NSG 6330 Women’s Health Study Guide 2025 – Complete Exam Review & Verified Solutions

NSG 6330 WOMEN'S HEALTH STUDY GUIDE LATEST 2025 COMPLETE SOLUTIONS WITH VERIFIED A+ ANSWERS What is the typical onset of Dysmenorrhea? Within 2 years of menarche Painful menstruation caused by excess prostaglandin and leukotriene levels Primary dysmenorrhea What Sx occur with primary dysmenorrhea? Uterine contraction, N/V, and Diarrhea Painful menstruation caused by an identifiable condition, normally of the uterus or pelvic Secondary dysmenorrhea What are some conditions that cause secondary dysmenorrhea? Endometriosis, Adenomyosis, Fibroids, PID, and IUDs What is the MC population that suffers from Secondary Dysmenorrhea? Women >25 yo What is the MC population that suffers from Primary Dysmenorrhea? Late teens and early 20's An 18 yo female presents to your clinic with complaints of cramps that radiate to her lower back and diarrhea. She says that it started when her period started, but has continues for 3 days now. You preform a PE, and note that everything is normal. Her labs also come back as normal. Dx? Tx? Primary dysmenorrhea NSAIDS --> start 2 days prior to start of menses and continue for 1-3 days A 27 yo female comes in with complaints of cramps that radiate to her lower back, bloating, and pain with sex. She states that it does not necessarily occur with the first day of her cycle. You note in her chart that she had an IUD placed ~6 months ago. You preform a PE and draw labs. PEis normal, and labs are all normal. Dx? Tx? Secondary Dysmenorrhea Treat underlying cause if possible, NSAIDS, if severe in this case, remove IUD What is the average length of time that perimenopause lasts? 3-5 years By definition, what is menopause? The last menses What is the average age of menopause? 51.5 years old What is the average age range most women enter Menopause in? 44-55 yo What is associated directly with early onset menopause? Smoking Premature menopause occurs before the age of what? 40 yo Which type of estrogen is the predominant circulating estrogen during Menopause? Estrone What is the MC Vasomotor Sx that menopausal women experience? When do they most commonly occur (time of day)? How long does it take for them to cease? Hot flashes At night 2-3 years What level of FSH is diagnostic of Menopause? >30What lifestyle change has been directly associated with relieving Menopause Sx? Increasing exercise HRT for Menopause increases the women's chance of developing what? Cardiovascular probs, Breast CA, and Cognitive decline What are the absolute CI's to HRT in a menopausal women? Undiagnosed vaginal bleeding, acute vascular thrombosis, liver probs, and Hx of endometrial/ovarian CA Name that condition: Abnormal uterine bleeding in the absence of an anatomical lesion DUB What is the MC origin of DUB? Hypothalamic-pituatary-ovarian hormonal axis What are the MC times for DUB to occur? Shortly after Menarche and during Perimenopause How can you Tx DUB? 1. Conservative Tx 2. OCPs 3. Progestin trial 4. D&C 5. Hysterectomy Which virus is directly linked to Cervical CA? HPV strains 16, 18, 31, and 33 Which HPV strains are strongly linked to Condylomata Acuminata? HPV strains 6 and 11 What is the MC age group that suffers from CIN? MC age group for CIS? MC age group for Cervical CA? Women in their 20's Women 25-35 Women >40 yoIf a women has an abnormal Pap smear, what is teh most appropriate technique, moving forward, for evaluation of the patient? Colposcopy with Bx How do you Tx pre-invasive cervical lesions? Electrocautery, conization, LEEP procedure When is Conization a better option than the LEEP procedure? When is LEEP favored in general? Conization is a better option for larger areas of concern LEEP is generally favored overall because it has a lower risk for causing an incompetent cervix What is the Tx for CIS? Hysterectomy and RADs Which imaging modality helps to differentiate between solid and cystic breast masses? US What is the MC benign condition of the breast? What is the second MC? Fibrocystic breast disease Fibroadenomas What procedure is BOTH diagnostic and therapeutic in fibrocystic breast disease? FNA **Contain straw colored fluid What is the MC population that experiences Fibroadenomas? AA women <25 yo How do you manage/Tx a Fibroadenoma? Bx all masses. Surgical excision or conservative management based on the patient's Sx What is the MC CA in females? Breast CA What is the 2nd MC COD from CA in females? Breast CAWhat are the geners directly associated with Breast CA? BRCA 1 and BRCA 2 What puts women at a higher risk for developing breast CA? Nulliparity, early menarche, late menopause, HRT Breast CA increases your risk of developing what other kind of CA? Endometrial CA What is the MC type of breast CA? Infiltrating Ductal Carcinoma How do you Tx a women who has estrogen receptive breast CA, or who is post menopausal? Tamoxifen Contraception *Add info* What conditions does the term PID include? Acute salpingitis, UID related pelvic cellulitis, Tubo-ovarian abscess, and pelvic abscess What are teh complications of PID? Infertility and ectopic pregnancy A young female presents with bilateral lower abdominal and pelvic pain. She has also been feeling nauseous, but has not vomited. She is afebrile. During the exam, you note positive chandelier's sign, and purulent vaginal discharge. No adnexal masses are noted. Dx? Tx? PID Mild: PO abx Severe: Hospitalization with IV abx and possible surgery. What testing should ALWAYS be done in a women that has confirmed PID? STD testing ---> more specifically Gonorrhea and Chlamydia Abortion is the termination of a pregnancy before what gestational age? 20 weeksName the condition: Spontaneous and premature expulsion of the products of conception Spontaneous abortion When is the MC time for a spontaneous abortion to occur? The first trimester A women comes in for her 20 week pregnancy visit. When you perform the exam, you note that the fundus does read at 20 cm, but instead is only present around 15cm. You also note the fundus feels boggy, adn is tender to palpation. What should you be suspicious of? Spontaneous abortion How soon after conception can serum bHCG be detected? Urine? 5 days 14 days Uterus softening at 6 weeks gestation Ladin's sign Uterine isthmus softening at 6-8 weeks gestation Hegar's sign Cervix softening 4-5 weeks gestation Goodell's sign Cervix and vulva bluish color at 8-12 weeks gestation Chadwick's sign When are fetal heart tones first heard? What is the normal rate? 10-12 weeks 120-160 bpm When can you first detect a fetus on PELVIC ultrasound? 5-6 weeks gestationWhen does a women first feel fetal movement? What is the term used to describe this? 16-20 weeks Quickening Spontaneous uterine contractions late in preg, that are NOT associated with cervical dilation Braxton-hicks contractions Palpable lateral bulge of softening of uterine cornus at 7-8 weeks gestation Piscacek's sign Cystocele *Add info* Rectocele *Add info* What are the MCCs of Vaginitis? BV, Trich, Yeast What are the MC presenting complaints of vaginitis? Vaginal burning, itching, pain, discharge, and inflammation what is the MCC of secondary amenorrhea? pregnancy a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D. osteoporosis reduced bone mass of lesser severity than osteoporosis.Mild thinning of the bone mass. Osteopenia represents a low bone mass and is not as severe as osteoporosis. Osteopenia results when formation of new bone (osteoid synthesis) is not sufficient to offset normal bone loss (osteoid lysis). osteopenia what is a normal blood loss? 10 ml to 80 ml is normal and anything above 80 ml is considered abnormal bleedingwhat is the hormone in the post menopausal women? estrone dyspareunia, painful intercourse, dryness and itchiness in a 50 y.o women? Urogenital atrophy due to menopause What test is the test done for menopausal women? Bone density what do you give to treat decreased bone density in post