PANCE Exam: Reproductive Review Questions & Answers

REPRODUCTIVE PHYSIOLOGY

Question: What are the three events that occur in the normal course of female puberty (in order of occurrence and with definition of each)?

1. Thelarche—the development of breasts
2. Pubarche—the development of axillary and pubic hair
3. Menarche—the first menstrual cycle

Question: What is the classification system commonly used to define the progression of breast and pubic hair development in puberty, and How many stages does the system have?
Tanner classification. There are five stages.

Question: Define the normal menstrual cycle:
The normal menstrual cycle is 28 days, with a flow lasting 2 to 7 days. The variation in cycle length is set at 24 to 35 days.

Question: In a normal menstrual cycle, when does ovulation typically occur?
Ovulation in a 28-day cycle typically occurs on day 14. The luteal (secretory) phase of the cycle is normally 14 days long. The estrogenic (proliferative) phase of the cycle can be variable (typically 14–16 days).

Question: What are the hormones, and their source, that are involved in maintaining a normal menstrual cycle?
From the ovary: Estrogen and progesterone.
From the pituitary: Follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In addition, prolactin- and thyroid-stimulating hormone are also vital in maintaining a normal menstrual cycle.
From the hypothalamus: Gonadotropin-releasing hormone (GnRH).

Question: Describe the effect of estrogen on the endometrium:
Estrogen causes growth of the endometrium. The endometrial glands lengthen and the glandular epithelium becomes pseudostratified. Mitotic activity is present in both the glands and the stroma.

When does implantation of the fertilized ovum typically occur?
At approximately 9 days following ovulation (day 23).

Question: What is the lifespan of a normal corpus luteum in the absence of pregnancy?
Approximately 14 days.

Question: What is the action of oxytocin?
It stimulates uterine contractions during labor and elicits milk ejection by myoepithelial cells of the mammary ducts.

Question: What is the function of FSH?
It stimulates maturation of the follicle(s) and the production of estradiol from the follicles.

Question: What is the function of LH?
It causes follicular rupture, ovulation, and establishment of the corpus luteum.

Question: During the luteal phase of the ovary, describe the corresponding phase of the uterus:
The secretory phase. After ovulation, the expelled follicle is called the corpus luteum. The corpus luteum secretes estradiol and progesterone, which cause secretory ducts to develop in the endometrial lining.

Question: What does a biphasic curve on a basal body temperature (BBT) chart of a 25-year-old woman indicate?
Normal ovulation and the effect of progesterone. A monophasic BBT curve indicates an anovulatory cycle. A temperature that remained elevated following a normal biphasic curve would indicate pregnancy.

Question: What is the cause of midcycle spotting or light bleeding?
The decline in estradiol that occurs immediately prior to the LH surge.

Question: Decline in which hormone heralds the onset of menses?
Normal menses occurs because of progesterone withdrawal.

Question: What is the function of prolactin?
It initiates and sustains lactation by the breast glands and it may influence synthesis and release of progesterone by the ovary and testosterone by the testis.

Question: What is the main physiological stimulus for prolactin release?
Suckling of the breast.

Question: What is oxytocin?
Oxytocin is a decapeptide synthesized by the posterior pituitary gland. It is a powerful uterotonic agent causing the uterus to contract. In nature, it is secreted in pulsatile fashion throughout labor. (The fetus also produces oxytocin and at least some traverses the placenta, escaping enzymatic breakdown.)

What is the definition of Mittelschmerz?
The cyclic abdominal pain located on either side of the abdomen, which can be felt during ovulation and may persist for approximately 2 days after.

Question: What is the squamocolumnar junction? Describe its importance and how it changes.
It is the junction between the columnar epithelium and the squamous epithelium of the cervix. This is also known as the transformation zone. Throughout a woman’s life, the squamous epithelium of the ectocervix (and vagina) invades the columnar epithelium of the endocervix. It is important because it is the squamous epithelium in this transformation zone that is most likely to become dysplastic.

Question: What pelvic type is the most common in women?
Gynecoid. It is estimated that approximately 50% of women have gynecoid pelvis. (It should be noted that in reality most women have intermediate pelvic shapes rather than true gynecoid, anthropoid, android, or platypelloid).


UTERUS

Question: What percentage of the female population has endometriosis?
More than 15%, and 7% of these women have it during their reproductive years.

Question: What is thought to be the most common etiology for endometriosis?
Retrograde menstruation.

Question: What are chocolate cysts?
Endometriomas (cystic forms of endometriosis on the ovary).

Question: What percentage of women with endometriosis also have infertility?
25% to 50%.

Question: Where is the most common site of endometriosis?
The ovaries (60%). Other sites include the cul-de-sac, uterosacral ligaments, broad ligaments, fallopian tubes, uterovesical fold, round ligaments, vermiform appendix, vagina, rectosigmoid colon, cecum, and ileum.

Question: What is considered the preferred means of establishing a diagnosis of endometriosis?
Direct visualization during diagnostic laparoscopy or laparotomy. Clinical presentation, laboratory evaluation, and/or pelvic ultrasound are considered inadequate to make a definitive diagnosis.

Question: What are the pharmacotherapeutic options for treating endometriosis?
Combined oral contraceptive agents, Progestin-only contraceptives, GnRH agonists, danazol (a 17-alpha-ethinyl testosterone derivative).

Question: What are common side effects of danazol (Danocrine)?
Hirsutism, amenorrhea, deepening of the voice, acne, weight gain, hot flashes, labile emotions, and decreased vaginal lubrications.

A 66-year-old postmenopausal woman presents with vaginal bleeding. What is the provisional diagnosis (top on list of differentials)?
Endometrial cancer; 15% of women with postmenopausal bleeding have endometrial cancer.

Question: What are the most common etiologies of endometrial cancer?
30% of these tumors are due to exogenous estrogens, 30% are due to atrophic endometriosis or vaginitis, 10% are due to cervical polyps, and 5% are due to endometrial hyperplasia.

Question: What are the risk factors for endometrial cancer?
Nulliparity, early menarche, late menopause, significant amounts of unopposed estrogen, and prior ovarian, endometrial, or breast cancer.

Question: Describe the initial office evaluation of a woman whose history is suspicious for endometrial cancer:
Pelvic examination, Pap smear, biopsy of any abnormal cervical or vaginal lesion, and endometrial biopsy.

Question: What percentage of women with endometrial cancer will have an abnormal Papanicolaou smear?
Approximately 50%.

Question: What is the most common clinical condition associated with the development of endometrial hyperplasia?
Polycystic ovary syndrome.

Question: What is Lynch syndrome type II?
A hereditary predisposition to the development of colon, breast, ovarian, and endometrial cancer.

Question: What is the most common type of benign gynecologic pelvic neoplasm?
Uterine leiomyomas (or uterine fibroids).

Question: What type of leiomyoma is symptomatic?
Submucosal myomas, though small, can cause profuse bleeding, potentially requiring a hysterectomy. Most other myomas are asymptomatic until grown large enough to cause obstruction or significantly distort the endometrial cavity.

Question: What is the difference between leiomyoma and leiomyosarcoma?
Uterine leiomyoma (aka uterine fibroids) are benign growths that arise from the uterine muscle and are seen in reproductive-aged patients typically presenting with menorrhagia and secondary dysmenorrhea. Leiomyosarcomas are a rare cancer of the uterine muscle wall and are seen in postmenopausal-aged patients typically presenting with postmenopausal vaginal bleeding and rapidly enlarging uterus.

Question: What are the indications for performing a dilation and curettage?
- Removal of endometrial polyp or hydatid mole
- Termination of pregnancy/incomplete abortion
- Removal of retained placental tissue
- Relief of profuse uterine hemorrhage

What major complication is associated with the performance of a dilation and curettage?
Perforation of the uterus.

Question: A woman presenting with pelvic pain and pressure when standing, the feeling of something protruding from the vaginal opening, and possible urinary incontinence or constipation is likely to have what?
Pelvic organ prolapse.

Question: Define the following: cystocele, rectocele, uterine prolapse, and vaginal prolapse:
- Cystocele is the downward displacement of the bladder into the vagina along the anterior wall and is usually associated with childbirth (e.g., delivery of a large baby, multiple deliveries, prolonged labor).
- Rectocele represents the displacement of the rectum into the posterior wall of the vagina and is also typically associated with multiparous women with history of long end-stage labor. There also maybe a link to those women who undergo midline episiotomy.
- Uterine prolapse is the descent of the uterus and cervix down the vaginal canal toward the introitus secondary to broken uterosacral ligaments or relaxation of the musculature of the pelvic floor. This is more likely to occur in women with a retroverted uterus.
- Vaginal prolapse is the downward displacement of the vaginal apex also due to loss of muscle and ligamental support and it typically follows a hysterectomy.

Question: Define total vs. subtotal, vaginal vs. abdominal, and simple vs. radical hysterectomy:
- “Total” or “subtotal” are used to denote whether the cervix is removed or retained. Total hysterectomy includes removal of the entire uterus and cervix. Subtotal hysterectomy includes uterus removal while the cervix remains intact.
- “Vaginal” or “abdominal” are used to specify the route of removal. Abdominal hysterectomy can be further clarified as either a laparoscopic or cesarean (open) approach.
- “Simple” or “radical” are used to denote whether vaginal tissue and pelvic lymph nodes are removed. Radical hysterectomy includes the removal of uterus, cervix, vaginal, and pelvic lymph nodes. Determining simple or radical depends on the condition being treated surgically.
- Oophorectomy denotes the removal of the ovaries and is separate from hysterectomy. Oophorectomy can be unilateral or bilateral.

Question: What are the indications for cesarean hysterectomy?
Most common include severe, life-threatening intrauterine infection, an unrepairable uterine scar, laceration of major uterine vessels, uterine atony (which is unresponsive to medical or therapeutic intervention), large leiomyomata, severe cervical dysplasia or early cervical cancer, and placenta accreta.
Uterine rupture and uterine inversion may also require hysterectomy.

Question: What is the most frequent complication of hysterectomy?
Infection. The most common organisms are those found in normal vaginal flora. Because the vagina is difficult to cleanse, most experts recommend antibiotic prophylaxis for all patients undergoing vaginal hysterectomy.

Question: What must be identified and located prior to clamping the infundibulopelvic ligament?
The ureter.


OVARY:

Question: What is the most common cause of pelvic pain in an adolescent woman?
Ovarian cysts.

Question: What is the most common type of ovarian cyst?
Follicular. The other types are corpus luteum and theca lutein cysts.

Question: What is the recommended treatment for uncomplicated follicular cysts?
Most resolve spontaneously within a few menstrual cycles (60 days) without treatment. Combined oral contraceptive agents can be used if recurrent.

