Pearls of Wisdom (POW) - Reproductive

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Pearls of Wisdom (POW) - Reproductive
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2012-06-30 17:28:17
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Pearls of Wisdom (POW) - Reproductive / OBGYN
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  1. What are the three events that occur in the normal course of female puberty (in order of occurrence and with definition of each)
    • Thelarche - breast development
    • Pubarche – axillary and pubic hair
    • Menarche – menstrual cycle
  2. What is the function of FSH?
    It stimulates maturation of the follicle and the production of estradiol from the follicles
  3. What is the function of LH?
    It causes follicular rupture, ovulation, and establishment of the corpus luteum.
  4. During the luteal phase of the ovary, describe the corresponding phase of the uterus?
    The secretory phase. After ovulation, the expelled follicle is called the corpus luteum. The corpus luteum secretes estradiol and pregesterone, which cause secretory ducts to develop in the endometrial lining.
  5. What is the cause of midcycle spotting or light bleeding?
    The decline in estradiol that occurs immediately prior to the LH surge.
  6. Decline in which hormone heralds the onset of menses?
    Progesterone withdrawal.
  7. What is the definition of mittelschmerz?
    The cyclic abdominal pain located on either side of the abdomen, which can be felt during ovulation and may persist for approximately 2 days after.
  8. What percentage of the femal population as endometriosis?
    More than 15% and 7% of these women have it during their reproductive years.
  9. What percentage of women with endometriosis also have infertility?
    25% to 50%
  10. What is the most common site of endometriosis?
    The ovaries (60%
  11. How do you treat endometriosis?
    Combined oral contraceptive agents, Progestin-only contraceptives, GnRH agonists, danazol (testosterone derivative)
  12. A 66 yo postmenopausal woman presents with vaginal bleeding. What is the provisional diagnosis?
    Endometrial cancer; 15% of women with postmenopausal bleeding have endometrial cancer
  13. What are the most common etiologies of endometrial cencer?
    30% of these tumors are due to exogenous estrogens, 30% are due to atrophic endometriosis or vaginitis, 10% are due to cervical polyps, and 5% are due to endometrial hyperplasia.
  14. What percentage of women with endometrial cancer will have an abnormal pap smear?
    50%
  15. What is the most common clinical condition associated with the development of endometrial hyperplasia?
    Polycystic ovary syndrome
  16. What is Lynch Syndrome Type II?
    A hereditary predisposition to the development of colon, breast, ovarian, and endometrial cancer.
  17. What type of leiomyoma is symptomatic?
    Submucosal myomas, though small, can cause profuse bleeding, potentially requiring a hysterectomy. Most other myomas are asymptomatic until grown large enough to cause obstruction or significantly distort the endometrial cavity.
  18. What must be identified and located prior to clamping the infundibulopelvic (Suspensory ligament) ligament?
    The ureter.
  19. What is the most common cause of pelvic pain in an adolescent woman?
    Ovarian cysts
  20. What is the most common type of ovarian cyst?
    Follicular. Corpus luteum and theca lutein cysts are the other.
  21. What is the recommended treatment for uncomplicated cysts?
    Most resolve spontaneously within a few menstrual cycles (60 days) without treatment. Combined oral contraceptive agents can be used if recurrent.
  22. What is the most common complication of ovarian cysts?
    Ovarian torsion
  23. What are the clinical manifestations of polycystic ovarian disease?
    Obesity, Virilization, Anovulation, Resistance to insulin (diabetes), increased hair, androgen increase, no period/amenorrhea
  24. Is the Stein-Leventhal syndrome a unilateral or bilateral phenomenon?
    Bilateral. Both ovaries are cystic and enlarged with a thickened and fibrosed tunica. Patients are often infertile, obese, and hirsute. This syndrome is a subtype of polycystic ovarian disease.
  25. What lab findings are seen in PCO?
    Most patients have increased LH-to-FSH ratio at 2:1 (or more), high fasting insulin an elevated serum glucose, and elevated sex androgens including DHEA-sulfate and/or testosterone.
  26. How are patients with PCO treated?
    Weight loss is the fist-line treatment for PCO. In addition, combined oral contraceptive pills for menstrual regulation and ovarian suppression; Biguanides (metformin) for menstural regulation, weight reduction, and to reestablish fertility; anti-androgen (spironolactone) for sex androgen suppression and hirsutism.
  27. What serum marker is associated with ovarian cancer?
    CA-125
  28. If a woman has ascites, what is the most likely tumor to be found?
    An ovarian carcinoma.
  29. What is Meigs syndrome?
    Ascites and hydrothorax in the presence of an ovarian tumor.
  30. What is the treatment for stage 1A or 1B ovarian cancer?
    Surgical excision alone (abdominal hysterectomy and bilateral salpingo—ophorectomy).
  31. What is a nabothian cyst?
    A mucous inclusion cyst of the cervix (usually asymptomatic and benign)
  32. ACOG recommended Pap guidelines?
    Pap smears should be initiated 3 years following the onset of sexual activity or age 21 and every year following.
  33. When can Pap be discontinued?
    70 with three previous normal pap smears
  34. What is the recommendation for HPV testing in women?
    Testing should occur with a Pap in high-risk patients or in reflex to an abnormal pap smear.
  35. What is ASC-US, LSIL, HSIL?
    • Atypical squamous cell of undetermined significance
    • Low-grade squamous intraepithelial lesion (CIN I)
    • High-grade squamous intraepithelial lesion (CIN II-III or CIS)
  36. What are the known subtypes of HPV associated with cervical cancer?
    6, 11, 16, 18.
  37. What are the risk factors for carcinoma of the cervix?
    HPV = (multiple partner exposure, early intercourse, early first preg)
  38. What is the most common presenting symptom for patients with cervical caner?
    Up to 80% of patients present with abnormal vaginal bleeding, most commonly postmenopausal. Only 10% note postcoital bleeding. Less frequently discharge and pain.
  39. What clinical triad is strongly indicative of cervical cancer extension to the pelvic wall?
    • Unilateral leg edema
    • Sciatic pain
    • Ureteral obstruction
  40. What is the normal pH of the vagina?
    3.8-4.4 (>4.9 indicates bacterial or protozoal infection)
  41. What is the predominant organism in a healthy vaginal discharge?
    Lactobacilli (95%)
  42. What is the treatment for a bartholin gland abscess?
    Marsupialization with the placement of a Word cath.
  43. What is the most common cell tye in vulvar and/or vaginal carcinoma?
    Squamous cell (90% vulvar; 85% vaginal)
  44. What is the most common location for vaginal carcinoma?
    Upper 1/3 of the posterior vaginal wall
  45. What causes condylomata acuminata (genital warts)?
    HPV 6 and 11.
  46. What other STI is commonly seen in combination with condylomata?
    Trichomonas vaginitis.
  47. What are the recommended treatment options for condylomata?
    Liquid nitrogen, podophyllin resin, topical imiquimod
  48. What are the three components of the cervical biopsy that you saw used?
    Acetic acid (white vinegar), Lugol's iodine, monsel to stop the bleeding.
  49. What is the most frequent gyn disease of children?
    Vulvovaginitis
  50. What is the most common cause of vaginitis?
    Candida albicans
  51. What predisposes a woman to vaginal candidiasis infections?
    Diabetes, oral contraceptive, and antibiotics
  52. What is the treatment for vaginal candidiasis?
    Antifungal drugs: clotrimazole (Gyne-Lotrimin), Monistat, Diflucan. For severe infections: amphotericin B, caspofungin, or vorcionazole
  53. What are the signs and symptoms for typical for gardnerella vaginitis?
    Frothy, grayish white, fishy smelling vaginal discharge.
  54. What do you look for on microscopic evaluation with saline and with 10% KOH with vaginitis?
    “Clue cells” and fishy odor.
  55. What is the treatment for gardnerella vaginitis?
    Metronidazole (Flagyl) either orally or vaginally.
  56. When should you avoid treating a woman with Flagyl?
    First trimester of pregnancy – use Clotrimazole instead.
