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What are the 3 major types of combined hormonal contraceptives (CHC)
Describe how the CHC's work to prevent pregnancy
- -The estrogen is the primary
- reason that the brain thinks "hey we don't need to make FSH and
- LH" - preventing ovulation
- -The progesterone helps with
- this, but its main effects are to thicken cervical mucus and thin the
- endometrial wall
When does most breakthrough follicle development happen? How can you prevent this?
during the Hormone Free Interval (HFI), can prevent this by not giving women a hormone free interval (causing amenorrhea)
What are the absolute contraindications to estrogen? (15 in 4 categories)
- -blood clot (DVT, PT, arterial clot)
- -Migraine with aura >15 mins (vasospastic)
- -uncontrolled HTN
- -Ischemic heart disease
- -Hx of CVA
- -valvular heart disease
- -Cancer: current breast, gyne, undiagnosed gyne bleeding
- -Gyne/obs: current pregnancy, <6 wks post partum if breast feeding
- -Other: Smoker over 35, diabetes, cirrhosis, liver tumor
What are the side effects of CHC use (3)
Nausea, breast tenderness, breakthrough bleeding
What are the risks of using CHC? (5)
- 1) VTE
- 2) MI
- 3) Stroke
- 4) gallbladder disease
- 5) ?breast Cancer
2 big advantages of nuvaring over OCP
- -only half the estrogen exposure
- -less irregular bleeding
How does depo-provira work? (3)
- High doses of progesterone:
- -suppression of ovulation via gonadatropins
- -increases cervical mucus viscosity
- -causes endometrial atrophy
Risks of using depo-provira (5)
- -menstrual disturbances
- -delayed return to fertility
- -weight gain
- -mood issues
- -reduced bone density
How does the Mirena work? (3)
- -mainly by profoundly suppressing the endometrium making implantation difficult (due to progesterone)
- -may inhibit ovulation
- -may impair sperm mobility
What are the risks of Mirena use?
- 1) infection
- 2) Expulsion
- 3) Perforation
- 4) Irregular bleeding
- 5) ectopic pregnancy (but overall risk is lower because mirena is so effective at stopping pregnancy)
IUD Contraindications (10 in three categories)
Obs/Gyne: pregnancy, distorted uterine cavity
Cancer: unexplained vaginal bleeding, cervix or endometrial ca, malignant trophoblastic disease, breast ca
Infectious: recurrent STD or PID, Puerperal sepsis, post-septic abortion,
What are the three main emergency contraceptives?
- -Plan B and Yuzpe are both high dose levonorgestrel (synthetic progestin)
- -Copper IUD
Describe the GPTPAL system
- Gravidity: total # of pregnancies of any gestation
- Parity: # of deliveries >20 weeks
- T - term births
- P - preterm births
- A - abortions
- L - number of living children (could be adopted)
What are the gestational ages for:
What is normal term?
- 1st: 0-12 weeks
- 2nd: 12-28 wks
- 3rd: 28-40 wks
Term is 37-42 weeks from LMP
Describe Nagele's rule for due date. What is the gold standard for due date?
- Due date = LMP - 3mon + 7 days
Gold standard is early U/S when fetus is at least 10cm big
Describe the reproductive (4), CV (4) and resp (5) changes in pregnancy
- Repro: increased vasc, hypertrophy of endo and myometrium, increased discharge, big boobs
- CV: Increased CV, decreased BP, increased vol, varicose veins
- Resp: increased tidal volume, decreased RV, increased O2 consump and minute ventilation, therefore minor resp alk
Describe renal (4), endocrine (2), and heme changes (2) in preg
When is the highest risk of VTE?
- Renal: increased freq, cystitis and pyelonephritis common, renal flow and GFR increase
- Endocrine: Increased insulin resistance, increased cortisol
- Heme: Hemodilution due to higher plasma increase, fibrinogen increases (VTE risk 2x in pregnancy, 5x in post partum period)
Describe the changes to the GI (3), derm (3), and MSK systems in pregnancy
- GI: progestin is an anticholinergic so decreased transit causes constipation, delatey gastric emptying, gallbladder stasis
- Derm: hyperpigmentation, striae, hair growth/loss
- MSK: loose ligaments, more nerve compression (Bell's, Carpal), LBP, Symphyseal pain
What is the most important modifiable risk factor associated with adverse pregnancy outcomes? What is the most common adverse event?
Smoking. These people MUST quit. No matter what you need to do. Spontaneous abortion is the most common A/E
How does smoking harm the baby? Is nicotine replacement harmful too?
Nicotine is a molecular and cellular poison. Vasoconstriction impairs blood flow to fetus. It is, but the nicotine levels are MUCH lower than what you get with smoking
What is the most common cause of mental retardation in pregnancy? What kind of malformations does it cause?
Drinking during pregnancy. Brain and heart
Why use methadone for baby and mom? (3)
- -Longer half life
- -allows for rehab
- -is oral and therefore avoids infectious risks
When do you screen for gestational diabetes?
at 24-28 weeks
Describe the menstrual cycle. (no pregnancy)
- Menstrual phase (variable (1-4 days))
- Proliferative phase (variable days, estrogen-dependent)
- 1) low E and P stimulates GnRH (and therefore LH and FSH) in this phase there is negative feedback
- 2) LH increases progesterone (stolen and converted to estrogen by theca interna), FSH increases estrogen and stimulates 3-30 follicles
- 3) estrogen builds up the endometrium thins cervical mucus
- Ovulation4) suddenly E and P have a positive feedback cycle with LH and FSH causing the LH surge , which causes ovulation. Later the FSH surge happens
- Luteal Phase (last 14 days)
- 5) Theca interna goes with egg and theca externa (corpus luteum) is now free to make the progesterone without the theca interna stealing it as before.
- 6) Switch back to negative feedback. Progesterone inhibits LH and FSH, causes endometrium to mature.
- 7) Second set of follicles develop and cause estrogen to peak. They eventually regress due to atresia
- 8) eventually the corpus luteum antrophies, causing the end of the progesterone release causing menses and the rise of FSH and LH, starting us over again.
