Obstetrics and Gynecology Notes for the USMLE Step 3 Exam - USMLE Forums
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Old 06-03-2011
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ObGyn Obstetrics and Gynecology Notes for the USMLE Step 3 Exam

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Parental right to kidís health: In some cases, you can keep information about a minor pt from their parents. These cases include pregnancy, contraception, STD, substance use, and emotional iussues.

Cervical Cancer: some RF include inutero exposure to DES.

Cervical Cancer screening: 3 years after onset sex or 18/21 (whichever is earlier). Risk for getting HPV (and thus cervical cancer) is lower in women if they donít have sex with men. Even if a woman is lesbian, should still get the regular screening schedule. Annual screening is the recommendation.

An adequate Pap smar should have endocervical or squamous metaplastic cells seen in the smear. If no endocervical cells are seen on a pap smear, should do follow up in 1 year for low risk women with hx of normal smear, whereas high risk women (abnormal previous smear, immunosuppresion), should have smear repeated in 4-6 months.

Cervical Pap revealing low grade squamous intraepithelial lesions (LSIL) or low grade cervical intraepithelial neoplasia (CIN1): These usually regress spontaneously, so just do expectant management. Should just do repeat cytology at 6 and 12 months, or HPV DNA testing at 12 months. If there is progression seen on the f/u, then treatment is indicated. If action is needed, the next step is always to do an excision, since this allows for histological examination.

High grade squamous intraepithelial lesion (HSIL): Includes CIN II and III, moderate/severe dysplasia, and carcinoma in situ. HSIL shoulod always be Rx with ablation or excision. Ablation can be done using cryosurgery or laser. Excision can be done using LEEP or laser/knife conization. LEEP is the TOC for HSIL, since itís accurate and low cost.

Bleeding is the most common complication after cervical conization (cone biopsy)., whether its cold knife or LEEP.

Atypical Squamous cells of unknown significance (ASCUS): If you see this on a pap smear, you should do HPV DNA testing. You do samples for both cytology and HPV DNA> Do cytology first, and if negative, no need for HPV DNA. If positive, should get HPV DNA. If the HPV DNA is a high risk type, do a immediate colposcopy. If test is negative, do repeat papin 1 year.

Cervical Cancer: HPV is strongly linked. Some RF include early initiation of sexual activity, multiple sexual partners, and high risk partners. Pap smear is effective screening. Screening should be started either at 18 yo (some say 21) or 3 years after initiation of sexual activity, whichever is earlier. This is because high grade cervical cytological changes donít happen until 3-5 years after HPV exposure.

Surgical Rx of CIN before conception increases incidence of cervicalincompetence and preterm birth by 2-3x. If a pregnant pt has PMH of this, should measure length of cervix in the second trimester. Repeated cervical exams to evaluate for cervical stenosis will be needed in the 2nd trimester. If a pt has hx of pregnancy loss after cervical surgery, then consider placing a cervical cerclage in the 2nd trimester. This will prevent loss of pregnancy d/t cervical incompetence.

Condylomata Acuminata (anogenital warts): can manifest with pruritis, bleeding, burning, tenderness, vaginal discharge, and pain. Large lesions can interfere with defecation, intercourse, and delivery. Looks like warty projections on the post wall of vagina. Another description is a flesh colored, hyperkeratotic papules. If you apply acetic acid to the lesions, they will turn white. These are caused by HPV, and is the MC viral STD in the USA. Rx includes chemical, immunotherapy, and surgery. First, try the chemical destruction (trichloroacetic acid application). This will destroy the lesion, although the clearance rate is low and repeated applications are often necessary. Safe for pregnancy, no intervention needed during delivery if lesions are present. Podophyllin has similar effect to trichloroacetic acid, but is contraindicated in pregnancy.

Gestational DM: All pregnant pt should be screened btw 24th and 28th weeks using 50 gm glucose tolerance test. You give 50 gm of glucose, then check levels 1 hour after. If on this first test, pt has a blood glucose > 140, should then give them a 3 h glucose tolerance test after ingesting 100 gm. If in this test, you get 2 or more blood glucose values > 105, 190, 165, and 145 at 0, 1, 2, and 3 hours respectively, then youíve dx gestational DM. The recommendation for a fasting blood glucose value on pregnant DM pt should range btw 60-90., and postprandial should be < 120. NPH insulin can e used. If this still doesnít workm, you can add rapid acting insulin (regular/lispro) if theer are persistent postprandial suboptimal glucose levels. Glargine insulin is teratogenic in experimental animals.

HIV screening in pregnant pt: strongly recommended, but not required by law, itís up to the pt.

Pt on OCP who wants to get pregnant: Pregnancy will be delayed for about 1 month after stopping OCP. There is no associated risk of infertility.

Even if somebody if on OCP, using barrier in addition to that is recommended d/t prevent STD.

Pt on OCP with hypoTH: Estrogen of OCP will increase TBG levels, which will decrease the free T4 (and increase total T4). Person should increase the dose of levothyroxine.

Norplant: 6 capsules of levonorgestrel which are placed subdermally, generally in the upper arm. Offers contraceptive protection for 5 years. MC complication is menorrhagia (prolonged vaginal bleeding during periods), which happens in 30% of cases. Less commonly, VTE, PE< TTP, stroke can happen.

Emergency Contraception: levonorgestrel is the recommended method. It has maximal efficacy when used the first 12 hours after intercourse, good efficacy within 48 hours, and appears to work even up to 120 hours after intercourse.

Pregnancy Rates for various contraceptives: Best are implantable and injectable contraceptives (implantable levonorgestrel and depot medroxyprogesterone acetate) have the lowest rate of pregnancy (< 2-3%). Barrier methods (diaphragm, cervical cap, male condom) have pregnancy rate of 12-14% mostly d/t inconsistent or incorrect use. OCP are very effective, but rate is higher than with implantable and injectable contraceptives. Spermicides if used alone have a high failure rate.

OCP contraindications: Absolute ones include hx of VTE/stroke, acute liver disease, hx of estrogen dependent tumor, pregnancy, abnormal uterine bleeding, heavy smokers who are older than 35, and hypertriglyceridemia.. Relative contraindications are migraines, poorly controlled HTN, and anticonvulsant drug therapy.

Anti-seizure medications lower efficacy of OCP by induction of P450. All antiseizure meds lower efficacy except gabapentin and valproate.

OCP: if taken perfectly (never miss a pill, takes pill at same time each day, no vomit/diarrhea), theer is 99.9% efficacy. Risk of fetal anomalites /2 use of OCP during pregnancy is negligible.

Depot medroxyprogesterone: can help decrease menstrual flow and produces temporal amenorrhea, diminishing episodes of blood loss in the pt. This can be useful if pt has a hematologic disorder. It also dereases the risks of PID and endometrial cancer.

Exercise induced amenorrhea: Females who maintain a lower weight or BMI may become hypoestrogenic, which causes amenorrhea. In addition, the low estrogen also predisposes them to developing osteopenia and even osteoperosis. Spontaneous fractures have been seen. Rx with gain weight, or HRT and Ca/Vit D if calories not possible. Remember that exercise induced amenorrhea is a diagnosis of exclusion (always check TH and prolactin). The hypoestrogenemia is d/t a decrease in the pulsatile secretion of LH.

Vulvovaginitis: Common infectious causes are candidiasis, bacterial vaginosis, and trichomoniasis. A good technique is saline and KOH prep for microscopy. On this, candidiasis will show pseudohyphae. Bacterial vaginosis will show clue cells. Trichomoniasis will show motile trichomonads and lots of PMN cells.

Bacterial Vaginosis: Imbalance in the normal vaginal bacterial flora associated w/ increased numberw of Gardnerella various bacteria. Dx when 3 of the following criteria are present: homogenous vaginal discharge, vaginal pH > 4.5, amine odor with KOH application, or presence of clue cells on microscopic exam of wet mount. Many women are asymptomatic, but BV often causes an excessive white/gray vaginal discharge or foul/fishy odor, especially after intercourse (d/t male semen). BV has association w/ pregnancy complications (spontaneous abortion, PROM, preterm delivery). Adverse outcomes of pregnancy are not improved when BV is screened for or treated in an average risk asymptomatic woman, so asymptomatic pt should be monitored but not treated. If you do decide to Rx, the Rx is oral metronidazole or clindamycin. If a pt is symptomatic or high risk (for preterm labor), then you should Rx the condition.

Tcichomoniasis: If symptomatic, characterized by a copious frothy gray-green discharge, fishy odor, vulvar and vaginal pruritis, or dysuria. On a smear, youíll se epear shaped motile organisms. Vaginal and cervical petechiae (strawberry cervix) can sometimes be seen. Rx is indicated for all women dx with trichomoniasis and their partners. Rx is with metronidazole. While it enters breast milk, no known side effects. General recommendation is to Rx with metro 2g PO for 1 dose, then breastfeeding should be d/c for 12-24 hours after the dose.

Atrophic Vaginitis: MCC of postmenopausal bleeding. Should always r/o more serious stuff (endometrial cancer) by endometrial biopsy before diagnosing this. Atrophic vaginitis is characterized by vaginal dryness, burning, dyspareunia, and reduced vaginal secretions, and vulvar pruritis. Sometimes, urinary symptoms might be seen. Pelvic exam shows loss of labial labial fullness, pallor of vaginal epithelium, and decreased vaginalsecretions. This is usually d/t declining estrogen levels. You might also see it in non-menopausal women, where estrogen production can be stunted by radiation rx, chemotherapy, immunologic disorders, and lactation. Rx with HRT, lubricants, or transvaginal estrogen replacement (cream, hrmone releasing rings).

