What is polyhydramnios?

answer

AFI>20 on U/S - may be present in normal pregnancies, but fetal chromosome developmental abnormalities must be considered

question

What are causes of polyhydramnios?

answer

maternal DM multiple gestation isoimmunization pulmonary abnormalities (cystic lung malformations) fetal anomalies (duodenal atresia, tracheoesophageal fistula, anencephaly) twin-twin transfusion syndrome

question

How does polyhydramnios present?

answer

usually ASx

question

How is polyhydramnios dx?

answer

fundal height greater than expected evaluation includes U/S for fetal anomalies, glu testing for DM and Rh screen

question

What are complications of polyhydramnios?

answer

preterm labor, fetal malpresentation, cord prolapse

question

What is oligohydramnios?

answer

AFI<5cm on U/S Usually ASx, but IUGR or fetal distress may be present

question

What are causes of oligohydramnios?

answer

fetal urinary tract abnormalities (renal agenesis, GU obstruction), chronic uteroplacental insufficiency, and ROM

question

How is oligohydramnios dx?

answer

sum of deepest amniotic fluid pocket in all 4 abdominal quadrants on U/S

question

How is oligohydramnios tx?

answer

r/o inaccurate gestational dates tx underlying cause, if possible

question

What are complications of oligohydramnios?

answer

assoc w/ 40x increase in perinatal mortality musculoskeletal abnormalities (clubfoot, facial distortion), pulmonary hypoplasia, umbilical cord compression, and IUGR

question

What is Rh isoimmunization?

answer

fetal RBCs leak into maternal circulation, maternal anti-Rh IgG abs form an cross the placenta, leads to hemolysis of fetal Rh RBCs (erythroblastosis fetalis)

question

What blood type of women are at risk for RH isoimmunization?

answer

Rh neg women who have had previous SAB or TAB as well as among those who have undergone a previous delivery w/ no RhoGAM given

question

How is Rh isoimmuniztion dx?

answer

sensitized Rh neg mothers w/ titers >1:16 should be closely monitored w/ serial u/s and amniocentesis for evidence of fetal hemolysis

question

How is Rh isoimmunization tx?

answer

Severe cases: initiate preterm delivery when fetal lungs mature Prior to delivery: intrauterine blood transfusions may be given to correct a low fetal hematocrit

question

How is Rh isoimmunization prevented?

answer

If Rh neg at 28wks and father is Rh+ or unknown, give RhoGAM If baby is Rh+, give RhoGAM postpartum Give RhoGAM to Rh neg mothers who undergo abortion or who have had placental abruption. T&S critical; follow B-hCG closely and prevent pregnancy for one year

question

What are complications of Rh isoimmunization?

answer

hydrops fetalis occurs when fetal hemoglobin drops to <7 g/dl other complications: fetal hypoxia, acidosis, kernicterus, prematurity, death

question

What is gestational trophoblastic disease (GTD)?

answer

range of proliferative trophoblastic abnormalities that can be benign or malignant - complete moles - incomplete (partial) moles

question

What are complete moles?

answer

usually result from sperm fertilization of an empty ovum, 46XX (paternally derived)

question

What are incomplete moles?

answer

occur when a normal ovum is fertilized by two sperm (or haploid sperm that duplicates its chromosomes); usually 69XXY and contain fetal tissue

question

How do moles present?

answer

present w/ first trimester uterine bleeding (most common), hyperemesis gravidarum, preeclampsia/eclampsia at <24wks, uterine size greater than dates

question

What are risk factors for gestational trophoblastic disease?

answer

extremes of age (<20 or >40yrs) and a diet deficient in folate or beta-carotene

question

How is gestational trophoblastic disease dx?

answer

no fetal heartbeat is detected. Pelvic exam may reveal enlarged ovaries (bilateral theca-lutein cysts) or expulsion of grapelike molar clusters into the vagina Labs: show markedly increased serum B-hCG (usually>100,000 mIU/mL) and pelvic ultrasound reveals a \"snowstorm\" appearance w/ no gestational sac or fetus present CXR: show lung metastases; D&C reveals \"cluster of grapes\" tissue

question

How is gestational trophoblastic disease tx?

answer

Evacuate the uterus and follow w/ weekly B-hCG. Treat malignant disease w/ chemotx (methotrexate or dactinomycin) and residual uterine disease w/ hysterectomy; chemotx and irradiation are highly effective for metastases

question

What are complications of gestational trophoblastic disease?

answer

molar pregnancy may progress to malignant GTD, including invasive moles (10-15%) and choriocarcinoma (2-5%) w/ pulmonary or CNS metastases. Trophoblastic pulmonary emboli may also be seen.

question

How do multiple gestations present?

answer

characterized by rapid uterine growth, excessive maternal weight gain, and palpation of three or more large fetal parts on Leopold's maneuvers

question

How are multiple gestations dx?

answer

ultrasound; hCG, HPL, and MSAFP are elevated for GA

question

How are multiple gestations tx?

answer

multifetal reduction and selective fetal termination is an option for higher-order multiple pregnancies; antepartum fetal surveillance for IUGR. Mgmt by a high-risk specialist is recommended

question

What are some complications of multiple gestations?

answer

Maternal: Pts are 6x more likely to be hospitalized w/ complications--e.g. preeclampsia, preterm labor, PPROM, placental abruption, pyelonephritis, postpartum hemorrhage Fetal: twin-to-twin transfusion syndrome, IUGR, and preterm labor

question

What are the risk factors for shoulder dystocia?

answer

obesity, diabetes, hx of macrosomic infant, and hx of prior shoulder dystocia

question

How is shoulder dystocia dx?

answer

dx by prolonged second stage of labor, recoil of the perineum (\"turtle sign\"), and lack of spontaneous restitution

question

How is shoulder dystocia tx?

answer

In the event of dystocia, be the mother's HELPER: Help reposition Episiotomy Leg elevated (McRoberts' maneuver Pressure (suprapubic) Enter the vagina and attempt rotation (Wood's screw) Reach for the fetal arm

question

What conditions is failure to progress assoc w/?

answer

chorioamnionitis occiput posterior position nulliparity elevated birth weight

question

How is failure to progress dx?

answer

First stage protraction or arrest: labor that fails to produce adequate rates of progressive cervical change Prolonged second-stage arrest: - nulliparous: inadequate cervical dilation after >3 hrs w/ regional anesthesia, >2hrs w/o - multiparous: inadequate cervical dilation after >2 hrs w/ regional anesthesia; >1 hrs w/o

question

How is failure to progress tx in the first stage?

answer

First stage: failure to have progressive cervical change - Latent ---Prima: >20hrs ---Multi: >14hrs ---Tx: therapeutic rest via parenteral analgesia; oxytocin; amniotomy; cervical ripening- Active ---Prima: >2hrs ---Multi: >2hrs after reaching 3-4cm ---Tx: amniotomy; oxytocin; C-section if the previous interventions are ineffective

question

How is failure to progress tx in the second stage?

answer

Arrest of fetal descent: - Prima>2hrs; >3hrs w/ epidural ---Tx: close observation w/ decrease in epidural rate and continued oxytocin - Multi: >1hr; >2hrs w/ epidural ---Tx: assisted vaginal delivery (forceps or vacuum). C-section

question

What are complications of failure to progress?

answer

Chorioamnionitis leads to fetal infxn, pneumonia, and bacteremia Some 10% of those affected have permanent injury, 11% have a risk of postpartum hemorrhage, and 3.8% are at risk of fourth-degree laceration.

question

What is spontaneous rupture of membranes?

answer

occurs >1 hr before onset of labor. May be precipitated by vaginal or cervical infxns, abnormal membrane physiology, or cervical incompetence

question

What is PPROM?

answer

preterm premature rupture of membrane rupture of membranes occurring at <37 wks' gestation

question

What is PROM?

answer

Premature rupture of membrane defined as rupture >18hrs prior to delivery.

question

What are the risk factors to PROM?

answer

low SES, young maternal age, smoking, STDs

question

How does rupture of membranes present?

answer

pts often report a \"gush\" of clear or blood-tinged amniotic fluid Uterine contractions may be present

question

How is rupture of membranes dx?

answer

First Step - sterile speculum exam reveals pooling of amniotic fluid in the vaginal vault - nitrazine paper test + (paper turns blue, indicating alkaline pH of amniotic fluid) - fern test + (ferning pattern is seen under a microscopic after amniotic fluid dries on a glass slide)Second Step - ultrasound to assess amniotic fluid volume If unsure: U/S- guided transabdominal instillationo f indigo carmine dye to check for leakage (unequivocal test) Minimize infxn risk: DO NOT perform digital vaginal exams on women who are not in labor or for whom labor is not planned immediately Check fetal heart tracing, maternal temperature, WBC count, and uterine tenderness for evidence of chorioamnionitis

question

How is PROM tx?

answer

Depends on GA and fetal lung maturity - Term: first check GBS status and fetal presentation; then labor may be induced or the pt can be observed for 24-72 >34-36wks gestation: labor induction may be considered <32wks gestation: expectant mgmt w/ best rest and pelvic restAbx: given to prevent infxn and to prolong the latency period in the absence of infxn - if signs of infxn or fetal distress develop, give abx (ampicillin and gentamicin) and induce labor Antenatal corticosteroids: (betamethasone or dexamethasone x 48hrs) - can be given to promote fetal lung maturity in the absence of intra-amniotic infxn prior to 32 wks GA

question

What are complications of PROM?

