d120 exam with 100% correct solutions 2024

1. Discuss the 4 Principles of Practice - answer-a. Safety is paramount b. Adhere to ethical practices c. Value base system health care delivery d. Prevention and early migration of disease 1. Identify the appropriate age and interval of recommended health screening for women. - answer-a. Woman 19-49 MMR, hep b, and varicella for those non immune. b. Girls 11-26 HPV vaccine c. Tdap 19-64 replace Td d. Women 50 influenza annually i. 19-49 annually for health care workers ii. Chronic diseases, HD, DM iii. Pregnant women e. Pneumococcal 65 or chronic disease, alcohol, immunocompromised f. Contraindicated in pregnant women i. MMR ii. Varicella iii. HPV 1. Outline the elements of the Well Woman Physical (refer to your women's health SOAP note from D117) - answer-a. History b. Physical Exam i. (1) inspection of the external genitalia, vagina, and cervix; (2) collection of cytologic specimens from the exocervix (or ectocervix) and superficial endocervical canal; and (3) palpation of the cervix, uterus, and adnexa. 1. Outline the elements of the Well Woman Physical (refer to your women's health SOAP note from D117) e cervix, uterus, and adnexa. - answer-a. History b. Physical Exam i. (1) inspection of the external genitalia, vagina, and cervix; (2) collection of cytologic specimens from the exocervix (or ectocervix) and superficial endocervical canal; and (3) palpation of th 1. Differentiate the signs of pregnancy a. Presumptive Skin and mucus membrane changes - answer-i. Chadwick sign dark discoloration of vulva vaginal walls ii. Abdominal stria iii. Linea nigra midline of lower abdomen iv. Chloasma pigmentation under eyes (hormonal contraceptives) b. Probable physical changes i. Uterine enlargement Piskacek Sign ii. Hagar Sign softer cervix iii. Pregnancy test c. Positive i. Fetal heartbeat endo ultrasound (6 weeks) ii. Fetal movements (7-8 weeks) 1. Identify the benign conditions of the vulva. - answer-a. White lesions i. Vitiligo 1. Loss of pigment / observation ii. Lichen sclerosis 1. Intense itching and dyspareunia/topical steroids, carcinoma iii. Lichen planus 1. Auto immune Wickham striae, classic fernlike or lacy patterns./ topical steroids iv. Lichen simples chronicus 1. Mimics psoriasa biosy needed/ immediate potency topical steroids v. Vulvovaginal atrophy 1. Postmenamaual decreased fat / estrogen creams/ moisturizers/ lubricants a. Red Lesions - answer-i. Eczema 1. Allergic contact mc, itching swelling and crusting /discontinue use of allergen ii. Seborrheic dermatitis 1. Red glazed shiney appreace on skin folds, greasy scalp areas/topical steroids iii. Psoriasis 1. Auto immune, red plaques with clear borders, biopsy, itscing is common, pustular form confused with candidia/ topical steroids a. Pigmented lesions - answer-i. Genital melanosis 1. Dark pigment on muscus menbranes/ expectant management ii. Acanthosis nigricans 1. Pigmented areas on vulva, axilla and neck r/t insulin resistance/ weight loss and glucose control. a. Ulcerations a fissures - answer-i. Aphthous ulcers 1. Painful like canker sores 2cm wide to 1cm deep / symptomatic ii. Bechet disease 1. Genital and oral ulcers with uveitis in combo with antivirals or IBS/depends iii. Chrons disease 1. Granulomatous intestinal tract inflammatory process/ treat bowels disease iv. Traumatic ulcerations 1. Scratching itching neglect /counseling suspect psych disorder a. Solid cysts or masses - answer-i. Epidermal cysts 1. MC, obstructed hair follicle/ body hair care/ deflation ii. Vulvar vestibular papillomatosis 1. Soft elongated papules/ reassurance iii. Genital warts 1. Human papilloma virus iv. Fox-fordyce disease 1. Chronic inflammation of apocrine glands/systemic antipruritic v. Hidradenitis suppurativa 1. Red papules painful recurrent seen in obesity/ corticosteroids, abt for celluutis, oral contraceptive reduces reoccurrence vi. Vascular lesion 1. tortuous varicosities; cherry angiomas and hematomas/Evaluation, compression; possible evacuation of expanding hematoma vii. Urethral caruncle 1. Solitary red papule at the urethral meatus; usually 1 cm diameter; appears as a collar around urethral opening/ Observation and biopsy as needed; estrogen creams; surgery rarely indicated a. The most significant of the vulvar anomalies are those that - answer-pose challenges to the assignment of gender at birth. a. Ambiguous genitalia can present with - answer-clitoromegaly, bifid clitoris, or midline fusion of the labioscrotal folds. Clitoral agenesis may result from the failure - answer-of the genital tubercle to develop. Incomplete development of the genitalia can result in a cloaca with no separation of the bladder and the vagina. . Female pseudo hermaphroditism is caused by - answer-in utero masculinization due to androgens from maternal or fetal congenital adrenal hyperplasia, androgen-producing tumors of the mother's ovary or adrenal glands, or the mother's use of exogenous androgens. Often the infant will present with ambiguous genitalia. The enlarged clitoris is the most conspicuous abnormality. a. Male pseudohermaphroditism, which most commonly results from - answer-mosaicism, may occur with varying degrees of virilization and müllerian development. a. Androgen insensitivity syndrome (a form of male pseudohermaphroditism and formerly called testicular feminization) is a - answer-genetic deficiency of androgen receptors that results in a 46,XY infant developing female external genitalia and, later in life, secondary sexual characteristics. a. True hermaphroditism is rare. The affected child has - answer-some degree of both female and male development externally and internally; dual gonadal development occurs with either a combined ovotestes or separate gonads. 1. Discuss iatrogenic anatomical changes of the vulva. - answer-a. WHo i. Type I—Partial or total removal of the clitoris and/or prepuce (clitoridectomy) ii. Type II—Partial or total removal of the clitoris and labia minora, with or without the excision of the labia majora (excision) iii. Type III—Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation) iv. Type IV—All other harmful procedures to the female genitalia for nonmedical purposes; for example, pricking, piercing, incising, scraping, and cauterizing a. Epithelial Changes - answer-i. Papillomatosis 1. Appear like papilloma virus/ reassurance ii. Contact dermatitis 1. irritation/ discontinue irritant a. Ulcerations and fistulas - answer-i. Ulcers 1. most ulceration of the vagina is associated with acute infection due to herpes simplex or cytomegalovirus;/ steroids ii. Fistulas 1. bladder or rectum into the vagina may occur due to surgical complication, infection, or malignancy/ surgical a. Cystic Masses - answer-i. Bartholin cyst 1. Cystic mass below hymenal ring at 4 or 8 o'clock; must rule out underlying malignancy in older women/ no treatment; if symptomatic, consider drainage with Word catheter placement or marsupialization ii. Gartner duct cyst 1. soft cystic structures formed from remnants of the Wolffian duct;/ asymptomatic a. Vaginal agenesis - answer-i. represents the most extreme instance of a vaginal anomaly, with total absence of the vagina except for the most distal portion that is derived from the urogenital sinus, a. Imperforate hymen - answer-i. bulging, membrane-like structure may be noticed in the vestibule, usually blocking egress of mucus. If not detected until after menarche, an imperforate hymen a. müllerian agenesis or Rokitansky-Küster-Hauser syndrome - answer-i. the uterus is absent but the fallopian tubes are spared, a. transverse vaginal septum, - answer-i. is most commonly found at the junction of the upper and middle thirds of the vagina a. midline longitudinal septum i. double cervix a. Adenosis of the vaginal - answer-i. wall consists of islands of columnar epithelium in the normal squamous epithelium. a. Urethral diverticula - answer-i. are small (0.3 to 3 cm), sac-like projections that can be found along the