OB/GYN exam 1

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OB/GYN exam 1
2014-01-23 16:08:35
OB GYN exam

OB/GYN exam 1
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  1. what are the landmarks within the vulva (pudendum)
    • mons pubis
    • labia majora and minora
    • clitoris
    • urethral orifice
    • vestibule (fourchette)
    • - skene's glands
    • - bartholin's glands
  2. this is a mound of adipose tissue, skin, and hair that cushions the pubic symphysis
    mons pubis
  3. when does the amount of fat on the mons pubis increase and decrease
    • increases at puberty
    • decreases at menopause
  4. these are skin folds that extend inferiorly and posteriorly, is the terminus of the round ligament of the uterus and is composed mostly of adipose tissue containing sudoriferous and sebaceous glands
    labia majora
  5. what is the homolog to the scrotum
    labia majora
  6. these are smaller skin folds medial to the labia majora containing sebaceous glands and are hairless
    labia minora
  7. this is the homolog to the penile shaft skin
    labia minora
  8. this is located where the labia minora merge anteriorly and it is a small, cylindrical mass of erectile tissue and nerves
  9. the body of the clitoris is mostly covered by what
    prepuce (AKA clitoral hood)
  10. the exposed portion of the clitoris is known as the what
  11. what is the glans penis homolog
  12. this is locate between the labia minor, has ducts of several glands, and contains the hymen (if present)
  13. what does the vestibule contain for anatomical structures
    • external urethral orifice: located anterior to the vaginal orifice and posterior to the clitoris
    • vaginal orifice
  14. what is the homolog to the membranous urethra
  15. this consists of 2 elongated masses of erectile tissue, and is located just deep to the labia on both sides of the vaginal orifice
    bulb of the vestibule
  16. what is the homolog to the corpus spongiosum
    bulb of the vestibule
  17. these glands provide lubrication during intercourse, they are located on both sides of the vaginal orifice (4 and 7 o'clock) and they open by ducts into the groove between the hymen and labia minora
    greater vestibular (Bartholin's) glands
  18. these glands produce a small amount of mucus during sexual arousal
    greater vestibular (Bartholin's) glands
  19. these are the homolog to the bulbourethral gland
    greater vestibular (bartholin's) glands
  20. these are located on either side of the urethral orifice and the secrete mucus into ducts that open into the urethral orifice
    paraurethral (skene's) glands
  21. these are the homolog to the prostate
    paraurethral (skene's) glands
  22. this is a diamond- shaped area medial to the thighs and buttocks in both males and females, and it contains the external genitalia and anus
  23. what is the perineum bounded by
    • pubic symphysis anteriorly
    • ischial tuberosities laterally
    • sacrotuberous ligaments posterolaterally
    • coccyx posteriorly
  24. what are the 2 triangular areas that are formed by a transverse line drawn between the ischial tuberosities
    • urogenital triangle
    • anal triangle
  25. which triangular area contains the external genitalia and the urethral orifice
    urogenital triangle
  26. which triangular area contains the anus and anal sphincter
    anal triangle
  27. what is bounded superiorly by the pelvic diaphragm and inferiorly by the skin
  28. this forms the floor of the pelvis and the roof of the perineum, it supports the abdominal and pelvic organs, and is important in fecal continence
    pelvic diaphragm
  29. what is the pelvic diaphragm composed of
    • levator ani
    • coccygeus
  30. what are the 3 muscles that compose the levator ani
    • puborectalis
    • pubococcygeus
    • iliococcygeus
  31. this provides a dynamic floor for support of abdominopelvic organs, and is tonically contracted most of the time to provide fecal/urinary continence
    levator ani
  32. this is a fibromuscular sheet that stretches across the pubic arch and provides the framework for attachment of the erectile body of the clitoris
    urogenital diaphragm
  33. what is the major source of vesicourethral control
    urogenital diaphragm
  34. this is the lowest point in the abdominal cavity for fluid accumulation and it is also known as the pouch of douglas
    rectouterine pouch
  35. why does excess fluid within the pouch of douglas occur
    • a ruptured ovarian cyst
    • local or distant malignancy
  36. this is the superior, dome-shaped, broad portion of the uterus
  37. this is the central, tapering part of the uterus
  38. this is the narrow, short area between the body and cervix of the uterus
  39. what are the 3 layers of tissue from the external surface to the uterine cavity of the uterus
    • perimetrium (serosa)
    • myometrium
    • endometrium
  40. this is part of the visceral peritoneum, it extends laterally as the broad ligament, anteriorly it continues overs the bladder forming the vesicouterine pouch, and posteriorly it continues over the rectum forming the rectouterine pouch