Question: What is the most common complication of ovarian cysts?
Torsion of the ovary. Torsion is more common in small- to medium-sized cysts and tumors. Emergency surgery is required.

Question: By how much is the incidence of functional cysts reduced by OCP use?
80% to 90%. Oral contraceptives suppress FSH and LH ovarian stimulation.

Question: What is Halban syndrome?
This is the persistence of a corpus luteum. Patients commonly present with delayed menses, pelvic mass, and negative pregnancy test. Clinically, this is often confused with an ectopic pregnancy

Question: What are the clinical manifestations of polycystic ovarian disease (PCO)? Explain using the mnemonic OVARIAN
Obesity
Virilization
Anovulation
Resistance to insulin (diabetes)
Increased hair
Androgen increase
No period/
Amenorrhea

Question: Is the Stein-Leventhal syndrome a unilateral or bilateral phenomenon?
Bilateral. Both ovaries are cystic and enlarged with a thickened and fibrosed tunica. Patients are often infertile, obese, and hirsute. This syndrome is a subtype of polycystic ovarian disease.

Question: What laboratory findings are seen in PCO?
Most patients have increased LH-to-FSH ratio at 2:1 (or more), high fasting insulin and elevated serum glucose, and elevated sex androgens including DHEA-sulfate and/or testosterone.

How are patients with PCO treated?
Weight loss is the first-line treatment for PCO. In addition, combined oral contraceptive pills for menstrual regulation and ovarian suppression; Biguanides (metformin) for menstrual regulation, weight reduction, and to reestablish fertility; anti-androgen (spironolactone) for sex androgen suppression and hirsutism.

Question: What serum marker is associated with ovarian cancer?
CA-125.

Question: If a woman has ascites, what is the most likely tumor to be found?
An ovarian carcinoma.

Question: What is Meigs syndrome?
Ascites and hydrothorax in the presence of an ovarian tumor.

Question: What is the treatment for stage 1A or 1B ovarian cancer?
Surgical excision alone (abdominal hysterectomy and bilateral salpingo-oophorectomy).

Question: What is the treatment for all other stages of ovarian cancer besides stage 1A or 1B?
Surgical resection followed by adjuvant chemotherapy or radiation.

Question: What are considered protective factors for the risk of ovarian cancer?
Multiparity, combined oral contraceptive use, and breast-feeding.


CERVIX

Question: What is a nabothian cyst?
A mucous inclusion cyst of the cervix (usually asymptomatic and benign).

Question: What are the American College of Obstetrics and Gynecology (2003) recommendations for Pap smear screening?
Pap smears should be initiated 3 years following the onset of sexual activity or age 21 (whichever comes first). Annually with conventional slide cytology or every 2 years with liquid-based cytology.
After the age of 30 years, women with three consecutively normal readings may be screened every 2 to 3 years. If the patient is at high risk despite age, continue annual screening.
No cytology screening after total hysterectomy if surgery for benign condition. If surgery for CIN I, II, or III, then annually three times before discontinuing.

Question: According to the American Cancer Society (2002) recommendations, at what age can routine Pap smears be discontinued in a woman with an intact cervix?
Age 70, if the patient has had three consecutive normal readings.

What is the recommendation for HPV testing in women?
HPV testing should occur at the time of Pap screening in any high-risk patient or in reflex following an abnormal Pap smear.

Question: What do ASC-US, LSIL, HSIL on a Pap screening pathology report represent?
ASC-US: atypical squamous cells of undetermined significance
LSIL: low-grade squamous intraepithelial lesion, i.e., mild dysplasia, CIN I
HSIL: high-grade squamous intraepithelial lesion, i.e., moderate to severe dysplasia, CIN II-III, carcinoma in situ

Question: What is the recommended further evaluation in a woman with ASC-US Pap result and HPV positive?
Colposcopy.

Question: How many times more likely is a woman with condyloma acuminatum (genital warts) to develop cervical cancer than a woman without this lesion?
4 times more likely. These women should have yearly Pap smear and be screened for other sexually transmitted infections.

Question: What are the known subtypes of HPV associated with cervical cancer?
HPV types 16, 18, and 31 are risk factors for cervical dysplasia, which can lead to cervical cancer.

Question: What are the risk factors for carcinoma of the cervix?
Multiple sexual partners, early age at first intercourse, early first pregnancy, and HPV positive.

Question: What is the most common type of cervical cancer?
80% are squamous cell and arise from the squamocolumnar junction of the cervix.

Question: What is the most common presenting symptom for patients with cervical cancer?
Up to 80% of patients present with abnormal vaginal bleeding, most commonly postmenopausal. Only 10% note postcoital bleeding. Less frequent symptoms include vaginal discharge and pain.

Question: What clinical triad is strongly indicative of cervical cancer extension to the pelvic wall?
1. Unilateral leg edema
2. Sciatic pain
3. Ureteral obstruction

Question: A colposcopically directed cervical biopsy from a 25-year-old G0P0 reveals a small focus of invasive squamous cell carcinoma. What is the next step in this patient’s management?
Cervical cone biopsy to establish the full extent of invasion.

Question: When performing a radical hysterectomy for cervical cancer, is it required to perform an oophorectomy too?
No. Early cervical cancer rarely spreads to the ovaries.

What are the advantages of radical hysterectomy relative to radiation therapy for stage I cervical cancer?
- Ovarian preservation is possible
- Unimpaired vaginal function
- Extent of disease can be established


VAGINA/VULVA

Question: What is the normal pH of the vagina?

3.8 to 4.4 (a vaginal pH greater than 4.9 indicates a bacterial or protozoal infection).

Question: What is the predominant organism in a healthy woman’s vaginal discharge?
Lactobacilli (95%).

Question: What is the treatment of choice for a Bartholin gland abscess?
Marsupialization with the placement of a Word catheter. This prevents recurrences.

Question: What is the most common cell type in vulvar and/or vaginal carcinoma?
Squamous cell (90% in vulvar carcinoma; 85% in vaginal carcinoma).

Question: What is the most common location for vaginal carcinoma?
Upper one-third of the posterior vaginal wall.

Question: What causes condylomata acuminata (genital warts)?
Human papilloma virus types 6 and 11.

Question: What other sexually transmitted infection is commonly seen in combination with condylomata acuminata?
Trichomonas vaginitis.

Question: What are the recommended treatment options for condylomata acuminata (genital warts)?
Liquid nitrogen, podophyllin resin, Aldara (topical imiquimod); not necessarily curative but treatment is focused on destruction of warts.

Question: What is the most frequent gynecologic disease of children?
Vulvovaginitis, the cause of which is poor perineal hygiene.

Question: What is the most common cause of vaginitis?
Candida albicans.

Question: What predisposes a woman to vaginal candidiasis infections?
Diabetes, oral contraceptives, and antibiotics.

What are the recommended forms of treatment for vaginal candidiasis infections?
Antifungal drugs commonly used to treat candidiasis are topical clotrimazole (Gyne-Lotrimin), topical tioconazole (Monistat), and oral fluconazole (Diflucan). It has been reported that a one-time dose of fluconazole (Diflucan) is 90% effective in treating a vaginal yeast infection.
In severe infections (generally in hospitalized patients), amphotericin B, caspofungin, or voriconazole may be used.

Question: What are the signs and symptoms typical for gardnerella vaginitis?
On physical examination, a frothy, grayish white, fishy smelling vaginal discharge is noted.

Question: What would you expect on microscopic evaluation with saline and with 10% KOH on a patient with gardnerella vaginitis?
“Clue cells,” which are epithelial cells with bacilli attached to their surfaces. On saline wet mount adding 10% KOH to the discharge produces a fishy odor.

Question: What is the recommended treatment for gardnerella vaginitis?
Metronidazole (Flagyl) either orally or vaginally.

Question: When should you avoid treating a woman with Flagyl (orally or vaginally)?
If she is in her first trimester of pregnancy, metronidazole may have teratogenic effects. Clotrimazole (Gyne-Lotrimin) may be used instead.

Question: A 42-year-old woman complains of painful urination and “leaking a bit” after she urinates. On pelvic examination, you feel a small mass under the urethra that emits a purulent discharge from the urethral meatus if compressed. What is the likely diagnosis?
Urethral diverticulum.

Question: What is the most common type of urinary fistula?
Vesicovaginal fistulas. These most commonly occur after surgical procedures, but they can also occur with invasive cervical carcinoma or radiotherapy due to cervical cancer.

Question: A patient presents with pain in her eyes, canker sores in her mouth, and sores and scars in her genital area. What is the diagnosis?
Behçet disease. This is a rare disease involving ocular inflammation, oral aphthous ulcers, and destructive genital ulcers (generally on the vulva). No cure is known, but remission may occur with high estrogen levels.

Question: What causes toxic shock syndrome (TSS)?
An exotoxin composed of certain strains of Staphylococcus aureus. Other organisms that cause toxic shock syndrome are group A streptococci, Pseudomonas aeruginosa, and Streptococcus pneumoniae.

Question: What are the known risk factors for the development of toxic shock syndrome (TSS)?
Tampons, IUDs, septic abortions, sponges, soft tissue abscesses, osteomyelitis, nasal packing, and postpartum infections can all house these organisms.

What dermatological changes occur with TSS?
Initially, the patient will have a blanching erythematous rash that lasts for 3 days, and 10 days after the start of the infection there will be a full thickness desquamation of the palms and soles.

Question: What criteria are necessary for the diagnosis of TSS?
All of the following must be present: Temperature > 38.9°C (102°F), rash, systolic BP < 90 mm Hg with orthostasis, and involvement of three organ systems (GI, renal, musculoskeletal, mucosal, hepatic, hematologic, or CNS). The patient must also have negative serologic tests for diseases such as RMSF, hepatitis B, measles, leptospirosis, and VDRL.

Question: How should a patient with TSS be treated?
Fluids, pressure support, fresh frozen plasma or transfusions, vaginal irrigation with iodine or saline, and antistaphylococcal penicillin or cephalosporin with anti-β-lactamase activity (nafcillin or oxacillin). Rifampin should be considered to eliminate the carrier state.


SEXUALLY TRANSMITTED INFECTIONS/PELVIC INFLAMMATORY DISEASE

Question: A 22-year-old patient presents with a complaint of painful blisters on the vulva and vaginal introitus. She admits to a prodrome of burning, tingling, and/or pruritus prior to the appearance of lesions. Upon examination, you note vesicles on an erythematous base. What is the probable diagnosis?
Herpes simplex virus.

Question: What is the causative bacterium in syphilis?
Treponema pallidum.

Question: What is the hallmark presenting sign of primary syphilis?
Painless ulcer (chancre).

Question: What are the presenting signs associated with secondary syphilis?
Nonpruritus maculopapular rash that includes the palms and soles (Condyloma latum), lymphadenopathy, and constitutional symptoms (fatigue/malaise). These symptoms present 4 to 6 weeks after the hallmark syphilitic chancre and persist for 2 to 6 weeks before the infection enters the latent phase.

