Obgyn 3

Sex cord stromal tumors

Meigs syndrome is defined as the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor.

Granulosa theca

Patients usually present with precocious pseudopuberty (70-80%) and have secondary sex characteristics at a very early age. These may include increased linear growth, breast enlargement, clitoral enlargement, pubic hair development, increased vaginal secretions, and vaginal bleeding.

trichomoniasis

Hysterectomy

The only guaranteed treatment for adenomyosis is total hysterectomy. Since disease is confined to the uterus, ovarian conservation can be employed. There are no large or controlled studies of medical or limited surgical therapy for this disease.

- ??

- cimetidine has been used safely during pregnancy to treat severe peptic ulcer disease as well as near term for the prevention of Mendelson's syndrome. Cimetidine is only recommended for use during pregnancy when benefit outweighs risk.

- ciprofloxacin: This drug should not be used during pregnancy unless the benefit outweighs the risk to both fetus and mother. -UK: As a precaution, avoiding use during pregnancy is preferred.

FDA pregnancy category: C

- azithromycin: Azithromycin has been assigned to pregnancy category B by the FDA.

Asymptomatic Bacteriuria

Asymptomatic bacteriuria is defined as isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen from an individual without symptoms or signs of urinary tract infection.

Treat even asymptomatic

Nitrofurantoin

Oral antibiotics are the treatment of choice for asymptomatic bacteriuria and cystitis:

Nitrofurantoin: 100 mg twice daily (avoid at 36+ weeks)

Two specimens from different sites

- they answered B

* Frank breech (50-70%) - Hips flexed, knees extended (pike position)

* Complete breech (5-10%) - Hips flexed, knees flexed (cannonball position)

* Footling or incomplete (10-30%) - One or both hips extended, foot presenting

I think the answer is A

partial perineal injury

Breach

Polymenorhea

Polymenorrhea is the medical term for cycles with intervals of 21 days or fewer

Menometrorrhagia is a condition in which prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal. It is thus a combination of metrorrhagia and menorrhagia.

Hypermenorrhea, also known as menorrhagia, is

a disruption in the normal menstrual flow of

girls and women.

give oxitocin and amniotomy

human papilloma virus.

??

- For primary amenorrhea, hormone therapy, consisting of an estrogen and a progestin, is recommended for women with estrogen deficiency. - A typical regimen consists of an estrogen with a dosage equivalent to 25 mcg/day of transdermal estradiol given unopposed (i.e., no progesterone) daily for 6 months with incremental dose increases at 6-month intervals until the required

maintenance dose is achieved.

- Cyclic progesterone therapy, given 12-14 days per month, should be instituted once vaginal bleeding begins.

Primary amenorrhe:

- Group I: low oestrogen, low FSH, and no hypothalamic-pituitary pathology, leading to a diagnosis of hypogonadotrophic hypogonadism.

- Group II: normal oestrogen, normal FSH, and normal prolactin, leading to a diagnosis of polycystic ovary syndrome.

- Group III: low oestrogen and high FSH, leading to a diagnosis of gonadal failure.

prophase

Chromosomes become visible, the nucleolus disappears, the mitotic spindle forms, and the nuclear envelope disappears

Squamous carcinoma

PID

- Deep symptoms are often related to disorders in the pelvis.

- Infectious/inflammatory conditions: cervicitis, PID, endometriosis

The only way to diagnose ovarian cancer is with exploratory operation.  -Intra operative biopsy is not usually done , biopsy may spread cancer cells.

 -Ca125 is for monitoring ( pre and post operative )

- it is not diagnostic and not specific.  -Imaging like u/s is recommended initially , but can not be diagnostic .

- If symptoms are present, they are often vague and non-specific. Patients with early disease are typically asymptomatic; thus, a majority of patients present in advanced stages of the disease. Common symptoms are abdominal bloating, nausea and emesis, early satiety, dyspepsia, increased abdominal girth, abdominal cramping, or a change in bowel habit suggestive of advanced disease.

- ascites, pleural effusion, palpable mass on pelvic examination, and abdominal distension that is dull to percussion.

- Transvaginal pelvic ultrasound is the preferred method to evaluate a suspected ovarian mass, providing both qualitative and quantitative information valuable in management: Worrisome findings include bi-lateral masses, complex masses with thick septations or solid tumour nodules, and abnormal Doppler flow.

The patient is suspected to have abortion. For which, vaginal os examination and ultrasound are indicated for confirmation.

Oseltamivir

Oseltamivir is preferred for treatment of pregnant women. Pregnant women are recommended to receive the same antiviral dosing as non-pregnant persons

Iron deficiency anemia

Colposcopy

Enoxaparin

Most common cause of postpartum fever is endometritis. Risk factors: ER CS after prolonged rupture of membranes and prolonged labor. Findings: moderate to high fever, exquisite uterine tenderness. Managed with multiple agent IV antibiotics.

Nitrofurantoin

Nitrofurantoin is category B drug during pregnancy

LH and FSH level

SSRI

This seems like premenstrual syndrome. The first line treatment of which are ssris

Candida albicans

Müllerian Agenesis

Combined estrogen progesterone.

Progesterone maintains the lining of the uterus, which makes it possible for a fertilized egg to attach and survive. Makes cervical mucous accessible by sperm. Allows the embryo to survive. Prevents immune rejection of the developing baby. Allows for full development of the fetus through pregnancy. Helps the body use fat for energy during pregnancy. Progesterone only used if women want to breastfeed her baby. If not so combined.

both lieomyoma and leiomyosarcoma not common in post menopause and can differentiate btw sarcoma + oma by present of

5-10 mitosis /10 high power field +atypia or more than 10 with or witout atypia

To approach pregnant with bleeding you have to decide is early pregnancy bleeding or late (antepartuem) bleed which judjed by a cutoff of time 20 weeks in that case the bleeding is early and there is 2 of most common causes of early pregnancy bleeding which is ectopic pregnancy and abortion in that threatened abortion is more convincing than other options

LH?

