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96 Cards in this Set
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w/u of pregnancy |
p/w amenorrhea enlarged uterus confirm with u/s at 4-5 weeks --> should see gestational sac confirm with serum b-hcg that should be ~1500 fetal heart motion present on u/s at 5-6 wks fetal heart sounds heard at 8-10 wks fetal movements felt by MD at 20 wks |
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First-trimester screening |
CBC (MCV is most reliable indicator of anemia) --> iron type & screen -> give Rhogam at 28 wks & wihtin 72 hrs of delivery cervical pap smear UA & urine cx --> ONLY time you tx Asx bacteremia immunizations --> flu test rubella but dont give vaccine Hep B surface Ag VDRL/RPR --> desensitized with penicillin allergy HIV testing --> start mom on HAART cervical cx for chlamydia/gonorrhea --> tx if they are positive (PO azithro & IM CTX) PPD & if positive do xray after 28 wks |
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Early trisomy 21 testing |
b-HCG pregnancy-associated plasma protein A (PAPP-A) fetal nuchal translucency if concerning, do CVS |
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Second trimester screening |
done btwn 15-20 wks MS-AFP - high in NTD b-HCG estriol can add inhibin A in high-risk women (inc sensitivity to 80%) |
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Inhibin A |
made by placenta during preg remains constant during 15th-18th week inhibin A is increased in Downs |
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Triple screen results for Downs |
low MS-AFP low estriol high b-hcg |
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Oral glucose tolerance test |
test at 24-28 wks oral glucose tolerance test - drink 50g glucose then check sugar 1 hr later --> >140 is abnormal if 1 hr test is >140 then perform 3hr 100g glucose test. Need 2 or more abnormal values >180 at 1 hr >155 at 2 hr >140 at 3 hr |
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GBS screening |
vaginal & rectal cx at 35-37 wks tx with either IV pen G or clinda or erythro is allergic if positive tx with IV abx if previous hx of baby with GBS, give IV abx regardless of cx results if mom got infection during current preg, give IV abx regardless of cx result |
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Abruptio placenta |
occurs in 3rd trimester placenta prematurely seperates from uterus p/w sudden onset vaginal bleeding severe, constant pelvic pain --> one of few things that gives pain in 3rd trimester look for hx of HTN, trauma, cocaine use |
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Placenta previa |
placenta covers internal os sudden-onset of vaginal bleeding painless hx of trauma, coitus, or pelvic exam NEVER do digital or speculum exam |
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Vasa previa |
life threatening to fetus when membranes rupture, fetal vessels are torn leading to sig blood loss in fetus painless to mom if seen, requires c-section |
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Placenta accreta |
accreta - does not penetrate entire thickness of endometrium increta - extends further into the myometrium percreta - placenta penetrates entire myometrium to uterine serosa |
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Uterine rupture |
hx of uterine scar --> vaginal birth after c-sect sudden-onset of abd pain and vaginal bleeding assoc with loss of electronic fetal heart rate, uterine contractions, & recession of fetal head |
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GBS in newborn |
pneumonia & sepsis within HRS 50% mortality rate GBS meningitis occurs after wk & is hospt acquired NOT via vertical transmission tx with intrapartum IV penicillin allergy --> IV cefazolin, clinda, or erythro no need to give abx with cx+ if doing c-sect |
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Toxoplasmosis |
chorioretinitis + intracranial calcifications + hydrocephalus handling cat feces, litter boxes, drinking raw goat milk, or eating raw meat vertical transmission is ONLY with primary infection of mom most serious infections occurs in 1st trimester mom has mono-like syndrome IUGR test with serologies tx with pyrimethamine & sulfadiazine |
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Varicella |
causes by herpes virus type 3 due to primary infection in mom greatest risk to fetus if rash appears in mom btwn 5 days antepartum & 2 days postpartum neonate has: zigzag skin lesions limb hypoplasia microcephaly microphthalmia chorioretinitis cataracts vaccinate against varicella BEFORE preg bc it's live-attenuated w/o vaccine & exposure, give VariZig to mom & neonate + oral acyclovir to mom |
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Rubella |
caused by togavirus (ssRNA) leads to: deafness (most common) cardiac - PDA cataracts MR HSM TCP blue berry muffin rash mom gets primary infection in first 10 wks of gestation no post-exposure ppx |