Question: What is the presenting feature of tertiary syphilis?
Neurosyphilis (neuro deficits including difficulty with coordination, memory loss, paralysis, gradual blindness, or dementia).

Question: What is the treatment for syphilis?
Benzathine PCN G, 2.4 million units IM × 1 dose. Additional doses if infection has been for >1 year or if the patient is pregnant. If the patient is penicillin-allergic, treat with doxycycline.

What causes a greenish gray frothy vaginal discharge with mild itching?
Trichomonas vaginitis.

Question: What is considered the hallmark pelvic examination finding in 20% of trichomonas infections?
Petechiae on the cervix (also known as a “strawberry cervix”).

Question: What microscopic findings are indicative of trichomonas infections?
The presence of mobile and pear-shaped protozoa with flagella is indicative of trichomonas.

Question: A 30-year-old woman complains of a painful sore on her vulva that first resembled a pimple. On examination, you find an ulcer with vague borders, gray base, and foul-smelling discharge. What is the probable diagnosis? Causative agent?
Chancroid. Gram stain, culture, and biopsy (used in combination because of the high false-negative rates) should show the causative agent Haemophilus ducreyi.

Question: What is considered the most appropriate treatment for chancroid?
Ceftriaxone 250 mg IM × 1 dose
or azithromycin 1g PO × 1 dose.

Question: What is the typical clinical presentation of lymphogranuloma venereum (LGV)? Causative agent?
Vesicopustular eruption, unilateral inguinal bubo, possible anal discharge, and rectal bleeding. The causative organism is a serotype of Chlamydia trachomatis.

Question: What is the most common sexually transmitted infection in the United States and sometimes asymptomatic in women?
Chlamydia trachomatis.

Question: What finding on Gram stain is indicative of Neisseria gonorrhea
Gram-negative diplococci.

Question: What is the treatment for Neisseria gonorrhea
Ceftriaxone 125 to 250 mg IM × 1 dose
or cefixime 400 mg PO × 1 dose
or cefpodoxime 400 mg PO × 1 dose.
Plus include either azithromycin 1 g × 1 dose
or doxycycline 100 mg BID × 7 days since 50% of patients are also infected with Chlamydia trachomatis.

Question: Which two organisms cause most cases of PID?
Neisseria gonorrhea and Chlamydia trachomatis.

What are the risk factors for pelvic inflammatory disease?
- Age < 25 years (cervix not fully matured)
- African American race
- Early onset of sexual activity
- Frequent sexual intercourse
- Multiple sexual partners
- Douching
- Presence of IUD
- Women with one episode are at increased risk for a second episode

Question: Why is a woman with pelvic inflammatory disease (PID) likely to have an exacerbation of symptoms when she menstruates?
The breakdown in cervical mucus, which typically acts as an antibacterial barrier, allows bacteria to ascend from the lower tract to the upper tract. Pelvic examination, intercourse, and exercise can all exacerbate symptoms.

Question: What are the criteria for diagnosis of PID (pelvic inflammatory disease)?
All of the following must be present:
- Adnexal tenderness
- Cervical and uterine tenderness
- Abdominal tenderness
In addition, one of the following must be present: (1) temperature > 38°C, (2) endocervix Gram stain positive for gram-negative intracellular diplococci, (3) leukocytosis > 10,000/mm3, (4) inflammatory mass on ultrasound or pelvic examination, or (5) WBCs and bacteria in the peritoneal fluid.

Question: Which patients with PID should be admitted?
Admit patients who are pregnant, have a temperature > 38°C (100.4°F), are nauseated or vomiting (which prohibits oral antibiotics), have pyosalpinx or tubo-ovarian abscess, have peritoneal signs, have an IUD, show no response to oral antibiotics, or for whom diagnosis is uncertain.

Question: What percent of patients with pelvic inflammatory disease become infertile?
10%.


BREAST

Question: Breast hyperplasia is a normal physiologic phenomenon in the neonatal period. How many months does this typically last?
Up to 6 months of age.

Question: What are the American Cancer Society’s 2003 recommendations for screening mammography?
Age ≥ 20 years—monthly breast self-examinations
Age 20 to 39 years—MD examination every 3 years
Age ≥ 40 years—annual MD examination and mammogram
For patients with (+) FH or risk factors, screening should begin earlier

According to the American Cancer Society in 2007, what are the recommendations for the use of MRI in breast cancer screening?
Screening MRI is recommended for women with an approximately 20% to 25% or greater lifetime risk of breast cancer, including women with a strong family history of breast or ovarian cancer (+BRCA mutations) and women who were treated for Hodgkin disease.

Question: After the establishment of fibrocystic breast disease, what is the recommended treatment?
Breast pain associated with fibrocystic change is best treated by avoiding trauma and by wearing a bra with adequate support. Some find that combined oral contraceptive agents limit the severity of the cyclical changes in the breast tissue. The fole of caffeine is controversial. Many patients report relief of symptoms after abstinence from coffee, tea, and chocolate.

Question: What is the most common type of benign breast tumor?
Fibroadenomas. These are usually solitary, mobile masses with distinct borders. They are more prevalent in women younger than 30 years.

Question: What is the recommended work-up for suspected fibroadenoma?
Diagnostic mammogram with ultrasound. If indeterminant, fine needle aspiration of the mass with pathology.

Question: What is the most common cause of unilateral bloody nipple discharge?
Benign intraductal papilloma. Growths usually develop just before or during menopause and they are rarely palpable. They are typically mobile and painless.

Question: What pattern of nipple discharge would one expect with benign galactorrhea?
Bilateral, induced, clear/white/yellow color.

Question: What diagnosis must be considered in a patient presenting with crusty, eczematous erosion of the nipple without nipple discharge?
Paget disease. This rare cancer occurs in 3% of breast cancer patients. It involves the excretory ducts of the breast.

Question: What is Peau d’orange?
French for skin of the orange. It describes the dimpling and thickening of the skin of the breast seen with breast cancer.

Question: A hard mass in the upper outer quadrant of the right breast of a 45-year-old woman is detected. What are the next steps?
Mammogram followed by an excision biopsy. A negative needle aspiration alone cannot rule out malignancy. False negative rates for fine needle biopsy are 3% to 30%.

Question: What are the risk factors for breast cancer?
Risk factors include family history, age over 40, high fat intake, nulliparity, early menarche, late menopause, cellular atypia in fibrocystic disease, radiation exposure to breast(s), and prior ovarian, endometrial, or breast cancer.

Is there an increased risk of breast cancer associated with estrogen replacement therapy?
There may be a slightly increased risk of breast cancer especially with long duration of use (10 or more years).

Question: What are the two genetic markers known to be linked to breast cancer?
BRCA-1 and BRCA-2.

Question: Geographically, where is breast cancer most common?
North America and northern Europe have an incidence and mortality rate five times that of most Asian and African countries.
Asians and Africans immigrants to North America or northern Europe maintain a lower rate of incidence; however, their offspring quickly assume a higher one. This points to environmental and dietary factors.

Question: Who have higher incidences of estrogen receptor–positive tumors, premenopausal or postmenopausal women?
Postmenopausal (60%). If the tumors are both estrogen and progesterone sensitive, then the antiestrogen drug tamoxifen is 80% effective. Otherwise, it is 40% to 50% effective.

Question: What is the most common histologic type of breast cancer?
Infiltrating ductal carcinoma (70%–80%). Subtypes are colloid, medullary, papillary, and tubular.

Question: What does a high cathepsin D level indicate in a woman with breast cancer?
A high risk of metastasis.

Question: What is the surgical treatment of choice for breast cancer?
Modified radical mastectomy: the removal of the breast tissue, pectoralis minor, and axilla. (A radical mastectomy includes the pectoralis major.) For small primary tumors, a partial mastectomy may be performed. This is a local lumpectomy with axillary node dissection and postoperative irradiation of the breast. It has not been shown whether radiation following a modified radical mastectomy affects survival.

Question: What is the most accurate prognostic indicator of breast cancer mortality?
Axillary node involvement, which is related to the size of the tumor, not the location; 40% to 50% of patients have axillary node involvement when diagnosed.

Question: Are the majority of breast cancers in the ducts or in the lobes?
Invasive ductal tumors account for 90% of all breast cancers. Only 10% are lobular.

Question: When does breast milk production typically begin?
Colostrum secretion usually persists for 3 to 4 days after delivery. Day 5 the fluid begins to change in composition. Mature milk is usually present by 1 to 2 weeks postpartum.

How does colostrum differ from breast milk?
Colostrum is more cellular and has more minerals, but is lower in calories. True milk has more fat and carbohydrate (especially lactose), but less protein.

Question: How many extra calories above baseline does a woman need when breast-feeding?
About 500 per day.

Question: How much daily dietary of calcium is recommended for lactating women?
1200 to 1500 mg per day.

Question: Why does lactation not occur during pregnancy even though the prolactin levels are elevated?
The receptor sites in the breast are competitively bound by estrogen and progesterone, preventing prolactin from activating lactation. When the placenta is delivered, these levels of estrogen and progesterone rapidly drop and the prolactin floods the receptors.

Question: What is the proper postpartum management of a mother who chooses not to breast-feed?
A firmly fitting (but not binding) bra, ice packs as needed, and decreased stimulation to the nipples such as loose clothes rubbing across the breast or direct contact from a shower.
Pharmacologic suppression including bromocriptine is no longer an indication due to severe maternal side effects and should not be prescribed. The introduction of 35 μg or higher oral contraceptives within 2 weeks of delivery may inhibit lactation in some women and may be of use to decrease the production of milk.

Question: What is likely occurring in a 2-week-old infant who wants to have feed every 1 to 2 hours but nurses only for 5 minutes at a time before falling asleep? What can the mother do to improve this?
Her infant is not nursing long enough with each episode. The infant is only receiving the “foremilk,” which is high in proteins, carbohydrates, and water. The infant falls asleep before getting the “hindmilk,” which is high in fat and satiates the appetite plus takes longer to digest.
The infant should be stimulated when he or she dozes off, changed to the opposite breast. If this fails, the mother can pump or express the hindmilk at that time and it can be given by another caregiver later so the mother can rest.

Question: Which vitamin is not found in human breast milk?
Vitamin K. It is administered to newborns at birth. Formula is also deficient in vitamin K.

Question: How does human milk differ from cow’s milk?
While the two are similar in calories, human milk has more lactose, less protein (and very different protein constitution), and slightly more fat (especially more polyunsaturated fatty acids and cholesterol, which are needed for brain development.) There is significantly more calcium, phosphorous, and iron in bovine milk.