Folic acid for pregnancy: Should start 0.4-0.8 mg/day of folic acid supplementation at least 1 month before conception.

First prenatal visit: should get blood type + antibody screen, Rh, CBC, rubella status, screen for syphyliss, chliamydia, and HIV, hep B surface antigen, U/A + culture, and pap smear. On subsequent visit, should check BP, weight, uterine fundal height, fetal heart tones, fetal presentation and activity, and urine glucose and protein. This discovers 50% of fetuses w/ growth abnormalities, prevention of 70% of eclampsia episodes, and detection of 80% of breech presentations.

Gestational Thrombocytopenia: benign condition, defined by the presence of 5 criteria. They include mild and asymptomatic thrombocytopenia, develop late in pregnancy, no hx of thrombocytopenia outside of pregnancy, no evidence of fetal thrombocytopenia, and spontaneous resolution once the child is delivered. Rx conservatively, and f/u to make sure the thrombocytopenia resolves after pregnancy.

HELLP syndrome: hemolysis, elevated liver enzymes, and low platelets. This is an ominous variant of severe preeclampsia, and is responsible for 20% of cases of thrombocytopenia in pregnancy. Rx with Mg sulfate to reduce seizure risk.

Asymptomatic bacteriuria in pregnant pt: should be Rx promptly, since it can quickly progress to cystitis and pyelonephritis. These 2 conditions are associated with preterm labor and premature birth. E. Coli is the most common, but S. Agalactiae can also be present. S. agalactiae indicates GBS colonization, which should be Rx with penicillin G or cephalexin.

Rho D immune globulin (anti-D immune globulin): Give at 28 wks if needed (father unknown status, mom is Rh Ė with no anti-D antibodies). Also, if there is feto-maternal hemorrhage during the birth (ex placental abruption), then you should consider giving anti-D. Do a rosette test. This helps determine presence of feto-maternal hemorrhage. If negative, than the standard dose of anti-D should be given. If positive, dose of anti-D should be increased accordingly. Eisenmenger Syndrome (reversal of L to R shunt) in pregnant pt: There is high risk of maternal and fetal deterioration. There is a 30-50% risk of mortality. There is alos higher risk of spontaneous abortion, preterm delivery, and fetal mortality. All pregnant pt with Eisenmenger syndrome are advised to abort the pregnancy.

Rh incompatibility can only happen if the mother is Rh Ė AND the father is Rh +.

Subchorionic hematoma: Bleeding btw the endometrium and gestational sac. Appears on US as a crescent shaped hypoechoic region adjacent to the gestational sac. MC source of first trimester bleeding. Manage expectantly until symptoms resolve or additional findings develop. Should re-evaluate in 1 weeek. There are no known therapeutic Rx for the condition. Pregnant women with this are at increased risk for spontaneous abortions.

Exercise during pregnancy: Should be continued as long as its comfortable. Avoid scuba diving, very stressful sports (distance running), and sports w/ risk of falling (ski).

Pruritis in pregnancy: Pruritis is very common during pregnancy. It affects up to 20% of pregnant women. Symptom may be a manifestation of pregnancy associated dermatosis. Usually involves the scalp, anus, vulva, and abdomen. Can just Rx symptomatically if needed (topical steroid, antihistamines).

Papular urticarial papules and plaques o fpregnancy (PUPPP): common pregnancy associated dermatosis that is characterized by erythematous papules within the striae gravidarum. Rx with tomical steroids.

Herpes gestationis (aka pemphigoid gestationis): uncommon blistering dermatosis that I sassociated with pregnancy. May first manifest as abd pruritis (and looked on as benign). Eventually, a rash develops. Rash is localized around umbilicus, and is characterized by papules, urticarial plaques, and vesicles. This is an autoimmune disorder (NOT caused by a virus). Itís an autoimmune disease. Thus, rx with corticosteroids mainly. For milder cases, just use triamcinolone (weaker steroid). In more advanced cases, systemic steroids are employed.

As a side note, topical steroids are usually the correct choices for answers asking about Rx of pregnancy associated dermatoses.

Serum AFP: usually measured during 16-20 wks gestation to detect open neural tube defects. An elevated AFP (> 2-2.5) is present in open spina bifida and anencephaly. This can also be present in other fetal abnormalities, like congenital nephrosis, ventral wall defects, etc. If you get an elevated AFP but itís not greater than 7.0, then do a repeat AFP. 30% of the repeat tests will end up being normal. If repeat values are high or if the AFP is > 7, then an US should be done to confirm gestational age and look for neurologic abnormalities. Amniocentesis becomes necessary only if the US is normal or inconclusive despite highi AFP levels.

Hemophilia A: X-linked recessive disorder. Leads to deficit in coag factor VIII. For a female to be a carrier, there must have been a FH in the past somewhere.

Chorionic villus Sampling: One complication of it is transverse limb abnormality. Risk depends on age of gestation, with risk being greatest when < 9 weeks, and lowest when > 11 wks. Risk doesnít depend on skill of operator, route of procedure, or gauge of needle.

HIV + pt who becomes pregnant: If pt is already on HAART, should continue the regimen if pregnancy is confirmed after 1st trimester. Zidovudine especially is nice because itís been shown to reduce vertical transmission. If pregnancy is ID early in the 1st trimester, can d/c HAART for remainder of 1st trimester then start it afterwards. Ultimately, the preferred mode of delivery in all HIV + women is elective C-section. Efavirenz and delavirdine are teratogenic. Studies have shown that HIV can be transmitted through breast milk, so these pt should not breast feed their kids. As a side note, there is some evidence that HAART can be transmitted into the breast milk as well. So in third world countries where formula is not easily accessible, there is some justification that continuing a pt on HAART while breastfeeding might not be as bad. Nevertheless, in the USA just feed with formula.

Hep B during pregnancy: Not associated with increased mortality or teratogeneciteratogenicity. However, perinatal transmission of virus is a concern in women with acute HBV infection (HBsAg, IgM anti-HBc, and HBeAg) in the third trimester and in those who are chronic carriers of the virus (anti-HBe, anti-HBs, and IgG anti-HBc). Admin of hep B vaccine and hep B Ig to the infant within 12 hours of delivery would be preferred means of managing the womanís condition. There is no evidence that C-section reduces the rate of maternal-infant transmission of HBV.

Premenstrual Syndrome (PMS): behavioral and physical symptoms that occur in the 2nd half of menstrual cycle. Huge variability in presentation (> 150 symptoms have been described). Premenstrual dysphoric disorder (PMDD) is a severe formof PMS characterized by the prominence of anger and irritability. SSRI are the first line therapy for PMDD. FLuoxetine has been shown to be good. About 15% of pt are resistant to fluoxetine. In such instances, alprazolam is a good alternative, and isgiven in luteal phase of menstrual cycle. Increasing the dose of fluoxetine in pt who are refractory to the initial Rx hasnít been shown to help. PMS has a significant association with psychiatric disorders (esp mood and anxiety disorders). Women who present with PMS have much higher incidence of depression in the past, and also have greater incidence of depressive episodes in the future.

Stress Urinary Incontinence: urine leaks with increased intraabd pressure. Leakage that occurs instantaneously with coughing is virtually diagnostic of stress urinary incontinence. This is d/t pelvic floor weakness, leading to loss of vaginal support d/t pelvic floor trauma during childbirth or vaginal atrophy following menopause. Can Rx with pelvic floor excercises.

Breech presentation: Management depends on which week it is that you see it. Before 28 wks, most breech presentations will become cephalic by the 34-36 weeks. After 36 weeks, only 6% of fetuses will be in breech position, and about 1/3 of them will convert to cephalic position. External cephalic version shouldnít be attempted until after 37 weeks gestation. At that time, version should onlybe done if there are no contraindications to vaginla delivery and fetal well being has been established. C-section should be done if these criteria arenít met.

Secondary Amenorrhea. Dx by missing periods for > 3 months if previously regular, and > 6 months if previously irregular. FSOM is always pregnancy test. Assuming its negative, next step is to do a progesterone challenge test. If test is + (bleeding after 2-3 days), then pt has a progesterone deficiency, for which the MCC is anovulation (can be idiopathic, TH, or hyperPL). If the progesterone challenge test is negative (no bleeding), then next step is the estsrogen and progesterone challenge test. If this is positive (bleeding), then there is a deficiency of estrogen (possibly d/t central or primary ovarian issue). If itís a central cause there will be low FSH. If itís the ovarian problem, FSH will be high. If ther is still no bleeding with the estrogen/progesterone challenge, then should r/o outflow tract obstruction.

Dysfunctinal uterine bleeding: Presents with sudden onset of heavy vaginal bleeding. Usually d/t anovulation. Itís the lack of ovulation, leading to hormonoal imbalance of progesterone which leads to endometrial overgrowth that eventually outgrows its blood supply leading to an irregular sloughing that can bleed a lot. Rx involves hormonal therapy to stabilize the endometrium. Estrogen should be used in all pt who are actively bleeding since it promotes hemostasis. High dose estrogen followed by progestin is the TOC.

