What is the best test to confirm intrauterine fetal demise?

real time ultrasonography to demonstrate an absence of fetal movement and cardiac activity

What should be performed after first episode of IUFD?

autopsy of fetus and placenta in all cases of stillbirth with permission of the parents

What are the risk factors for maternal cervical insufficiency?

maternal obstetrical trauma
past gyn procedures (LEEP, cone biopsy)
DES exposure
multiple gestation
Hx of preterm birth
Hx of second trimester pregnancy loss

What is the gold standard for evaluating cervix for cervical incompetence?
transvaginal ultrasound

What qualifies as a short cervix?

cervical length below 10th percentile for gestational age
includes cervices less than 25mm at gestational age 23-28wks

What is a major source of estrogen in menopausal women?

peripheral conversion of adrenal androgens by the aromatase enzyme present in adipose
tissue
why obese women tend to have milder menopausal symptoms

What is pseudocyesis?
Rare psychiatric condition: uncommon condition in which a woman presents with many s/sx
of pregnancy such as amenorrhea, enlargement of the breasts and abdomen, morning
sickness, weight gain, sensation of fetal, sensation of fetal movement and reported positive

urine pregnancy test per the patient. U/S will reveal a normal endometrial stripe and the
pregnancy test in office will be negative

What conditions are postterm pregnancies at increased risk for?

oligohydramnios
- assoc with increased fetal morbidity
- monitor postterm pregnancies twice weekly

What is lupus anticoagulant?

seen in pts with SLE and is a potential cause of recurrent pregnancy loss due to thrombus
development with the placenta

How is lichen sclerosis treated?

high-potency topical steroids are considered first-line therapy

What causes the transaminitis in preeclampsia?

damage to the liver caused by stretching of the hepatic (Glisson's) capsule
- leads to RUQ pain

What is the purpose of magnesium sulfate in the treatment of

eclampsia/preeclampsia?
given to prevent the further development of seizures while delivery of the fetus is
accomplished

How is septic abortion managed?

Cervical and blood cultures followed by IV antibiotics and gentle suction curettage. Vigorous
suction curettage may cause perforation of the uterus and should be avoided

What is the FSH level seen in Turner syndrome who have ovarian dysgenesis
and poor ovarian function?
FSH should be high due to negative feedback

When should you suspect intraamniotic infection?

prolonged or premature rupture of the membranes when maternal fever, leukocytosis, uterine
tenderness or tachycardia is detected. Fetal tachycardia is another feature of chorioaminonitis

What is the appropriate treatement of chorioamnionitis associated with

premature rupture of the membranes?
systemic broad-spectrum Abx and expedited delivery of the fetus

What is the next step if cervical dysplasia is found in high risk women?
colposcopy

How are UTIs treated in pregnant women? Includes ASx bacteriuria

7 day course of nitrofurantoin, amoxicillin, or first gen cephalosporin to decrease risk of
cystitis, pyelonephritis, preterm birth, and perinatal mortality

What are the classic sx of abruptio placentae?

vaginal bleeding
abdominal pain
uterine contractions
uterine tenderness
- absence of blood does not r/o this condition

What are the SE and risks of OCPs?

breakthrough bleeding
amenorrhea

HTN
venous thromboembolic disease
decreased risk of ovarian and endometrial cancer
increased risk of cervical cancer
liver disorders (hepatic adenoma)

What do early decels look like?

uniform shape from contraction to contraction
onset of the early decel is early in the contraction phase of the uterus

What do late decels look like?

show uniform shape from contraction to contraction
Onset is late in the contraction phaes of the uterus

What do variable decels look like?

decels of variable shape that do not reflect the assoc intrauterine pressure curve. Onset varies
in relationship to contraction phase of the uterus

What is the sinusoidal fetal heart rate indicate?

uniform oscillations of 3-5 cycles per minute
considered a sign of fetal distress and the inability of the CNS to control the HR

What causes early decels?

fetal head compression

What causes late decels?

umbilical cord compression

What causes late decels?

uteroplacental insufficiency --> fetal hypoxia--> fetal acidosis

What are the physical exam findings of atrophic vaginitis in post-menopausal

females?
vaginal dryness and dysuria
pale, dry vaginal mucosa
diminished labial fat pad
scarce pubic hair
Mod and severe cases require local estrogen tx

What are the criteria for mild preeclampsia?

HTN > 140/90
Proteinuria > 0.3g/24h (300mg/24h)
after 20th week of gestation

What are the criteria for severe preeclampsia?