Question: A breast-feeding mother presents to your office complaining of fever, chills, and a swollen red breast. What is the most likely diagnosis and causative organism?
Mastitis. Staphylococcus aureus is the most common cause of mastitis. Mastitis is seldom present in the first week postpartum. It is most often seen 3 to 4 weeks postpartum.

What is the treatment for acute mastitis?
Warm compresses to breast, analgesics, dicloxacillin, or a cephalosporin.

Question: Can a nursing mother with mastitis continue to nurse?
Yes, as long as there is no abscess formation. Nursing facilitates the drainage of the infection and the infant will not be harmed because he/she is already colonized.


MENSTRUAL DISORDERS

Question: Define the following: menorrhagia, metrorrhagia, menometrorrhagia, polymenorrhea, and oligomenorrhea:
Menorrhagia—excessive amount of vaginal bleeding or duration of bleeding during menses
Metrorrhagia—bleeding between menstrual periods
Menometrorrhagia—excessive amount of blood at irregular frequencies
Polymenorrhea—menstrual periods < 21 days apart
Oligomenorrhea—menstrual periods > 35 days apart

Question: What is secondary amenorrhea?
No menstruation for 6 months or more in a woman who previously had regular menses.

Question: What is the most common cause of secondary amenorrhea?
Pregnancy. The second most common cause is hypothalamic hypogonadism, which can be due to weight loss, anorexia nervosa, stress, excessive exercise, or hypothalamic disease.

Question: A 27-year-old woman presents with secondary amenorrhea for 6 months. What is the appropriate initial evaluation?
Pelvic examination, Pap smear, pregnancy test, laboratory studies (prolactin, FSH, LH, TSH), and progestin challenge.

Question: A 26-year-old woman with secondary amenorrhea and an essentially normal work-up is given progestin 10 mg for 7 days (or an IM injection of progesterone 100 mg). She responds with a normal menstrual period. What does this tell you?
She has a functional endometrium and a normal production of estrogen. Patients producing less than 40 pg/mL of estrogen will not bleed. This test is called the progesterone challenge.

Question: What are the two major differential diagnoses in a patient with secondary amenorrhea who fails a progestin challenge?
Premature ovarian failure and hypothalamic dysfunction. Premature ovarian failure can be diagnosed if the serum FSH level is high; hypothalamic dysfunction can be diagnosed in setting of low FSH and LH.

Question: List the differential diagnosis of persistent vaginal bleeding in a preadolescent woman:
Neoplasia, precocious puberty, ureteral prolapse, trauma (including sexual assault), vulvovaginitis, exposure to exogenous estrogen, Shigella infection, group A and β-hemolytic streptococcal infection, and foreign body in vagina.
Foreign body is the most common and presents with bloody, foul smelling discharge.

What blood tests would be appropriate in the evaluation of a female child with precocious puberty?
Serum levels of FSH, LH, prolactin, TSH, estradiol, testosterone, dehydroepiandrosterone sulfate (DHEAS), and HCG.

Question: In a woman of reproductive age, what is the first step in the evaluation of abnormal uterine bleeding following the history and physical examination?
A pregnancy test.

Question: What is the recommended treatment for massive intractable dysfunctional uterine bleeding?
25 mg IV conjugated estrogens.

Question: What are the recommended pharmacotherapeutic interventions for primary dysmenorrhea?
NSAIDs or combined oral contraceptive agents.
If nonresponsive to the above interventions, tocolytic agents (salbutamol) or calcium channel blockers (nifedipine) or progestins (medroxyprogesterone) have been shown to be effective.

Question: What are the four main etiologies of secondary dysmenorrhea?

1. Endometriosis
2. Pelvic inflammatory disease
3. Uterine fibroids
4. Pelvic congestion (typically occurs in multiparous women who have pelvic vein varicosities and congested pelvic organs)

Question: A 37-year-old woman, G2 P2 presents with a history of lengthening menses and acquired dysmenorrhea. This problem had been subtly going on for 2 years and now is a quality-of-life issue. Examination reveals a top normal size globular-shaped uterus. What is the most likely diagnosis?
Adenomyosis.


MENOPAUSE

Question: What are some causes of premature menopause?
Smoking, radiation, chemotherapy, and anything else that limits the ovarian blood supply.

Question: What is the median age for menopause?
51 years.

Question: What is the most common cause of postmenopausal bleeding?
Atrophic endometrium and/or atrophic vaginitis.

What are the common changes associated with estrogen depletion?
Menstrual cycle changes, cardiovascular disease, osteoporosis, genitourinary atrophy, vasomotor, and psychological symptoms.

Question: What are the expected changes in gonadotropin levels after menopause?
FSH increases 10- to 20-fold and LH increases three fold, reaching a maximum 1 to 3 years after menopause. With the lack of ovarian response to FSH and LH, there is less estrogen and progesterone being produced. In turn, no negative feedback is in place to inhibit the rise of FSH and LH.

Question: Which hormones decline as a result of menopause?
Estrogen and androstenedione. Progesterone production also decreases.

Question: What hormone is secreted more by the postmenopausal ovary than the premenopausal ovary?
Testosterone. Prior to menopause, the ovary contributes 25% of circulating testosterone, and in menopause the ovary contributes 40% of circulating testosterone.

Question: What is the cause of mild hirsutism in menopause?
Increased free androgen to estrogen ratio as a result of decreased SHBG and estrogen.

Question: After menopause, what is the percent of bone loss per year?

2.5% for the first 4 years, and then 1% to 1.5% annually.

Question: What risk factors are associated with bone loss and osteoporosis?
White and Asian race, thin women, sedentary lifestyle, smoking, coexisting endocrine disease, long-term steroid use, and age of menopause.

Question: How does estrogen therapy help maintain bone mass?
Estrogen has a direct effect on osteoblasts, improves intestinal absorption of calcium, and decreases renal excretion of calcium.

Question: Why does vaginitis and vaginal atrophy increase during the postmenopausal years?
Because of estrogen deficiency, the vaginal pH increases from 3.5–4.5 to 6.0–8.0, predisposing it to colonization of bacterial pathogens.

Question: What effect does estrogen therapy have on colorectal cancer?
It significantly decreases the risk of colon cancer (50%).

Question: What effect does estrogen have on Alzheimer disease?
Alzheimer disease is less frequent among HRT users and cognitive function in affected individuals is improved.

A 63-year-old woman asks you about the risk–benefit ratio for estrogen therapy. What do you tell her?
Estrogen therapy is currently recommended for postmenopausal women who are NOT in a high-risk category for breast cancer; to improve cardiovascular health—research suggests that estrogen decreases the risk of CHD by 35%; to limit the risk of osteoporosis, including decreased risk of hip fractures by 25% and risk of vertebral fractures by 50%; for control of vaginal atrophy and vasomotor side effects of hypoestrogenic state. Hormone replacement therapy should be used with caution since unopposed estrogen increases the risk of endometrial cancer eight times (addition of progestins will eliminate this risk); it could potentially increase the risk of breast cancer in those with known risk factors; it can lead to hypercoagulable state (DVT).

Question: What are the contraindications to estrogen therapy?
Estrogen-sensitive cancers, chronically impaired liver function, undiagnosed genital bleeding, acute vascular thrombosis, neurophthalmologic vascular disease, and known or suspected pregnancy.

Question: What is the mainstay of treatment for postmenopausal osteoporosis?
Bisphosphonates.


CONTRACEPTIVE METHODS

Question: What are the absolute contraindications to the use of hormonal-based contraceptive agents? Explain using the mnemonic CONTRACEPTIVE:
Coronary disease
Obesity/hyperlipidemia type II
Neoplasm of liver
Cerebrovascular disease
Estrogen-dependent tumors
Pregnancy
Thrombophlebitis
IDDM
Vaginal bleeding undiagnosed
Enzymes of liver increasing

Question: What chemical changes may predispose patients taking oral contraceptives to weight gain?
Increases in low-density lipoproteins, decreases in high-density lipoproteins, and sodium retention.

Question: How much is menstrual blood flow decreased by OCP use?
On average by 60%.

Question: What are the overall risks and benefits to combined oral contraceptives?

Risks: Increase the risk for thromboembolism, MIs, CVAs, hypertension, amenorrhea, cholelithiasis, and benign hepatic tumors.

Benefits: Regulate the menstrual cycle, decrease premenstrual symptoms, and curb the progression of endometriosis, ovarian cysts, and benign breast disease. They also decrease the risk of ovarian and endometrial cancer, decrease the incidence of ectopic pregnancy, salpingitis, and anemia. They are known to be therapeutic against rheumatoid arthritis.

For women using oral contraceptives for 4 years or less, what is the reduction in the risk of ovarian cancer?
30%. For 12 or more years of use, the risk is decreased by 80%.

Question: For women using oral contraceptives for at least 2 years, what is the reduction in the risk of endometrial cancer?
40%. This increases to 60% for 4 or more years of use.

Question: What effect does oral contraceptive use have on the risk of developing cervical cancer?
Oral contraceptive users as a group are at higher risk for cervical neoplasia. This increased risk may be secondary to sexual habits rather than the pill itself.

Question: What are the estrogen-mediated side effects of oral contraceptive pills?
Headache, nausea, breast enlargement or tenderness, fluid retention, chloasma, and telangiectasia.

Question: What are progestin-/androgen-mediated side effects of oral contraceptive pills?
Depression, fatigue, acne, oily skin, and increased appetite.

Question: What is the incidence of venous thrombosis among oral contraceptive users?
10–20/100,000 users. Much higher incidence in smokers.

Question: How effective is breast-feeding alone in preventing pregnancy?
98% for the first 6 months in women who have not resumed their menses.

Question: How does DepoProvera work?
High levels of progestin suppressing FSH and LH levels and eliminating the LH surge. This inhibits ovulation.

Question: What is the effect of progestin on the uterus?
It results in a shallow atrophic endometrium and a thick cervical mucus. These both result in decreased sperm transport.

Question: What is the delay in return to fertility after DepoProvera?
6 months to 1 year.

Question: What is the risk of ectopic pregnancy in women with an IUD in place?
5%. Hormone-based IUD users have a 6- to 10-fold increase in ectopic rates compared with copper IUD users.

Question: How long after exposure can emergency oral contraceptives be given?
Up to 72 hours. It is most effective if initiated in 12 to 24 hours. Emergency contraception provides a 75% reduction in the risk of pregnancy. Patients should have a negative pregnancy test prior to treatment.

What is the total dose of estrogen that should be used in combined emergency oral contraceptive pills?
200 μg of ethinyl estradiol—2 doses of 100 μg taken 12 hours apart.

Question: Besides emergency contraceptive pills, what other contraceptive method can be used to prevent pregnancy after unprotected intercourse?
Copper IUD.

Question: How long after the removal of Norplant capsules must patients wait to become pregnant?
Ovulation usually occurs within 3 months.