posterior urethra in the midline of the anterior vaginal wall a. Epidemiology - answer-i. The more common type occurs in older women and is frequently related to long-standing lichen sclerosis. ii. The less common type occurs in younger women and is related to infection with the human papillomavirus and smoking. iii. Most tumors are squamous cell carcinomas, and they occur mainly in postmenopausal women iv. vulvar cancer may also occur in association with the venereal diseases syphilis, lymphogranuloma venereum, and granuloma inguinale 1. vulvar and vaginal cancer.a. Clinical features - answer-i. Itching is the most common symptom, although some patients present with palpable or visible abnormalities of the vulva. ii. Asymptomatic iii. Approximately 20% of the lesions have a "warty" appearance, and the lesions are multicentric in about two-thirds of cases. vulvar and vaginal cancer a. Diagnosis - answer-i. Diagnosis requires biopsy of suspicious lesions, which can be done in the office with the patient under local anesthesia. vulvar and vaginal cancer a. Management - answer-i. Most cases of VIN can be treated adequately by local superficial surgical excision with primary closure. margins of about 5 mm are usually adequate. For extensive lesions involving most of the vulva, a "skinning" vulvectomy ii. Since the 1980s, a vulva-conserving approach has been used for most primary lesions, and the groin dissection has usually been performed through a separate groin incision vulvar and vaginal cancer Prognosis - answer-i. The overall survival rate for vulvar carcinoma is about 70%. ii. Patients with positive nodes have a 5-year survival rate of about 50%, whereas those with negative nodes have a 5-year survival rate of about 90%. a. Bacterial vaginosis s/s - answer-· normal balance of bacteria in the vagina is disrupted, causing overgrowth of certain lactobacilli · Foul or fishy smelling vaginal discharge that increases before menses and after intercourse · Thin, gray-white ("spilled milk") vaginal discharge · Itching and burning are rare unless coinfection with another pathogen i. Presence of 3 out of 4 of the following i s diagnostic of bacterial vaginosis (BV; Amsel criteria) ii. Copious, thin, grayish-white discharge that coats the vagina iii. Vaginal pH 4.5 iv. Positive whiff test (fishy odor of vaginal discharge when 10% KOH is added to sample) v. Clue cells on wet prep (20% more clue cells than epithelial cells) 1. If microscopy unavailable: examination findings plus positive whiff test and pH 4.5 are considered positive 2. Commercially available DNA probe for diagnosing BV is available 3. Consider STI, HIV, trichomoniasis, and Candida infection with repeated infections vi. Treatment a. Bacterial vaginosis tx - answer-1. Metronidazole 500 mg PO bid for 7 days 2. Metronidazole gel 0.75% intravaginal applicator once qd for 5 days 3. Clindamycin 2% vaginal cream 1 applicator hs for 7 days 4. Clindamycin 300 mg bid for 7 days or 5. Clindamycin 100 mg vaginal supp hs for 3 days or 6. Tinidazole 1000 mg qd for 5 days or 2000 mg qd for 2 days 7. Secnidazole (Solosec) 2 g PO once; sprinkle in applesauce and finish within 30 min; do not chew granules 8. Intermittent treatment with vaginal metronidazole gel q1wk or 2 g PO q1mo 9. Intravaginal boric acid 600 mg at hs 1 to 2 times weekly may control symptoms (boric acid taken orally can cause death) 10. Treat for any concurrent Candida infection with diflucan 150 mg 11. Follow-up in 1 mo to repeat Amsel criteria, condom use, and COCs may ↓ recurrence and IUDs may ↑ infection risk to upper GU organs a. Vulvovaginal candidiasis s/s - answer-i. overgrowth of normal yeast that occurs in vagina secondary to hormonal imbalances or changes in vaginal acidity ii. Intense vulvar and vaginal itching and burning; occasional pain with fissuring iii. Thick, creamy ("cottage cheese appearing") vaginal discharge, nonodorous iv. Vulvar erythema causing dysuria and dyspareunia v. Balanitis, urethritis, cutaneous lesions/rash on the penis i. wet prep with KOH slide shows budding yeast or hyphae a. Vulvovaginal candidiasis tx - answer-i. Treatment 1. Topical OTC 2. Clotrimazole (Gyne-Lotrimin) 1% crm: 1 applicator hs for 7 to 14 days 3. Miconazole (Monistat) 2% crm: 1 applicator hs for 7 days 4. Tioconazole (Vagistat) 6.5% ointment: 1 applicator hs once 5. Topical prescription (if recurring, increase number of days used) 6. Butoconazole (Gynazole-1) 2% crm: 100 mg/applicator once. 7. Terconazole (Terozol-3) 80 mg vaginal supp or 40 mg/applicator: 1 supp or applicator qd ×3d 8. Diflucan 150 mg tab PO once; may repeat q3d for three doses if not improved or recurring 9. Treat causes to prevent recurrence 10. Not recommended in first or second trimester of pregnancy (causes miscarriage) a. PID s/s - answer-i. II. Signs and symptoms 1. Minimum criteria for diagnosis: treat as PID if the woman is sexually active, no other cause is identified, and she meets these three criteria 2. Lower abdominal tenderness; worsens with movement and intercourse 3. Adnexal tenderness and/or mass 4. Cervical motion tenderness (CMT [highest sensitivity]) with purulent endocervical exudate (highest specificity) 5. Oral temperature 101°F 6. AUB and vaginal discharge 7. N/V 8. Dysuria, urinary frequency a. PID test - answer-i. III. Diagnostic testing 1. Elevated WBC, ESR, C-reactive protein 2. STI test for Neisseria gonorrhoeae or Chlamydia trachomatis (CT) 3. Transvaginal or pelvic U/S may show thickened, fluid-filled tubes or free pelvic fluid 4. Urine hCG (do not miss pregnancy) PID - answer-I. Usually caused by gonorrhea, chlamydia, Escherichia coli, group A streptococci, Mycoplasma genitalium, Gardnerella vaginalis II. Commonly occurs between 15 and 30 yr of age S/Sa. Trichomoniasis vaginitis - answer-i. Definition: infection caused by Trichomonas vaginalis, most common anaerobic, flagellated protozoan found in the vagina is considered an STI ii. Signs and symptoms 1. Yellow-green frothy discharge and foul odor with appearance of "strawberry cervix" 2. Vulvar itching; redness and burning of genitalia 3. Dysuria 4. Dyspareunia and symptoms may increase with intercourse or after menses TX-a. Trichomoniasis vaginitis - answer-i. Treatment should include partner i. Initial treatment 1. Metronidazole 2 g orally once 2. Tinidazole 2 g orally once 3. Metronidazole 500 mg bid for 7 days (more effective for men) ii. Recurrent treatment 1. Metronidazole 500 mg bid ×7d 2. Metronidazole 2 g qd ×7d 3. Tinidazole 2 g qd ×7d iii. Consider betadine or vinegar douche qd0 for 1 mo iv. Follow-up women in 3 mo for recheck of vaginal secretions v. No sexual intercourse for 7 days after treatment vi. Refer to GYN if symptoms persist or if pregnant TESTING-a. Trichomoniasis vaginitis - answer-i. Diagnostic testing 1. Wet prep shows trichomonads and WBC 10/hpf (may see trichomonads in urine specimen); must keep slide moist and warm for better visualization 2. Whiff test negative for amine odor 3. pH 4.5 4. Commercial testing with Trichomonas Rapid Test of vaginal secretions S/S-a. Gonorrhea - answer-i. Infection caused by N. gonorrhoeae, involving any mucus membrane (e.g., commonly genitalia, but also pharynx or eyes); may disseminate into joints, endocardium, and meninges ii. After exposure, approximately 60% to 90% of women become infected iii. If untreated, approximately 15% will have PID with increased risk of infertility TESTING-a. Gonorrhea - answer-i. Diagnostic testing 1. Cervical or urethral culture/sensitivity or urine nucleic acid amplification test (NAAT) for GC/CT; urine hCG 2. Consider posterior oropharynx or rectal NAAT (will not delineate type or sensitivity of gonorrhea) 3. Culture and sensitivity (if NAAT unavailable) of any source; use swabs with plastic or wire shafts with rayon or Dacron tips (cotton tips are toxic to N. gonorrhoeae) 4. Consider testing for HIV and other STIs TX-a. Gonorrhea - answer-1. Ceftriaxone 250 mg* IM once plus 2. Azithromycin 1 g† once or