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CMV |
most common of sensorineural deafness in children spread by infected body fluids IUGR prematurity microcephaly jaundice HSM periventricular calcifications chorioretinitis pneumonitis tx with ganciclovir or foscarnet |
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Herpes simplex |
most common cause of transmission is contact with maternal genital lesions during active HSV episode greatest risk is primary infection in 3rd trimester neonatal infection acquired during delivery has 50% mortality rate meningoencephalitis MR pneumonia HSM, jaundice petechia if active lesions, deliver via c-sect tx with acyclovir 4 weeks before delivery date |
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HIV |
viral load >1000 --> elective c-sect baby gets ZDV for 6 wks after delivery NO BREASTFEEDING WITH HIV avoid efavirenz |
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Syphilis |
first trimester: non-immune hydrops fetalis maculopapular or vesicular peripheral rash anemia TCP HSM late-acquired: dx after 2 yrs of age hutchinson teeth (notches in teeth) saber shins (curved shins) mulberry molars deafness due to CNVIII palsy saddle nose tx with IM penicllin |
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Hep B virus |
primary infection in 3rd trimester get vertical transmission during vaginal delivery BUT NOT indication for c-sect neonate gets vaccination & Ig mom gets vaccine & Ig |
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Contraindications to breastfeeding |
HIV active Tb HTLV-1 herpes simplex with lesions on breast drugs of abuse cytotoxic meds (eg MTX, cyclosporine) galactosemia |
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HTN in pregnancy |
>140/90 gestation HTN is after 20 wks with end-organ damage or neuro sxs: preeclampsia eclampsia HELLP syndrome sustained HTN --> IUGR HTN also increases risk of abruptio placenta |
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Preeclampsia |
HTN + sudden weight gain + edema + proteinuria mild sustained BP >140/90 proteinuria (>300mg/day) severe sustained BP >160/110 >5g/day proteinuria risk factors: multiple gestation hydatidiform mole DM chronic HTN chronic renal dz |
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Tx of HTN |
only tx if BP >160/100 goal is 140-150/90-100 tx with b-blocker (labetalol), methyldopa, CCB |
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Eclampsia |
preeclampsia + tonic-clonic seizures occurs in last half of preg seizure thought to be secondary to diffuse cerebral vasospasm leading to cerebral perfusion deficits & edema tx with IV hydralazine or labetalol for BP control & Mg sulfate for seizures NEVER GIVE ACEI OR THIAZIDES |
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HELLP syndrome |
5-10% of preeclamptic pts develop HELLP tx with IV MgSO4 if before wk 36, give steroids to help fetal lung maturity can lead to: DIC abruptio placenta fetal demise ascites hepatic rupture |
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High risk cardiac problems that should avoid preg |
pulm HTN Eisenmenger syndrome severe valvular dz prior postpartum cardiomyopathy |
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Peripartum cardiomyopathy |
heart failure with no identifiable cause develops last month of preg to 5 months postpartum risk factors: multiparity age >30 multiple gestations preeclampsia |
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Cardiac drugs to avoid in preg |
ACEI aldosterone antagonists amiodarone warfarin |
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PE in preg |
leading cause of maternal death in US 50% of these pts have underlying thrombophilic d/o |
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Anticoagulation in preg |
DVT or PE A-fib with underlying heart dz (EF <30%) Eisenmenger syndrome anti-coagulate with LMWH NO WARFARIN DURING PREGNANCY |
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Thyroid d/o in preg |
HYPERthyroid - IUGR & stillbirths
HYPOthyroid - intellectual deficits in offspring & miscarriage
if hypothyroid, increase thyroxine dose 25-30%
tx hyperthyroid with PTU in first trimester or methimazole afterwards |
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Diabetes in preg |
target glucose <90 or <120 1 hr post meal GDM is initially managed by diet & light exercise if lifestyle changes dont improve --start insulin if pt refuses, can give metformin & glyburide during breastfeeding, avoid oral hypoglycemics HbA1c in each trimester starting at 32 wks, do wkly NST & AFI fetus has delayed fetal maturity so prefer to deliver at 39-40 wks do c-sect if fetus is >4500g (shoulder dystocia) |
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Induced abortion |
D&C - perform before week 13 medical abortion - mifepristone (progesterone antagonist) and misoprostol (prostaglandin E1) most common delayed complication is cervical trauma & cervical insufficiency |