What phase are the eggs stuck in until they are chosen?
Differentiate primary and secondary dysmenorrhea
- Primary: no identifiable organic cause
- Secondary: due to clinically identifiable organic cause.
Briefly describe the 4 steps to fertilization and conception
- 1) oocyte is transported to the ampulla
- 2) sperm undergo the capacitation and acrosomal reaction
- 3) oocyte is fertilized and oocyte undergoes second meiotic division
- 4) male and female pronuclei come together and make a zygote
What happens to start menses in puberty?
Gonadostat becomes less sensitive to the background estrogen and starts pulsing (at night), this releases LH and FSH which starts the cycle
What are the stages pubertal development in order (5)
- 1) Thelarche (breasts)
- 2) Adrenarche (pubes)
- 3) growth spurt
- 4) Menarche
- 5) maturation of these characteristics
First boobs and pubes, then you grow, then you flow
What are the age cutoffs for early and late puberty?
- early: any sexual maturation before age 7
- late: absence of any puberty signs by age 14
Why are girls with precocious puberty short?
estrogen fuses the growth plates
Describe the difference between True (central) and (peripheral) precocious puberty. 2 DDx for each
- True: hypergonadotropic hypergonadism
- -usually idiopathic in females
- -pituitary tumors (need MRI)
- Pseudo: hypogonadotrophic hypergonadism
- -testicular/ovarian tumor
What phase of gametogenesis gives genetic variability and the haploid gene number
Meiosis (crossover gives the variability)
What does HCG do?
Keeps the corpus luteum producing progesterone
What happens to the mesonephric and paramesonephric ducts in males and females
- Should say upper 1/3 of vagina
Where does the lower 2/3 of the vagina come from?
What does the differentiation to male external genetalia require (2)
- 1) testosterone from the testes
- 2) 5 alpha reductase to convert test to DHT
What do the genital tubercle, genital swellings, and genital folds become in males? females?
- genital tubercle: glans, clitoris
- genital swellings: scrotoum, labia majora
- genital folds: urethra, labia minora
What is the transitional zone of the cervix?
Where columnar epithelium changes to squamous epithelium due to increased estrogen. (columnar epithelium leaves the cervix)
Describe Congenital Adrenal Insufficiency (3 points)
- -one true crises state in sexual ambiguity cases
- -low/no aldosterone production reduces salt retention
- -NEED TO CHECK electrolyte levels
How do trisomies come about?
because of non-disjunction during meiosis
Describe Turner's and Klinefelter syndromes (3 points each)
- - 45 - XO
- - Webbed neck
- - 1:2000 live female births
- - 47 - XXY
- - most frequent abnormality of sexual diff
- - infertile
Describe the two types of amenorrhea?
- Primary: absence of menarche by age 15-16
- Secondary: amenorrhea for 6 months after menarche
What system (other than gyne) is heavily affected in Turners?
Describe the DDx of primary amenorrhea (4 in 2 categories)
- NO secondary sexual char's:
- -primary ovarian failure (MOST COMMON): usually Turner's
- -central hypogonadism (problem with HPO axis), nutrition
- WITH secondary sexual chars:
- -absence of vagina (mullerian agenesis)
- -imperforate hymen
Describe congenital androgen insensitivity (3 points)
- -Primary amenorrhea with secondary sex char's
- -Testicular feminization
- -non-functional testosterone receptors with an XY karyotype
What is the first thing you ALWAYS need to do when someone comes in with any type of amenorrhea?
What is the DDx of secondary amenorrhea (besides pregnancy) (4)
- -Hypothalamic amenorrhea (weight loss, exercise-induced)
- -Premature ovarian failure
What are the cardinal Sx and Signs of PCOS? (4 points, one with 3 subpoints)
- -anovulation (infertility)
- -hyperandrogenism (Hisutism, Acne, male pattern baldness)
- -Polycystic ovaries
Describe the pathophysiology of PCOS
- 1) genetic insulin resistance and obesity causes hyperinsulinemia
- 2) stimulates ovary to make more androgens, which in turn makes more estrogen
- 3) lower FSH causes anovulation, higher LH causes even higher androgen production (increased LH/FSH ratio)
- 4) Not sure what causes the cysts (there are many theories on the etiology of this disease)
Describe hypothalamic amenorrhea (2 points)
- -cessation of menses with no identifiable organic cauuse
- -Due to insufficient pulsatile GnRH release.
Describe premature ovarian failure (3)
- -1% of women with elevated FSH/LH < age 40
- -most cases are idiopathic
- -HRT to mimic normal ovarian function
Diagnostic criteria for PCOS (need 2/3)
- 1) polycystic ovaries on U/S (>10 follicles/ovary)
- 2) Oligo-anovulation (infertility)
- 3) Clinical of biochemical evidence of hyperandrogenism
Treatment for PCOS
-OCP for those not trying to conceive (increases levels of sex hormone binding globulin, also reduces circulating androgen levels)
-clomiphene (hypothalamus estrogen receptor blocker) and metformin for those trying to concieve
Causes of AUB (6 in 3 categories)
- -Organic causes: repro tract lesions, systemic disease
- -Dysfunctional causes: anovulatory, ovulatory
- -Iatrogenic causes: hormones, nonhormonal drugs
4 good (patient-centred) questions to assess AUB
- 1) How are your periods
- 2) How many days do they last
- 3) Do you think they are heavy?
- 4) Do your periods bother you or affect your life?
Who are the people that are at elevated risk for endometrial cancer? (6 over 2 categories)
- Have had an increased number of ovulations:
- -not on OCP
- -Haven't had kids
Describe ovulatory (3) and anovulatory (3) bleeding, including treatment. Most common tmt for both?
- -90% of AUB
- -non-cyclic and due to anovulatory production of estrogen
- -want to decrease proliferative endometrium with OCP, IUD, or Mirena
- -10% of AUB
- -associate with regular cyclic menstruation
- -hormones don't work, use NSAIDS to decrease endometrial prostaglandins
Most common treatment for both is endometrial ablation
What is DUB?