HTN >160/110
Proteinuria 5g/24h
oliguria
elevated liver enzymes
thrombocytopenia
possible pulmonary edema

What are the criteria for eclampsia?

occurrence of grand mal seizures in pts with either mild/severe preeclampsia

What drug is used to tx HTN in pregnancy?

methyldopa

What is a SE of epidural anesthesia in terms of urination?

overflow incontinence
tx: intermittent catheterization

How is complete placenta previa managed?

scheduled C/S

What causes hypogonadotropic hypogonadism and what are pts are risk for?
decrease in circulating sex hormones due to decreased concentrations of LH and FSH
condition increases risk for osteoporosis
Causes:
- strenuous exercise
- anorexia nervosa
- marijuana use
- starvation
- stress
- depression
- chronic illness

What is the definition of IUFD?

fetal demise occurring beyond 20wks

How is infertility tx in women with premature ovarian failure?

in vitro fertilization

What are the characteristics of premature ovarian failure?

amenorrhea, hypoesetrogenism, elevated serum gonadotropin levels in women younger than
40yo
- menopausal sx
- increased FSH and LH and decreased estrogen
Causes:
- secondary to follicle atresia or a low initial number of primordial follicles
- idiopathic
- mumps

- oophoritis
- irradiation
- chemotherapy
- autoimmune disorders: Hashimoto's thyroiditis, Addison's disease, Type 1 diabetes,
pernicious anemia

How is fetal weight estimated in cases of suspected FGR?

abdominal circumference
head to abd circumference ratio useful to differentiate symmetric vs. asymmetric FGR
fetal size to estimate fetal size

What are risk factors for endometritis?

prolonged ROM
prolonged labor
operative vaginal delivery and c/s

what are sx of endometritis?

fever
uterine tenderness
foul-smelling lochia
Caused by: polymicrobial infxn
Tx: IV clinda and gent

If a pregnant pt is hypertensive before 20wks, what is the cause?

chronic HTN or hydatiform mole

What is the most common cause for decreased fertility in women in their
fourth decade who are still experiencing menstrual cycles?
age-related decreased ovarian reserve

How is acute preterm labor managed?

bed rest and tocolysis for as long as possible with a long-term goal of reaching 34-36wks
gestational age

What are medical causes of dyspareunia?

endometriosis
local infxns
vulvar/vaginal growths
estrogen deficiency

What are psychological causes of dyspareunia?

somatization disorder
pain disorder

How are inevitable abortions tx?

IV fluids, suction currettage and RhoGAM admin

How is mild preeclampsia tx if far from term?

bed rest and close observation
MgSO4 admin during labor and w/in 24hrs of delivery in mild preeclamptics

What are characteristics of granulosa cell tumors?

produce excessive amounts of estrogen
- precocious puberty in younger children
- postmenopausal bleeding in elderly pts (absence of postmenopausal signs)

How do Sertoli-Leydig cell tumors present?

androgens and cause defeminization followed by masculinization

- women in child bearing years may complain of altered body contour, flattening of the
breasts, and scanty, irregular menstruation, ultimately ending in amenorrhea
- may develop hirsutism, coarsening of features and enlargement of the clitoris

What conditions is MSAFP decreased?

Edward Syndrome and Down Syndrome

What are results of the quad screen that indicate Down Syndrome?
Low MSAFP
Low estriol
High BHCG
High Inhibit A level

What are results of quad screen that indicate Edward Syndrome?

Low MSAFP
Low estriol
very low BHCG
High Inhibin A

What is the most common cause of abnormal MSAFP?

gestational age error

How is dysfunctional uterine bleeding treated?

usually result of anovulation
- mild = iron supp
- moderate = protestin + iron
- active bleeding/severe = estrogen
If >35 get an endometrial biopsy

What is interstitial cystitis?

chronic condition of bladder; Triad:

- urinary urgency (including nocturia)
- urinary frequency
- chronic pelvic pain (presenting sx)
exacerbated by:
- sexual intercourse
- filling of bladder
- exercise
- spicy foods and certain beverages
pain relieved by voiding
Dx: cystoscopy classically demonstrates submucosal petechiae or ulcerations

What is a missed abortion?

dead fetus that is still retained in the uterus
dx suspected when there is disappearance of the nausea and vomiting of early pregnancy and
an arrest of uterine growth

What is the definition of abortion?

spontaneous loss of pregnancy that occurs before 20 wks gestations
suspicous when:
- disappearance of n/v
- arrest of uterine growth

What is a threatened abortion?

any hemorrhage occurring before the 20th week gestation w/ a live fetus; cervix is closed and
there is no passage of fetal tissue
mild lower abd pain may be noted and fetal hear is active on u/s

What is an inevitable abortion?