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Spont abortion/fetal demise |
spont abortion - < 500g OR < 20 wks advanced maternal age previous spont abortion maternal smoking fetal demise - >20 wks most common sx is loss of fetal movement antiphospholipid syndrome overt GDM maternal trauma severe maternal isoimmunization fetal infection |
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Types of natural abortion |
painful cramps continued bleeding dilated cervix |
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Missed abortion |
loss of early preg sxs (eg nausea, breast tenderness) loss of fetal cardiac activity nonviable fetus on u/s |
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Ectopic pregnancy |
most common risk factor is PID any tubal scarring or adhesions increases risk - infections IUD tubal ligation/surg congenital risks dx with b-HCG >1500 & no intrauterine preg on u/s |
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Ruptured ectopic pregnancy |
assume when: unstable (hypotension, tachycardia) sxs of peritoneal irritation (guarding/rigidity) tx with immediate laparotomy/salpingectomy |
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Vaginal vs abd sono |
intrauterine preg seen: vaginal - 5 wks & b-hcg >1500 abd - 6 wks & b-hcg >6500 |
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Indications to use MTX |
preg mass <3.5cm absence of fetal heart motion b-hcg <6000 no hx of folate supplementation |
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IUGR |
weight is <5-10 percentile for gestational age or <2500g (5lb 8oz) accurate early preg dating is essential symmetic IUGR: aneuploidy infection (TORCH) structural anomalies (eg cardiac, NTD, ventral wall defects) aymmetric IUGR --> derives from issues in mom HTN small vessel dz (SLE) malnutrition tobacco, etoh, street drugs follow with serial u/s, NST, AFI, biophysical profiles, & umbilical artery doppler |
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Macrosomia |
weight >90-95 percentile for gestational age birth weight is 4000-4500g risk factors include: DM prolonged gestation obesity multiparity tx with elective c-sect |
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Invasive fetal testing |
CVS performed at 12-14 wks preg loss rate is 0.7%
amnio after 15 wks AFP & Achase screen for NTD preg loss rate is 0.5%
percutaneous umbilical blood sample u/s guided aspiration of fetal blood from umbilical vein after 20 wks preg loss 1-2%
fetoscopy transabd fiberoptic scope performed at 20 wks for intrauterine surg & fetal skin bx preg loss is 2-5% |
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Premature rupture of membranes |
rupture of fetal membranes before onset of labor most common cause --> ascending infection from lower genital tract dx with sterile speculum exam --> post fornix pooling of AF (nitrazine & ferning positive) |
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Chorioamnionitis |
maternal fever + uterine tenderness + PROM if contractions are present --> NO tocolysis get cervical cx, IV abx & deliver |
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Tx of PROM |
<24 wks bed rest at home 24-33 wks hospt & give IM betamethasone, cervical cx, & amp + erythromycin >34 wks initiate delivery |
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Stages of labor |
Stage 1a - latent phase (can take days) begins with regular contractions & ends with acceleration of cervical dilation (up to 3cm) Stage 1b - active phase begins at acceleration of cervical dilation & ends at 10cm (>1.2cm/hr) tx with IV oxytocin Stage 2 - descent begins at cervical dilation of 10 cm and ends with delivery of fetus should occur in <2hr Stage 3 - expulsion begins with delivery of baby and ends with removal of placenta should last <30 mins tx with IV oxytocin |
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Umbilical cord prolapse |
emergency! compressed cord jeopardizes fetal oxygenation most often occurs with ROM occurs before fetal head is engaged bradycardia maybe only clue terbutaline (beta-2 agonist) may be used to reduce contractions --> emergency c-sect |
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Approach to non-reassuring fetal tracings |
d/c meds IV bolus high-flow O2 change mom's position vaginal exam to r/o prolapsed cord scalp stimulation to observe for accelerations deliver via c-sect if tracing does not normalize |
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Postpartum hemorrhage |
uterine atony - most common cause rapid or protracted labor chorioamnionitis MgSO4 overdistended uterus tx with oxytocin or uterine massage retained placenta assoc with accessory placental lobe or abnormal uterine invasion tx with manual removal uterine inversion beefy bleeding mass appearing from vagina tx with uterine replacement & IV oxytocin |
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Postpartum fever |