  57. A 42 year old woman complain of painful urination and “leaking a bit” after she urinates. On pelvic you feel a small mass under the urethra that emits a purulent discharge from the urethral meatus if compressed. What is the likely diagnosis?
    Urethral diverticulum.
  58. What is the most common urinary fistula?
    Vesicovaginal fistulas. Most common after surgical procedures, but can occur with invasive cervical carcinoma or radiotherapy.
  59. A patient presents with pain in her eyes, canker sores in her mouth, and sores and scars in her genital area. Dx?
    Behcet disease. Ocular inflammation, oral apthous ulcers, and destructive genital ulcers (usually on the vulva). No cure, but may go into remission with high estrogen levels.
  60. What causes toxic shock syndrome?
    Exotoxin from Staph Aureus. Also by group A strep, pseudomonas, and strep pneumo.
  61. What are risks for toxic shock syndrome?
    Tampons, IUDs, septic abortions, sponges, abscesss, osteomyelitis, nasal packing, postpartum infections.
  62. What derm changes occur with toxic shock syndrome?
    Blanching erythematous rash that lasts for 3 days, and 10 days after the start of the infection there will be a full thickness desquamation of the palms and soles.
  63. How do you diagnose toxic shock syndrome?
    Fever (>102), rash, systolic <90 with orthostasis, involvement of three organ systems (GI, renal, MS, mucosal, hepatic, hematologic, or CNS). Patient must also have negative serologic tests for RMSF (rocky mountain), hepB, measles, leptospirosis, and VDRL (syphilis)
  64. How should you treat toxic shock syndrome?
    Fluids, pressure support, FFP, or transfusions. Vaginal irrigation with iodine or saline. Antistaphylococcal PCN or cephalosporin with anti-b-lactamase activity (nafcillin or oxacillin). Rifampin should be considered to eliminate the carrier state.
  65. A 22 year old patient presents with a complaint of painful blisters on the vulva and vaginal introitus. She admits to a prodrome of burning tingling, and/or puritis prior to the appearance of lesions. You note vesicles on an erythematous base. Dx?
    Herpes simplex virus.
  66. What is the causative bacterium in syphilis?
    Treponema pallidum.
  67. What is the hallmark of primary syphilis?
    Painles ulcer. Chancre.
  68. What are the presenting signs associated with secondary syphilis?
    Nonpuritis maculopapular rash that includes the palms and soles (condyloma latum), lyphadenopathy, and consititutional symptoms (fatigue/malaise). These symptoms present 4-6wks after the hallmark syphilitic chancre and persist for 2-6wks before the infection enters the latent phase.
  69. What is the presenting feature of tertiary syphilis?
    Neurosyphilis. (Neuro deficits including difficulty with coordination, memory loss, paralysis, gradual blindness, or demetia.)
  70. What is the treatment for syphilis?
    PCN G – 2.4 million units IM. Additional doses for >1 year or pregnancies. If PCN allergy use Doxy (100?).
  71. What causes a greenish gray frothy vaginal discharge with mild itching?
    Trichomonas vaginitis.
  72. What is considered the hallmark pelvic exam in 20% of trichomonas infections?
    Strawberry Cervix
  73. What are the microscopic findings of trichomonas infection?
    Presence of mobil and pear-shaped protozoa with flagella.
  74. 30 year old complains of painful sore on her vulva that first resembled a pimple. On exam you find an ulcer with vague borders, gray base, and foul-smelling discharge. Dx? Agent?
    Chancroid. Gram stain, culture, and bx (used in combo) to find haemophilus ducreyi.
  75. What is considered the most appropriate treatment for chancroid?
    Rocephin (Ceftriaxone 250) or Azithro 1g PO
  76. What is the presentation of lymphogranuloma vereum (LGV)? Agent?
    Vesicopustular eruption, unilateral bubo, possible anal discharge, and rectal bleeding. Chlamydia.
  77. What is the most common STI and is sometimes asymptomatic in women?
    Chlamydia trachomatis.
  78. What finding on gram stain is indicative of neisseria gonorrhea?
    Gram-negative diplococci.
  79. What is the treatment for gonorrhea?
    Rocephin (Ceftriaxone 125-250 or cefixime 400 or cefpodoxime 400) + azithromycin 1g or doxy 100mg (for chlamydia coverage)
  80. Which two organisms cause most cases of PID?
    Gonorrhea and chlamydia.
  81. What are the risk factors of PID?
    • Age <25 (not fully mature cervix)
    • Black
    • Early onset sex
    • Frequent sex
    • Multiple partners
    • Douching
    • Presence of IUD
    • Women with one episode
  82. What is a woman with PID likely to have an exacerbation of symptoms when she menstruates?
    The breakdown of mucus, which typically acts as an antibacterial barrier, allows bacteria to ascend from the lower tract to the upper tract. Pelvic exam, sex, and exercise can all exacerbate symptoms.
  83. What are the criteria for dx of PID?
    • Adnexal tenderness
    • Cervical and uterine tenderness
    • Abdominal tenderness
    • PLUS one: Fever, gram-negative intracellular diplococci, leukocytosis (>10,000), inflammatory mass on U/S or exam, or WBC and bacteria in the peritoneal fluid.
  84. Which patients with PID should be admitted?
    Pregnant, fever, n/vm pyosalpix or tubo-ovarian abscess, peritoneal signs, IUD, no response to abx, or uncertain of dx.
  85. What percentage of those with PID become infertile?
    10%
  86. Breast hyperplasia is a normal physiologic phenomenon in the neonatal period. How many months does this last?
    Up to 6 months of age.
  87. According to ACS what is the recommendation for the use of MRI in breast cancer screening?
    Screening MRI is recommended for women with approximately 20-25% or greater lifetime risk of breast cancer, including women with a strong family history of breast or ovarian cacner (_BRCA mutations) and women who were treated for Hodgkin disease
  88. After the establishment of fibrocystic breast disease, what is the recommended treatment?
    Breast pain associated is best treated by avoiding trauma and by wearing a bra with adequate support. Some find that combined oral contraceptive agents limit the severity of the cyclical changes in the breast tissue. The role of caffeine is controversial.
  89. What is the most common type of benign breast tumor?
    Fibroadenomas.
  90. What is the work-up for suspected fibroadenoma?
    Dx mammogram with ultrasound. Then FNA.
  91. What is the most common cause of unilateral bloody nipple discharge?
    Benign intraductal papilloma. Growths usually develop just before or during menopause and they are rarely palpable. Thy are typically mobile and painless.
  92. What diagnosis must be considered in a patiente presenting with crusty, eczematous erosion of the nipple without nipple discharge?
    Paget disease.
  93. Is there an increased risk of breast cancer associated with estrogen replacement therapy?
    There may be a slightly increased risk of breast cancer especially with longer duration of use (10 years or more)
  94. Geographically, where is breast cancer most common?
    North America and northern Europe have an incidence and mortality rate five times that of most Asian and African countries. Asian and Africans immigrants to North America or northern Europe maintain a lower rate of incidence; however their offspring quickly assume a higher one. This points to environmental and dietary factors.
  95. What have higher incidences of estrogen receptor-positive tumors, premenopausal or postmenopausal women?
    Postmenopausal (60%). If the tumors are both estrogen and progesterone sensitive, then the antiestrogen drug tamoxifen is 80% effective. Otherwise it is 40 to 50% effective.
  96. What is the most common histologic type of breast cancer?
    Infiltrating ductal carcinoma (70-80%). Subtypes are colloid, medullary, papillary, and tubular.
  97. When does milk production typically begin?
    Colostrum secretion usually persists for 3 to 4 days after delivery. Day 5 the fluid begins to change in composition. Mature milk is usually present by 1 to 2 weeks postpartum.
  98. How does clostrum differ from breast milk?
    Colostrum is more cellular and has more minerals, but is lower in calories. True milk has more fat and carbohydrate (especially lactose), but less protein.
  99. How many extra calories above baseline does a woman need when breast-feeding?
    About 500 per day.
  100. How much daily calcium is recommended for lactating women?
    1200 to 1500mg per day.