After several months of amenorrhoea, an elevated FSH level may be more predictive of impending menopause.

- After menopause, oestrone, which is derived from estradiol metabolism in the liver and peripheral conversion of androstenedione in adipose tissue, becomes the dominant oestrogen.

Rectovaginal prolapse (rectocele )

- most common type of prolapse is Cystourethrocele

- cystocele (bladder prolapse), rectocele (prolapse of the rectum or large bowel), and enterocele (prolapse of the small bowel); all of these are often associated with prolapse of the uterus. Uterine prolapse is the loss of anatomical support for the uterus

- Rectocele: postmenopausal woman, posterior vaginal protrusion, digital assisted removal of stool.

Elective c/s at ?

The indications for CS:

1) maternal: 2 previous LSCS, placenta previa, fulminating pre-eclampsia, active primary genital herpes simplex, HIV (>1000 copies) , mother request.

2) fetal: breech, twin and 1st is not cephalic, abnormal CTG/fetal blood sample, cord Prolapse, delay in 1st stage of labour (malpresentation, malposition).

DM type 2

Ampicillin

* nitrofurantoin was completely avoided in the third trimester because of hemolytic effects on the newborn. Currently, restriction of this agent is limited to the last several weeks of pregnancy. Use during this period can cause hemolytic anemia in the fetus or neonate as a consequence of their immature erythrocyte enzyme systems (glutathione instability).

Continue breast feeding, hot compressor and antibiotic.

Heat or ice packs, continued nursing/pumping, antibiotics (dicloxacillin/cephalexin) (erythromycin if pen-allergic

Marsupialization

It is a Bartholin cyst, it needs to be drained with a simple incision and drainage but if it continued to recur, then Marsupialization should be done.

Rupture of membranes for more than 18 hours.

Ashermann Syndrome

Unintended miscarriage

Chorionic villus sampling (10 - 12 wk):1-2% risk of spontaneous abortion.

Observe BP

If <36w: IP conservative

>36: MgSO4 and deliver

Between 34-36 weeks gestation the benefit of giving steroids is unclear. Mgso4 is indicated for this case, it is indicated if there is severe preeclampsia.

Estrogen

● Local estrogen replacement (ideal): Premarin® cream, vagifem® tablets, or Estring

● Oral or transdermal hormone replacement therapy (if treatment for systemic symptoms is desired)

● Good hygiene

Metronidazole

Gonorrhea

- Gonococcal conjunctivitis tends to occur 2-7 days after birth but can present later.

- Chlamydial conjunctivitis usually has a later onset than gonococcal conjunctivitis; the incubation period is 5-14 days.

Cerclage at 12-13 weeks

Usually at the end of the 1rst trimester and removed in the third trimester. Emerging evidence indicates that progesterone suppositories are superior to cerclage in preventing preterm labour late in pregnancy

Asherman's syndrome.

Intrauterine adhesion (or intrauterine synechiae) is a condition in which scar tissue develops within the uterine cavity. Intrauterine adhesion accompanied by symptoms (eg, infertility, amenorrhea or hypomenorrhea) is also referred to as Asherman syndrome. It's primarily caused by curettage for pregnancy complications.

Natural vaginal delivery trial

PE

During pregnancy, risk is increased because venous capacitance and venous pressure in the legs are increased, resulting in stasis, and because pregnancy causes a degree of hypercoagulability.

-Lithotomy positioning during delivery or in gynecologic/urologic procedures also has been associated with compressive femoral neuropathy. The sensory branch of the femoral nerve, the saphenous nerve, innervates skin of the medial thigh and the anterior and medial aspects of the calf.

-The cutaneous branch of the obturator nerve supplies the skin of the middle part of the medial thigh

active third stage

Routine oxytocin administration in third stage of labor can reduce the risk of PPH by > 40%

ruptured ectopic pregnancy

Ureteral injury

Ureteral injuries are common, owing to the size and location of the ureter, and generally are the result of excessive electro cautery and lasering adjacent to the ureter during surgery.

Continue breastfeeding

The American Academy of Neurology and the American Academy of Pediatrics advise that women with epilepsy taking aeds can breastfeed. If mothers receiving ethosuximide, phenobarbital or primidone choose to breastfeed, they should exercise caution and closely monitor the infant for sedation, lethargy and any significant clinical findings.

Continue breastfeeding

These data support the recommendation of the American Academy of Pediatrics that HBV infection not be considered a contraindication to breastfeeding of infants who receive the HBIG and HBV vaccine as advised.

Flucanazole

- Increasing are the numbers of fungal UTI, particularly those caused by Candida spp, and, to a lesser extent, by Aspergillus spp and Cryptococcus neoformans.

-  Candiduria is a condition most often found in elderly, hospitalized, or immunocompromised patients. 

- Candida albicans is the most common species

isolated, accounting for more than half of all fun

gal infection cases. 

- The mainstay of antibiotic treatment for candiduria is the azolic compounds, mainly fluconazole 200 mg orally daily for 2 weeks

Feto-ultrasonography

CS

Hysterectomy bilateral salbingo oophrectomy

Definitive: bilateral salpingo-oophorectomy +/- hysterectomy

Ruptured ectopic pregnancy

Suspicion of an ectopic pregnancy increases if free fluid (representing blood) is visualised, either surrounding the uterus or in the Pouch of Douglas, although a small amount of free fluid in the Pouch of Douglas, a transudate due to increased vascular permeability, is common in early pregnancy.