answer

preterm labor and delivery, chorioamnionitis, placental abruption, cord prolapse

question

What is preterm labor?

answer

defined as onset of labor between 20-37wks' gestation occurs in >10% of all U.S. pregnancies and is the primary cause of neonatal morbidity and mortalityregular uterine contractions + concurrent cervical change at <37wks' gestation.

question

What are risk factors to preterm labor?

answer

multiple gestation, infxn, PROM, uterine anomalies, previous preterm labor or delivery, polyhydramnios, placental abruption, poor maternal nutrition, and low SES. Most pts have no identifiable risk factors

question

How does preterm labor present?

answer

pts may have menstrual-like cramps, onset of low back pain, pelvic pressure, and new vaginal discharge or bleeding

question

How is preterm labor dx?

answer

- requires regular uterine contractions (>/= 3 contractions of 30sec each over a 30min period) and concurrent cervical change at <37 wks' gestation - Assess CI to tocolytics (infxn, nonreassuring fetal testing, placental abruption) - perform sterile speculum exam to r/o PROM - Obtain an U/S to r/o fetal or uterine anomalies, verify GA, and assess fetal presentation and amniotic fluid volume - Obtain cultures for chlamydia, gonorrhea, and GBS. Obtain a UA and urine culture

question

How is preterm labor tx?

answer

- hydration and best rest - unless CI, begin tocolytic tx (B-mimetics, MgSO4, CCBs, PGIs) and give steroids to accelerate fetal lung maturation. Give penicillin or ampicillin for GBS prophylaxis if preterm delivery is likely

question

What are complications of preterm labor?

answer

RDS, intraventricular hemorrhage, PDA, necrotizing enterocolitis, retinopathy of prematurity, bronchopulmonary dysplasia, death

question

What is fetal malpresentation?

answer

defined as any presentation other than vertex (i.e. head closet to birth canal, chin to chest, occiput anterior).

question

What are the risk factors for fetal malpresentation?

answer

prematurity, prior breech delivery, uterine anomalies, poly- or oligohydramnios, multiple gestations, PPROM, hydrocephalus, anencephaly, and placenta previa

question

What is the most common form of fetal malpresentation?

answer

breech presentation= presentation of fetal lower extremities or buttocks into the maternal pelvis - Frank breech (50-75%): thighs are flexed and the knees are extended - Footling breech (20%): one or both legs are extended below the buttocks - Complete breech (5-10%): thighs and knees are flexed

question

How is fetal malpresentation tx?

answer

Follow: up to 75% spontaneously change to vertex by wk 38 External version: apply directed pressure to the maternal abdomen to turn the infant to vertex. Success rate is roughly 50%. Trial of breech vaginal delivery: attempt only if delivery is imminent; otherwise contraindicated. Elective C-section: recommended given the lower risk of fetal morbidity

question

What are the risk factors of version?

answer

placental abruption and cord compression so be prepared for an emergency C-section if needed.

question

What are complications of trial of breech vaginal delivery?

answer

cord prolapse and/or head entrapment

question

What are the maternal factors for C-section?

answer

- prior classical C-section (vertical incision predisposes to uterine rupture w/ vaginal delivery) - active genital herpes infxn - cervical carcinoma - maternal trauma/demise - HIV infxn - prior transverse C-section (relative indication)

question

What prophy should be given to women who undergo a C-section?

answer

sodium citrate should be used to decrease gastric acidity and prevent acid aspiration syndrome

question

What are the fetal and maternal factors for C-section?

answer

- cephalopelvic disproportion (most common cause of primary C-section) - placenta previa/placental abruption - failed operative vaginal delivery - post-term pregnancy (relative indication)

question

What are the fetal factors for C-section?

answer

- fetal malposition (e.g. posterior chin, transverse lie, shoulder presentation) - fetal distress - cord compression/prolapse - erythroblastosis fetalis (Rh incompatibility)

question

What is an episiotomy?

answer

surgical extension of the vaginal opening into the perineum - Types; Media and mediolateral

question

What are the complications of episiotomy?

answer

extension to the anal sphincter (third degree) or rectum (fourth degree), which is more common w/ midline episiotomy, as well as bleeding, infxn, dyspareunia, and in rare cases, rectovaginal fistula formation or maternal death

question

Are episiotomies recommended?

answer

NOT recommended

question

What is postpartum hemorrhage?

answer

defined as a loss of >500mL of blood for vaginal delivery OR >1000 mL for C-section occurring before, during, or after delivery of the placenta

question

What are complicates of postpartum hemorrhage?

answer

acute blood loss (potentially fatal), anemia due to chronic blood loss (predisposes to puerperal infxn), and Sheehan's syndrome (pituitary ischemia and necrosis; the primary cause of anterior pituitary insufficiency in adult females, most commonly presenting as failure to lactate)

question

What are the risk factors for uterine atony?

answer

- uterine overdistention (multiple gestation, macrosomia, polyhydramnios) - Exhausted myometrium (rapid or prolonged labor, oxytocin stimulation) - Uterine infxn - Conditions interfering w/ contractions (anesthesia, myomas, MgSO4)

question

What are the risk factors for genital tract trauma?

answer

- precipitous labor - operative vaginal delivery (forceps, vacuum extraction) - large infant - inadequate episiotomy repair

question

What are the risk factors for retained placental tissue?

answer

placenta accreta/increta/percreta Placenta previa uterine leiomyomas preterm delivery previous C-section/curettage

question

How is uterine atony dx?

answer

palpation of soft, enlarged, \"boggy\" uterus Most common cause of postpartum hemorrhage (90%)

question

How is genital tract trauma dx?

answer

manual and visual inspection of the lower genital tract for any laceration >2 cm long

question

How is retained placental tissue dx?

answer

manual and visual inspection of the placenta and uterine cavity for missing cotyledons. U/S may also be used to inspect the uterus

question

How is uterine atony tx?

answer

bimanual uterine massage (usually successful) Oxytocin infusion Methergine (methylergonovine) if not hypertensive Prostaglandin

question

How is genital tract trauma tx?

answer

surgical repair of the physical defect

question

How is retained placental tissue tx?

answer

manual removal of remaining placental tissue curettage w/ suctioning (take care not to perforate the uterine fundus)

question

What is the ultimate lifesaving tx for all uterine causes of postpartum hemorrhage?

answer

for all uterine causes, when bleeding persists after conventional tx, uterine/internal iliac artery ligation or hysterectomy can be lifesaving

question

What are the characteristics of postpartum endometritis?

answer

- fever >38 degrees C w/in 36hrs - uterine tenderness - malodorous lochia

question

What are the 7Ws of postpartum fever (10 days postdelivery)?

answer

Womb (endomyometritis) Wind (atelectasis, pneumonia) Water (UTI) Walk (DVT, pulmonary embolism) Wound (incision, episiotomy) Weaning (breast engorgement, abscess, mastitis) Wonder drugs (drug fever)

question

What are temperature requirements for postpartum infxns?

answer

>/= 38 degrees C for at least two of the first ten postpartum day (not including the first 24hrs)

question

What are the risk factors for postpartum endometritis?

answer

emergent C-section PROM prolonged labor multiple intrapartum vaginal exams intrauterine manipulations delivery low SES young age prolonged ruptured membranes bacterial colonization corticosteroid use

question

How is endometritis tx?

answer

Hospitalize broad-spectrum empiric IV Abx (clinda and gent) until pts have been afebril for 48hrs (24hrs for chorioamnionitis) add ampicillin for complicated cases

question

If persistent postpartum fever is not responsive to broad spectrum abx, what condition must be considered?

answer

septic pelvic thrombophlebitis - pelvic infxn leads to infxn of the vein wall and intimal damage, leading in turn to thrombogenesis - clot is invaded by microorganisms - suppuration follows, w/ liquefaction, fragmentation and finally, septic embolization

question

How does septic pelvic thrombophlebitis present?

answer

abd and back pain and a picket-fence fever curve (\"hectic\" fevers) w/ wide swings from normal to as high as 41 degrees C

question

How is septic pelvic thrombophlebitis dx?

answer

blood cultures and CT looking for a pelvic abscess

question

How is septic pelvic thrombophlebitis tx?

answer

broad spectrum Abx anticoagulation w/ heparin x 7-10 days

question

What is Sheehan's syndrome?

answer

pituitary ischemia and necrosis that leads to anterior pituitary insufficiency secondary to massive obstetric hemorrhage and shock

question

How does Sheehan's syndrome present?

answer

primary cause of anterior pituitary insufficiency in adult females. Most common presenting syndrome is failure to lactate (due to decrease prolactin levels) other sx: include weakness, lethargy, cold insensitivity, genital atrophy, menstrual disorders

question

How is Sheehan's syndrome dx?

answer

established w/ provocative hormonal testing and MRI of the pituitary and hypothalamus to rule out tumor or other pathology

question

How is Sheehan's syndrome tx?