menopausal women? Give calcitonin, calcium biphosphinate, glass of milk and SWIMMING what is diagnostic for menopause? FSH greater then 30 mIU/mL what is another name for fibroids? Leiomytomata what fibroid is the most common cause of uterine bleeding? submucous fibroid what is the most common presenting symptom of leiomytomata? bleeding what is the is medication used to treat fibroids? mifepristone and GnRh a young person of reproductive age comes in the RLQ pain what is your top 4 differential? pregnancy, ectopic pregnancy, appendicitis, ruptured ovarian cyst what size cyst to you need to remove? over 8 cm, under you need to monitor remove what gives you a risk for getting ovarian cancer? women with breast cancer are common to get ovarian this is why breast cancer women should get pelvic exams done every 6 months/yearly AND ORDER the BRCA 1 gene if you have a first degree relative of ovarian cancer* CIN-1 comes back abnormal after first pap what do you do?repeat the pap smear then you them to do a colposcopy which is a cervical biopsy what is the most appropriate/definitive technique for histologic evaluation of cervical dysplasia/neoplasia? colposcopy with biopsy how do you diagnose neoplasm? acetic acid or staining with toluene blue on the vulva will cause the lesion to be highlighted what stain do you use for a suspected vaginal neoplasm/VULVAR CANCER? lugol staining/ toluidine blue Cervical cancer- [HPV] - (4) 16,18,31,33* what is the best fetal heart rate? 120-160 really want 140 or higher** G P G=number of pregnancies, P is deliveries, **** full term, premature, abortions, living ** what is the formula used to calculate when a women is due? aka the EDC Nagele RULE, LMP go back 3 months and add 7 days*** what is mom is rH neg and baby is rH positive? fetal demise-->hydrops fetalis why must you get the rubella titer for rubella? bc baby can become blind and deaf PAPP-A tests for trisomy 21 during the trimester. if you get a result = risk for trisomy 21 FIRST low increased if your pt is in the the SECOND trimester and has a low unconjugated estriol and a low AFP with a HIGH inhbin A what does this mean?there is 75% to 80% there is neural tube defect!!! 50% of spontaneous/incomplete abortion during the 1st trimester is caused by one main ting, what is this #1 cause of these abortions? chromosomal abonormality** B-Hcg doubles very 48 hours so if her quantitative(number value) number is 240 monday then wednesday it should be? 480-this shows the fetus is progressing bleeding, cervix is closed and no products of connection threatened bleeding cervix open and products of conception not yet passed inevitable bleeding, open and partial products on conception incomplete bleeding, open cervix and there are products of conception complete NO bleeding, cervix is closed, no products of concepttioon MISSED missed does not have bleeding!!! snowstorm and grapes on US complete hydatiform mole-this is more common and benign -the pregnancy will not be viable complete will not have a While incomplete will have grapes and snowstorm with a fetus. how would you diagnose any GTD? fetus -Bhcg is greater then 100,000 and diagnose by US GUSH OR LEAKAGE OF FLUID or vaginal discharge"peed myself" but its amniotic fluid PROM premature rupture of membranes is when the membranes rupture before lab around weeks and amniotic fluid will leak out, you usually have to go into labor,how do you treat this?37 best thing to do deliver the fetus via C-section to treat!! how do you diagnose? the sterile speculum with nitreazine paper and/or fern test at the bedside YOU DO NOT DO A DIGITAL EXAM ON PROM...WHY? the baby will come out! you will indice labor you need to go to OR and do a Csection!! how do you to dilate the cervix ** Prostaglandin cervical gel hwat is the difference between chronic HTn and PIH which is pregnancy induced HTN? before 20 weeks is chrnic an after is PIH how do you treat HTN chronic or PIH? METHYLDOPA what is the triade for eclampsia or preeclampsia? HTN, edema of lower extremities and proteinuriea what is the server form of ecmalpsia/preeclmapsia HELLP syndrome -hemolysis, elevated liver enzymes and low platelets what is difference between ecmalpsia and preeclampsia? ecmap-same symptoms + seizures # 1 complicaiton of pregnancy in relation to fetus is DIC -know DIC is always associated with pregnancy give Mg sulfate and tell pt they will feel flushed for what two things? pre term labor and mild pre-eclampsia continues it for 24 hours after the delivery MGSO4 iis given before 34 weeks for lungs to develop before deliver to mom and baby after betamethasone or may be given for acute management of high blood pressure after the baby has been delivered•Hydralazine or labetalol ROGAM is administered - weeks if the mom is known to be rh negative!! also must give if the women miscarries to prevent? 28-29 any future miscarriage, must give this in the ER if miscarried Rho gram is mg given at 28 weeks of gestation and within hours after delivery the rH positive baby 300 72-this is the second dose PAINFUL VAGIAL BLEEDING abruptio palcenta** what is MCC of third trimester bleeding? abruptio palcenta** what does abruption lead to? DIC B is most C is most common dangerous PAINLESS VAGINAL BLEEDING placenta previa why can you not do a digital pelvic exam in placent previa? incites severe bleeding Leopold remover who's you where the fetus is and makes sure they re in the proper vertical position Define menopause. absence of menses for 12 consecutive months, usually b/t 48 and 55 y/o What is the mean age at natural menopause?51.5 In what age range do most women reach menopause? 95% of women reach menopause between 44 and 55 How is smoking associated with menopause? early menopause What is the cut off age for defining premature menopause? before age 40 What lab value is diagnostic of menopause? FSH > 30 mIU/mL What treatments are used for symptomatic improvement of menopausal symptoms? HRT, exercise, topical estrogens, soy, black cohosh, ginseng Vit D + Ca supplementation, bisphosphonates, SERMs, calcitonin for risk of osteoporosis What are contraindications to HRT? H/O breast or endometrial cancer, undiagnosed vaginal bleeding, acute vascular thrombosis, liver disease How long do vasomotor symptoms of menopause last? 2-3 yr (3-6 wk w/ HRT) Define dysmenorrhea. pain w/ menses (bearing down, aching, cramping) Define PMS. cluster of emotional, behavioral and physical symptoms occurring 5 days before menses for 3 consecutive cycles Describe the epidemiology of PMS. 75% of women have PMS to some degree, 5% have severe dysfunction most common in late 20s-early 30s Describe the pathophysiology of PMS. used to be attributed to hormones; now, physiologic ovarian function changing serotonin levels, which are affected by EST and PROG less GABA during luteal phaseWhat are the diagnostic criteria for PMS? 1. s/s in the 5 days prior to menses for 3 consecutive cycles 2. s/s resolve w/in 4 days after onset of menses 3. s/s interfere w/ daily activity 4. 