Dysfunctional Uterine Bleeding is AUB that is not attributable to an organic cause
Describe the 4 phases of the sexual response cycle
- Excitation: erection in males, erection of nipples, vagina/labial swellling
- Plateau: Increased pleasure with increased stimulation
- Orgasmic: Euphoria, quick (<1s) contractions of pelvic muscles
- Resolution: muscles relax, refractory
How long do you need to have symptoms before you can diagnose sexual dysfunction?
What is something you can prescribe for premature ejaculations?
What specific health concerns should you think of in women who have sex with women? (3 points)
- -increased breast and cervical ca
- -more likely to be smokers and drinkers
- -adolescents still have penile sex but have lower rates of condom use.
What specific heal concerns should you think of in men who have sex with men (3 points)
- -increased anal and oropharyngeal ca's
- -smoking is more common
- -screen for substance abuse
Describe gender identity
your innermost sense of what gender you are
Describe the difference between transgender and transexual
- transgender: behaviour crosses the norms expected of your anatomical sex in society
- Transexual: inner self gender identity is opposite to their anatomical sex at birth
What is the most common cause of spontaneous abortion? Three other causes
Uterine defects, unstable thyroid or diabetes, major medical condition
Describe the 6 different types of spontaneous abortion
- 1) Complete - all products expelled
- 2) Incomplete - some products expelled
- 3) threatened - bleeding withOUT cervical dilatation or product expulsions
- 4) Inevitable - bleeding WITH cervical dilatation
- 5) Missed - non viable preg with NO products expelled
- 6) Septic - self explanatory
Describe medical and surgical abortion
- medical: misoprostol opens cervix and starts contractions
- Surgical: vacuum D and C
What is the prevalence of ectopic pregnancy? Greatest RF? Most common site?
Medical management of an ectopic pregnancy
methotrexate, then follow BhCG and Sx to make sure that mom is out of danger.
What is the definition and prevalence of recurrent pregnancy loss?
3+ consecutive pregnancy losses < 20 weeks
occurs in 1% of women.
Most important concept in managing recurrent pregnancy loss?
- TLC - they need to be reassured:
- -freq visits
- -freq U/S
- -FH by doppler after 14 weeks
4 points that need to be brought up to a woman wanting an abortion
- 1) no adverse outcomes for mom, or for future pregnancies
- 2) conseling is important
- 3) discuss contraception
- 4) regret, grief and sadness may occur, but incidence is equal to those who continue their pregnancies
Describe the Sx you see with uterine leiomyomas (fibroids) (5)
- -usually asymptomatic
- -pressure related (constipation, urinary retention)
- -Pain: when torsion is present
- -can contribute to infertility
Is there a cancer concern with uterine leiomyomas?
not really (only 0.1% progress)
Treatment options for fibroid. how best to diagnose?
- -usually observation
- -myomectomy (surgery)
- -Uterine artery embolization
-Diagnose with U/S
What is the most common gynecological tumor?
fibroid (uterine leiomyoma)
List the three types of endometrial hyperplasia with risk of progression to Ca
- 1) Simple (1%)
- 2) Complex (5-15%)
- 3) Complex with atypia (25%)
What is the most common gyne cancer?
Describe the 4 stages of endometrial ca
- I - limited to uterus
- II - limited to cervix
- III - still in the neigbourhood (serosa, adnexa, vagina, LN's)
- IV - Metastatic (anywhere else)
Describe endometrial Ca Management (4)
- 1) Surgery: staging laparotomy/hysterectomy
- 2) Radiation: adjuvant or palliative
- 3) Hormonal: Provera (conservative therapy in young women who want to conserve fertility)
- 4) Chemo: adjuvant or palliative
What are the two categories of gestational trophoblastic disease.
- 1) Benign: hydatidiform mole
- -complete or partial
- 2) Malignant
- -Invasive mole
- -placental site trophoblastic tumor
Describe the pathogenesis of a complete and an incomplete hydatidiform mole
- Complete: complete paternal set of genes (2 sperm and no egg usually; 46XX or 46XY)
- Incomplete: two from dad, one from mom (69 XXY, or 69 XXX)
How do you diagnose a hydatidiform mole (3). How to treat (2)?
- 1) quantitiative BhCG (higher than normal)
- 2) U/S shows no heart sounds and "snowstorm"
- 3) pathology from D and C
Treat with D&C with methotrexate
Discuss 5 key points surrounding Gestational Trophoblastic Disease
- 1) Molar preg can be treated by suction D&C or hysterectomy
- 2) in 95% of women BhCG normalizes by 25 weeks
- 3) Risk of persisitant disease after exacuation is 19%
- 4) Rucurrence risk of GTN after 1 molar preg is 1-2%
- 5) no increased risk of congenital abnormalities or miscarriage in subsequent pregs
Which population is more likely to get gestational diabetes?
Describe the pathophysiology of gestational diabetes (3)
- -insulin resistance
- -impaired insulin secretion
- -increased hepatic glucose production
RF's for GDM (8)
- -previous diagnosis
- -previous macrosomic baby
- -Age >35
- -BMI > 30
- -Steroid use
- -acanthosis nigricans
Describe the approach to screening women for GDM (flow chart)
Oral Glucose Tolerance Test; (Fasting) Plasma Glucose
Describe some of the complications of GDM and DM (7 in 2 categories)
- 1) Obstetrical: macrosomia, induction of labour, stillbirth, preterm birth, preeclampsia
- 2) Developmental: fetal lung immaturity, polyhydramnios
What is common in pregnant women with pre-existing DM? (2)
- -congenital abnormalities (give 5 mg of folate; 3x more common than baseline)
What should you do if a diabetic wants to get pregnant (2)
control their sugars and switch them to insulin
What is the goal blood sugars in the intrapartum timeframe
4 key points about GDM in the post-partum period (6 weeks)
- -delivery usually cures GDM
- -Encourage breast feeding
- -increased risk of developing DM II
- -screen at 6 weeks and 6 months and prior to next pregnancy
What happens to TSH as BhCG increases? Why?