Downís syndrome: Various screening mechanisms are available. At 10 weeks, you can check the nuchal translucency thickness (suggestive, but not diagnostic). In the 2nd trimester, you can do a quadruple screen (AFP low, hCG, unconjugated estriol, and inhibin A) which can detect 80-85% of cases. The only 100% detection method is to do karyotyping with an amniocentesis.

Chlamydia: Major cause of infertility, PID, and ectopic pregnancy in women. Always screen at initial prenatal visit, and in women under 25 or at increased risk should have repeat testing in 3rd trimester. Chlamydia endometritis during pregnancy can lead to chorioamnionitis and premature delivery of the fetus. Untreated infection during pregnancy can also lead to conjunctivitis and pneumonia in the newborn baby. Itís an STD, so sexual contact was somehow involved In getting it. Reactivation of latent Chlamydia infection during pregnancy doesnít happen. Best Rx is azithromycin (1 g PO single dose) or doxycycline (100 mg PO bid 7 days). However, doxycycline, fluoroquinolones, and erythromycin are contraindicated in pregnant pt. Thus in these pt, use erythromycin (500 mg PO qid for 7 days) and amoxicillin (500 mg PO tid for 7 days).

Tb in pregnancy: Standard regimen is INH, rifampin, and ethambutol. If there is chance of MDR, add pyrazinamide to it. There is a lack of data regarding teratogenicity of pyrazinamide, so itís not used in pregnant women unless there is strong evidence that MDR is present.

Rectocele: displacement of the rectum through the posterior vaginal wall defects. Usually caused by damage to rectovaginal septum incurred through vaginal childbirth. Presents with pelvic pressure/heaviness, LBP, and constipation. You can demonstrate the protrusion through the wall while bearing down on a gyne exam. Surgery is the best Rx, but women who are poor surgical candidates can use pessaries (structures designed tosuppoort the vaginal wall). Pessaries should only be used in conjunction with vaginal estrogen. Without it, these can cause chronic discharge and bleeding secondary to injury of the vaginal tissues.

Preeclampsia: Having a hx of it increases the possibility in future pregnancies. Risk is at least 7x higher, but is not guaranteed.

Menopause: There is rapid loss ofbone mass following menopause. Weightbearing excercises, Ca and vit D supplementation can prevent postmenopausal bone loss. HRT is necessary if pt has milder symptoms. There are lots of CV side effects with HRT, so avoid unless necessary.

Perimenopause: the time extending from 2-8 years preceding menopause until 1 year following the last menstrual period. This state is associated with normal ovulatory cycles interspersed with anovulatory cycles that vary in length. The hormone levels are inconsistent during this time, and estrogen is often unopposed, which leads to irregular menses and heavy breakthrough bleeding can happen. If a pt complains of an episode of hjeavy dysfunctional bleeding or of > 6 months of irregular menses, then endometrial biopsy or a vaginal US to ensure endometrial thickness stays < 4 mm is indicated.

CF causing infertility: 20% chance of being infertile in a female with CF. Mostly itís d/t the malnutrition which can cause secondary amenorrhea. Also, cervical mucus in CF pt is thick and tenacious. In males, 95% of themwith CF are infertile. Sperm transport in these pt is impaired.

Nippl eDIscharge: Uusally benign, but you want to know whether the discharge is spontaneous or provoked, and whether itís unilateral or bilateral. In general, malignant causes have a spontaneous, unilateral and guiac + or grossly bloody discharge. Other benign causes tend to have a bilateral nipple discharge. All pt with a unilateral spontaneous nipple discharge should get mammogram. If something is suspicious on mammogram, go a FNA or open breast biopsy, and examine cytology.

Androgen Insensitivity Syndrome (AIS): Presents with primary amenorrhea, bilateral inguinal masses, and breast development w/o pubic or axillary hair. Genotype is 46 XY, but there is a female phenotype. There are no Mullerian structures (uterus, fallopian tube), and vagina ends in a blind pouch.

Pregnant pt with UTI: first line is cephalexin, amoxicillin, or nitrofurantoin. Fluoroquinolones can cause tendon rupture in kids. Tetracycline can cause dental stsaining and reduced bone growth in the fetus. Bactrim can cause hyperbilirubinemia and kernicterus in the fetus. If a women develops pyelonephritis, should admit to hospital and give IV ceftriaxone or augmentin until afebrile for 24-28 hours. If pt develops pyelo, then for the remainder of the pregnancy they should be given low dose abx prophylaxis (cephalexin or nitrofurantoin) and get occasional urinary evals. If pyelonephritis doesnít resolve, do a renal US to look for perinephric abscess or renal calculi.

Imperforate Hymen: Presents with cyclic pelvic/abd pain with primary amenorrhea. Sometimes, a small suprapubic mass (uterus containing retained menstrual blood) can be palpated. Perineal exam will show a bulging, bluish ,membrane between the labia. The blue color is d/t blood sequestration behind the hymen (aka hematocolpos).

Studies have shown that adolescents in the private practice setting are concerned about the use of OCP leading to weight gain.

Spinal Bifida: uncommon condition (1/1000) that is characterized by a cleft in the spinal column, which can be open or covered by skin. Folic acid supplementation is effective in reducing the risk for developing spina bifida. Risk is always present. If you have a first degree relative with spina bifida, your chances of having a child with it are increased, but still low.

Myelomeningocele: presents with protrusion of tissue in the midline lumbar region, with decreased muscular strength in both legs. Most pt with myelomeningocele also have hydrocephalus and CHiari II malformation, so urgent neurosurgery eval is needed. Surgical closure of the defect must be done within 24-48 hours to prevent infections of the CNS.

Epilepsy in pregnant pt: Although anti-epileptic drugs are associated with increased risk of congenital abnormalities, over 90% of women with epilepsy have normal pregnancy. In addition, there is no agreement about which drug is the most/least teratogenic, so the drug that is working best for the pt when she gets pregnant should be continued. You should screen early for neural tube defects with serum AFP screening, amniocentesis and US are also important. In asddition, high dose (4 mg/day) folic acid is recommended prior to conception and 1st trimester, since phenytoin and valproic acid might lower contration of folate. Breast feeding is not contraindicated while taking anti-epileptics.

Seat belts in pregnancy: Both lap and shoulder straps should be used. There are no adverse events associated with using seat belts.

Anticoagulation in pregnancy: Generally pt on long term anticoagulation are on warfarin, which is contraindicated in pregnancy. Pt planning to get pregnant should stop warfarin and get LMWH or subcutaneous unfrationated heparin.

HRT: While older PMS women on HRT are at increased risk for CV events, the same thing doesnít apply to younger women with premature ovarian failure. HRT (conjugated equine estrogen and medroxyprogesterone) can be used in younger patients with careful monitoring without excess cardiovascular risk. You donít want to give only estrogen (unopposed) in a pt with an intact uterus (risk of endometrial cancer).

Treatment decision for critically ill newborns: Life sustaining treatment may be withheld or withdrawn from a critically ill infant if the potential for joy is overwhelmed by pain and suffering expected to be endured by the child. Parents have the right to withhold or withdraw life support from a critically ill newborn if their decision is in the best interest of the child. If a parentís decision is not in the best interest of the child, you might have to get a court order to treat.

Diagnosis of a pregnant woman with hyperTH: Must have high free T4, and TSH must be <0.01. Gestational Transient thyrotoxicosis is the dx if T4 is mildly increased, and TSH is slightly decreased at the end of the first trimester. GTT doesnít happen after 14 weeks.

Breast Masses: Most palpable masses in < 35 yo are benign, MC fibrocystic disease or fibroadenoma. Symptosm of fibrocystic disease can get worse during pregnancy d/t hormonal changes. Features suggestive of malignancy include immobile, hard, single, irregular borders. A cystic mass sho9uld always be eval with FNA. If fluid is bloody, send for cytology. If not bloody, re-eval in 4-6 weeks.

Sickle cell disease: pt with this are at high risk for complications during pregnancy, so make sure that they have good contraception. Depotmedroxyprogesterone is a good hoice. Use of combined OCP is controversial. Although no studies have shown that SCD pt who use OCP have higher chance of VTE, many still donít use it. History of stroke is always a contra to using OCP. IUDs should be avoided in SCD pt. IUD can increase uterine bleeding, worsening the anemia of SCD.

PID: Presents with fever, chills, and lower abd pain. Vaginal discharge can be present. Exam shows positive cervical motion and adnexal tenderness. Some peritoneal signs might be present (mild). RF for PID are: oral contraception, no barrier contraception, multiple sexual partners, age < 35 yo, AA. Rx with cefotoxin + doxyycycline or ceftriaxone + doxycycline.

Retroverted Uterus: Found in 11% of population. There is no increased risk of abortion. Usually will reposition to anterior position btw 12-16 weeks, but if it doesnít happen automatically, physician has to manually reposition it to avoid uterine incarceration in the sacral region. Surgery is recommended only for p with dyspareunia related to retroverted uterus. Sometimes, chronic PID or endometriosis can cause a retroverted uterus.

PCOS: Presents with infertility, hirsutism, irregular menses, obesity, and increased ovarian volume measured by US. The cause of infertility is anovulation. Weight reduction in obese/overweight pt can restore ovulation, decrease androgen production, and help with pregnancy. Even a moderate reduction in weight can restore fertility.If weight reduction fails to restore ovulation, clomiphene citrate can be tried.