answer

replacement of all deficient hormones. However, some pts may recover TSH and even gonadotropin fxn after cortisol replacement alone

question

What causes breast hypertrophy in pregnancy?

answer

increased estrogen and progesterone inhibition of prolactin release

question

What stimulates milk production after delivery?

answer

after delivery of the placenta, hormone levels decrease markedly and prolactin is released, stimulating milk production

question

What can also stimulate milk production?

answer

periodic infant suckling leads to further release of prolactin and oxytocin, which stimulate myoepithelial cell contraction and milk ejection (\"let-down reflex\")

question

What is colostrum?

answer

\"early breast milk\" contains protein, fat, secretory IgA, and minerals. W/in one wk postpartum, mature milk w/ protein, fat, lactose, and water is produced

question

What are the benefits of IgA in colostrum?

answer

provide passive immunity for the infant and protect against enteric bacteria

question

What conditions is breastfeeding contraindicated?

answer

HIV infxn, active hepatitis (HBV and HCV), and use of certain medications (tetracycline, chloramphenicol, warfarin)

question

What are some benefits of breastfeeding?

answer

decreased incidence of infant allergies, early upper respiratory tract infxns, and GI infxns; facilitation of mother-child bonding; and maternal weight loss

question

What is mastitis?

answer

cellulitis of the periglandular tissue caused by nipple trauma from breastfeeding coupled w/ the introduction of bacteria, usually S. aureus from the infant's pharynx into the nipple ducts. Affects 2-3% nursing women

question

How does mastitis present?

answer

sx begin 2-4wks postpartum breast sx are usually unilateral and include breast tenderness, a palpable mass, erythema, edema, warmth, and possible purulent nipple drainage. Significant fever, chills, and malaise may also be seen.

question

How is mastitis dx?

answer

differentiate from simple breast swelling Infxn suggested by focal sx, + breast milk culture, an increase in WBC count and fever

question

How is mastitis tx?

answer

1) continued breastfeeding to prevent accumulation of infected material (or use of breast pump in pts who are no longer breastfeeding) 2) PO abx (dicloxacillin, cephalexin, amoxicillin/clavulanate, azithromycin, clindamycin) 3) if abscess present, treat w/ I&D

question

Does menarche precede thelarche in women?

answer

no Thelarche PRECEDS menarche (8-11yrs) Menarche (10-16yrs)

question

What occurs during the follicular phase of menstruation?

answer

development of straight glands and thin secretions of the uterine lining (proliferative phase) increased FSH-->growth of follicles-->increased estrogen production

question

What is the hormonal profile of ovulation?

answer

LH and FSH spike

question

What occurs during ovulation?

answer

rupture of the ovarian follicle and release of mature ruptured follicular cells involute and creates the corpus luteum

question

What occurs during luteal phase of menstruation?

answer

length of time that the corpus luteum can survive without further LH stimulation the corpus luteum produces estrogen and progesterone, allowing the endometrial lining to develop thick endometrial glands w/ thick secretions (secretory phase) In absence of implantation, the corpus luteum cannot be sustained, and the endometrial lining sloughs off

question

What is the definition of menopause?

answer

cessation of menses for a minimum of 12 months as a result of cessation of follicular development

question

At what age is premature menopause?

answer

ovarian failure and menstrual cessation before age 40

question

What are the sx of menopause?

answer

HAVOC Hot flashes (vasomotor instability) Atrophy of Vagina Osteoporosis Coronary artery diseaseOther sx: insomnia, anxiety/irritability, vaginal bleeding, poor concentration, mood changes, dyspareunia, and loss of libido

question

How is menopause dx?

answer

Labs: increased FSH and increased LH DEXA scan to follow bone density for osteoporosis Lipid profile: increased total cholesterol, decreased HDL

question

How is menopause tx?

answer

Vasomotor sx: - HRT (combination of estrogen and progestin) ---WHI STUDI: HRT shown to increase cardiovascular morbidity and mortality and may increase the incidence of breast and endometrial cancers. Rx HRT carefully ---Post-hysterectomy pts do not need progestin. Unopposed estrogen in pts w/ a uterus predisposes to endometrial cancer - Non-HRT: Venlafaxine and less commonly, clonidine can be given to decrease the frequency of hot flashesVaginal atrophy - long term: estradiol vaginal ring - short term: estrogen vaginal cream will relieve sx Osteoporosis: - tx w/ daily calcium supplementation and exercise; possibly bisphosphonates

question

What are the CI of HRT?

answer

vaginal bleeding suspected or known breast cancer endometrial cancer hx of thromboembolism chronic liver disease hypertriglyceridemia

question

What are absolute CI to estrogen-containing hormonal methods (OCPs, NuvaRing, \"the patch\"?

answer

pregnancy hx of CAD or DVT Breast cancer undx abnormal vaginal bleeding estrogen-dependent cancer benign or malignant liver neoplasm current tobacco use and age >35yo

question

What are absolute CI to Mirena and Copper IUDs?

answer

known or suspected pregnancy unexplained vaginal bleeding until dx current purulent cervicitis PID that is active (w/in three mo) or recurrent confirmed sx actinomycosis on culture (but not ASx colonization) a bicornuate or septate uterus cervical or uterine cancer Pap smear w/ squamous intraepithelial lesions or two atypical Pap smears hx of heart valve replacement or artificial joints

question

What are CI to Copper IUDs alone?

answer

copper intolerance (allergy to copper, Wilson's disease) severe dysmenorrhea and/or menorrhagia

question

What are the CI to Mirena alone?

answer

Levonorgestrel allergy breast cancer acute liver disease or liver tumor hx of + BRCA

question

What is unique about combined hormonal contraception methods?

answer

protect against endometrial, ovarian, and breast cancer

question

How should sexual assault pts be approached?

answer

- Take full hx, including contraceptive use, last time of coitus, condom use prior to assault, drug and alcohol use, hx of STDs, hx of mental illness or deficiency, description of the assailant, location, and time of the assault, circumstances of assault (penile penetration, use of condoms, extragenital acts, use or displays of weapons), and pt's actions since assault (douching, bathing, brushing teeth, urination/defecation, changing clothes) - Conduct complete physical exam: making note of any signs of trauma, along w/ a detailed pelvic exam, including a survey of the external genitals, vagina, cervix, and anus.

question

How is sexual assault dx?

answer

- saline prep for sperm - gonorrhea and chlamydia smear/culture (including rectal if appropriate) - serologic testing for HIV, syphilis, HSV, HBV, CMV - serum pregnancy test - blood alcohol level; urine tx screen

question

How is sexual assault tx?

answer

- STD tx (ceftriaxone plus doxycycline) - HIV risk assessment and possible postexposure prophylaxis - EC for pregnancy prevent - refer for psychological counseling - Arrange for follow-up w/ the same physician or w/ another provider if more appropriate - Follow-up should include repeat screening for STDs, repeat screening for pregnancy, and a discussion of coping methods w/ appropriate referrals for psychiatric care if needed

question

Which contraceptive methods have proven to be the most effective (>99%)?

answer

- implanon - Mirena IUD - Copper IUD - Surgical sterilization

question

What contraceptive methods have proven to be very effective (90-99%)?

answer

- Depo-Provera - Ortho-Evra (the patch) - NuvaRing (\"the ring\") - OCPs (combined estrogen and progestin) - Progestin-only \"minipills\"

question

Which contraceptive methods have proven to be moderately effective (75-90%)?

answer

- male condoms - diaphragm w/ spermicide - female condom - fertility awareness methods

question

Which contraceptive methods have proven to be the least effective (68-74%)?

answer

- withdrawal - spermicide

question

What are the etiologies of pediatric vaginal discharge?

answer

- infectious vulvovaginitis - foreign objects - candidal infection - sarcoma botryoides (rhabdomyosarcoma)

question

What organism often causes pediatric infectious vulvovaginitis?

answer

group A strep STDs (think possible child abuse)

question

What must you be concerned about if a pediatric patient presents with a candidal pediatric vaginal discharge?

answer

worry about diabetes!

question

How does sarcoma botryoides present in the vagina?

answer

\"bunches of grapes\"

question

What is the definition of precocious puberty?

answer

Onset of sexual characteristics before age of 8

question

What are the different types of precocious puberty?

answer

1) Central precocious puberty: results from early activation of hypothalamic GnRH production. Most commonly idiopathic (also known as constitutional or true); may be related to obesity. Can also be caused by CNS tumors 2) Peripheral precocious puberty: aka pseudo-precocious puberty. Results from nonhypothalamic GnRH production

question

How does precocious puberty usually present?

answer

- Signs of estrogen excess: breast development, possibly vaginal bleeding-->ovarian cysts or tumors - Signs of androgen excess: pubic and/or axillary hair, enlarged clitoris, acne, and/or increased body odor) suggest adrenal tumors or congenital adrenal hyperplasia (CAH)

question

How is precocious puberty dx?