It decreases, because both hormones share a common subunit. HCG actually stimulates the thyroid as well to a certain extent
What hormone should you measure in pregnant people with hyperthyroid?
free T4, not TSH because it fluctuates with HCG levels
Risks of hyperthyroid in pregnancy (4)
- -neonatal hyperthyroidism
- -premature labour
Causes of hyperthyroid in preg (3)
- -hyperemesis gravidarum
- -Gestational Trophoblastic Disease
The last two have higher levels of HCG which stimulates the thyroid
What should you recommend regarding prenatal vitamins and thyroid replacement?
take them 12 hours apart, as the minerals in the PNV's affect the absorption of the medication
What is one thing you should check in a women you suspect has post-partum depression
2 key points (each) on hyperthyroidism and hypothyroidism in pregnancy
- -medicate just so free T4 is at upper range of normal so you don't cause neonatal hypothyroid
- -antibodies can cross placenta and cause hyperthyroid
- -adequate replacement to prevent decreased IQ
- -goal of TSH <2.5 in trimesters 1 and 2, < 3.0 in 3
Define HTN and severe HTN in pregnancy
- HTN: diastolic BP >90
- Severe: systolic >160, or diastolic >110
3 drugs used in severe gestational HTN, non-severe gestational HTN
- severe: labetalol, nefidipine, hydralazine
- non-severe: ", ", methyldopa
When do you deliver at less than 37 weeks?
- -HELLP syndrome
- -severe preeclampsia
- -severe FGR with oligohydramnios
- -non-reassuring fetal testing
If you need to deliver between 24-34 weeks what should you give?
What is first line tmt for eclampsia and prophylaxis for those with pre-eclampsia
What are the 4 theories of endometriosis pathogenesis
- 1) retrograde menstruation
- 2) Immune deficiency
- 3) Lymphatic/hematologic spread and coelomic metaplasia
- 4) angiogenesis, neurogenesis, etc
What is the most important RF in a patient you suspect has endometriosis?
if they have a 1st degree relative with endometriosis
What is the classic triad of endometriosis?
- Dysmenorrhea (painful period)
- Dyspareunia (painful sex)
- Dysuria (painful urination)
What is the first line tmt of endometriosis-related pelvic pain? What is the definitive tmt?
1st line is progestin (the anti-estrogen) or CHC, definitive is laparotomy/ablation (also the gold standard for diagnosis)
When do you recommend surgery for patients with endometriosis?
2 major points
- 1) Patients with pelvic pain and:
- -refractory to medical management
- -acute adenexal event (rupture)
- -severe invasive disease
- 2) endometriomas and pain
What is a key Sx you can use to differentiate adenomyosis from endometriosis? Another differentiating factor
Endometriosis does not cause menorrhagia (heavy flow). They have an enlarged, boggy uterus
What is pathogonomic for adenomyosis?
diffuse thickening of the endometrial-myometrial junction
Treatment options for adenomyosis? (3)
- 1) Hysterectomy is the only definitive tmt
- 2) ?CHC
- 3) ?Uterine Artery Embolization
What are the primary mediators involved in myometrial contraction? (2)
What are the 2 first line tmts for dysmenorrhea?
- 1) OTC analgesics (especially NSAIDS)
- 2) Combined Oral Conraceptives
How can you prevent a chronic pelvic pain syndrome?
treat initial pain Sx adequately and early.
Describe the two steps in the general approach to pelvic pain
- 1) empiric trial of therapy (OCP and GnRHa works on almost all causes of pelvic pain)
- 2) Intensive diagnostic evaluation followed by targeted therapy
3 main causes of secondary dysmenorrhea
endometriosis, adenomyosis, PID
3 mood and 3 physical Sx of PMS
mood: irritability, depression, fatigue
Physical: abdominal bloating, fluid retention, breast tenderness
Describe the cycle of violence
- -Outburst: explosive anger
- -Honeymoon: apology, promise reform
- -Tension building: progressive hostility, loss of temper
4 good questions to ask someone you think is suffering abuse?
- does the patient feel Safe?
- has the patient felt Abused in a relationship?
- are there Family or Friends that can help?m
- does the patient have an Emergency plan?
5 good concepts for dealing who is suffering from abuse?
- Routinely screen every patient
- Ask directly, nonjudgmentally, kindly
- Document findings
- Assess patient safety
- Review options and provide referrals
Definition of menopause, mean age, what causes it to come earlier?
Cessation of menstruation for at least 12 months due to the depletion of follicles
earlier in women who smoke
Difference between primary ovarian insufficiency and menopause
primary is the cessation of menstruation due to depletion of follicles before age 40
3 main features of menopause
- -low estrogen
- -high FSH
List 3 early-onset (perimenopausal), immediate-onset (right after menopause), and late onset Sx of menopause
- early: hot flashes, night sweats, fatigue
- Immediate: vaginal atrophy, urinary incontinence, pelvic floor relaxation
- Late: osteoporosis, CV disease, dementia
What are the benefits of HRT? What are 3 contraindications?
- symptom relief and disease prevention (especially osteoporosis).
- 1) estrogen-sens ca (breast, endometrial, unexplained vaginal bleeding)
- 2) CV (clots, known CVS disease)
- 3) active liver disease
Which gives a greater chance of developing breast cancer: HRT or lack of exercise?
Lack of exercise is twice as likely to cause cancer
What are the FOUR indications for hormone replacement therapy?
- 1) VASOMOTOR SX
- 2) vaginal atrophy
- 3) Bone loss prevention
- 4) cvs protection in women 55-59 (not >60)
What should you do in ANY woman over 35 with irregular bleeding?
take an endometrial biopsy
What is the chance that a couple will conceive within a given cycle
What are the relative freq's of the different infertility probs?
- 1/3 are male factors
- 1/3 are tubal/pelvic factors
- 1/3 are other (ovulation, unexplained infert, etc)
What are the 4 things you need for conception
tubes, sex, eggs, sperm
How do you investigate tubal patency (3)
- hysterosalpingogram (contrast and x-ray)
- laparoscopy with dye injection
Indications for IVF (5)
- -Tubal blockage
- -Male Factor
- -Unexplained fertility
What is the difference between primary and secondary infertility?