Low energy electromagnetic fields (video displays, power lines) have not been demonstrated to be dangerous to fetuses.

Syphilis in pregnancy: Any woman with positive VDRL/FTA-ABS tests are considered infected until proven otherwise. Untreated syphilis has a very high prevalence (80%) of adverse fetal outcomes (MR, stillbirth, neonatal death). Rx with penicillin. If pt has pen allergy, do pen desensitization. By giving incremental doses of oral penicillin V.

Adolescents are at increased risk of adverse pregnancy outcomes: These include increased perinatal mortality, preterm delivery, and premature/low birth weight). However, there is no risk of increased congenital malformations. There is risk of the baby having a future cognitive disorder, however.

Cysts during pregnancy: 70% of non-pregnant women with purely cystic pelvic masses < 10 cm in size have spontaneous resolution. Surgical removal during pregnancy is indicated for adnexal cysts that are > 5 cm, and persist over time (d/t high risk of rupture, hemorrhage, torsion, which can lead to preterm delivery). So surgery during 2nd trimester to decrease chance of fetal complications.

Infertility: male cause accounts for 20-30% of causes. Semen analysis is the first evaluation. Identification of azoospermia and severe oligospermia are causes if infertility. Anovulation is another potential cause of infertility. This can be evaluated using basal body temperature measurements, serum progesterone, or serum prolactin measurement. Measure the progesterone at mid-leutal phase. Hysterosalpingography is used to detect tubal and uterine abnormalities.

Septate Uterus: formof mullerian fusion defect that can cause significant fertility problems. Raises risk of poor implantation on an inhospitable surface. Surgical removal of the septum has been shown to be effective in treating 2nd trimester complications, but not for correcting first trimester complications. Hysteroscopy metroplasty is an endoscopy surgery that can be used to treat it.

Tetanus: Give toxoid to ppl with dirty wounds who got their last dose > 5 years ago, and clean wounds who got last dose > 10 years ago. In addition, pregnant women who have not completed a 3 dose primary immunization series or a booster in the last 10 years should be given a combination of tetanus-dpitheria toxoids. Tetanus immune globulin should be given to ppl who have gotten < 3 doses of tetanus vaccine or with unknown immunization status. Pregnancy doesnít change any of these recommendations.

Endometriosis: dysmenorrheal, dyspareunia, and infertility. Mostly involves the ovaries, broad ligaments, uterus, fallopian tubes, and sigmoid colon. Thus, there is also a risk of intestinal obstruction. This condition is not a RF for breast or cervical cancer.

Endometriosis: Presence of endometrial tissue in the ovaries, fallopian tubes, or other abnormal sites, causing pelvic pain and infertility. Consider it strongly in pt who experience dysmenorrheal, after years of painless menstruation. Dx is hard, and best done with laparoscopy to visualize the implants. Can Rx with NSAIDs, GnRH analog, danazol (synthetic androgen), or oral contraceptive. S\Surgery involves removal of lesions.

Mild Preeclampsia
- Either BP > 140/90 or increase over pre-pregnant by > 30/15
- Proteinuria > 300 mg
- Nondependent edema (face or hands)
- Tx: induce labor if at term, or if unstable preterm, or if lung development in fetus is confirmed
o Betaemethasone: enhance lung maturity
o Start Mg SO4 for seizure prophylaxis during labor, continue 12-24 h post delivery

Severe Preeclampsia
- BP > 160/110 + proteinuria > 5 g OR organ manifestations as listed above
- Tx: overall goals are to prevent eclampsia, lower mom HTN, deliver the baby
o Initial: MgSO4 to prevent seizure, hydralazine for BP
o Once stable: see gestational age of baby
ß 24-32 wk: wait for beclamethasone and more maturity
ß > 32 or organ failure signs: deliver immediately
- pt. may worsen immediately postpartum
o keep BP down, use MgSO4 for 24 h post delivery
o if have HELLP, thrombocytopenia may worsen: give steroids to hasten return to normal levels

Eclampsia
- increased DTR is an ominous sign that preeclampsia might be progressing to eclampsia
- grand mal seizures in pre-eclampsia pt not d/t other causes
- having severe pre-eclampsia is NOT a prerequisite
- MCC death of mom in eclampsia is intracerebral hemorrhage
- Clinical S/S
o Seizure can come anytime relative to labor and delivery
o Tonic clonic, and may or may not have aura
o Retinal hemorrhages is an extremely ominous sign, since it could mean that vascular damage has happened in other organs.
o Microangiopathic hemolytic anemia is seen, but itís not necessarily ominous
- Treatment
o Main goal is to deliver ASAP. Mg prevents further seizures, but doesnít stop a current seizure.
o Manage seizure, lower BP, prevent more seizures
o Hydralazine or labetalol to quickly lower the acute increased BP
o MgSO4 for seizures: as good as or better than anticonvulsants
ß Initiate at time of diagnosis, continue for 12-24 h after delivery
ß Get to therapeutic level w/o OD
ß OD treat w/ IV CaCl or Ca gluconate for cardiac protect
Signs OD: dyspnea, loss DTR, hyporeflexia (first sign)
o Treat mom will treat fetus
o Only deliver baby once pt is stable: NSVD is fine, only c-section of Ob indications are there

Pregnancy risk category C: Either 1) studies in animals have shown adverse effect, but no studies have been done in pregnant women, or when 2) no studies have been done on animals or pregnant women.

Risk category B: 1) animal studies have not demonstrated fetal risk, but no controlled studies have been done in pregnant women, or 2) animal studies have shown adverse effect that wasnít confirmed in studies on pregnant women.

Risk D: There is evidence of human fetal risk, but benefits might possibly outweigh the risk.

Risk A: studies have shown no increased risk of fetal abnormalities.

Risk X: studies in anomals or humans have shown fetal abnormalities, and risk of use will outweight any benefit.

Turnerís syndrome: Generaly pt have primary amenorrhea, but ovarian function and morphology is highly variable. Some women might become pregnant, but the changces are very low.

Steroid therapy for preterm labor: reduces risk of infant RDS and intraventricular hemorrhage. 2 commonly employed regimens are btamethasone or dexamethasone administered intramuscularly. Should be given to any pregnant owoman from 24-34 wks gestation with intact membranes who are at high risk of preterm delivery (contractions, cervical dilation).

Uterine Prolapse: usually seen in multiparous, postmenopausal woman with hx of multiple vaginla deliveries. Presents with sensation of pressure or heaviness in pelvic area, which is relieved by lying down and aggravated by prolonged standing or exertion. There may be a visible mass at the introitus. In chronic cases, pt might have bleeding or discharge from ulcerative, superficial epithelium. All symptomatic pt should have surgical correction of the defect in the pelvic support.

Nephrolithiasis: US is test of choice to detect in pt who should avoid radiation exposuire. Helical CT is best choice, but CT has radiation.

Arrest of active phase of labor: cervix is dilated and effaced, but over some time dilation doesnít increase and the fetal descent stays at the same station. In nulliparous women, the MCC of arrest is hypotonic uterine contractions. Other things that might cause arrest include pelvic anatomy, fetus size, and fetal presentation. For pt with problem with uterine contractions, augmentation of labor using oxytoxin is the most appropriate next step.

Postpartum endometritis: polymicrobial infection of the pregnancy endometrium characterized by fever, uterine tenderness, foul smelling vaginal discharge, and leukocytosis. Presents a couple days after delivery. Rx is with clindamycin and gentamicin. Metronidazole is contraindicated in breastfeeding mothers. Endometritis happens most often after a C-section (especially if labor started already or after the membranes ruptured). The route of delivery (C-section vs vaginal) is the most important RF in development of endometritis.

Post partum hemorrhage: MCC is uterine atony. FSOM is to do a pelvi eexam to look for any retained placental fragments. If there are no retained POC, then start doing a manual uterine massage to sitmulate the uterus to contract and stop the bleeding. If bimanual doesnít help, then give them IV oxytocin.

Poor glycemic control in pregnant patients: Some risks for the fetus include macrosomia, hypoCa, hypoglycemia, hyperviscosity, respiratory difficulty, CHF, and cardiomyopathy. The MC cardiomyopathy presenting in babies of these mothers is hypertrophic interventricular septum, leading to ventricular outflow obstruction. This can even present as CHF. Rx this heart condition by just observe and do conservative management. Defect oftens correct spontaneously

Shoulder dystocia: failure of fetal shoulders to pass through maternal pelvis once the fetal head has been delivered. It is dx when the ant shoulder cannot be delivered with mild, downward pressure. RF include macrosomia and maternal DM, and obesity. When it happens, the mother should be told not to push, while you attempt to reposition the fetus. You should give suprapubic pressure after repositioning. If that doesnít work, then you can try McRObertís maneuver.

Delivering a twin: If the fetal heart rateis reassuring, then the 2nd twin doesnít have to be delivered within a fixed time frame after the first twin. Once the first twin is delivered, assess the position and HR of the 2nd twin. If labor has halted, then oxytoxin should be administered.

Ascities: Common causes are hepatic cirrhosis, cancer, CHF, peritoneal tb, pancreatic disease. Can narrow the ddx by checking the serum to ascetic fluid albumin gradient (SAAG). To get this value, you subtract the ascetic fluid albumin from the serum albumin. If SAAG >= 1.1, then there is portal HTN, indicating cirrhosis, CHF, or alcoholic hepatitis. If SAAG < 1.1, then causes include peritoneal tb, peritoneal carcinomatosis, nephritic syndrome, and pancreatitis.
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Parental right to kidís health: In some cases, you can keep information about a minor pt from their parents. These cases include pregnancy, contraception, STD, substance use, and emotional iussues.