answer

1) radiograph of wrist and hand to determine bone age --if bone age is w/in one yr of chronological age, puberty has not started or has just recently begun --if bone age is >chronological age by >2yrs, puberty has been present for at least one year or is progressing rapidly 2) Conduct a GnRH agonist (leuprolide) stimulation test -- Central precocious puberty: if LH response is + obtain a cranial MRI to look for CNS tumors -----in girls 6-8yrs of age w/ signs of precocious puberty, the incidence of CNS tumor is 2% in the absence of other CNS signs -----If CNS tumors ruled out, constitutional precocious puberty is likely etiology --Peripheral precocious puberty: if LH response is neg, order the following: -----U/S of ovaries and/or adrenals to look for ovarian or adrenal cyst/tumors -----Estradiol: levels will be increased in ovarian cysts or tumors -----Androgen (DHEA, DHEAS): esp critical in setting of advanced bone age or signs of adrenarche -----17-OH progesterone: to screen for advanced bone age or adrenarche

question

What are causes of central precocious puberty (GnRH-dependent)?

answer

constitutional (idiopathic) Hypothalamic lesions (hamartomas, tumors, congenital malformations) Dysgerminomas Hydrocephalus CNS infxns CNS trauma/irradiation Pineal tumors (rare) NF w/ CNS involvement Tuberous sclerosis

question

What are the causes of peripheral precocious puberty (GnRH-indepedent)?

answer

CAH Adrenal tumors McCune-Albright Syndrome (polyostotic fibrous dysplasia) Gonadal tumors Exogenous estrogen, oral (OCPs) or topical Ovarian cysts (females)

question

How is central precocious puberty tx?

answer

1st line: leuprolide w/ tx, physical changes regress or cease to progress

question

How is peripheral precocious puberty tx?

answer

Tx the cause Ovarian cysts: no intervention is necessary, all cysts will usually regress spontaneously CAH: Tx w/ glucocorticoids. Surgery is NOT required for the tx of ambiguous genitalia Adrenal or ovarian tumors: require surgical resection McCune-Albright syndrome: antiestrogens (tamoxifen) or estrogen synthesis blockers (ketoconazole or testolactone) may be effective

question

What is the definition of primary amenorrhea/delayed puberty?

answer

absence of menses by age 16 w/ secondary sexual development present, or the absence of secondary sexual characteristics by age 14

question

What are the causes of delayed puberty (absence of secondary sexual characteristics)?

answer

- Constitutional growth delay: the most common cause - 1mary ovarian insufficiency: most commonly Turner's syndrome. Look for a hx of radiation and chemotx - Central hypogonadism: may be caused by variety of factors, including: ---undernourishment, stress, prolactinemia, or exercise ---CNS tumor or cranial irradiation ---Kallmann's syndrome (isolated gonadotropin deficiency) assoc w/ anosmia.

question

What are the causes of primary amenorrhea (secondary sexual characteristics present)?

answer

- Mullerian agenesis: absence of 2/3 of the vagina; uterine abnormalities - Imperforate hymen: presents w/ hematocolpos (blood in vagina) that cannot escape, along w/ a bulging hymen. Requires surgical opening - Complete androgen insensitivity: pts present w/ breast development (aromatization of testosterone to estrogen) but are amenorrheic and lack pubic hair

question

How is primary amenorrhea dx?

answer

1) get a pregnancy test 2) obtain a radiograph to determine if bone age is consistent w/ pubertal onset (>12yrs in girls) --Constitutional growth delay: (bone age <12yrs) short stature but normal growth velocity --If bone age is >12 and no signs of puberty, obtain LH/FSH and consider where the problem is on the HPA axis 3) U/S may be needed to evaluate the ovaries 4) Obtain a karyotype if suspect Turner's syndrome 5) If have normal breast development and uterus: measure prolactin and obtain a cranial MRI

question

What hormonal profile indicates constitutional growth delay?

answer

decrease GnRH decrease LH/FSH decrease estrogen/progesterone at prepuberty levels (puberty has not started yet)

question

What hormonal profile indicates hypothalamic or pituitary problem?

answer

decreased GnRH decreased LH/FSH decrease estrogen/progesterone (hypogonadotropic hypogonadism)

question

What hormonal profile indicates that the ovaries have failed to produce estrogen?

answer

increased GnRH increased LH/FSH decreased estrogen/progesterone (hypergonadotropin hypogonadism)

question

What hormonal profile indicates PCOS or a problem w/ estrogen receptors?

answer

increased GnRH increased LH/FSH high estrogen or testosterone

question

In work up for primary amenorrhea, if have normal pubertal hormone levels, what does this indicate?

answer

anatomic problem (menstrual blood can't get out)

question

What are causes of hypogonadotropic hypogonadism?

answer

- Kallmann's syndrome (GnRH deficiency) - Tumors, infection, trauma, chronic disease - Anorexia, excess exercise, weight loss, stress - Hypothyroidism - Hyperprolactinoma

question

What are the causes of hypogonadotropic hypogonadism?

answer

- anorexia, excess exercise, weight loss, stress - Sheehan's syndrome - neoplasms - panhypopituitarism - hyperprolactinemia - hypothyroidism

question

What are causes of Hypergonadotropic hypogonadism?

answer

- Turner's syndrome - premature ovarian failure (chemotx, radiation, idiopathic) - pure gonadal dysgenesis - Savage's syndrome (gonadropin- resistant ovary syndrome)

question

What causes anovulatory problem?

answer

- androgen insensitivity (increase testosterone, increase estrogen) - PCOS (increase estrogen, androgen) - Enzyme deficiency (17alpha- hydroxylase or aromatase)

question

What are secondary anatomic causes of amenorrhea?

answer

Normal hormone levels! - Asherman's syndrome due to endometritis, scarring after delivery, or D&C - Cervical stenosis

question

How is primary amenorrhea tx?

answer

- Constitutional growth delay: No tx - Hypogonadism: Begin HRT w/ estrogen alone at the lowest dose. 12-18mo later, begin cyclic estrogen/progesterone therapy (if the uterus is present) - Anatomic: requires surgical intervention

question

What is the first step in the work-up of primary and secondary amenorrhea?

answer

PREGNANCY TEST!

question

How is secondary amenorrhea dx?

answer

absence of menses for 6 consecutive months in women who have passed menarche

question

How is secondary amenorrhea dx?

answer

1) Get pregnancy test 2) If neg B-hCG: measure TSH and prolactin - increased TSH= hypothyroidism - increased prolactin = (inhibits release of LH and FSH) points to a thyroid pathology. Order an MRI of the pituitary to rule out tumor - very increased prolactin = suggests a prolactin-secreting pituitary adenoma 3) If normal B-hCG: initiate progestin challenge (10 days of progestin) - positive progestin challenge (withdrawal bleed): indicates anovulation that is likely due to noncyclic gonadotropin secretion-->PCOS or idiopathic anovulation. Check LH levels and if LH is moderately high, etiology is likely PCOS. Marked elevation of LH can indicate premature menopause - neg progestin challenge (no bleed): indicates uterine abnormality or estrogen deficiency. Check FSH levels --increased FSH: indicates hypergonadotropic hypogonadism/ovarian failure --decreased FSH: obtain a cyclic estrogen/progesterone test. A positive withdrawal bleed points to hypogonadotropic hypogonadism; a neg withdrawal bleed suggests an endometrial or anatomic problem 4) Look for signs of hyperglycemia (polydipsia, polyuria), or hypotension: conduct a 1mg overnight dexamethasone suppression test to distinguish CAH, Cushing's syndrome, and Addison's syndrome 5) Look for clinical virilization: measure testosterone, DHEAS, and 17-hydroxyprogesterone --mild pattern: PCOS, CAH, or Cushing's syndrome --moderate to severe pattern: look for an ovarian or adrenal tumor

question

How is secondary amenorrhea treated?

answer

Hypothalamic: reverse the underlying cause and induce ovulation w/ gonadotropins Tumors: excision; medical tx for prolactinomas (e.g. bromocriptine, cabergoline) Premature ovarian failure (age <40yrs): if the uterus is present, tx w/ estrogen plus progestin replacement tx

question

What is primary dysmenorrhea?

answer

menstrual pain associated w/ ovulatory cycles in the absence of pathologic findings. Caused by uterine vasoconstriction, anoxia, and sustained contractions mediated by an excess of prostaglandin (PGF2alpha)

question

How does primary dysmenorrhea present?

answer

- low, midline, spasmodic pelvic pain that often radiates to the back or inner thighs - cramps occur in the first 1-3 days of menstruation and may be associated w/ nausea, diarrhea, headache, and flushing - no pathologic findings on pelvic exam

question

How is primary dysmenorrhea tx?

answer

- NSAIDs - topical heat therapy - combined OCPs - Mirena IUD

question

What is secondary amenorrhea?

answer

menstrual pain for which there is an organic cause: - endometriosis - adenomyosis - tumors - fibroids - adhesions - polyps - PID

question

How does secondary amenorrhea present?

answer

Similar to primary dysmenorrhea, but look for pathology. - palpable uterine mass - cervical motion tenderness - adnexal tenderness - vaginal or cervical discharge - visible vaginal pathology (mucosal tears, masses, prolapse)

question

How is secondary amenorrhea dx?

answer

1) Obtain B-hCG to exclude ectopic pregnancy 2) Order: - CBCPD to r/o infxn or neoplasm - UA to r/o UTI - gonococcal/chlamydial swabs to rule out STDs/PID - Stool guaic to r/o GI pathology 3) Look for pelvic pathology that causes pain

question

What is the difference between endometriosis and adenomyosis?