VB, lower abd cramps that may radiate to the back and perineum and a dilated cervix. U/S
demonstrates ruptured or collapsed gestational sac w/ absence of fetal cardiac motion.
Incomplete abortion has same presentation except that there is an incomplete evacuation of

the conceptus.
U/S reveals endometrial debris

How is primary amenorrhea dx?

1) pelvic exam/ultrasound
2) If uterus present, check FSH; if uterus absent check karyotype/serum testosterone
3) If serum FSH is increased, check karyotyping; If serum FSH is decreased, get cranial MRI
- FSH if no breast development
- Pituitary MRI if FSH is decreased
- Karyotyping if FSH is increased

How does ruptured fetal umbilical vessel present?

- antepartum hemorrhage w/ characteristic fetal heart changes progressing from tachy to
brady to sinusoidal pattern
Dx: Apt test: differentiates maternal from fetal blood; vasa previa is fetal blood; maternal
vital signs should be stable

What is vasa previa?

rare condition
fetal blood vessels traverse the fetal membranes across the lower segment of the uterus
between the baby and the internal cervical os (velamentous cord insertion)
vulnerable to tearing during natural or artificial rupture of membranes
- condition carries high fetal mortality rate (75%) due to fetal exsanguination
Tx: when dx, immediate C/S

How is idiopathic central precocious puberty managed?

GnRH agonist therapy
- prevents premature fusion of epiphyseal plates-->short stature

What is the gold standard of dx endometriosis?

laparoscopy

What is the initial tx for PPH?

bimanual uterine massage, fluid resuscitation, uterotonic agents (oxytocin, methylergonovine,
carboprost), and blood transfusion as needed

How is a spontaneous abortion/missed abortion dx?

transvaginal ultrasound

How is a missed abortion tx?

Remove POC from the uterus
- D&C (surgical)
- vaginal misoprostal (medically)
- serial imaging to ensure complete natural expulsion f POC (expectantly)

What is midcycle pain (mittelschmerz)?

common in women w/ regular menstrual periods who are not taking birth control pills
(ovulating women). Pain is a result of ovulation
two weeks after LMP
unilateral pain

How does ovarian torsion present?

sudden-onset lower quadrant abd pain that radiates to the groin or back and is accompanied
by nausea and vomiting. An adnexal mass is usually present

What is ovarian hyperstimualtion syndrome?

iatrogenic complication of ovulating- inducing drugs
characterized by: abd pain due to ovarian enlargement and may be accompanied by ascites,
respiratory difficulty, and other systemic findings

What is the next step in mgmt when a pt receives an abnormal MSAFP?

U/S to confirm gestational age, detect fetal structural anomalies, detect multiple gestation and
confirm a viable pregnancy

What is the differential dx if a middle-aged woman is experiencing night

sweats, insomnia, and irregular menses?
menopause
hypothyroidism
Work-up by getting serum TSH and FSH

How is chlamydia tx if gonorrhea is neg?

single dose of azithromycin or a 7 day course of doxy

What is false labor?

last 4-8 wks
contractions felt in lower abd, irregular, occur at an interval that does not shorten and do not
increase in intensity
absent progressive cervical changes
contractions readily relieved by sedation
Tx: reassure pts

How is complex hyperplasia tx in premenopausal women WITHOUT atypia?

cyclic progestins
F/U with endometrial biopsy after 3-6 mo of tx
low risk of progression to endometrial cancer

Why do pts have irregular menses in the first 1-2 years following menarche?
Most of the cycles are anovulatory
irregular and may be complicated by menorrhagia

What are sx of DVT?

fever, unilateral leg pain, swelling, redness and calf tenderness
bilateral edema is likely benign edema of pregnancy

What kind of cancer does tamoxifen have increased risk for?

endometrial cancer
decreases risk for osteoporosis

How is gestational diabetes screened?

between 24-28wks of gestation
- proper initial screening test is the one hr 50gram oral GTT
- after 1hr, if blood glu is <140, then gestational diabetes is ruled out
- if >140, three hour OGTT performed
Gestational diabetes is dx if two or more of the serum glu values obtained during the three
hour test are elevated above the values listed:
- fasting>95
- 1hr>180
- 2hr>155
- 3hr>140

How is ectopic pregnancy dx?