doxycycline 100 mg† bid for 7 days 3. Alternative therapy (if ceftriaxone not available) 4. Gentamicin 240 mg IM plus azithromycin 2 g orally once 5. Cefoxitin 2 g IM once plus probenecid 1 g once plus azithromycin 1 g once 6. Doxycycline 100 mg bid for 7 days 7. Cefixime 400 mg once plus azithromycin 1 g once or doxycycline 100 mg bid for 7 days a. Avoid sexual intercourse until therapy is completed (or for 7 days after single-dose therapy) b. When treating, consider chlamydia; consider treating sexual partners exposed within the last 60 days c. Retest 3 mo after treatment or at earliest opportunity within 12 mo using NAAT testing d. If reinfection suspected, obtain culture and repeat with same antibiotic regimen0 e. If drug resistance suspected, consider increasing dose of ceftriaxone to 1 g and azithromycin 2 g once f. Report the infection to the health department 8. Test of cure should be done with NAAT, at least 28 days after completion of treatment; if standard treatment and no continued symptoms then no test of cure needed 9. With positive test of cure: 10. If reinfection suspected, obtain culture and repeat with same regimen 11. If drug resistance suspected, consider increasing dose of ceftriaxone to 1 g and azithromycin 2 g once 12. Refer to infectious disease specialist if continued positive test of cure S/Sa. Chlamydia trachomatis - answer-i. ectopic pregnancy, and PID ii. Signs and symptoms 1. May be asymptomatic with mild dyspareunia 2. Mucopurulent cervicitis or vaginal discharge with spotting usually after intercourse 3. Abdominal or pelvic pain or "heaviness" 4. Pelvic examination: positive CMT with purulent discharge from cervix; cervix is friable with erosions and irritation 5. Dysuria TESTING-a. Chlamydia trachomatis - answer-i. Diagnostic testing 1. Urine NAAT for N. gonorrhoeae/CT; urine hCG 2. Culture swab for C/S from cervix or urethra and if indicated, from anal or oral sites; culture swabs should be plastic or wire shafts with rayon or Dacron tips (cotton tips are toxic to N. gonorrhoeae and CT) 3. Consider testing for HIV and other STIs TX--a. Chlamydia trachomatis - answer-i. Treatment 1. Recommended therapy: azithromycin 1 g once or doxycycline 100 mg bid for 7 days (if treating empirically and suspect N. gonorrhoeae, also treat with ceftriaxone 250 mg IM once) 2. Alternative therapy for 7 days (caution with pregnancy or lactation) 3. Erythromycin base 500 mg qid (may cause GI upset) 4. Levofloxacin 500 mg qd (caution if 18 yr of age) 5. Ofloxacin 300 mg bid (caution if 18 yr of age) a. When treating, consider gonorrhea; consider treating all sexual partners exposed within the last 60 days b. Avoid sexual intercourse until therapy is completed (or for 7 days after single-dose therapy) c. Return for repeat "test of cure" in 3 mo (if suspect poor compliance, can retest in 4 wk after treatment) d. Report the infection to the health department a. Syphilis S/S - answer-i. systemic disease caused by Treponema pallidum, Incubation period is 10 to 90 days, Recent outbreaks of syphilis have been associated with increases in HIV infection, drug use, and poverty condition ii. II. Signs and symptoms (may occur at any stage up to 30 yr after exposure) 1. Early syphilis has three periods of infectivity a. Primary stage consists of single painless firm, round ulcer (chancre) at site of infection; heals in 3 to 6 wk b. Secondary stage consists of A. Nonpruritic rough, reddish brown macular rash on torso, hands, and feet or large, raised white lesions in warm, moist areas of mouth or perineum (condyloma lata) B. Lymphadenopathy particularly in epitrochlear area; nodes are nontender and rubbery C. Anorexia, weight loss, arthralgia 2. Early latent stage may have no obvious symptoms, but disease can be transmitted a. Has positive serology b. Occurs within first year of infection 3. Latent syphilis and neurosyphilis are usually asymptomatic for years before symptoms occur and include progressive cardiovascular, skin, and neurologic symptoms a. Dementia b. Gradual blindness and deafness c. Loss of coordination, paralysis, numbness d. Aortic dilation and aortic valve regurgitation, ascending aortic arch calcification e. Skin manifestation with ulcers, elevated round, irregular, serpiginous-shaped lesions (gummas) usually seen in HIV+ persons a. Syphilis i. . Diagnostic testing - answer-1. Need to use combination tests to avoid false-positive results: RPR and VDRL; if positive, order FTA-ABS 2. Test for HIV, GC/CT, hepatitis B and C SyphilisSyphilis TX - answer-1. Primary stage: benzathine penicillin G 2.4 million U IM in a single dose or amoxicillin 3 g + probenecid 500 mg bid for 14 days; if allergic to PCN, doxycycline 100 mg bid for 14 days 2. If allergic to penicillin, treat for 14 days with 3. Doxycycline 100 mg bid 4. Ceftriaxone 1 to 2 g IM qd 5. Tetracycline 500 mg qid 6. Refer to infectious disease specialist and health department . Herpes genitalis S/S - answer-a Definition: chronic, life-long viral infection i. Many people are asymptomatic and unaware of transmission to others ii. Two types: HSV-1 (usually oral-labial) and HSV-2 (usually genital); however, either one can infect any mucous membrane; virus remains in the ganglia after infection iii. Recurrent episodes (common) are usually milder and of shorter duration a. Possible triggers A. Stress, illness, fever B. Menstrual changes, intercourse, trauma C. Fatigue, poor nutrition iv. Signs and symptoms 1. May have "flulike" illness with first outbreak along with lymphadenopathy, watery vaginal discharge, and dysuria 2. Vesicular lesions initially, followed by an ulcerated area on an erythematous base; vesicles appear "punched-out" on the skin; the surrounding skin may be spared of redness or swelling 3. Pain at site of the lesion with very little itching; prodromal symptoms may include pain or paresthesias of buttocks, thighs, legs ("boxer shorts" area) 4. Lesions usually last for about 7 to 10 days; recurrent episodes may be less severe . Herpes genitalis TEST - answer-1. Urine hCG 2. Lesion: HSV PCR assay of lesion with differentiation between HSV-1 and HSV-2 (most sensitive) or viral culture for herpes 3. STI testing for GC/CT and BV HERPES TX - answer-1. Initial outbreak therapy for 7 to 10 days; should be started within 72 hr for best results, but do not withhold medications if presents later (can be extended if not healed in 10 days) 2. Acyclovir 400 mg tid or 200 mg 5 ×d 3. Famciclovir 250 mg tid 4. Valacyclovir 1 g bid 5. B. Episodic/recurrent therapy should be started at first signs of infection 6. Acyclovir 400 mg tid or 800 mg bid for 5 days or acyclovir 800 mg tid for 2 days 7. Famciclovir 125 mg bid for 5 days or 1000 mg bid for 1 day or 500 mg once, followed by 250 mg bid for 2 days 8. Valacyclovir 500 mg bid for 3 days or 1 g qd for 5 days 1. Suppressive therapy (e.g., for ≥10 outbreaks/yr) requires daily therapy a. Acyclovir 400 mg bid b. Famciclovir 250 mg bid c. Valacyclovir 500 mg or 1 g qd A. Reevaluate annually and consider providing the patient with refills depending on use to ensure immediate treatment of outbreaks HERPES i. General measures - answer-1. Warm, wet soaks to the genital area using vinegar/water; gently pat dry perineal area (do not rub) 2. No feminine hygiene products or douching, no feminine pads; if concerned about discharge, have extra underwear available 3. Sleep without underwear or clothing in the genital area 4. Wear loose-fitting all-cotton clothing and underwear 5. No intercourse while the lesions are active or any symptoms are present 6. If symptoms are severe and urination is affected, may need to use topical xylocaine before urination or may consider intermittent catheterization for comfort 7. OTC pain medications such as NSAIDs or acetaminophen 8. Use condoms for all sexual encounters after symptoms have resolved; this may decrease the risk of transmission 9. Advise patients that the virus can spread even without the symptoms being present and