- Primary: Never conceived, one year of trying
- Secondary: failure to conceive when there has been conception in the past
What is the treatment for PCOS in someone who wants to get pregnant? (2)
Name 4 assistive reproduction technologies
- 1) Ovulation Induction
- 2) intrauterine insemination
- 3) IVF
- 4) Intracytoplasmic sperm injection
At what point should you use clinical judgement rather than the U/S measurement for due date? What should you do before then?
23 weeks. Any U/S measurement before this, you throw out the date based on LMP and use the U/S date
What is the best parameter for determining gestational age?
CRL (Crown-Rump Length) in T1, need to be at least 7 weeks along though.
Explain to the patient why we use U/S as the primary method of dating? (3)
- -isnt meant to be biological dating
- -not trying to predict when conception occurred
- -Trying to set up a common frame of reference
When should you do a screening anatomy U/S
18-20 weeks, this is offered to all women and will set the due date
What does MSS help define the risk for? (2)
- -Aneuploidy (trisomy 21 (downs) or 18 (edwards))
- -Open Neural Tube Defect
When are the MSS samples drawn? Why is it important to get the dates right? Most common cause of false positive test?
- 1st trimester (11-14 wks)
- 2nd trimester (15-20 wks)
The levels (and the risk) are based on gestational age. Incorrect gestational age is the most common cause of false positive test
What is the ONLY form of non-invasive prenatal testing for Down's available to parents with multiple gestation
Indications for amniocentesis without previous MMS test (3)
- 1) major abnormality on U/S
- 2) IVF + ICSI (lazy sperm injection) pregnancy
- 3) Woman or partner has had child with chrom abnormality or is a carrier
When should you do fetal surveillance? (3) What types are there? (3)
- When the fetus is at risk:
- -maternal DM
- -Suspected placental insufficiency
- -fetal anomaly
Types: Non-stress test, fetal movement counts, Biophysical profile
What do you see in a reassuring biophysical profile (BPP) (8-10/10)
- done over 30 mins
- LAMBR mnemonic-2 points for each
- -Limb extension (1)
- -Amniotic Fluid (2cmx2cm)
- -Movement (3+)
- -Breathing (1 episode > 30 s)
- -Reasurring NST
What is the definition of preterm birth?
Delivery before 37/52 GA
List survival rates by gestational age
- 22 weeks (rare)
- 23 weeks (0-30%)
- 25 weeks (75-78%)
- 29 weeks (>97%)
5 risk factors for preterm birth
- -previous preterm birth
- -multiple pregnancy-Cervical procedures (e.g. LEEP, cone, etc)
How can we predict preterm birth? (3)
- 1) Hx looking for RF's
- 2) fetal fibronectin (if +ve: 1/6 chance of premature delivery in next 2/52, if -ve: 1/125 chance, best for its NPV)
- 3) U/S to determine cervical length (if <2.5 cm in <32/52 asyp, if >3.0 cm in symptomatic there is <1% risk of delivering)
How do we prevent preterm labour in patients we are concerned about?
Give IM or vaginal progesterone
What is the definition of preterm labour?
6-8 contractions in one hour or 4 contractions in 20 mins AND documented cervical change
How do you treat premature labour (3)
- -Stop the process (tocolysis)
- -Optimize Fetal Condition (e.g. steroids, magnesium)
- -Optimize the environment that the fetus is born in (e.g. a centre with an NICU)
How do steroids help with premature infants, when you can give it, and two regimens
- -stimulate type II pneumocytes to make surfactant
- -effective up to 34 weeks
- -Betamethasone IM 12mg q24h x2
- -Dexamethasone IM 6mg q12h x4
How does magnesium help with preterm infants? When can you give it up to?
It is a neuroprotective agent which decreases neurological injury and cerebral palsy. Can be given up until 32/52
What are the two things that tocolysis achieves
- Gives 24 hours for transport
- gives 48 hours for steroids and Mg to work
Achieves no other goals
What are 2 tocolytic drugs used in Canada
- Indomethacin (an NSAID)
- CCB (usually Nefedipine)
4 counterindications to giving indomethasone
- -Problems with NSAIDS (allergy, ulcers, renal problems)
- -Fetal abnormalities
What is the definition of premature rupture of membranes? How prevalent?
rupture of fetal membranes before the onset of labour. Happens in 10% of pregnancies
How can you diagnose PROM? (3)
- Sterile speculum exam
- -pooling of fluid in vagina
- -Nitrazine (pH test)
- -Ferning - crystallization of NaCl in amniotic fluid
What does giving broad-spectrum Abx do when given to a woman with ROM. What else can you do?
In increases the latent period (time between ROM and delivery). If they are early, give them tocolytics and steroids/Mg
What can cause maternal alloimunization?
- 1) Previous blood transfusion
- 2) Previous IVDU
- 3) Feto-maternal transfusion from previous pregnancy
Describe the pathophysiology of fetal anemia due to alloimmunization
- 1) maternal Rh DD or Rh Dd IgG crosses placenta
- 2) attaches to fetal antigen-covered RBC's
- 3) destroys RBCs
- 4) fetal anemia
How does Winrho work?
- -Anti-D Ig binds to Anti-D coated RBC's and macrophages rapidly clear them
- -this prevents the antigen-specific B cells from becoming activated
When should Rh negative women get WinRho? (3)
- -28 weeks
- -postpartum (if fetus is Rh positive)
- -also if there is any other way that fetal and maternal blood may mix (trauma, ectopic preg, etc)
How do you test if a pregnancy is at risk for fetal anemia?
- -all women are screened for presence of antibodies to red cell antigens
- -If present, check the titre: critical titre is (1:16 or greater, or rapidly increasing)
What is the gold standard for determining if a fetus is anemic?
Describe 4 ways to indirectly test for fetal anemia
- 1) antibody titre in mother: (if it is increased, the risk is increased)
- 2) U/S: hydrops (fluid filled compartments in fetus) indicates severe anemia
- 3) Amniocentesis: measure bili as an indirect measure of hemolysis
- 4) Doppler: "thinner" blood moves faster and is more likely to be anemic (measured at MCA)
How do you treat severe fetal anemia?
in utero blood transfusion, winrho is just for prophylaxis
Besides having them followed by an OB, what should all alloimmunized have in their prenatal care? (4)
- -test father
- -serial titres
- -Serial U/S if above critical (1:16) titres
- -be ready to give a life-saving in utero blood transfusion
What are the TORCHS perinatal infections
What do you see in congenital CMV?