1+ affective and somatic symptoms 5. occur during luteal phase, w/7 d asx phase during follicular phase What are dietary recommendations for PMS? limit caffeine, alcohol, and chocolate; small, frequent meals What are conservative treatments for PMS? stress management, CBT, aerobic exercise What are pharmacologic treatments for PMS? bromocriptine (mastodynia), vit E, calcium carbondate, Mg, B6, spironolactone, NSAIDs, fluoxetine, sertraline, OCPs, estradiol patch, GnRH agonists What is the definitive treatment for PMS? B/L oophorectomy What are causes of secondary dysmenorrhea? endometriosis, adenomyosis, endometrial polyps, PID Describe the epidemiology of secondary dysmenorrhea. incidence increases with age, usually 25+ affected What causes primary dysmenorrhea? increase in prostaglandins during the luteal phase when estrogen and progesterone decline, leads to inc. uterine contractions, thus dec. uterine blood flow, thus hypoxia Describe the epidemiology of primary dysmenorrhea. most common late teens to early 20s How are primary and secondary dysmenorrhea related to the first day of the cycle? primary: symptoms usually begin on first day or soon after, last 1-3 days secondary: less related to first day of cycle S/S of dysmenorrhea pelvic/abdominal pain or cramps, N/V/D, HAWhat is the most common misdiagnosis of primary dysmenorrhea? secondary dysmenorrhea due to endometriosis Describe the characteristic pattern of pain of endometriosis. starts 1-2 weeks before menses, reaches peak 1-2 days before menses, relieved at onset of flow or shortly after What drugs are used to treat primary dysmenorrhea? NSAIDs, analgesics (even codeine if needed), acetaminophen, antiprostaglandins, OCPs How are NSAIDs prescribed to treat primary dysmenorrhea? to be taken at the earliest onset of symptoms or 1-2 days before How do COX-2 inhibitors compare to NSAIDs for the treatment of primary dysmenorrhea? more expensive and less proven record of safety; equally effective but not better than naproxen What COX-2 inhibitors are effective in treating primary dysmenorrhea? rofecoxib, valdecoxib, lumiracoxib How do OCPs decrease s/s of primary dysmenorrhea? by inhibiting ovulation or by altering the endometrium, leading to decreased PGs How long should OCPs for dysmenorrhea be continued? 6-12 months (if pt does not want contraception), most patients report improved symptoms even after stopping What are the components of the GPtpal score? G = gravida = total # of pregnancies P = para = outcome of pregnancies t = term, p = premature, a = abortion, l = living children Outline the 5 main components of a women's health history. 1. Menstrual history (menarche through menopause) 2. Reproductive history 3. Vulvovaginal symptoms (includes STI history) 4. Sexual orientation and response 5. Health promotion/counseling What are the 2 histologic types of cervical cancer?80-90% squamous cell carcinoma 10-20% adenocarcinoma Where does cervical cancer arise? the transformation zone: the area b/t the endocervical columnar epithelium and the ectocervical squamous epithelium What is the most common STI in the US? HPV What percentage of cervical cancer is attributable to HPV 16 or 18? 70% What is the single most important risk factor for cervical cancer? persistent infection with a high-risk HPV subtype, like 16 or 18 What subtypes of HPV are associated with genital warts? 6, 11 What are risk factors for cervical cancer? HPV infection, smoking, multiple sexual partners, prior H/O cervical cancer, immunosuppression, long-term OCP use, coinfection w/ Chlamydia, parity, genetic polymorphisms, early age at first birth At what age should women have their first PAP smear according to ACOG guidelines? 21 What are the ACOG guidelines for PAP smears for women ages 21-29? screen every 3 yrs (liquid-based or conventional cytology) What are the ACOG guidelines for PAP smears for women ages 30-65? every 3 years w/ cytology if 3 consecutive negatives and no H/O invasive carcinoma, HIV infection, immunosuppression, or DES exposure or every 5 yrs w/ cytology and HPV testing What are the ACOG guidelines for PAP smears for women who have undergone a hysterectomy? discontinue screening if hysterectomy was for benign indications and no H/O high grade CIN What are the ACOG guidelines for PAP smears for women 65 and older?discontinue screening if 3+ negative cytology tests in a row and no abnormal tests in the last 20 years What is the treatment for stage 0 (carcinoma in situ) cervical cancer? total hysterectomy, cervical conization, ablation w/ cryotherapy or laser (depending on whether they want to keep uterus) + F/U w/ PAP q 3 mo for 1 yr, then q 6 mo. for 1 yr. What is the treatment for invasive cervical carcinoma (anything above stage 0)? simple/radical hysterectomy +/- RT, CT (depends on exact stage) What system is used to classify PAP test results? Bethesda system What are the Bethesda classifications for PAP results? 1. NOCA = no observable cellular abnormality 2. NILM = no evidence of intraepithelial lesion/malignancy 3. ASC-US = atypical squamous cells of undetermined significance 4. ASC-H = cannot exclude high grade lesion 5. LSIL = low grade squamous intraepithelial lesion 6. HSIL = high 7. CIS = carcinoma in situ (has not invaded basement membrane) 8. squamous cell carcinoma = invasive What is a koilocyte? cellular changes that can occur as a result of HPV How are samples from a cervical biopsy classified? CIN = cervical intraepithelial neoplasia = invasive cancer CIN 1 = mildly atypical cells in lower 1/3 of epithelium CIN 2 = moderately atypical cells in basal 2/3 of epithelium CIN 3 = severely atypical cells in greater than 2/3 of epithelium What stain is used to classify CIN 2 cervical cancers? p16 immunostaining if neg. = LSIL if pos. = HSIL At what age do we start to worry that women cannot clear HPV infection? 30 What condition are HPV 6 and 11 associated with?condyloma acuminata (genital warts) What HPV strains are included in the Gardasil vaccine? 6, 11, 16, 18 What are the age guidelines for the Gardasil vaccine? routine vaccination of all females 11-12 y/o (before first sexual activity) can be given in males or females ages 9-26 How is Gardasil given? IM injection, 3 doses 2nd is 2 mo. after the first 3rd is 6 mo. after the first What ages of males and females can Gardasil 9 be given to? females 9-26 males 9-15 What patients should NOT receive the Gardasil vaccine? allergies to yeast and other vaccine components, pregnant women Describe the Cervarix vaccine. divalent: HPV 16, 18 females 9-26 y/o most effective if before first sexual activity What grade lesions are treated with cryotherapy? ASC-US and LSIL What are the two types of cervical conization procedures? LEEP and LLETZ What is the LEEP procedure used for? when you can see the whole lesion Risk factors for ovarian cancer late first parity, low parity, early menarche, late menopause, endometriosis, HRT > 5 yr, FH, BRCA mutation, high fat diet What factors decrease the risk of ovarian cancer?breastfeeding > 18 mo, late menarche, early menopause, multiparity, hysterectomy, tubal ligation, OCP use, low fat diet S/S of ovarian cancer vague! abdominal fullness, back pain, constipation, diarrhea, nausea, early satiety, fatigue, pelvic pains, urinary symptoms PE findings for ovarian cancer inguinal LAD, abdominal mass, ascites, Sister Mary Joseph nodule, pelvic or adnexal mass What is the most common ovarian tumor in children? endodermal sinus tumor What is the most common type of ovarian cancer? epithelial What labs will be increased in the case of germ cell ovarian cancer? beta-HCG, alpha fetoprotein, neuron specific enolase, LDH What imaging is used initially for an adnexal mass? Doppler transvaginal US What US findings are suggestive of ovarian cancer? complex cystic/solid areas, extramural fluid, echogenicity, wall thickening, septa, papillary projections What conditions can cause an increased CA-125? epithelial ovarian tumor, PID, endometriosis, functional ovarian cyst, pregnancy, menstruation What is the lifetime risk of ovarian cancer for women with BRCA 1 or 2 mutation? 