Valvular contamination

Epithelial cells — cells that line your hollow organs and form your skin — in your urine may be a sign of a tumor. But more often, they indicate that the urine sample was contaminated during the test, and a new sample is needed

ACTIVE third stage

Active management of the third stage of labor, which involves immediate manual removal of the placenta and the administration of a uterotonic agent, has been shown to reduce the incidence of hemorrhage

DIC

Abruptio placentae, amniotic fluid embolism, sepsis, and severe preeclampsia are obstetric conditions associated with disseminated intravascular coagulopathy

Iron

I don't know what they mean by “iron nothing”. Iron-deficiency anemia is by far the most frequent type of anemia seen in pregnancy, accounting for more than 90% of cases

SVD

Criteria for trial of labor include patient consent, nonrepetitive cesarean indication (e.g. Breech , plcanta previa), Previous low segment transverse uterine incision, clinically adequate pelvis.

trial of labor after cesarean" means that you plan to go into labor with the goal to deliver vaginally, but still may need to C-section

OCP can protect you from ovarian cancer

Oral contraceptives that prevent ovulation appear to provide significant protection against the occurrence of ovarian cancer.

Amniotic Emboli.

A woman in the late stages of labor becomes acutely dyspneic with hypotension; she may experience seizures quickly followed by cardiac arrest. Massive DIC-associated hemorrhage follows and then death. Most patients die within an hour of onset. Currently no definitive diagnostic test exists. The United States and United Kingdom AFE registries recommend the following 4 criteria, all of which must be present to make the diagnosis of AFE:

- Acute hypotension or cardiac arrest 

- Acute hypoxia 

- Coagulopathy or severe hemorrhage in the ab

sence of other explanations

- All of these occurring during labor, cesarean

delivery, dilation and evacuation, or within 30 minutes postpartum with no other explanation of findings

Fluconazole

Treatment is only for symptomatic or high-risk patients. Fluconazole or, for resistant organisms, amphotericin B; sometimes flucytosine is added.

Endometrial biopsy

- An endometrial biopsy is needed to confirm a diagnosis of endometrial cancer. A biopsy removes a small sample of the lining of the uterus (endometrium) to be looked at under a microscope.

- Tamoxifen is used to treat women with estrogen receptor-positive breast cancer. It can be used in conjunction with chemotherapy. It is also given as a 5-year course of preventive treatment following surgery.

- Tamoxifen is a selective estrogen receptor modulator and acts as an estrogen receptor antagonist in the breast and as an agonist in the uterus and bone. Studies of tamoxifen therapy for 5 years have demonstrated a 50% reduction in local breast recurrence, 30% decrease in mortality, and prevention of new breast cancer development. The risks of endometrial cancer and thromboembolic events due to hypercoagulability are increased two to four times with tamoxifen but occur in fewer than 1% of women taking the medication.

Penicillin

Uncomplicated UTI

Ƒ first line: amoxicillin (250-500 mg PO q8h x 7 d) Ƒ alternatives: nitrofurantoin (100 mg PO bid x 7 d)

CS

In light of recent studies that further clarify the longterm risks of vaginal breech delivery, the decision regarding mode of delivery should depend on the experience of the healthcare provider. Cesarean delivery will be the preferred mode for most physicians because of the diminishing expertise in vaginal breech delivery. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. The following criteria have been suggested for vaginal breech delivery:

Normal labor curve, Gestational age greater

than 37 weeks, Frank or complete breech pre

sentation. Because of the risk of umbilical cord

prolapse, vaginal delivery of a fetus in the

footling breech position is not recommended. 

Absence of fetal anomalies on ultrasound exami

nation  Adequate maternal pelvis,  Estimated fe

tal weight between 2500 g and 4000 g , Docu

mentation of fetal head flexion. Hyperextension

of the fetal head occurs in about 5% of term

breech fetuses, requiring cesarean delivery to

avoid head entrapment.  Adequate amniotic flu

id volume (defined as a 3-cm vertical pocket) 

Availability of anesthesia and neonatal support.

- If a vaginal breech delivery is planned, the woman should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher in it than in a cesarean delivery, and the patient's informed consent should be documented.

Chorionic villous biopsy

Chorionic villus sampling (CVS) is a diagnostic procedure performed under US guidance. In this procedure we aspirate by catheter from pregnant uterus between 10-12 weeks gestation. The tissue is sent to laboratory for karyotyping. Amniocentesis is diagnostic procedure performed after 15 weeks (second trimester).

Bartholin carcinoma

Bartholin carcinoma on average occurs in women over the age of 50; however, any new Bartholin mass in a woman over the age of 40 should be excised. Treatment of diagnosed Bartholin cancers is radical vulvectomy and bilateral lymphadenectomy. Recurrence is disappointingly common, and a 5-year overall survival rate of 65% is noted

OCP

medical treatment of endometriosis

1) Nsaids (e.g. Naproxen sodium – Anaprox®)

2) Pseudopregnancy:

o Cyclic/continuous estrogen-progestin (OCP)

o Medroxyprogesterone (Depo-Provera®)

o Dienogest (Natazia®)

3) Pseudomenopause o 2nd line: only short-term (<6 mo) due to osteoporotic potential with

prolonged use, Unless combined with add-back therapy (e.g. Estrogen/progesterone or SERM); if Long-term use required, add-back estrogen+progesterone

o Danazol (Danocrine®): weak androgen

* Side effects: weight gain, fluid retention, acne, hirsutism, voice change

o Leuprolide (Lupron®): gnrh agonist (suppresses pituitary)

* Side effects: hot flashes, vaginal dryness, re

duced libido Can use ≥12 mo with add-back progestin or estrogen

4) Surgical

o Conservative laparoscopy using laser, electro

cautery ± laparotomy Ablation/resection of im

plants, lysis of adhesions, ovarian cystectomy of endometriomas o De

finitive: bilateral salpingo-oophorectomy ± hysterectomy

o ± follow-up with medical treatment for pain control not shown to impact on preservation of fertility

o Best time to become pregnant is immediately after conservative surgery

not enough answering options

But most likely it is Gram-positive branching filaments of Actinomyces species.