  101. Why does lactation not occur in pregnancy even though the prolactin levels are elevated?
    The receptor sites in the breast are competitively bound by estrogen and progesterone, preventing prolactin from activating lactation. When the placenta is delivered, these levels of estrogen and progesterone rapidly drop and the prolactin floods the receptors.
  102. Which vitamin is not found in human breast milk?
    Vitamin K.
  103. How does human milk differ from cow's milk?
    While the two are similar in calories, human milk has more lactose, less protein (and very different protein constitution), and slightly more fat (especially more polyunsaturated fatty acids and cholesterol, which are needed for brain development.) There is significantly more calcium, phosphorous, and iron in bovine milk.
  104. A breast-feeding mother presents to your office complaining of fever, chills, and a swollen rest breast. What is the most likely diagnosis and causative organism?
    Mastitis. Staphylococcus aureus is the most common cause of mastitis. Mastitis is seldom present in the first week postpartum. It is most often seen 3 to 4 weeks postpartum.
  105. What is the treatment for acute mastitis?
    Warm compresses to breast, analgesics, dicloxacillin, or a cephalosporin.
  106. Can a nursing mother with mastitis continue to nurse?
    Yes, as long as there is no abscess formation. Nursing facilitating the drainage of the infection and the infant will not be harmed because he/she is already colonized.
  107. What is secondary amenorrhea?
    No menstruation for 6 months or more in a woman who previously had regular menses.
  108. What is the most common cause of secondary amenorrhea?
    Pregnancy. The second most common cause is hypothalamic hypogonadism, which can be due to weight loss, anorexia nervosa, stress, excessive exercise, or hypothalamic disease.
  109. A 27 year old woman presents with secondary amenorrhea for 6 months. What is the appropriate initial evaluation?
    Pelvic examination, pap smear, pregnancy test, laboratory studies (prolactin, FSH, LH, TSH), and progestin challenge.
  110. A 26 year old woman with secondary amenorrhea and an essentially normal work-up is given progestin 10mg for 7 days (or an IM injection of progesterone 100mg). She responds with a normal menstrual period. What does this tell you?
    She has a functional endometrium and a normal production of estrogen. Patients producing less than 40pg/mL of estrogen will not bleed. This test is called the progesterone challenge.
  111. What are the two major differential diagnoses in a patient with secondary amenorrhea who fails a progestin challenge?
    Premature ovarian failure and hypothalamic dysfunction. Premature ovarian failure can be diagnosed if the serum FSH level is high; hypothalamic dysfunction can be diagnosed in setting of low FSH and LH.
  112. List the differential diagnosis of persistent vaginal bleeding in a preadolescent woman:
    Neoplasia, precocious puberty, ureteral prolapse, trauma (including sexual assault), vulvovaginitis, exposure to exogenous estrogen, shigella infection, group A and B-hemolytic streptococcal infection, and foreign body in vagina. Foreign body is the most common and presents with bloody, foul smelling discharge.
  113. What blood tests would be appropriate in the evaluation of a female child with precocious puberty?
    Serum levels of FSH, LH, prolactin, TSH, estradiol, testosterone, dehydroepiandrosterone sulfate (DHEAS), and HCG.
  114. What is the recommended treatment for massive intractable dysfunctional uterine bleeding?
    25mg IV conjugated estrogens
  115. What are the recommended pharmacotherapeutic interventions for primary dysmenorrhea?
    NSAIDs or combined oral contraceptive agents. If non-responsive to the above interventions, tocolytic agents (salbutamol) or CCB (nifedipine) or progestins (medroxyprogesterone) have been shown to be effective.
  116. What are the four main etiologies of secondary dysmenorrhea?
    • Endometriosis
    • PID
    • Uterine fibroids
    • Pelvic congestion (typically occurs in multiparous women who have pelvic vein varicosities and gested pelvic organs)
  117. A 37 year old woman, G2 P2 presents with a history of lengthening menses and acquired dysmenorrhea. This problem had beed subtly going on for 2 years and now is a quality-of-life issue. Examination reveals a top normal size globular-shaped uterus. What is the most likely diagnosis?
    Adenomyosis.
  118. What are some causes of premature menopause?
    Smoking, radiation, chemotherapy, and anything else that limits the ovarian blood supply.
  119. What is the median age for menopause?
    51yrs
  120. What is the most common cause of postmenopausal bleeding?
    Atrophic endometrium and/or atrophic vaginitis.
  121. What are the expected changes in gonadotropin levels after menopause (ie when someone asks for a blood test to see if they are in menopause, what do you order, and what are you looking for?)
    FSH increases 10-20 fold and LH increases three fold, reaching a maximum 1 to 3 years after menopause. With the lack of ovarian response to FSH and LH, there is less estrogen and progesterone begin produced.
  122. Which hormones decline as a result of menopause?
    Estrogen and androstenedione. Progesterone production also decreases.
  123. What hormone is sereted more bt the postmenopausal ovary than the premenopausal ovary?
    Testosterone. Prior to menopause, the ovary contributes 25% of circulating testosterone, and in menopause the ovary contributes 40% of circulating testosterone.
  124. What does vaginitis and vaginal atrophy increse during the postmenopausal years?
    Because of estrogen deficiency, the vaginal pH increases from 3.5-4.5 to 6.0-8.0, predisposing it to colonization of bacterial pathogens.
  125. What effect does estrogen therapy have on colorectal cancer?
    It significantly decreases the risk of colon cancer (50%).
  126. A 63 year old woman asks you about the risk-benefit ratio for estrogen therapy. What do you tell her?
    Estrogen therapy is currently recommended for postmenopausal women who are NOT in a high-risk category for breast cancer to improve cardiovascular health – research suggests that estrogen decreases the risk of CHD by 35%; to limit the risk of osteoporosis, including decreased risk of hip fractures by 25% and risk of vertebral fractures by 50%; for control of vaginal atrophy and vasomotor side effects of hypoestrogenic state. Hormone replacement therapy should be used with caution since unopposed estrogen increases the risk of endometrial cancer eight times (addition of progestins will eliminate this risk); it could potentially increase the risk of breast cancer in those with known risk factors; it can lead to hypercoagulable state (DVT)
  127. What are the contraindications to estrogen therapy?
    Estrogen-sensitive cancers, chronically impaired liver function, undiagnosed genital bleeding, acute vascular thrombosis, neurophthalmologic vascular disease, and known or suspected pregnancy.
  128. What is the mainstay of treatment for postmenopausal osteoporosis?
    Bisphosphonates.
  129. What are the absolute contraindications to the use of hormonal -based contraceptive agents? Explain using CONTRACEPTIVE:
    • Coronary disease
    • Obesity
    • Neoplasm of liver
    • Cerebrovascular disease
    • Estrogen-dependent tumors
    • Pregnancy
    • Thrombophlebitis
    • IDDM
    • Vaginal bleeding undiagnosed
    • Enzymes of liver increasing
  130. What chemical changes may predispose patients taking oral contraceptives to weight gain?
    Increased LDL, decreases in HDL, and sodium retention.
  131. How much is menstrual blood flow decreased by OCP use?
    On average by 60%
  132. What are the overall risks and benefits to combined oral contraceptives?
    • Risks: increased risk for clots, MIs, CVAs, HTN, amenorrhea, cholelithiasis, and benign hepatic tumors.
    • Benefits: regulate the menstrual cycle, decrease premenstrual symptoms, and curb the progression of endometriosis, ovarian cysts, and benign breast disease. They also decrease the risk of ovarian and endometrial cancer, decrease the incidence of ectopic pregnancy, salpingitis, and anemia. They are known to be therapeutic against RA.
  133. For women using oral contraceptives for four years or less, what is the reduction in the risk of ovarian cancer?
    30%. For 12 or more years of use, the risk is decreased by 80%
  134. For women using oral contraceptives for at least 2 years, what is the reduction in the risk of endometrial cancer?
    40%. This increases to 60% for 4 or more years of use.
  135. What effect does oral contraceptive use have on the risk of developing cervical cancer?
    Oral contraceptive users as a group are at higher risk for cervical neoplasm. This increased risk may be secondary to sexual habits rather than the pill itself.