Question: How long after delivery should a postpartum tubal ligation be performed? Why?
It is common practice to wait 8 to 12 hours postpartum before inducing anesthesia for tubal ligation. This time interval is useful to allow the patient to reach cardiovascular stability and increase the likelihood of gastric emptying.


INFERTILITY

Question: What percentage of American couples are infertile?
15% to 20% of women older than 35 years in the United States are infertile.

Question: What is the difference between primary and secondary infertility?
Primary—no conception or history of conception. Secondary—at least one prior episode of conception (even if did not result in term pregnancy and birth).

Question: What percentage of infertility is due to the male factor?
40%. Problems with the cervix, uterus, fallopian tubes, peritoneum, or ovulation account for the remaining 60%.

Question: What are the numbers for a normal semen analysis?
1 mL in volume (>20,000,000 sperm) with >50% motility.

Question: How long do sperm stay in the vagina postcoitus?
At least 72 hours; however, sperm are motile only for 6 hours. When performing a rape kit, it is important to test for acid phosphatase. This enzyme is present for 24 hours and confirms that ejaculation has occurred.

Question: What hormone is a marker of changes in basal body temperature?
Progesterone.

Question: In the evaluation of infertility, what procedure can be both diagnostic and therapeutic?
Hysterosalpingogram. It is typically performed between cycle days 6 and 10.


UNCOMPLICATED PREGNANCY

What percentage of pregnant women get “morning sickness”?
50% to 70%. It generally occurs in the first trimester (up to week 14–16).

Question: How should morning sickness be treated?
Frequent small meals, carbohydrates, IV hydration, and antiemetics as last resort.

Question: What is hyperemesis gravidarum?
Excessive vomiting during pregnancy that results in starvation (ketonuria), dehydration, and acidosis.

Question: What is pica?
This is a craving for eating nonfoods, such as laundry starch and clay, during pregnancy. If severe, it can result in nutritional deficiencies and anemia. It is also possible that the agent ingested may be toxic to the developing fetus.

Question: Does the presence of a thick endometrial stripe on ultrasound indicate an intrauterine pregnancy?
The endometrium can be thickened due to the hormonal stimulation associated with either an ectopic or intrauterine pregnancy, so this is not a consistent sign of a normal pregnancy.

Question: When can an intrauterine gestational sac be identified by an abdominal ultrasound?
In the fifth week. A fetal pole can be identified in the sixth week and an embryonic mass with cardiac motion in the seventh week.

Question: For a gestational sac to be visible on ultrasound, what must the β-hCG level be?
At least 6500 mIU/mL for a transabdominal ultrasound, and 2000 mIU/mL for a transvaginal ultrasound.

Question: What secretes β-hCG? Why?
Placental trophoblasts secrete β-hCG to maintain the corpus luteum, which in turn maintains the uterine lining. The corpus luteum is maintained through the sixth to eighth week of pregnancy, by which time the placenta begins to produce its own progesterone to maintain the endometrium.

Question: How soon after implantation can β-hCG be detected?
2 to 3 days.

Question: At what rate do β-hCG levels rise?
They double every 48 hours.

Question: At what gestational age does hCG peak?
8 to 10 weeks.

Name four physiologic actions of hCG:
1. Maintenance of corpus luteum and continued progesterone production
2. Stimulation of fetal testicular testosterone secretion promoting male sexual differentiation
3. Stimulation of the maternal thyroid by binding to TSH receptors
4. Promotes relaxin secretion by the corpus luteum

Question: What does a progesterone level of 25 ng/mL or higher indicates about a pregnancy?
A viable, uterine pregnancy. Serum progesterone is produced by the corpus luteum in the pregnant patient and remains constant for the first 8 to 10 weeks of pregnancy.

Question: Which routine screenings should be performed on pregnant women?
Hepatitis B and C, syphilis, rubella, chlamydia, gonorrhea, and other STDs. Women in high-risk categories should also be screened for HIV.

Question: By which week of gestation can a mother feel fetal movement? What is the term used to describe this?
16th to 20th week of gestation; termed “quickening.”

Question: Which week of gestation can fetal heart tones be detected by Doppler?
12th week.

Question: When can one auscultate the fetal heart?
Ultrasound: 6 weeks
Doppler: 10 to 12 weeks
Stethoscope: 18 to 20 weeks

Question: What immunizations are contraindicated during pregnancy?
In general, live virus vaccines are contraindicated during pregnancy. These include measles, mumps, rubella, oral polio, and varicella. On the other hand, all toxoids, immunoglobulins and killed virus vaccines are considered safe in pregnancy and should not be withheld, if indicated.

Question: What are the drug-labeling categories for use during pregnancy?
The FDA lists five categories of labeling:
Category A: Safe for use in pregnancy.
Category B: Animal studies have demonstrated the drug’s safety and human studies do not reveal any adverse fetal effects.
Category C: The drug is a known animal teratogen, but no data are available about human use; or there are no data in either humans or animals.
Category D: There is a positive evidence of human fetal toxicity, but benefits in selected situations makes use of the drug acceptable despite its risks.
Category X: The drug is a definite human and animal teratogen and should not be used in pregnancy.

Question: In general, at what time during pregnancy is the fetus most susceptible to teratogens?
During the embryonic period, which lasts from 2 to 8 weeks postconception. This is the time of organogenesis.

Name the anticoagulant safe in pregnancy:
Heparin. Warfarin is contraindicated.

Question: What is the known effect of folic acid deficiency in pregnancy?
Folate deficiency is associated with neural tube defects (i.e., spina bifida, anencephaly).

Question: What effect does pregnancy have on BUN and creatinine?
Both are decreased. This is the result of increased renal blood flow and increased glomerular filtration rate.

Question: Why should pregnant women rest in the left lateral decubitus position?
To avert supine hypotension syndrome due to compression of the IVC by the uterus.

Question: What is the normal PCO2 in pregnancy?
30 to 34 mm Hg from chronic mild hyperventilation, presumably as a result of progesterone.

Question: What is the predominant change in the lung volumes in pregnancy?
Decrease in functional residual capacity by as much as 15% to 25%. Tidal volume increases by 40%.

Question: What WBC count is expected during pregnancy?
WBC counts of 15,000 to 20,000 are considered normal during pregnancy.

Question: What are the normal physical changes in the cervix during pregnancy?
Softening and cyanosis.

Question: What are the expected changes in cervical mucous and vaginal flora during pregnancy?
Thick tenacious mucous forms a plug blocking the cervical canal. Increased cervical and vaginal secretions result in thick, white odorless discharge. The pH is between 3.5 and 6.0 resulting from increased production of lactic acid from the action of Lactobacillus acidophilus.

Question: What is the average weight gain in pregnancy?
11 kg (25 lbs). Only 30% of the maternal weight gain is attributed to the placenta and fetus. Another 30% is attributed to blood, amniotic fluid, and extravascular fluid. Another 30% is attributed to maternal fat.

Question: In general terms, what is the physiology of the maternal immune system in pregnancy?
Pregnancy represents a 50% allograft from the paternal contribution. As a result, there is a general suppression of immune function.

Question: What are the normal changes in the auscultative heart examination during pregnancy?
Exaggerated split S1 with increased volume of both components. Systolic ejection murmurs heard at the left sternal border are present in 90% of patients, soft and transient diastolic murmurs are heard in 20%, and continuous murmurs from breast vasculature are heard in 10%. The significance of murmurs in pregnancy must be carefully evaluated and clinically correlated. Harsh systolic murmurs and all diastolic murmurs should be taken seriously and worked up before being attributed to pregnancy.

Why is pregnancy termed a “hyperparathyroid state”?
The fetomaternal unit has the primary goal of transporting calcium across the placenta (by active transport) for fetal skeletal development. This consumes most of the maternal calcium. With this increase in calcium need, parathyroid hormone levels are increased by 30% to 50% to bring calcium from the maternal bone, kidney, and intestine into the serum.

Question: A pregnant patient complains that her contact lenses are painful to wear recently. Is this normal?
Yes. Corneal thickness increases in pregnancy and can cause discomfort when wearing lenses fitted before pregnancy.

Question: What kind of changes occur in the cardiovascular system of a pregnant patient?
Cardiac output increases by 30% in the first trimester and then 50% by the second trimester.
Stroke volume increases 25% and hemoatocrit drops due to hemodilution.
Plasma volume increases by 50% and pulse increases 12 to 18 bpm.
Systolic and diastolic blood pressure decrease by 10 to 15 mm Hg in the second trimester, then gradually returns to prepregnant levels in the third trimester.

Question: What happens to the bladder anatomy during pregnancy?
The bladder is displaced superiorly and anteriorly.

Question: What kind of changes occur in the gastrointestinal system of a pregnant patient?
Gastric emptying and GI motility decrease leading to GERD and constipation. In the third trimester, GERD can also be the result of increased intraabdominal pressure. Alkaline phosphatase increases. Peritoneal signs such as rigidity and rebound are diminished or absent.

Question: Can iodinated radiodiagnostic agents be used in pregnant patients?
No. They should be avoided because concentration in the fetal thyroid can cause permanent loss of thyroid function. Nuclear medicine scans, pulmonary angiography with pelvic shielding, and impedance plethysmography are preferred.

Question: What radiation dose increases the risk of inhibited fetal growth?
10 rad. Typical abdominal and pelvic films deliver 100 to 350 mrad. A shielded chest X-ray should deliver under 10 mrad to the fetus. Do not withhold necessary X-rays.

Question: When does labor begin?
Labor begins with the onset of regular, rhythmic contractions that lead to serial dilatation and effacement of the cervix. Thus, to say labor has begun, one must observe changes in the cervix. The presence of contractions alone does not qualify for the onset of labor.

Question: What are the four stages of labor and delivery?
Stage I: Onset of labor to complete dilation of the cervix
Stage II: Cervical dilation to birth
Stage III: Birth to delivery of the placenta
Stage IV: Placenta delivery to stability of the mother (about 6 hours)

How long is the average latent phase of labor?
In a nullipara, the average is 6.4 hours; in the multipara, the average is 4.8 hours

Question: What is the rate of cervical dilation (active phase) in primiparous and multiparous women?
The active phase begins when the uterus is regularly contracting and the cervix is 3 to 4 cm dilated. The minimal dilation is 1 cm/h for primiparous and 1.5 cm/h for multiparous women.

Question: What are the six movements of delivery?
1. Descent
2. Flexion
3. Internal rotation
4. Extension
5. External rotation
6. Expulsion

Question: How long may a patient push once fully dilated?
Provided that the fetal heart pattern is reassuring and maternal expulsive forces remain effective, a second stage may last up to 2 hours (average nullipara is 40 minutes, multipara 20 minutes); up to 3 hours is appropriate if the patient has regional analgesia/anesthesia. Beyond these time limits, one sees an increase in fetal acidosis and lower Apgar scores, as well as a greater risk of maternal postpartum hemorrhage and febrile morbidity.