Although this patient is having regular menstrual cycle, this is mostly a case of Polycystic ovarian syndrome, in PCOS: Obesity (in 40% to 50% of patients)

Signs of virilization, including deepening voice and masculinization of body habitus

Cutaneous signs of androgenization, such as hirsutism, acne, oily skin, and male pattern baldness; acanthosis nigricans (gray-brown, velvety

discoloration of skin, usually at the neck, groin, and axillae) (according to Clinical Key)

- In PCOS Determining the LH/FSH ratio is useful because a ratio of 3:1 is virtually diagnostic of PCOS; however, a normal ratio does not exclude

the diagnosis, as LH levels fluctuate widely throughout the course of a day.

Also Thyroid-stimulating hormone (TSH) is measured to rule out hypothyroidism

chlamydia

Tests for chlamydial infection should be done in all patients. It is particularly important that these should be performed in mothers with untreated gonorrhea, and mother and newborn infant should be tested (clincalkey)

bacterial vaginosis

question is not complete , could be normal vaginal discharge, but from the available choices the answer is most likely to be (B) since its whitish discharge, while Trichomoniasis characteristically causes a yellowish-green.

HSV 2

There are two main subtypes of herpes simplex virus (HSV): HSV-1, which classically causes oral herpes, and HSV-2, which classically causes genital herpes; however, both types can cause symptoms in almost any anatomic site.

Unopposed estrogen.

The leading role in the pathogenesis of endometrial hyperplasia is given relative or absolute hyperestrogenic, the absence of antiestrogenic effects of progesterone or insufficient effect.

Endometriosis

The most common cause of secondary dysmenorrhea is endometriosis. The main clinical features are dysmenorrhea, chronic pelvic pain and infertility

psychotherapy

Sertraline, paroxetine & nortriptyline are the safest & most effective in PPD. Psychological treatments for PPD are often the treatment of choice for women, as they are effective for the treatment of depressive symptoms and do not involve the risks of exposure to medications.

female gets puberty 1-2 years earlier than male.

Cystocele

Esophagus

Many patients are now diagnosed antenatally. Fetal ultrasound shows polyhydramnios and often no stomach bubble.If the baby presents with a pure atresia (no fistula), the initial findings at delivery are similar. The nasogastric tube coils in the upper oesophageal pouch; Additionally, a maternal history of polyhydramniosis may indicate the fetus' inability to swallow amniotic fluid, suggesting a blockage.

asymptomatic

Most fibroids are asymptomatic. However, severe localized abdominal pain can occur if a fibroid undergoes so-called “red degeneration,” torsion (seen most commonly with a pedunculated subserosal fibroid). Pain is the most common complication of fibroids in pregnancy, and is seen most often in women with large fibroids (> 5 cm) during the second and third trimesters of pregnancy.

- Some studies have suggested that small and large fibroids (≥ 6 cm) have different growth patterns in the second trimester (small fibroids grow whereas large fibroids remain unchanged or decrease in size), but all decrease in size in the third trimester. Fibroids that did increase in volume, the growth was limited almost exclusively to the first trimester, especially the first 10 weeks of gestation, with very little if any growth in the second and third trimesters

For the baby

Born at low birthweight

Preterm delivery

Asphyxia ‘ fetal distress ‘

Fetal death & stillbirth.

BV

- Candidiasis is typically diagnosed clinicallywith evidence of erythema and a thick,white, cottage cheese-like discharge adherent to lateral vaginal walls, but may be confirmed by 10% potassium hydroxide (KOH) wet mount preparation or culture. If bacterial vaginosis or trichomoniasis is suspected, vaginal samples for vaginal ph, amine ('whiff') test, saline, and KOH microscopy (wet mount) aid diagnosis, together with clinical findings.

- The ph and amine testing can be performed either through direct measurement or by colorimetric testing. It is Important that the swab for ph evaluations be obtained from the mid-portion of the vaginal side wall to avoid false elevations in ph results caused by cervical mucus, blood, semen, or other products An elevated ph is seen in bacterial infections and atrophic vaginitis.

HSV

Genital ulcers in HSV are multiple, painful ulcers start as vesicular lesions and progress to ulceration, then crusted lesions.

Kegel exercise.

obturator

Propylthiouracil

cimetidine

Active PID

nsaids

???

Levothyroxine

Natural vaginal delivery trial

continue

There is no documented evidence that breastfeeding spreads HCV. Therefore, having HCV-infection is not a contraindication to breastfeed. HCV is transmitted by infected blood, not by human breast milk. There are no current data to suggest that HCV is transmitted by human breast milk.

Primary dysmenorrhea.

dm type 2

The mother is at risk of developing type 2 diabetes in the next 10 to 20 years

anti epileptic

Mullerian agenesis?

Mullerian agenesis : to development of mullerian duct ( no vagina, uterus, cervix) but present with primary amenorrhea and secondary sexual chch

They have breast and pubic hair but no uterus

Tx: no hormone needed, creat vagina, IVF surrogate.

Gonadal dysgenesis: breast and uterus absent

Increase in FSH, no ovarian follicles

Tx: E+ P, egg donor.

Natural vaginal delivery.

Answer She's candidate of TOLAC ( trial of Labor after cesarean) because she underwent one low-transverse CS and everything is normal with no other uterine scar or previous rupture

??

During delivery, as the infant proceeds to move down the vaginal canal, the infant stretches the perineum, levator ani, and pelvic fascia. Specifically, the pubococcygeus muscle is at risk for stretching to the point of tearing. The pubococcygeus muscle supports the urethra, vagina, and vaginal canal and damage to this muscle could lead to urinary stress incontinence post delivery whenever the patient coughs or increases her intraabdominal pressure by bearing down.