  136. What are the estrogen-mediated side effects of oral contraceptive pills?
    Headache, nausea, breast enlargement or tenderness, fluid retention, chloasma, and telangiectasia.
  137. What are progestin/androgen-mediated side effect of oral contraceptive pills?
    Depression, fatigue, acne, oily skin, and increased appetite.
  138. What is the incidence of venous thrombosis among oral contraceptive users?
    10-20/100,000 users. Much higher incidence in smokers.
  139. How effective is breast-feeding alone in preventing pregnancy?
    98% for the first 6 months in women who have not resumed their menses.
  140. How does DepoProvera work?
    High levels of pregestin suppressing FSH and LH levels and eliminating the LH surge. This in hibits ovulation.
  141. What is the effect of progestin on the uterus?
    It results in a shallow atrophic endometrium and a thick cervical mucus. These both result in decreased sperm transport.
  142. What is the delay in return to fertility after Depo?
    6months to 1year
  143. What is the risk of ectopic pregnancy in women with an IUD in place?
    5%. Hormone-based IUD users have a 6-to-10 fold increase in ectopic rates compared with copper IUD uers.
  144. How long after exposure can emergency oral contraceptives be given?
    Up to 72 hours. It is more effective if initiated in 12 to 24 hours. Emergency contraception provides a 75% reduction in the risk of pregnancy. Patients should have a negative pregnancy test prior to treatments.
  145. What is the total dose of estrogen that should be used in combined emergency oral contraceptive pills?
    200mcg of ethinyl estradiol – 2 doses of 100mcg taken 12 hours apart.
  146. Besides emergency contraceptive pills, what other contraceptive method can be used to prevent pregnancy?
    Copper IUD
  147. How long after the removal of Implanon must patients wait to become pregnant?
    Ovulation usually occurs within 3 months.
  148. How long after delivery should a postpartum tubal ligation be preformed? Whay?
    It is common practice to wait 8 to 12 hours postpartum before inducing anesthesia for tubal ligation. This time interval is useful to allow the patient to reach cardiovascular stability and increase the likelihood of gastric emptying.
  149. What percentage of American couples are infertile?
    15% to 20% of women older than 35 years in the United States are infertile.
  150. What is the difference between primary and secondary infertility?
    Primary – no conception or history of conception. Secondary – at least one prior episode of contraception (even if did not result in term pregnancy and birth)
  151. What percentage of infertility is due to the male factor?
    40%. Problems with the cervix, uterus, fallopian tubes, peritoneum, or ovulation account for the remaining 60%.
  152. How long do sperm stay in the vagina postcoitus?
    At least 72 hours; however sperm are motile only for 6 hours. When preforming a rape kit, it is important to test for acid phosphatase. This enzyme is present for 24 hours and confirms that ejaculation has occurred.
  153. What hormone is a marker of changes in basal body temperature?
    Progesterone.
  154. In the evaluation of infertility, what procedure can be both diagnostic and therapeutic?
    Hystersalpingogram. It is typically performed between cycle days 6 and 10.
  155. What percentage of pregnant women get “morning sickness”?
    50 to 70%. It generally occurs in the first trimester (up to week 14-16)
  156. How should morning sickness be treated?
    Frequent small meals, carbohydrates, IV hydration, and anti-emetics as last resort.
  157. What is hyperemesis gravidarum?
    Excessive vomiting during pregnancy that results in starvation (ketonuria), dehydration, and acidosis.
  158. Does the presence of a thick endometrial strip on ultrasound indicate an intrauterine pregnancy?
    The endometrium can be thickened due to the hormonal stimulation associated with either an ectopic or intrauterine pregnancy, so this is not a consistent sign of a normal pregnancy.
  159. When can an intrauterine gestational sac be identified by an abdominal ultrasound?
    5th week. A fetal pole can be identified in the sixth week and an embryonic mass with cardiac motion in the 7th week.
  160. For a gestational sac to be visible on ultrasound, what must the HCG level be?
    At least 6500 for transabdominal or 2000 for transvaginal.
  161. What secretes HCG? Why?
    Placental trophoblast secrete HCG to maintain the corpus luteum, which in turn maintains the uterine lining. The corpus luteum is maintained through the sixth to eith week of pregnancy, by which time the placenta begins to produce its own progesterone to maintain the endometrium.
  162. How soon after implantation can HCG be detected?
    2 to 3 days.
  163. At what rate do HCG levels rise?
    They double every 48 hours.
  164. At what gestational age does HCG peak?
    8 to 10wks
  165. What are four actions of HCG?
    • Maintenance of corpus luteum and continued progesterone production.
    • Stimulation of fetal testicular testosterone secretion promoting male sexual differentiation
    • Stimulation of the maternal thyroid by binding to TSH receptors
    • Promotes relaxin secretion by the corpus luteum
  166. What does a progesterone level of 25ng/mL of higher indicates about a pregnancy?
    A viable, uterine pregnancy. Serum progesterone is produced by the corpus luteum in the pregnant patient and remains constant for the first 8 to 10 weeks of pregnancy.
  167. Which routine screenings should be performed on pregnant women?
    Hep B and C, syphilis, rubella, chlamydia, gonorrhea, and other STDs. Women in high-risk categories should also be screened for HIV.
  168. By which week of gestation can a mother feel fetal movement? What is the term used to describe this?
    16th to 20th week of gestation termed “quickening”.
  169. Which week of gestation can fetal heart tones be detected by Doppler?
    12th week.
  170. When can one auscultate the fetal heart?
    • U/S: 6wks
    • Doppler: 10-12wks
    • Stethoscope:18 to 20wks
  171. In general, at what time during pregnancy is the fetus most susceptible to teratogens?
    During the embryonic period, which lasts form 2 to 8wks postconception. This is the time of organogenesis.
  172. What is the known effect of folic acid deficiency in pregnancy?
    Folate deficiency is associated with neural tube defects (ie spina bifida, anecephaly)
  173. What effect does pregnancy have on BUN and creatinine?
    Both are decreased. This is the result of increased renal lood flow and increased glomerular filtration rate.
  174. What should pregnant women rest in the left lateral decubitus position?
    To avery supine hypotension syndrome due to compression of the IVC by the uterus.
  175. What is the normal PCO2 in pregnancy?
    30 to 34mmHg from chronic mild hyperventilation, presumably as a result of progesterone.
  176. What is the predominant change in the lung volumes in pregnancy?
    Decrease in functional residual capacity (FRC) as much at 15-25%. Tidal volume increases by 40%.
  177. What WBC count is expected during pregnancy?
    WBC counts of 15,000 to 20,000 are considered normal during pregnancy.
  178. What are normal changes in the auscultative heart examination during pregnancy?
    Exaggerated split S1 with increased volume of both components. Systolic ejection murmurs hear at the left sternal border are present in 90% of patients, soft, and transient diastolic murmurs are heard in 20% and continuous murmurs from breast vasculature are heard in 10%. The significance of murmurs in pregnancy must be carefully evaluated and clinically correlated. Harsh systolic murmurs and all diastolic murmurs should be taken seriously and worked up before being attributed to pregnancy.
  179. Why is pregnancy termed a “hyperparathyroid state”?
    The fetomaternal unit has the primary goal of transporting calcium across the placenta (by active transport) for fetal skeletal devlopment. This consumes most of the maternal calcium. With this increase in calcium need, parathyroid hormone levels are increased by 30 to 50% to bring calium form the maternal bone, kindey, and intestine into the serum.
  180. A pregnant patient complains that her contact lenses are painful to wear recently. Is this normal?
    Yes. Corneal thickness increases in pregnancy and can cause discomfort when wearing lenses fitted before pregnancy.
  181. What kind of changes occur in the cardiovascular system of a pregnant patient?
    • Cardiac output increases by 30% in the first trimester and then 50% by the second trimester.
    • Stroke volume increases 25% and hematocrit drops due to hemodilution.
