First lasts until 12 weeks but is also defined as up to 14 weeks GA

Second lasts from 12 to 24 weeks (14-28 weeks GA)

Third lasts from 24 weeks to delivery (28 weeks GA)

What is the major cause of spontaneous abortions in the 1st trimester?

What about in the 2nd trimester?

1st trimester - chromosomal abn

2nd trimester - uterine or environmental origins

What might be your NSIM be of a pt who has reccurent spontaneous abortions in the 1st trimester?

What if you have a pt who's having it in 2nd trimester?

1st trimester - do a chromosomal analysis of the parents

2nd trimester - do a hysterosalpingogram to r/o structural abn like bi/uni-cornate uterus, septate uterus

What is the threshold of radiation exposure that a pregnant woman would need to cause serious fetal damage?

What organ systems are most effected in 1st trimester? In later pregnancy?

10 rads

An X-ray of the abd/pelvis is less than 1 rad

The heart and limbs are most affected in 1st trimester. In later pregnancy, the brain is more sensitive

Is birth weight reduced in pregnant women who exercise?

Is there an increase in growth retardation of conceptus?

What's the rec'd amount of exercise for prgenant women?

Yes, BW is less

No, GR does not occur

They should exercise 30 mins daily at a moderate intensity, one that allows her to carry on a conversation while exercising

Gestational age of a fetus is the number of weeks and days measured from ________.

Devepmental age (aka conceptional age or embryonic age) is the number of weeks and days since ________.

last menstrual period (LMP)

fertilization

GA is usually 2 weeks more than DA

Take the date of the woman's last menstrual period (LMP), subtract 3 months and add 7 days.

If LMP is unknown, U/S can be used to calculate EDD. However, be aware that dating pregnancy via U/S becomes less accurate as the pregnancy progresses,so the earlier the better.

Ex: LMP was 4/15/02, EDD is 1/22/03

When can you auscultate fetal heart via:

1) Non-electronic fetoscopy

2) Doppler U/S

1) 20 weeks

2) 10 weeks

23 - 24 weeks, depending on the institution

How does pregnancy affect:

1) CO

2) Systemic vascular resistance

1) CO increases, first by increase in stroke volume, then by increase in HR as SV slowly returns to pre-pregnancy levels in 3rd trimester

2) SVR decreases as a result of elevated progesterone (progesterone causes vascular SM relaxation)

How does pregnancy affect:

1) Tidal Volume

2) Expiratory Reserve Volume

3) Minute Ventilation

1) V_t increases

2) ERV decreases to make way for greater V_t

3) Minute ventilation increases due to increased V_t with a constant respiratory rate. This leads to increased pO2 and decreased pCO2 levels

What acid base status to pregnant women typically maintain?

Why does this occur?

Repiratory alkylosis - this leads to increased CO2 gradient between mom and fetus which facilitates O2 delivery to fetus

This resp alk is caused by increased Tidal Volume (which increases Minute Ventilation), which is a result of progesterone

What causes the n/v seen in pregnant women?

How can it be treated?

Elevation in estrogen, progesterone, and hCG. It may also be due to hypoglycemia.

Can be treated with frequent snacking

What is hyperemesis gravidarium (2 criteria)?

What must you r/o when a women gets hyperemesis gravidarium?

-HEG is severe form of morning sickness in which women lose >5% of pre-pregnancy weight AND go into ketosis (from starvation state)

-May also see mildly elevated AST, ALT, lipase, and amylase

You need to r/o a molar pregnancy via U/S

-Recall, that a molar pregnancy can also cause HTN in early pregnancy!

How does pregnancy affect:

1) Lower esophageal sphincter tone

2) Large bowel motility

1) LES tone is decreased, leading to ptyalism (spitting during pregnancy)

2) Large bowel motility is decreased, leading to increased water reabsorption and thus constipation

How does pregnancy affect:

1) GFR

2) RAAS System

3) Sodium Level

1) GFR increases by 50% in pregnancy

   -Side Note: Glycosuria is nml in pregnancy   b/c of the increased GFR but relative impairment of tubular reabsorption

2) RAAS system is upregulated, thus increasing aldosterone levels, thus leading to increased sodium reabsorption

3) Na levels remain same because although there's increased sodium reabsorption, there's more filtered through the glomerulus (b/c GFR is higher)

How does pregnancy affect:

1) Plasma volume

2) Hematocrit

3) WBC Count

1) Plasma volume increases by 50%

2) RBC Volume increases by 20-30%, which leads to a dilutional decrease in Hct (dilutional anemia)

3) WBC increases to around 10.5, and during labor it shoots up to 20

Fibrinogen and Factors VII - X are increased

Anti-thrombin III levels are decreased

hPL is the "growth hormone of pregnancy"--it acts as an insulin antagonist in mommy. This not only provides high glucose for the baby to grow, but also increases the insulin and protein synthesis level

It also causes lypolysis with concomitant increase in circulating free fatty acids.

Iron, folate, caclium.

Their protein intake should also increase

-Date and outcome of previous pregnancies (spontaneous abortion [SAB], therapeutic abortion [TAB], ectopic pregnancy, term delivery)

-Mode of delivery

-Length of time in labor and second stage

-Birth weight

-Any complications

-Present pregnancy

-Last menstrual period

-Symptoms during pregnancy

-Obstetric history (reviewed later)

-Pap smear (unless one was done in <6 months)

-Cultures for gonorrhea and chlamydia

-Bimanual exam, making sure size of uterus is consistent w/ gestational age from LMP (if LMP is unsure or inconsisent with exam, U/S dating is indicated)

Remember, accurating dating is crucial for all subsequent obstetrical evaluations and interventions

Elevations in maternal serum AFP is concerning for what?

Low maternal serum AFP is concerning for what?

High - Neural Tube defects

Low - Down's Syndrme (you may also see increased beta-hCG) and some aneuploidies

What is the "triple screen?"

What is the "quad screen?"

Triple - beta-hCG, estriol, AFP

Quad - those listed above + inhibin A

What are Braxton Hicks contractions?

How can you differentiate this from preterm labor?

How can you prevent BHC from occuring?

BHC, aka false labor or practice contractions, are sporadic uterine contractions that sometimes start around six weeks into a pregnancy. However, they are not usually felt until the 2nd or 3rd trimester.

Woman may complain of infrequent and irregular cramping.

You can prevent BHC from occuring by drinking 10-14 glasses of water per day. Dehydration may cause these contractions.

It consist of four distinct actions, each helping to determine the position of the fetus. The maneuvers are important because they help determine the position and presentation of the fetus, which in conjunction with correct assessment of the shape of the maternal pelvis can indicate whether the delivery is going to be complicated, or whether a C-section is necessary

It's done beyond 32-34 weeks

What is the glucose loading test testing?

How does it work?

What do you do if it's positive?

It a sceening tests for gestational DM

You give the pt 50 g of oral glucose, and check serum glucose 1 hr later. If it's >140mg/dL, it's positive.

If positive, you confirm it with a glucose tolerance test, which is diagnostic of gestational DM

A woman comes to you in her 3rd trimester complaining of back pain.

What is it usually caused by?

How do you manage it?

Caused by shift in center of gravity putting increased strain on lower back.

-Recommend mild exercise and stretching, as they can both cause release of endophins and reduce amount of back pain.

-Gentle massage, heating pads, and acetaminophen can also be used.

-For severe lower back pain, mm relaxants or occasionally narcotics can be used

Elevation of LE above level of heart. This may be due to increased hydrostatic pressure in LE venous system due to compression of IVC by baby.

You should also advise her to sleep on her side to decrease IVC compression.

A pregnant woman comes to you complaining of symptoms c/w GERD.

NSIM?

Pt should be started on antacids, advised to eat multiple small meals per day and avoid lying down w/in an hour of eating.

If this continues, perscribe H2 blockers or PPIs

A pregnant woman at the end of her 2nd trimester presents with pain in the adnexa/lower abdomen.

What might this be due to?

How do you manage it?

Due to rapid expansion of uterus and stretching of ligamentous attachements, such as round ligament

Pain is self-limiting but may be relieved by warm compresses or acetaminophen

Percutaneous umbilical blood sampling - which involves placing a needle transabdominally into uterus and phlebotomizing the umbilical cord.

This is used in general for obtaining fetal Hct. Can also be used for fetal transfusion, karytype analysis, and assessment of fetal platelet count in alloimmune thrombocytopenia

beta-hCG

In ectopic pregnency, it is classically low for gestational age because ectopics have poorly implanted placenta with less blood supply than in the endometrium. Thus the level of beta-hCG doesn't double every 48 hrs like in a normal pregnancy.

Define the following terms:

1) Abortus

2) Complete abortion

3) Incomplete abortion

4) Inevitable abortion

5) Threatened abortion

6) Missed abortion

1) Abortus - fetus lost before 20 weeks gestation, < 500 g, or < 25 cm

2) Complete abortion - complete expulsion of all POC before 20 weeks gestation

3) Incomplete abortion - partial expulsion of some but not all POC before 20 weeks gestation

4) Inevitable abortion - loss of amniotic fluid but no expulsion of products; vaginal bleeding and dilation of cervix such that a viable pregnancy is unlikely; U/S would show ruptured sac and no heart beat

5) Threatened abortion - ANY vaginal bleeding before 20 weeks, w/o dilation of cervix or expulsion of POC (nml pregnancy w/ bleeding)

6) Missed abortion - death of embryo or fetus before 20 weeks w/ complete retention of POC

A woman has an incomplete abortion.

What's the management?

Incomplete abortion - partial expulsion of some but not all POC before 20 weeks gestation

Management - it can be allowed to finish on its own, but can be taken to completion w/ either D&C or administration of prostaglandins (e.g. misoprostol) to induce cervical dilation and uterine contractions

A woman has a threatened abortion.

How do you manage it?

What are these pts at risk for?

Threatened abortion - any vaginal bleeding before 20 weeks, w/o dilation of cervix or expulsion of POC (nml pregnancy w/ bleeding)

Management - pt should be followed for continued bleeding. Often bleeding will resolve, however these pts are at higher risk for preterm labor (PTL) and preterm premature rupture of membranes (PPROM).

A pregnant woman who is Rh (-) experiences some vaginal bleeding.

Management?

RhoGAM should be given to all Rh (-) women who have vaginal bleeding during pregnancy

Also, any tissue that hte pt may have passed at home and at the hospital should be sent to pathology to make sure POC passed and for chromosome analysis.

When do you do a D&C vs a D&E for the management of an incomplete or missed abortion?

D&C is done in the first trimester (0-12 weeks)

D&E is done in the second trimester (12-24 weeks)

Note: between 16-24 weeks, either a D&E may be performed or labor can be induced with high dose of oxytocin and prostaglandins

A 36 y/o G1P0 at 35 wga pw malaise, anorexia, n/v for several days. She's lost several pounds in the past week b/c of loss of apetite. She denies HA or visual changes. She's no no meds except prenatal vitamins. On exam she afebrile, BP 110/70, is mildly jaundice and confused. She has no edema. Fetal heart monitor shows FHT at 160, non-reactive, w/ good variablility. Labs show WBC 25,000, Hct 42, platelets 50,000, elevated LFTs, glucose 43, low fibrinogen, elevated PT/PTT, and elevated ammonia level.

Dx?                      Which women are more prone to this?

Pathophys?

Prognosis?

