Authors: Luke Carlson
Editor: Miriam Andrusier
1) Mixed enteric and skin flora
• Bartholin cyst gland abscess – mixed enteric and skin flora
2) Puerperal sepsis
• Patient is demonstrating signs and symptoms of septic shock: fever >38C (41C), tachycardia (130/min), tachypnea (30/min), and hypotension
• Puerperium = period of ~6 weeks after childbirth, during which, the mother’s reproductive organs return to their original non-pregnant condition
3) Protracted active phase of labor
• Out of date answer (should be normal labor); new guidelines set active phase at 6cm, however older guidelines had 4cm as active phase
• The cervix should dilate at a rate of ≥1cm every 2 hours during the active phase of labor (6-10 cm cervical dilation)
• Protracted active phase is when you have < 1cm dilation over 2 hours
4) Augmentation of labor with oxytocin
• Out of date answer (active labor should be at 6cm)
• If patient was 6cm dilated (active phase), augmentation of labor with oxytocin to increase strength and frequency of contractions
• Protracted active phase of labor
5) Enterocele
• Pelvic organ prolapse
• “Something moving” = peristalsis, stool
6) Synchronization of the endometrium
• Hormonal imbalance → menometrorrhagia (irregular and heavy bleeding)
• OCPs promote regular menses – cause synchronization of the endometrium by providing progesterone that will cause endometrial shedding and oppose estrogen-induced endometrial hyperplasia
7) Observation and continued monitoring
• This fetal heart rate tracing is normal with moderate variability although no accelerations makes it non-reactive, there is nothing more to do here
8) Observation
• Hematocrit of 37% is within normal limits
• Lochia – normal bleeding postpartum, up 2-6 weeks, both vaginal or cesarean delivery
9) Progesterone supplementation until 10 weeks’ gestation
• Corpus luteum is responsible for producing progesterone during the first 6-12 weeks of gestation
• Placenta takes over progesterone production around 8-12 weeks
• Providing progesterone supplementation until 10 weeks would provide adequate time for placenta to take over production
10) Acetaminophen
• Acetaminophen is safe for use in pregnancy & is first line tx for headache in pregnancy
• NSAIDs are second line tx for abortive migraine treatment during pregnancy
• Butalbital, ergotamine not recommended during pregnancy
• Sumatriptan – abortive
• Meperidine – opioid, risk of withdrawal syndrome if used in excess
11) Hypogonadism
• Chemotherapy-induced premature ovarian failure → menopause-like symptoms
12) Application of heat to the area
• Plugged duct - afebrile breastfeeding mother, tender edematous area (can be lateral aspect as in this patient)
○ Tx: warm compress
• Galactocele - afebrile breastfeeding mother with a non-tender mass
• Mastitis would be treated with antibiotics (eg, dicloxacillin and continued breastfeeding)
13) Endometrial biopsy
• Endometrial biopsy indicated in women >45 with postmenopausal or abnormal uterine bleeding
14) Sexual assault
• Elderly patient with dementia has a lateral 3cm laceration and erythematous, edematous vaginal perineal body = trauma (unlikely she did this to herself)
15) Wet mount preparation
• Gardenerella vaginalis (bacterial vaginosis) and Trichomonas vaginalis (trachomoniasis) have foul-smelling, watery vaginal discharge – wet mount preparation can help differentiate between the two
16) Fetal ultrasonography
• Fetus at 32 weeks should be ~32 cm fundal height
• U/S to identify possible fetal growth restriction - whenever there is a size-date discrepancy, its best to do an ultrasound
17) Testosterone
• ↑ testosterone → Hirsutism + irregular menses
● PCOS has elevated testosterone and LH:FSH at least >2:1
18) Mixed aerobes and anaerobe
• Postpartum endometritis – cesarean delivery, purulent lochia, uterine fundal tenderness, fever >24 hours
19) Antibiotic therapy
• Maternal fever + fetal tachycardia = suspicious for chorioamnionitis
• Management: broad-spectrum antibiotics (ampicillin + gentamicin) then delivery (cesarean delivery is not done in chorioamnionitis unless there is another indication eg, breech)