  41. in this layer of the uterus, the fundus is the thickest part (2cm) and the cervix is the thinnest part
  42. what are the 3 layers of the myometrium
    • outer: longitudinal/oblique
    • middle (thickest): circular
    • inner: longitudinal/oblique
  43. this layer of the uterus is a highly vascularized inner tissue layer composed of simple columnar epithelium (ciliated and secretory) lining the uterine cavity
  44. these are invagination of the luminal epithelium extending almost to the myometrial layer
    endometrial (uterine) glands
  45. what are the endometrial layers
    • stratum basalis
    • stratum functionalis
  46. which endometrial layer is shed during menses
    stratum functionalis
  47. this endometrial layer is a permanent layer and it gives rise to the stratum functionalis after each menstruation
    stratum basalis
  48. which arteries of the uterus give rise to the arcuate arteries within the myometrium
    internal iliac arteries
  49. which arteries within the uterus give rise to radial arteries that penetrate deep into the myometrium
    arcuate arteries
  50. what supplies the stratum basalis with materials required for regeneration of the stratum functionalis after menses
    straight arterioles
  51. what arterioles supply the stratum functionalis
    spiral arterioles
  52. these constrict under the influence of prostaglandins released in response to decreasing estrogen and progesterone levels during the menstrual phase of the reproductive cycle
    spiral arterioles
  53. the cervical canal opens into what
    uterine cavity at the internal os
  54. the cervix opens into what
    the vagina at the external os
  55. what elongates during pregnancy (after the 28th week) becoming the lower uterine segment
  56. what are the two main cell types of the cervix
    • squamous epithelial cells: located on the visible surface (ectocervix or exocervix)
    • columnar epithelial cells: located in the cervical canal (endocervix)
  57. this is the portion of the cervix extending into the vagina (includes parts of the endocervix and exocervix)
  58. what is the recessed vagina that borders the lateral cervix called
  59. this is where the columnar cells meet the squamous cells
    squamocolumnar junction
  60. the position of the squamocolumnar junction depends on what 2 factors
    • woman's age
    • hormonal status
  61. this is the area between the original and new squamocolumnar junction, 95% of cervical neoplasia occurs here
    transformation zone
  62. transformation from one cell type to another is known as what
  63. when columnar cells are visible on the ectocervix, this is known as what
  64. when is ectropion common
    • near menarche
    • during pregnancy
    • using oral contraceptives
  65. this is when columnar epithelium everts onto the portion of the cervix
  66. this protects sperm for phagocytes, and is a source of supplemental energy for sperm
    cervical mucus
  67. how much cervical mucus is produced in a women of reproductive age
    20-60 ml/day
  68. this anatomical structure is approximately 4" long, it functions in the transport of secondary oocyte, ovum, zygote, and sperm.
    fallopian tubes (aka oviducts or uterine tubes)
  69. where are the fallopian tubes located
    between folds of the broad ligament
  70. what are the 3 parts of the fallopian tubes
    • infundibulum
    • ampulla
    • isthmus
  71. this part of the fallopian tube opens to the pelvic cavity and the lateral portion has fimbriae (fringe of finger-like projections)
  72. this produces local currents that draw the ovulated secondary oocyte into the fallopian tube
  73. this part of the fallopian tube is the longest part, it composes the lateral 2/3 of the tube length, and extends medially
  74. this part of the fallopian tube is a narrow, thick-walled, short section, it is connected to the anteriolateral wall of the uterus
  75. what are the 3 layers of the fallopian tubes (from internal to external)
    • mucosa
    • muscularis
    • serosa
  76. this layer of the fallopian tubes is composed of ciliated epithelium, the waving action of the cilia propels the oocyte/fertilized ovum toward the uterine cavity. It also contains secretory (peg) cells with microvilli that secrete fluid containing nutrients for the oocyte/fertilized ovum and sperm
  77. this layer of the fallopian tubes contains an inner region of circular smooth muscle, the outer region has a longitudinally oriented smooth muscle, and its peristaltic smooth muscle contractions transport the oocyte/fertilized ovum toward the uterine cavity
  78. this layer of the fallopian tubes is the outer coat composed of serous membrane
  79. what are the 4 major pelvic ligaments
    • cardinal
    • round
    • broad
    • uterosacral
  80. these ligaments anchor the cervix and vagina to the pelvic wall and along the bladder it provides most of the passive support of the uterus
    cardinal ligaments
  81. these ligaments are connective tissue bands between layers of the broad ligament, extends from the part of the uterus just below the uterine tubes to the labia majora and helps maintain anteversion