Dx - acute fatty liver of pregnancy

Pathophys - inherited defects in mitochondrial beta-oxidation of FA or LCAD deficiency in mom and baby predisposes to both of them to build up of FA in liver (b/c they can't break them down properly)

Prognosis - usually fatal to mom and baby

Notes:

-Unlike in HELLP, these pts have nml BP

-Usually manifests in late pregnancy

-MC in nulliparous women

-LFTs are usually elevated > 500

A pregnant woman comes to you with lower abdominal cramping at the beginning of her 3rd trimester.

How do you distinguish between preterm labor and incompetent cervix?

What's the management for incompetent cervix?

Pts who present with mild cramping and have advacing cervical dilation on serial exams and/or an amniotic sac bulging through cervix are more likely to have an incompetent cervix. In such cases the cramping is being instigated by cervical dilation and exposed membranes.

Tx - cerclage (suture placed around cervix)

In the case of PTL, the cramping is due to uterine contractions causing cervical dilation.

1) Karyotype of parents and POC

2) Exam of maternal anatomy. First with hysterosalpingogram; if this is non-diagnostic, proceed to hysteroscopic or laproscopic exam

3) Screen for: hypothyroidism, DM, APA, hypercoagulability, and SLE

4) Obtain serum progesterone levels during luteal phase

5) Culture the cervix, vagina, and endometrium to r/o infection

How do you treat a pt with anti-phospholipid Ab who wants to get pregnant but is having difficulty with spontaneous abortions?

How do you treat a pt with thrombophilia who wants to get pregnant but is having difficulty with spontaneous abortions?

Chorioamniontitis, non-reassuring fetal testing, and significant placental abruption.

Usually if none of these 3 occur, then the mom is given a tocolytic to prevent labor, and is also given betamethasone to hasten fetal lung maturity before birth.

Hydrate her!

Remember, dehydrated people have higher levels of serum ADH, and ADH differs from oxytocin by only one amino acid, thus ADH can bind to oxytocin receptors and lead to contractions.

A pregnant woman at 36 weeks is undergoing preterm labor. You give her tocolytic therapy and she starts having headaches, fatigue, flushing, and diplopia.

-What drug was given?

-What if she had headaches, anxiety, and tachycardia?

-She could have been given Magnesium Sulfate or a Calcium Channel Blocker

-Those SE are more c/w Beta-2 agonist therapy (terbutaline or ritodrine)

What are the 5 classes of drugs that can be used for tocolytic therapy?

Give examples of each.

Name some complications of each.

Beta-2 agonisits (terbutaline and ritodrine) - tachycardia, HA, anxiety

MgSO4 - HA, fatigue, flushing, diplopia

Ca Channel Blockers (nifedipine) - same as above

Prostaglandin Inhibitors (indomethicin) - fetal complications suchas premature constriction of ductus arteriosus, pulm HTN, and oligohydramnios 2ndary to fetal renal failure

Oxytocin Antagonist (atosiban) - no significant SE

A 45 y/o woman comes in b/c of worsening lower abd pain, nocturia, urinary urgency and frequency (relieved w/ urination) over the past few months. She also complains of recent dyspareunia and has stopped having intercourse b/c of it. She denies f/c. Exam is remarkable for lower abd pain w/o rebound/guarding, and extreme pain on palpation of anterior vaginal wall, no cervical motion tenderness. UA is negative.

Dx?

Interstitial cystitis

-Remember the classic triad: urgency, frequnecy, and chronic pelvic pain (in absence of another disease that could cause these Sx)

-Pain is typically exacerbated by sex, bladder filling, exercise, spicy food, and some beverages

-Pain is typically relieved by voiding

-Cystoscopy will typically show submucosal ulcerations and petechiae

What are the current recommendations for the management of preterm premature rupture of membranes?

Give mommy corticosteroids to facilitate lung development before birth.

Recall PPROM means the membrane ruptured before 37 week and before contractions

What is the most common indication for C-section?

What's it usually caused by?

Failure to progress

It's usually caused by cephalopelvic disproportion. Remember the 3 "Ps" - pelvis, passenger, power.

What do you do with the following BPP profiles?

A) 8-10

B) 6 w/o oligohydramnios

C) 6 w/ oligohydramnios

D) 0-4

A) No intervention required

B) If mature lungs -> deliver; if immature lungs repeat w/in 24 hrs

C) Deliver

D) Deliver

Pregnant woman comes in with decreased featl movements. Fetal heart tones are heard by Doppler, and non-stress test is reactive.

NSIM?

-Repeat the non-stress test weekly

-Had the NST been non-reactive, then vibroacoustic stimulation is indicated, if that doesn't work then BPP is indicated

What must you have a high suspicion for when a woman has hyperemesis gravidarium?

What's the NSIM?

Gestational trophoblastic disease (hydatidiform mole or choriocarcinoma).

Check beta-hCG levels as a screen. If they're high, then you do an U/S to confirm GTD.

-Enlarged Uterus

-Hyperemesis

-Markedly elevated beta-hCG

First is dietery modification

Second is subQ insulin (it does not cross the placenta)

Chlorpropamide and tolbutamide (sulfonlyureas)  cross the placenta and can cause fetal hyperinsulinism, macrosomia, and prolonged neonatal hypoglycemia

What kinds of abnormalities do you see in an infant of a DM mother as far as:

1) Size

2) Glycemic level

3) Calcium level

4) Hematocrit

1) Macrosomia due to the growth effect of insulin in all tissues of baby's body

2) Hypoglycemia (due to hyperinsulinemia)

3) Hypocalcemia due to PTH suppression

4) Polycythemia due to fetal hypoxia that occurs in the face of increased basal metabolic rate induced hyperglycemia in utero. Thi results in hyperviscosity

Complications - cord prolapse, entrapment of fetal head, estimated fetal weight btwn 2,000 - 3,800g

Contraindications - nulliparity, incomplete breech presentation, estimated fetal wight >3,800g. In these cases, do a C-section

What is prolonged fetal HR deceleration defined by?

What is fetal bradycardia defined by?

What might these be caused by?

-HR deceleration - anytime HR falls below 100-110 for longer than 2 mins

-Brady - longer than 10 mins

-These can be signs of complications such as: placental abruption, cord prolapse, tetanic contraction, uterine rupture, PE, amniotic fluid embolus, and seizure

1) Pre-uterine - any event leading to maternal hypotension or hypoxia, such as seizure, amniotic fluid embolus, PE, MI, resp failure

2) Uteroplacental - placental abruption, infarction, hemorrhaging previa, uterine hyperstimulation

3) Postplacental - cord prolapse, cord compression, rupture of a fetal vessel

What is the management for prolonged decelerated fetal HR?

What if maternal hypotension ensues?

1) Place mom in left or right lateral decubitus position to resolve a decelerated FHR due to compression of IVC

2) O2 by facemask

2) If maternal hypotension ensues, give IVF and ephedrine

A pregnant woman 34 weeks in comes to you with sudden onset of abdominal pain. She said all of a sudden she felt a "popping sensation," followed by abdominal pain. Examination shows palpable fetus high in abdomen, vaginal bleeding, and FHR decelerations.

Dx?

NSIM?

Dx - Uterine Rupture

NSIM - Immediate C-section and Ex-lap

It's limited to 24-34 weeks. Also, it requires 24-48 hrs to have maximum benefit on fetal lung maturity.

Corticosteroid treatment has NOT proven to have a benefit after 34 weeks gestation

An asymptomatic pregnant woman comes to you with bacturia.

Do you treat?

Yes, treat with nitrofurantoin, amoxicillin, or a 1st gen cephalosporin for 1 week

If this is left untreated, it can lead to cystitis, acute pyelonephritis, and preterm birth and increased perinatal mortality!

GYN surgeries like cervical loop electrosurgical excision(LEEP) procedure or cone biopsy of cervix.

Also, prior obstetrical trauma, multiple gestation, Mullerian anomalies, and Hx of preterm birth or a 2nd trimester pregnancy loss

A pregnant woman has several risk facotrs for cervical insufficiency.

How do you further evaluate this woman?

Transvaginal U/S is the "gold standard" for evaluating cervix for incompetence

It's used to look for presence of funneling of cervix or shortening of cervical length

Recall, cervical length should be more than 25 mm at 24 weeks

In a woman with PCOS, how can you treat:

1) Infertility

2) Obsesity/DM

3) Hirsutism

1) Infertility - clomiphene, which is a SERM which partially agonizes ER on hypothalamus which prevents normal feedback inhibition. This leads to increased GnRH and FSH release. Metformin used in conjunction with clomiphene has shown to improve ovulation

2) Obesity/DM - metformin

3) Hirsutism - spironolactone, which not only blocks androgen receptors, but blocks production of androgens

What is the reason for the anovulatory cycles in  a girl who has just gone through menarche?

When else do you see anovulatory cycles?

B/c young females undergoing menarche have an immature HPA axis that may fail to produce gonadotropins (LH and FSH) in proper quantities and ratios to induce ovulation

You also see anovulation in older women undergoing menopause

What are some causes of galactorrhea that is bilateral and guaiac negative?

How do you work such a pt up (tests)?

Prolactinoma, hypothyroidism, overstimulation of nipple, OCPs, and medications which lower dopamine levels

R/O pregnancy w/ beta-hCG, and measure serum prolactin and TSH levels. Possibly even MRI of brain to r/o prolactinoma

24-28 weeks. If they're high risk, then do it earlier.

Note:

-If woman is Rh-, then you check if she's alloimmunized at first prenatal visit. If not -> give Rhogam at 28 wga and w/in 72 hrs PP; if yes, monitor fetus for hydrops.

-GBS screen is done at 35-37 wga. If positive -> give intrapartum AbX

What are 3 causes of symmetric IUGR?

What are 6 causes of asymmetric IUGR?

Which one is caused by insult to fetus before 28 weeks?

What is the best measurement of symmetry vs asymmetry?

Symmetric - chromosomal abn, congenital abn, TORCH infections. This one results from an insult to the fetus before 28 weeks

Asymmetric - maternal HTN, Pre-ecclampsia, Uterine anomalies, anti-phospholipid syndrome, maternal collagen vascular disease, cigarette smoking

Best measure = head circumference to abdomen circumference ratio

What is the main pathogenesis of symmetric IUGR?

Asymmetric IUGR?

Symmetric - due to fetal factors such as chromosomal abn, congenital infections, and congenital anomalies

Asymmetric - results from fetal adaptation to non-ideal maternal factors. Caused by fetal redistribution of blood flow to vital abd viscera

Delivery is defnitive Tx for women beyond  34 wga, when lungs are mature, or w/ presence of signs of fetal or maternal deterioration

For women < 35 wga, when lungs aren't mature, management depends on state of both mom and fetus. Any deterioration requires stabilization and delivery. If mom and baby are both stable, then dexamethazone Tx should be considered and delivery performed when pregnancy reaches 34 wga.

How does Chorioamnionitis present?

When should you suspect it?

What's the Tx?

-Mommy fever (100.4+) + any one of the following: mommy tachycardia, mommy leukocytosis (>15,000), fetal tachycardia ( >160),  uterine tenderness, foul smelling amniotic fluid

-Suspect it in any woman with preterm premature rupture of membranes (PPROM) = rupture of amniotic sac before 37 weeks gestation but with the onset of labor

NSIM: IV broad spectrum AbX (as chorioamnionitis is frequently polymicrobial) and immediate delivery expedited with oxytocin

28 y/o woman w/ PMHx of HTN and DMII at 35 wga p/w sudden onset of abn uterine contractions, abdominal and back pain. Exam shows suprapubic pain, fetal tachycardia.