Cervical Cancer: some RF include inutero exposure to DES.

Cervical Cancer screening: 3 years after onset sex or 18/21 (whichever is earlier). Risk for getting HPV (and thus cervical cancer) is lower in women if they donít have sex with men. Even if a woman is lesbian, should still get the regular screening schedule. Annual screening is the recommendation.

An adequate Pap smar should have endocervical or squamous metaplastic cells seen in the smear. If no endocervical cells are seen on a pap smear, should do follow up in 1 year for low risk women with hx of normal smear, whereas high risk women (abnormal previous smear, immunosuppresion), should have smear repeated in 4-6 months.

Cervical Pap revealing low grade squamous intraepithelial lesions (LSIL) or low grade cervical intraepithelial neoplasia (CIN1): These usually regress spontaneously, so just do expectant management. Should just do repeat cytology at 6 and 12 months, or HPV DNA testing at 12 months. If there is progression seen on the f/u, then treatment is indicated. If action is needed, the next step is always to do an excision, since this allows for histological examination.

High grade squamous intraepithelial lesion (HSIL): Includes CIN II and III, moderate/severe dysplasia, and carcinoma in situ. HSIL shoulod always be Rx with ablation or excision. Ablation can be done using cryosurgery or laser. Excision can be done using LEEP or laser/knife conization. LEEP is the TOC for HSIL, since itís accurate and low cost.

Bleeding is the most common complication after cervical conization (cone biopsy)., whether its cold knife or LEEP.

Atypical Squamous cells of unknown significance (ASCUS): If you see this on a pap smear, you should do HPV DNA testing. You do samples for both cytology and HPV DNA> Do cytology first, and if negative, no need for HPV DNA. If positive, should get HPV DNA. If the HPV DNA is a high risk type, do a immediate colposcopy. If test is negative, do repeat papin 1 year.

Cervical Cancer: HPV is strongly linked. Some RF include early initiation of sexual activity, multiple sexual partners, and high risk partners. Pap smear is effective screening. Screening should be started either at 18 yo (some say 21) or 3 years after initiation of sexual activity, whichever is earlier. This is because high grade cervical cytological changes donít happen until 3-5 years after HPV exposure.

Surgical Rx of CIN before conception increases incidence of cervicalincompetence and preterm birth by 2-3x. If a pregnant pt has PMH of this, should measure length of cervix in the second trimester. Repeated cervical exams to evaluate for cervical stenosis will be needed in the 2nd trimester. If a pt has hx of pregnancy loss after cervical surgery, then consider placing a cervical cerclage in the 2nd trimester. This will prevent loss of pregnancy d/t cervical incompetence.

Condylomata Acuminata (anogenital warts): can manifest with pruritis, bleeding, burning, tenderness, vaginal discharge, and pain. Large lesions can interfere with defecation, intercourse, and delivery. Looks like warty projections on the post wall of vagina. Another description is a flesh colored, hyperkeratotic papules. If you apply acetic acid to the lesions, they will turn white. These are caused by HPV, and is the MC viral STD in the USA. Rx includes chemical, immunotherapy, and surgery. First, try the chemical destruction (trichloroacetic acid application). This will destroy the lesion, although the clearance rate is low and repeated applications are often necessary. Safe for pregnancy, no intervention needed during delivery if lesions are present. Podophyllin has similar effect to trichloroacetic acid, but is contraindicated in pregnancy.

Gestational DM: All pregnant pt should be screened btw 24th and 28th weeks using 50 gm glucose tolerance test. You give 50 gm of glucose, then check levels 1 hour after. If on this first test, pt has a blood glucose > 140, should then give them a 3 h glucose tolerance test after ingesting 100 gm. If in this test, you get 2 or more blood glucose values > 105, 190, 165, and 145 at 0, 1, 2, and 3 hours respectively, then youíve dx gestational DM. The recommendation for a fasting blood glucose value on pregnant DM pt should range btw 60-90., and postprandial should be < 120. NPH insulin can e used. If this still doesnít workm, you can add rapid acting insulin (regular/lispro) if theer are persistent postprandial suboptimal glucose levels. Glargine insulin is teratogenic in experimental animals.

HIV screening in pregnant pt: strongly recommended, but not required by law, itís up to the pt.

Pt on OCP who wants to get pregnant: Pregnancy will be delayed for about 1 month after stopping OCP. There is no associated risk of infertility.

Even if somebody if on OCP, using barrier in addition to that is recommended d/t prevent STD.

Pt on OCP with hypoTH: Estrogen of OCP will increase TBG levels, which will decrease the free T4 (and increase total T4). Person should increase the dose of levothyroxine.

Norplant: 6 capsules of levonorgestrel which are placed subdermally, generally in the upper arm. Offers contraceptive protection for 5 years. MC complication is menorrhagia (prolonged vaginal bleeding during periods), which happens in 30% of cases. Less commonly, VTE, PE< TTP, stroke can happen.

Emergency Contraception: levonorgestrel is the recommended method. It has maximal efficacy when used the first 12 hours after intercourse, good efficacy within 48 hours, and appears to work even up to 120 hours after intercourse.

Pregnancy Rates for various contraceptives: Best are implantable and injectable contraceptives (implantable levonorgestrel and depot medroxyprogesterone acetate) have the lowest rate of pregnancy (< 2-3%). Barrier methods (diaphragm, cervical cap, male condom) have pregnancy rate of 12-14% mostly d/t inconsistent or incorrect use. OCP are very effective, but rate is higher than with implantable and injectable contraceptives. Spermicides if used alone have a high failure rate.

OCP contraindications: Absolute ones include hx of VTE/stroke, acute liver disease, hx of estrogen dependent tumor, pregnancy, abnormal uterine bleeding, heavy smokers who are older than 35, and hypertriglyceridemia.. Relative contraindications are migraines, poorly controlled HTN, and anticonvulsant drug therapy.

Anti-seizure medications lower efficacy of OCP by induction of P450. All antiseizure meds lower efficacy except gabapentin and valproate.

OCP: if taken perfectly (never miss a pill, takes pill at same time each day, no vomit/diarrhea), theer is 99.9% efficacy. Risk of fetal anomalites /2 use of OCP during pregnancy is negligible.

Depot medroxyprogesterone: can help decrease menstrual flow and produces temporal amenorrhea, diminishing episodes of blood loss in the pt. This can be useful if pt has a hematologic disorder. It also dereases the risks of PID and endometrial cancer.

Exercise induced amenorrhea: Females who maintain a lower weight or BMI may become hypoestrogenic, which causes amenorrhea. In addition, the low estrogen also predisposes them to developing osteopenia and even osteoperosis. Spontaneous fractures have been seen. Rx with gain weight, or HRT and Ca/Vit D if calories not possible. Remember that exercise induced amenorrhea is a diagnosis of exclusion (always check TH and prolactin). The hypoestrogenemia is d/t a decrease in the pulsatile secretion of LH.

Vulvovaginitis: Common infectious causes are candidiasis, bacterial vaginosis, and trichomoniasis. A good technique is saline and KOH prep for microscopy. On this, candidiasis will show pseudohyphae. Bacterial vaginosis will show clue cells. Trichomoniasis will show motile trichomonads and lots of PMN cells.

Bacterial Vaginosis: Imbalance in the normal vaginal bacterial flora associated w/ increased numberw of Gardnerella various bacteria. Dx when 3 of the following criteria are present: homogenous vaginal discharge, vaginal pH > 4.5, amine odor with KOH application, or presence of clue cells on microscopic exam of wet mount. Many women are asymptomatic, but BV often causes an excessive white/gray vaginal discharge or foul/fishy odor, especially after intercourse (d/t male semen). BV has association w/ pregnancy complications (spontaneous abortion, PROM, preterm delivery). Adverse outcomes of pregnancy are not improved when BV is screened for or treated in an average risk asymptomatic woman, so asymptomatic pt should be monitored but not treated. If you do decide to Rx, the Rx is oral metronidazole or clindamycin. If a pt is symptomatic or high risk (for preterm labor), then you should Rx the condition.

Tcichomoniasis: If symptomatic, characterized by a copious frothy gray-green discharge, fishy odor, vulvar and vaginal pruritis, or dysuria. On a smear, youíll se epear shaped motile organisms. Vaginal and cervical petechiae (strawberry cervix) can sometimes be seen. Rx is indicated for all women dx with trichomoniasis and their partners. Rx is with metronidazole. While it enters breast milk, no known side effects. General recommendation is to Rx with metro 2g PO for 1 dose, then breastfeeding should be d/c for 12-24 hours after the dose.

Atrophic Vaginitis: MCC of postmenopausal bleeding. Should always r/o more serious stuff (endometrial cancer) by endometrial biopsy before diagnosing this. Atrophic vaginitis is characterized by vaginal dryness, burning, dyspareunia, and reduced vaginal secretions, and vulvar pruritis. Sometimes, urinary symptoms might be seen. Pelvic exam shows loss of labial labial fullness, pallor of vaginal epithelium, and decreased vaginalsecretions. This is usually d/t declining estrogen levels. You might also see it in non-menopausal women, where estrogen production can be stunted by radiation rx, chemotherapy, immunologic disorders, and lactation. Rx with HRT, lubricants, or transvaginal estrogen replacement (cream, hrmone releasing rings).