day 0 - atelectasis day 1 - UTI tx with IV abx day 2-3 - endometritis (hx c-sect or PROM) --> tx with clinda & genta day 4-5 - wound infection tx with IV abx, wet-to-dry wound packing day 5-6 - septic thrombophlebitis (wide fever springs) --> tx with IV heparin day 7-21 --> infectious mastitis tx with clox |
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Benign breast dz |
1) fibroadenoma 2) fibrocystic dz 3) intraductal papilloma 4) fat necrosis - trauma to breast 5) mastitis - inflamed & painful |
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Malignant breast disease |
1) ductal carcinoma in situ 2) lobular carcinoma in situ 3) invasive ductal carcinoma 4) invasive lobular carcinoma 5) inflammatory breast cancer 6) Paget's disease of the breast/nipple |
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Nipple discharge |
bilateral = prolactinoma get prolactin level & TSH unilateral non-bloody - intraductal papilloma unilateral bloody - cancer order mammogram |
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Fibrocystic disease |
occurs in age 20-50 cyclical & b/l painful lumps pain varies with menstrual cycle simple cyst has sharp margins & post acoustic enhancement on u/s will collapse on FNA tx with OCP |
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Fibroadenoma |
discrete, firm, non-tender highly mobile breast nodule next step is clinical breast exam then order mamogram for >40 & u/s otherwise bx has to be done to confirm surg for growing fibroadenoma |
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DCIS |
surgical resection with clear margins RT with tamoxifen for 5 yrs |
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LCIS |
only tamoxifen for 5 yrs no surg needed usually pre-menopausal |
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Risks with tamoxifen |
endometrial carcinoma thromboembolism contraindications: active smoker previous or at high-risk thromboembolism |
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Invasive ductal carcinoma |
most common form of breast cancer 85% of all cases b/l in 20% |
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Paget's disease of the breast/nipple |
pruritic, erythematous, scaly nipple lesion can be confused with eczema or psoriasis look for inverted nipple with d/c |
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Breast cancer screening guidelines |
mamogram q1-2 yrs for ages 50-74 |
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Aromatase inhibitors |
eg anastrozole, exemestane, letrozole block estrogen synthesis standard in HR+ post-menopausal woman increase risk of osteoporosis |
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Leiomyoma |
most common benign uterine tumor smooth muscle growth of myometrium enlarged, firm, asymmetric, non-tender uterus b-hcg negative p/w intermenstrual bleeding and menorrhagia dx with either u/s, hysteroscopy, but histology is definitive dx can observe with serial pelvic exam or give GnRH analog 3-6 months but ultimately may need to surgically remove myomectomy preserves fertility but increases risk of uterine rupture |
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Adenomyosis |
abnormal location of endometrial glands & stroma found within myometrium causes dysmenorrhea & menorrhagia uterus is soft, symmetrical but tender dx with u/s with cystic areas tx with observation or give IUD |
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Endometrial carcinoma |
post-menopausal woman with vaginal bleeding most important risk factor --> unopposed estrogen state |
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Ovarian simple cyst |
luteal or follicular cysts most common cyst during reproductive age usually asx but can cause torsion f/u in 6-8 wks contraception can prevent new cysts |
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Ovarian complex cyst |
dermoid cyst - benign cytic teratoma rarely develop into squamous cell carcinoma tx with laparoscopic removal |
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Germ cell tumor |
most common in young woman present in early-stage disease most common type is dysgerminoma tumor markers - LDH, b-hcg, AFP |
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Epithelial tumor |
most common ovarian cancer in post-menopausal women most common type is serous tumor markers - CA-125 & CEA |
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Granulosa-theca stromal tumor |
seen in post-menopausal women secrete estrogen --> lead to endometrial hyperplasia tumor marker - estrogen |
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Sertoli-Leydig cell stromal tumor |
secretes testosterone so p/w masculinization sxs tumor marker - testosterone |
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Krukenberg tumor |
metastatic gastric cancer to ovary hx of peptic ulcer dz mucin-producing adenocarcinoma tumor marker - CEA |