Dx?

Abrupto Placenta

Vagnial bleeding is also a common presenting sign, but it is not always present.

IV broad spectrum AbX (b/c chorioamnionitis is frequently polymicrobial) and IMMEDIATE dilvery (expidited with oxytocin).

The gestational age of pregnancy does not matter b/c the amniotic sac has ruptured

What are 3 diagnostic tests for determining if fluid collected is amniotic fluid?

What if all those test are equivocal?

1) Pooling - observation of amniotic fluid pooling in vagina

2) Nitralizine - nitralizine paper turns blue w/ addn'l of amniotic fluid

3) Ferning - amniotic fluid sample crystalizes under microscopy when estrogen present

If all these tests are equivocal, U/S exam can determine quantity of fluid

A 24 y/o G1P0 w/ no PMHx at 35 wga p/w with non-reassuring fetal heart tones. She is given high dose oxytocin to expedite delivery. After delivery, she suffers a generalized tonic clonic seizure.

Dx?

Maternal - asthma, glaucoma

Obstetric - >1 prior C-section, non-ressuring fetal testing (b/c uterine contraction leads to decreased blood flow to baby)

Stress test.

If they can, and the pregancy is term and cephalic, then VD is indicated

If they cannot, then C-section is usually indicated

What is an amniotomy?

What must you avoid doing when performing an amniotomy?

It's manually rupturing the amniotic sac to induce labor.

Do NOT elevate fetal head from the pelvis to release more amniotic fluid b/c this may lead to prolapse of umbilical cord beyond fetal head

1) Early - begins and ends @ same time as contractions. Result from increased vagal tone secondary to head compression during contraction

2) Variable - occur @ any time and drop precipitously. Result from umbilical cord compression

3) Late - begins @ peak of contraction. Result from utero-placental insufficiency. Can progress to bradycardia, especially during contractions [bad prognosis]

1) Maternal heptatitis

2) Maternal HIV

3) Fetal thrombocytopenia

What are the 3 Stages of Labor?

Stage 1 - onset of labor -> complete cervical dilation and effacement. Has 2 phases: Latent Phase (onset of labor to 4 cm dilation, slow cervical change), Active Phase (4 cm - 9 cm dilation, rate of cervical change increase)

Stages 2 - completely dilated cervix -> delivery of baby

Stage 3 - delivery of baby -> delivery of placenta

What stage of labor is most a/w fetal decelerations?

Which decelerations are reassuring and which are not?

What's the Tx for non-reassuring decelerations?

Stage 2

Reassuring ones are repetitive early and variable decelerations. They resolve quickly aftereach contraction and there's no loss of variablility

Non-reassuring signs are repetitive late decelerations, bradycardias, loss of variablility.

Management: Give O2 via facemask to mommy, turn her on L-side to minimize IVC compression. If this doesn't resolve it, fetal position and station assessed to see if VD can be preformed--if fetus is above "O" station -> C-section

What are 2 complications of vacuum delivery?

What is a complication of forcep use?

Cephalohematoma and shoulder dystocia

Rarely sub-galeal hematoma

Forceps - facial nerve palsy

1) Cord lengthening

2) Gush of blood

3) Uterine fundal rebound

What is a retained placenta defined as?

What do you do in such cases?

Placenta that doesn't deliver w/in 30 mins

Clinician can manually remove it by placing hand w/in uterus. If this doesn't work, then curettage can be performed

What are the 3 degrees of birthing lacerations defined by?

Tx for each?

What must always be done on these pts?

Stage I - involves mucosa or skin -> interrupted suture

Stage II - extends to perineal body but NOT anal sphincter -> repaired in layers

Stage III - extends to or through anal sphincter -> anal portion repaired w/ interrupted suture, the rest is repaired like in Stage II

Stage IV - anal mucosa itself entered

Remember, a rectal exam should always be done on these pts

What is the MCC of antenatal hemorrhage?

What is the most essential test to Dxing cause of bleeding?

Placenta previa and abrupto placenta

Pelvic U/S is essential in Dxing cause of bleeding b/c pelvic exam carries risk of exacerbaing beleding before placenta previa can be r/o

What is the MCC of anesthetic related eath in OB?

How can it be avoided?

Aspriration Pneumonitis

Reducing both volume and acidity of gastric contents can help avoid this.

-fetal size (does mom have gDM?)

-maternal BMI; obese women have less success

-Hx of previous successful NSVD after C-section

-Spontaneous contractions vs pitocin induced contractions (spontaneous has better prognosis)

-loss of station

-tetanic contractions

-fetal decelerations

-bleeding

What are common indications for induction of labor?

How do you assess whether induction will be successful?

Indications - post-term pregnancy (w/ favorable cervix), IUGR, PROM, IUFD, twin pregnancy beyond 38 wga, health risks to mom (ecclampsia)

-The cephalopelvic proportion will tell you whether labor will be successful.

-Bishop score is measure of likelihood of vaginal delivery - score of >8 means vaginal delivery likely to happen; score of <5 labor unlikely to start w/o induction

A 40 y/o G1P0 comes in at 37 wga complaining of a rash on her abdomen. It started on her abdomen and spread down to her thighs, and is becoming increasingly pruritic. She has no Hx of skin disorders. She denies fever and malaise. Exam shows abdomen covered with red papules and plaques w/o excoriations or bullae. Face, arms, and legs are uneffected.

Dx?

Pruritic urticarial papules and plaques of pregnancy (PUPPP) - MC dermatologic cond'n of pregnancy!

-more common in nulliparous women and occurs in 2nd and 3rd trimester

-characterized by erethematous papules and plaques that are intensely pruritic and appear first on abdomen -> spread to buttocks, thighs, and extremities but not face

Note: Prurigo gestationis is a very rare dermatosis of pregnancy characterized by small, pruritic trunkal -> extremities excoriations btwn 25-30 wga. Tx is oral antihistamines and topical corticosteroids 

A pt w/ purulent vaginal discharge receives a positive nucleic amplification test for chlamydial infection, but it's negative for gonorrhea.

Tx?

This test is 99% specific for chlamydial infection, thus they should be treated with azithromycin or doxycyclin

The test is 98-100% sensitive for gonorrhea, so given the negative test, this pt should NOT be treated for gonorrhea (with ceftriaxone)

What's vaginismus caused by?

What's the underlying cause?

Tx?

-Caused by involuntary contraction of perineal musculature.

-Underlying cause is psychological (a previous sexual experience that has left them psychologically scared, strict religious beliefs about sex)

-Tx - Kegel exercises and gradual dilation of vaginal muscles. If this doesn't work, you can refer to a sexual therapist

25 y/o female at 28 wga comes in b/c of preterm labor and rupture of membranes. U/S shows bilateral renal agenesis.

NSIM?

AFP can be used to ____ fetal anomalies.

High levels are a/w what 4 things?

Low levels are a/w what 3 things?

Screen

High - NT defects, abd wall defects, multiple gestation, inaccurate gestational age

Low - Downs syndrome, Edwards Syndrome, and inaccurate gestational age

A pregnant woman comes in with decreased serum alpha-fetoprotein.

NSIM?

Do an U/S to r/o innacurate dates as cause of low alpha-fetoprotein.

After this is done, THEN you do amniocentesis

When is chorionic villus sampling indicated?

What kinds of studies can be done using the sample acquired?

When is Cordocentesis indicated?

-Chorionic villus sampling indicated for early screeing in women with known genetic diseases. Performed between 10-12 weeks

-Sampled placental tissue may be analyzed for fetal chromosomal abn, biochemical, or DNA-based studies. CVS cannot detect anatomic defects like neural tube defects, abd wall defects (omphalocele, gastroschesis), etc

-Cordocentesis (aka Percutaneous Umbilical Blood Sampling) is used for rapid karyotype analysis, or when fetal blood dyscrasias (Rh disease, etc) are suspected, or when mosaicism is suspected by CVS or amniocentesis

What criteria must a woman meet to be Dx'd with PCOS?

What test is rec'd for work-up of PCOS

Rotterdam Criteria:

1) Clinical (i.e. hirsutism, acne, male pattern baldness or androgenic allopecia) and/or biochemical (i.e. high serum androgen concentrations) hyperandrogenism

2) Amenorrhea or oligomenorrhea

3) Pelvic U/S w/ cystic ovaries; small cysts are noted around ovaries in a classic "string of pearls" appearance

-Oral Glucose Tolerance Test

A pt with purulent vaginal discharge receives a Gram stain positive for PMNs filled with Gram (-) diplococci.

Tx?

Ceftriaxone and azithromycin

Since Gram Stain can't ID chlamydia and coinfection is common, simultaneous Tx to eradicate both organisms is indicated

Pt comes in with high grade squamous intra-epithelial lesions (HSIL).

NSIM?

What's the goal of this management?

Any woman with cytologic evidence of HSIL should be given a colposcopy and biopsy. The goal here is to r/o invasive cervical cancer

If the biopsy is negative, then repeat colposcopy and biopsy should be done at 6-8 weeks after delivery

What is a LEEP procedure?

When is it indicated?

LEEP = Loop Electrosurgical Excision Procedure

It's indicated for all pts with exception of pregnant women and adolesecents with HSIL on PAP smear

Excsion in pregnant women is only consideredif the lesion is suggestive of invasive cancer on colposcopy

A 37 y/o G3P2 comes in at 35 wga b/c of vaginal bleeding w/o uterine contractions. Prenatal testing has shown pregnancy to be progressing normally. She is stable. Fetal heart monitoring is reassuring. Exam shows bright red blood per vagina.

Dx?

RFs?

Dx - Placenta previa (abn insertion of placenta in a way that obstructs internal os). Presents as painless vaginal bleeding

RFs - multiparity, advanced maternal age, prior C-sections, smoking, multiple gestations

Depends on status of mom and fetus, and gestational age of fetus:

1) If Term and mom stable -> schedule C-section continue to monitor mom and baby closely

2) If NOT term and mom stable -> closely monitor mom and baby until 36 wga, then do amniocentesis to assess fetal lung maturity. IF mature -> C-section; if not mature -> steroids

3) If extended or massive bleeding -> emergent C-section REGARDLESS OF GESTATIONAL AGE

35 y/o G3P2 at 35 wga comes in b/c of painles vaginal bleeding w/o uterine contractions. Mom is in no pain, and her vitals are wnl and stable. Fetal heart tracings show rapid deterioration.

Dx?

Vasa previa - where fetal BVs cross fetal membranes in lower segment of uterus btwn fetus and internal os.

P/W painless vaginal bleeding but rapid deterioration of fetal heart tracing as the hemorrhage is fetal in origin

What's the MCC of mucopurulent cervicitis?

What may predispse to this other than multiple partners and unprotected sex?

Chlamydia trachomatis

OCP use may preferentially predispose to colonization w/ Chlamydia

Gonorrhea is a less common cause of mucopurulent cervicitis

A 45 y/o woman pw/ night sweats, flushing, and insomnia.

What's the DDx?

What do you check in this woman?

DDx: Menopause vs. Hyperthyroidism

Menopause - irregular/absent menses, heat intolerance, flushing, insomina, headaches, night sweats

Hyperthyroidism - heat intolerance, night sweats, irregular menses, tremor, WL, hyperreflexia, diarrhea, palpitations

Check FSH and TSH levels

What 4 criteria are required for Dxing Bacterial Vaginosis?

Tx?