that asymptomatic spread is more common in the first year of infection a. Genital warts - answer-a. Genital warts i. Definition: viral lesion caused by HPV commonly found in anogenital area 1. Increases risk of vulvar and cervical cancers 2. Most common STI; highly contagious 3. Lesions may occur up to 3 to 6 mo after exposure 4. Condoms may decrease the risk but will not be protective because the virus infects areas not covered by condoms 5. Can be transmitted vertically during birth a. Genital warts S/S - answer-1. May be small, singular, or multiple papules or plaques; can have a typical "cauliflower" appearance or be flat, pedunculated, or rough 2. Warts can be found on the vulva, in the vaginal or anal opening, under the foreskin of the penis, or on the scrotum; warts may be large enough to limit vaginal, urethral, or anal opening 3. Depending on the size and location, warts can be painful and pruritic 4. May regress spontaneously a. Genital wartsTESTING - answer-1. Usually just visual inspection 2. If no resolution after treatment or worsening with treatment, consider biopsy 3. Urine hCG a. Genital warts TX - answer-1. topical therapies; therapy may take as long as 3 mo to ablate lesions 2. Results improve if 6 warts 3. If no response to treatment in 3 to 6 wk, consider switching to another treatment 4. B. Patient-applied therapies (avoid with pregnancy) 5. Podoflox 0.5% solution or gel 6. Apply with a cotton swab to visible warts bid for 3 days, followed by no therapy for 4 days 7. Repeat as necessary up to 4 cycles 8. Imiquimod 5% cream 9. Apply at hs 3 times a week for up to 16 wk 10. Wash with soap and water 6 to 10 hr after application 11. Sinecatechins 15% ointment (extract from green tea) 12. Apply tid until resolution, but not longer than 16 wk 13. Do not wash off 14. No sexual contact while the ointment is on the skin i. Provider-applied therapies WARTS - answer-1. Cryotherapy with liquid nitrogen q1-2wk 2. Podophyllin resin 10% to 25% in compounded tincture of benzoin use ≤ 0.5 mL/treatment 3. The area of application should be small and only on intact lesions 4. Apply to each wart and allow to dry before wearing clothes 5. Wash off after 1 to 4 hr to reduce irritation 6. Avoid with pregnancy 7. Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80% to 90% 8. Before application, apply a small amount of Vaseline on the surrounding skin to prevent the acid from touching healthy tissue 9. For intense pain, neutralize with soap or sodium bicarb (i.e., baking soda) 10. Repeat treatment q1wk 11. Can be used with both vulvar and vaginal warts and in pregnant women i. Recommend HPV immunizations - answer-1. Gardasil 9 for males and females. 2. 9 to 14 yr of age: two dose series, 6 mo apart 3. 15 to 26 yr of age: three dose series at 0, 1 to 2, and 6 mo 4. If doses are 5 mo between two dose series and 5 mo between first and third dose, then a booster needs to be given at the appropriate interval 5. Not recommended during pregnancy but if becomes pregnant on series, no intervention is required. 6. Immunocompromised persons should receive three dose series. 7. If patient has completed a valid series of any HPV vaccine, no additional doses are required. 8. Refer to a dermatologist, plastic surgeon or GYN for possible surgical or laser therapy to excise or ablate multiple lesions 1. Discuss breast cancer - answer-a. Etiology i. The incidence and mortality rates for breast cancer are approximately five times higher in North America and northern Europe than they are in many Asian and African countries. ii. About 5-10% of breast cancer cases are hereditary and result from mutations in the BRCA1 or BRCA2 gene. These genetic mutations also increase the risk of ovarian cancer. Hereditary breast cancer is particularly common in premenopausal women. b. Risk factors c. Types of tumors d. Staging e. Clinical features i. Extension to the skin may cause retraction and dimpling, whereas ductal involvement may cause nipple retraction. Blockage of skin lymphatics may cause lymphedema and thickening of the skin, a change referred to as peau d'orange f. Treatment i. surgery g. Prognosis i. the status of the axillary lymph nodes has been considered to be the single most important prognosticator. ii. In the National Surgical Adjuvant Breast Project, patients with negative lymph nodes had an actuarial 5-year survival of 83% a. A diagnostic cone biopsy of the cervix is indicated in the following circumstances: - answer-a. i. Pap smear shows a high-grade lesion and the colposcopic examination is unsatisfactory. ii. Endocervical curettings show a high-grade lesion. iii. Pap smear shows a high-grade lesion that is not confirmed on punch biopsy. iv. Pap smear shows adenocarcinoma in situ. v. Microinvasion is present on the punch biopsy. 1. breast disorders. a. Nipple discharge - answer-i. Physiologic causes: 1. Pregnancy and lactation or recent lactation (e.g., bilateral clear to straw colored with early pregnancy) 2. COC use 3. Overstimulation of breasts 4. Cysts (e.g., unilateral discharge, is usually serous to greenish color) 5. Nipple piercing 6. Cloudy/milky appearance may be common in premenopausal women and is usually bilateral and painless ii. Pharmacologic causes include the following: 1. Estrogen products, herbal products with estrogenic effects 2. Metoclopramide 3. Most common psychiatric medications a. Clomipramine b. Risperidone c. Fluphenazine d. Haloperidol breast disorders i. Pathologic causes - answer-are usually unilateral, persistent, spontaneous, and localized to a single duct noted on nipple: 1. Cancer (e.g., unilateral discharge, usually clear to bloody color) 2. Pituitary lesion causing hyperprolactinemia 3. Severe head trauma, extensive thoracic surgery 4. Mammary duct ectasia (e.g., sticky green-black discharge) a. Fibrocystic breast changes i. Definition: premenstrual breast tenderness; may be either consistent or cyclic - answer-i. Signs and symptoms 1. Lumpy breast(s) with nodules of varying sizes and shapes but usually smooth, well defined, and mobile 2. Tenderness on palpation to one or both breasts, ∼1 to 2 wk before menses and may resolve for 2 wk after menses 3. Tenderness may be aggravated by menopause and/or initiation of HRT 4. May have nipple discharge that is clear to dark, cloudy color a. Fibrocystic breast changes TEST - answer-i. Diagnostic testing 1. Breast examination should include location, size, smoothness, and mobility of mass 2. Diagnostic mammogram and/or U/S if indicated; consider 3D mammography (if available) 3. Refer for diagnostic needle biopsy/draining (if indicated) Fibrocystic breast changes TX - answer-1. Decrease or stop caffeine, tea, chocolate, and nicotine 2. Wear a good supportive bra 3. Apply hot or cold compresses to breast when pain occurs 4. NSAID of choice 5. Vitamin E 1000 IU 1 tab qd, vitamin B6: 50 to 100 mg 1 tab qd (may help with pain) 6. Switch to COCs with lowest estrogenic activity or discontinue use a. Refer to breast surgeon if nodules are painful and need further evaluation a. Atrophic vaginitis - answer-i. Hypoestrogenic women having undergone natural or surgical menopause may have dyspareunia and postcoital bleeding resulting from atrophy of the vaginal and vulvar epithelium. ii. Treatment Atrophic vaginitis is treated with vaginal estrogen cream. a. Inflammatory vaginitis - answer-i. Desquamative inflammatory vaginitis (DIV) is a fairly rare clinical syndrome characterized by diffuse exudative vaginitis, epithelial cell exfoliation, and a profuse purulent vaginal discharge 1. ("strawberry cervix"). ii. By the time women are diagnosed, their symptoms have usually been present for years, and they have typically been treated repeatedly for a "vaginal infection" without any long-term improvement. iii. Initial therapy should be with 2% clindamycin cream, one applicator full (5 g) intravaginally daily for 7 days. If this is not effective, intravaginal 10% hydrocortisone daily for 14 days may be tried. a. Endocervicitis - answer-i. The diagnosis of cervicitis is based on the finding of a purulent endocervical discharge, generally yellow or green in color, and referred to as "mucopus ii. N. gonorrhoeae and C. trachomatis are associated with mucopurulent endocervicitis 50% of the time. Other etiologies include M. genitalium, bacterial vaginosis, and birth control pills. iii. dual therapy is recommended, and should include an intramuscular injection of ceftriaxone 250 mg, and a single oral dose of azithromycin (1 g). iv. It is imperative that all sexual partners be treated with a similar antibiotic regimen. Cervicitis is commonly associated with BV, which, if not treated concurrently, leads to significant persistence of the symptoms and signs of cervicitis. a. Tubo-ovarian abscess - answer-i. Tubo-ovarian abscess (TOA), an endstage process of acute PID, is diagnosed when a patient with PID has a pelvic mass that is palpable during bimanual examination. ii. About 75% of women with a tubo-ovarian abscess respond to antimicrobial therapy alone. Failure of medical therapy suggests the need for drainage of the abscess. iii. Although drainage may require surgical exploration, percutaneous drainage, guided by imaging studies (ultrasonography or computed tomography) should be used as an initial option if possible. a. Acute and recurrent cystitis - answer-i. Several factors increase the risk for cystitis, including sexual intercourse, the use of a diaphragm and a spermicide, delayed postcoital micturition, and a history of a recent urinary tract infection ii. Escherichia coli is present in the urine of 80% of young women with acute cystitis iii. There has been an increasing linear trend in the prevalence of resistance of E. coli (10%) to the fluoroquinolones (e.g., ciprofloxacin) iv. Nitrofurantoin (macrocrystals, 100 mg orally twice daily for 5 days) or trimethoprim-sulfamethoxazole (160/800 mg orally twice daily for 3 days) are the optimal choices for empirical therapy for uncomplicated cystitis. v. In patients with typical symptoms, an abbreviated laboratory workup followed by empirical therapy is recommended. a. Acute pyelonephritis - answer-i. cystitis-like illness with mild flank pain. E. coli accounts for more than 80% of these cases. Microscopy of unspun urine reveals pyuria and gram-negative bacteria. A urine culture ii. . Pyelonephritis in a pregnant patient can cause premature labor and preterm delivery if not treated promptly. iii. trimethoprim-sulfamethoxazole (160/800 mg every 12 hours for 14 days) or a quinolone (e.g., levofloxacin 750 mg daily for 7 days). Inpatient treatment regimens include the use of parenteral levofloxacin (750 mg daily), ceftriaxone (1 to 2 g daily), ampicillin (1 g every 6 hours), and gentamicin (especially if Enterococcus species are suspected) or aztreonam (1 g every 8 to 12 hours). Symptoms should resolve after 48 to 72 hours. iv. If fever and flank pain persist after 72 hours of therapy, ultrasonography or computed tomography should be considered to rule out a perinephric or intrarenal abscess or ureteral obstruction . Perinatal infections - answer-1 i. Perinatal infections are sometimes listed using the acronym "TORCH," the letters standing for Toxoplasmosis, Other, Rubella, Cytomegalovirus, and Herpes simplex virus. a. Toxoplasmosis - answer-i. The infection is usually without symptoms in the mother, but when symptoms do occur they involve fever, rash, and fatigue. ii. Household cats litter box iii. Uncooked/undercooked food from infected beef, lamb, and other animals iv. Can result in fetal microcephaly fetal hepatomegaly enlarged placenta v. Treatment during pregnancy for infected women is available using spiramycin. Rubella - answer-a. Rubella i. Vaccination has reduced the rate of infection in pregnant women with a reported incidence of 0.1% of pregnancies. ii. The vaccine should not be given during pregnancy. iii. spreads by respiratory droplets, and has an incubation period of 2 to 3 weeks. The symptoms are malaise and myalgia in the presence of a nonpruritic, maculopapular, reddish rash. iv. Deafness, retinopathies, and central nervous system and cardiac malformations are the most common teratogenic manifestations. No treatment is available for rubella, v. but prevention using the measles, mumps and rubella (MMR) vaccine is strongly recommended. Cytomegalovirus - answer-a. i. Cytomegalovirus (CMV) is the most common intrauterine viral infection. ii. The transmission is via contaminated urine, blood, saliva, semen, or cervical secretions. iii. A vaccine is available but should not be administered during pregnancy. iv. The highest rate of transmission is in the third trimester but the severity of fetal effects is highest in the first trimester. The infection may also be "reactivated" during pregnancy v. Perinatal fetal effects include jaundice, thrombocy vi. The "blueberry muffin baby" has been described with the appearance caused by numerous petechiae on the skin. Amniotic fluid is positive (by PCR) for CMV with active infection, and for 4 to 8 months maternal IgM antibodies topenia, intrauterine growth restriction (IUGR), and microcephaly. vii. . Ganciclovir and valacyclovir have been used in nonpregnant women and in neonates after birth a. Syphilis - answer-i. A perinatal infection with Treponema pallidum may cause stillbirth, IUGR, nonimmune hydrops, rhinitis, hepatosplenomegaly, "mulberry molars" and "saber shins," "saddle nose deformity," and interstitial keratitis. Prenatal testing for syphilis is mandated in the United States. ii. The treatment for syphilis in pregnancy is benzathine penicillin. iii. Patients who have a positive penicillin skin test should be desensitized and treated with penicillin, 1. Define the Barker hypothesis. - answer-a. Poor placental development has been linked to preeclampsia, preterm birth, and intrauterine growth restriction (IUGR), all of which are associated with low birth weight (2500 grams), and may play a role in fetal programming of chronic diseases later in life elements of prenatal care. - answer-1. Women who test negative for hepatitis B surface antigen and are at high risk for hepatitis B infection (e.g., health care workers) are candidates for vaccination before and during pregnancy 2. Infants born to women who test positive for hepatitis B surface antigen should receive both hepatitis B immune globulins (HBIG) and hepatitis B vaccine within 12 hours of birth, followed by two more injections of hepatitis B vaccine in the first 6 months of life. 1. Discuss confirmation of pregnancy and determination of viability. - answer-a. About 30-40% of all pregnant women will have some bleeding during early pregnancy (e.g., implantation bleeding), i. Test for pregnancy b. The pregnancy test detects human chorionic gonadotropin (hCG) in the serum or the urine c. The use of transvaginal ultrasonography has improved the accuracy of predicting viability in early pregnancies. i. 5 weeks' gestation or a mean hCG level of about 1500 IU/L d. The presence of a gestational sac of 8 mm (mean sac diameter) without a demonstrable yolk sac, 16 mm without a demonstrable embryo, or the absence of fetal cardiac motion in an embryo with a crown-rump length of greater than 5 mm indicates probable embryonic demise i. Doppler not recommended 1. Discuss the incidence of early pregnancy loss and define the types of spontaneous abortion - answer-. a. Spontaneous abortion occurs in 10-15% of clinically recognizable pregnancies. b. more than 50% of all conceptions are lost, the majority in the 14 days following conception. c. if a live, appropriately growing fetus is present at 8 weeks' gestation, the fetal loss rate over the next 20 weeks (up to 28 weeks) is in the order of 3%. 