    • Plasma volume increases by 50% and pulse increases 12 to 18 bpm
    • Systolic and diastolic blood pressure decrease by 10 to 15mmHg in the second trimester, then gradually returns to prepregnant levels in the third trimester.
  182. What kind of changes occur in the GI system of a pregnant patient?
    Gastric emptying and GI motility decrease leading to GERD and constipation. In the third trimester, GERD can also be the result of increased intraabdominal pressure. Alkaline phosphatase increases. Peritoneal signs such as rigidity and rebound are diminished or absent.
  183. Can iodinated radiodiagnostic agents be used in pregnant patients?
    No. They should be avoided because concentration in the fetal thyroid can cause permanent loss of thyroid function. Nuclear medicine scans, pulmonary angiography with pelvic shielding, and impedance plethysmography are preferred.
  184. What radiation dose increases the risk of inhibited fetal growth?
    10rad. Typical abdominal and pelvic films deliver 100 to 350mrad. A shielded chest x-ray should deliver under 10 mrad to the fetus. Don not withhold necessary x-rays.
  185. When does labor begin?
    Labor begins with the onset of regular, rhythmic contractions that lead to serial dilatation and effacement of the cervix. Thus, to say labor has begun, one must observe changes in the cervix. The presence of contractions alone does not qualify for the onset of labor.
  186. What are the four stages of labor and delivery?
    • Stage I: Onset of labor to complete dilation of the cervix
    • Stage II: Cervical dilation to birth
    • Stage III: Birth to delivery of the placenta
    • Stage IV: Placenta delivery to stability of the mother (about 6 hours)
  187. How long is the average latent phase of labor?
    In a nullipara, the average is 6.4hrs; in the mmultipara, the average is 4.8hrs
  188. What is the rate of cervical dilation (active phase) in primiparous and multiparous women?
    The active phase begins when the uterus is regularly contracting and the cervix is 3 to 4cm dilated. The minimal dilation is 1cm/h for primiparous and 1.5cm/h for multiparous women.
  189. What are the six movements of delivery?
    • Descent
    • Flexion
    • Internal rotation
    • Extension
    • External rotation
    • Expulsion
  190. How long may a patient push once fully dilated?
    Provided that the fetal heart pattern is reassuring and maternal expulsive forces remain effective, a second stage may last up to 2 hours (average nullipara is 40 minutes, multipara 20 minutes); up to 3 hours is appropriate if the patient has regional analgesia/anesthesia. Byond these time limits, one sees an increase in fetal acidosis and lower Apgar scores, as well as a greater risk of maternal postpartum hemorrhage and febrile morbidity.
  191. What is “effacement” if the cervix?
    Effacement refers to the foreshortening and thinning of cervix as it is drawn upwards (intraabdominally). It is usually expressed in percentages by which cervical length has been reduced (from 0%, or uneffaced, to 100%, or fully effaced).
  192. What agents may be used to ripen the cervix?
    Both chemical and physical agents have been used. Oxytocics, prostaglandins (especially PGE2), progesterone antagonists (RU-486), and dehydroepiandrosterone are such pharmacologic agents. Laminaria and foley catheter balloons are examples of physical dilators.
  193. What other uterotonic agents are there besides oxytocin?
    Vasopressin (antidiuretic hormone), prostaglandins (PGE2 and PGF2a) and thromboxane are natural oxytocics. Ergot alkaloids (eg Methergine( and the synthetic prostaglandin 15-methyl-F2-a-PG are used clinically to increase uterine contractions, especially for postpartum uterine atony.
  194. Does epidural analgesia affect the course of labor?
    Studies have showed that epidural analgesia does not slow the progress of labor in the first stage of labor. However, the second stage of labor appears to be prolonged for an average of 20 to 25 minutes. There is no evidence that this prolongation is harmful to the fetus.
  195. What is a “walking epidural”?
    An intrathecal opiod or epidural opiod plus an ultralow dose of local anesthetic, followed by continuous infusion of opiod and local anesthetics, for labor analgesia. These regimens cause no or minimal motor block on the lower extremities, and allow the mother to ambulate in the early first stage of labor.
  196. What complications are seen with precipitous labors?
    There is a higher incidence of fetal trauma (intracranial hemorrhage and fractured clavicle) and long-term neurologica injury. The mother is at higher risk for pelvic laceractions and postpartum hemorrhage (including somewhat paradoxically, from uterine antony).
  197. What is the most common cause of a prolonged active phase of labor?
    Cephalopelvic disproportion caused by contraction of a narrowed midpelvis.
  198. What is the first step in the evaluation of a protraction or arrest disorder of labor?
    Assess fetopelvic size. If disproportion is suspected, augmentation should not be undertaken.
  199. At term, what percentage of fetuses are in vertex presentation?
    95%
  200. What is the largest risk for breech presentation?
    • Frank Breech: Thighs flexed, legs extended
    • Complete breech: At least one leg flexed
    • Incomplete (footling) breech: At least one foot below the buttocks with both thighs extended
  201. What is the most common breech position? Frank breech
  202. What is the modified Ritgen maneuver?
    It describes the elevation of the fetal chin achieved by placement of the delivering hand between the maternal coccyx and perineal body, while the other hand guides the crowning vertex. This technique assists in extension of the fetal head and allows the clinician to control delivery.
  203. What is the difference between high forceps, mid forceps, and low forceps deliveries?
    • High forceps refers to the use of forceps when a baby is not yes in the birth canal (rarely used).
    • Mid forceps refers to the use of forceps when a baby is in the birth canal and within reach (used in case of fetal distress).
    • Low forceps refers to the use of forceps when the baby's head is at the pelvic floor (most often used to shorten labor when the mother is tiring or to control normal labor).
  204. How can ruptured membranes be diagnosed?
    Nitrazine paper will turn blue and a ferning pattern will be seen under the microscope in the presence of amniotic fluid. Also, look for pooling of amniotic fluid in the posterior fornix.
  205. What are the degrees of perineal tears that may occur with delivery? Describe.
    • First: Perineal skin or vaginal mucosa
    • Second: Submucosa of vagina or perineum
    • Third: Anal sphincter
    • Fourth: Rectal mucosa
  206. What are the advantages and disadvantages of a mediolateral episiotomy?
    Allows for greater room without lacerating the external sphincter ani or rectum. However, these episiotomies are associated with a greater blood loss and postartum pain, greater likelihood for suboptimal healing, and subsequent dyspareunia.
  207. What are the advantages and disadvantages of a midline (median) episiotomy?
    • These are easier to repair, associated with the lower blood loss, usually heal better (less postpartum discomfort and better cosmetic result), and less subsequent dyspareunia.
    • The principal disadvantage to such an episiotomy, compared to a mediolateral one, is the greater propensity to extend into the external anal sphincter or reectum resulting in possible rectal dysfunction or rectal prolapse in the future.
  208. How can fetal lung maturity be assessed?
    The L/S ratio; if the ratio of lecithin to sphingomyelin is more than 2:1, then the fetal lungs are mature.
  209. What are the benefits of antepartum corticosteroids in premature babies?
    Increased lung compliance, increased surfactant production, less respiratory distress syndrome, less intraventricular hemorrhage, less necrotizing enterocolitis, and less neonatal mortality.
  210. What is the normal fetal heart rate?
    120 to 160 bpm. If bradycardia is detected, position the mother on her left side and administer oxygen and an IV fluid bolus.
  211. Are accelerations normal?
    Yes and no. Rapid heart rate can indicate fetal distress; 2 accelerations every 20 minutes are normal. An acceleration must be at least 15 bpm above baseline and last at least 15 seconds.
  212. What causes variable decelerations?
    Transient umbilical cord compression. These often change with maternal position.
  213. A baby is born with a pink body, blue extremities, and a heart rate of 60. The neonate is mildly irritable (grimaces) and has a weak respirations and no muscle tone. What is this patient's Apgar?
    4 = Extremities (1) + HR (1) + Grimace (1) + Respiratory (1) + Muscle tone (0)
  214. What percentage of pregnancies are ectopic?
    1.5%. Ectopic pregnancies are the leading cause of death in the first trimester.