Amsel Criteria

1) Thin, gray-white vaginal discharge

2) Vaginal pH > 4.5

3) Positive "whiff" test upon add'n of KOH to vaginal discharge

4) "Clue cells" (vaginal epithelial cells w/ adherent coccobacilli) on wet mount

Tx: Metronidazol (flagyl)

Cause: A change in normal bacterial flora including the reduction of Lactobacilli, which may be due to the use of antibiotics or pH imbalance, allows more resistant bacteria to gain a foothold and multiply

Who is more at risk in Intrahepatic cholestasis of pregnancy, mom or baby?

What's the preferred Tx of ICP?

Baby - can result in fetal prematurity, meconium stained amniotic fluid, and intrauterine demise

Tx - early delivery once fetal lung maturity is established; in the interim, you can use ursodeoxycholic acid

When is Excisional diagnostic/treatment w/ Cold Knife Conization or Loop electrosurgical excision procedure (LEEP) indicated?

Qid 4755

Cervical lesions highly suspcious of invasive lesions (HSIL, CIN II, and CIN III)

Persistent documented CIN for 24 months confirmed by colposcopies

Cone Knife Conization and LEEP are used to both treat the CIN and give histologic evaluation of the entire cervical transformation zone

A woman comes in w/ vulvar lesions that turn white when trichloracetic acid is applied.

Dx?

Tx?

Condyloma acuminata (HPV)

Tx depends on size:

-Small lesions - treated in office w/ trichloracetic acid or podophyllin

-Large lesions - treated with excision or fulguration (elecric current)

Regardless of Tx, recurrence rate is high

Describe the lesions of lichen planus.

Lichen sclerosis.

Planus - hyperkeratotic, erosive, or papulosquamous in appearance. Often pruritic, sore, and can cause local vaginal discharge (if located around genitals)

Sclerosis - white, thin, and wrinkled skin. Typically affects post-menopausal females, and causes pruritis

What are the features of fetal hydantoin syndrome?

What causes it?

midfacial hypoplasia, microcephaly, cleft lip and palate, digital hypoplasia, hirsutism, and developmental delay

Caused by use of anti-convulsant medications, MCly phenytoin and carbamazepine

Rhinitis (aka snuffles, can be bloody), hepatosplenomegaly, and skin lesions.

Later findings include interstitial keratitis, Hutchinson teeth, saddle nose deformity, saber shins, deafness, and CNS involvement

Midfacial hypoplasia (also seen in fetal hydantoin syndrome), microcephaly, and stunted growth.

CNS damage may manifest as hyperactivity, MR or learning disabilities.

A 30 y/o woman p/w chronic pelvic and lower back pain for several months. Pain is worse premenstrually. Vitals are nml. She is sexually active with 1 partner; pregnancy test is negative. Exam shows tenderness to posterior vaginal fornix and tenderness w/ mov't of uterus.

Dx?

How do you Dx?

What is this pt at risk of developing?

-Dx - endometriosis

-Dx by laproscopy (gold standard). CT is unable to distinguish btwn soft tissues to make the Dx of endometriosis

-Pt is at risk of develping infertility. Possible mechanism include adhesion formation w/in peritoneum -> interferes w/ nml transfer of oocytes from ovarian surface to fallopain tubes,

What are the characteristic findings of Trichomonas vaginalis infection?

Is it considered an STD?

What's the management of a pt with Trich?

-Vulvovaginal pruritis, green, frothy, foul-smelling vaginal discharge. May also have dyspareunia. Some women are completely asymptomatic. Vaginal pH is usually higher than normal.

-Yes, this is considered an STD

-Give oral metronidazol (flagyl) to both the pt and their sexual partner(s)

1) HTN

2) Pre-ecclampsia

3) Cocaine abuse

4) Smoking

5) Advanced maternal age

What are the main differences between false and true labor?

What's the management for false labor and when do you see it during pregnancy?

Differences include:

-In True labor, contractions occur at regular intervals with progressively shortening intervals and increasing intensity. Contractions are felt in back and upper abd and are NOT relieved by sedation. Cervical change may occur

-In False labor, contractions are irregular, intervals do NOT shorten and do NOT increase in intensity. Contractions are felt in lower abd, and are relieved by sedation. Cervical change does NOT occur.

-Management - reassure pt, and discharge home

-Seen in last 4-8 weeks of pregnancy

B/C the mom still has thyroid stimulating Abs (TSI), which can be as high as 500x nml for several months following thyroidectomy.

The hyperthyroidism will likely NOT be do to any levothyroxine therapy the pt is on b/c it does not cross the placenta

A 30 y/o G1P1 comes in at 19 wga b/c of vagnail bleeding and lower abd discomfort. She has had no passage of tissue from her vagina, and she's had no Hx of recent trauma. Vitals are wnl. Exam shows closed cervix, tender uterus, and free adnexae. U/S shos nml fetal heart motion.

Dx?

NSIM?

-Dx - Threatened Abortion, which is ANY hemorrhage before 20 wga w/ a live fetus (no passage of fetal tissue) and closed cervix.

-NSIM - Reassurance and f/u U/S one week later Hospitalization is NOT necessary in these pts.

1) Breakthrough bleeding

2) Amenorrhea

3) HTN (mechanism = increased Na and water retention)

4) Venous thromboembolic disease (stroke and MI)

5) Decreased risk of ovarian and endometrial cancer

6) Increased risk of cervical and breast cancer

7) Liver disorders (hepatic adenoma which can RUPTURE!)

Weight gain is NOT as a SE of combined OCP use

A 20 y/o female with Hx of schitzophrenia comes in complaining of weight gain, amenorrhea, breast tenderness, and galactorrhea. Urine pregnancy test is negative.

Dx?

Antipsychotic induced amenorrhea. Antipsychotics both typical and atypical target the mesolimbic pathway by inhibiting DA, and a SE of this is inhibition of other DA pathways such as the  nigrostriatal pathway (extrapyramidal SE) and tubuloinfundubibular pathway (amenorrhea).

Of all the antipsychotics, risperidone has been found to increase prolactin levels the most.

Treatment is symptomatic relief

Ursodeoxycholic acid

Males - cryptorchidism, microphallus, hypospadias, testicular hypoplasia

Females - clear cell adenocarcinoma of the vagina and cervix, cervical abn (hypoplasia), uterine malformations (T-shaped, small uterine cavity), vaginal adenosis, vaginal septae

What will the levels of the following hormones be that are most predictive of Down syndrome?

beta-hCG

MSAFP

Estriol

Inhibin A

beta-hCG - high

Inhibin A - high

MSAFP - low

Estriol - low

What are the 2 mechanisms by which pregnancy affects thyroid function?

1) Increased estrogen -> increased synthesis of thyroid binding globulin (TBG) -> increased total T3/T4

2) beta-hCG -> mild stimulation of TSH receptor -> small increase in free T3/T4, and mild decrease in TSH, however free T3/T4 and TSH are usually within normal limits

What is Transient HTN of pregnancy?

How can you distinguish it from Pre-ecclampsia?

HTN that appears in 2nd half of pregnancy or during L&D, and is not accompanied by proteinuria (< 300 mg/24 hrs)

Pre-eccampsia pts have > 300 mg/24hrs

30 y/o woman gives birth and sufferes severe post-partum bleeding requiring aggressive resuscitation. A week later she returns to your office complaining of an inability to lactate.

Dx?

What else might you see in this woman?

Sheehan's Post-partum necrosis of the anterior pituitary

Normally post-partum fall in estrogen and progsterone combined with nipple stimulation by suckling child -> increase prolactin concentration -> lactation

You might also see hypothyroidism (loss of TSH), and an amenorrhea, loss of pubic and axiallary hair (loss of FSH)

Name 6 modifiable risk factors including 2 drugs for osteoporosis.

Name 6 non-modifiable RFs.

Modifiable:

1) Low estrogen levels

2) Malnutrition (esp Ca and VitD)

3) Immobility

4) Cigarrette smoking

5) EtOHism

6) Drugs - glucocorticoids, anticonvulsants

Non-Modifiable

1) Female

2) Advanced age

3) Small body size

4) Late menarche/early menopause

5) Ethnicity (Caucasian or Asian)

6) Positive family Hx

What's the NSIM of a premenopausal woman who has a PAP smear positive for low-grade squamous intra-epithelial lesion (LSIL)?

What if the pt was post-menopausal?

Pre-menopausal - colposcopy to r/o CIN 2 or 3

Post-menopausal - can do one of 3 things:

1) Colposcopy

2) HPV testing. If positive -> colposcopy

3) Repeat PAP smear in 6-12 months. If Abn then -> colposcopy

What is the treatment for vaginal cancer?

Qid 3745

Depends on Staging and Size:

-Stage I and II tumors (no extension into pelvic wall and no metastasis) that are less than 2 cm in size -> surgical removal

-Stage I and II tumors greater than 2 cm -> radiation therapy

-Stage III and IV, and tumors > 4 cm in size -> combination chemotherapy

KEEP IN MIND that age and co-morbid conditions must be considered. So if pt is old and has many co-morbidities, they are not good surgical or chemotherapy candidates -> radiation therapy alone is indicated

A 25 y/o G1P1 comes in at 32 wga b/c of hirsutism and acne. Serum testosterone and DHEA-sulfate levels are high, estradiol levels are nml, and estriol levels are undetectable.

Dx?

How do you explain these lab values?

Mom is carrying a baby with aromatase deficiency.

Normally, the placenta uses DHEA-sulfate made by fetal adrenal gland and converts it to estriol--the estrogen of pregnancy. Since baby's placenta isn't doing that, then androgens (DHEA-sulfate and testosterone) build up in fetus and mommy -> hirsutism in mommy

What will you see in terms of internal and external genitelia of a female with aromatase deficiency?

What otehr sequelae will you expect to see?

-Virulization of external genitelia

-Normal female internal genitelia

-Other sequelae include: delayed puberty, osteoporosis, undetectable estrogens, high gonadotropins, and polycystic ovaries

During which part of the menstrual cycle does the cervical mucus change such that sperm can get through?

What consistency and pH is this mucus?

What might you see microscopically?

-During the ovulatory phase the cervical mucus will change from thick and acidic to thin, clear, with a pH 6.5 or greater

-Microscopically you'll see ferning

-During the follicular, and mid/late luteal phases, the mucus is thick and acidic, which prevent sperm penetration

Amniotic fluid embolus usually presents with what 3 signs?

What is the #1 feared complication of AFE?

-Respiratory failure, cardiogenic shock, seizures

-Main feared complication is DIC, so look out for a purpuric rash

-NSIM - respiratory support; if facemask with 100% O2 isn't correcting hypoxia, then intuabtion and mechanical ventilation is req'd

OCP use decreases the risk of what 4 things?

How do OCPs cause HTN?

-Decreases risk of: endometrial and overian cancer, PID, ectopic pregnancy

-Increased Na and water retention

What tissues does Tamoxifen act as an agonist and what tissues does it act as an antagonist (with respect to estrogen receptor)?

What can you use to avoid any RFs of Tamoxifen?

-It's an antagonist to breast tissue ER

-It's a partial agonist to endometiral ER -> increased risk of endometrial carcinoma

-It's an agonist on osteoclast ER -> decreased risk of ostoeporosis

-Raloxifine can be used. It acts as an antagonist to ER in breast and endometrium, and an agonist in bone

How is the progression of labor measured in latent phase vs active phase of Stage I labor?

Define protracted active phase of Stage I labor.

Define protracted Stage II labor.

How do you manage each?