Folic acid for pregnancy: Should start 0.4-0.8 mg/day of folic acid supplementation at least 1 month before conception.

First prenatal visit: should get blood type + antibody screen, Rh, CBC, rubella status, screen for syphyliss, chliamydia, and HIV, hep B surface antigen, U/A + culture, and pap smear. On subsequent visit, should check BP, weight, uterine fundal height, fetal heart tones, fetal presentation and activity, and urine glucose and protein. This discovers 50% of fetuses w/ growth abnormalities, prevention of 70% of eclampsia episodes, and detection of 80% of breech presentations.

Gestational Thrombocytopenia: benign condition, defined by the presence of 5 criteria. They include mild and asymptomatic thrombocytopenia, develop late in pregnancy, no hx of thrombocytopenia outside of pregnancy, no evidence of fetal thrombocytopenia, and spontaneous resolution once the child is delivered. Rx conservatively, and f/u to make sure the thrombocytopenia resolves after pregnancy.

HELLP syndrome: hemolysis, elevated liver enzymes, and low platelets. This is an ominous variant of severe preeclampsia, and is responsible for 20% of cases of thrombocytopenia in pregnancy. Rx with Mg sulfate to reduce seizure risk.

Asymptomatic bacteriuria in pregnant pt: should be Rx promptly, since it can quickly progress to cystitis and pyelonephritis. These 2 conditions are associated with preterm labor and premature birth. E. Coli is the most common, but S. Agalactiae can also be present. S. agalactiae indicates GBS colonization, which should be Rx with penicillin G or cephalexin.

Rho D immune globulin (anti-D immune globulin): Give at 28 wks if needed (father unknown status, mom is Rh Ė with no anti-D antibodies). Also, if there is feto-maternal hemorrhage during the birth (ex placental abruption), then you should consider giving anti-D. Do a rosette test. This helps determine presence of feto-maternal hemorrhage. If negative, than the standard dose of anti-D should be given. If positive, dose of anti-D should be increased accordingly. Eisenmenger Syndrome (reversal of L to R shunt) in pregnant pt: There is high risk of maternal and fetal deterioration. There is a 30-50% risk of mortality. There is alos higher risk of spontaneous abortion, preterm delivery, and fetal mortality. All pregnant pt with Eisenmenger syndrome are advised to abort the pregnancy.

Rh incompatibility can only happen if the mother is Rh Ė AND the father is Rh +.

Subchorionic hematoma: Bleeding btw the endometrium and gestational sac. Appears on US as a crescent shaped hypoechoic region adjacent to the gestational sac. MC source of first trimester bleeding. Manage expectantly until symptoms resolve or additional findings develop. Should re-evaluate in 1 weeek. There are no known therapeutic Rx for the condition. Pregnant women with this are at increased risk for spontaneous abortions.

Exercise during pregnancy: Should be continued as long as its comfortable. Avoid scuba diving, very stressful sports (distance running), and sports w/ risk of falling (ski).

Pruritis in pregnancy: Pruritis is very common during pregnancy. It affects up to 20% of pregnant women. Symptom may be a manifestation of pregnancy associated dermatosis. Usually involves the scalp, anus, vulva, and abdomen. Can just Rx symptomatically if needed (topical steroid, antihistamines).

Papular urticarial papules and plaques o fpregnancy (PUPPP): common pregnancy associated dermatosis that is characterized by erythematous papules within the striae gravidarum. Rx with tomical steroids.

Herpes gestationis (aka pemphigoid gestationis): uncommon blistering dermatosis that I sassociated with pregnancy. May first manifest as abd pruritis (and looked on as benign). Eventually, a rash develops. Rash is localized around umbilicus, and is characterized by papules, urticarial plaques, and vesicles. This is an autoimmune disorder (NOT caused by a virus). Itís an autoimmune disease. Thus, rx with corticosteroids mainly. For milder cases, just use triamcinolone (weaker steroid). In more advanced cases, systemic steroids are employed.

As a side note, topical steroids are usually the correct choices for answers asking about Rx of pregnancy associated dermatoses.

Serum AFP: usually measured during 16-20 wks gestation to detect open neural tube defects. An elevated AFP (> 2-2.5) is present in open spina bifida and anencephaly. This can also be present in other fetal abnormalities, like congenital nephrosis, ventral wall defects, etc. If you get an elevated AFP but itís not greater than 7.0, then do a repeat AFP. 30% of the repeat tests will end up being normal. If repeat values are high or if the AFP is > 7, then an US should be done to confirm gestational age and look for neurologic abnormalities. Amniocentesis becomes necessary only if the US is normal or inconclusive despite highi AFP levels.

Hemophilia A: X-linked recessive disorder. Leads to deficit in coag factor VIII. For a female to be a carrier, there must have been a FH in the past somewhere.

Chorionic villus Sampling: One complication of it is transverse limb abnormality. Risk depends on age of gestation, with risk being greatest when < 9 weeks, and lowest when > 11 wks. Risk doesnít depend on skill of operator, route of procedure, or gauge of needle.

HIV + pt who becomes pregnant: If pt is already on HAART, should continue the regimen if pregnancy is confirmed after 1st trimester. Zidovudine especially is nice because itís been shown to reduce vertical transmission. If pregnancy is ID early in the 1st trimester, can d/c HAART for remainder of 1st trimester then start it afterwards. Ultimately, the preferred mode of delivery in all HIV + women is elective C-section. Efavirenz and delavirdine are teratogenic. Studies have shown that HIV can be transmitted through breast milk, so these pt should not breast feed their kids. As a side note, there is some evidence that HAART can be transmitted into the breast milk as well. So in third world countries where formula is not easily accessible, there is some justification that continuing a pt on HAART while breastfeeding might not be as bad. Nevertheless, in the USA just feed with formula.

Hep B during pregnancy: Not associated with increased mortality or teratogeneciteratogenicity. However, perinatal transmission of virus is a concern in women with acute HBV infection (HBsAg, IgM anti-HBc, and HBeAg) in the third trimester and in those who are chronic carriers of the virus (anti-HBe, anti-HBs, and IgG anti-HBc). Admin of hep B vaccine and hep B Ig to the infant within 12 hours of delivery would be preferred means of managing the womanís condition. There is no evidence that C-section reduces the rate of maternal-infant transmission of HBV.

Premenstrual Syndrome (PMS): behavioral and physical symptoms that occur in the 2nd half of menstrual cycle. Huge variability in presentation (> 150 symptoms have been described). Premenstrual dysphoric disorder (PMDD) is a severe formof PMS characterized by the prominence of anger and irritability. SSRI are the first line therapy for PMDD. FLuoxetine has been shown to be good. About 15% of pt are resistant to fluoxetine. In such instances, alprazolam is a good alternative, and isgiven in luteal phase of menstrual cycle. Increasing the dose of fluoxetine in pt who are refractory to the initial Rx hasnít been shown to help. PMS has a significant association with psychiatric disorders (esp mood and anxiety disorders). Women who present with PMS have much higher incidence of depression in the past, and also have greater incidence of depressive episodes in the future.

Stress Urinary Incontinence: urine leaks with increased intraabd pressure. Leakage that occurs instantaneously with coughing is virtually diagnostic of stress urinary incontinence. This is d/t pelvic floor weakness, leading to loss of vaginal support d/t pelvic floor trauma during childbirth or vaginal atrophy following menopause. Can Rx with pelvic floor excercises.

Breech presentation: Management depends on which week it is that you see it. Before 28 wks, most breech presentations will become cephalic by the 34-36 weeks. After 36 weeks, only 6% of fetuses will be in breech position, and about 1/3 of them will convert to cephalic position. External cephalic version shouldnít be attempted until after 37 weeks gestation. At that time, version should onlybe done if there are no contraindications to vaginla delivery and fetal well being has been established. C-section should be done if these criteria arenít met.

Secondary Amenorrhea. Dx by missing periods for > 3 months if previously regular, and > 6 months if previously irregular. FSOM is always pregnancy test. Assuming its negative, next step is to do a progesterone challenge test. If test is + (bleeding after 2-3 days), then pt has a progesterone deficiency, for which the MCC is anovulation (can be idiopathic, TH, or hyperPL). If the progesterone challenge test is negative (no bleeding), then next step is the estsrogen and progesterone challenge test. If this is positive (bleeding), then there is a deficiency of estrogen (possibly d/t central or primary ovarian issue). If itís a central cause there will be low FSH. If itís the ovarian problem, FSH will be high. If ther is still no bleeding with the estrogen/progesterone challenge, then should r/o outflow tract obstruction.

Dysfunctinal uterine bleeding: Presents with sudden onset of heavy vaginal bleeding. Usually d/t anovulation. Itís the lack of ovulation, leading to hormonoal imbalance of progesterone which leads to endometrial overgrowth that eventually outgrows its blood supply leading to an irregular sloughing that can bleed a lot. Rx involves hormonal therapy to stabilize the endometrium. Estrogen should be used in all pt who are actively bleeding since it promotes hemostasis. High dose estrogen followed by progestin is the TOC.

Downís syndrome: Various screening mechanisms are available. At 10 weeks, you can check the nuchal translucency thickness (suggestive, but not diagnostic). In the 2nd trimester, you can do a quadruple screen (AFP low, hCG, unconjugated estriol, and inhibin A) which can detect 80-85% of cases. The only 100% detection method is to do karyotyping with an amniocentesis.