answer

endometriosis is functional endometrial glands and stroma OUTSIDE the uterus. Adenomyosis is endometrial tissue IN the myometrium of the uterus.

question

How does endometriosis present?

answer

presents w/ cyclical pelvic and/or rectal pain and dyspareunia (painful intercourse)

question

How does adenomyosis present?

answer

presents w/ classic triad of noncyclical pain, menorrhagia, and an enlarged uterus

question

How is endometriosis diagnosed?

answer

Requires direct visualization by laparoscopy or laparotomy Classic lesions: blue-black (\"raspberry\") or dark brown (\"powder-burned\") appearance Ovaries may have endometriomas (characteristic \"chocolate cysts\")

question

How is adenomyosis diagnosed?

answer

U/S useful but cannot distinguish btw leiomyoma and adenomyosis MRI can aid in diagnosis but is costly

question

How is endometriosis tx?

answer

Pharmacologic: inhibit ovulation. First line: combo OCPs; GnRH analogs (leuprolide) and danazol. Conservative surgical tx: excision, cauterization, or ablation of the lesions and lysis of adhesions. 20% pts can become pregnant after tx Definitive surgical tx: TAH/BSO +/- lysis of adhesions

question

How is adenomyosis tx?

answer

Pharmacologic: largely symptomatic relief. First line: NSAIDs + OCPs or progestins Conservative surgical tx: endometrial ablation or resection using hysteroscopy. Complete eradication of deep adenomyosis is difficult and results in high tx failure Definitive tx: Hysterectomy is the only definitive tx

question

What are the complications of endometriosis?

answer

infertility (most common cause among menstruating women >30 yrs of age)

question

What are the complications of adenomyosis?

answer

rarely, can progress to endometrial carcinoma

question

What is the definition of abnormal uterine bleeding?

answer

vaginal bleeding that occurs six or more months following the cessation of menstrual function is cancer related until proven otherwise.

question

What is menorrhagia?

answer

increased amount of flow (>80mL of blood loss per cycle) or prolonged bleeding (flow lasting >8 days); may lead to anemia

question

What is oligomenorrhea?

answer

an increase length of time btw menses (35-90 days between cycles)

question

What is polymenorrhea?

answer

frequent menstruation (<21 day cycle); anovular.

question

What is metrorrhagia?

answer

bleeding btw periods

question

What is menometrorrhagia?

answer

excessive and irregular bleeding

question

How is abnormal uterine bleeding diagnosed?

answer

1) obtain B-hCG to r/o ectopic pregnancy 2) order a CBC to r/o anemia 3) Check the following: - pap smear to r/o cervical cancer - TFTs to r/o hyper/hypothyroidism and hyperprolactinemia - obtain plt count, bleeding time, PT/PTT to r/o von Willebrand's disease and factor XI deficiency - order u/s to evaluate the ovaries, uterus, and endometrium. Look for uterine masses, polycystic ovaries, and thickness of the endometrium - If endometrium is >4mm in a postmenopausal woman, obtain an endometrial biopsy. An endometrial biopsy should also be obtained if the pt is >35 yo, obese (BMI>35yo) and diabetic

question

How is heavy uterine bleeding tx?

answer

1) for hemorrhage, high-dose estrogen IV stabilizes the endometrial lining and stops bleeding w/in one hour 2) If bleeding is not controlled w/in 12-24hrs, a D&C is indicated

question

How is ovulatory bleeding tx?

answer

Goal: decrease blood loss 1) NSAIDs to decrease blood loss 2) If pt is hemodynamically stable, tx w/ OCPs or Mirena IUD to thicken the endometrium and control the bleeding. If not effective w/in 24hrs, look for alternative dx

question

How is anovulatory bleeding tx?

answer

Goal: convert proliferative endometrium to secretory endometrium - give progestins x 10 days to stimulate withdrawal bleeding - for young pts w/ anovulatory bleeding who may also have a bleeding disorder, give desmopressin followed by a rapid increased in von Willebrand's factor and factor VIII (lasts roughly six hrs)

question

What are the tx options for abnormal uterine bleeding if medical mgmt fails?

answer

- D&C: an appropriate diagnostic/therapeutic option - Hysterectomy: can help identify endometrial polyps as well as aid in the performance of directed uterine biopsies - Hysterectomy or endometrial ablation: appropriate in women who fail or do not want hormonal tx, have symptomatic anemia, and/or experience a disruption in their quality of life from persistent, unscheduled bleeding.

question

What are the complications of abnormal uterine bleeding?

answer

- anemia - endometrial hyperplasia - +/- carcinoma

question

What is congenital adrenal hyperplasia?

answer

21-hydroxylase deficiency that can present in its most severe, classic form as a newborn female infant w/ ambiguous genitalia and life-threatening salt wasting. Milder forms present later in life. 11Beta-hydroxylase deficiency is a less common cause of adrenal hyperplasia.

question

How does CAH present?

answer

excessive hirsutism, acne, amenorrhea and/or abnormal uterine bleeding, infertility, and rarely a palpable pelvic mass.

question

What is the difference btw hirsutism vs. virilization vs. defeminization?

answer

hirsutism: male hair pattern virilization: frontal balding, muscularity, clitoromegaly, and deepening of the voice Defeminization: decrease brest size; loss of feminine adipose tissue

question

How is CAH dx?

answer

- increased androgens (testosterone > 2ng; DHEAS > 7 ug/mL): r/o adrenal or ovarian neoplasm - increased serum testosterone: suspect ovarian tumor - increased DHEAS: suspect an adrenal source (adrenal tumor, Cushing's syndrome, CAH) - increased 17-OH progesterone levels (either basally or in response to ACTH stimulation)

question

What is the differential to hyperandrogenism?

answer

PCOS 21-hydroxylase deficiency (late onset, nonclassic) CAH 21-hydroxylase deficiency- (congenital, classic) CAH Hypothyroidism Hyperprolactinemia Androgen-secreting neoplasm Cushing's syndrome

question

How is CAH tx?

answer

glucocorticoids (prednisone) To remove hair growth will need: laser ablation, electrolysis, or conventional hair removal techniques must be used to remove unwanted hair

question

How does the most severe form of PCOS present?

answer

hyperandrogenism insulin resistance acanthosis nigricans

question

What is PCOS?

answer

most common endocrine disorder in reproductive women AKA Stein-Leventhal syndrome

question

What are the diagnostic criteria for PCOS?

answer

1. polycystic ovaries 2. oligo-anovulation 3. clinical or biochemical evidence of hyperandrogenism

question

How does PCOS present?

answer

High BP BMI > 30 Stigmata of hyperandrogenism or insulin resistance (menstrual cycle disturbances, hirsutism, obesity, acne, androgenic alopecia, acanthosis nigricans)

question

What conditions are patients w/ PCOS as risk for?

answer

Type 2 DM Insulin resistance Infertility Metabolic syndrome--insulin resistance, obesity, atherogenic dyslipidemia, HTN

question

How is PCOS dx?

answer

Labs: (biochemical hyperandrogenemia) - increased testosterone (total +/- free) - DHEAS - DHEA

question

What other conditions need to be excluded when dx PCOS?

answer

Other causes of hyperandrogenism: - TSH, prolactin - 17-OH progesterone to r/o nonclassical CAH - Consider screening in the setting of clinical sx of Cushing's syndrome (moon facies, buffalo hump, abd striae) or acromegaly (increased head size)Other causes of metabolic abnormalities: - 2hr oral glu tolerance test - fasting lipid and lipoprotein levels (total cholesterol, HDL, LDL, triglycerides)

question

What other tests can be used to dx PCOS?

answer

- U/S: look for >8 small, subcapsular follicles forming a \"pearl necklace\" sign - Gonadotropins: Increased LH/FSH ratio (>2:1) - Fasting insulin levels - 24hr urine for free cortisol: adult-onset CAH or Cushing's syndrome

question

How is PCOS tx for women who are not attempting to conceive?

answer

Tx w/ a combo of OCPs, progestin, and metformin (or other insulin-sensitizing agents)

question

How is PCOS tx for women who are trying to conceive?

answer

Clomiphene +/- metformin is first-line tx for ovulatory stimulation

question

How is Hirsutism tx?

answer

combo OCPs are first line; antiandrogens (spironolactone, finasteride) and metformin may also be used

question

What kind of tx can be given to PCOS pts to reduce cardiovascular risk factors and lipid levels?

answer

advice on: diet, weight loss, and exercise plus potentially lipid-controlling medication

question

What are the complications of PCOS?

answer

increase risk of early onset type 2 DM increase risk of miscarriages increase risk of long-term risk of breast and endometrial cancer due to unopposed estrogen secretion

question

How is infertility defined?

answer

defined as inability to conceive after 12 months of normal, regular, unprotected sexual activity

question

What is the difference between primary and secondary infertility?

answer

Primary: no prior pregnancies Secondary: at least one prior pregnancy

question

What are the male causes of infertility?