-Latent phase is timed based on total hours, while active phase is timed based on cm of cervical dilation per hr. Latent phase should take <20 hrs in nullip and <14 hrs in a multip.

-Protracted active phase - <1cm/hr in a nulligravid, and <1.2cm/hr in multigravid (this is rate of cervical dilation.

-Protracted Stage II - >3hrs w/ regional anesthesia or 2hrs w/o in a nulligravid; >2hrs w/ regional anesthesia or 1 hr w/o in a mulitigravid

-Manage by assessing the 3 P's (power, passenger, passage):

1) If insufficient power (external tocometer and intrauterine pressure catheter [IUPC] indicate insufficient uterine contraction) -> give oxytocin

2) If large passenger or passage (i.e. fetal macrosomia, macrocephaly, small pelvic brim on exam, prominent ischial spines on exam) -> C-section b/c these are unalterable factors

What is a Zavanelli Maneuver?

What does it attempt to accomplish?

-Pushing the baby back into uterine cavity followed by C-section

-This is a last resort in the case of shoulder dystocia

A 23 y/o G1P1 at 32 wga comes in because of decreased fetal mov'ts.

NSIM?

What constitutes a reactive non-stress test?

What's the MCC of non-reactive test?

-Reactive test = 2 accelerations of 15 bpm aove baseline lasting 15 secs in a 20 minutes interval

-MCC of non-reactive test = sleeping fetus

When is CST indicated?

What constitutes a positive contraction stress test?

What does this tell you?

What is NSIM if it is positive?

-CST indicated with a BPP of 4-6

-Positive test = late decelerations noted after each contraction

-Means that fetus may not be able to cope with the contractions of normal child birth

-Delivery (usually C-section) is recommended

What is the most important measure to take if a once a woman has a spontaneous abortion evacuated?

Do an autopsy of fetus and placenta - it's important to try and Dx cause of fetal demise after 1st episode to try and prevent recurrence of same issue in subequent pregnancies

Serial beta-hCG monitoring is req'd for suspicioun of a molar or ectopic pregnancy. This is not done after successful evacuation of spontaneous abortion

What is the most common preventable cause of fetal growth restriction in US?

What is the most commonly ID'd infectious agent a/w FGR?

Smoking

CMV, but it can't ebe effectively prevented or treated in most cases

A 25 y/o woman comes to you b/c of pain with defecation and hematuria. Vitals are nml. Exam shows tender adnexal mass. U/S shows homogeneous adnexal mass as well.

Dx?

How do you Dx?

Endometriosis - recall the MC sites for endometriosis include the surface of the ovary, peritoneal surface of cul-de-sac and broad ligament, uterosacral ligaments, and rectovaginal septum

Dx by laproscopic exam

What is the MCC of post-partum hemorrhage?

What are 4 RFs for this?

How do you manage it?

-Uterine atony

-RFs include uterine hyperdistension due to a large fetus (so beware of this infants of DM moms), polyhydramnios, multiple gestation, increased parity

-Management:

1) First step are supportive measures (massage fundus to stimulate contraction); IVF should be started as well

2) If this fails to control bleeding, administer oxytocin -> causes contraction of myometrial fibers and retraction of myometrial BVs

How do you distinguish mild from severe pre-ecclampsia in terms of BP and level of proteinuria?

What's drug of choice in both situations?

Qid 4779, 4780

Mild - BP of 140/90 and proteinuria > 0.3g/24hr after 20 wga

Severe - BP of 160/110, proteinuria > 5g/24hr, oliguria, elevated LFTs, thrombocytopenia, and possibly pulmonary edema

Methyldopa, an alpha-2 agonist, is first-line Tx of HTN in pregnancy

What are 4 physcial manifestations and 5 symptoms of premenstrual syndrome (PMS)?

When does PMS usually occur and when does it regress?

What's the best way to confirm Dx?

-Physical manifestations: bloating, fatigue, HA, breast tenderness

-Symptoms - anxiety, mood swings, difficulty concentrating, decreased libido, and irritability

-PMS begins 1-2 wks prior to menses, and regresses around the time of menstrual flow

-Maintaining a menstrual diary for at least 3 cycles is useful aid in confirming Dx

-Pts with placental abruption in labor should always be managed aggressively to insure rapid vaginal delivery b/c it will remove the retroplacental hemorrhage which acts as an impetus for DIC and hemorrhage

-C-section should be done when rapid deterioration of either mom and/or baby occur

25 y/o G1P2 at 35 wga p/w mild edema of hands and feet, n/v, jaundice, anorrhexia, epigastric pain, and fatigue. 24hr urine protein is 400mg. Labs show elevated LFTs and prolonged PT and PTT, and low glucose. CBC is wnl. 

Dx?

Pathogenesis?

Tx?

-Most likely acute fatty liver of pregnancy

-Pathogenesis – MC is inherited defects in ß-oxidation of FA

-Tx: prompt delivery, usually emergently, AFTER maternal stabilization. Maternal stabilization requires glucose infusion and reversal of coagulopathy (FFP, packed RBCs and platelets)

37 y/o woman comes to you with complaints of severe pain with menstruation, and heaving menstrual bleeding. U/S shows a symmetrically enlarged uterus.

Dx?

Management?

Most likely Dx is Adenomyosis

For women 35 and older, it's mandatory to do an endometrial curettage to r/o endometrial carcinoma

Adenomyosis MCly p/w symmetrically enlarged uterus and can be "boggy"

Leiomyoma MCly p/w asymmetrically enlarged uterus

Endometrial carcinoma MCly p/w no enlargement of uterus

Between 1:8 to 1:32, but most centers use 1:16.

Anything less than 1:8 is considered not alloimmunized and would require Rhogam at 28 wga, w/in 72 hrs post-partum, and if a bleed occurs during pregnancy.

After initial measures to tilt mom to left, give her O2, and D/Cing oxytocin

It's used to assess for fetal hypoxia

A 34 y/o G2P1 comes in at 30 wga because she has not felt fetal movements in the past day.

What's the NSIM if:

A) Fetal heart tones are not present?

B) Fetal heart tones are present?

A) Not present -> ultrasound to look for fetal heart beat. If no heart beat, then IUFD diagnosed

B) Present -> NST (reactive defined by presence of 2 or more accels w/in 20 mins)

  -If non-reactive -> vasoaucustic stimulation

  -If reactive -> f/u NST in 1 week

What are the 3 main causes of Dysfunctional Uterine bleeding?

Define each.

-Anovulatory

1. Occurs in extremes of reproductive life (menarche and menopause)

2. Due to excessive estrogen stimulation relative to progesterone -> produces endometrial hyperplasia, and when stroma eventually can’t hold it anymore the hyperplastic endometrium sloughs off -> bleeding

3. Absent secretory phase of cycle (when progesterone is normally high)

-Inadequate Luteal Phase

1. Ovulatory type of DUB

2. Due to inadequate maturation of corpus luteum -> delayed dev’t of secretory phase

3. Decreased serum 17-hydroxyprogesterone -Irregular Shedding of Endometrium

1. Ovulatory type of DUB

2. Due to cont’d secretion of progesterone -> persistent luteal phase

3. Menstrual effluent composed of mixture of proliferative and secretory glands

36 y/o woman w/ Hx of DM and HTN p/w irregular menstural cycles and heavy mentrual bleeding. She is sexually active with one partner, and uses barrier contraception. Vitals are wnl. Exam is unremarkable. Pregnancy test is negative.

Dx?

NSIM?

Dx: Dysfunctional Uterine Bleeding (DUB)

-If woman is >35, obese, cHTN, or DM, she is at high risk of endometrial hyperplasia or carcinoma -> endometrial biopsy

-If woman is not at risk of the above and/or endometrial biopsy is negative -> cyclic progestins

-If cyclic progestins don’t work -> endometrial ablation or hysterectomy

What is the diagnostic imaging technique of choice for Dxing an ectopic pregnancy?

What if it is equivocal?

Transvaginal U/S is test of choice!

-Transabdominal U/S can only reliably visualize gestational sacs when ß-hCG is >6,500 IU/L -Transvaginal U/S can visualize gestational sacs when ß-hCG is btwn 800 – 6,500 IU/L—thus transvagional U/S is test of choice for Dxing ectopic pregnancy

-If transvagional U/S fails to reveal intrauterine or adnexal sac when ectopic is suspected, then serial ß-hCGs are needed to rule it out:   -Doubling of ß-hCG Q48hrs -> nml pregnancy -Slower rise in ß-hCG -> abn pregnancy

What is the MC site for endometriosis to occur?

What are common presenting signs?

What can it result in?

How do you Dx?

-MC sites are overies, peritoneal surfaces of cul-de-sac, the broad and uterosacral ligaments and rectovaginal septum

-Characterized by dysmenorrheal, dyspareunia (esp when it’s located in cul-de-sac, the fornicies of uterosacral ligaments), dyschezia, hematochezia, hematuria, and pre/postmenstrual spotting

-Can result in infertility

-Dx: Laproscopic exam (f/b biopsy gives definitive Dx. There is NO imaging or lab study that can confirm Dx of endomteriosis)

What is symmetric fetal growth restriction caused by?

What is asymmetric fetal growth restriction caused by?

What's the most reliable index for estimating fetal size in IUGR?

-Asymmetrical occurs after 28 weeks and is characterized by normal head size, and a reduced in abd circumference

   -Caused by: maternal HTN, pre-ecclampsia, uterine abn, maternal anti-phospholipid syndrome, collagen vascular disease, maternal smoking

-Symmetrical occurs before 28 weeks and results from fetal defects such as genetic/chromosomal anomalies or early congenital infection

-Abdominal circumference is most reliable index for estimation of fetal size b/c it’s affected in both symmetric and asymmetric FGR

27 y/o G1P1 at 25 wga comes in b/c of intense pruritis of the palms and soles that is worse at night. Vitals are nml. LFTs show elevated Alk Phos, AST, ALT, and serum bile acids.

Dx?

NSIM?

What is baby at risk for?

Cholestasis of Pregnancy

NSIM: Assess fetal lung maturity and deliver if mature. If not, ursodeoxycholic acid is promising

Fetus more at danger than mom – prematurty, meconium asp, intrauterine demise

What is interstitial cystitis?

How does it?

How do you Dx it?

What is a cystocele?

How does it present?

-IC – chronic condition of bladder of unk etiology and pathophys

-IC is characterized by triad of urinary urgency, frequency, and chronic pelvic pain in absence of another disease.

    -Exacerbated by sex, bladder filling, exercise,  spicy food

    -Relieved by voiding

-Dx: Cystoscopy – will show submucosal petechiae or ulcerations

-Cystocele – herniation of bladder w/ associated descent of anterior vaginal wall

-P/W urinary frequency, urgency, and incontinence, but is MCly asymptomatic and Dx’d incidentally

-Herniation of upper anterior vaginal wall will be seen

What is physiologic leukorrhea?

Why does it occur?

In whom does it present?

-Thick, whitish or yellowish vaginal discharge

-Caused by estrogen stimulation of increased bloodflow to vagina

-Can occur normally during pregnancy and is even seen in newborn females due to intra-uterine estrogen exposure

What is Lichen Sclerosus?

What's the pathogenesis?

What is the classic physical exam finding?

NSIM?