- -cognitive impariment
How can you prevent vertical transmission of HSV?
- -for anyone who has had herpes, acyclovir after 36 weeks until birth
- -someone with active lesions: C/S
What do you do if a non-immune mother is exposed to chicken pox? (2)
- -Varicella Ig (within 96 hrs of exposure)
Which of the following vaccines are safe to give in pregnancy?
a) Varivax (chicken pox)
b) HPV vaccine
c) Hep B
- a) varivax: no
- b) HPV vaccine: no
- c) Hep B: YES
- d) influenza: YES!!!!!!!!!!!!!!!!!
Are active genial warts an indication for C/S?
Describe delivery in an HIV +ve woman (3)
- 1) viral load >1000: C/S before ROM (38 wks)
- 2) viral load is undetectable: vaginal delivery ok, avoid scalp sampling
- 3) AZT infused IV at onset of labour or ROM
What can GBS do to a baby after delivery? When do you treat (6)? How?
- neonatal sepsis
- treat when (6P's)
- -Positive culture
- -Previously affected infant
- -"Pee" (GBS +ve bacturia)
- -unknown culture results with:
- -Preterm labour
- -Prolonged ROM
Treat with Pen G (IV)
What do you do with an asymptomatic bacteruria in a pregnant woman?
treat it. increased risk for pylonephritis, sepsis, and adverse pregnancy outcomes
What effects will a viral have on a fetus?
-Risk of congenital syndromes (4)
-Neonatal infection (2)
- -Risk of congenital syndromes (Toxo, CMV, Varicella, Rubella)
- -Anema (parvo)
- -neonatal (HIV, hepatitis)
5 causes of hisutism
- 1) PCOS
- 2) adult onset CAH
- 3) meds: danazol, anabolic steroids
- 4) Tumors: elevated androgens
- 5) idiopathic: increased sensitivities in receptors in some ethnic groups
Most common cause of infertility in women?
Why is acanthosis nigricans present in PCOS??
Because of the hyperinsulinemia
What are you trying to r/o with the 17OHprogesterone in a suspected PCOS case?
Describe how CAH causes virilization
- 1) Autosomal recessive defect
- 2) one of the enzymes responsible for converting cholesterol to steroid are f'd
- 3) precursors accumulate and androgen levels rise
- 4) Have super high ACTH levels
What is the most common cause of CAH? How does it lead to salt wasting? What is a good blood test for this?
21-hydroxylase deficiency. No aldosterone is produced which leads to hyponatremia and hypokalemia. High 17OHprogesterone is suggestive of this
What are the type of HPV that will cause genital warts? What are the strains that will cause cervical dysplasia?
- warts: 6 and 11
- dysplasia: 16 and 18
How do you get HPV?
do NOT need penetrative sexual contact to contract it. condoms do not help
How do you know if you have HPV? (3) How long do infections last?
- -usually asymptomatic
- -may have a bump (plantar wart)
- -may have an abnormal pap
Usually resolve in 2 years
How do you differentiate HSV, Canchroid, syphilis.
- 1) HSV clusters and it painful
- 2) Canchroid is more diffuse and is painful
- 3) Syphilis is a sole lesion and is painless
Describe the 2 types of herpes viruses. How do you treat?
- HSV1 above the waist
- HSV2 below the waist
Treat with acyclovir, or acyclovir-type drugs
What causes syphilis? How do you treat?
a spirochete called Treponema palladium. Always treat with penicillin. Even if allergic
What causes chancroid? How to diagnose? tmt?
caused by H. ducreyi. Usually diagnose by ruling out syphilis and HSV. Treat with azuthromycin.
How do you differentiate the discharge STI's? (culture results)
- Chlamydia: intracellular and cannot be cultured
- Trich: flagellated
- Gonorrhea: diplococci
What 5 types of people do you treat right away for mucopurulent cervicitis?
- -<25 years old
- -new partner or > 2 partners in past year
- -HIV +ve
- -unlikely to return for follow up
Desribe how to differentiate candidiasis, BV, and trich based on: Sx, signs, vaginal pH, amine test, saline microscopy
Treatment for Chlamydia and gonorrhea
azithromycin (1gm) and ceftriazone 250 mg
treatment for BV and candidiasis
- BV - metronidazole
- Candidiasis - azoles
What are the 5 classical Sx of PID?
- -abdominal pain
- -adnexal tenderness
- -cervical motion tenderness
- -vaginal discharge
What are the MINIMUM diagnostic criteria for PID?
- Sexually active (or otherwise at risk) with pelvic/lower abdominal pain and:
- -Uterine tenderness OR
- -Adenexal tenderness OR
- -Cervical motion tenderness
What is the gold standard for diagnosing PID?
laparoscopy showing tubal erythema +/- mucopurulent exudates
Which PID patients do you treat as an inpatient?
- -tubo-ovarian abscess
- -outpatient tmt failure
- -poor compliance likely
What are the three cell cetagories in the ovary and their tumors
- Eggs: germ cell tumors
- granulosa cells, theca cells, fibroblasts: sex cord stromal tumors
- Surface epithelium: surface epithelium tumors (most common tumors)
In a BRCA1 carrier, what type of ovarian cancer are they at increased risk for?
serous carcinoma of the ovary and fallopian tube
What is the most common neoplasm of the ovaries? When is it most commonly found?
Mature teratoma (dermoid cyst). These are gross and have hair, teeth, etc. Most commonly found in the first three decades.
If someone has hyperthyroidism and an ovarian mass, what should you be thinking?
Struma ovarii. Thyroid tissue in the teratoma.