  215. What is the risk of a repeat ectopic pregnancy?
    10% to 15%
  216. What are the risk factors for ectopic pregnancy? Use ECTOPIC:
    • Endometriosis
    • Congenital anomaly of tubes
    • Tubal surgery
    • Old abdominal scar
    • PID
    • In vitro fertilization
    • Contraceptive pills
  217. When and how does an ectopic pregnancy most commonly present?
    6 to 8 weeks into the pregnancy. Patients usually present with amenorrhea and sharp, generally unilaterla abdominal or pelvic pain.
  218. In an ectopic pregnancy, is an adnexal mass a common finding?
    No. An adnexal mass is actually found in less than 50% of cases. Abdominal pain is the most frequent symptom. Amenorrhea is the second most common symptom.
  219. What is the most common site of implantation in an ectopic pregnancy?
    The ampulla of the fallopian tube (95%). Less common sites are the abdomen, uterine cornua, cervix, and ovary.
  220. How do HCG levels differ in women with ectopic pregnancies versus intrauterine pregnancy?
    In 85% of women with ectopic pregnancy, the HCG level is lower than expected.
  221. Which is the most common sign of an ectopic pregnancy by transvaginal ultrasound: adnexal mass or absence of an intrauterine pregnancy?
    The absence of an intrauterine pregnancy at an HCG level >2000 is highly predictive of an ectopic pregnancy. An adnexal mass or gestational sac in the adnexal is less reliable finding and is not always seen in early ectopic pregnancies. Follow-up U/S is always recommended in high-risk patients to ensure intrauterine pregnancy.
  222. Who is eligible for methotrexate treatment of an ectopic pregnancy?
    Patient who are hemodynamically stable with unruptured gestations <4cm in diameter by ultrasound.
  223. What criteria are used for assuring the success of methotrexate?
    With a single-dose therapy, the HCG levles should fall by 15% between days 4 and 7 after therapy and continue to fall weekly until undetectable.
  224. What are the indications for laparotomy for the treatment of ectopic pregnancy?
    Common indications for laparotomy include an unstable patient, large hemoperitoneum, cornual pregnancy, and lack of appropriate surgical tools for laparoscopy. A large ectopic (>6cm) and fetal heart tones in the adnexa may also be considered as indications for laparotomy.
  225. A patient who is 3mo pregnant presents to your office with pelvic pain. On examination, a retoverted and retoflexed uterus is found. What is the diagnosis?
    Incarceration of the uterus. Patients typically complain of rectal and pelvic pressure. Urinary retention may be found. The knee0chest position or rectal pressure may correct the problem.
  226. What are the differences spontaneous, threatened, incomplete, complete and missed abortions?
    • Spontaneous: loss of fetus before 20th week
    • Threatened: Uterine cramping and bleeding in the first 20 weeks of gestation without the passage of products of conception or cervical dilatation.
    • Incomplete: Partial abortions in which part of the products of conception are aborted and part remain within the uterus. Cervix is dilated on examination, and D/C is necessary to remove the remainder of tissue.
    • Complete: When all products of conception have been passed, cervix is closed, and uterus is firm and nontender.
    • Missed: no uterine growth, no cervical dilation, no passage of fetal tissue, and minimal cramping or bleeding. Dx is made by the absence of fetal heart tones and an empty sac on ultrasound.
  227. What percentage of pregnancies result in spontaneous abortions? What is the number one cause of natural abortions?
    15-20%. Genetic defects (50%) usually the result of an abnormal number of chromosomes.
  228. Name three independent risk factors for spontaneous abortion?
    Increasing parity, maternal age, and paternal age.
  229. What is the effect of smoking and drinking on abortion rate?
    Women who smoke more than 14 cigs daily have 1.7times greater chance of a spontaneous abortion. Those who drink alcohol at least 2 days a week have a twofold greater risk for spontaneous abortion.
  230. How do spontaneous abortions most commonly present?
    Abdominal pain followed by vaginal bleeding typically before 8 to 9 weeks of gestation.
  231. What is the chance of spontaneous abortion once fetal cardiac activity is established at eight weeks of gestation?
    3 to 5%
  232. In what percentage of patients will spontaneous labor occur within 3 weeks of fetal death?
    80%. It may be helpful to induce labor with vaginal suppositories due to the psychological effects of carrying a dead baby.
  233. At what gestational age is suction or vacuum curettage used to terminate the pregnancy?
    7 to 13weeks of gestation
  234. What is the most common cause of postabortal pain, bleeding, and low-grade fever?
    Retained gestational tissue or clot.
  235. What is the most likely diagnosis in a patient whose uterus is larger than expected from the history of gestation, has vaginal bleeding, and passes grape-like tussue from the vagina?
    Hyditidiform mole.
  236. How does age influence the incidence of hydatidiform moles?
    Compared to women aged 25 to 29 years, women older than 50 years have a 300 to 400 fold increase in risk and women younger than 15 years have a 6 fold increase. Similarly, increased paternal age (above 45 years of age) also confers an increased risk of a complete molar pregnancy, although the increase is much lower and adjusted for maternal age.
  237. How is HCG useful in the evaluation of gestational trophoblastic disease?
    Both molar pregnancies and gestational choriocarcinomas produce HCG due to their trophoblastic origin. The tumor marker correlates well with the volume of disease and can be followed as a marker during therapy.
  238. With what endocrine abnormalities are moles and other gestational trophoblastic neoplasms associated?
    Hyperthyroidism.
  239. Describe the characteristics of gestational choriocarcinoma:
    Gestational choriocarcinoma contain both cytotrophoblast and syncytiotrophoblast elements. They are considered invasive molar pregnancies. Invasive moles are pathologically similar to complete hydatidiform moles but invade beyond the normal placentation site into the myometrium. Penetration into the venous system can result in venous metastases to the lower genital tract and lungs.
  240. Why is induction of labor with oxytocin or prostaglandin not recommended for the evacuation of molar pregnancies?
    Uterine contractions against the undilated cervix theoretically carries an increased risk for the dissemination of trophoblast throughout the systemic circulation.
  241. What is the most common presentation of twins?
    Vertex-vertex. If the first twin is vertex and the second breach, it is still possible to attempt a vaginal delivery because the extra space afforded after the birth of the first baby allows room to manipulate the position of the second.
  242. What is the average gestational age at delivery for twins, triplets, and quadruplets?
    • Twins: 36-37weks
    • Triplets: 33-34wks
    • Quadruplets: 30-31wks
    • 3 or more reduced to twins: 35-36 weeks
  243. What are the risk factors for elevated maternal serum a-fetoprotein? Explain using the mneumonic MSAFP:
    • Multiple gestations
    • Spina bifida (NTDs)
    • Abdominal wall defects (omphalocele, gastroschisis)
    • Fetal death
    • Placental anomalies
  244. What conditions are suggested by an elevated maternal serum a-fetoprotein?
    Neural tube defects (an encephalopathy), ventral abdominal wall defects, fetal demise, multiple fetuses. A low a-fetoprotein is indicative of a Down syndrome.
  245. What are the baseline congenital anomaly risks in the general population?
    • Regardless of family history or teratogenic exposure, the background risk for major congenital anomalies is 3% to 5%. These include abnormalities that, if uncorrected, affect the health of the individual. Some examples are pyloric stenosis, cleft lip and palate, and neural tube defects.
    • The background rate for minor congenital anomalies is 7% to 10%. These include strabismus, polydactyly, misshapen ears, etc. If uncorrected, they do not significantly affect the health of the individual.
  246. Why is the Rh status of a pregnant patient important?
    If the mother is Rh negative and the fetus is Rh positive, there is a risk of developing Rh isoimmunization and fetal anemia, hydrops, and.or fetal loss.
  247. When should RhoGAM be used?
    Within 3 days of the birth of an Rh+ child if the mother is Rh-. It should also be used in the event of any mixing of fetal and maternal blood (eg trauma). RhoGAM is safe because it does not pass the placenta barrier. (Standard dose is 300mg)
  248. What should Rh-negative women with ectopic pregnancies be given RhoGAM
    Administration of mini-RhoGAM (50mcg) is recommended with any failed pregnancy up to 12 weeks (with full dose RhoGAM after 12 weeks)
  249. A young patient has a threatened abortion in the first trimester. Lab studies reveal she is Rh negative and her husband is Rh positive. What is the recommended management of this patient?