-Chronic inflammatory premalignant cond’n of anogenital/vulvar region MC in women. P/W anogenital discomfort including pruritis, dyspareunia, dysuria, and dyschezia

-Autoimmune pathogenesis

-PE: “porcelain-white polygonal macules and patches” with an atrophic “cigarette paper” quality. Sclerosus and scarring can lead to obliteration of labia minora and clitoris and decreased diameter of introitus

-NSIM: Vulvar punch biopsy to r/o vulvar SCC (which occurs more commonly in LS&A)

-Tx: Topical corticosteroids BID x 4 weeks, then transition to topical calcineurin inhibitor for maintenance therapy. In fact, this is one of the few cond’ns where high-potency topical steroids on genitals is encouraged

What are the 6 Ps of Lichen Planus?

How do you describe Lichen Slcerosis?

-pruritic, planar, purple, polygonal papules and plaques

-Porcelain-white polygonal macules and patches with an atrophic "cigarrete paper" quality

Who is in danger of bleeding out in placenta previa?

Who is in danger of bleeding out in vasa previa? What is vasa previa?

Management for ruptured vasa previa?

-Mom is in danger of bleeding out in placenta previa b/c the BVs are of maternal origin

-Baby is in danger of bleeding out in vasa previa b/c the BVs are of fetal origin

-Vasa previa is when fetal BVs traverse fetal membranes across lower segment of uterus btwn baby and internal os (velamentous cord insertion) -> these vessels are vulnerable to tearing during neural or artificial rupture of membranes -> rapid progression to fetal decelerations and sinusoidal wave forms

-Management for ruptured vasa previa - immediate C-section!

Define mild pre-ecclampsia.

Define severe pre-ecclampsia.

How do you differentiate these from cHTN?

-Mild - BP >140/90 and >0.3g urine protein/24hrs

-Severe - BP >160/110 and >5g urine protein/24hrs

Pre-ecclampsia will occur at 20 wga and later, whereas cHTN occurs < 20 wga and typically does not involve significant proteinuria

What is pseudocyesis?

What physical exam findings is it a/w?

Management?

-Cond’n where woman presents w/ S&S of pregnancy (amenorrhea, enlargement of breasts and abd, monrning sickness, weight gain, sensation of fetal mov’ts, report of positive urine pregnancy test), however U/S reveals normal endometrial stripe and pregnancy test in office is negative

-Is a form of conversion disorder. Depression caused by this need is behind the occurrence of some hormonal changes mimicking those of pregnancy

-Management – Psychiatric evaluation and treatment

A 24 y/o G2P1 with Hx of a recent planned abortion p/w f/c, lower abd pain/tenderness, bloody purulent vaginal discharge.

Dx?

What 3 things do you do for this woman in order of succession?

-Septic Abortion - medical emergecy that results from infection of POC 

-NSIM:

1) obtain cervical and blood cultures

2) broad spectrum AbX

3) gentile suction curettage to remove infectious nidus

Trich - p/w malodorous, green, thin, frothy vaginal discharge + vaginal and vulvar pruritis, dysuria, and dyspareunia

Bacterial Vaginosis (note: this is not an "-itis") -causes non-painful, non-inflammatory, non-pruritic gray discharge with a fishy smell. A/W sex but NOT and STD. You’ll see clue cells under microscopy.

Candida Vaginitis -causes non-malodorous, white, and thick discharge. The pH is normal ( 4-4.5), as opposed to the above 2

In androgen insensitivity sydnrome (male pseudohermaphroditism) what is the reason for absent uterus, upper 2/3 of vagina, and fallopian tubes?

What are the testosterone levels in these pts?

What's the Tx?

-Due to presence of mullerian inhibiting factor (MIF) produced by testes -> prohibits formation of uterus, fallopain tubes, and upper vagina

-Testosterone is w/in normal range for males (high for females)

-Tx: testicular resection at puberty (so pt can even undergo puberty) and creation of a neo vagina

A 24 y/o woman with essential HTN and DMI comes to you b/c her pregnancy test was positive. You confirm the pregnancy test with a positive beta-hCG. She is currenlty on an ACE-I and insulin.

What changes to her regimen should you make?

What if she wasn't taking any medication for the HTN, what do you do?

The change in regimen depends on the pt's BP:

-If BP is >120/80 -> discontinue ACE-I and add on either labetalol or methyldopa

-If BP is <120/80 -> taper/discontinue anti-hypertensives

-If pregnant pt isn't taking any anti-hypertensives despite having essential HTN, then you begin anti-hypertensive therapy once their BP >150 systolic or 95 diastolic

What's the management for preterm rupture of membranes?

Preterm rupture of membranes:

-Give steroids for lung maturity

-If not in labor give latency AbX (Amoxicillin + Erythromycin) so baby is kept relatively safe from infection btwn the time of membrane rupture and delivery

-If < 34 weeks, let mom labor if labor comes

-If there's concern of infection or fetal distress -> deliver

-NEVER GIVE TOCOLYTIC DRUGS b/c this can mask infection (why???)

-Tocolysis - although it has not proven to be successful, it's still used b/c it's the best we have to prevent preterm labor. The goal of tocolysis is so that baby can remain in utero long enough for steroid administration to take effect

Notes:

-Magnesium has a duel puprose in preterm labor:

1) Tocolytic

2) Decreases the indicence of cerebral palsy (mechanism unknown)

A 29 y/o woman comes in b/c of gray vaginal discharge with a fishy smell. A Dx of bacterial vaginosis is diagnosed, and metronidazol is perscribed.

What should you advise this woman avoid while taking metronidazol?

Alcohol - metronidazol can cause disulferam-like reactions, meaning it inhibits acetaldehyde dehydrogenase -> acetaldehyde byproduct of alcohol breakdown accumulates in blood stream -> n/v, hypotension

Recall, fomepizol is the drug that inhibits alcohol dehydrogenase

24 y/o G3P1 at 32 wga p/w dyspnea x 2 months. She denies any recent illness, calf pain/tenderness, or cp. Vitals are nml. Exam shows lungs that are CTAB, heart is RRR w/ II/VI systolic murmur at LUSB.

Dx?

Pathophys?

Physiologic dyspnea of pregnancy - presents in up to 75% of women in 3rd trimester of pregnancy

May be due to progesterone induced hyperventilation

What physiologic change during pregnancy predisposes them to developing pulmonary edema?

What type of antepartum therapy can put mom at further risk of developing pulmonary edema?

Plasma osmolality is decreased during pregnancy

Giving tocolytics, like terbutaline or other beta-2 agonists as well as Magnesium increases susceptibility to pulm edema, especially w/ use of isotonic fluids

27 y/o G3P3 at 14 wga p/w n/v, vaginal bleeding, and tachycardia all of which have been off and on for 8 weeks. On exam, she is tachycardic, afebrile, with uterine fundus 4 cm below umbilicus. No fetal heart tones obtained by doppler. beta-hCG is 1.5 million IU/mL, TSH is undetectable, free T4 is high. U/S shows cystic tissue in uterus.

Dx?

NSIM?

Dx - gestational trophoblastic disease (could be a molar pregnancy)

NSIM - CXR b/c lungs are MC site of metastasis in GTD

Hb Electrophoresis and CBC

Hb Electrophoresis is definitive and preferable b/c other hemoglobinopathies can also be detected

Name 4 diseases that are increased in incidence in Ashkenazi Jews.

Of these, which one has the highest carrier frequency?

Fanconi anemia, Tay-Sachs, CF, Niemann-Picks

Tay Sachs has the highest carrier frequency (1/30 as opposed to 1/3000 in nml population)

What is a first trimester screening test for Down syndrome?

What is the best second trimester screening test for Down syndrome?

1st trimester -Nuchal translucency measurement + maternal serum pregnancy associated plasma protein (PAPP-A) test

2nd trimester - quadruple test (maternal serum AFP, unconjugated estriol, hCG, inhibin A)

Which forms of contraception have the highest success rate?

What is the % pregnancy rate?

What has the highest pregnancy rate?

-Depo-Provera, IUD, sterilization, and implanon have the highest success rate. There is a 1% pregnancy rate with these

-OCPs have a 3% pregnancy rate

-Male condoms have a 12% pregnancy rate

-Diaphragm w/ spermicide has the highest pregnancy rate (18%)

1) Contractions Q 5 mins for 1 hr

2) Rupture of membranes

3) Fetal mov'ts <10 per two hrs

4) Vaginal bleeding

A 21 y/o G1P1 comes in at 40 wga in active labor. She is very uncomfortable and requests an epidural. You are unable to place external fetal heart monitor b/c pt cannot lie still.

What can you do to assess fetal well-being before giving the epidural?

-A fetal scalp electrode is most reliable way to document fetal well-being if external methods are not possible

-Remember, giving an epidural w/o first confirming fetal status is dangerous

-recommend a tight fitting braw

-avoid nipple stimulation or manipulation

-apply ice packs to breasts

-analagesics to manage pain

-bromocriptine used to be used for this, but is no longer used b/c of the side effects

-Chancre - initially appears as a painless papule then evolves into a punched-out, raised ulcer with painless inguinal lymphadenopathy

-Chancroid - deep ulcer w/ purulent base and painFUL lymphadenopathy

-Herpes - multiple painful vesicles following a prodrome of burning and pruritis

What is Granuloma inguinale?

What's it caused by?

-Granuloma inguinale - painless genital ulcer w/ red, beefy base and NO adenopathy

-Caused by Klebsiella

Recall, the chancre of syphilis presents as painless punched out ulcer w/ indurated margins AND painless inguinal adenopathy

It expresses the concept that professionals have a duty to protect the pt from harm.

An example would be a physician's decision not to place a fetal heart monitor on a fetus that is anencephalic b/c he/she will not perform a C-section if fetal distress is detected. An anencephalic infant will not survive, and performing a C-section will be unnecessarily harmful to the mother. Thus he/she is acting under the principle that he/she is protecting the mom from unnecessary harm of C-section.

1) Early menopause

2) Glucocorticoid therapy

3) Sedentary lifestyle

4) Alcohol consumption

5) Hyperthyroidism

6) HyperPTHism

7) Anti-convulsant therapy

8) VitD deficiency

9) FHx of early severe osteoporsis

10) FHx of chronic liver disease

11) FHx of chronic renal disease

16 y/o girl is brought in by her mother b/c she is not menstruating and she has no secondary sex characteristics.

NSIM in working up this pt depends on what?

What test can distinguish between central and peripheral cause of amenorrhea?

NSIM depends on if U/S shows they have a uterus or not:

-Uterus absent -> karyotype, serum testosterone

  -If XY (normal male testosterone levels) -> androgen insensitivity syndrome (pt have no pubic hair)

  -If XX (normal female testosterone levels) -> abnormal Mullerian dev't (pts have pubic hair)

-Uterus present (means she's likely genotypically female)- serum FSH

  -Increased -> karytope

  -Decreased -> cranial MRI

-FSH will tell you if the cause of amenorrhea is central (hypogonadotropic hypogonadism) or peripheral (hypergonadotropic hypogonadism)

-increase in lumbar lordosis

-relaxation of the ligmanents supporting the sacroilliac and other joints of the pelvic girlde due to hormonal factors

A 27 y/o woman at 28 wga comes in b/c of right flank pain radiating to the groin. UA shows specific gravity of 1.02, 2+ blood, and negative glucose, ketones, protein, leuko esterase, and nitrites.

Dx?

How do you Dx?

Nephrolithiasis

U/S of abdomen - this avoids radiation exposure to baby. U/S can detect secondary signs of obstruction such as hydronephrosis or hydroureter

Note: physiologic hydronephrosis of pregnancy must be distinguished from pathological hydronephrosis 2/2 stones

When should isolated amenorrhea be evaluated in a female child?