1: 45% 2: 25% What is the most common route of spread of endometrial cancer? direct extension to cervix or outward through myometrium and serosa What is the most common type of endometrial cancer? endometrioid adenocarcinoma What is the most important prognostic factor of endometrial cancer?histologic grade Prognostic factors of endometrial cancer histologic grade and stage, lymphatic spread, tumor size, age, depth of myometrial invasion, surgical stage, peritoneal cytology, lymphovascular invasion Ages most affected by endometrial cancer postmenopausal, 50-59 Risk factors for endometrial cancer nulliparity, unopposed estrogen, late menopause, obesity, chronic anovulation, tamoxifen use, DM, HTN, breast/ovary/colon cancer, FH What is the most common cause of vulvar ulcers? herpes virus Genital herpes: pathogen HSV (usually 2, can be type 1) Genital herpes: transmission intimate contact, even during asymptomatic periods When is asymptomatic shedding of HSV most likely? during the 6 mo-1 year after the first episode and right before or after a recurrence Protective factors for endometrial cancer OCPs, progestin-only pills, est/prog HRT, high parity, pregnancy, physical activity, smoking S/S of endometrial cancer postmenopausal/abnormal uterine bleeding; vaginal discharge; pelvic pain/mass; weight loss What is the most common cause of postmenopausal bleeding? How can this be ruled out? atrophy transvaginal US: endometrial thickness < 4 mm = low risk of malignancy How is endometrial cancer diagnosed? office endometrial biopsy What labs should be obtained during the workup of endometrial cancer? TSH, FSH, estradiol, CBC, prolactin, CA-125, PAPWhen should a woman with Lynch II (HNPCC) mutation or a family member with the mutation undergo EMB? begin at 35 Treatment for endometrial cancer stages I/II: TAH-BSO, LN dissection, tumor resection stages III/IV: radiation + surgery advanced/recurrent: chemo Prognosis of endometrial cancer most diagnosed at stage I, so good prognosis. When is the risk of recurrence of endometrial cancer the greatest? first 3 years after treatment F/U schedule for endometrial cancer q 3 mo. for 3 yrs, then q 6 mo. for 2 yrs., then annually Genital herpes: incubation 2-12 d Genital herpes: s/s first episode: HA, fever, malaise, urethritis, LAD prodrome of tingling/itching, then painful fluid-filled vesicles, then ulcers/erosions surrounded by red halos How do HSV 1 and 2 differ? HSV 1 infection is less likely to present with ulcers (but w/ HSV 2 they can also be absent), recurrence and subclinical shedding are less likely w/ HSV 1 than 2 What patient education should be provided in regards to genital herpes? asymptomatic shedding, reduce shedding by using condoms, have partner tested, can take antivirals as chronic suppressive therapy What antiviral is used for chronic suppressive therapy for genital herpes? Valacyclovir (500 mg PO daily, best studied, once daily dose) can also use acyclovir Describe laboratory testing for genital rred = culture + PCR (but low sensitivity) can also perform serum HSV IgG (type 1/2 specific) Treatment of first episode of genital herpes Valacyclovir 1 g PO BID for 7-10 d Treatment for recurrent episodes of genital herpes Valacyclovir 1 g PO qd for 5 d start during prodrome or w/in 1 d of lesion onset Why is herpes commonly misdiagnosed as candidiasis? itching from candidiasis can lead to ulcers/excoriations, imitating the ulcers seen in herpes infection How can herpes and vulvovaginal candidiasis be differentiated? herpes: flu-like symptoms, significant pain, complaint about ulcer/erosion, burning vulvar pain, pain referred to legs What is the relationship between timing of a pregnant mother being infected with herpes and the risk of transmission to baby? infected during first 1/2 of pregnancy: risk of transmission < 1% higher if infected closer to time of delivery and if mother has a H/O HSV and active outbreak during pregnancy What drug is used for pregnant mothers with HSV infection (recurrent or for suppressive therapy)? acyclovir Condyloma acuminata (genital warts): pathogen HPV 6, 11 Genital warts: incubation weeks to months What percent of the population has been infected with HPV at some point in their lives? What percent has clinical s/s? 30-60% 1% of those infected Describe appearance of genital inful pink-to-white exophytic/papillomatous growth, small at first, then coalesces to form large cauliflower-like mass What is used to diagnosis genital warts? colposcopy w/ acetic acid or iodine (can see small and flat lesions) + cytologic smear an HPV-DNA test also exists What is the risk to baby born to a mother with genital warts? respiratory papillomatosis, which causes laryngeal papillomas, predisposing the baby to recurrent pneumonia When should a pregnant mother with genital warts be treated? 30-32 wks (if unsuccessful, C-section necessary) What is the treatment for genital warts during pregnancy? electrocoagulation, cryotherapy, CO2 laser therapy at about 32 wks What are provider-applied methods of treating genital warts? bi/trichloracetic acid, podophyllin, cryosurgery, electrosurgery, surgical incision, laser vaporization What are patient-applied methods of treating genital warts? podofilox or imiquimod What genital wart treatments should NOT be used during pregnancy? podophyllin, podofilox, imiquimod What is vestibular micropapillomatosis? normal small papillae of the inner labia minora, often confused for genital warts Do you examine and treat partners of patients with HPV? Why or why not? no, because subclinical infection is so likely Chancroid: pathogen Haemophilus ducreyi (gram negative rod) In what areas of the world is chancroid most common? Africa and the Caribbean Chancroid: incubation4-10 d Chancroid: s/s erythematous papule, then pustule, then saucer-shaped ragged ulcer surrounded by inflammatory wheal lesion is tender with heavy discharge painful inguinal adenopathy, may become fluctuant buboes How is chancroid diagnosed? specialized culture media, but not widely available can perform scraping, which demonstrates school of fish pattern Chancroid: treatment hygiene important azithromycin 1 g PO once OR ceftriaxone 250 mg IM once aspirate fluctuant lymph nodes After antibiotic therapy, when should s/s of chancroid improve? 3-7 d (if none at 7 d, re-evaluate for other diagnoses or co-infection) Should sexual partners of a patient with chancroid be treated? yes, regardless of symptoms, if they had sexual contact with infected patient in the 10 d preceding symptom onset Lymphogranuloma venereum: pathogen chlamydia trachomatis L1-L3 Lymphogranuloma venereum: incubation 7-21 d Epidemiology of lymphogranuloma venereum M:F = 6:1 more common in tropical areas of Africa, Asia and southeastern US associated with HIV in MSM LGV: s/s tender unilateral inguinal/femoral LAD +/- ulcer at site of inoculation+/- proctocolitis +/- constitutional s/s How is LGV diagnosed? exclusion + complement fixation test for chlamydia (blood test) LGV: treatment Doxycycline 100 mg PO BID for 21 d Gonorrhea: pathogen Neisseria gonorrhoeae (gram negative diplococcus) Gonorrhea: ... Syphilis: pathogen Treponema pallidum (spirochete) Syphilis: transmission sexual contact, transplacental Syphilis: primary stage red, round, firm painless ulcer with raised edges, usually about 1 cm 3 wk after inoculation, heals spontaneously Syphilis: secondary stage 6-12 wk flu-like s/s (fever, myalgias, LAD) maculopapular rash, including palms and soles, condyloma lata resolves spontaneously, then enters latent phase Syphilis: tertiary stage 5-20 years7 granulomas (gummas) of skin and bones, CV syphilis w/ aortitis, neurosyphilis Syphilis: diagnosis first: RPR or VRDL (repeat at 1 to 3 mo after lesion if initially negative) confirmatory: FTA-ABS or TPPA Syphilis: treatmentBenzathine PCN G (treatment of choice, even during pregnancy) PCN allergic: doxycycline, tetracycline, azithromycin, or desensitization so PCN can be given How can you confirm successful treatment of syphilis? RPR or VDRL at 6, 12, and 24 mo. What is the Jarisch-Herxheimer reaction? inflammatory reaction that occurs after treatment for syphilis or other spirochetes; fever, chills, malaise, HA, myalgia, rash, pharyngitis Normal vaginal pH 3.5-4.5 Normal vaginal bacteria Lactobacillus What pathogen commonly causes bacterial vaginosis? Gardnerella vaginalis What pH is associated with bacterial vaginosis? > 4.7 What is the most common cause of "vaginitis?" bacterial vaginosis Risk factors for bacterial vaginosis multiple sexual partners, female sexual partners, smoking, douching, lack of vaginal lactobacilli S/S of bacterial vaginosis maybe none thin, grey-white adherent discharge fishy, amine odor +/-dyspareunia How is bacterial vaginosis diagnosed? 