    The patient will need 50mcg of RhoGAM IM. After the first trimester, the dose is increased to 300mcg IM.
  250. What is the most common medical complication of pregnancy?
    UTI
  251. What is the treatment of GDM?
    Diet, insulin, exercise. Do not give patients oral hypoglycemics because these cross the blood-brain barrier.
  252. What level of serum glucose in a patient with GDM warrents hospital admission?
    Persistent hyperglycemia (>200mg)
  253. When should you be most concerned about apregnant patient with underlying heart disease?
    During weeks 18 to 24, when the female body experiences a maximal increase in cardiac output (40%)
  254. What are some of the common misconceptions about the management of asthma during pregnancy?
    Dyspnea is common pregnancy with or without underlying asthma. Medications should be used sparingly. Uncontrolled asthma causes more fetal harm than medications.
  255. What are the factors during pregnancy that increase the risk of aspiration of stomach contents?
    Increased intragastric pressure from the gravid uterus, progesterone-induced relaxation of the lower esophageal sphincter, delayed gastric emptying in labor, and depressed mental status from analgesia.
  256. Is appendicitis more common during pregnancy?
    No (approximately 1 out of 850). However, the outcome is worse. Prompt diagnosis is important because the incidence of perforation increases from 10% in the first trimester to 40% in the third.
  257. During which trimester of pregnancy is acute appendicitis most common?
    The second trimester.
  258. How is appendix typically displaced during pregnancy?
    Superiorly and laterally. Diagnosis of appendicitis in pregnant patients may be further complicated by the fact that a normal pregnancy can itself cause an increased WBC. In a pregnant patient, pyuria with no bacteria suggests appendicitis. Pregnant patients may lack GI distress, peritoneal signs on examination, and fever may be absent or low grade.
  259. What viral or protozoal infections require extensive work-up during pregnancy? Define ToRCH:
    • Toxoplasma gondii
    • Rubella
    • Cytomegalovirus
    • Herpes genitalis
  260. What foods put a pregnant woman at risk for mercury poisoning?
    The only rela human exposure to organic mercury is through consumption of fish, primarily from predatory fish such as shark, swordfish, pike, and bass.
  261. Why is ephedrine usually the first choice to treat maternal hypotension?
    Ephedrine does not produce significant uterine vascular constriction, and therefore, it does not result in decreased uterine blood flow.
  262. What causes dependent and nondependent edema in pregnant women?
    Compression of veins by the growing uterus causes dependent edema, whereas hypoalbuminemia can cause nondependent edema.
  263. Define pregnancy- induced hypertension:
    An increase in the systolic pressure >30mmHg or an increase in diastolic pressure >15mmHg over baseline, measured on two separtate occasions at least 6 hours apart.
  264. What are the pharmacotherapeutic options for the treatment of hypertension of pregnancy?
    Methlydopa, labetalol, hydralazine, and clonidine. Antihypertensive treatment is indicated if the systolic BP is >170mmHg or the diastolic >100mmHg. Although many choose to treat earlier. Other options not used as frequently include nifedipine, atenolol, prazosin, and minoxidil.
  265. What are the nonpharmacotherapeutic options for the treatment of hypertension of pregnancy?
    Sodium restriction to 2 to 3g/d;abstaining from alcohol and tobacco; weight reduction; moderate activity as tolerated but rigorous activity should be limited; more frequent prenatal visits and ultrasound surveillance is recommended to monitor of fetal anomalies/stress or preeclampsia.
  266. Define preeclampsia:
    Hypertension (a systolic pressure >160mmHg or diastolic pressure >100mmHg) after 20 weeks of estimated gestational age with generalized edema or proteinuria of 5g or more in a 24-hour period.
  267. Who is more likely to have preeclampsia: primiparous or mulitparous women?
    Primiparous. Other risk factors include pregnancies associated with a large placenta, patients with a history of HTN, renal disease, family history of preeclampsia, older women, women with multiple gestations, and women with prior vascular disease.
  268. Which two drugs are used to treat eclampsia?
    Magnesium sulfate, 4 to 6g bolus IV followed by a 2g/h infusion, and hydralazine, 10 to 20mg IV. Labetalol may also be used.
  269. Should blood pressure be lowered acutely in a preeclampsia patient?
    No. Dangerous hypertension (>170/100) should be gradually lowered with hydralazine, 10mg IV followed by a drip.
  270. How should hydralazine be dosed for a preeclamptic patient?
    Hydralazine should be given in 5mg boluses every 20 minutes until adequate BP control (90/110 diastolic) is achieved or a total of 20 mg is reached.
  271. What is the major cause of death in women with eclampsia?
    Intracranial hemorrhage.
  272. What are the warning signs of impending seizure in a patient with preeclampsia?
    Headache, visual distubances, hyperreflexia, and abdominal pain.
  273. What is the treatment for eclampsia?
    Delivery. Until you are able to deliver you can use mag sulfate, valium, hydralazine. Phenytoin or diazepam can be used for seizures resistant to mag therapy.
  274. How long should treatment continue after delivery for a woman with preeclampsia?
    24hours. The cure for pre-eclampsia is delivery. Antihypertensives and antiseizure medication (IV mag sulfate) should be continued until there is no longer a risk to the mother.
  275. If a patient had an eclamptic seizure prior to delivery, can they have additional after delivery?
    Yes. Up to 10 days postpartum.
  276. At what point does magnesium become toxic?
    Respiratory arrest occurs at levels >12mEq/L. Loss of reflexes occurs at levels >8mEq/L and can therefore be used as a guide for treatment.
  277. What is the antidote for magnesium toxicity?
    Calcium gluconate (1g IV push); magnesium should be stopped if the DTRs disappear.
  278. What is the difference between placenta previa and abruptio placenta?
    • Placenta previa: implantation of the placenta in the lower uterine segment thus covering the cervical os. Presentation is painless vaginal bleeding with a soft nontender uterus
    • Abruptio placenta: premature separation of the placenta from the uterine wall. Abruptio placenta causes painful uterine bleeding.
  279. A patient present in her third trimester complaining of vaginal bleeding but no pain or contractions. How should you diagnose this patient?
    With a transabdominal ultrasound. Since 95% of placenta previas can be diagnosed this way, a vaginal examination should be avoided until placenta previa has been ruled out via ultrasound. Abruptio placentae is generally accompanied by pain, shock, or an expanding uterus. It is not easily diagnosed on ultrasound.
  280. What are the risk factors for placenta previa?
    Previous cesarean section, previous placenta previa, multiparity, multiple induced abortions, maternal age over 40 years, and multiple gestations.
  281. What are the risk factors for placental abruption?
    Smoking, trauma, cocaine, hypertension, alcohol, PROM, trauma, previous abruptio placentae, and retroplacental fibroids.
  282. What are the presenting signs and symptoms of abruptio placentae?
    Placental separation before delivery is associated with vaginal bleeding (78%) and abdominal pain (66%) as well as with tetanic uterine contractions, uterine irritability, and possible fetal death.
  283. What PE finding may be discovered in abruptio placenta?
    Rapidly increasing fundal height secondary to bleeding into the uterus or a higher than expected fundal height.
  284. What are the etiologies for uterine repture (both gyn and ob)
    Oxytocin stimulation, cephalopelvic disproportion, grand multiparity, abdominal trauma, prior hysterotomy, previous c-section, myotomy, curettage, or manual removal of the placenta.
  285. What is the number one risk factor for uterine rupture?
    Previous c-section.
  286. What are the common signs of uterine rupture?
    Fetal distress, unrelenting pain, hypotension, tachycardia, and vaginal bleeding. Fetal distress is usually the first sign of uterine rupture.
  287. What tow findings on PE are indicative of uterine rupture?
    Loss of uterine contour and palpable fetal part.