answer

- testicular injury or infection - meds (corticosteroids, cimetidine, spironolactone) - thyroid or liver disease - signs of hypogonadism - varicocele

question

What is the work-up for male causes of infertility?

answer

TSH prolactin karyotype (r/o Klinefelter's syndrome) Semen analysis

question

What is the tx of male causes of infertility?

answer

tx of hormonal deficiency intrauterine insemination donor insemination in vitro fertilization intracytoplasmic sperm injection

question

What are ovulatory factors that affect infertility?

answer

age (incidence increases w/ age) sx of hyper-hypothyroidism galatorrhea menstrual cycle abnormalities

question

How are ovulatory factors that affect infertility dx?

answer

basal body temp ovulation predictor midluteal progesterone early follicular FSH +/- estradiol level (ovarian reserve) TSH, prolactin, androgens ovarian sonography (antral follicle count) endometrial biopsy (luteal phase defect)

question

How are ovulatory factors that affect infertility tx?

answer

Tx depends on the etiology (e.g. levothyroxine, dopamine) Induction of ovulation w/ clomiphene, gonadotropins, and pulsatile GnRH IUI IVF

question

What are the tubal/pelvic factors that affect infertility?

answer

Hx of PID appendicitis endometriosis pelvic adhesions tubal surgery

question

How are tubal/pelvic factors that affect infertility dx?

answer

hysterosalpingogram endometrial biopsy

question

How are tubal/pelvic factors that affect infertility tx?

answer

laparoscopic resection or ablation of endometriomas or fibroids IVF

question

What are cervical factors that affect infertility

answer

abnormal Pap smears postcoital bleeding cryotherapy conization DES exposure in utero

question

How are cervical factors that affect infertility dx?

answer

Pap smear Physical exam Antisperm antibodies

question

How are cervical factors that affect infertility tx?

answer

IUI w/ washed sperm IVF

question

How do cyst and abscess of Bartholin's duct present?

answer

obstruction of the gland leads to pain, swelling, and abscess formation. - presents w/ periodic painful swelling on either side of the introitus and dyspareunia - a fluctuant swelling 1-4cm in diameter is seen in the inferior portion of either labium minus - tenderness is evidence of active infection

question

How are cysts/abscess of Bartholin's duct tx?

answer

ASx cysts do not require therapy-->frequent warm soaks may be helpful If abscess develops-->aspiration or I&D. Culture for Chlamydia and other pathogens Abx unnecessary unless cellulitis is present

question

What is vaginitis?

answer

spectrum of conditions that cause vulvovaginal sx such as itching, burning, irritation, and abnormal discharge.

question

What are the most common causes of vaginitis?

answer

- bacterial vaginosis - vulvovaginal candidiasis - trichomoniasis

question

What are the keys to dx bacterial vaginosis?

answer

odor, increased discharge mild vulvar irritation homogenous, grayish-white, fishy/stale odor \"clue cells\" + Whiff test (fishy smell)

question

What are the keys to dx trichomonas?

answer

increase discharge, odor, pruritus, dysuria \"strawberry petechiae\" in the upper vagina/cervix profuse, malodorous, yellow-green, frothy motile trichomonads (flagellated organisms that are slightly larger than WBCs)

question

What are the keys to dx candidal vaginal infxn?

answer

pruritis, dysuria, increased discharge erythematous, excoriated vulva/vagina thick, white, curdy texture w/o odor Hyphae

question

How is bacterial vaginosis tx?

answer

Po or vaginal metronidazole or clindamycin

question

How is Trichomonas tx?

answer

single-dose PO metronidazole or tinidazole. TREAT PARTNERS; test for other STDs

question

How is vaginal yeast tx?

answer

topical azole or PO fluconazole

question

What are complications of bacterial vaginosis?

answer

chorioamnionitis/endometritis infxn preterm delivery miscarriage PID

question

What are complications of trichomonas?

answer

chorioamnionitis/endometritis infxn perterm delivery miscarriage PID

question

What are complications of vaginal yeast infxn?

answer

oral azoles should be avoided in pregnancy

question

What are some normal secretions of the vagina?

answer

midcycle estrogen surge: clear, elastic, mucoid secretions luteal phase/pregnancy: thick and white secretions; adhere to the vaginal wall

question

What are the risk factors for bacterial vaginosis?

answer

pregnancy >1 sexual partner female sexual partner frequent douching

question

What are the risk factors for trichomonas?

answer

an STD unprotected sex w/ multiple partners

question

What are the risk factors for yeast infxn of the vagina?

answer

DM broad spectrum abx use pregnancy corticosteroids HIV OCP use IUD use young age at first intercourse increase frequency of intercourse

question

What is cervicitis?

answer

inflammation of uterine cervix

question

What are causes of cervicitis?

answer

Chlamydia, gonococcus, Trichomonas, HSV, HPV, trauma, radiation, exposure, malignancy

question

How does cervicitis present?

answer

yellow-green mucopurulent discharge; + cervical motion tenderness; absence of other signs of PID

question

What is PID?

answer

polymicrobial infxn of upper genital tract that is associated w/ Neisseria gonorrhea, Chlamydia, and endogenous aerobes/anaerobes

question

What are risk factors for PID?

answer

douching, smoking, multiple sex partners, and prior STDs and/or PID

question

What are acute causes of pelvic pain?

answer

Appendicitis Ruptured ovarian cyst Ovarian torsion/abscess PID Ectopic pregnancy

question

How does PID present?

answer

lower abd pain, fever, chills, menstrual disturbances, and a purulent cervical discharge Cervical motion tenderness (chandelier sign) and adnexal tenderness

question

How is PID dx?

answer

Acute lower abd pain or pelvic pain - uterine tenderness - adnexal tenderness - cervical motion tenderness WBC count >10,000 Order B-hCG and u/s to r/o pregnancy and to evaluate for the possibility of tubo-ovarian abscess U/S: noninvasive means of dx PID Look for: - thickening or dilation of the fallopian tubes - fluid in the cul-de-sac - multicystic ovary - tubo-ovarian abscess

question

How is PID tx?

answer

Abx tx ASAP while awaiting culture results. All Sex partners should be examined and tx appropriately Outpt regimens: 1) Ofloxacin or levofloxacin x 14 days +/- flagyl x 14 days 2) Ceftriaxone IM x 1 dose or cefoxitin plus probenecid + doxycycline x 14 days +/- flagyl x 14 daysInpt regimens: - Cefoxitin or cefotetan plus doxycycline x 14 days - clindamycin plus gentamicin x 14 days

question

What are surgical options to tx PID?

answer

- drainage of a tubo-ovarian/pelvic abscess is appropriate if teh mass persists after antibiotic tx; the abscess is >4-6cm; or the mass is in the cul-de-sac in the midline and drainable through the vagina - If abscess is dissecting the rectovaginal septum and is fixed to the vaginal membrane, colpotomy drainage is appropriate - If pt's condition deteriorates, perform exploratory laparotomy - Surgery may range from TAH/BSO w/ lysis of adhesions in severe cases to conservative surgery for women who desire to maintain fertility

question

What are complications of PID?

answer

- 25% of women w/ acute disease develop repeated episodes of infxn, chronic pelvic pain, dyspareunia, ectopic pregnancy, infertility - RUQ pain (Fitz-Hugh- Curtis syndrome) may indicate an associated perihepatitis (abnormal liver fxn, shoulder pain) - risk of infertility increases w/ repeated episodes of salpingitis

question

What is toxic shock syndrome?

answer

caused by preformed S. aureus toxin (TSST-1) occurs w/in 5 days of the onset of a menstrual period in women who have used tampons

question

How does TSS present?

answer

abrupt onset of fever, vomiting, and watery diarrhea, w/ fever 38.9 or higher diffuse macular erythematous rash nonpurulent conjunctivitis is common desquamation, especially of the palms and soles, generally occurs during recovery w/in 1-2 wks of illness

question

How is TSS dx?

answer

blood cultures are neg b/c sx result from preformed txin and are not due to invasive properties of the organism

question

How is TSS tx?

answer

- rapid rehydration - antistaphlococcal drugs (nafcillin, oxacillin); vanco if have a penicillin allergy - corticosteroids can reduce the severity of illness and decreased fever - manage renal or cardiac failure

question

What are the complications of TSS?

answer

the mortality rate is 3-6% - ARDS, intractable, hypotension, hemorrhage secondary to DIC

question

What are fibroids?

answer

most common benign neoplasm of the female genital tract Tumor is discrete, round, firm, and often multiple and is composed of smooth muscle and connective tissue. Tumors are estrogen and progesterone sensitive, so they often increase in size during pregnancy and decrease after menopause

question

What are malignant transformations of fibroids?

answer

leiomyosarcoma

question

How do fibroids present?

answer

Most are ASx Sx: - bleeding: longer, heavier periods; anemia - pressure: pelvic pressure and bloating; constipation and rectal pressure; urinary frequency or retention - pain: secondary dysmenorrhea, dyspareunia - pelvic sx: firm, nontender, irregular enlarged (\"lumpy-bumpy\") or cobblestone uterus may be seen

question

How are fibroids dx?

answer

CBC: look for anemia U/S: look for uterine myomas; exclude ovarian masses MRI: delineate intramural and submucous myomas

question

What are the pharmacologic tx of fibroids?