3 out 4 findings: characteristic discharge positive Whiff test pH > 4.5 clue cells on wet mountWhat is considered the gold standard for diagnosis of bacterial vaginosis? Gram stain from discharge What is the treatment for bacterial vaginosis? Metronidazole 500 mg PO BID for 7 d OR Clindamycin 300 mg PO BID for 7 d (both also available in topical preps) Important patient education for bacterial vaginosis: avoid alcohol while taking metronidazole avoid douching, use mild soap, loose cotton underwear What percent of cases of vaginal candidiasis are caused by candida albicans? 80-90% Predisposing factors for vaginal candidiasis immunosuppression, DM, broad-spectrum antibiotics, after intercourse or during late luteal phase S/S of vaginal candidiasis: vulvovaginal itching, burning pain, and redness clumpy white discharge (may be scant in many cases) How is vaginal candidiasis diagnosed? KOH prep, showing branching hyphae and spores normal pH often diagnosed based on clinical s/s What frequency of infection deems vaginal candidiasis recurrent? What should be performed in this case? 4 episode w/in 1 yr vaginal culture to identify other strains of candida (like glabrata) that are less susceptible to azoles Describe the following treatments for vaginal candidiasis: Miconazole OTC, cream or suppository Fluconazole Rx, 150 mg PO onceTerconazole Rx, cream or suppository Which type of vaginitis is considered sexually transmitted? trichomoniasis Trichomoniasis: pathogen Trichomonas vaginalis (anaerobic unicellular flagellated protozoan) Trichomoniasis: s/s copious frothy grey/green/yellow discharge w/ unpleasant odor vulvar erythema, edema, pruritis "strawberry" cervix (10%) pH > 6 Trichomoniasis: diagnosis wet prep, showing motile trichomonads can confirm with culture if needed Trichomoniasis: treatment Metronidazole or Tindazole 2 g PO once Name possible etiologies of cervicitis. most common: gonorrhea and chlamydia (mucopurulent) others: HSV, HPV, BV pathogens, frequent douching How is cervicitis diagnosed clinically? cervical motion tenderness in absence of s/s of PID Most cases of gonorrhea occur in what age range? 15-24 During what season does gonorrhea infection incidence peak? late summer Risk factors for gonorrhea low SES, urban residence, nonwhite or nonAsian race, early age at sexual activity, illicit drug use, being unmarried, H/O STIs How do male to female/female to male rates of transmission of gonorrhea compare?male to female = 80-90% female to male = 20-25% (after single sexual encounter) Incubation time of neisseria gonorrhea 2-8 d S/S of gonorrhea "discharge and dissemination" mucopurulent cervicitis, PID pharyngitis, arthritis, rash How is gonorrhea diagnosed? NAAT (for chlamydia as well) can be urine, endocervical swab or vaginal swab What is the treatment for gonorrhea? ceftriaxone 250 mg IM once + azithromycin 1 g PO once Explain the relationship b/t treating for gonorrhea and chlamydia? incubation time is shorter for gonorrhea, so when treating gonorrhea you also treat for chlamydia (unless NAAT shows neg. for chlamydia) when treating chlamydia, you only treat chlamydia What is the most common bacterial STI? chlamydia How is chlamydia transmitted? sexually, vertically Risk factors for chlamydia 15-24 y/o, earlier age at sexual activity, multiple sexual partners What percentage of women with chlamydia are asymptomatic? up to 70%! What is the most important risk associated with untreated chlamydial infection? PID, resulting in infertility or increased risk of ectopic pregnancies According to the the CDC, who needs screened for chlamydia?sexually active women 25 and younger, 25+ w/ risk factors (new or multiple partners), all pregnant women S/S of chlamydia none! mucopurulent cervicitis, hypertrophic, friable cervix PID, pyuria, dysuria How is chlamydia diagnosed? endocervical/vaginal swab for urine for NAAT Q-tip test: yellow-green discharge from cervix How is chlamydia treated? Azithromycin 1 g PO once (or Doxycycline 100 mg PO BID for 7 d) rescreen at 3-4 and 12 mo. What is the risk of recurrence of BV after treatment? 30% (provide this info in patient education!) Describe the pathophysiology of atrophic vaginitis. lack of vaginal effects of estrogen due to prepubertal status, lactation, or postmenopausal status vaginal pH increases to 5-7, flora becomes mixed, vaginal mucosa thins S/S of atrophic vaginitis serosanguineous, watery discharge dyspareunia, dryness, spotting increased susceptibility to trauma/infection Describe wet mount findings for atrophic vaginitis. small, rounded parabasal epithelial cells and increased PMNs How does the vaginal mucosa appear in cases of atrophic vaginitis? thin, with few or absent rugae What is the treatment for atrophic vaginitis? intravaginal estrogen cream What are the components to a preconception history?risk assessment (work, infectious disease, hereditary disorders, domestic violence, nutrition/BMI, meds, substances, psych, pre-term birth) patient education (timing and practices to conceive) When is the fetal heart beat audible with doppler US? 8-10 weeks When is the fetal heart beat detectable with TVU? 5-6 weeks How can you estimate date of delivery? Nagele's rule LMP + 7 d, then count back 3 months (adjust for cycles longer/shorter than 28 d) What is the gold standard for estimating gestational age? measurement of crown-rump length at 7-14 wk What weeks correspond to 1st, 2nd, and 3rd trimesters? 1st = up to 12 wk 2nd = 12-24 (or 28) 3rd = 24 or 28 to term What is the average total weight gain during pregnancy for a healthy woman? 27.5 # How much extra calories/protein should a pregnant woman consume per day? 300 extra calories, 5 g protein What are the ideal weight gains during pregnancy based on prenatal weight? underweight (<90% IBW) = 28-40 # normal weight (90-135% IBW) = 25-35 # overweight (> 135% IBW) = 15-25 # What are appropriate weight gains by trimester? before 28 weeks = 0.5 #/week after 28 weeks = 1 #/week What is the normal range for fetal heart rate? 120-160 (closer to 120-140 closer to term)When does the fetal heart rate become reactive? What does this mean? 32-34 weeks; the FHR increases with fetal movements What does diagonal conjugate measure? When is it considered adequate? sacral promontory to pubic symphysis 11.5 cm What does intertuberous diameter measure? When is it considered adequate? distance between ischial tuberosities 10 cm (approximately width of fist) What is Chadwick sign and when does it appear? bluish or reddish-purple coloration of vaginal and cervical mucosa about 4 weeks gestation What is Hegar sign? When does it appear? softening of the cervical isthmus about 7 weeks gestation What is Goodell sign? softening of the vaginal portion of the cervix When should pregnant women receive the Tdap vaccine? b/t 27 and 36 weeks gestation What is the schedule for prenatal visits? 0-32 weeks = every 4 weeks 32-36 weeks = every 2 weeks 36+ weeks = every week What PE components should be performed at every prenatal followup visit? BP, weight, fundal height, FHT, fetal presentation, edema What lab should be performed at every prenatal followup visit? UA for protein and glucose When should Group B strep testing be performed during pregnancy? 35-37 weeks How is GBS testing performed during pregnancy?sweep a swab from vaginal introitus to anus What is the treatment if a mother's GBS test is positive? IV PCN G or ampicillin (clindamycin if allergic) When should gestational diabetes screening be performed during pregnancy? 24-28 weeks (or earlier if high risk) When should screening for asymptomatic bacteriuria take place during pregnancy? What tests are used? 12-16 weeks, urine C + S When are ultrasounds performed throughout pregnancy and why? 1st trimester: for gestational age 20 weeks: amniotic fluid volume, placental location, malformations, gestational age, gender after 30 weeks: as needed When is prophylactic RhoD immunoglobulin given to Rh- mothers? 