  288. Why is the incidence of thromboembolism increased in pregnancy?
    Venous stasis from the uterine pressure on the inferior vena cava, increase in clotting factors, increased fibrinogen, and decreased fibrinolysis
  289. What are some of the risk factors for thromboembolism in pregnancy?
    C-section, multiparity, bed rest, obesity, increased maternal age, and surgical procedures.
  290. What are the predisposing factors for amniotic fluid embolism?
    Older maternal age, multiparity, c-section, amniotomy, and insertion of intrauterine fetal monitoring devices.
  291. How does amniotic fluid enter maternal circulation?
    Through uterine tears or injury or through endocervical veins.
  292. What are the major consequences of amniotic fluid embolism?
    Cardiorespiratory collapse and DIC. Treatment is supportive.
  293. What is the mortality rate in amniotic fluid embolism?
    About 80%
  294. How does cocaine adversly affect pregnancy?
    Cocaine is especially toxic during pregnancy. The most common complication caused by cocaine during pregnancy is abruptio placentae, which may result in felta death. In addition, brain anomalies, intestinal atresia, and limb reduction defects have been described. Investigators have also reported increases in congenital heart defects in exposed infants. Cocaine may cause these effects by vasocontrictions and subsequent infarction.
  295. Does methadone have the same adverse affect as cocaine in pregnancy?
    Not even close. In fact, one study compared cocaine-abusing women to women being treated with methadone and found a much higher complication rate in the cocaine-abuse group. Methadone is not thought to be a teratogen.
  296. What is neonatal abstience syndrome, and what agents cause it?
    It is caused by maternal heroin addiction or maternal methadone treatment during pregnancy. It results from neonatal withdrawal and consists of tremulousness, hyperreflexia, high pitch cry, sneezing, sleepiness, tachypnea, yawning, sweating, fever, and seizures. The onset of symptoms is at birth.
  297. What are the signs and symptoms of fetal alcohol syndrome?
    Infants suffer from intrauterine growth restriction , mental retardation, and develop a characteristic facies, which consists of short palpebral fissures, a flat midface, a thin upper lip, and hypoplastic philtrum. Alcohol abuse is the most common preventable cause of mental retardation during pregnancy.
  298. At what time during gestation is the fetus most susceptible to alcohol toxicity?
    Probably in the second and third trimesters. In a study of 60 women, those who were heavy drinkers but stopped after the first trimester had children with normal mentation and behavioral patterns.
  299. What are the major adverse effects of smoking during pregnancy?
    Smoking causes intrauterine growth restriction and increases the incidence of preterm delivery in a dose-dependent manner. The incidence of placenta previa, abruptio placentae, and spontaneous abortion also appears to be increased in smokers.
  300. What are the indications for cardiotocographic monitoring in a pregnant trauma patient?
    All women past 20 weeks gestation with indirect or direct abdominal trauma require 4 hours of monitoring. Loss of beat-to-beat variability, uterine contractions, or fetal bradycardia or tachycardia demands immediate obstetrical consultation.
  301. When monitoring a pregnant trauma victim, whose vital signs are the most sensitive, those of the mother or those of the fetus?
    The fetal heart rate is more sensitive to inadequate resuscitation. Remember that the mother may lose 10% to 20% of her blood volume without a change in vital signs, whereas the baby's heart rate may increase or decrease above 160 or below 120, indicating significant fetal distress. The most common pitfall is failure to adequately resuscitate the mother.
  302. What are maternal risk factors for shoulder dystocia?
    • Diabetes, maternal obesity, postterm babies, and mothers with excessive weight gain.
    • Intrapartum risk factors include a prolonged second stage of labor, oxytocin use (augmentation or induction), and midforecps deliveries.
  303. What is the best known fetal risk factor for shoulder dystocia?
    Feral weight. The risk is approximately 0.2% if the fetus weighs 2500 to 3000g but rises to about 10% if the baby weighs 4000 to 5000g and up to 20% if the baby weighs more than 4500g in diabetic patient's these latter weight-associated risks are approximately doubled.
  304. What is the difference between a classic c-section and a newer c-section?
    • A classic c-section is a vertical incision in the uterus. This type of c-section predisposes women to future uterine rupture. Hence, subsequent deliveries should be made via c-section as well.
    • The newer c-sections are low transverse incisions; they have a much lower rate of uterine rupture with subsequent deliveries.
  305. What percentage of women can have vaginal births after low transverse incision c-sections (aka VBAC)?
    75%. Vaginal birth is contraindicated after a classic c-section.
  306. What is the average blood loss for vaginal delivery and for cesarean section?
    400 to 600mL for vaginal delivery and 800 to 1000mL for c-section.
  307. Why is a rapid c-section delivery an important part of maternal resuscitation?
    Removing the fetus relieves aortocaval compression. With uterine contraction after delivery, some blood may enter the circulation and may help increase venous return. Cadiac output produced by chest compression may be more adequate without the fetus.
  308. What happens if some placenta or fetal membranes are left inside the uterus?
    Retained tissue or products of conception may lead to postpartum hemorrhage. It also increases the risk of postpartum endometritis.
  309. What is the puerperium?
    This peuperium refers to the time just after birth and lasts about 6 weeks. It is the time ti takes the uterus to return to its nonpregnant state.
  310. What are the causes of immediate postpartum hemorrhage?
    Uterine atony, followed by vaginal/cervical lacerations, and retained placenta or placental fragments.
  311. What is the most common cause of post partum hemorrhage?
    Uterine atony.
  312. What factors predispose one to uterine atony?
    Fetal macrosomia, polyhydramnios, abnormal labor progress, amnionitis, oxytocin stimulation, and multiple gestations.
  313. What is routinely done to decrease the risk of postpartum hemorrhage?
    Uterine massge and oxytocin. Lacerations are sutured. In severe cases, where bleeding cannot be stopped, the hypogastric vessels are ligated or a hysterectomy is performed.
  314. What lochia?
    Lochia refers to the uterine discharge that follows delivery. It consists of necrotic decidua, blood, inflammatory cells, and bacteria. This discharge lasts about 5 weeks.
  315. A patient presents 3 days post postpartum with a fever, malaise, and lower abdominal pain. On examination, a fould lochia and tender boggy uterus are present. What is the most likely diagnosis?
    Endometritis. This typically occurs 1 to 3 days postpartum. It is felt that the mechanism of infection is from ascending cervicovaginal flora.
  316. Is endometritis more common after vaginal delivery or c-section?
    The rate of endometritis is 5 to 10 times greater after c-section.
  317. What is the treatment for endometritis?
    Admission and IV broad-spectrum antibiotics.
  318. Why is the risk of a thromboembolic event increased in the postpartum time?
    While immediate platelet count changes are variable, platelet counts reach a peak at 2 weeks postpartum. Fibrinogen levels remain elevated for at least 1 week as do factors VII, VIII, IX, and X. In addition, there is greater vessel trauma and less mobility.
  319. What postpartum immunizations are part of standard care?
    Rubella and rubeola immunizations vaccinations should be administered to all susceptible post partum women. In theory, diptheria and tetanus toxoid boosters may also be administered if indicaated. The non-isoimmunized Rh-negative patient should aos receive anti-D immune globulin if her child is Rh-positive.
  320. How common are “postpartum” blues?
    50 to 70% of mothers will have postpartum blues.
  321. How common is postpartum depression?
    Only 4 to 10% of postpartum mothers will have true postpartum depression.
  322. When does ovulation resume postpartum?
    In nonlactating women, ovulation may occur as early as 27 days postpartum. The average is 10 weeks. In women exclusively breast-feeding, ovulation may be delayed for the duration of active breast-feeding, although the mean is 6 months.
  323. When may coitus resume following delivery?
    Most physicians instruct their patients to abstain from coitus for 6 weeks. From a physiologic standpoint, once uterine involution and perineal healing are complete, coitus may resume.
  324. What is Sheehan syndrome?
    Anterior pituitary necrosis following postpartum hemorrhage and hypotension. It results in amenorrhea, decreased breast size, and decreased pubic hair.

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