    round ligaments
  82. this ligaments are the lateral peritoneal folds that anchor the uterus to the pelvic wall, it divides the pelvis into anterior and posterior compartments and the folds envelope the round ligament
    broad ligament
  83. this portion of the broad ligament contains the fallopian tubes
  84. these ligaments lie on either side of the rectum and anchor the uterus to the sacrum
    uterosacral ligaments
  85. the uterus is normally maintained in what type of position
    anteverted position (anterior "tilt" over the urinary bladder)
  86. what are the other possible uterine positions
    • retroversion: posterior tilt
    • anteflexion: anterior flexion
    • retroflexion: posterior flexion
    • retrocession: both uterus and vaginal canal lie closer to the rectum than the bladder
  87. a complete uterine prolapse is known as what
  88. this is a fibromuscular, expandable tube containing transverse mucosal rugae
  89. this functions as a passageway for sperm, menstrual discharge, and babies
  90. what is the normal position of the vagina
    it is normally directed superiorly and posteriorly (toward the coccyx)
  91. this anatomical structure of the vagina is a circular recess (vault) located at the site of cervical attachment
  92. the inner layer of the vaginal mucosa is composed of what type of cells that lines the entire vagina
    stratified squamous epithelium
  93. what is the normal vaginal pH
  94. what is the cephalopelvic anatomy of the fetal skull
    • non-compressible base
    • flexible vault
    • sutures
    • fontanelles
    • diameters
  95. what is the cephalopelvic anatomy of the maternal bony pelvis
    • 2 innominate bones (ilium, ischium, pubis)
    • coccyx
    • sacrum
  96. what are Caldwell's four basic bony pelvic shapes
    • gynecoid (50%)
    • android (<30%)
    • anthropoid (20%)
    • platypelloid (3%)
  97. which of the Caldwell basic bony pelvis shapes are favorable for vaginal delivery and which are not
    • Favorable: gynecoid, anthropoid
    • Unfavorable: android, platypelloid
  98. estimating the size and type of female pelvis by PE is done when
    • at new OB appt
    • during labor to assess fetal descent
  99. what are the pelvic planes
    • pelvic inlet
    • plane of greatest diameter
    • midplane (plane of least diameter)
    • pelvic outlet
  100. this pelvic plane is the entrance to the true pelvis
    pelvic inlet
  101. what are the boundaries of the pelvic inlet
    • superior border of pubis
    • linea terminalis (iliopectineal line)
    • sacral promontory
  102. in the pelvic inlet, the fetal head enters in what type of position
    transverse position
  103. when is the fetal head engaged with the pelvic inlet (and no it is not when it is asked to be married lol)
    it is engaged when the biparietal passes the linea terminalis
  104. what are the boundaries of the plane of greatest diameter
    • posterior pubis at maximum convexity
    • superior border of obturator formina
    • 2nd/3rd sacral vertebral junction
  105. what type of fetal head orientation is through the plane of greatest diameter
    anterior/posterior orientation
  106. this is the most important plane of the pelvis
    midplane (plane of least diameter)
  107. what are the boundaries of the midplane (plane of least diameter)
    • lower posterior pubic edge anteriorly
    • ischial spines and sacrospinous ligaments laterally
    • sacrum posteriorly
  108. which pelvic plane is a frequent site of transverse arrests
    midplane (plane of least diameter)
  109. this pelvic plane is clinically significant especially with low arrests
    pelvic outlet
  110. what are the boundaries of the pelvic outlet
    • sacrotuberous ligaments and sacrococcygeal joint posteriorly
    • inferior margins of pubic rami anteriorly
    • ischial tuberosities laterally
  111. what are the 3 key planes to assess in clinical pelvimetry
    • inlet
    • midplane
    • outlet
  112. what are the three estimates of the inlet
    • obstetric conjugate
    • diagonal conjugate
    • true (anatomic) conjugate
  113. explain the obstetric conjugate
    • it is the actual space available to the fetus
    • the fetal head is engaged when the biparietal diameter passes thru the inlet
  114. describe the diagonal conjugate
    • clinical estimation of obstetric conjugate
    • usually 1.5-2 cm bigger
    • >11.5 cm is "adequate"
  115. explain the true (anatomic) conjugate
    actual entrance to the true pelvis
  116. when does fetal head engagement occur
    • when the fetal biparietal diameter passes through the pelvic inlet (ie level of linea terminalis)
    • can occur prior to onset of labor in nulliparous pts
  117. this is when the bony presenting part is defined as its level above or below the ischial spines
  118. the bony presenting part is at the level of what when the head is engaged
    ischial spines (0 station)
  119. what type of fetal head engagement is when the head engages "cock-eyed".