When should lack of secondary sex charactersitics be evaluated in a female child?

16 for isolated amenorrhea

14 for abesent sex characteristics

If a woman has PPROM, when is tocolysis typically done?

Do you give long or short term tocolysis?

What's the goal in tocolyzing the woman?

What if the woman is GBS unknown?

Tocolysis is usually done prior to 34 weeks, never beyond 34 wga

You're going to give short term tocolytics with the goal of delaying laobr for long enough for glucocorticoids to be given to promote fetal lung maturity

If woman is GBS unknown and has PPROM -> penicillin prophylaxis

In order to reduce the risk of:

-IRDS

-Necrotizing enterocolitis

-Neonatal intraventricular hemorrhage

-Neonatal death

In the case of PPROM:

1) What examination technique is contraindicated and why?

2) What 3 bad things can happen? And what do you do if ANY of these things occur?

3) The closer mom gets to 34 wga, the ______ your threshold gets for inducing labor.

1) Digital vaginal exam is contraindicated in PPROM b/c it increases the risk of infection to baby

2) The 3 bad things are: labor, infection (chorioamnionitis), and placental abruption. If ANY of these things happen -> DELIVER BABY regardless of gestational age. This is b/c the risk of harm to baby/mom is outweights the benefit of keeping baby inside mom to mature it.

3) The closer to 34 wga, the lower the threshold is for inducing labor.

What is the NSIM of a pre-menopausal pt who has "atypical squamous cells of undetermined significance" (ASCUS) on PAP smear?

What if the pt had "low-grade squamous intra-epithelial neoplasia" (LSIL)?

-ASCUS - do reflex HPV testing

  -If positive (high risk HPV detected) -> colposcopy

  -If negative -> repeat PAP in 1 year

-LSIL or HSIL - do colposcopy

Uterine rupture is usually preceded by maternal agitation, hyperventilation, and tachycardia.

Uterine ruptre is rare and most often a problem during active labor, NOT during the antepartum period

Name 5 RFs for stress incontinence.

What key findings will you see on physical exam that point to stress incontinence?

What's the Tx?

-RFs include: multipartiy (biggest RF), morbid obesity, pregnancy, COPD, smoking

-On PE you may see: uterine prolase and/or cystocele -> indicates pelvic floor weakness. Classically pt's UA, cystometry, and post-void residual is normal

-Tx: Kegel exercises, pessaries (small plastic device inserted into  vagina or rectumwhich helps support structures above pelvic floor) and estrogen modulation (if post-menopausal)

A 38 y/o G1P1 presents for evaluation of infertility. Her previous pregnancy was 6 yrs ago. She has regular 28-day mentrual cycles. She has no Hx of STDs or abd surgery. She denies smoking, drinking, or drug use. Her vitals are wnl, and her BMI is 24. Physical exam is unremarkable.

Dx?

Pathophys?

What 3 tests can you do to Dx this?

-Oocyte aging (decreased ovulatory reserve)

-At birth, women possess 3 million oocytes, but by puberty this number drops to 300K. A signficant drop in oocyte number (ovulatory reserve) takes place during a woman's 4th decade

-Infertility due to aging can be assessed using early follicular phase FSH level (high), clomiphene challenge test (clomiphene blocks hypothalamic-pituitary ER -> should normally increase GnRH and FSH), or an inhibin-B level (low?)

A 40 y/o G1P0 comes in at 11 wga for antenatal counceling. She expresses her concern that the baby may have Down Syndrome given her advanced age, and would like to have the baby tested. She says she wants to abort if DS is Dx'd. U/S shows nuchal translucency.

NSIM?

What if this method doesn't work?

NSIM - Chorionic villus sampling. CVS involves aspriation of small quantitiy of placenta. It can be done at 10-12 wga. The fetal derived cells are karyotyped and subject to FISH studies to detect aneuploides, and also some enzyme deficiencies.

-If CVS doesn't work or you can't do it, then early amniocentesis is done

-MSAFP cannot provide a confirmatory Dx and is unable to indicate risk of trisomy

When is chorionic villus sampling done?

When is diagnostic amniocetnesis done?

When is MSAFP done?

CVS - 10-12 wga. NOTE: CVS performed before 9-10 wga is a/w increased incidence of distal limb defects and fetal death!

Diagnostic Amniocentesis - 16-18 wga

MSAFP - Second trimester (beyond 12 wga)

FSH - increased

LH - increased

FSH:LH ratio > 1.0

Remember, this results from loss of feedback inhibition of estrogen on FSH and LH. FSH elevation is greater b/c clearance of FSH from circulation is slower

-How long after delivery does a woman need to have SS of depression before a Dx of post-partum depression can be made?

What sign or symptom of post partum depression is most useful in distinguishing it from post-partum blues?

-2 weeks

-Abivalence toward the newborn

1. Hx of PP depression

2. Marital conflict

3. Lack of perceived social support

4. Thoughts about terminating pregnency

5. Stressful life events in previous 12 months

6. Sick leave in past 12 months related to hyperemesis

7. Uterine irritability

8. Psychiatric disorder

-Isotretinoin shouldn't be used in women of reproductive age unless 2 effective forms of contraception have been used for at least 1 month before initiating Tx

-Contraception must be cont'd during Tx (pregnancy tests should done while pt is on isotretinoin) and 1 month after isotretinoin is discontinued

What is urethropexy?

What does it attempt to correct?

What test can you do to Dx urethral hypermobility?

It's surgical suspension of the urethra from the posterior surface of the pubic symphisis in order to correct urinary stress incontinence

Recall, stress incontinence often results from weakening of the pelvic floor musculature, leading to urethral hypermobility.

Urethral hypermobility may be Dxed by inserting a cotton swab into urtheral orifice and demonstrating an angle of >30 degrees upon increase in intra-abd pressure.

A 40 y/o G5P5 p/w urination when laughing and sneezing.

NSIM?

What is the MOST beneficial Tx for this cond'n?

NSIM - recommend Kegel exercises to restore pelvic floor strength

Urethropexy is the MOST beneficial Tx for pts -> restores urethrovesical angle -> improves sphincter function

What's the most appropriate NSIM of a pt with an amniotic fluid embolus?

What about for a PE due to DVT?

AFE - intubation and mechanical ventilation

PE - low molecular weight heparin

What can be a cause of RUQ pain in a pt with pre-ecclampsia?

What type of liver pathology can occur in pre-ecclampsia?

Stretching of the liver capsule (Glisson's capsule) -> RUQ pain b/c the peritoneum is innervated by somatic nn that provide localized sensation of pain.

Pre-ecclampsia can lead to cetrilobular necrosis, hematoma formation, and formation of thrombi in portal capillary system.

-Cervical cerclage

-If the pregnancy is 24-34 weeks, then tocolysis and corticosteroids are indicated.

What is the NSIM of pts with symptomatic endometriosis?

What if the pt is asymptmatic or has mild disease?

-GnRH agonists and OCPs are the best management. OCPs provide negative feedback to HPA axis -> decreases LH/FSH -> stops ovarian production of sex hormones causing endometrial growth and worsening of pain

-If pt is asymptomatic or has mild disease -> observation

-If medical management fails -> laproscopy (this provides a definitive diagnosis as well)

-Nipple soreness

-Burning pain in the breast worse with feeding

-Tips of nipples are pink and shiny with peeling at the periphery

What's the NSIM of a preterm woman who p/w vaginal bleeding 2/2 placenta previa?

Management depends on severity of bleeding:

-If bleeding is severe bleeding, uncontrolable bleeding, mom's vitals are unstable, unreassuring fetal heart rates (any one of these) -> Emergency C-sectionb

-If bleeding is controlled and mom + baby stable -> corticosteroid therapy and scheduled later C-section

A 27 y/o G2P1 comes in at 33 wga b/c of sudden onset of severe abd pain. She denies any vaginal bleeding or d/c. She's afebrile, 90/60, HR 130. Exam she is diaphoretic and cold, has increased uterine tone with some contractions, and uterine tenderness. 

Dx?

Abruptio placentae.

Bleeding is seen in 80% of pts, so absence of vaginal bleeding does not rule this out. Bleed may be retroplacental and not appear on vaginal exam 

What type of incontinence is seen commonly a/w epidural anesthesia?

What's the pathophysiology?

Tx?

Overflow incontinence is a/w epidural anesthesia b/c the anesthesia blocks both afferents and efferents from bladder -> pt fails to sense a full bladder and is unable to void voluntarily

Tx - intermittent placement of a foley catheter to drain bladder while the anesthesia wears off

What does the Tx for dysfunctional uterine bleeding (DUB) depend on?

How do you treat DUB?

Qid 2390, what is the rationalle???

Depends the severity of bleeding:

-Mild -> iron supplementation

-Moderate but no active bleeding -> progestin should be added

-Moderate w/ active bleeding OR severe bleeding -> D&C or Endometrial ablation

Remember, if pt is at high risk for endometrial carcinoma (DM, HTN, >35, obese) -> NSIM is endometrial biopsy to r/o endometrial carcinoma. If biopsy is negative, THEN you give cyclic progestins if indicated as above.

A 27 y/o G2P2 delivers a healthy baby at 39 wga. She develops shaking chills w/in 10 mins follwoing the delivery. Twelve hours later, her Temp is 100.4, BP 120/86, HR 76, RR 16, her WBC count is 11,000 with 78% polys. She continues to have bloody discharge.

Dx?

NSIM?

Dx - this is normal. Low grade fever and leukocytosis are common in the first 24 hrs post-partum, and intra/postpartum chills are common as well. Vaginal bleeding is just lochia rubra.

After 3-4 days locia rubra turns pale (lochia serosa), and later turns white/yellow (lochiaalba)

What Quad Screen result is indicative of Edward Syndrome?

Down Syndrome?

Edward - low MSAFP, low estriol, very low beta-hCG, and nml inhibin A

DS - low MSAFP, low estriol, high beta-hCG, high inhibin A

-Maintain corpus luteum (most important function)

-Promote male sexual differentiation

-Stimulate maternal thyroid gland

When should women be screened for syphillis in pregnancy? What do you do if it's positive?

When is it recommended that women in general get screened for chlamydia?

RPR and VDRL screening tests should be done in the first prenatal visit. If positive, confirm the Dx with FTA-ABS test (fluorescent treponemal antibody absorption test. Tx is penicillin

Screening for chlamydia should be done in all women age 24 and younger and those at increased risk (Hx of STD, new or multiple partners)

When is the Biophysical profile indicated?

What are the components of the BPP and how is it scored?

-In high risk pregnancies or in cases of maternal or physican concern, decreased fetal mov'ts, or a non-reactive NST.

-BPP components include: NST, fetal tone, fetal mov'ts (3 in 10 min), fetal breathing (30 in 10 min), AFI (5-20)

-Each component is given a score of 2 if present and 0 if absent/abnormal

-A score of 8-10 is normal -> reassure and repeat BPP in 1 week

GnRH agonists

-Continuous GnRH -> supression of LH and FSH -> supression of estrogen production, follicle maturation, and ovulation -> no uterine change -> relief of pain

Note: GnRH agonists can also be used to treat other disorders related to estrogen production including adenomyosis, menorrhagia, breast cancer

At what gestational age is external cephalic version indicated for breech position?

What is the management for breech position before that and why?

When is C-section indicated?

-External cephalic version is indicated at 37 wga and beyond. 

-The majority of breech presentations before 37 wga self-correct by 37 wga, thus routine f/u is indicated for breech presentation before 37 wga.