Chlamydia: Major cause of infertility, PID, and ectopic pregnancy in women. Always screen at initial prenatal visit, and in women under 25 or at increased risk should have repeat testing in 3rd trimester. Chlamydia endometritis during pregnancy can lead to chorioamnionitis and premature delivery of the fetus. Untreated infection during pregnancy can also lead to conjunctivitis and pneumonia in the newborn baby. Itís an STD, so sexual contact was somehow involved In getting it. Reactivation of latent Chlamydia infection during pregnancy doesnít happen. Best Rx is azithromycin (1 g PO single dose) or doxycycline (100 mg PO bid 7 days). However, doxycycline, fluoroquinolones, and erythromycin are contraindicated in pregnant pt. Thus in these pt, use erythromycin (500 mg PO qid for 7 days) and amoxicillin (500 mg PO tid for 7 days).

Tb in pregnancy: Standard regimen is INH, rifampin, and ethambutol. If there is chance of MDR, add pyrazinamide to it. There is a lack of data regarding teratogenicity of pyrazinamide, so itís not used in pregnant women unless there is strong evidence that MDR is present.

Rectocele: displacement of the rectum through the posterior vaginal wall defects. Usually caused by damage to rectovaginal septum incurred through vaginal childbirth. Presents with pelvic pressure/heaviness, LBP, and constipation. You can demonstrate the protrusion through the wall while bearing down on a gyne exam. Surgery is the best Rx, but women who are poor surgical candidates can use pessaries (structures designed tosuppoort the vaginal wall). Pessaries should only be used in conjunction with vaginal estrogen. Without it, these can cause chronic discharge and bleeding secondary to injury of the vaginal tissues.

Preeclampsia: Having a hx of it increases the possibility in future pregnancies. Risk is at least 7x higher, but is not guaranteed.

Menopause: There is rapid loss ofbone mass following menopause. Weightbearing excercises, Ca and vit D supplementation can prevent postmenopausal bone loss. HRT is necessary if pt has milder symptoms. There are lots of CV side effects with HRT, so avoid unless necessary.

Perimenopause: the time extending from 2-8 years preceding menopause until 1 year following the last menstrual period. This state is associated with normal ovulatory cycles interspersed with anovulatory cycles that vary in length. The hormone levels are inconsistent during this time, and estrogen is often unopposed, which leads to irregular menses and heavy breakthrough bleeding can happen. If a pt complains of an episode of hjeavy dysfunctional bleeding or of > 6 months of irregular menses, then endometrial biopsy or a vaginal US to ensure endometrial thickness stays < 4 mm is indicated.

CF causing infertility: 20% chance of being infertile in a female with CF. Mostly itís d/t the malnutrition which can cause secondary amenorrhea. Also, cervical mucus in CF pt is thick and tenacious. In males, 95% of themwith CF are infertile. Sperm transport in these pt is impaired.

Nippl eDIscharge: Uusally benign, but you want to know whether the discharge is spontaneous or provoked, and whether itís unilateral or bilateral. In general, malignant causes have a spontaneous, unilateral and guiac + or grossly bloody discharge. Other benign causes tend to have a bilateral nipple discharge. All pt with a unilateral spontaneous nipple discharge should get mammogram. If something is suspicious on mammogram, go a FNA or open breast biopsy, and examine cytology.

Androgen Insensitivity Syndrome (AIS): Presents with primary amenorrhea, bilateral inguinal masses, and breast development w/o pubic or axillary hair. Genotype is 46 XY, but there is a female phenotype. There are no Mullerian structures (uterus, fallopian tube), and vagina ends in a blind pouch.

Pregnant pt with UTI: first line is cephalexin, amoxicillin, or nitrofurantoin. Fluoroquinolones can cause tendon rupture in kids. Tetracycline can cause dental stsaining and reduced bone growth in the fetus. Bactrim can cause hyperbilirubinemia and kernicterus in the fetus. If a women develops pyelonephritis, should admit to hospital and give IV ceftriaxone or augmentin until afebrile for 24-28 hours. If pt develops pyelo, then for the remainder of the pregnancy they should be given low dose abx prophylaxis (cephalexin or nitrofurantoin) and get occasional urinary evals. If pyelonephritis doesnít resolve, do a renal US to look for perinephric abscess or renal calculi.

Imperforate Hymen: Presents with cyclic pelvic/abd pain with primary amenorrhea. Sometimes, a small suprapubic mass (uterus containing retained menstrual blood) can be palpated. Perineal exam will show a bulging, bluish ,membrane between the labia. The blue color is d/t blood sequestration behind the hymen (aka hematocolpos).

Studies have shown that adolescents in the private practice setting are concerned about the use of OCP leading to weight gain.

Spinal Bifida: uncommon condition (1/1000) that is characterized by a cleft in the spinal column, which can be open or covered by skin. Folic acid supplementation is effective in reducing the risk for developing spina bifida. Risk is always present. If you have a first degree relative with spina bifida, your chances of having a child with it are increased, but still low.

Myelomeningocele: presents with protrusion of tissue in the midline lumbar region, with decreased muscular strength in both legs. Most pt with myelomeningocele also have hydrocephalus and CHiari II malformation, so urgent neurosurgery eval is needed. Surgical closure of the defect must be done within 24-48 hours to prevent infections of the CNS.

Epilepsy in pregnant pt: Although anti-epileptic drugs are associated with increased risk of congenital abnormalities, over 90% of women with epilepsy have normal pregnancy. In addition, there is no agreement about which drug is the most/least teratogenic, so the drug that is working best for the pt when she gets pregnant should be continued. You should screen early for neural tube defects with serum AFP screening, amniocentesis and US are also important. In asddition, high dose (4 mg/day) folic acid is recommended prior to conception and 1st trimester, since phenytoin and valproic acid might lower contration of folate. Breast feeding is not contraindicated while taking anti-epileptics.

Seat belts in pregnancy: Both lap and shoulder straps should be used. There are no adverse events associated with using seat belts.

Anticoagulation in pregnancy: Generally pt on long term anticoagulation are on warfarin, which is contraindicated in pregnancy. Pt planning to get pregnant should stop warfarin and get LMWH or subcutaneous unfrationated heparin.

HRT: While older PMS women on HRT are at increased risk for CV events, the same thing doesnít apply to younger women with premature ovarian failure. HRT (conjugated equine estrogen and medroxyprogesterone) can be used in younger patients with careful monitoring without excess cardiovascular risk. You donít want to give only estrogen (unopposed) in a pt with an intact uterus (risk of endometrial cancer).

Treatment decision for critically ill newborns: Life sustaining treatment may be withheld or withdrawn from a critically ill infant if the potential for joy is overwhelmed by pain and suffering expected to be endured by the child. Parents have the right to withhold or withdraw life support from a critically ill newborn if their decision is in the best interest of the child. If a parentís decision is not in the best interest of the child, you might have to get a court order to treat.

Diagnosis of a pregnant woman with hyperTH: Must have high free T4, and TSH must be <0.01. Gestational Transient thyrotoxicosis is the dx if T4 is mildly increased, and TSH is slightly decreased at the end of the first trimester. GTT doesnít happen after 14 weeks.

Breast Masses: Most palpable masses in < 35 yo are benign, MC fibrocystic disease or fibroadenoma. Symptosm of fibrocystic disease can get worse during pregnancy d/t hormonal changes. Features suggestive of malignancy include immobile, hard, single, irregular borders. A cystic mass sho9uld always be eval with FNA. If fluid is bloody, send for cytology. If not bloody, re-eval in 4-6 weeks.

Sickle cell disease: pt with this are at high risk for complications during pregnancy, so make sure that they have good contraception. Depotmedroxyprogesterone is a good hoice. Use of combined OCP is controversial. Although no studies have shown that SCD pt who use OCP have higher chance of VTE, many still donít use it. History of stroke is always a contra to using OCP. IUDs should be avoided in SCD pt. IUD can increase uterine bleeding, worsening the anemia of SCD.

PID: Presents with fever, chills, and lower abd pain. Vaginal discharge can be present. Exam shows positive cervical motion and adnexal tenderness. Some peritoneal signs might be present (mild). RF for PID are: oral contraception, no barrier contraception, multiple sexual partners, age < 35 yo, AA. Rx with cefotoxin + doxyycycline or ceftriaxone + doxycycline.

Retroverted Uterus: Found in 11% of population. There is no increased risk of abortion. Usually will reposition to anterior position btw 12-16 weeks, but if it doesnít happen automatically, physician has to manually reposition it to avoid uterine incarceration in the sacral region. Surgery is recommended only for p with dyspareunia related to retroverted uterus. Sometimes, chronic PID or endometriosis can cause a retroverted uterus.

PCOS: Presents with infertility, hirsutism, irregular menses, obesity, and increased ovarian volume measured by US. The cause of infertility is anovulation. Weight reduction in obese/overweight pt can restore ovulation, decrease androgen production, and help with pregnancy. Even a moderate reduction in weight can restore fertility.If weight reduction fails to restore ovulation, clomiphene citrate can be tried.

Low energy electromagnetic fields (video displays, power lines) have not been demonstrated to be dangerous to fetuses.