  120. when a fetal head engagement is asynclitic, it should raise your suspicion of what
    cephalopelvic disproportion (CPD)
  121. this type of fetal head engagement is when the head engages parallel to the pelvic plane
  122. what are the estimates of the midplane
    • pelvic side walls
    • bispinous diameter
    • sacrospinous ligament
  123. what is the average interspinous diameter (estimates of the midplane)
  124. explain the pelvic side walls for estimates of the midplane
    • convergent
    • parallel (usual and desired)
  125. explain the bispinous diameter (distance between ischial spines) of estimates of the midplane
    • prominent
    • average
  126. explain the sacrospinous ligament for estimates of the midplane
    usually 3 fingers between the ishial spine and midline sacrum
  127. under the estimate of pelvic outlet, what is the estimation of prominence of the coccyx in the posterior sagittal view
  128. under the estimate of pelvic outlet, what is the estimation of the subpelvic angle at the infrapubic angle
  129. under the estimate of pelvic outlet, what is the estimation of intertuberous diameter at the bituberous diameter
  130. in embryology, when do the gonads begin to form
    4 weeks
  131. in embryology, when does the undifferentiated embryo begin to respond to gene effects of Y chromosome
    8-9 weeks
  132. in embryology, when do the primordial germ cells in the ovary complete first meiotic division giving the primary oocytes
    20 weeks
  133. what determines the development of phenotype
  134. a phenotype is divided into what 2 parts
    • genital ducts (how we look internally)
    • external genitalia (how we look externally)
  135. what are the different genital ducts in phenotype
    • paramesonephric (muellerian) ducts
    • mesonephric (wolffian) ducts
  136. what are the different parts of the external genitalia for phenotype
    • urogenital sinus
    • genital tubercle
  137. under embryology, explain gender differentiation (Jost model)
    • genetic sex determined at time of fertilization (chromosomal sex)
    • genetic sex determines gonadal sex
    • gonadal sex determines phenotypic sex
    • phenotypic appearance develops due to hormones produced by fetal testes (or not)
  138. the Y chromosome contains a specific gene region.. what is it
    sex-determining region (SRY) which codes for testis determining factor (TDF)
  139. the TDF codes for 2 hormones that are directly responsible for male differentiation.. what are the 2 hormones
    • testosterone: produced by Leydig cells-- enters fetal circulation and acts systemically-- also converted to DHT
    • muellerian inhibiting substance (MIS): produced by Sertoli cells-- acts locally
  140. which hormone stimulates specific tissues to undergo changes resulting in male phenotypic features
    testosterone (and DHT)
  141. which hormone causes involution of pre-programmed internal female components
    Muellerian Inhibiting substance (MIS)
  142. what are the 3 separate components within the embryo that makes up the female genital system
    • gonads: ovaries
    • genital ducts: uterus, fallopian tubes, upper 1/3 of vagina
    • genital tubercle: lower 2/3 of vagina, labia, clitoris, Skene's glands, Bartholin's glands
  143. an absence of Y chromosome gene products (testosterone) results in the involution of which ducts
    wolffian ducts
  144. what is the most common abnormal uterine development
    uterus bicornis
  145. what are the different hymenal abnormalities
    • annular hymen
    • septate hymen
    • cribriform hymen
    • imperforate hymen
  146. what are the different types of pseudohermaphrodites
    • CAH (46,XX)
    • Androgen insensitivity syndrome (46, XY)
  147. what are the releasing hormones of the hypothalamus
    • gonadotropin-releasing hormone (GnRH)thyrotropin-releasing hormone (TRH)
    • corticotropin-releasing hormone (CRH)
  148. what are the inhibitory hormones of the hypothalamus
    • prolactin-inhibiting factor (PIF)
    • somatotropin release-inhibiting factor (SRIF)
  149. the hypothalamus receives feedback from which organs
    • pituitary
    • ovaries
    • breast
  150. this hormone causes production and release of LH and FSH
  151. what inhibits GnRH
    gonadotropins (LH, FSH)
  152. what enhances the release of GnRH
  153. which hormone tonically prevents the release of prolactin from pituitary lactotrophs
    prolactin inhibiting factor
  154. where does the pituitary transmit signals to
    • hypothalamus
    • ovaries
    • breast
  155. where does the pituitary gland receive feedback from
    • ovaries
    • breasts
  156. what are the transmitters for the ovaries
    • estrogens
    • progesterone
  157. this hormone of the ovaries is secreted by theca interna cells/granulosa cells of the follicle. It is secreted by the corpus luteum after ovulation
    estrogens (estradiol, estrone, estriol)
  158. this hormone of the ovaries is secreted by the corpus luteum after ovulation
  159. how many ovulations are in a lifetime
    400 ovulations
  160. in the endometrium, which hormone is proliferative and which one is secretory
    • estrogen= proliferative
    • progesterone= secretory
  161. in the breasts, which hormone is proliferative, secretory, production, and expression
    • estrogen= proliferative
    • progesterone= secretory
    • prolactin= production
    • oxytocin= expression
  162. what are the 2 phases of the menstrual cycle
    • follicular- begins with 1st day of menstruation