answer

NSAIDs combined hormonal contraception Medroxyprogesterone acetate or danazol to slow or stop bleeding. GnRH analogs (leuprolide or nafarelin) to decrease the size of myomas, suppress further growth, and decrease surrounding vascularity (for prior to surgery also)

question

What are the surgical tx of fibroids?

answer

emergent surgery is indicated for torsion of the a pedunculated myoma - women of childbearing years: myomectomy or hysteroscopy w/ leiomyoma resection - women who have completed childbearing: total or subtotal abd or vaginal hysterectomy - uterine artery embolization (~25% will need further invasive tx)

question

What are the complications of fibroids?

answer

infertility may be due to myoma that distorts the uterine cavity and plays a role similar to that of an IUD

question

What must be ruled out in a uterine mass that continues to grow after menopause?

answer

malignancy

question

What are the two types of endometrial cancer?

answer

Type I: endometroid adenocarcinomas derive from atypical endometrial hyperplasia (most common female reproductive cancer in the US) Type II: serous or clear cell histology

question

How does endometrial cancer present?

answer

Type I: vaginal bleeding (early finding), pain, (late finding); metabolic syndrome Type II: no vaginal bleeding

question

How is endometrial cancer dx?

answer

endometrial/endocervical bx vaginal U/S shows a thickened endometrium leading to hypertrophy and neoplastic change

question

How is endometrial cancer tx?

answer

Type I: high-dose progestins for women of childbearing age/ TAH/BSO +/- radiation for postmenopausal women Type II: TAH/BSO w/ adjuvant chemotx for advanced stage cancer

question

What strains of HPV are implicated in cervical cancer?

answer

HPV 16: squamous cell carcinoma HPV 18: adenocarcinoma

question

What are the risk factors for cervical cancer?

answer

immunosuppression infection w/ HIV Hx of STDs tobacco use high parity OCPs

question

What strains does the Gardisil vaccine protect against?

answer

Type 6, 11, 16, 18

question

Are hormonal contraceptives protective against endometrial cancer?

answer

YES

question

How does cervical cancer present?

answer

metrorrhagia, postcoital spotting, and cervical ulceration are the most common signs bloody or purulent, malodorous, nonpruritic discharge may appear after invasion

question

What are the screening guidelines for cervical cancer?

answer

- Starting at 21 or no more than 3 yrs after becoming sexually active - women >/= 30 yo who have had three consecutive normal tests may increase their screening interval to once every three years - for women >/= 30yo, HPV DNA testing for high-risk strands may be used for screening as well. - screening should be d/c for women >/= 70yo who have had three or more normal Pap smears. - Women w/ DES exposure and/or immunocompromised status (including HIV positivity) should continue as long as they do not have a life-limiting condition

question

What are the follow-up steps for Pap result of atypical glandular cells?

answer

< 35yo w/ no endometrial cancer risk factors: - proceed to colposcopy, endocervical curettage (ECC), and HPV DNA testing >/= 35yo +endometrial cancer factors, or abnormal bleeding - all above and add endometrial biopsy

question

What are the follow-up steps for Pap result of Atypical squamous cells of undetermined significance?

answer

</= 21yo - repeat Pap at 12 months. If Pap smear is neg or reveals ASC-US or LSIL, repeat at 12mo >21yo - immediate colposcopy, HPV DNA testing and repeat Pap smear at 6 mo

question

What are the follow-up steps for Pap result of low grade squamous intraepithelial lesions?

answer

</= 21yo - repeat Pap smear at 12 mo. If pap smear is neg or reveals ASC-US or LSIL, repeat at 12 mo >21yo - immediate colposcopy

question

What are the follow-up steps for Pap smear result of high grade squamous intraepitheial lesions or atypical squamous cells suspicious of high-grade dysplasia?

answer

immediate colposcopy is indicated for ALL age groups

question

How is CIN I tx?

answer

CLOSE OBSERVATION >21yo: Pap smear at 6-12mo and/or HPV DNA testing at 12 mo is indicated <21yo: HPV testing NOT recommended After two neg Paps or a neg DNA test, pts can be managed w/ routine annual follow-upIf persistent CIN I can be treated w/ ablative (cryotherapy or laser ablation) or excisional therapy (loop electrosurgical excision procedure (LEEP); laser and cold-knife conization)

question

How is CIN II and III tx?

answer

ablative (cryotherapy or laser ablation) or excisional therapy (LEEP; laser and cold-knife conization) Hysterectomy is a tx option for recurrent CIN II or III

question

How is CIN I, II or III w/ neg margins followed-up?

answer

Pap smear at 12mo and/or HPV testing

question

How is CIN II or III w/ + margins followed- up?

answer

Pap smear at 6mo; consider repeat ECC If margins unknown, obtain a Pap smear at 6mo and HPV DNA testing at 12mo

question

How is microinvasive cervical cancer tx?

answer

cone bx and close follow-up or simple hysterectomy

question

How is Stages IA2, IB1, and IIA cervical cancer tx?

answer

may be treated either w/ radical hysterectomy w/ concomitant radiation and chemotx or w/ radiation plus chemotx alone

question

What is Stages IB2, IIB, III, and IV cervical cancer tx?

answer

tx w/ radiation tx plus concurrent cisplastin-based chemotx

question

What type of cancer is vulvar cancer predominantly?

answer

90-95% squamous lesions occurring in women >50yo melanoma basal cell carcinoma adenocarcinoma sarcoma Bartholin's gland tumors metastatic disease

question

What are the risk factors for vulvar cancer?

answer

HPV (16,18, 31) lichen sclerosis infrequent medical exams diabetes obesity HTN CV disease immunosuppression

question

How does vulvar cancer present?

answer

presents w/ pruritus, pain, ulceration of the mass Early: lesions may appear white, pigmented, raised, thickened, nodular, ulcerative Late: presents w/ large, cauliflower-like or hard ulcerated area in the vulva

question

How is vulvar cancer dx?

answer

1) punch biopsy for any suspicious lesions VIN I and II: associated w/ mild and moderate dysplasia VIN III: carcinoma in situ

question

How is vulvar precancerous lesions tx?

answer

reduce irritative or other predisposing causes. Topical corticosteroids (e.g. betamethasone, clobetasol) and crotamiton are particularly effective for pruritus

question

How is high-grade VIN tx?

answer

topical chemotx, laser ablation, wide location excision, skinning vulvectomy, and simple vulvectomy

question

How is invasive vulvar cancer tx?

answer

treated w/ 1) radical vulvectomy and regional lymphadenectomy 2) wide local excision of the primary tumor w/ inguinal lymph node dissection +/- preoperative radiation, chemotx, or both

question

What type of cancer is vaginal cancer in postmenopausal women?

answer

squamous cell carcinoma

question

What are risk factors for vaginal cancer?

answer

immunosuppression chronic irritation (long-term pessary use or prolapse of female organs) low SES radiation for cervical cancer hysterectomy for dysplasia multiple sexual partners DES exposure

question

How does vaginal cancer present?

answer

characterized by abnormal vaginal bleeding, an abnormal discharge or postcoital bleeding presents in the upper third of the vagina in 75% of pts

question

How is vaginal cancer dx?

answer

cytology, colposcopy and biopsy

question

How is vaginal cancer tx?

answer

- local excision of involved areas when they are few and small - extensive involvement of the vaginal mucosa may require partial or complete vaginectomy - invasive disease requires radiation tx or radical surgery

question

What are the risk factors of ovarian cancer?

answer

- age - low parity - decreased fertility - delayed childbearing - + FHx - BRCA1 mutation and BRCA2 mutation - Lynch II syndrome or HNPCC - OCPs taken for 5yrs or more decrease risk by 29%

question

How do benign and malignant ovarian tumors present?

answer

- Generally ASx - mild, nonspecific GI sx or pelvic pressure/pain - early disease: typically not detected on routine pelvic exam - Some 75% of woman present w/ advanced malignant disease (abd pain, bloating, palpable abd mass, and ascites)

question

What tumor markers are used to monitor progression and recurrence of ovarian cancer?

answer

CA-125

question

What must be ruled out if a palpable ovarian or adnexal mass in a premenarchal or postmenopausal pt?

answer

ovarian neoplasm

question

What does increased CA-125 indicate in premenopausal women?

answer

endometriosis

question

What does increased CA-125 indicate in postmenopausal women?

answer

increased likelihood that the ovarian tumor is malignant

question

What are characteristics of a benign pelvic mass?

answer

mobile cystic unilateral smooth

question

What are characteristics of a malignant pelvic mass?

answer

fixed solid/firm bilateral nodular

question

What are characteristics of a benign adnexal mass via transvaginal U/S?

answer

<8 cm cystic unilocular unilateral calcifications

question

What are characteristics of a malignant adnexal mass via transvaginal U/S?

answer

>8 cm solid or cystic and solid multilocular bilateral ascites

question

How are ovarian masses tx in premenarchal women?

answer

Masses > 2cm require exploratory laparotomy

question

How are ovarian masses tx in premenopausal women?