1. What are the etiologies of recurrent pregnancy loss? - answer-a. Three successive spontaneous abortions usually occur before a patient is considered to be a recurrent aborter. b. Infection i. Mycoplasma ii. Listeria toxoplasma c. Smoking and alcohol d. Psychological stress e. Medical disorders i. Dm ii. Hypothyroid iii. SLE iv. Age 30 40 1. Discuss the management of each type of early pregnancy loss. - answer-a. Threatened abortion i. Of those in whom a live fetus is present, 94% will produce a live baby ii. Once a live fetus has been demonstrated to the couple on ultrasonography, management consists essentially of reassurance b. Incomplete abortion i. Once the patient's condition is stable, the remaining products of conception should be evacuated from the uterus using appropriate pain control. ii. Pathologic eval and prompt treatment c. Missed abortion i. US to confirm ii. Spontaneous d. Recurrent abortion i. Systemic disorder ii. Lupus anticoagulant iii. Hysteroscopy iv. Chromosome assessment v. over half of couples with recurrent losses will have normal findings during the standard evaluation. vi. congenital abnormalities of the uterus can now be diagnosed using pelvic ultrasonography vii. cervical incompetence 1. suture 1. How is gestational age estimated and the EDC calculated? - answer-a. Gestational age should be determined during the first prenatal visit. b. Estimated date of confinement (EDC) or "due date" may be determined by adding 9 months and 7 days to the first day of the last menstrual period. Ultrasonography may also be used to estimate gestational age. Measurement of fetal crown-rump length between 6 and 11 weeks' gestation can define gestational age to within 7 days. At 12 to 20 weeks, gestational age can be determined within 10 days by the average of multiple measurements 1. Describe the physiologic changes associated with each body system during pregnancy. - answer-a. Cardiovascular system i. The disproportionate increase in plasma volume compared with the red cell volume results in hemodilution with a decreased hematocrit reading, sometimes referred to as physiologic anemia of pregnancy. ii. diastolic pressure decreases more markedly; this reduction begins in the first trimester, iii. Pregnancy does not alter central venous pressures. iv. Pregnancy does not alter central venous pressures. v. Because of venous compression, the rate of blood flow in the lower veins is also markedly reduced, causing a predisposition to thrombosis. vi. During late pregnancy, the uterus can also partially compress the aorta and its branches. vii. Poseiro effect. femoral pulse is not palpable viii. Pregnancy requires about 1 g of elemental iron: 0.7 g for mother and 0.3 g for the placenta and fetus ix. Plasma volume expands proportionately more than red blood cell volume, leading to a fall in hematocrit. x. Hematocrit readings below 27%, or above 39%, are associated with less favorable outcomes. Despite the relatively low "optimal" hematocrit, the arteriovenous oxygen difference in pregnancy is below nonpregnant levels. a. Respiratory system - answer-i. The diaphragm at rest rises to a level of 4 cm above its usual resting position. ii. As pregnancy progresses, the enlarging uterus elevates the resting position of the diaphragm. iii. the vital capacity (VC) remains unchanged. These characteristics—reduced FRC with unimpaired VC—are analogous to those seen in a pneumoperitoneum iv. Total body oxygen consumption increases by about 15-20% in pregnancy v. In pregnancy, the elevations in both cardiac output and alveolar ventilation are greater than those required to meet the increased oxygen consumption. vi. The rise in minute ventilation reflects an approximately 40% increase in tidal volume at term; the respiratory rate does not change during pregnancy vii. progesterone increases ventilation. viii. such increased respiratory sensitivity to CO2 is characteristic of pregnancy and probably accounts for the hyperventilation of pregnancy. ix. The hyperventilation of pregnancy results in a respiratory alkalosis. x. There is a slight downward trend in arterial PO2 as pregnancy progresses xi. Despite the absence of obstructive or restrictive effects, dyspnea is a common symptom in pregnancy. Some studies have suggested that dyspnea may be experienced by as many as 60-70% of women at some time during pregnancy a. Renal system - answer-i. The urinary collecting system, including the calyces, renal pelves, and ureters, undergoes marked dilation in pregnancy, ii. As the uterus enlarges, partial obstruction of the ureter occurs at the pelvic brim in both the supine and the upright positions. iii. Renal plasma flow and the glomerular filtration rate (GFR) increase early in pregnancy. Maximum plateau elevations of at least 40-50% above nonpregnant levels are reached by mid-gestation, and they remain unchanged to term iv. The elevated GFR is reflected in lower serum levels of creatinine and urea nitrogen, v. sodium balance is maintained with exquisite precision. vi. Potassium metabolism during pregnancy remains unchanged vii. The hyperventilation (low partial pressure of CO2 in arterial blood [PaCO2]) of pregnancy results in respiratory alkalosis, which is compensated by renal excretion of bicarbonate. viii. The maternal extracellular volume, which consists of intravascular and interstitial components, increases throughout pregnancy, leading to a state of physiologic extracellular hypervolemia. ix. Renin levels remain elevated throughout pregnancy, x. The uterus and placenta, like the kidney, can produce renin, and extremely high concentrations of renin occur in the amniotic fluid. a. Homeostasis - answer-i. In pregnancy, the insulin response to glucose stimulation is augmented. By the 10th week of normal pregnancy and continuing to term, fasting concentrations of insulin are elevated and those of glucose reduced. ii. Glycogen synthesis and storage by the liver increases, and gluconeogenesis is inhibited. iii. After early pregnancy, insulin resistance emerges, so glucose tolerance is impaired. The fall in serum glucose for a given dose of insulin is reduced compared with the response to earlier pregnancy. iv. A variety of humoral factors derived from the placenta have been suggested to account for the antiinsulin environment of the latter part of pregnancy. Perhaps the most important are cytokines and human placental lactogen (hPL) v. During the second half of pregnancy, probably as a result of rising hPL levels, lipolysis is augmented, and fasting plasma concentrations of free fatty acids are elevated. vi. Pregnancy is thus associated with an increased risk of ketoacidosis, especially after prolonged fasting. vii. rise in fasting triglyceride concentration. a. Endocrine - answer-a. Endocrine i. The thyroid gland undergoes moderate enlargement during pregnancy. ii. Placenta-derived human chorionic gonadotropin (hCG) has a TSH-effect on the thyroid gland, which can result in abnormally low levels of TSH in the first trimester, when hCG concentrations are highest. iii. TBG is increased during pregnancy because the high estrogen levels induce increased hepatic synthesis. iv. Only minimal amounts of thyroid hormone cross the placenta. it synthesizes thyroid hormone from its own thyroid gland to meet its requirements v. Adrenocorticotropic hormone (ACTH) and plasma cortisol levels are both elevated from 3 months' gestation to delivery vi. Unlike the level of thyroid hormones, the mean unbound level of cortisol is elevated in pregnancy a. Metabolism - answer-i. Aldosterone is a mineralocorticoid synthesized in the zona glomerulosa of the adrenal cortex. The main source in pregnancy is the maternal adrenal. 1. Aldosterone secretion is regulated by the renin-angiotensin system. 2. Aldosterone stimulates the absorption of sodium and the secretion of potassium in the distal tubule of the kidney, thereby maintaining sodium and potassium balance. 