A (I'm not sure! This is as it wrote before, we need to pregnancy test to diffrentiate) Persistent corpus luteum cysts are often associated with dull lowerquadrant pain. This pain and a missed menstrual period are the most common complaints associated with persistent corpus luteum cysts. Pelvic examination usually discloses an enlarged, tender, cystic, or solid adnexal mass. Because of the triad of missed menstrual period, unilateral lower-quadrant pain, and adnexal enlargement, ectopic pregnancy is often considered in the differential diagnosis. A negative pregnancy test eliminates this possibility, whereas a positive pregnancy test mandates further evaluation regarding the location of the pregnancy.

I think B

Narcotic analgesia???

I think they are asking about the cause of distress, narcotics can cause fetal distress.

* Maternal intravascular volume status– Hypovolemia is usually considered greater problem forregional anesthesia

* Coagulation status– Coagulopathy and thrombocytopenia can becontraindications to neuraxial block placement.

* Regional anesthesia safe in chronic fetal stress.General anesthesia usually preferred in dire distress ‐ placental abruption, severe fetal bradycardia, uterine rupture. Intermediate degrees of distress often managed well with regional anesthesia.

rubilla vaccin

To decreade risk of congintal heart disease :

1-Viral Infections – Women who contract rubella (German Measles) during the first three months of pregnancy have an increased risk of having a baby with a heart defect ,women should avoid becoming pregnant for one month after receiving the MMR vaccine.

2-Take 400 micrograms of folic acid supplement a day during the first trimester (first 12 weeks) of your pregnancy

3-Avoid drinking alcohol or taking drugs.

4-If you have diabetes, make sure it's controlled.

before prepare of operation?

- Premature rupture of membranes (PROM) refers to membrane rupture before the onset of uterine contractions. preterm PROM (PPROM) refers to PROM before 370/7ths weeks of gestation.

- The classic clinical presentation of PPROM is a sudden "gush" of clear or pale yellow fluid from

the vagina. However, many women describe intermittent or constant leaking of small amounts of fluid or just a sensation of wetness within the vagina or on the perineum

- In women with PROM at term, labor should be induced immediately, generally with oxytocin (Pitocin) infusion, to reduce the risk of chorioamnionitis. Labor should be induced immediately, regardless of gestational age, in patients with intrauterine infection, placental abruption, or evidence of fetal compromise.

- if uterine contraction present: tocolytic contraindicated

- if Chorioamnionitis: start IV Abx and delivery.

- tx depends on age:

<24 w: bed rest orinduce labour

24-33: IM betamethasone, 7d ampicillin and erythromycin

>34: delivery

???

I think B, according to DSM 5 criteria the pt should be sx free for 1 week in the 1st part of the cycle (follicular phase) and present in 2nd half of cycle (luteal phase)

Diagnosis requires a consistent pattern of emotional and physical symptoms occurring after ovulation and before menstruation to a degree that interferes with normal life.

I think gestational

BP >140 start after 20w gestation, no edema or proteinurea. Tx only during pregnancy

Preeclampsia: Mild--> HTN, proteinurea, edema

If preterm: MgSO4 and betamethasone

If term: delivery

Severe--> HTN, proteinurea, edema, mental status change, vision change, impaired liver function

Tx: MgSO4 and control BP hydralazynie , delivery

??

-

smoking cessation

Women who smoke during early pregnancy are more likely to have a child with congenital heart defects

CS

C/S recommended if: the breech has not descended to the perineum in the second stage of labor after 2 h, in the absence of active pushing, or if vaginal delivery is not imminent after 1 h of active pushing.

abruptio placente

both of them have clinical sx are almost the same. but the abdominal pain of UR will be gone after rupture, and then following by imminent sign like hyperventilaion, agitation or tachycardia). when you palpated abdominal you can feel the baby stay right under abdominal skin or outside of uterus. - Base on the Hx. UR Hx like previous classic incision, myomectomy or excess oxytocin.

- abruptio-MOTOR VEHICLE ACCIDENT

- uterine rupture-PRIOR CS

- triad of uterine rupture=late trimester bleedind+loss of fetal heart tracing(bradycardia) and inability to identify uterine contractions!!

- Abruptio placenta-the most common bleeding in T3, painful bleeding...w/out those from above

- if uterine rupture: immediate laparotomy and delivery.

Reassurance

Their answer:

Women who use oral contraceptives have been shown to have a reduced risk of endometrial cancer. This protective effect increases with the length of time oral contraceptives are used and continues for many years after a woman stops using oral contraceptives. Cervical cancer: Long-term use of oral contraceptives (5 or more years) is associated with an increased risk of cervical cancer

But I think the pt has PCOS and the question will be what cancer she is at risk if stopped taking progestrone?

The answer will be endometrial cancer, because of the unopposed estrogen (PCOS: hyperestrogenism:endometrial hyperplasia)

Cemitidin

Cimetidine has been assigned to pregnancy category B by the FDA

Heparin

Pregnancy and the puerperium are well-established risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE), which are collectively referred to as venous thromboembolic disease (VTE).

- For pregnant women, we recommend adjusted dose subcutaneous low molecular weight heparin

- We suggest that anticoagulant therapy continue at least six weeks postpartum (Grade 2C). We suggest a total duration of anticoagulant therapy of at least three to six months for women whose only risk factors for VTE were transient (eg, pregnancy) (Grade 2C). Patients with persistent risk factors for VTE may require longer therapy.

- Thrombolytic therapy should be reserved for pregnant or postpartum patients with life-threatening acute PE (ie, persistent and severe hypotension due to the PE))

Biopsy of the lesion

Cracked nipples

Cracked or bleeding nipples because the virus is in the blood.