    • luteal- begins with pre-ovulation, ends with 1st day of menses
  163. which phase of the menstrual cycle is the only portion with a defined duration
    luteal phase
  164. estrogen has what type of effect in breast enlargement
    • fat (adipose) deposition
    • ductal growth
  165. progesterone has what type of effect in breast enlargement
    • alveolar (ampullary) hypertrophy
    • secretory maturation
  166. in breastfeeding, this is released 1-2 days post delivery, it is composed of protein, fat, and minerals. It contains the secretory IgA, it is a laxative and there is approximately 40cc/day for 3-6 days
  167. this is recommended as the sole nutrient for the first 6 months of life
    breast milk
  168. what are the components of puberty
    • thelarche
    • adrenarche (pubic then axillary)
    • somatic growth
    • menarche
  169. what is the staging for puberty
    tanner 1-5
  170. what age range is associated with thelarche
  171. what age range is associated with adrenarche (pubic)
  172. what age range is associated with peak height velocity
  173. what age range is associated with menarche
  174. what age range is associated with adrenarche (axillary)
  175. which tanner stage is associated with sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly along the labia
    stage 2
  176. which tanner stage is associated with darker, coarser, curlier hair, spreading sparsely over the pubic symphysis
    stage 3
  177. which tanner stage is associated with coarse and curly hair as in adults; area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs
    stage 4
  178. which tanner stage is associated with hair in adult quantity and quality, spread on the medial surfaces of the thighs but not up over the abdomen
    stage 5
  179. what is recognized as the prime etiologic factor in the development of dysplasia
  180. which types of HPV are high grade
  181. which types of HPV are considered low grade
  182. what are the factors for unplanned pregnancies
    • underutilization of contraception
    • poor compliance with contraceptive method
    • choice not to use
  183. what are the different contraceptive types for family planning
    • hormonal- combination estrogen/progesterone or progestin only
    • IUD
    • barrier
    • behavioral
  184. what are the 5 different delivery methods for contraceptives
    • oral
    • transdermal
    • subdermal
    • injection (IM and subq)
    • intravaginal
  185. what are the different combination OCPs used
    • mononphasic- each pill has same amount of hormones
    • multiphasic- dose of hormone varies among the pills in the package
  186. what are the most popular reversible contraceptives in the US
  187. what is the MOA for OCPs
    • prevention of ovulation (suppresses LH surge)
    • thickens cervical mucus
    • limits proliferation of endometrium
    • alteration of normal tubal motility
  188. what are the commonly used 3rd gen progestin only OCP
    • desogestrel
    • norgestimate
  189. what is the 4th gen progestin only OCP
  190. why would 3rd gen progestins be more useful
    • less androgen side effects
    • less negative effect on lipid profile
    • epidemiologic studies question increased risk of VTE
  191. why would 4th gen progestins be more useful
    • may be helpful in PMS- esp breast tenderness, bloating
    • hyperkalemic risk likely overstated
  192. this progestin OCP binds to aldosterone receptors and blocks aldosterone action in the kidneys, it increase sodium and water excretion and potassium retention
  193. what are the absolute CI for OCP
    • hx of thromboembolic dz, stroke or ischemic heart dz
    • undiagnosed genital bleeding
    • active hepatic dz
    • hx of estrogen-dependent tumor
    • >35 who smoke >15 cig/day
    • pregnancy
  194. what are the relative CIs for OCP
    • >35 with hx of migraine with focal components
    • immobility
    • poorly controlled HTN
    • >35 with obesity
    • concomitant anti-convulsant use
    • hypertriglyceridemia
  195. what are some complications associated with OCPs
    • thromboembolism
    • stroke
    • HTN
    • post-pill amenorrhea
    • increased incidence of cholelithiasis
    • benign hepatic tumors
  196. which start method for OCP does not require back up contraceptive use
    first day start
  197. a pt calls worried because she has missed 1 pill of her OCPs, what can you tell her to do
    take 2 pills on the following day (no backup is needed)
  198. a pts is worried because she missed 2 pills in her OCP regimen, what should she be instructed to do
    take 2 pills for 2 days, use other contraceptive method
  199. a pts is worried because she has missed 3 pills of her OCP regimen, what should she be instructed to do
    • discontinue the pills
    • have a menses cycle
    • re-initiate on sunday post-menses
  200. which OCPs are for continuous use where no sugar pills are needed
    • seasonale
    • seasonique (4 menses/yr)
    • lybrel
    • other OCP (skip placebo week)
  201. what are the advantages for transdermal contraceptive (ortho evra)
    • therapeutic effect achieved at lower peak dose since 1st pass metabolism avoided
    • plasma hormone levels remain constant- no peaks, troughs
    • sustained delivery= increased compliance
    • good for non-swallowers
    • drugs stops immediately when removed
  202. what are the transdermal contraceptive methods
    • ortho evra
    • nuva ring
  203. which OCPs are useful for lactating mothers or tobacco users over age 35