Describe the serum markers you are looking for the following subtypes of cancer
-Germ Cell (3)
-Sex Cord Stromal (2)
- -Epithelial (all): CA 125 (can only use it to track treatment efficacy, see if tumor has returned)
- -Germ cell:
- -Choriocarcinoma: BhCG
- -Endodermal Sinus Tumor: elevated AFP
- -Malignant teratoma: nothing
- -Sex Cord Stromal:
- -Sertoli Leytig tumor: testosterone
- -Granulosa Cell Tumor: estrogen
- -GI: CEA
- -Endometrium: CA 125
Describe the 4 stages of ovarian ca
- Stage I: confined to ovary
- Stage II: beyond ovary but confined to pelvis
- Stage III: upper abdomen or on bowel
- Stage IV: On liver or lungs
Which LN's do you biopsy for suspected ovarian Ca? Why do you need to do staging surg?
para-aortic. Remember that they descend from the upper abdomen in utero. Need to do staging surgery because there is a super high metastatic potential in these women.
If you are doing a hysterectomy, is it worth doing a prophylactic salpingectomy to reduce the risk of cancer? What about if you are removing the ovaries?
No? Need to do 300 in order to prevent one cancer. If you are removing the ovaries because of cancer concerns then you NEED to remove the tubes too.
Describe the ages often affected with BRCAI and II induced ovarian ca, also contrast estrogen sens
- BRCAI: under age 55, usually not estrogen sens
- BRCAII: usually 60-65, more likely to be estrogen sens
What are the criteria for BRCA testing (4)? Treatment for BRCA carriers (3)
- -personal or personal Hx of early onset (<50) breast, ovarian, uterine ca
- -invasive serous ca at <60 years old
- -bilateral breast ca
- -FHx that include rare ca's (e.g. male breast ca)
- -Screening (surveillance)
- -oral contraceptives
- -Surgical risk reduction (prophylactic oophorectomy (with tubes)
Three types of benign adnexal tumors
Follicular cysts, luteal cysts, dermoid (teratoma)
What are the three things necessary for continence?
- 1) anatomical support of urethral vesical junction
- 2) Urethral sphincter mechanism
- 3) intact nervous system
ANS portion and spinal level for storage and urination
- Storage: Sympathetic, T10-L2
- Peeing: Parasymp, S2-S4
What is the most common cause of stress incontinence?
Hypermobility of the urethra due to lax ligaments
What is the definition of OAB?
- -frequency (>8 voids/day)
- -nocturia (> voids/day)
- - +/- incontinence
Describe stress, urge, mixed, overflow, and total incontinence
- stress: due to increased abdominal pressure
- Urge: need to go now
- mixed: mix of urge and stress
- Overflow: overdistended bladder (seen in old people with floppy bladders)
- Total: usually due to a fistula.
Treatment for urinary incontinency
- 1) lifestyle (no caffeine, stop smoking)
- 2) pelvic floor muscle training (stress inc.)
- 3) surgery for ligamentous laxity (stress)
- 4) Anticholinergic (oxybutinin, TCAs) for OAB, Beta 3 agonists
Describe how you evaluate uterine prolapse (4)
- 1st degree: stays within the vagina
- 2nd degree: down to the level of the introitus
- 3rd degree: past the introitus with straining
- 4th degree: outside the introitus without straining
Describe the following pap smear abnormalities (together make up 5% of all paps, other 95% are normal):
- ASCUS: atypical squamous cells of unknown significance
- ASC-H: atypical squamous cells favour high grade
- LSIL: low grade squamous intraepithelial lesion
- HSIL: high grade squamous intraepithelial lesions
- AGC: atypical glandular cells
- AIS: adenocarcinoma in situ
- Cancer: has gone past the basement membrane
How many CIN (cervical intraepithelial neoplasm) III progress to cancer?
What are the cervical cancer screening guidelines (as of 2012)?
- 1) start screening at 21, or 3 years after first sexual encounter whichever is last
- 2) screen every 2 years until 29
- 3) when 30+ with 3 consecutive negative paps and no RF's, pap every 3 years.
- 4) stop at age 65 or 70 if no abnormal results
Screen more frequently if immunosupressed, have had CIN or cervical ca, or were exposed to DES in utero
Describe the staging of cervical ca (4 stages)
- Stage I: confined to cervix
- Stage II: spread to upper vagina
- Stage III: spread to lower vagina or pelvic sidewall
- Stage IV: spread to other organs
4 important points on vulvar cancer
- 1) bimodal incidence, increasing in younger age
- 2) often associated with dermatoses in older women
- 3) delayed diagnosis not uncommen in women with chronic pruritis
- 4) biopsy suspicious lesions
Describe the diagnosis of vaginal cancer (4)
- DIAGNOSIS OF EXCLUSION
- -any new vaginal carcinoma developing at least 5 years after a diagnosis of cervical ca
- -no disease on the cervix
- -no disease on the vulva
- -no disease penetrating from the rectum
regular uterine contractions AND cervical change (dilation and effacement)
What kind of contractions are necessary for delivery? (4)
- -last for 60 seconds
- -reach 50-60 mmHg
- -occur every 2-3 minutes
- result in good progress
Describe the 4 P's of labour
- Power - contractions
- Passenger - presentation (head first), position ideal (occiput ant, R or L), fetal attitude (flexed), fetal size reasonable
- Passage - want a gynecoid (female-like passage, inlet diameter is the limiting factor)
What is the smallest diameter on the fetal head?
Describe the stages of labour
- 1st: onset of true labour until complete dilation
- -latent: effacement and early dilation
- -active: cervix is 3-4 cm about 1 cm/hour dilation and >1cm/hour fetal descent
- 2nd: full dilation until delivery of fetus
- 3rd: delivery of fetus until delivery of placenta
When do you do when the fetus is crowning?
Put your non-dominant hand on the head and hold in, and put your dominant hand on the perineum. Both of these reduce tearing.
Describe how to deliver a baby after crowning
- 1) push the baby's head to prevent tearing and put dominant hand on perineum
- 2) In this position, slowly deliver the head
- 3) allow for restitution and external rotation (head is not pointing sideways)
- 4) Deliver the anterior shoulder by pushing down and getting the anterior shoulder under the pubic symphysis.
- 5) push upward on an arc to the mother's tummy to deliver the posterior shoulder (This is what causes the most perineal damage!)