20. Haemophilus ducreyi
• Chancroid - painful, large deep ulcer with yellow/grey exudates, well-demarcated borders, and soft, friable base (bleeds easily)
• You “do cry” with ducreyi = painful
21) Acute respiratory distress syndrome
• Toxic shock syndrome secondary to Staphylococcus aureus
• Presents with fever, hypotension, diffuse red macular rash – systemic illness due to exotoxin release (TSS toxin-1)
• Common cause of morbidity/mortality in TSS is ARDS
22) Ovarian torsion
• One complication of cystic teratoma is ovarian torsion
• Variable mass densities cause intrinsically unstable suspension across the infundibulopelvic ligaments (cystic teratomas are large and their weight is not balanced causing them to rotate and cause torsion)
23) Indirect antiglobulin (Coombs) test
• Rh-negative mothers screened with Rh (D) type antibody test at initial prenatal visit (to make sure she doesn’t have Rh antibodies)
24) Pap smears annually
• CIN 3 requires 1 and 2 years post-procedural pap testing to rule out vaginal recurrence
● If patient had CIN 2 or greater, pap smear should be done annually for 20 years after diagnosis, regardless of hysterectomy
25) Administration of Rho (D) immune globulin
• Routine administration of Rho (D) immune globulin for Rh-negative pregnant mothers at 28 weeks gestation and within 72 hours postpartum
26) Biopsy of the mass
• Clear fluid = simple cyst
• Complex cyst – cystic component, cloudy fluid on aspiration, solid mass still present after aspiration – biopsy solid mass
• A simple cyst would resolve with aspiration and would follow-up in 2-4 months for
possible recurrence
27) Injury to the femoral nerve
• Compression of the femoral nerve under the inguinal ligament can occur with prolonged pushing and extreme hip flexion (lithotomy position during childbirth)
28) Serum antiphospholipid antibody assay
• Maternal evaluation for intrauterine fetal demise includes Kleihauer-Betke test, antiphospholipid antibodies and coagulation studies
• Antiphospholipid antibody syndrome (APS) is an autoimmune hypercoagulable state – causes miscarriages, stillbirths, preterm deliveries and preeclampsia
● Suspect it in this patient especially because she has a history of DVT
29) Cesarean removal of the fetus
• Intrauterine fetal demise – fetal death after 20 weeks, no fetal cardiac activity
• Management:
• 20-23 weeks – dilation and evacuation OR vaginal delivery (cesarean section by maternal
choice or prior classical)
• >24 weeks – vaginal delivery (cesarean section by maternal choice or prior classical)
• Complication: coagulopathy after several weeks of retention
30) Infection with human papillomavirus
• Condyloma acuminata (HPV 6, 11) – venereal warts
• Epithelial cells with irregular nuclear contour and distinct halo around the nucleus with
dense outer rim of cytoplasm (“sunny side up” egg)
31) Primary dysmenorrhea
• Cramping lower abdominal pain occurring immediately prior to or during menstruation; nausea, vomiting, diarrhea; normal pelvic examination
• Due to excessive prostaglandin production
• Managed with NSAIDs (not sexually active) or OCPs (sexually active)
32) No significant adverse effect
• No significant weight loss; US shows ~10-week gestation which is consistent with gestational age, patient is able to tolerate SOME food
• No evidence of fetal growth restriction
33) Uninhibited bladder contractions
• Urge incontinence – detrusor muscle hyperactivity
• Unable to make it to the bathroom when feeling need to void
34) Tighter glucose control
• Complications of maternal diabetes
• 1 st trimester: congenital heart disease, NTD, small left colon syndrome, spontaneous
abortion
• 2nd and 3rd trimesters: fetal hyperglycemia and hyperinsulinemia which leads to
polycythemia, organomegaly, neonatal hypoglycemia, macrosomia (shoulder dystocia,
brachial plexopathy)
35) Polyhydramnios
• Gestational diabetes → macrosomia + polyhydramnios = larger than expected fundal height
• U/S did not reveal evidence of multiple gestation
• Proper dating at 18 weeks
36) “What do you think is happening with your mother?”