Question: What is “effacement” of the cervix?
Effacement refers to the foreshortening and thinning of cervix as it is drawn upwards (intra-abdominally). It is usually expressed in percentages by which cervical length has been reduced (from 0%, or uneffaced, to 100%, or fully effaced).

Question: What agents may be used to ripen the cervix?
Both chemical and physical agents have been used. Oxytocics, prostaglandins (especially PGE2), progesterone antagonists (RU-486), and dehydroepiandrosterone are such pharmacologic agents. Laminaria and foley catheter balloons are examples of physical dilators.

Question: What other uterotonic agents are there besides oxytocin?
Vasopressin (antidiuretic hormone), prostaglandins (PGE2 and PGF2α) and thromboxane are natural oxytocics. Ergot alkaloids (e.g., Methergine) and the synthetic prostaglandin 15-methyl-F2-α-PG are used clinically to increase uterine contractions, especially for postpartum uterine atony.

Question: Does epidural analgesia affect the course of labor?
Studies showed that epidural analgesia does not slow the progress of labor in the first stage of labor. However, the second stage of labor appears to be prolonged for an average of 20 to 25 minutes. There is no evidence that this prolongation is harmful to the fetus.

Question: What is a “walking epidural”?
An intrathecal opioid or epidural opioid plus an ultralow dose of local anesthetic, followed by continuous infusion of opioid and local anesthetics, for labor analgesia. These regimens cause no or minimal motor block on the lower extremities, and allow the mother to ambulate in the early first stage of labor.

What complications are seen with precipitous labors?
There is a higher incidence of fetal trauma (intracranial hemorrhage and fractured clavicle) and long-term neurologic injury. The mother is at higher risk for pelvic lacerations and postpartum hemorrhage (including, somewhat paradoxically, from uterine atony).

Question: What is the most common cause of a prolonged active phase of labor?
Cephalopelvic disproportion caused by contraction of a narrowed midpelvis.

Question: What is the first step in the evaluation of a protraction or arrest disorder of labor?
Assess fetopelvic size. If disproportion is suspected, augmentation should not be undertaken.

Question: At term, what percentage of fetuses are in vertex presentation?
95%.

Question: What is the largest risk for breech presentation?
Prematurity; 25% of fetuses are breech at 28 weeks, but most correct by term.

Question: What are the three types of breech presentation?
Frank breech: Thighs flexed, legs extended
Complete breech: At least one leg flexed
Incomplete (footling) breech: At least one foot below the buttocks with both thighs extended

Question: What is the most common breech position?
Frank breech.

Question: What is the modified Ritgen maneuver?
It describes the elevation of the fetal chin achieved by placement of the delivering hand between the maternal coccyx and perineal body, while the other hand guides the crowning vertex. This technique assists in extension of the fetal head and allows the clinician to control delivery.

Question: What is the difference between high forceps, mid forceps, and low forceps deliveries?
High forceps refers to the use of forceps when a baby is not yet in the birth canal (rarely used).
Mid forceps refers to the use of forceps when a baby is in the birth canal and within reach (used in cases of fetal distress).
Low forceps refers to the outlet and forcep is used when the baby’s head is at the pelvic floor (most often used to shorten labor when the mother is tiring or to control normal labor).

Question: How can ruptured membranes be diagnosed?
Nitrazine paper will turn blue and a ferning pattern will be seen under the microscope in the presence of amniotic fluid. Also, look for pooling of amniotic fluid in the posterior fornix.

What are the degrees of perineal tears that may occur with delivery? Describe.
First degree: Perineal skin or vaginal mucosa
Second degree: Submucosa of vagina or perineum
Third degree: Anal sphincter
Fourth degree: Rectal mucosa

Question: What are the advantages and disadvantages of a mediolateral episiotomy?
Such an episiotomy allows for greater room without lacerating the external sphincter ani or rectum. However, these episiotomies are associated with a greater blood loss and postpartum pain, greater likelihood for suboptimal healing, and subsequent dyspareunia.

Question: What are the advantages and disadvantages of a midline (median) episiotomy?
These are easier to repair, associated with a lower blood loss, usually heal better (less postpartum discomfort and better cosmetic result), and less subsequent dyspareunia.
The principal disadvantage to such an episiotomy, compared to a mediolateral one, is the greater propensity to extend into the external anal sphincter or rectum resulting in possible rectal dysfunction or rectal prolapse in the future.

Question: How can fetal lung maturity be assessed?
The L/S ratio; if the ratio of lecithin to sphingomyelin is more than 2:1, then the fetal lungs are mature.

Question: What are the benefits of antepartum corticosteroids in premature babies?
Increased lung compliance, increased surfactant production, less respiratory distress syndrome, less intraventricular hemorrhage, less necrotizing enterocolitis, and less neonatal mortality.

Question: What is the normal fetal heart rate?
120 to 160 bpm. If bradycardia is detected, position the mother on her left side and administer oxygen and an IV fluid bolus.

Question: Are accelerations normal?
Yes and no. Rapid heart rate can indicate fetal distress; 2 accelerations every 20 minutes are normal. An acceleration must be at least 15 bpm above baseline and last at least 15 seconds.

Question: What causes variable decelerations?
Transient umbilical cord compression. These often change with maternal position.

A baby is born with a pink body, blue extremities, and a heart rate of 60. The neonate is mildly irritable (grimaces) and has weak respirations and no muscle tone. What is this patient’s Apgar?
1 + 1 + 1 + 1 + 0 = 4



COMPLICATED PREGNANCY

Question: What percentage of pregnancies are ectopic?

1.5%. Ectopic pregnancies are the leading cause of death in the first trimester.

Question: What is the risk of a repeat ectopic pregnancy?
10% to 15%.

Question: What are the risk factors for ectopic pregnancy? Explain using the mnemonic ECTOPIC:
Endometriosis
Congenital anomaly of tubes
Tubal surgery
Old abdominal scar
PID
In vitro fertilization
Contraceptive pills

Question: When and how does an ectopic pregnancy most commonly present?
6 to 8 weeks into the pregnancy. Patients usually present with amenorrhea and sharp, generally unilateral abdominal or pelvic pain.

Question: In an ectopic pregnancy, is an adnexal mass a common finding?
No. An adnexal mass is actually found in less than 50% of cases. Abdominal pain is the most frequent symptom. Amenorrhea is the second most common symptom.

Question: What is the most common site of implantation in an ectopic pregnancy?
The ampulla of the fallopian tube (95%). Less common sites are abdomen, uterine cornua, cervix, and ovary.

How do hCG levels differ in women with ectopic pregnancies versus intrauterine pregnancy?
In 85% of women with ectopic pregnancy, the hCG level is lower than expected.

Question: Which is the most common sign of an ectopic pregnancy by transvaginal ultrasound: adnexal mass or absence of an intrauterine pregnancy?
The absence of an intrauterine pregnancy at an hCG level >2000 mIU/mL is highly predictive of an ectopic pregnancy. An adnexal mass or gestational sac in the adnexal is less reliable finding and is not always seen in early ectopic pregnancies. Follow-up ultrasound is always recommended in high-risk patients to ensure intrauterine pregnancy.

Question: Who is eligible for methotrexate treatment of an ectopic pregnancy?
Patients who are hemodynamically stable with unruptured gestations <4 cm in diameter by ultrasound.

Question: What is the mode of action of methotrexate?
Methotrexate is a folic acid antagonist.

Question: What criteria are used for assuring the success of methotrexate?
With a single-dose therapy, the hCG levels should fall by 15% between days 4 and 7 after therapy and continue to fall weekly until undetectable.

Question: What are the indications for laparotomy for the treatment of ectopic pregnancy?
Common indications for laparotomy include an unstable patient, large hemoperitoneum, cornual pregnancy, and lack of appropriate surgical tools for laparoscopy. A large ectopic (>6 cm) and fetal heart tones in the adnexa may also be considered as indications for laparotomy.

Question: A patient who is 3 months pregnant presents to your office with pelvic pain. On examination, a retroverted and retroflexed uterus is found. What is the diagnosis?
Incarceration of the uterus. Patients typically complain of rectal and pelvic pressure. Urinary retention may be found. The knee–chest position or rectal pressure may correct the problem.

Question: What are the differences between spontaneous, threatened, incomplete, complete, and missed abortions?
Spontaneous abortion is the loss of the fetus before the 20th week of gestation.
Threatened abortion is uterine cramping or bleeding in the first 20 weeks of gestation without the passage of products of conception or cervical dilatation.
Incomplete abortions are partial abortions in which part of the products of conception are aborted and part remain within the uterus. The cervix is dilated on examination, and dilation and curettage is necessary to remove the remainder of tissue.
Complete abortion is when all the products of conception have been passed, the cervix is closed, and the uterus is firm and nontender.
Missed abortion is defined as no uterine growth, no cervical dilation, no passage of fetal tissue, and minimal cramping or bleeding. Diagnosis is made by the absence of fetal heart tones and an empty sac on ultrasound.

What percentage of pregnancies result in spontaneous abortions? What is the number one cause of natural abortions?
15% to 20%. Genetic defects (50%), usually the result of an abnormal number of chromosomes.

Question: Name three independent risk factors for spontaneous abortion:
Increasing parity, maternal age, and paternal age.

Question: What is the effect of smoking and drinking on the abortion rate?
Women who smoke more than 14 cigarettes daily have a 1.7 times greater chance of a spontaneous abortion. Those who drink alcohol at least 2 days a week have a twofold greater risk for spontaneous abortion.

Question: How do spontaneous abortions most commonly present?
Abdominal pain followed by vaginal bleeding typically before 8 to 9 weeks of gestation.

Question: What is the chance of spontaneous abortion once fetal cardiac activity is established at eight weeks of gestation?
3% to 5%.

Question: In what percentage of patients will spontaneous labor occur within 3 weeks of fetal death?
80%. It may be helpful to induce labor with vaginal suppositories due to the psychological effects of carrying a dead baby.

Question: At what gestational age is suction or vacuum curettage used to terminate the pregnancy?
7 to 13 weeks of gestation.

Question: What is the most common cause of postabortal pain, bleeding, and low-grade fever?
Retained gestational tissue or clot.

Question: What is the most likely diagnosis in a patient whose uterus is larger than expected from the history of gestation, has vaginal bleeding, and passes grape-like tissue from the vagina?
Hydatidiform mole.

Question: How does age influence the incidence of hydatidiform moles?
Compared to women aged 25 to 29 years, women older than 50 years have a 300- to 400-fold increase in risk and women younger than 15 years have a 6-fold increase. Similarly, increased paternal age (above 45 years of age) also confers an increased risk of a complete molar pregnancy, although the increase is much lower and adjusted for maternal age.