Folate

If these are the only available choices, this is the answer because folate deficiency causes macrocytic anemia.

Mulleirn duct

• Müllerian agenesis (including absence of the uterus, cervix and/or vagina) is the etiology in 15% of cases of primary amenorrhoa.

• gonadal dysgenesis has no 2' sexual characters.

They answer a!!

Phenytoin may cause harm to an unborn baby, but having a seizure during pregnancy could harm both mother and baby. Tell your doctor right away if you become pregnant while taking this medicine. If you become pregnant while taking phenytoin, your name may be listed on a pregnancy registry. This is to track the outcome of the pregnancy and to evaluate any effects of phenytoin on the baby. Phenytoin can make birth control pills less effective. Ask your doctor about using non hormonal birth control (condom, diaphragm with spermicide) to prevent pregnancy while taking this medicine. Phenytoin can pass into breast milk and may harm a nursing baby. You should not breast-feed while you are using this medicine.

I think she can breast feed:

Phenytoin (Dilantin) and carbamazepine (Tegretol) are compatible with breast-feeding. From AAFP.

Septicides in condoms

There is a strong association between the use of condoms coated with nonoxynol 9 and the occurrence of UTI, which suggests that vaginal spermicides interfere with the normal vaginal flora and promote colonization by S. Saprophyticus.

Douching habits is associated with stds (gonorrhea, chlamydia, syphilis, trichomoniasis, or herpes simplex virus-2)

Endometrial hyperplasia

The most common endocrine manifestation of Granulosa-Theca Cell Tumors in postmenopausal women is abnormal uterine bleeding. This is caused by resumption of endometrial proliferation due to estrogen production by the tumor. For this reason, endometrial hyperplasia and/or endometrial adenocarcinoma may be a concomitant finding in women with GCT.

Order prolactin level

Women who breastfeed have a delay in resumption of ovulation postpartum. This is believed to be due to prolactin-induced inhibition of pulsatile gonadotropin-releasing hormone release from the hypothalamus.

Do cultures

The very act of a patient entering a doctor's chamber and expressing his problem is taken as an implied (or implicit) consent for general physical examination and routine investigations. But, intimate examination, especially in a female, invasive tests and risky procedures require specific expressed consent. Expressed (explicit) consent can be oral or written.

Overian a

Anatomical position of these vessels. Also if uterine artery is mentioned as choice it is more common to be injured in such a procedure.Femoral is in the thigh while ovarian is within the procedure site.

We need viral load to decide if it is more than 1000 the pregnant should be counseled about CS. If less than 1000, there is no contraindication to vaginal delivery, as aobvious the Q is missing important information

Two specimens are obtained with the Pap smear: an ectocervical sample performed by scraping the T-zone with a spatula, and an endocervical sample obtained with a cytobrush in the nonpregnant woman or a cotton-tip applicator in a pregnant woman. ( Kaplan OBS and GYNE chapter of disorders of cervix and uterus)

Cervix

In women, the cervix is the most common site of gonorrhea

Miconazole

It is a topical antifungal of -azole family. A is an antibacterial and certain parasites.

- second most common cause of vaginitis.

- Candida albicans is the most common cause.

- Vaginal vulvar pruritus, burning, or irritation (which may be worse during intercourse) and dyspareunia are common, as is a thick, white, cottage cheese–like vaginal discharge that adheres to the vaginal walls

- Vaginal pH is < 4.5; budding yeast, pseudohyphae, or mycelia are visible on a wet mount, especially with KOH.

- ?? Maybe A!

- Endometriomas are blood-filled cysts arising from the ectopic endometrium. Endometriomas are associated with endometriosis, which causes a classic triad of painful and heavy periods and dyspareunia.

Turner

Endometrial biopsy

the scenario mentioned goes more with Molar Pregnancy

- The most common symptom is bleeding prior to 16 weeks of gestation.

-  The most common sign is fundus larger than dates.

Androgen insensitivity syndrome

46XY

Uterin absent: MIF

Estrogen from testes

Pubic hair absent and testeron level of a male

Tx: Estrogen, remove testes and creat vagina

Nsaids

Hysterectomy with ...

A definitive diagnosis of adenomyosis can only be made from histological examination of a hysterectomy specimen

Most common cause of secondary amenorrhea is pregnancy

But I think the answer here is menopause becuase:

FSH and LH levels become persistantly elevated In menopause.

Ovarian

IDA

due to iron treatment, reactional elevation in retics count?

pap

AUB investigations ; in addition to lab tests, you have to screen for cervical cancer,& possibility of cervicitis by gonorrhea or chlamydia. For patient younger than 45 years old with unopposed prolonged estrogen exposure ( e.g. Obesity ) or with persistent AUB despite medical management , u have to take an endometrial biopsy. Frequent, heavy or prolonged AUB in women > 45 years

necessitate endometrial biopsy

Abnormal uterine bleeding (type: Menorrhagia):

Heavy prolonged bleeding--> endometrial hyperplasia, uterine fibroid, IUD, DUB.

Type: metrorrhagia: intermenstrual bleed--> Endodermal polyps, endometrial/cervical cancer, exogenous estrogen.

wound dehiscence

Active PID

An intrauterine device (IUD or coil)[1] is a small contraceptive device, often 'T'-shaped, often containing either copper or levonorgestrel, which is inserted into the uterus. They are one form of long-acting reversible contraception which are the most effective types of reversible birth control.[2] Failure rates with the copper IUD is about 0.8% while the levonorgestrel IUD has a failure rate of 0.2% in the first year of use.

Mullerian

The question is incomplete but depending on the answers given it seems it's primary ammonorhea.

Antispasmodic

Epinephrine remains the drug of choice for asystole in children. Atropine is not indicated.)

epidural and spinal anesthesia, B/c in General anesthesia the drugs are given to the mother will affect the infant.