answer

1) observe for 4-6wks for ASx, mobile, unilatera, simple cystic masses <8-10cm. Most will resolve spontaneously 2) Surgical eval for masses >8-10cm as well as for those that are unchanged on repeat pelvic exam and U/S

question

How are ovarian masses tx in postmenopausal women?

answer

ASx: unilateral simple cysts <5cm in diameter w/ a normal CA-125 should be closely followed w/ U/S Palpable masses warrant surgical evaluation by exploratory laparotomy

question

How is ovarian cancer tx surgically?

answer

surgical staging followed by TAH/BSO w/ omentectomy and pelvic and para-aortic lymphadenectomy benign neoplasms warrant tumor removal or unilateral oophorectomy

question

What ovarian tumor marker is used to follow endodermal sinus tumors?

answer

AFP

question

What ovarian tumor marker is used to follow embryonal carcinoma?

answer

AFP, hCG

question

What ovarian tumor marker is used to follow choriocarcinoma?

answer

hCG

question

What ovarian tumor marker is used to follow dysgerminoma?

answer

LDH

question

What ovarian tumor marker is used to follow granulosa cell tumors?

answer

inhibin

question

Do postmenopausal ovarian tumor pts receive postoperative chemo?

answer

Yes, routine except for women w/ early-stage or low-grade ovarian cancer

question

In what types of ovarian tumor pts receive radiation tx?

answer

dysgerminomas

question

What kind of prevention can be done for ovarian cancer?

answer

Women w/ BRCA1 mutation should be screened annually w/ U/S and CA-125 testing Prophy oophorectomy is recommended by age 35 or whenever childbearing isOCP use to decrease risk

question

What are the risk factors for pelvic organ prolapse?

answer

vaginal birth (particularly w/ use of forceps) genetic predisposition advancing age prior pelvic surgery connective tissue disorders increased intra-abdominal pressure assoc w/ obesity or straining w/ chronic constipation

question

How does pelvic organ prolapse present?

answer

sensation of a bulge or protrusion in the vagina urinary or fecal incontinence, a sense of incomplete bladder emptying, and dyspareunia are also seen

question

How is pelvic organ prolapse dx?

answer

women perform the Valsalva maneuver while in the lithotomy position

question

How is pelvic organ prolapse tx?

answer

supportive measures include a high-fiber diet and weight reduction in obese pts and limitation of straining and lifting pessaries may temporarily reduce prolapse and are helpful in women who do not wish to undergo surgery or who are chronically ill Most common surgical procedure: vaginal or abdominal hysterectomy w/ vaginal vault suspension

question

What are the causes of urinary incontinence w/o specific urogenital pathology?

answer

Delirium/confusional state Infxn Atrophic urethritis/vaginitis Pharmaceutical Psychiatric causes (esp depression) Excessive urinary output (hyperglycemia, hypercalcemia, CHF) Restricted mobility Stool impaction

question

How is total urinary incontinence presented?

answer

uncontrolled loss at all times and in all positions exclude fistula

question

What is the mechanism of total urinary incontinence?

answer

loss of sphincteric efficiency (previous surgery, nerve damage, cancer infiltration). Abnormal connection btw the urinary tract and skin (fistula)

question

What is the tx for total urinary incontinence?

answer

surgery

question

How does stress incontinence present?

answer

occurs after increase in intra-abdominal pressure (coughing, sneezing, lifting)

question

What is the mechanisms of stress incontinence?

answer

urethral sphincteric insufficiency due to laxity of pelvic floor musculature; common in multiparous women or after pelvic surgery

question

How is stress incontinence tx?

answer

kegel exercises and pessary vaginal vault suspension surgery

question

How does urge incontinence present?

answer

strong, unexpected urge to void that is unrelated to position or activity spasticity, flaccidity, rectal sphincter tone

question

What is the mechanism of urge incontinence?

answer

detrusor hyperreflexia or sphincter dysfxn due to inflammatory conditions or neurgenic disorders of the bladder.

question

How is urge incontinence tx?

answer

anticholinergic medications or TCAs; behavioral training (biofeedback)

question

How does overflow incontinence present?

answer

chronic urinary retention, distended bladder

question

What is the mechanism of overflow incontinence?

answer

chronically distended bladder w/ increased intravesical pressure that just exceeds the outlet resistance, allowing a small amount of urine to dribble out

question

How is overflow incontinence tx?

answer

placement of urethral catheter in acute settings tx underlying diseases. Timed voiding.

question

How is urinary incontinence dx?

answer

1) Obtain UA and urine culture to exclude UTI 2) voiding diary; possible urodynamic testing 3) serum Cr to exclude renal dysfxn 4) cystogram to demonstrate fistula sites and descensus of the bladder neck

question

What is the differential dx for breast mass?

answer

fibrocystic disease fibroadenoma mastitis/abscess fat necrosis breast cancer

question

What is breast fibrocystic change?

answer

most common of all benign breast conditions exaggerated stromal tissue response to hormones and growth factors Findings: cysts (gross and microscopic), papillomatosis, adenosis, fibrosis, and ductal epithelial hyperplasia

question

How does fibrocystic change present?

answer

- cyclic bilateral mastalgia and swelling, w/ sx most prominent just before menstruation - rapid fluctuation in the size of the masses in common - other sx: irregular, bumpy consistency to the breast tissue (\"oatmeal w/ raisins\")

question

How is fibrocystic change dx?

answer

FNA: discrete mass that is suggestive of a cyst is indicated to alleviate pain as well as to confirm the cystic nature of the mass Excisional bx: if no fluid is obtained or if fluid is bloody on aspiration

question

How is fibrocystic change tx?

answer

dietary modifications (e.g. caffeine restriction) danazol may be given for severe pain but is rarely used in the view of its side effects (acne, hirsutism, edema) consider use of OCPs, which decrease hormonal fluctuations

question

What is fibroadenoma?

answer

benign, slow-growing breast tumor w/ epithelial and stromal components. Most common breast lesion in women <30yo.

question

What is cystosarcoma phyllodes?

answer

large fibroadenoma

question

How does fibroadenoma present?

answer

round/ovoid, rubbery, discrete, relatively mobile, nontender mass 1-3cm in diameter usually solitary, although up to 20% of pts develop multiple fibroadenomas Tumors do not change during the menstrual cycle. Does not occur after menopause unless the pt is on HRT

question

How is fibroadenoma dx?

answer

breast u/s can differentiate cystic from solid masses. needle biopsy or FNA excision w/ pathologic exam if the dx remains uncertain

question

How is fibroadenoma tx?

answer

excision is curative, but recurrence is common

question

What are the risk factors for breast cancer?

answer

- female gender, older age - personal hx of breast cancer - breast cancer in a first-degree relative - BRCA1 and BRCA2 mutations (assoc w/ early onset) - a high-fat and low-fiber diet - hx of fibrocystic change w/ cellular atypia - increased exposure to estrogen (nulliparity, early menarche, late menopause, first full-term pregnancy after age 35)

question

What are the early findings of breast cancer?

answer

single, nontender, firm-to-hard mass w/ ill-defined margins or as mammographic abnormalities w/ no palpable

question

What are later findings of breast cancer?

answer

skin or nipple retraction, axillary lymphadenopathy, breast enlargement, redness, edema, pain, fixation of the mass to the skin or chest wall

question

What are late findings of breast cancer?

answer

- ulceration; supraclavicular lymphadenopathy; edema of the arm; metastases to bone, lung, and liver - prolonged unilateral scaling erosion of the nipple w/ or w/o discharge (Paget's disease of the nipple)

question

How does metastatic disease present/

answer

back or bone pain, jaundice, weight loss firm or hand axillary node >1cm axillary nodes that are matted or fixed to the skin (stage III); ipsilateral supraclavicular or infraclavicular nodes (Stage IV)

question

How is breast cancer dx in postmenopausal women?

answer

mammography: look for increased density w/ microcalcifications and irregular borders. Can detect lesions roughly two years before they become clinically palpable

question

How is breast cancer dx in premenopausal women?

answer

U/S (<30yo), which can distinguish a solid mass from a benign cyst

question

What are the tumor markers used in breast cancer?

answer

CEA and CA 15-3 and CA27-29

question

What is the receptor status of tumor (breast cancer)?

answer

ER PR HER2/neu

question

What labs can be followed in breast metastatic disease?

answer

increased ESR increased alkaline phosphatase (liver and bone metastases) increased calcium

question

What imaging can be followed in breast metastatic disease?

answer

CXR CT of chest, abd, pelvis, and brain Bone scan

question

How is breast cancer tx pharmacologically?

answer

All hormone receptor +--->pts receive tamoxifen ER neg-->receive chemo Trastuzumab: mAB that binds to HER2/neu receptors on the cancer cell, is highly effective in HER2/neu-expressive cancers

question

How is breast cancer tx surgically?

answer

- partial mastectomy (lumpectomy): plus axillary dissection followed by radiation tx - modified radical mastectomy (total mastectomy plus axillary dissection)

question

What are the CI to breast conserving tx?

answer

large tumor size, subareolar location, multifocal tumors, fixation to the chest wall, or involvement of the nipple or overlying skin

question

How should Stage IV breast cancer be tx?

answer

radiotherapy and hormonal tx mastectomy may be required for local sx control

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