Transvaginal U/S
- perform when BHCG is btw 1500 and 6500
Laparoscopy is last resort dx method

How is BV tx?
oral metronidazole
vaginal metronidazole and clindamycin also possible

How is stress incontinence tx?

pelvic muscle exercises (Kegel exercises)
Urethropexy

How does breast engorgement present?

common problem assoc w/ breast feeding
- bilateral breast tenderness and swelling
- presents 24-72hrs postpartum
- peaks 3-5 days after delivery
- resolves spontaneously

How should a young woman who presents with a breast lump be evaluated?
return after menstrual period for reexamination (may reveal regression of mass) if no obvious
signs of malignancy present

What is the mechanism of central precocious puberty?

early activation of the hypothalamic-pituitary-ovarian axis
FSH and LH will be elevated

What is the mechanism of peripheral precocious puberty?

low FSH and LH
caused by gonadal or adrenal release of excess sex hormones

How can ovulation be induced in PCOS pts?

clomiphene citrate tx and metformin tx

What is the earliest sign of mag sulfate toxicity?

depression of DTR
Tx: stop mag sulfate and admin calcium gluconate

How is threatened abortion tx?

1) ascertain that fetus is present and alive via u/s
2) reassurance and performance of u/s one week later
3) bed rest and abstain from sex

How is infertility evaluated?

1) detailed H&P
2) Confirm ovulation (mid-cycle pelvic pain and/or midluteal phase serum progesterone level
b/c corpus luteum produces progesterone)

What causes low back pain in third trimester of pregnancy?

increased lumbar lordosis and relaxation of ligaments supporting the joints of pelvic girdle

What causes early decels?

nonreassuring heart rate pattern that are the result of fetal head compression
resolve at end of uterine contraction

What is a biophysical profile?

scoring system to evaluate fetal well being (high risk pregnancies, or when there is
materna/physician concern like decreased fetal movements or non-reactive NST)
Five parameters:
1) NST
2) Fetal tone
3) Fetal movement
4) Fetal breathing
5) amniotic fluid index
8-10 is considered normal
repeated only once or twice weekly until term for high risk pregnancies

What are concerning signs of BPP?

1) presence of oligohydramnios (AFI<5)-->consider delivery since it can result in umbilical

cord compression and therefore fetal compromise
2) consider delivery if AFI is 6 but contraction stress test is non-reassuring
3) Consider delivery if BPP is 4 without oligohydramnios and fetal lungs are mature
4) Delivery if BPP< 4

How does uterine rupture present?

intense abd pain assoc with vaginal bleeding, which can range from spotting to massive
hemorrhage.
Pts are hypovolemic, retraction of presenting parts on pelvic exam, palpability of fetal
extremities, on abd exam

How does ABO incompatibility generally present?

occurs in group O mothers with group A, B baby
ABO incompatibility causes less severe hemolytic disease of newborn than does Rh(D)
incompatibility. Affected infants are usually ASx at birth w/ absent or mild anemia and
develop neonatal jaundice
Tx: phototherapy

How is spyhillis tx in pts who have penicillin allergies?

confirm allergy with skin testing
then desensitization so that she can safely take the medication

How does cervical mucus present in ovulatory phase of menstrual cycle?

cervical mucus is profuse, clear and thin
will stretch to approximately 6 cm and exhibit ferning on a microscope slide smear
preparation

What is the BHCG threshold for transvaginal ultrasound to visualize a

intrauterine/extrauterine pregnancy?
BHCG is 1500-2000
If <1000 both BHCG and transvaginal ultrasonography should be repeated in 2-3 days

How does T4/T3 change with pregnancy?

Pregnancy is associated w/ increase in TBG, resulting in increased total T4 and T3-->a
normal free T4 and normal TSH

How does pregnancy change BUN and Cr?

serum BUN and Cr usually decreased in pts due to increase in renal plasma flow and GFR

What is the def of arrest of dilatation?

lack of change for 2hrs in nulliparous and multiparous pts

What is the def of arrest of descent?

lack of change for 2hr in primigravid pts and 1 hr in multigravid pts with an extra hr allowed
in an epidural is in place

How should arrest of labor be tx?

if inadequate contractions, give oxytocin and alter fetal malpresentation
if abnormality in maternal pelvis, C/S

How is placenta previa tx?

emergency C/S

Why should ASx bacteriuria be treated?

to prevent pyelo in pregnant pts

What is a contraindication to raloxifene tx?

used as an agonist in bnoe tissue and first line agent for prevention of osteoporosis and
decreases breast cancer sik
BUT increases risk of thromboembolism
- so if have Hx of DVT, cannot be used

How is fertility tx in pts with acquired hypogonadotropic hypogonadism?