Syphilis in pregnancy: Any woman with positive VDRL/FTA-ABS tests are considered infected until proven otherwise. Untreated syphilis has a very high prevalence (80%) of adverse fetal outcomes (MR, stillbirth, neonatal death). Rx with penicillin. If pt has pen allergy, do pen desensitization. By giving incremental doses of oral penicillin V.

Adolescents are at increased risk of adverse pregnancy outcomes: These include increased perinatal mortality, preterm delivery, and premature/low birth weight). However, there is no risk of increased congenital malformations. There is risk of the baby having a future cognitive disorder, however.

Cysts during pregnancy: 70% of non-pregnant women with purely cystic pelvic masses < 10 cm in size have spontaneous resolution. Surgical removal during pregnancy is indicated for adnexal cysts that are > 5 cm, and persist over time (d/t high risk of rupture, hemorrhage, torsion, which can lead to preterm delivery). So surgery during 2nd trimester to decrease chance of fetal complications.

Infertility: male cause accounts for 20-30% of causes. Semen analysis is the first evaluation. Identification of azoospermia and severe oligospermia are causes if infertility. Anovulation is another potential cause of infertility. This can be evaluated using basal body temperature measurements, serum progesterone, or serum prolactin measurement. Measure the progesterone at mid-leutal phase. Hysterosalpingography is used to detect tubal and uterine abnormalities.

Septate Uterus: formof mullerian fusion defect that can cause significant fertility problems. Raises risk of poor implantation on an inhospitable surface. Surgical removal of the septum has been shown to be effective in treating 2nd trimester complications, but not for correcting first trimester complications. Hysteroscopy metroplasty is an endoscopy surgery that can be used to treat it.

Tetanus: Give toxoid to ppl with dirty wounds who got their last dose > 5 years ago, and clean wounds who got last dose > 10 years ago. In addition, pregnant women who have not completed a 3 dose primary immunization series or a booster in the last 10 years should be given a combination of tetanus-dpitheria toxoids. Tetanus immune globulin should be given to ppl who have gotten < 3 doses of tetanus vaccine or with unknown immunization status. Pregnancy doesnít change any of these recommendations.

Endometriosis: dysmenorrheal, dyspareunia, and infertility. Mostly involves the ovaries, broad ligaments, uterus, fallopian tubes, and sigmoid colon. Thus, there is also a risk of intestinal obstruction. This condition is not a RF for breast or cervical cancer.

Endometriosis: Presence of endometrial tissue in the ovaries, fallopian tubes, or other abnormal sites, causing pelvic pain and infertility. Consider it strongly in pt who experience dysmenorrheal, after years of painless menstruation. Dx is hard, and best done with laparoscopy to visualize the implants. Can Rx with NSAIDs, GnRH analog, danazol (synthetic androgen), or oral contraceptive. S\Surgery involves removal of lesions.

Mild Preeclampsia
- Either BP > 140/90 or increase over pre-pregnant by > 30/15
- Proteinuria > 300 mg
- Nondependent edema (face or hands)
- Tx: induce labor if at term, or if unstable preterm, or if lung development in fetus is confirmed
o Betaemethasone: enhance lung maturity
o Start Mg SO4 for seizure prophylaxis during labor, continue 12-24 h post delivery

Severe Preeclampsia
- BP > 160/110 + proteinuria > 5 g OR organ manifestations as listed above
- Tx: overall goals are to prevent eclampsia, lower mom HTN, deliver the baby
o Initial: MgSO4 to prevent seizure, hydralazine for BP
o Once stable: see gestational age of baby
ß 24-32 wk: wait for beclamethasone and more maturity
ß > 32 or organ failure signs: deliver immediately
- pt. may worsen immediately postpartum
o keep BP down, use MgSO4 for 24 h post delivery
o if have HELLP, thrombocytopenia may worsen: give steroids to hasten return to normal levels

Eclampsia
- increased DTR is an ominous sign that preeclampsia might be progressing to eclampsia
- grand mal seizures in pre-eclampsia pt not d/t other causes
- having severe pre-eclampsia is NOT a prerequisite
- MCC death of mom in eclampsia is intracerebral hemorrhage
- Clinical S/S
o Seizure can come anytime relative to labor and delivery
o Tonic clonic, and may or may not have aura
o Retinal hemorrhages is an extremely ominous sign, since it could mean that vascular damage has happened in other organs.
o Microangiopathic hemolytic anemia is seen, but itís not necessarily ominous
- Treatment
o Main goal is to deliver ASAP. Mg prevents further seizures, but doesnít stop a current seizure.
o Manage seizure, lower BP, prevent more seizures
o Hydralazine or labetalol to quickly lower the acute increased BP
o MgSO4 for seizures: as good as or better than anticonvulsants
ß Initiate at time of diagnosis, continue for 12-24 h after delivery
ß Get to therapeutic level w/o OD
ß OD treat w/ IV CaCl or Ca gluconate for cardiac protect
Signs OD: dyspnea, loss DTR, hyporeflexia (first sign)
o Treat mom will treat fetus
o Only deliver baby once pt is stable: NSVD is fine, only c-section of Ob indications are there

Pregnancy risk category C: Either 1) studies in animals have shown adverse effect, but no studies have been done in pregnant women, or when 2) no studies have been done on animals or pregnant women.

Risk category B: 1) animal studies have not demonstrated fetal risk, but no controlled studies have been done in pregnant women, or 2) animal studies have shown adverse effect that wasnít confirmed in studies on pregnant women.

Risk D: There is evidence of human fetal risk, but benefits might possibly outweigh the risk.

Risk A: studies have shown no increased risk of fetal abnormalities.

Risk X: studies in anomals or humans have shown fetal abnormalities, and risk of use will outweight any benefit.

Turnerís syndrome: Generaly pt have primary amenorrhea, but ovarian function and morphology is highly variable. Some women might become pregnant, but the changces are very low.

Steroid therapy for preterm labor: reduces risk of infant RDS and intraventricular hemorrhage. 2 commonly employed regimens are btamethasone or dexamethasone administered intramuscularly. Should be given to any pregnant owoman from 24-34 wks gestation with intact membranes who are at high risk of preterm delivery (contractions, cervical dilation).

Uterine Prolapse: usually seen in multiparous, postmenopausal woman with hx of multiple vaginla deliveries. Presents with sensation of pressure or heaviness in pelvic area, which is relieved by lying down and aggravated by prolonged standing or exertion. There may be a visible mass at the introitus. In chronic cases, pt might have bleeding or discharge from ulcerative, superficial epithelium. All symptomatic pt should have surgical correction of the defect in the pelvic support.

Nephrolithiasis: US is test of choice to detect in pt who should avoid radiation exposuire. Helical CT is best choice, but CT has radiation.

Arrest of active phase of labor: cervix is dilated and effaced, but over some time dilation doesnít increase and the fetal descent stays at the same station. In nulliparous women, the MCC of arrest is hypotonic uterine contractions. Other things that might cause arrest include pelvic anatomy, fetus size, and fetal presentation. For pt with problem with uterine contractions, augmentation of labor using oxytoxin is the most appropriate next step.

Postpartum endometritis: polymicrobial infection of the pregnancy endometrium characterized by fever, uterine tenderness, foul smelling vaginal discharge, and leukocytosis. Presents a couple days after delivery. Rx is with clindamycin and gentamicin. Metronidazole is contraindicated in breastfeeding mothers. Endometritis happens most often after a C-section (especially if labor started already or after the membranes ruptured). The route of delivery (C-section vs vaginal) is the most important RF in development of endometritis.

Post partum hemorrhage: MCC is uterine atony. FSOM is to do a pelvi eexam to look for any retained placental fragments. If there are no retained POC, then start doing a manual uterine massage to sitmulate the uterus to contract and stop the bleeding. If bimanual doesnít help, then give them IV oxytocin.

Poor glycemic control in pregnant patients: Some risks for the fetus include macrosomia, hypoCa, hypoglycemia, hyperviscosity, respiratory difficulty, CHF, and cardiomyopathy. The MC cardiomyopathy presenting in babies of these mothers is hypertrophic interventricular septum, leading to ventricular outflow obstruction. This can even present as CHF. Rx this heart condition by just observe and do conservative management. Defect oftens correct spontaneously

Shoulder dystocia: failure of fetal shoulders to pass through maternal pelvis once the fetal head has been delivered. It is dx when the ant shoulder cannot be delivered with mild, downward pressure. RF include macrosomia and maternal DM, and obesity. When it happens, the mother should be told not to push, while you attempt to reposition the fetus. You should give suprapubic pressure after repositioning. If that doesnít work, then you can try McRObertís maneuver.

Delivering a twin: If the fetal heart rateis reassuring, then the 2nd twin doesnít have to be delivered within a fixed time frame after the first twin. Once the first twin is delivered, assess the position and HR of the 2nd twin. If labor has halted, then oxytoxin should be administered.

Ascities: Common causes are hepatic cirrhosis, cancer, CHF, peritoneal tb, pancreatic disease. Can narrow the ddx by checking the serum to ascetic fluid albumin gradient (SAAG). To get this value, you subtract the ascetic fluid albumin from the serum albumin. If SAAG >= 1.1, then there is portal HTN, indicating cirrhosis, CHF, or alcoholic hepatitis. If SAAG < 1.1, then causes include peritoneal tb, peritoneal carcinomatosis, nephritic syndrome, and pancreatitis.[/QUOTE]
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