3. Aldosterone secretion rates decline in pregnancy-induced hypertension and, in some cases, may fall below nonpregnant levels. ii. Although calcium absorption is increased in pregnancy, total maternal serum calcium declines. The fall in total calcium parallels that of serum albumin, 1. Ionic calcium, the physiologically important calcium fraction, remains essentially constant throughout pregnancy because of increased maternal production of parathyroid hormone. The latter facilitates the transfer of calcium across the placenta to the fetus for adequate bone development, and at the same time the mobilization of calcium from the mother's skeleton to maintain adequate calcium homeostasis 2. Calcium ions are actively transported across the placenta, and fetal serum levels of total as well as ionized calcium are higher than maternal levels in late pregnancy 1. What are the mechanisms of transfer from mother to fetus across the placenta? - answer-a. simple diffusion, facilitated diffusion, and active transport. b. Low molecular size and lipid solubility promote simple diffusion c. Glucose is the main energy substrate of the fetus, although amino acids and lactate may contribute up to 25% of fetal oxygen consumption. a. Innate and adaptive immunity - answer-a. Innate and adaptive immunity i. The innate immune response is the first line of defense, and includes surface barriers (mucosal immunity), saliva, tears, nasal secretions, perspiration, blood and tissue monocytes/macrophages, natural killer (NK) cells, endothelial cells, polymorphonuclear neutrophils, the complement system, dendritic cells, and the normal microbial flora. ii. the adaptive immune system is composed of cell mediated (T lymphocytes) and humoral responses (B lymphocytes-antibodies). Activation of T and consequently B lymphocytes is critical for the development of lifelong immune responses. iii. B cells exposed to antigen for the first time produce IgM Development of fetal immunity - answer-i. Fetal B cells secrete IgG or IgA during the second trimester, ii. Fetal B cells are first detected in the liver by 8 weeks iii. Maternal IgG crosses the placenta as early as the late first trimester, but the efficiency of the transport is poor until 30 weeks. iv. for this reason, premature infants are not as well protected by maternal antibodies. IgM, because of its larger molecular size, is unable to cross the placenta. Physiologically, newborns have higher neutrophil and lymphocyte counts, and the proportion of lymphocytes and the absolute lymphocyte count are higher in neonates than in adults a. Immunologic responses during pregnancy The mother's immunologic defense system remains intact during pregnancy - answer-i. There are three reasons to suggest that vitamin D may be an important regulator of the immune system during pregnancy. ii. Pregnant women are at higher risk of severe infection and death from certain pathogens such as viruses (hepatitis, influenza, varicella, cytomegalovirus, polio), bacteria (listeria, streptococcus, gonorrhea, salmonella, leprosy), and parasites (malaria, coccidioidomycosis) compared with nonpregnant women. iii. SUPPLEMENT VITAMIN D 1. Define the four stages of parturition. - answer-a. Activation i. Normally, the signals for myometrial activation can come from uterine stretch as a result of fetal growth, or from activation of the fetal hypothalamic-pituitary-adrenal (HPA) axis as a result of fetal maturation ii. The concept of a role for the fetal lung in the initiation of parturition is particularly attractive because the fetal lung is the last major organ to mature. b. Stimulation i. Placental production of crh ii. involving uterine contractility, cervical ripening, and decidual/fetal membrane activation iii. For most of pregnancy, uterine quiescence is maintained by the action of progesterone. iv. PRA inhibits progesterone action. The ratio of PRA to PRB in the myometrium in labor is increased, which in effect results in a progesterone withdrawal. v. Functional progesterone withdrawal results in functional estrogen predominance, in part as a result of the increase in placental production of estrogen. vi. Cervical ripening is largely mediated by the actions of prostaglandins, uterine contractility by the actions of gap junctions and myosin light-chain kinase, and decidual/fetal membrane activation by the actions of enzymes such as metalloproteinases, which ultimately lead to rupture of the membranes. c. Involution i. During expulsion of the fetus, there is a dramatic increase in the release of maternal oxytocin which facilitates the initiation of the final phase of labor. ii. Phase 3 involves placental separation and continued uterine contractions. iii. Placental separation occurs by cleavage along the plane of the decidua basalis. iv. Uterine contraction is essential to prevent bleeding from large venous sinuses that are exposed after delivery of the placenta, and is primarily effected by oxytocin. v. This is further supported by oxytocin let down during early breast feeding. a. Human Placental Lactogen - answer-i. Human placental lactogen antagonizes the cellular action of insulin and decreases maternal glucose utilization, which increases glucose availability to the fetus. Gestational diabetes a. Corticotropin-releasing hormone - answer-i. measured as early as 12 weeks' gestation ii. Fetal cortisol stimulates placental CRH release, which then stimulates fetal ACTH secretion, completing a positive feedback loop that plays an important role in the activation and amplification of labor, both preterm and term. a. Prolactin - answer-i. During pregnancy, maternal prolactin levels rise in response to increasing maternal estrogen output that stimulates the anterior pituitary lactotrophs. The main effect of prolactin is stimulation of postpartum milk production. ii. secreted by the fetal pituitary may be an important stimulus of fetal adrenal growth. Prolactin may also play a role in fluid and electrolyte shifts across the fetal membranes. a. Progesterone ! - answer-i. In the luteal phase, it induces secretory changes in the endometrium and in pregnancy, higher levels induce decidual changes. ii. Up to the sixth or seventh week of pregnancy, the major source of progesterone (as 17-hydroxyprogesterone) is the ovarian corpus luteum. iii. If the corpus luteum of pregnancy is removed before 7 weeks and continuation of the pregnancy is desired, progesterone should be given to prevent spontaneous abortion. iv. Progesterone prevents uterine contractions and may also be involved in establishing an immune tolerance for the products of conception v. suppresses gap junction formation, placental CRH expression, and the actions of estrogen, cytokines, and prostaglandin. This steroid hormone therefore plays a central role in maintaining uterine quiescence throughout most of pregnancy. Estrogens - answer-a. i. Cholesterol is converted to pregnenolone in the placenta. This precursor is converted into DHEA-S largely in the fetal, and to a lesser extent the maternal, adrenals. ii. Estriol (E3), the most abundant estrogen in human pregnancy, is synthesized in the placenta from 16α-hydroxy-DHEA-S, which is produced in the fetal liver from adrenal DHEA-S iii. A sudden decline of estriol in the maternal circulation may indicate fetal compromise in a neurologically intact fetus. a. Androgens - answer-i. During pregnancy, androgens originate mainly in the fetal zone of the fetal adrenal cortex. ii. Fetal androgens enter the umbilical and placental circulation and serve as precursors for estrone, estradiol, and estriol iii. The fetal testis also secretes androgens, particularly testosterone, which is converted within target cells to dihydrotestosterone (DHT), which is required for the development of male external genitalia. The main trophic stimulus appears to be hCG. a. Glucocorticoids - answer-i. Cortisol is derived from circulating cholesterol ii. Both the fetal adrenal and the placenta participate in cortisol metabolism. iii. Toward the end of pregnancy cortisol promotes differentiation of type II alveolar cells and the biosynthesis and release of surfactant into the alveoli. iv. Cortisol also plays an important role in the activation of labor, increasing the release of placental CRH