Question: How is human chorionic gonadotropin (hCG) useful in the evaluation of gestational trophoblastic disease?
Both molar pregnancies and gestational choriocarcinomas produce BhCG due to their trophoblastic origin. The tumor marker correlates well with the volume of disease and can be followed as a marker during therapy.

With what endocrine abnormalities are moles and other gestational trophoblastic neoplasms associated?
Hyperthyroidism.

Question: Describe the characteristics of gestational choriocarcinoma:
Gestational choriocarcinomas contain both cytotrophoblast and syncytiotrophoblast elements. They are considered invasive molar pregnancies. Invasive moles are pathologically similar to complete hydatidiform moles but invade beyond the normal placentation site into the myometrium. Penetration into the venous system can result in venous metastases to the lower genital tract and lungs.

Question: Why is induction of labor with oxytocin or prostaglandins not recommended for the evacuation of molar pregnancies?
Uterine contractions against an undilated cervix theoretically carries an increased risk for the dissemination of trophoblast throughout the systemic circulation.

Question: What is the most common presentation of twins?
Vertex–vertex. If the first twin is vertex and the second breach, it is still possible to attempt a vaginal delivery because the extra space afforded after the birth of the first baby allows room to manipulate the position of the second.

Question: What is the average gestational age at delivery for twins, triplets, and quadruplets?
Twins: 36–37 weeks
Triplets: 33–34 weeks
Quadruplets: 30–31 weeks
3 or more fetuses reduced to twins: 35–36 weeks

Question: What are the risk factors for elevated maternal serum α-fetoprotein? Explain using the mnemonic MSAFP (elevated MSAFP):

Multiple gestations
Spina bifida (NTDs)
Abdominal wall defects (Omphalocele, gastroschisis)
Fetal death
Placental anomalies

Question: What conditions are suggested by an elevated maternal serum α
-fetoprotein?
Neural tube defects (an encephalopathy), ventral abdominal wall defects, fetal demise, multiple fetuses. A low α-fetoprotein is indicative of Down syndrome.

Question: What are the baseline congenital anomaly risks in the general population?
Regardless of family history or teratogenic exposure, the background risk for major congenital anomalies is 3% to 5%. These include abnormalities that, if uncorrected, affect the health of the individual. Some examples are pyloric stenosis, cleft lip and palate, and neural tube defects.
The background rate for minor congenital anomalies is 7% to 10%. These include strabismus, polydactyly, misshapen ears, etc. If uncorrected, they do not significantly affect the health of the individual.

Why is the Rh status of a pregnant patient important?
If the mother is Rh negative and the fetus is Rh positive, there is a risk of developing Rh isoimmunization and fetal anemia, hydrops, and/or fetal loss.

Question: Which type of blood test is used to determine if a patient needs RhoGAM therapy?
A Kleihauer-Betke checks for fetomaternal bleeding.

Question: When should RhoGAM (anti-Rh immunoglobulin) be used?
Within 3 days of the birth of an Rh+ child (if the mother is Rh−). It should also be used in the event of any mixing of fetal and maternal blood (e.g., trauma). RhoGAM is safe because it does not pass the placenta barrier.
The standard dose of RhoGAM is 300 mg.

Question: Should Rh-negative women with ectopic pregnancies be given RhoGAM?
The administration of mini-RhoGAM (50 μg) is recommended with any failed pregnancy up to 12 weeks (with full dose RhoGAM after 12 weeks).

Question: A young patient has a threatened abortion in the first trimester. Laboratory studies reveal she is Rh negative and her husband is Rh positive. What is the recommended management of this patient?
The patient will need 50 μg of Rh immunoglobulin (RhoGAM) IM. After the first trimester, the dose is increased to 300 μg IM.

Question: What are some common causes of polyhydramnios?
Maternal causes include diabetes, Rh incompatibility, and other hematological diseases. Fetal causes are anencephaly, duodenal atresia, tracheoesophageal fistula, and pulmonary disorders.

Question: What is the most common medical complication of pregnancy?
Urinary tract infections.

Question: What is the treatment for gestational diabetes?
Diet, insulin, and exercise. Do not give patients oral hypoglycemics because these cross the blood–brain barrier.

Question: What level of serum glucose in a patient with gestational diabetes warrants hospital admission?
Persistent hyperglycemia (>200 mg).

Question: When should you be most concerned about a pregnant patient with underlying heart disease?
During weeks 18 to 24, when the female body experiences a maximal increase in cardiac output (40%).

Question: What are some of the common misconceptions about the management of asthma during pregnancy?
Dyspnea is common in pregnancy with or without underlying asthma. Medications should be used sparingly. Uncontrolled asthma causes more fetal harm than medications.

What are the factors during pregnancy that increase the risk of aspiration of stomach contents?
Increased intragastric pressure from the gravid uterus, progesterone-induced relaxation of the lower esophageal sphincter, delayed gastric emptying in labor, and depressed mental status from analgesia.

Question: Is appendicitis more common during pregnancy?
No (approximately 1 out of 850). However, the outcome is worse. Prompt diagnosis is important because the incidence of perforation increases from 10% in the first trimester to 40% in the third.

Question: During which trimester of pregnancy is acute appendicitis most common?
The second trimester.

Question: How is the appendix typically displaced during pregnancy?
Superiorly and laterally. Diagnosis of appendicitis in pregnant patients may be further complicated by the fact that a normal pregnancy can itself cause an increased WBC. In a pregnant patient, pyuria with no bacteria suggests appendicitis. Pregnant patients may lack GI distress, peritoneal signs on examination, and fever may be absent or low grade.

Question: What viral or protozoal infections require extensive work-up during pregnancy? Define ToRCH:
Toxoplasma gondii
Rubella
Cytomegalovirus
Herpes genitalis

Question: What foods put a pregnant woman at risk for mercury poisoning?
The only real human exposure to organic mercury is through consumption of fish, primarily from predatory fish such as shark, swordfish, pike, and bass.

Question: What is the recommended fish consumption for pregnant women to avoid mercury poisoning?
Fish consumption by pregnant women should be limited to 350 g per week. Fetuses are more susceptible to toxic effects of mercury than their maternal hosts. Large exposures to methyl mercury have resulted in infants with microcephaly, mental retardation, cerebral palsy, and blindness.

Question: Why is ephedrine usually the first choice to treat maternal hypotension?
Ephedrine does not produce significant uterine vascular constriction, and therefore, it does not result in decreased uterine blood flow.

Question: What causes dependent and nondependent edema in pregnant women?
Compression of veins by the growing uterus causes dependent edema, whereas hypoalbuminemia can cause nondependent edema.

Question: Define pregnancy-induced hypertension:
An increase in the systolic pressure > 30 mm Hg or an increase in diastolic pressure > 15 mm Hg over baseline, measured on two separate occasions at least 6 hours apart.

What are the pharmacotherapeutic options for the treatment of hypertension of pregnancy?
Methyldopa, labetalol, hydralazine, and clonidine. Antihypertensive treatment is indicated if the systolic BP is >170 mm Hg or the diastolic is >110 mm Hg. Although many choices to treat earlier. Other options not used as frequently include nifedipine, atenolol, prazosin, and minoxidil.

Question: What are the nonpharmacotherapeutic options for the treatment of hypertension of pregnancy?
Sodium restriction to 2 to 3 g/d; abstaining from alcohol and tobacco; weight reduction; moderate activity as tolerated but rigorous activity should be limited; more frequent prenatal visits and ultrasound surveillance is recommended to monitor for signs of fetal anomalies/stress or preeclampsia.

Question: Define preeclampsia:
Hypertension (a systolic pressure > 160 mm Hg or a diastolic pressure > 110 mm Hg) after 20 weeks of estimated gestational age with generalized edema or proteinuria of 5g or more in a 24-hour period.

Question: Who is more likely to have preeclampsia: primiparous or multiparous women?
Primiparous. Other risk factors include pregnancies associated with a large placenta, patients with a history of HTN, renal disease, family history of preeclampsia, older women, women with multiple gestations, and women with prior vascular disease.

Question: Which two drugs are used to treat eclampsia?
Magnesium sulfate, 4 to 6 g bolus IV followed by a 2 g/h infusion, and hydralazine, 10 to 20 mg IV. Labetalol may also be used.

Question: Should blood pressure be lowered acutely in a preeclampsia patient?
No. Dangerous hypertension (>170/110) should be gradually lowered with hydralazine, 10 mg IV followed by a drip.

Question: How should hydralazine be dosed for a preeclamptic patient?
Hydralazine should be given in 5 mg boluses every 20 minutes until adequate BP control (90/110 diastolic) is achieved or a total of 20 mg is reached.

Question: What is the major cause of death in women with eclampsia?
Intracranial hemorrhage.

Question: What are the warning signs of impending seizure in a patient with preeclampsia?
Headache, visual disturbances, hyperreflexia, and abdominal pain.

Question: What is the treatment for eclampsia?
Delivery!!! Until you are able to deliver you can use magnesium sulfate, valium, and hydralazine. Phenytoin or diazepam can be used for seizures resistant to magnesium therapy.

How long should treatment continue after delivery for a woman with preeclampsia?
24 hours. The cure for preeclampsia is delivery. Antihypertensives and antiseizure medication (IV magnesium sulfate) should be continued until there is no longer a risk to the mother.

Question: If a patient had an eclamptic seizure prior to delivery, can they have additional after delivery?
Yes. Up to 10 days postpartum.

Question: At what point does magnesium become toxic?
Respiratory arrest occurs at levels >12 mEq/L. Loss of reflexes occurs at levels >8 mEq/L and can therefore be used as a guide for treatment.

Question: What is the antidote for magnesium toxicity?
Calcium gluconate (1 g IV push); magnesium should be stopped if the DTRs disappear.

Question: What does HELLP stand for?
Hemolysis
Elevated
Liver enzymes
Low
Platelet levels
The HELLP syndrome is a very severe form of preeclampsia. Signs and symptoms include RUQ pain/tenderness, nausea, vomiting, edema, jaundice, GI bleeding, and hematuria in addition to the symptoms of preeclampsia.

Question: What is the difference between placenta previa and abruptio placenta?
Placenta previa is the implantation of the placenta in the lower uterine segment thus covering the cervical os. Presentation is painless vaginal bleeding with a soft nontender uterus.
Abruptio placenta is the premature separation of the placenta from the uterine wall. Abruptio placenta causes painful uterine bleeding.
Both are complications of third trimester pregnancies.