• “Before you tell, ask”
• Before discussing potentially difficult situations, find out how the patient (in this case, family) perceives the medical situation
37) Myelomeningocele
• Neural tube defects cause increase in AFP
• Down syndrome cause decrease in AFP, estriol; increase inhibin, B-hCG
38) Reexamination after menses
• Fibrocystic breast disease – multiple breast masses that have cyclic premenstrual tenderness
• Examination after menses would likely demonstrate reduced size and tenderness of cystic masses
39) No screening indicated
• Pap smear required every 3 years (patient had pap test 8 months ago)
• X-ray of the chest is not a recommended screening test by USPSTF
• Low-dose CT scan for lung cancer is indicated at 55 years with >30-pack-year smoking,
current smoker, or quit in the last 15 years
• Mammogram not indicated because she had one 8 months ago
• Colonoscopy screening for colon cancer starts at age 50 with
40) There are no contraindications
• There are no contraindications for using levonorgestrel as emergency contraception (effective within 72hrs after intercourse)
● Migraine with aura is a contraindication to estrogen use
41) Progesterone
• Progesterone increases after ovulation (day 14) and is the predominant hormone in the luteal phase of the menstrual cycle
• LH surge occurs 36 hours prior to ovulation (day 14 in 28-day cycle), levels drastically fall
once ovulation occurs
42) Pelvic radiation therapy
• Uterine sarcoma is a very rare cancer of uterine smooth muscle or connective tissue and has a significantly increased risk with prior exposure to radiation therapy (patient has a history, 20 years ago)
43) Choriocarcinoma
• Recent pregnancy + ↑↑ HCG ≈ choriocarcinoma
● Choriocarcinoma generally occurs within 6 months of pregnancy
● Hydatidiform mole would show snowstorm appearance on ultrasound
44) Urethral culture for Chlamydia
• Chlamydia commonly causes urethritis
45) Laparoscopy
• Endometriosis = dyspareunia + pelvic pain + diarrhea + induration and nodularity on pelvic examination
• Diagnosis: direct visualization (laparoscopy) and surgical biopsy
• Treatment: medical (OCPs, NSAIDs), or surgical resection
46) Hemorrhagic corpus luteum cyst
• Day 20 in a 28-day cycle corresponds with the luteal phase
• Corpus luteum cysts – normal part of the menstrual cycle
• Have potential to grow up to 10cm and can bleed into itself
• As the cyst enlarges it may cause ovarian torsion
• Cyst may rupture causing internal bleeding and pain
47) Routine newborn screening
• Congenital hypothyroidism (CH) – hoarse cry, large fontanelles, large protruding tongue, umbilical hernia, dry skin, hypotonia
• Newborn screening for congenital hypothyroidism mandated in all 50 states
• Performed within 2-4 days after birth in the hospital (patients discharged before 48
hours are tested before discharge)
48) Amniotic fluid embolism
• Frothy pink sputum with pulmonary edema after complicated delivery with abruption placenta, DIC secondary to AFES
• DIC – thrombocytopenia, prolonged PT/PTT, decreased fibrinogen, increase D-dimer
(fibrin split products)
• Timelines is helpful
• This occurred right after cesarean delivery which is a risk factor
• Pulmonary embolism more likely after several days
49) Prolapse of the fetal umbilical cord
• Without cephalic presentation to fill pelvic inlet, there is potential for the umbilical cord to prolapse
50) Fetal platelet destruction
• Immune thrombocytopenia purpura (ITP) – autoimmune disease with antibodies directed against several platelet surface antigens
• Anti-platelet antibodies with attack the patient’s own platelets and will also cross the
placenta (because they’re IgG) and destroy fetal platelets
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