Acquired hypogonadotropic hypogonadism is a cause of amenorrhea seen most commonly in
assoc with significant stressors, eating disorders and excessive exercise
Tx: pulsatile GnRH therapy can induce ovulation in these pts

What is the cause of hypotension in pts with epidural anesthesia?

blood redistribution to lower extremities and venous pooling

What are the characteristics of HELLP syndrome?

thrombocytopenia
microangiopathic hemolytic anemia
increased liver enzymes
preeclampsia

How is HELLP tx?

delivery if women are beyond 34 wks gestation
for pregnancies less than 34wks, mgmt depends on fetal and maternal states. Give
dexamethasone if maternal stable and fetus lung maturity can be performed.

What is painless third trimester vaginal bleeding?

placenta previa
r/o before doing a pelvic exam

If a pt presents with vaginal discharge and severe vulvar pruritis, with thin,
malodorous vaginal discharge and marked vulvar and vaginal erythema, with
a vaginal discharge pH of 5.5, what is the likely infxn?
flagellated motile organisms-->Trichomonas
BV does not cause inflammation

What type of pt presents with primary amenorrhea and anosmia?

Kallmann's syndrome (46XX)--congential absence of GnRH secretion
- present w/ amenorrhea and absent secondary sexual characteristics such as breast
development and pubic hair
FSH and LH low (GnRH deficiency)

What is physiologic leukorrhea?

copious vaginal discharge that is white or yellow in appearance, nonmalodorous, and occurs
in the absence of other sx or findings

How is CIN I in a low risk pt managed?

expectantly managed with either repeat Pap smear screening at 6 and 12 mo or HPV testing at
12 mo
Positive results on either of these tests should be evaluated w/ repeat colposcopy

What is emergency contraception?

Levonorgestrel and can be given up to 120hrs after unprotected intercourse

How is amenorrhea worked-up?

1) H&P
2) r/o pregnancy
3) Lab tests: FSH to r/o ovarian failure, prolactin to evaluate for hyperprolactinemia, TSH to
evaluate for hypothyroidism and hyperthyroidism

Why are infants born to pts with Graves disease treated with surgery at risk
for thyrotoxicosis?
b/c passage of thyroid stimulating immunoglobulin across the placenta

How is PID tx?

inpatient tx w/ cefotetan plus doxycycline

If a pt in the immediate postpartum period presents with low-grade fever,

leukocytosis, and vaginal discharge, what should the next step in management
be?
normal findings, vaginal discharge (lochia) is initially bloody, then serous and finally white
to yellow in color days following delivery

If bilateral solid ovarian masses are discovered incidentally in a multiparous

African-American pregnant woman, what is the likely cause?
pregnancy luteoma
- benign self-limited condition that requires no treatment

What causes irregular menstrual cycles shortly after menarche?

hypothalamic-pituitary-gonadal axis immaturity is a cause of irregular menstrual cycles in
women shortly following menarche

What causes anovulation and amenorrhea in lactating mothers?

elevated prolactin levels suppress GnRH release thereby suppressing LH and FSH production
and ovulation.

What should be considered in a pt who has recently undergone amniocentesis

and has an abrupt onset of hypoxia with respiratory failure, cardiogenic
shock, and DIC?

amniotic fluid embolism

What is the most common cause of mucopurulent cervicits?

Chlamydia trachomatis

How are chlamydia and gonorrhea treated simultaneously?

ceftriaxone and azithromycin

What diagnostic test should be pursued if there is suspect for decreased fetal
movement?
nonstress test
Normal: 20min 2 accelerations of fetal heart rate of at least 15 beats per minute above
baseline lasting at least 15 seconds
most common cause for nonreactive test is sleeping baby, so use vibroacoustic stimulation to
wake the baby up

When should an endometrial biopsy be taken for diagnosis of dysfunctional

bleeding?
>35yo
HTN, diabetes, obesity

In pts who are taking Levothyroxine, how does their treatment change when
they are receiving estrogen replacement therapy?
requirement for levothyroxine increases.
Causes:
- induction of liver enzymes
- increased level of TBG
- increased volume of distribution of thyroid hormones
Similar to pregnancy.

What type of cancer are pts with PCOS at risk for?

endometrial hyperplasia/carcinoma

Pts exposed to DES in utero are at risk for what type of cancer?
clear cell adenocarcinoma of the vagina and cervix
also cervical anomalies and uterine malformations

If a fetus has been diagnosed with a severe congenital anomaly incompatible

with life, how should the labor be managed?
labor should be allowed to proceed

What are the SE of OCPs?

venous thromboembolism
cardiovascular events/stroke
elevation of triglyceride levels
cholestasis or cholecystitis
DM
HTN

What are OCPs protective against?

ovarian cysts and cancer
endometrial cancer
benign breast disease
dysmenorrhea (anemia)