24-28 weeks gestation How does fundal height correspond to gestational age? 8-12 weeks: at/just above pubic symphysis 16 weeks: midway b/t pubic symphysis and umbilicus 20 weeks: umbilicus 20-36 weeks: cm above pubic symphysis corresponds to gestational age 36+: lightening (baby moves down) At what gestational age do you begin to measure fundal height? 20 weeks What is the MacDonald manuever? measurement of fundal height in cm from top of pubic symphysis to top of uterine fundus When is the MacDonald manuever for fundal height most reliable? 22-32 weeks gestation How closely does fundal height correlate with gestational age? +/- 2 cm (if discrepancy is larger, assess fetal size and possibly amniotic fluid via US) What is the Leopold manuever?palpation of abdomen to determine fetal lie and size At what gestational age do you begin to perform the Leopold manuever? 22 weeks When is the Leopold manuever most reliable? 26-28 weeks When should a pregnant mother be advised to not travel and stay close to home? 36+ weeks When should you begin vaginal exams to assess dilation/effacement of cervix? 37-38 weeks When can induction be considered? 41-42 weeks When would you perform biophysical and/or stress testing on a fetus? 40-42 weeks gestation What are some non-pharmacologic treatments for N/V w/ pregnancy? small, frequent meals low-fat diet avoid provoking foods, odors What are pharmacologic treatments for N/V w/ pregnancy? 1st line: pyridoxine + doxylamine 2nd line: promethazine, metoclopramide, ondansetron What event is gestational age measured from? the first day of the last normal menstrual period (2 weeks before ovulation) What event is developmental/fetal age measured from? time of implantation (4-6 days after ovulation) Define the following terms: preterm infant born b/t 20 and 37 weeks term infantborn b/t 37 and 42 weeks postterm infant born after 47 weeks macrosomic infant/large for gestational age fetal weight at or above the 90th percentile for gestational age low birth weight infant less than or equal to 2000 g very low birth weight infant less than or equal to 1500 g extremely low birth weight infant less than or equal to 1000 g neonatal period birth to 28 days of life perinatal period 28 weeks gestation to first 7 days of life What is hyperemesis gravidarum? extreme N/V during pregnancy characterized by dehydration, weight loss, and ketonuria When does N/V associated with pregnancy normally subside? b/t 13-16 weeks What changes to the breasts occur during pregnancy? mastodynia, engorgement, prominent Montgomery's tubercles, colostrum secretion, secondary breast tissue When does quickening occur? primiparous: 18-20 weeks multiparous: as early as 14 weeks What changes to the skin occur during pregnancy? chloasma, darkened linea nigra and areolae, striae, spider telangectasia Describe Braxton Hicks as early as 28 weeks felt as tightening/pressure that disappears w/ walking or exercise (real contractions get more intense!) When are limb buds visible on US? 7-8 weeks When are finger and limb movements visible on US? 9-10 weeks When do beta-hCG levels peak and at what level? at about 10 weeks; 100,000 What is the initial lab test used in office to test for pregnancy? urine beta-hCG When does beta-hCG become detectable in the serum? 7 days after conception, or 21 days after LNMP How long is normal pregnancy? 280 days (40 weeks) calculated from 1st day of LNMP What is the gold standard for diagnosing early and late pregnancy failure? US When should a female planning to become pregnant begin taking folic acid supplements? 3 months before conception What diseases are especially important to ask about in the medical history during the first prenatal visit? DM, endocrine disorders, H/O of blood transfusion, HTN, epilepsy, autoimmune diseases What should be performed and when for a pregnant mother with a H/O of spontaneous preterm birth? transvaginal sonogram during 2nd trimester to evaluate for risk of recurrent preterm birth What lab tests are performed at the first prenatal visit? BUG V. SHHRUG blood: ABORH, CBC, HH, platelet count USGDM if indicated varicella syphilis: VDRL or RPR HBSAg HIV rubella urine culture GC/chlamydia When should followup care for Rh incompatibility occur? 28 weeks What urine tests are performed at every prenatal visit? protein, glucose, ketones What genetic screening can be performed during the first trimester? If this is performed, what should be done b/t 15-19 weeks? fetal nuchal translucency, maternal serum PAPP-A and free/total beta-hCG 15-19 weeks: maternal serum AFP When is the quad screen offered, and what does it include? 15-20 weeks (16-18 is ideal) beta-hCG, unconj. estriol, inhibin A, AFP What tests are included in the triple screen? beta-hCG, estriol, AFP What tests are included in the quad+ screen? beta-hCG, uE3, AFP, inhibin A, PAPP-A What patients should be offered invasive prenatal genetic screening? technically all, but especially: women > 35, abnormal pedigree or risk factors for inherited diseases When is chorionic villus sampling performed? b/t 9-13 weeks gestation When is amniocentesis performed? b/t 15-20 weeks gestation How does maternal BP change with pregnancy?SBP and DBP drop by 5-7 mmHg early in the 2nd trimester, then return to normal during the 3rd trimester How does normal renal function vary with pregnancy? GFR increases by 50% and serum creatinine decreases to 0.4-0.6 mg/dL (leading to urinary frequency!) Why do varicose veins increase during pregnancy? progesterone causes smooth muscle relaxation; increased pressure in abdomen decreases venous return Why do leg cramps/numbness occur during pregnancy? hypothesis: decreased calcium or magnesium How are leg cramps during pregnancy treated? possibly calcium carbonate or calcium lactate or magnesium citrate, local heat, massage, flexion of feet What are the guidelines for sex during pregnancy? no proven adverse outcome, but if cramping, spotting, or bright red bleeding follows coitus, patient should be seen by clinician no intercourse if preterm labor! How much dietary protein is required per day during pregnancy? 1 g/kg per day + 20 g/d during 2nd half of pregnancy How much calcium intake is required during pregnancy and lactation? 1200 mg/d How much and when is iron supplementation needed during pregnancy? 30 g/d during 2nd and 3rd trimesters When should folic acid supplementation be taken and how much is required? 3 months before conception to 3 months after; 0.4 mg/d When should you tell a first time mother to come to the hospital to prepare for labor? when contractions are 3-5 minutes apart for 1-2 hours or amniotic sac ruptures When should you tell a multiparous mother to come to the hospital for labor? onset of contractions or amniotic sac rupturesWhat are some danger signals mothers should be informed of and told to call/report for care? vaginal bleeding, decreased fetal movement, swelling of face/hands, convulsions, epigastric pain, HA, blurred vision, chills/fever, severe/unusualy abdominal or back pain, rupture of membranes What is lightening and when does it normally occur? descent of the fetal head into the pelvic brim 1st pregnancy: 2 weeks before labor (later for multiparas) How can false labor be identified? lack of cervical changes in presence of contractions (Braxton Hicks) Define station. location of presenting part in birth canal in relation to ischial spines What are the different classifications of station? station -3: at level of pelvic inlet, presenting part is floating station 0: at ischial spines, presenting part is engaged station +3: level of perineum What frequency, length, and intensity of contractions correspond to active labor? every 2-3 minutes, last 1 minute, 40 mmHg of pressure Define lie. relationship between long axis of fetus and long axis of mother (vertex, breech, or transverse) Define vertex. head down Define breech. sacrum down Define transverse lie. long axis of fetus is perpendicular to long axis of mother Define attitude. relation of fetal parts to each other (flexed is best) Define position. presenting part of fetus and its relationship to right or left of maternal pelvisWhat are the different fetal positions possible during L & D? right/left occiput anterior, right/left occiput posterior, right/left occipitotransverse What fetal position is ideal for L&D? occipitoanterior What fetal position is most common during engagement? occipitotransverse What are the cardinal movements of labor? 