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Cervical cancer HPV types |
HPV 16, 18, 31, 33, 35 HPV 6 & 11 are assoc benign condyloma acuminata |
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Cervical neoplasia screening |
start at age 21 regardless of everything else conventional method - 50% sensitivity liquid-based method - 75-80% sens for ASCUS - do HPV PCR for age <30 q3yr with cytology only for age >30 q5yr with cytology+HPV testing |
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Management of abnormal pap in preg |
CIN/dysplasia pap & colposcopy q3 months repeat pap & colposcopy 6-8 wks post-partum micro invasive cervical cancer cone bx to ensure no frank invasion deliver vaginally & re-evaluate & tx 2 months post-partum invasive cancer before 24 wks - definitive tx (radical hysterectomy +RT) after 24 wks - c-sect at 32-33 wks then start tx |
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HPV vaccine |
protects aginast HPV 6, 11, 16, 18 guard against HPVs assoc with 70% of cervical cancer & 90% of genital warts give to ALL males & females before age 26 vaccine not recommended for preg, lactating or immunosuppressed women |
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Primary dysmenorrhea |
recurrent, crampy lower abd pain n/v/d during menstruation sxs begin 2-5 yrs after onset of menstruation normal pelvic exam due to excessive endometrial prostaglandin F2 tx with NSAIDs then OCP |
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Secondary dysmenorrhea |
dysmenorrhea due to: endometriosis adenomyosis leiomyomas |
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Endometriosis |
occurs in women >30 endometrial glands outside the uterus causes dysmenorrhea dyspareunia dyschezia (painful bowel movements) most common site is in ovary definitive dx is with laproscopic visualization tx with OCPs & second line is testosterone derivatives or GnRH analogs |
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Primary amenorrhea |
absence of menses at age 14 usually no secondary sexual development breasts indicate adequate estrogen production if breasts & uterus are present --> secondary amenorrhea if breast & uterus absent --> order FSH & karyotype gonadal dysgenesis (Turners) hypothalamic-pituitary failure |
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Secondary amenorrhea |
imperforate hymen --> bulging bluish membrane btwn labia (hematocolpos) vaginal septum anorexia nervosa excessive exercise preg before first menses |
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Mullerian agenesis |
with breasts but no uterus, fallopian tubes, cervix, or upper vagina XX with normal female secondary sexual characteristics normal estrogen & testosterone levels tx with surgical vaginal reconstriction |
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Kallmann syndrome |
anosmia + amenorrhea hypothalamus doesnt produce GnRH tx with hormone replacement |
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Secondary amenorrhea w/u |
1) b-hcg 2) TSH (r/o hypothyroidism) 3) prolactin (most common is med side effect) 4) progesterone challenge test - w/d bleeding is diagnostic of anovulation 5) estrogen-progesterone challenge test |
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Causes of anovulation |
PCOS hypothyroid pituitary adenoma elevated prolactin meds (anti-psychotics & anti-depressants) |
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PCOS |
gradual onset of hirutism obesity acne, irregular bleeding, & infertility chronic anovulatory cycle dx with elevated LH/FSH ratio (3:1) & u/s shows b/l enlarged ovaries predisposition to endometrial cancer bc of high estrogen tx with OCP & spironolactone to suppress hair follicles |
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HRT |
tx for: menopausal hot flashes GU atrophy dyspareunia start with lowest dose can only give for 4 yrs NOT FOR: osteoporosis liver dz active thrombosis unexplained vaginal bleeding with a uterus - give estrogen + progestin w/o uterus - continuous estrogen |
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Molar pregnancy |
hypertension hyperthyroidism hyperemesis gravidarum no fetal heart tones fundus larger than dates |
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Hydatiform mole |
serial b-hcg CXR (r/o mets) D&C OCP for 1 yr |
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Post-partum hemorrhage |
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Post-partum thyroiditis |
can occur up to 1 yr after delivery can present as hyperthyroid alone, hypothyroid alone, or hyperthyroid followed by hypothyroid similar to Hashimoto's thyroiditis so can have anti-peroxidase Abs can have re-occurrences assoc with goiter & hypothyroid within 5-10 yrs so should get annual TSH tx sxs with propranolol or atenolol |
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Pregnancy induced thyrotoxicosis |
with signs of hyperthyroid, test only TSH relative to pregnancy ref ranges |