and prostaglandins. a. First-trimester screen - answer-i. A combination of maternal age, fetal nuchal translucency (NT) thickness and maternal serum-free β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein-A (PAPP-A) are included in the first-trimester screen ii. Elevated levels of free β-hCG and low levels of plasma protein-A are associated with an increased risk for Down syndrome. iii. Visualization of the nasal bone on first-trimester ultrasound has been shown to reduce the risk for Down syndrome, whereas nonvisualization (absence) has been associated with an increased risk. fetal aneuploidy. - answer-Abnormal number of chromosomes. a. Second-trimester screen - answer-i. Traditionally, a woman was offered the serum triple screening test that measures α-fetoprotein (AFP), hCG, and unconjugated estriol (UE3) at 16 to 20 weeks' gestation. ii. If the MSAFP level is elevated, an ultrasound should be done to rule out multiple gestation, fetal demise, or inaccurate gestational age (all of which can give false-positive results). iii. If none of these factors are present, amniocentesis is recommended to determine the amniotic fluid AFP level and to measure acetylcholinesterase (AChE). Acetylcholinesterase is a protein that is present only if there is an open neural tube defect. iv. The combination of low MSAFP, elevated hCG, and low UE3 levels (triple screen) has a detection rate for Down syndrome of approximately 70%, with a positive screen result in approximately 5% of all pregnancies. a. Nausea and vomiting complicate up to 70% of pregnancies. - answer-i. Eating small, frequent meals, and avoiding greasy or spicy foods may help. Also, having protein snacks at night, saltine crackers at the bedside, and room-temperature sodas are nonpharmacologic approaches that may provide some relief. ii. Vitamin B6 (pyridoxine) and acupressure ("sea sickness arm bands") may be effective a. Leg cramps - answer-i. Massage and stretching may afford some relief during an attack. Both calcium and sodium chloride supplementation ii. vitamin D 1000 to 2000 IU/day for pregnant women Daily requirements are 400 to 600 IU/day, which is the amount of vitamin D in prenatal vitamins, so prenatal vitamins will not correct the deficiency. 1. What is the recommended weight gain for pregnancy? - answer-Normal pregnancy requires an increase in daily caloric intake of 300 kcal. a. Underweight 19 28-40 lbs.. b. Normal c. Overweight 25-29.5 15-25 d. Obese ≥30.0 11-20 1. What is the recommendation for the interval of follow up visits during pregnancy? Identify the assessments performed during these visits. - answer-a. Prenatal visits should be scheduled every 4 weeks until 28 weeks' gestation, every 2 to 3 weeks until 36 weeks, and then weekly until delivery b. blood pressure, weight, urine protein and glucose, uterine size for progressive growth, and fetal heart rate. After the woman reports quickening (first sensation of fetal movement, on average at 20 weeks' gestation) and at each subsequent visit, she should be asked about fetal movement. Between 24 and 34 weeks, women should be taught the warning symptoms of preterm labor (uterine contractions, leakage of fluid, vaginal bleeding, low pelvic pressure, or low back pain). c. Beginning at 28 weeks, systematic examination of the abdomen should be carried out at each prenatal visit to identify the lie (e.g., longitudinal, transverse, oblique), presentation (e.g., vertex, breech, shoulder), and position (e.g., flexion, extension, or rotation of the occiput) of the fetus. d. screening for gestational diabetes should be performed between 24 and 28 weeks' gestation. i. Risk factors for selective screening include family history of diabetes; previous birth of a macrosomic, malformed, or stillborn baby; hypertension; glycosuria; maternal age of 30 years or older; or previous gestational diabetes. e. universal screening for maternal colonization of group B streptococcus at 35 to 37 weeks' gestation. 1. Differentiate the types of assessment of fetal well-being. - answer-a. A combination of maternal self-assessment, nonstress testing (NST), and real-time ultrasonic assessment is used to evaluate fetal well-being. b. A simple technique (kick counting) i. used to assess fetal well-being. The mother assesses fetal movement (kick counts) each evening while lying on her left side. She should recognize 10 movements in 1 hour and if she does not, she should retest in 1 hour. If she still does not have 10 fetal movements in 1 hour, c. Nonstress test i. the mother resting in the left lateral supine position, a continuous fetal heart rate tracing is obtained using external Doppler equipment 1. A normal fetus responds to fetal movement with acceleration in fetal heart rate of 15 beats or more per minute above the baseline for at least 15 seconds (Figure 7-3). If at least two such accelerations occur in a 20-minute interval, the fetus is regarded as being healthy, and the test is said to be reactive. d. Ultrasonic assessment i. Reduced fluid (oligohydramnios) suggests fetal compromise. Oligohydramnios can be defined as an amniotic fluid index (AFI) of less than 5 cm. 1. When amniotic fluid is reduced, the fetus is more likely to become compromised as a result of umbilical cord compression. ii. Excessive amniotic fluid (polyhydramnios; AFI 23 cm) can be a sign of poor control in a diabetic pregnancy iii. Fetal breathing (chest wall movements) and fetal movements (stretching and rotational movements) are also used to assess the fetus. A fetus that has at least 30 breathing movements in 10 minutes or 3 body movements in 10 minutes is considered healthy. One of the earliest signs of fetal anemia caused by Rh alloimmunization is an elevated fetal middle cerebral artery (MCA) One of the earliest signs of fetal anemia caused by Rh alloimmunization is an elevated fetal middle cerebral artery (MCA) - answer-i. 1. signs are an increase in the size and thickness of the placenta and fetal hepatomegaly. If the hemolysis is allowed to progress untreated, it will result in severe extramedullary hematopoiesis, portal hypertension, hypoalbuminemia, and the progressive development of in utero heart failure or hydrops fetalis i. the overall risk of immunization for the second full-term, RhD-positive, ABO-compatible pregnancy is about one in six pregnancies. - answer-i. All pregnant RhD-negative women who are not sensitized to the D antigen should routinely receive prophylactic Rh immune globulin at 28 weeks' gestation, within 72 hours of delivery of an RhD-positive fetus, and at the time of recognition of any of the problems cited above that are associated with fetomaternal hemorrhage. RHD risk factors - answer-a. i. In RhD-negative patients whose anti-D antibody titers are positive (i.e., those who are RhD-sensitized), the RhD status of the father of the baby should be determined. ii. If the father is RhD-negative, the fetus will be RhD-negative and hemolytic disease will not occur, so further monitoring is unnecessary. 1. If the father is RhD-positive, his Rh genotype should be determined using quantitative polymerase chain reaction 2. first immunized pregnancy is not in serious jeopardy when the anti-D antibody titer remains below 1 : 16. I RDD MANGMT - answer-i. Intrauterine Transfusion 1. The goal is to transfuse fresh group O, Rh-negative packed red blood cells. 2. Transfusions usually cannot be done until 18 to 20 weeks' gestation, because fetal size limits vascular access. 3. The overall survival rate following intrauterine transfusion is about 90%, but it is significantly lower for fetuses with hydrops before the transfusion. ii. Fetal Intraperitoneal Transfusion 1. In nonhydropic fetuses, the blood should be absorbed within 7 to 9 days 2. intraperitoneal transfusion is reserved for cases in which intravascular transfusion is not possible, such as gestational age less than 20 weeks. iii. Intravascular Transfusion 1. Under ultrasonic guidance, and using sterile technique, a 22-