NSAID

This is a case of primary dysmenorrhea. The first line of treatment is nsaids. Combination of estrogen and progesterone steroid agents are the second line to suppress prostaglandins.

OCP

Treatment of DUB includes replacing the lacking hormone using OCP.If not successful nsaids can be used.

OCP for DUB

- women who are anovulatory

- women over 35 w/normal endometrial biopsy.

Continue lactating

A patient with HCV and HBV can lactate safely.

Labia majora

The most common type is Squamous cell carcinoma and the most common site is the inner edge of labia majora or minora.

Seizure

- elective cerclage at 13-14 w is appropriate after sonographic demonstration of fetal normality. (Rule out labour or Chorioamnionitis) if cervical length <25 mm before 24 w or if there is hx of preterm birth at <34 w.

Start immediately

Treatment should be instituted immediately and, whenever possible, in conjunction with all sexual partners with metronidazole (safe in pregnancy)

Overian a

Cervix

miconazole

Hysterectomy+oophorectomy

Because she don't have any plan of getting pregnant anymore + Hx of similar problem which increase the risk of getting cancer

Turner

Urine dipstick analysis

question incomplete Explanation: the answer is chronic hypertension if she presents before 20 weeks of pregnancy. The answer is gestational hypertension if she presents after 20 weeks with systolic >140 or diastolic >90. The answer is pre-eclampsia if she presents after 20 weeks with hypertension and proteinuria or has adverse outcomes like headache, renal dysfunction, IUGR, or systolic >160, or diastolic >100. The answer is eclampsia if she pre-eclampsia with seizures (not caused by other neurologic diseases).

??

Hysterectomy with …

The diagnosis is suggested by symptoms and diffuse uterine enlargement in patients without endometriosis or fibroids. Transvaginal ultrasonography and MRI are commonly used for diagnosis, although definitive diagnosis requires histology after hysterectomy.

- Endometritis is inflammation of the endometrial lining of the uterus. It can be divided into pregnancy-related endometritis and endometritis unrelated to pregnancy.

- When the condition is unrelated to pregnancy, it is referred to as pelvic inflammatory disease (PID)

Risk factors: Emergency C section after pro

longed membrane rupture and prolonged labor

In postpartum cases, patients present with fever,

chills, lower abdominal pain, and foul-smelling lochia

FSH /LH

The diagnosis is suspected in the presence of irregular menstrual bleeding, obesity, hirsutism and infertility. PCO is confirmed with LH to FSH ratio, which is in the range of 3:1 The normal LH to FSH ration in ovulatory patient is 1.5: 1

Lieomyoma (uterine fibroids)

Most common cause of post-menopausal bleeding is leiomyoma. First task is to exclude endometrial neoplasia. A biopsy finding of benign endometrium or a vaginal ultrasonography finding endometrial thickness < 4 mm reliably rules out endometrial hyperplasia or cancer.

Hepatitis C with cracked nipples

HIV is an absolute contraindication  There are no sufficient data to say whether Hepatitis C with cracked nipple is contraindicated but it is advised against

Histopathology

 Any pelvic mass should be assumed to be a cancer until proven otherwise, particularly in a patient with a prior history of breast cancer or a family history of breast/ovarian cancer. 

- Most ovarian cysts are discovered incidentally in pregnant ladies who come for their regular pregnancy US.

- CA 125 is often recommended for postmenopausal women with an ovarian cyst.

-  CA 125 may be recommended for premenopausal women whose ovarian cyst appears very large or suspicious for cancer on ultrasound.

- CA 125 does not give definitive diagnosis of ovarian cancer but it is considered one of the earliest steps toward diagnosis, as elevated levels of CA 125 necessitate further more definitive investigation modalities. 

- Histopathological analysis is used for definitive diagnosis.

?? HTN!!

Primary amenorrhea (my answer although it should be 16yo)

- Primary amenorrhea is the failure of menses to occur by age 16 years, in the presence of normal growth and secondary sexual characteristics. If by age 13 menses has not occurred and the onset of puberty, such as breast development, is absent, a workup for primary amenor

rhea should start.

- Secondary amenorrhea is defined as the cessation of menses sometime after menarche has occurred. Oligomenorrhea is defined as menses occurring at intervals longer than 35 days apart.

Beta hcg

Quantitative hcg testing, often called beta hcg (β-hcg), measures the amount of hcg present in the blood. It is used to screen for pregnancy.

Implantation bleeding

Small amount of spotting associated with the normal implantation of the embryo into the uterine wall, called implantation bleeding. This is usually very minimal, but frequently occurs on or about the same day as your period was due.

Observation??

She's in the first stage of labor (active), Management includes: - Periodic assessment of the frequency and strength of uterine contractions and changes in cervix and in the fetus' station and position. - Monitoring the fetal heart rate at least every 15 minutes.

Inadequate urine output

Urine dipstick analysis

High blood pressure with epigastric pain may indicate early eclampsia. Urine dipstick analysis is appropriate to detect the proteinuria & the need for delivery.

Primary

Postpartum hemorrhage is defined as bleeding more than 500 ml after deliv- ery. Early postpartum bleeding occurs within 24 hours of delivery, while late postpartum bleeding occurs 24 hours to 6 weeks later

Hysterectomy?!

Primary

A loss of these amounts within 24 hours of delivery is termed early or primary PPH, whereas such losses are termed late or secondary PPH if they occur 24 hours after delivery.

Oxytocin??