    progesterone only agents
  204. what are the SE of progesterone only agents
    • irregular spotting and bleeding
    • amenorrhea
    • weight gain (Depo-Provera)
    • increased follicular cysts
    • acne flares
  205. what is the most reliable of all forms of contraception
    implants, injections, IUD (mirena)
  206. what is the MOA for progesterone only agents
    • thickens cervical mucus
    • thins endometrium
    • reduces tubal motility

    *no reliable suppression of ovulation
  207. what are the different progesterone only agents
    • Oral- mini pill:
    • - micronor
    • - nor-qd
    • - ovrette
    • injectable:
    • - depo-provera
    • IUD:
    • - mirena
    • Implantable:
    • - implanon
  208. which IUD is a functional spermicide, the copper iron decreases sperm motility and ability to fertilize. The inflammatory changes in the endometrium is spermicidal
    copper IUD
  209. this IUD thickens cervical mucus, thins endometrial lining, and inhibits sperm transport
    mirena (secretes levonorgestrel)
  210. what are some barrier contraceptive methods
    • diaphragm
    • cap/femcap
    • condom
    • sponge
  211. what are the behavioral methods, AKA natural family planning or fertility awareness-based
    • standard days method (cycle-beads)
    • ovulation method- cervical mucus
    • two day- cervical mucus
    • symptothermal- BBT (basal body temp, cervical mucus changes= spinnbarkheit)
  212. what are the sterilization methods
    • vasectomy
    • BTL
    • transcervical tubal occlusion
  213. this is known as the physiologic process by which ejaculated sperm acquire the ability to fertilize ova
    sperm capacitation
  214. this reaction is when enzymes digest the zona pellucida until the sperm cell membrane can fuse with egg cell membrane
    acrosomal reaction
  215. where does fertilization occur
    in the ampulla
  216. which blastocyte produces hCG
    trophoblast (chorion)
  217. when is the hCG hormone detectable and what does it do within the uterus
    • it is detectable 7-10 days post-fertilization
    • it preserves the corpus luteum until the placenta can take over (menses is deferred)
  218. what is the average time frame for the hCG values to double
    every 2.2 days
  219. how long does the hCG values rise
    60-90 days then plateus
  220. why would hCG levels be abnormally low
    in ectopic and spontaneous abortion
  221. why would hCG values be higher than normal
    gestational trophoblastic neoplasia
  222. during implantation, explain the factors within the fallopian tubes that may affect fertility
    • estrogen facilitates "sticking"
    • progesterone inhibits "sticking"
    • prostaglandin E relaxes tube
    • prostaglandin F stimulates tubal motility
  223. during implantation, when should the zygote reach the endometrial cavity
    ~ 3 days s/p ovulation
  224. during implantation, when does the zygote attach to the endometrium
    by day 5-6 s/p ovulation
  225. what forms the placenta
    placenta = decidua basalis + chorion frondosum
  226. what does the trophoblast (chorion) split into
    syncytiotrophoblast: erodes into decidua basalis forming lacunae (nitabuch's layer- fibroid degeneration)

    • cytotrophoblast: chorion frondosum- forms fetal villi which coalesce into umbilical vessels
    • - chorion laeve
  227. this is a zone of fibrinoid degeneration in the decidua basalis, it prevents placental invasion into the uterus
    Nitabuch's layer
  228. which type of the placenta invasion adheres to the myometrium
    placenta accreta
  229. which type of the placental invasion invades the myometrium
    placenta increta
  230. which type of placental invasion perforates through the myometrium
    placenta percreta
  231. what is the function of the placenta
    • allows growth, movement and development
    • physiologic buffer and antibacterial barrier
  232. this occurs when there is not enough amniotic fluid due to insufficient production, in early pregnancy it leads to pulmonary hypoplasia (Potter's syndrome- renal agenesis), and if late in pregnancy it can be associated with meconium, hypoxia, adhesions, or umbilical cord compression
  233. this occurs when there is too much amniotic fluid (~2L), either due to decreased elimination (swallowing- MC), or increased production, it may lead to premature labor, maternal discomfort, cord prolapse, or fetal malpresentation
    polyhydramnios (hydramnios)
  234. how is the amniotic fluid index used for amniotic fluid assessment
    • divide the abdomen into 4 quadrants
    • measure largest "pocket" of fluid in each quadrant
    • add them together to get total
  235. fetal hemoglobin has a higher affinity for ____
  236. decreasing the O2 affinity by decreasing the pH is known as what
    Bohr effect
  237. how many grams of Hg does the fetus have
  238. explain the umbilical cord
    • one vein- oxygenated and pressurized R side
    • two arteries- deoxygenated and flaccid L side
    • 50-60cm in length
  239. what is the fetal cardiovasculature
    • ductus venosus
    • ductus arteriosus
    • foramen ovale
  240. within fetal circulation, this forms a primary diversion that ensures improved oxygenation of brain and heart and limits flow to the lungs. It is functionally closed in 50% of term infants within 24 hours
    ductus arteriosus
  241. a PDA risk is inversely proportional to what
    gestational age
  242. within fetal circulation, this provides a direct shunt of oxygenated blood from the R atrium to systemic circulation.