1. engagement 2. descent (all other movements superimposed on this) 3. flexion 4. internal rotation 5. extension 6. external rotation (aka restitution) What are the stages of labor? 1st: encompasses cervical effacement and dilatation (to 10 cm) from beginning to end 2nd: delivery of fetus 3rd: delivery of placenta 4th: first hour postpartum What are the substages of the first stage of labor? latent: regular contractions w/ cervical changes active: 4 cm dilatation to full dilatation How fast does dilatation occur during the active phase of the first stage of labor? 1 cm per hour First stage of labor average length? primiparas: 6-18 hours multiparas: 2-10 hours Second stage of labor length? primiparas: 30 min - 3 hr multiparas: 5-30 min Third stage of labor length? 0-30 minutes all pregnanciesWhat labs should be performed when a mother presents for L&D? HH, type and screen if needed (+ clot for cross-match) urine for protein and glucose Describe care given during the first stage of labor. patient can sit comfortably, but should not lie supine; only liquids by mouth; IV fluids if necessary; monitor pulse, BP, I&Os; pain relief How often should fetal monitoring be performed during the active phase of the 1st stage of labor? every 30 minutes How often should fetal monitoring be performed during the 2nd stage of labor? every 15 minutes What are some risk factors requiring continuous fetal monitoring? IUGR, HTN, DM, multiple gestations How often should be cervix be assessed during the active phase of the first stage of labor? every 2 hours What should be performed immediately after delivery of the fetus? inspection and repair of lacerations of the perineum, vagina, and cervix What are the signs of placental separation? 1. fresh flow of blood from vagina 2. umbilical cord lengthens outside vagina 3. uterine fundus rises up 4. uterus becomes firm and globular How long does it normally take the placenta to separate? usually 2-10 minutes after delivery of baby, sometimes up to 30 min How can you reduce postpartum bleeding? uterine massage, administration of oxytocin What is the puerperium period? period after delivery of baby to 6 weeks postpartum What is the main concern during the fourth stage of labor?maternal hemorrhage What is the benefit of early breastfeeding to the mother? facilitates involution of the uterus, leading to less blood loss due to increased uterine contractions What is the benefit of early breastfeeding to the baby? passive immunity What risks are increased in multiple gestations? hypertensive disorders, anemia, pre-term birth, GDM, ante- and post-partum hemorrhage, maternal death, UTI, uterine atony What percent of twins are monozygotic and dizygotic? 33% mono, 67% di What is twin-twin transfusion syndrome? vascular anastomoses formed during embyronic life leading to local shunting of blood to one fetus and away from the other Describe the outcomes of twin-twin transfusion syndrome. receiving twin is plethoric, edematous, and hypertensive and can die of heart failure other twin in small, pallid and dehydrated What causes conjoined twins? incomplete separation of a single fertilized ovum on the 13th-14th day; if later, incomplete twinning occurs Which forms of twins is hereditary? dizygotic What percent of dizygotic twins are the same sex? 75% Epidemiology of twinning most common in blacks, then whites, then Asians increases w/ maternal age increased incidence with use of ART dizygotic twinning more common after long-term use of OCP and use of ovulation stimulants What are some signs that should alert you to a possible multiple pregnancy?uterus measuring larger than GA, large weight gain, polyhydramnios, H/O ART, high MSAFP, palpation of multiple small parts, multiple FHTs What are the most common diagnostic tests used for multiple gestations? MSAFP and US How does multiple gestation affect a mother's anemia status? hypochromic normocytic anemia is almost universal, due to high fetal demand for iron and low HH/RBC count What findings on US suggest dizygotic twins? different genders, separate placentas, thick dividing membrane, twin peak sign (membrane inserts into 2 fused placentas) What percent of twin pregnancies result in premature rupture of membranes? 25% (risk increases with higher multiples) What risks to the babies are increased in multiple pregnancies? developmental anomalies, IUGR, pre-term birth, cord compression, placental previa, twin-twin transfusion syndrome (monochorionic), PROM, CP, prolapse of cord, malpresentation How often should growth scans be performed in multiple pregnancies? every 4 weeks during the 3rd trimester What supplements should be provided from multiple gestations? folic acid, iron, calcium, vitamins, magnesium, zinc, essential fatty acids Why are tocolytics often used for multiple gestations? What is the most often used tocolytic? to postpone labor 48 hours to allow for effects of steroids magnesium sulfate When should a mother having multiples present to the hospital for delivery? > 4 contractions in 1 hr at < 34 weeks gestation How often should fetal monitoring be performed in multiple gestations? continuously What are indications for ceasarian in multiple gestations? malpresentation, large disparity in size, monoamniotic twins, placental previa What is the most common presentation of twins?both cephalic (40%) What are treatments for postpartum hemorrhage in multiple gestations? oxytocin, fundal massage, ergots, or prostaglandin analog How do MSAFP levels in multiple gestations compare to that of singleton pregnancies? twins = 2.5 x higher (if 4.5 x higher than median, US and/or amniocentesis needed) What is a healthy amount of weight gain during a pregnancy with twins? ideal weight for height + 35-45 lbs How does the L&D process for multiple gestation differ from that of a singleton pregnancy? performed in OR and early epidural in case of emergent C-section; mother should present to hospital earlier; US performed to determine position of babies; continuous fetal monitoring; placenta(s) examined after birth What are locked twins and how is this avoided? when Twin A is noncephalic and the babies heads become lodged in the birth canal; avoid by performing C section whenever twin A is in a noncephalic position What is the most common complication of pregnancy? spontaneous abortion Define spontaneous abortion. loss of embryo or fetus less than 500 g and less than 20 weeks gestation Define threatened abortion. uterine bleeding before completion of the 20th week in the presence of a viable pregnancy; no cervical dilation Define complete abortion. expulsion of all products of conception before the 20th week of gestation Define incomplete abortion. expulsion of some, but not all, products of conception before the 20th week of gestation Define inevitable abortion. uterine bleeding before the 20th week, with cervical dilation but without expulsion of products of conception yetDefine missed abortion. a nonviable pregnancy that has been retained in the uterus without cervical dilation Define septic abortion. intrauterine fetal demise + infection of the uterus When do most spontaneous abortions occur? 