Question: A patient presents in her third trimester complaining of vaginal bleeding but no pain or contractions. How should you diagnose this patient?
With a transabdominal ultrasound. Since 95% of placenta previas can be diagnosed this way, a vaginal examination should be avoided until placenta previa has been ruled out via ultrasound. Abruptio placentae is generally accompanied by pain, shock, or an expanding uterus. It is not easily diagnosed on ultrasound.

Question: What are the risk factors for placenta previa?
Previous cesarean section, previous placenta previa, multiparity, multiple induced abortions, maternal age over 40 years, and multiple gestations.

Question: What are the risk factors for placental abruption?
Smoking, trauma, cocaine, hypertension, alcohol, PROM, trauma, previous abruptio placentae, and retroplacental fibroids.

What are the presenting signs and symptoms of abruptio placentae?
Placental separation before delivery is associated with vaginal bleeding (78%) and abdominal pain (66%) as well as with tetanic uterine contractions, uterine irritability, and possibly fetal death.

Question: What physical examination findings may be discovered in abruptio placenta?
Rapidly increasing fundal height secondary to bleeding into the uterus or a higher than expected fundal height.

Question: What are the etiologies for uterine rupture (both gynecologic and obstetric)?
Oxytocin stimulation, cephalopelvic disproportion, grand multiparity, abdominal trauma, prior hysterotomy, previous cesarean section, myotomy, curettage, or manual removal of the placenta.

Question: What is the number one risk factor for uterine rupture?
Previous cesarean section.

Question: What are the common signs of uterine rupture?
Fetal distress, unrelenting pain, hypotension, tachycardia, and vaginal bleeding. Fetal distress is usually the first sign of uterine rupture.

Question: What two findings on physical examination are indicative of uterine rupture?
Loss of uterine contour and palpable fetal part.

Question: Why is the incidence of thromboembolism increased in pregnancy?
Venous stasis from the uterine pressure on the inferior vena cava, increase in clotting factors, increased fibrinogen, and decreased fibrinolysis.

Question: What are some of the risk factors for thromboembolism in pregnancy?
C-section, multiparity, bed rest, obesity, increased maternal age, and surgical procedures.

Question: What are the predisposing factors for amniotic fluid embolism?
Older maternal age, multiparity, C-section, amniotomy, and insertion of intrauterine fetal monitoring devices.

Question: How does amniotic fluid enter maternal circulation?
Through uterine tears or injury or through endocervical veins.

Question: What are the major consequences of amniotic fluid embolism?
Cardiorespiratory collapse and DIC. Treatment is supportive.

Question: What is the mortality rate in amniotic fluid embolism?
About 80%.

How does cocaine adversely affect pregnancy?
Cocaine is especially toxic during pregnancy. The most common complication caused by cocaine during pregnancy is abruptio placentae, which may result in fetal death. In addition, brain anomalies, intestinal atresia, and limb reduction defects have been described. Investigators have also reported increases in congenital heart defects in exposed infants. Cocaine may cause these effects by vasoconstrictions and subsequent infarction.

Question: Does methadone have the same adverse affect as cocaine in pregnancy?
Not even close. In fact, one study compared cocaine-abusing women to women being treated with methadone and found a much higher complication rate in the cocaine-abuse group. Methadone is not thought to be a teratogen.

Question: What is neonatal abstinence syndrome, and what agents cause it?
It is caused by maternal heroin addiction or maternal methadone treatment during pregnancy. It results from neonatal withdrawal and consists of tremulousness, hyperreflexia, high pitch cry, sneezing, sleepiness, tachypnea, yawning, sweating, fever, and seizures. The onset of symptoms is at birth.

Question: What are the signs and symptoms of fetal alcohol syndrome?
Infants suffer from intrauterine growth restriction, mental retardation, and develop a characteristic facies, which consists of short palpebral fissures, a flat midface, a thin upper lip, and hypoplastic philtrum. Alcohol abuse is the most common preventable cause of mental retardation during pregnancy.

Question: At what time during gestation is the fetus most susceptible to alcohol toxicity?
Probably in the second and third trimesters. In a study of 60 women, those who were heavy drinkers but stopped after the first trimester had children with normal mentation and behavioral patterns.

Question: What are the major adverse effects of smoking during pregnancy?
Smoking causes intrauterine growth restriction and increases the incidence of preterm delivery in a dose-dependent manner. The incidence of placenta previa, abruptio placentae, and spontaneous abortion also appears to be increased in smokers.

Question: What are the indications for cardiotocographic monitoring in a pregnant trauma patient?
All women past 20 weeks gestation with indirect or direct abdominal trauma require 4 hours of monitoring. Loss of beat-to-beat variability, uterine contractions, or fetal bradycardia or tachycardia demands immediate obstetrical consultation.

Question: When monitoring a pregnant trauma victim, whose vital signs are the most sensitive, those of the mother or those of the fetus?
The fetal heart rate is more sensitive to inadequate resuscitation. Remember that the mother may lose 10% to 20% of her blood volume without a change in vital signs, whereas the baby’s heart rate may increase or decrease above 160 or below 120, indicating significant fetal distress. The most common pitfall is failure to adequately resuscitate the mother.

Question: What are maternal risk factors for shoulder dystocia?
Diabetes, maternal obesity, postterm babies, and mothers with excessive weight gain.
Intrapartum risk factors include a prolonged second stage of labor, oxytocin use (augmentation or induction), and midforceps deliveries.

What is the best known fetal risk factor for shoulder dystocia?
Fetal weight. The risk is approximately 0.2% if the fetus weighs 2500 to 3000 g but rises to about 10% if the baby weighs 4000 to 5000 g and up to 20% if the baby weighs more than 4500 g. In diabetic patient’s these latter weight-associated risks are approximately doubled.

Question: What is the difference between a classic C-section and a newer C-section?
A classic C-section is a vertical incision in the uterus. This type of C-section predisposes women to future uterine rupture. Hence, subsequent deliveries should be made via C-section as well.
The newer C-sections are low transverse incisions; they have a much lower rate of uterine rupture with subsequent deliveries.

Question: What percentage of women can have vaginal births after low transverse incision C-sections (aka VBAC)?
75%. Vaginal birth is contraindicated after a classic C-section.

Question: What is the average blood loss for vaginal delivery and for cesarean section?
400 to 600 mL for vaginal delivery and 800 to 1000 mL for cesarean section.

Question: Why is a rapid cesarean delivery an important part of maternal resuscitation?
Removing the fetus relieves aortocaval compression. With uterine contraction after delivery, some blood may enter the circulation and may help increase venous return. Cardiac output produced by chest compression may be more adequate without the fetus.

Question: What happens if some placenta or fetal membranes are left inside the uterus?
Retained tissue or products of conception may lead to postpartum hemorrhage. It also increases the risk of postpartum endometritis.


POSTPARTUM

Question: What is the puerperium?
The puerperium refers to the time just after birth and lasts about 6 weeks. It is the time it takes the uterus to return to its nonpregnant state.

Question: What are the causes of immediate postpartum hemorrhage?
Uterine atony, followed by vaginal/cervical lacerations, and retained placenta or placental fragments.

Question: What is the most common cause of postpartum hemorrhage?
Uterine atony.

Question: What factors predispose one to uterine atony?
Fetal macrosomia, polyhydramnios, abnormal labor progress, amnionitis, oxytocin stimulation, and multiple gestations.

What is routinely done to decrease the risk of postpartum hemorrhage?
Uterine massage and oxytocin. Lacerations are sutured. In severe cases, where bleeding cannot be stopped, the hypogastric vessels are ligated or a hysterectomy is performed.

Question: What is lochia?
Lochia refers to the uterine discharge that follows delivery. It consists of necrotic decidua, blood, inflammatory cells, and bacteria. This discharge lasts about 5 weeks.

Question: A patient presents 3 days postpartum with a fever, malaise, and lower abdominal pain. On examination, a foul lochia and tender boggy uterus are present. What is the most likely diagnosis?
Endometritis. This typically occurs 1 to 3 days postpartum. It is felt that the mechanism of infection is from ascending cervicovaginal flora.

Question: Is endometritis more common after vaginal delivery or C-section?
The rate of endometritis is 5 to 10 times greater after C-section.

Question: What is the treatment for endometritis?
Admission and IV broad-spectrum antibiotics.

Question: Why is the risk of a thromboembolic event increased in the postpartum time?
While immediate platelet count changes are variable, platelet counts reach a peak at 2 weeks postpartum. Fibrinogen levels remain elevated for at least 1 week as do factors VII, VIII, IX, and X. In addition, there is greater vessel trauma and less mobility.

Question: What postpartum immunizations are part of standard care?
Rubella and rubeola immunization vaccinations should be administered to all susceptible postpartum women. In theory, diphtheria and tetanus toxoid boosters may also be administered if indicated. The non-isoimmunized Rh-negative patient should also receive anti-D immune globulin if her child is Rh positive.

Question: How common are “postpartum” blues?
50% to 70% of mothers will have postpartum blues.

Question: How common is postpartum depression?
Only 4% to 10% of postpartum mothers will have true postpartum depression.

Question: When does ovulation resume postpartum?
In nonlactating women, ovulation may occur as early as 27 days postpartum. The average is 10 weeks. In women exclusively breast-feeding, ovulation may be delayed for the duration of active breast-feeding, although the mean is 6 months.

Question: When may coitus resume following delivery?
Most physicians instruct their patients to abstain from coitus for 6 weeks. From a physiologic standpoint, once uterine involution and perineal healing are complete, coitus may resume.

What is Sheehan syndrome?
Anterior pituitary necrosis following postpartum hemorrhage and hypotension. It results in amenorrhea, decreased breast size, and decreased pubic hair.


REFERENCES
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Bickley L. Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2007.
Decherney A, Nathan L, Goodwin TM, Laufer N. Current Diagnosis and Treatment Obstetrics & Gynecoogy. 10th ed. Lange Series. New York, NY: McGraw-Hill; 2007.
DeGowin R, LeBlond R, Brown D. DeGowin’s Diagnostic Evaluation. The Complete Guide to Assessment, Examination, and Differential Diagnosis. 8th ed. New York, NY: McGraw-Hill; 2004.
Lemcke D, Pattison J, Marshall L, Cowley D. Current Care of Women Diagnosis & Treatment. Lange Series. New York, NY: McGraw-Hill; 2004.
Saslow D, et al. American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography. CA Cancer J Clin. 2007;57:75–89.http://caonline.amcancersoc.org/cgi/content/full/57/2/75#T1.
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Smith R, Saslow D, et al. American Cancer Society Guidelines for Breast Cancer Screening: Update 2003. CA Cancer J Clin. 2003;53:141.
Centers for Disease Control. Cervical Cancer Screening Guidelines, Table 1. http://www.cdc.gov/std/hpv/ScreeningTables.pdf. Accessed June 2009.
UpToDate (online 17.1). www.uptodateonline.com. Accessed May 2009, June 2009.