    foramen ovale
  243. in a foramen ovale, when is the flap fusion completed
    by age 2 in 75% of children
  244. within fetal circulation, this allows interstate size bypass of hepatic circulation of oxygenated blood, it is functionally closed within minutes of delivery and structurally closed within 3-4 days.
    ductus venosus
  245. what is the remnant of the ductus venosus called
    ligamentum venosum
  246. velamentous vessels over the internal os are known as what
    vasa previa
  247. what are the maternal adaptations for pregnancy
    • cardiovascular
    • respiratory
    • renal
    • glucose metabolism
  248. when does maternal cardiac output increases peak
    at second trimester
  249. what are the mechanical effects of the gravid uterus
    • supine hypotensive syndrome
    • - IVC and iliac vein compression
    • - decreased preload leads to decreased cardiac ouput---syncope
    • varicosities, hemorrhoids, edema
    • predisposition to DVT
  250. why is there a higher risk for UTI/pyelonephritis in pregnancy
    • the collecting system dilates
    • - uterine mechanical obstruction
    • - progesterone relaxation of smooth muscle (including ureters)
  251. during a pregnancy, when does insulin resistance emerge
    late pregnancy
  252. what is the reason for gestational diabetes at 28 weeks
    the placenta secretes diabetogenic substances: human placental lactogen (hPL), increased unbound cortisol, and progesterone. This leads to impaired glucose tolerance and insulin resistance emerges
  253. what are the sxs associated with the diagnosis of pregnancy
    • missed period= amenorrhea
    • breast tenderness
    • nausea/vomiting
    • fatigue
  254. what are 3 categories of signs for the diagnosing pregnancy
    • presumptive- skin changes
    • probably- uterine changes
    • positive- fetal proof
  255. that are the presumptive skin changes in diagnosing pregnancy
    • chadwick's sign- bluish hue of the cervix/uterus
    • linea niagra- due to melanocyte stimulated by estrogen
    • chloasma= "mask of pregnancy" due to melanocyte stimulated by estrogen
  256. what are the probably signs in diagnosing pregnancy
    • piskacek's sign- asymmetric uterine enlargement
    • Hegar's sign- ability to compress connection between the cervix and fundus
  257. what are the positive signs in diagnosing a pregnancy
    • detect a heartbeat
    • - fetal Doppler 9-12 weeks
    • - fetoscope 20 weeks

    • "quickening" mom feels the baby move
    • - primigravida 18-20 weeks
    • - multigravida 15-17 weeks
  258. how is a pregnancy confirmed
    • labs- b-hCG:
    • blood
    • - HCG first detected 6-8 days after fertilization

    • urine
    • - detects levels >25 IU/L

    • US
    • - gestational sac at 4.5-5 weeks (21 days after fertilization
    • - fetal pole at 6-7 weeks
    • - heartbeat at 5.5-6 weeks
  259. when is the new OB apt during the 1st trimester booked
    • 10-12 weeks
    • often associated with a group orientation/class
  260. how often are routine OB appts
    • 12-28 wks appt monthly
    • 28-36 wks appt every 2 weeks
    • >36 wks appt weekly
  261. what are the elements of the new OB visit
    • accurate dating of the pregnancy
    • counseling
    • history (overall health and reproductive history)
    • pap smear if due
    • clinical pelvimetry
    • labs
  262. in a reproductive history, what does gravida mean
    number of pregnancies
  263. in a reproductive history, what does para mean
    • there are 4 parts
    • - full term birth
    • - preterm birth
    • - abortions (both spontaneous and induced)
    • - living children
  264. when dating a pregnancy, the 1st day of the last menstrual period + 7 days + 9 months= estimated delivery date or estimated date of confinement is known as what rule
    Naegle's rule
  265. when is an early ultrasound used for dating a pregnancy
    required if uncertain LMP or irregular periods
  266. when using the US for dating, which trimester is when it measures the "crown-rump" length and is accurate +/- week
    1st trimester
  267. when using the US for dating, which trimester is when you measure the biparietal diameter and femur length and it is accurate +/- 2 weeks
    2nd trimester
  268. when using the US for dating, which trimester is when you measure the BPD + femur length, and it is accurate +/- 3 weeks
    3rd trimester
  269. what should a pt that is pregnant be counseled on
    • travel
    • exercise
    • delivery planning
    • drug/alcohol use
    • medications/herbals/OTC
    • sex
    • domestic violence
  270. explain the counseling for travel in a pregnant pt
    • can safely travel up to 37 weeks
    • travel in pressurized commercial airplane presents no problems
    • high altitudes (>8k ft) can cause problem in complicated pregnancies
    • car travel should include correct seatbelt wear
    • biggest risk DVT (max 6 hrs/day driving, stop q 2 hrs)
    • carry copy of medical records
  271. explain the counseling for exercise in a pregnant pt
    • encouraged (30 min or more a day)
    • continue established patterns
    • - exceptions: no impact, contact, straining after 1st trimester)