80% occur before 12 weeks gestation What is the most common aneuploidy? monosomy X (Turners syndrome) What is Asherman syndrome? formation of scar tissue within uterine cavity as a result of D&C that leads to problems like miscarriage and/or infertility Describe cervical insufficiency. painless cervical shortening or dilation that occurs in the 2nd/early 3rd trimester (up to 28 weeks) resulting in preterm birth What factors contribute to cervical insufficiency? congenital anomalies, DES exposure, H/O cervical conization What factors are associated with increased risk of spontaneous abortion? age of mother, endocrine problems, H/O of spontaneous abortion or fetal demise, chromosomal abnormalities, infection, anatomic defects, autoimmune disease, toxic exposure What maternal infections are associated with abortion? Toxoplasma gondii, HSV, CMV, Listeria monocytogenes, Chlamydia What is the most common uterine abnormality contributing to abortion? septate uterus Describe anembryonic pregnancy. embryo fails to develop or is resorbed after loss of viability; seen on US as empty gestational sac w/o fetal pole; s/s similar to missed or threatened abortion What might a CBC performed for spontaneous abortion show? anemia (if significant bleeding), high ESR and WBC (even w/o infection)How is spontaneous abortion diagnosed? serum beta-hCG and transvaginal US At what size embryonic sac should you see a yolk sac? Embryo? yolk sac: mean sac diameter of 8 mm (5-6 weeks) embryo: 16 mm How od beta-hCG levels change with spontaneous abortion? drop 21-35% in 48 hours (slower suggests ectopic pregnancy) S/S of ectopic pregnancy bleeding, abdominal/pelvic pain, +/- adnexal mass, +/- syncope What are complications of spontaneous abortion? uterine perforation or cervical insufficiency (D&C), excessive bleeding, infection, intrauterine adhesions, infertility Treatment for threatened abortion monitoring, pelvic rest Treatment for missed or incomplete abortion expectant, medical (Misoprostol), or surgical management Treatment for complete abortion monitor for bleeding, if minimal, no further treatment; send products of conception to pathology if no specimen available and no previous US confirmation of intrauterine pregnancy, follow serial hCG What is the most common site of ectopic pregnancy? fallopian tube What is the leading cause of pregnancy-related death during the first trimester? ectopic pregnancy What is a heterotopic pregnancy? intrauterine pregnancy + ectopic pregnancy Risk factors for ectopic pregnancy H/O PID, smoking, presence of IUD, fallopian tube damage, ART (association, maybe not RF)Contrast timing of rupture of different locations of ectopic pregnancy. Isthmus: 6-8 weeks Ampullary: 8-12 Interstitial: 12-16 How does smoking affect the fallopian tubes? decreases the motility of their cilia, making it harder for a fertilized egg to traverse the tube Describe the pain associated with ectopic pregnancy. unilateral or bilateral, abdominal or pelvic, localized or generalized (vague pain means you need high level of suspicion!) In what percent of ectopic pregnancy will bleeding occur? about 75% What blood tests should be performed for suspected ectopic pregnancy? Why? HCT- intra-abdominal bleeding beta hCG- abnormal rise = abnormal pregnancy progesterone- < 5 ng/mL = abnormal pregnancy What is the hCG discriminatory zone and how is it used? mIU/mL at this level or above, US should show an intrauterine gestation What imaging is used to diagnose ectopic pregnancy? transvaginal US (but may be too small to detect if early) What US finding confirms the diagnosis of ectopic pregnancy? gestational sac w/ yolk sac or embryo within the adnexae; may see hyperechoic tubal ring What is the standard surgical treatment for ectopic pregnancy? laparoscopy Describe medical management for ectopic pregnancy. can use methotrexate, if patient is hemodynamically stable and diagnosis of ectopic is confirmed follow serial hCG first daily then weekly until 0 Relative contraindications to MTX for ectopic pregnancy embryonic cardiac motion, gestational sac > 3.5 cm, abnormal LFTS or renal functionWhat is the treatment for a ruptured ectopic pregnancy? emergency surgery, request blood products, Rhogam if RhWhat defines recurrent pregnancy loss? 3+ spontaneous abortions before 20 weeks gestation, with fetus weighing less than 500 g How accurate are at home urine pregnancy tests and when do they become positive? high sensitivity; around the time of the missed period How do beta hCG levels change with pregnancy? rise to a max of 100,000 at 10 weeks, decrease throughout 2nd trimester, level off at 20,000- 30,000 during 3rd trimester When can you see the gestational sac on TVU? What beta hCG level does this correspond to? 5 weeks; When can you see fetal heart motion on TVU? What beta hCG level does this correspond to? 6 weeks; Define grand multip. woman whose parity is greater than or equal to 5 How can you determine EDD in the event that the LMP is unknown? US (most accurate weeks 7-13) What is the rule of thumb for the relationship between using US and LMP to date a pregnancy? the two should not differ by more than 1 week during the 1st trimester, 2 weeks during 2nd trimester, and 3 weeks during 3rd trimester What is the threshold of viability of a fetus? 23-24 weeks How does cardiac output change with pregnancy? increases by 30-50%, maxes out at week 20-24; first b/c of increased SV, then HR How does BP differ with pregnancy and why? SBP decreases 5-10, DBP decreases 10-15 up to week 24 (increases to normal after that) increased progesterone lowers systemic vascular resistance How does pulmonary function change during pregnancy?Tidal volume increases, but total lung capacity decreases What defines hyperemesis gravidarum? weight loss of at least 5% of prepregnancy weight and ketosis What causes morning sickness associated with pregnancy? high estrogen, progesterone, beta hCG; hypoglycemia How does GI function change during pregnancy? prolonged gastric emptying + decreased GES tone = reflux; decreased motility of large bowel = increased water absorption + constipation How does renal function change during pregnancy? kidneys increase in size and ureters dilate; GFR increases, so BUN and creatinine decrease Why does anemia of pregnancy occur? plasma volume increases disproportionately relative to RBC count How does the platelet concentration change during pregnancy? decreases as a result of increased plasma volume and peripheral destruction; if drops to 100,000,000/mL, this is abnormal How does the WBC count change during pregnancy? increases, especially during labor Where does most of the estrogen produced during pregnancy come from? the placenta (still some from ovaries) Describe the structure of beta hCG. composed of an alpha and beta subunit; alpha subunit is identical to that of LH, FSH, and TSH, whereas the beta subunit is unique Where is human placental lactogen produced and what is its function? the placenta; induces lipolysis and acts as an insulin antagonist to provide constant nutrients to fetus How do thyroid hormones change with pregnancy? thyroid binding globulin increases, leading to increased total T3 and T4; hCG weakly stimulates thyroid, leading to increased T3 and T4 and decreased TSH; overall, pregnancy considered euthyroidHow many extra calories are needed per day while breastfeeding? 500 What is the recommendation for performing a PAP smear at the initial prenatal visit? one should be performed if it has done been done in the last 6 months What questions about s/s should be asked at every prenatal followup visit? fetal movement, bleeding, vaginal discharge, irritative voiding symptoms, contractions When should exams of the cervix at every visit begin? 37+ weeks What glucose values are diagnostic of GDM during a GTT? fasting: 95 1 hr: 180 2 hr: 155 3 hr: 140 What analgesics can be used for back pain during pregnancy? Tylenol first; can use muscle relaxants or narcotics if needed NO ASPIRIN or NSAIDs! How is constipation during pregnancy treated? increased water intake; stool softeners or bulking agents; laxatives can be used, but are avoided during the 3rd trimester What is the treatment for GERD during pregnancy? avoid lying down 1 hr a