The optimal management of poor labor progression in the active phase is to confirm that the patient is in the active phase (cervix is at least 5 to 6 cm), administer oxytocin, and wait four hours.

most likely B not psychosis

- In postpartum OCD, the sufferer is terrified of committing harm; so much so that it scares her to even think about harming the infant. Women with postpartum OCD resist their obsessional thoughts; meaning that they try to dismiss the obsessions or neutralize them with some other thought or behavior. The thoughts seem as if they are against every moral fiber of their being

Endometrial biopsy

Obese= estrogen

This procedure is used in women who are at risk for endometrial carcinoma, polyps, or hyperplasia. Include those with HTN, DM, chronic anovulation (eg, PCOS), obesity, atypical glandular cells (AGUS) on Pap smear, new-onset menorrhagia, and those older than 70 years or any woman older than 35 years with new-onset irregular bleeding (especially if nulliparous).

Every 5 years

- For women age 30 to 65 years, screening interval can be lengthened to every 5 years if both cytology and HPV testing are utilised.

HSV Post-herptic lesion

because it's painful vesicles, chancres are painless ulcers

Rupture of membrane 18 h?

both are correct but B might be a more common cause. "more common in the setting of prematurity and prolonged rupture of the membranes"

Platelets, creatinine and liver function test

In cases of severe pre-eclampsia the patient may progress to having HELLP syndrome which is microangiopathic blood smear, elevated liver enzymes and a low platelets count.

* Tests to consider in preeclampsia

FBC, LFTs, serum creatinine, coagulation screen

Endometrial biopsy

An endometrial biopsy is considered the gold standard for evaluation of post-menopausal bleeding. Endometrial biopsy can be obtained with an endometrial pipelle in the outpatient setting, or by hysteroscopy and curettage (with or without dilatation) in either the outpatient or inpatient setting

Bacterial vaginosis

uterine biopsy

Screen all women with postmenopausal vaginal bleeding (PMB) for endometrial cancer.

Total abdominal hysterectomy (TAH)

pap smear

Rectovaginal fistula

The clinical presentation of RVF varies little. A few patients are asymptomatic, but most report the passage of flatus or stool through the vagina. Patients may also experience vaginitis or cystitis. At times, a foul-smelling vaginal discharge develops, but frank stool through the vagina usually occurs only when the patient has diarrhea.

Labia majora mass.

Uterosacral ligament

The uterosacral ligaments are by far the most important ligaments in preventing uterine prolapse.

51

Natural menopause is defined as the permanent cessation of menstrual periods, determined retrospectively after a woman has experienced 12 months of amenorrhea without any other obvious pathological or physiological cause. It occurs at a median age of 51.4 years in normal women, and is a reflection of complete, or near complete, ovarian follicular depletion, with resulting hypoestrogenemia and high follicle-stimulating hormone (FSH) concentrations.

Unclear question!

pain in the RLQ can indicate appendicitis, ovarian torsion, or ectopic pregnancy

- appendicitis: fever, tachycardia; RLQ tenderness, with or without guarding and rebound tenderness; rectal tenderness usually seen in the first trimester

- appendicitis: minimal abdominal tenderness and/or vaginal bleeding; pelvic examination may reveal a mass, eliciting cervical motion tenderness if haemoperitoneum is present; tubal rupture can cause haemodynamic instability

Endometrial ca

Chronic anovulation — In anovulatory women, sex steroid hormones are produced, but not cyclically, resulting in irregular uterine bleeding. In particular, chronic estrogen production unopposed by adequate progesterone production allows continued proliferation of the endometrium. This can lead to endometrial hyperplasia or carcinoma. Anovulation is common both at

menarche and during the menopausal transition. Polycystic ovary syndrome is the most common endocrine disorder associated with anovulation. Thyroid dysfunction and elevated prolactin levels are other common endocrine disor

ders related to anovulation

???

Sulfonylureas are antidiabetic drugs widely used in the management of diabetes mellitus type 2. They act by increasing insulin release from the beta cells in the pancreas.

Effect on fetus: The safety of sulfonylurea therapy in pregnancy is unestablished. Prolonged hypoglycemia (4 to 10 days) has been reported in children born to mothers taking sulfonylureas at the time of delivery. Impairment of liver or kid

ney function increase the risk of hypoglycemia, and are contraindications. As other anti-diabetic drugs cannot be used either under these circumstances, insulin therapy is typically recommended during pregnancy and in hepatic and renal failure, although some of the newer agents offer potentially better options.

Increased androgen activity

Bad prognostic factor

Abortion

Do culture

Why not reassure? Lochia is a normal physiology during the first 3 postpartum weeks

Vaginal discharge is grossly bloody (lochia rubra) for 3 to 4 days, then becomes pale brown (lochia serosa), and after the next 10 to 12 days, it changes to yellowish white (lochia alba).

Preterm labor

- pregnancy 20-36 w, 3 or > contraction in 30m, dilated 2 or more dilated 2 cm or > or changing

- most common RF: prior preterm

- intervention only for singleton not twins

- if cervical length 25 or > mm: weekly IM 17 hydroxy progestrone

- if cervical length < 25: weekly IM 17 hydroxy progestrone plus cerclage before 24 w

- if cervical length 20 mm: daily vaginal progesterone before 24 w (no prior preterm)

Never use tocolytic: preeclampsia, maternal heart disease, cervical dilation > 4cm, Abruptio placenta, DIC, fetal death, Chorioamnionitis

If any of these present--> delivery

If <34 or < 2,500 g: betamethasone and Tocolytcis. Otherwise deliver

- most common used Tocolytcis: MgSO4 (check deep tendon reflex for toxicity). Others: CCBs, terbutaline (hypotention, tachycardia)

Never use indomethacin: close PDA

Gonadotropin

We can diagnosis KS by exclusion, physical Ex (delay puberty + insomnia), The main biochemical parameters in men are low serum testosterone and low/normal levels of the gonadotropins LH and FSH. In women low serum estradiol and low/normal levels of LH and FSH. Normal anterior pituitary function & Normal appearance of the hypothalamus and pituitary region on MRI.