    • - be aware balance may be affected by changed COG (center of gravity)
    • no new regimens
    • - consider hydro- support
    • - avoid hot tubs (increased body temp associated with neural tube defects and miscarriage)
  272. explain the counseling for delivery planning in a pregnant pt
    • breast feeding (should be emphasized best feeding method for most infants)
    • labor and delivery
    • - lamaze
    • - emergency indications- cared for on L&D >20 weeks
  273. what are the CI in breast feeding an infant
    • HIV
    • chemical dependency
    • certain medications
    • active TB
  274. what are the emergency indications that require care on the L&D floor >20 weeks
    • regular contractions q 3-5 minutes
    • rupture of membranes
    • vaginal bleeding
  275. explain the counseling for medications/herbals in a pregnant pt
    • if it is not prescribed or recommended, don't use it
    • if it is already prescribed, ensure compatibility with pregnancy (class A, B or C)
    • consider lactation issues
  276. which FDA drug classification is when controlled studies show risk of fetal harm is remote
  277. which FDA drug classification is when there is no evidence of fetal risk
  278. which FDA drug classification is when there are no controlled studies in humans or animals
  279. which FDA drug classification has a positive evidence of fetal risk
  280. which FDA drug classification has clear evidence of fetal risk outweigh any possible benefit
  281. which medications should be prescribed to a pregnant pt
    • prenatal vitamins
    • folic acid
    • - best if pre-conception (NT closure at 28 days)
    • - 0.4-0.8mg po daily (all women childbearing age)
    • - 4.0mg if:
    •   -anticonvulsants, to thwart deficiency,esp valproate, and carbamazepine- val now additional alert regarding decreased cognitive development
    •   - history of NTD
    •   - type 1 diabetes, BMI >35, FH of NTD
    • Fe/Colace
  282. which medications are CI in pregnant pts
    • ACEI
    • high dose ASA
    • acne meds (Accutane, cat X)
    • tetracyclines
    • sulfonamides- not in late pregnancy
    • coumadin
  283. what is the most preventable cause of low birth weight infants
  284. this is the most frequent recognizable cause of mental retardation
    fetal alcohol syndrome
  285. what are the discriminating features of FAS
    • short palpebral fissures
    • flat midface
    • short nose
    • indistinct philtrum
    • thin upper lip
  286. what are the associated features of FAS
    • epicanthal folds
    • low nasal bridge
    • minor ear abnormalities
    • micrognathia
  287. explain the counseling for sexual activity in a pregnant pt
    • not harmful unless abortion or preterm labor threatens
    • pregnancy can cause changes in comfort and desire
    • increased uterine activity after intercourse:
    • - breast stimulation
    • - orgasm
    • - prostaglandins in semen
  288. how is the fundal height measured
    it is measured from the top of the symphysis to top of the fundus in cm
  289. this measurement is a gross estimation of fetal growth
    fundal height
  290. what are the general rules for maternal weight
    • 1st trimester- 3-6 lbs (no need to increase caloric intake now)
    • after 20 weeks approx. 1 lb/week
    • 25-35 lbs overall weight gain recommended for women with a normal BMI
  291. if a pt has poor weight gain during pregnancy, what can that lead to
    increase risk for preterm birth/LBW
  292. if a pt has excessive weight gain during pregnancy, what can that lead to
    • increased risk for macrosomia
    • c-section
    • postpartum weight retention
  293. how are fetal heart tones assessed, what is the normal range
    • assessed with a Doppler
    • normal range 120-160
  294. this maneuver begins at 28 weeks and confirms, lie, presentation, and estimated fetal weight
    leopolds maneuvers
  295. this is a technique to assess fetal well being after 28 weeks
    fetal movement counts
  296. explain the fetal movement counts
    • mom lays on her left side
    • mother should recognize 10 fetal movements in 1 hr
    • if <10 some have mom drink glucose containing fluid and repeat for another hour
    • if still <10 should come to L&D for assessment of "decreased fetal movement"
  297. what are some complications associated with pregnancy
    • heartburn
    • constipation
    • hemorrhoids
    • leg cramps
    • backaches
    • round ligament pain
    • N/V
    • PUPPP
  298. when does round ligament pain usually present
    early second trimester
  299. what is the treatment for round ligament pain
    • reassurance
    • activity modification
    • analgesics rarely indicated
  300. what is the treatment for hyperemesis
    • support, hydration, small bland foods, sleep positioning, ginger
    • vitamin B6 25 mg TID/Unisome (doxylamine) 25 mg po qhs
    • anti-emetics
    • antihistamines
    • anticholinergics
    • motility
    • corticosteriods
    • admission with IV supportive care and fetal monitoring
  301. this is skin d/o is benign, seen in the 3rd trimester, resolves with parturition, and is treated how
    • PUPPP
    • treat with topical corticosteroids

    PUPPP (pruritic urticarial papules and plaques of pregnancy)