- 6) allow the rest of the baby to be delivered sponatenously with maternal effort
Why do we give oxytocin to women in the 3rd stage of labour?
Causes muscles to contract and limits PPH
What are the criteria for dystocia?
- 4+ hours of <0.5 cm/hr dilation
- 1+ hr with no descent while pushing.
Pearls for for dystocia (6)
- -delay admission until active labour
- -active management of labour (ROM, oxytocin, instrumental delivery)
- -the only "P" we can change is power
- -MAXIMIZE QUALITY OF CONTRACTIONS
6 indications for induction of labour
- Basically whenever the risk to mother or child is greater than the continuation of pregnancy.
- -Severe hypertension
- -Severe intrauterine growth restriction
- -significant maternal disease
- -post term or post-date pregnancy
- -intrauterine fetal demise
3 ways of inducing labour
- oxytocin infusions
What is the DDx for small for gestational age, with accurate dates.
- -Normal small fetus
- -Impaired growth because of aneuploidy, infection (symmetrical)
- -IUGR because of placental insuff (asymmetrical, the worst to miss)
4 variable that affect transport to the fetus (causing IUGR)
any of these can cause IUGR
What is the most sensitive predictor of impaired growth/placental insufficiency
RF's for IUGR (4)
- substance use
- past Hx
Describe the 4 types of twinning
Differentiate abruption and placenta previa with regards to bleeding, pain, uterine tone, and digital exam
abruption: bleeding, painful, tense uterus, only once previa is ruled out
PP: bleeding, occasionally painful, soft uterus, NO DIGITAL EXAM OR SEX
How does U/S do at diagnosing placenta previa and abruption
- placenta previa: awesome
- abruption: shitty
How do you treat antepartum hemorrhage (bleeding in pregnancy)?
2 large bore IV's, we often underestimate the amount of blood loss.
What are the D's and C of tort law?
- Deriliction of Duty
What is in a Reassuring (normal) Non-stress test?
2 accels, >15 bpm above baseline, lasting >15s in 20 mins. No decelerations
What is the definition of the peurperium?
from delivery of the baby to about 6 weeks post partum
What are the questions you should ask about during the first post partum visit (6 weeks)
- the 7 B's!
- -Bottom (perenium?)
- -Birth control
2 cardiac complications that can happen in the peurperium
- -Pre-eclampsia, eclampsia
- -Post Partum cardiomyopathy
What is something you should do at the 6/52 PP visit in a woman that wants to get pregnant again?
- Preconception planning for the next pregnancy!!
- -Tell her that she should have 2+ years between birth dates
- -optimize medical illnesses
- -Supplementation: PNV and folate
Why is the colostrum (first 5 days of milk) known as liquid gold?
- -rich source of Ig's
What are the benefits of breast feeding? (5)
- -GIT function improved
- -Improved host defence
- -reduced acute illnesses (even after cessation)
- -reduced rates of chronic diseases
- -improved cognitive development
Contraindications to breast feeding (3 categories)
Infectious causes: HIV (in developed nation), HSV or Hepatitis with open sores, varicella, TB
Lifestyle: drug or alcohol abuse
Meds: antimetabolites, anything radioactive
Key concept about meds and breastfeeding
meds are almost all safe for breastfeeding
What is one of the most common causes of post partum maternal death? Define it
- - >500 mls at vaginal delivery
- - > 1000 mls at C/S
- - Enough bleeding to cause hemodynamic instability
What are the 5 causes of PPH?
- The 5 T's
- Tone - Uterine atony (75%)
- Trauma - lacerations of genital tract
- Tissue - retained placental tissue
- Thrombin - Coagulation defects, DIC, abruption
- Traction - Uterine inversion
What are 4 things you can do in the third stage of labour to prevent PPH?
- 1) oxytocin after delivery of anterior shoulder
- 2) early cord clamping
- 3) gentle cord traction to deliver the placenta
- 4) ensure uterus is well contracted
Definition of PP depression
depressed mood most of the day, nearly every day, for at least two weeks
when are women most likely to develop psychosis? Is this a big deal?
Develop psychosis after childbirth
A MEDICAL EMERGENCY!
What are three PP RF's for suicide?
- -after a stillbirth
- -pregnant adolescents
- -in women with prior hospitalization with a psychiatric dx
What is a key concept for the treatment of medical conditions in pregnancy?
The right treatment when you are not pregnant is almost always the right treatment when you are pregnant!
Should you image in pregnancy?
Yes. If you need it, the radiation exposure is less than dangerous levels. DO WHAT YOU HAVE TO DO TO MAKE THE DIAGNOSIS
Red Flags of headache in pregnancy: (6)
- -sudden onset or significant change
- -Neuro S/S
- -New headache if patients 40+
- -Meningeal signs
- -recent trauma
- -Hx of HTN or endocrine disease
Describe the important facts on these medical conditions in pregnancy:
-Cardio conditions (4 points)
-Resp conditions (2)
- -Cardio: Stenotic lesions get worse, regurge gets better (lower BP), pulm HTN means you shouldnt get pregnant, NYHA I-II do fine
- -Resp: optimize asthma control, think of pregnancy induced causes of SOB
Describe the important facts on these medical conditions in pregnancy:
-Heme conditions (2 points)
-Neuro conditions (1)
- -Heme: anemia and thrombocytopenia are common in preg, BUT make sure to think of HELLP, preeclampsia, ITP, and TTP
- -Neuro: Seizure control is important, we want monotherapy, but dont play with meds
Describe the important facts on these medical conditions in pregnancy:
-Gastro conditions (2 points)
-Renal conditions (2)
- -Gastro: if IBD in remission before preg, it will do fine; there are liver disorders specific to preg
- -Renal: normal to have some proteinuria; chronic renal disease will affect pregnancy outcome
Describe the important facts on these medical conditions in pregnancy:
-Rheum conditions (2 points)
-Thrombotic conditions (2)
- -Rheum: Lupus flare can be confused with pre-eclampsia; risk of neonatal heart block with positive SSA and SSB Abs
- -Thrombotic: preg is a prothrombic state; always keep VTE in the back of your mind