-C-section is only indicated in cases of breech presentation that don't correct with ECV prior to labor

How can you tell whether someone has a  central or peripheral cause of precocious puberty?

What's the treatment for each?

Central - pt has pubertal levels of basal LH that increase with GnRH stimulation

  -Tx: continuous GnRH therapy

Peripheral - how LH levels (due to negative feedback of estrogen) with no response to GnRH

  -Tx: Ketoconazol?

Depends on the severity:

-Mild - moisturizers and lubricants

-Moderate to severe - low dose vaginal estrogen therapy

What is the pathophysiologic cause of primary dysmenorrhea?

Tx?

-Caused by increased prostaglandins. During menstruation there's a release of prostaglandins during the breakdown of the endometrium.

Tx: NSIADs

When and how does mid-cycle pain occur?

Mid-cycle pain occurs about 2 weeks after the LMP and usually lateralizes to one side. The pain is due to ovulation itself.

Unlike in ovarian torsion, an ovarian mass is NOT present

What is ovarian hyperstimulation sydrome?

How does it present?

Why is it so important to monitor pts on Mg?

What are the 1st and 2nd signs of Mg toxicity?

Tx?

It can cause respiratory depression!!!

First sign is depression of deep tendon reflexes, the second is respiratory depression

Tx: STOP Mg and administer calcium gluconate

A 29 y/o woman presents with dysmenorrhea, infertility, and enlarged non-tender uterus. Her FSH, prolactin, and thyroid function tests are nml.

Dx?

What are ecclamptic seizures caused by?

What sign might herald the onset of eccamptic seizures?

NSIM?

It's caused by vasospasm

Increased DTRs herald the onset of ecclamptic seizures

NSIM - IV Magnesium sulfate! After stabilization, THEN you can deliver/C-section mom (which is definitive Tx)

How do you differentiate androgen insensitivity sydrome from 5-alpha reductase deficiency?

Both of these result in female external genitilia in a genotypic male.

However, in 5-alpha reductase deficiency results in virilization during puberty due to increased testosterone 2/2 fact that testosterone can't converted to DHT (so it builds up). These pts also have normal male internal genitilia (SEED) b/c they are testosterone dependent

When should screening for gDM be done for high risk women?

Low risk women?

What test is performed as screen and what constititues a positive?

What if this test is positive?

-Screening for gDM is done at first prenatal visit in high risk women, but for low-risk women it should be done at 24-28 weeks.

-A 1-hr 50 gm glucose tolerance test is done as screening test, and the test is positive if glucose levels is > 140

-If positive, then 3-hr 100 gm OGTT is performed to confirm Dx of gDM

What is the management fo sudden onset of hirsutism or viriluzation during pregnancy with pelvic U/S showing:

1) No ovarian mass

2) Bilateral cystic masses

3) Bilateral solid masses

4) Unilateral solid mass

Qid 2415

1) Abd CT to r/o adrenal mass

2) Serial beta-hCG to r/o gestational trophoblastic disease. Most likely theca lutein cyst (bilateral multiseptated cystic adnexal masses in a woman with GTD, multiple gestation, ovarian hyperstimulation, or fetal hydrops. They can also occur in a normal pregnancy due to hypersensitivity to normal levels of hCG.)

3) Reassurance and f/u U/S. Most likely a pregnancy luteoma (replacement of nml ovarian parenchyma by solid proliferation of luteinized stromal cels under influence of hCG). It's MC in African-American multiparous women in 30's and 40's.

4) Laproscopic biopsy or laprotomy to r/o malignancy

What is a pregnancy luteoma and how does it present?

Who does it more commonly present in?

Tx?

-Hyperproliferation of theca lutein cells (cells of theca interna) -> virulzation/hirsutism (due to excess production of androgens

-More common in African American women

-No Tx required, this is self-limiting

Bilateral involvement. In benign edema of pregnacy, both legs are involved, whereas in women with DVT only one leg is usually affected.

Unlike in pre-ecclampsia, there is no HTN or proteinuria in either of these conditions

1) High fever (104F)

2) Failure to responed to AbX

3) Inability to take PO meds 2/2 n/v

4) Pregnancy

5) Pts at risk of non-compliance (teenagers, low SES)

A 30 y/o G1P0 p/w vaginal bleeding and RLQ pain. Her LPM was 5 wks ago. Vitals are nml and stable, and there's no active vaginal bleeding. Cervical os is closed. Vaginal U/S shows no intra or extrauterine pregnancy, and beta-hCG is 1000 mIU/mL.

DDx?

NSIM?

This could be a viable or non-viable intrauterine pregnancy, or ectopic pregnancy.

NSIM - repeat beta-hCG in 48 hrs

  -In viable pregnancies, beta-hCG doubles Q48 hrs, however in nonviable and ectopic pregnancies beta-hCG increases at a slower rage

  -Also, transvaginal U/S can only detect intra/extrauterine pregnancies with beta-hCG of 1500-2000 mIU/mL

Once an IUFD is Dx, what is the immediate concern?

What's the pathophysiology?

How do detect early signs of this problem?

Mangement of IUFD?

-DIC is of immediate concern in IUFD b/c placenta gradually releases tissue factor into maternal circualtion -> chronic consumptive coagulopathy

-Fibrinogen levels in low-nml range (recall, fibrinogen is normally HIGH in pregnancy), low platelets, increased D-dimer, and/or increased PT/PTT

-Management depends on mom's coagulation panel:

 -ANY abnormalities -> induction of labor

 -No abnormalities -> either expectant management or induction of labor

A newly pregnant woman comes in for her first prenatal visit and VDRL test confirms that she has syphilis. She is allergic to penicillin.

NSIM?

First, confirm pt truly has an allergy to penicillin and not just an adverse response. Skin testing can confirm true allergy

If pt is truly allergic, penicillin desensitization is rec'd, which is done by giving incremental doses of oral penicillin V

Post-term pregnancies are at risk for what 5 things?

In a pregnant woman is post-term, how do you manage the pregnancy if the cervix is (and why?):

1) Unfavorable

2) Favorable

Post-term pregnancies are at risk for oligohydramnios, macrosomia, meconium aspiration, uteroplacental insufficiency, and dysmaturity (skin peeling, meconium staining, long nails, fragile).

1) Unfavorable - expectant managment, with twice weekly U/S evaluations for oligohydramnios (which can occur post-term w/in 24-48 hrs). Induction is not undertaken w/ unfavorable cervix b/c risk for C-section significantly increases.

2) Favorable - induction of labor; this is b/c her induction is more likely to be successful.

What are 3 first-line drugs for UTI in a pregnant woman?

What are 2 pregnancy complications a/w UTI (bot symptomatic and asymptomatic)?

-UTI drugs include: Nitrofuratoin, amoxicilin (+/- clavulanate), cephalexin)

-UTI is a/w preterm birth, and low birth weight

What 2 tests help you determine how much Rho-Gam to give an Rh (-) mommy during pregnancy?

Name a situation where it would be necessary to give MORE Rho-Gam than just the standard dose?

-Rosette test - qualitative test that determines the presence of feto-maternal hemorrhage; subjequent Kleihauer-Betke stain (aka fetal RBC stain using flow cytometry) evaluates how much hemorrhage occured

-Placental abruption can cause increased fetomaternal hemorrage requiring higher amoutns of Rho-Gam

Give 3 SS of breast engorgement.

When does this typically peak after delivery?

Tx?

1) Breast fullness

2) Breast tenderness

3) Breast warmth

Occurs 3-5 days post-partum and improves spontaneously in most pts

Tx: Cool compress, acetaminophen/NSAIDs may be used for symptomatic control

How do you distinguish breast engorgement from mastitis?

How do you distinguish plugged ducts from mastitis?

How is mastitis treated?

How is a plugged duct treated?

-All of these p/w breast pain and tenderness

-Mastitis is unilateral (as is plugged duct), and fever is > 100.9 (38.3) is present

-Tx for mastitis - antistaphylococcal agents

-Tx for plugged duct - improving quality of breastfeeding. Persistently plugged ducts resulting in galctocele can be treated with aspiration

What are the risks of progression to endmetrial cancer in pts with:

1) Simple endometrial hyperplasia

2) Complex endometrial hyperplasia

3) Simple atypical endometrial hyperplasia

4) Complex atypical endometrial hyperplasia

1) 1%

2) 3%

3) 8%

4) 29%

Think of a penny, nickle, dime, quarter

A 30 y/o woman with HTN and DMII comes to you saying she no longer wants children. Endometrial biopsy shows endometrial hyperplasia.

NSIM?

Depends on the presence of atypia:

  -Presence of atypia + good surgical candidate -> total hysterectomy

  -No presence of atypia +/- poor surgical candidate +/- desired continued child bearing -> cyclic progestin

Recall, the risk of progression to cancer in endometrial hyperplasia WITHOUT atypia is as high as 3% (relatively low), whereas WITH atypia is as high as 29%

A 25 y/o G2P2 recently gave birth to a healthy baby girl. She plans on breast feeding. She does not want to have any children for at a few years.

What form of contraception is indicated?

Progestin-only OCP b/c they do not afect the volume or composition of milk. Also they do not carry a risk of venous thrombosis

Combined estrogen-progesterone OCP will cause supression of milk production

A 22 y/o woman comes to you worried she is pregnant. She had unprotected sex with her boyfriend 48 hrs ago.

What can you offer her?

What legal restriction exists with this option?

Levonorgestrel (plan B)

-It's an emergency contraception that is effective up to 120 hrs after intercourse, although effectiveness is greater the earlier it's taken

-Women under 18 must obtain a perscription, but if they're over 18 they can get it OTC

3-4 stools

6 wet daipers

weight gain

sound of swallowing

Type I DM is a/w micro/macro-somia (which one?)

Gestational DM is a/w micro/macro-somia (which one)

Type I DM - microsomia and hypoglycemia

gDM - macrosomia and hypoglycemia

donor - oligohydramnios, anemia, IUGR

recipient - polyhydramnios, polycythemic, and has volume overload -> heart failure

A 25 y/o woman who is a known heroin abuser delivers an infant who is limp, unresponsive, and has a HR of 100 bpm.

NSIM?

-Give positive pressure ventilation and prepare to intubate

Note: Giving this infant naloxone (narcan) cause life-threatening withdrawal

A 27 y/o G2P1 comes to you with vaginal spotting and uterine cramping. Her LMP was 6 wks ago and she began spotting 3 days ago. Her vitals and PE are nml.

What 2 lab test will help you determine if this is a viable pregnancy vs a non-viable or ectopic pregnancy?

What if the labs suggest a non-viable/ectopic pregnancy?

-Serial beta-hCGs - viable intrauterine pregnancies will double Q48hrs, where as non-viable or ectopic pregnancies will have slower doubling rate

-Progesterone level >25ng/mL suggests a healthy pregnancy. A failing pregnancy (e.g. non-viable intrauterine pregnancy) will have a lower progesterone level

-If the labs suggest a non-viable/ectopic pregnancy yet U/S does not reveal an intrauterine pregnancy or ectopic, you do a D&C (which is both therapeutic and diagnostic); treatment with methrotraxate or mifepristone is NOT indicated since a Dx is has not been ascertained

1) U/S shows fetal pole outside uterus

2) beta-hCG is over the descrimination zone (2000 mIU/mL) but no intrauterine pregnancy is visualized on U/S

3) Inappropriate rise in beta-hCG, and/or the levels of beta-hCG don't fall after a diagnostic D&C