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Practice Questions 2


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The use of EFM
increased the overall cesarean delivery rate

The use of EFM increased the use of vacuum and forceps

did not reduce overall perinatal mortality
What % of cases of CP occur before the onset of labor
Decrease in FHR variability with betamethasone but not
Normal FHR _____ provides reassurance about fetal status.
scalp pH not very predictive
(single contraction lasting more than 2 minutes)
Any conditions in which the risks of emergency contraception use outweigh the benefits?
Women with previous ectopic pregnancy, cardiovascular disease, migraines, or liver disease and women who are breastfeeding may use emergency contraception.
women who are breastfeeding may use emergency contraception?
emergency contraception to women with undiagnosed genital bleeding?
Don't deny anyone emergency contraception.
⬢ What screening procedures are needed before provision of emergency contraception?
No clinical examination or testing is required

Should not be withheld or delayed in order to test for pregnancy, nor should it be denied because the unprotected coital act may not have occurred on a fertile day of the menstrual cycle.
⬢ When should emergency contraception be initiated?
up to 120 hours after intercourse
which is more effective for Emergency contraception - levonorgestrel or combined estrogen-progesterone?
The levonorgestrel-only regimen is preferred to the combined estrogen–progestin regimen,
PLAN B is Best TT
Are antiemetics useful as an adjunct to treatment with the levonorgestrel-only regimen?
not necessary
Are antiemetics useful as an adjunct to treatment with the combined regimen?
may be beneficial because the incidence of nausea
Antiemetic taken _____ before the first dose of emergency contraception has been shown to decrease the incidence or severity of nausea
1 hour
Emergency contrception dose should be repeated if vomiting occurs within ____ of taking a dose.
2 hours
If severe vomiting occurs, emergency contraception may be administered how?
Is emergency contraception safe if used repeatedly?
May be used even if the woman has used it before, even within the same menstrual cycle
What clinical follow-up is needed after use of emergency contraception?
No scheduled follow-up is required after use of emergency contraception
For what reasons should patient f/u after emergency contraception?
menstrual period is delayed by a week or more

persistent irregular bleeding

lower abdominal pain
When should regular contraception be initiated or resumed after use of emergency contraception?

short term contraception
longterm contraception
barrier contraceptives immediately

Short-term hormonal contraceptives (eg, pills, patches, and rings) may be started either immediately (with a backup barrier method) or after the next menstrual period.

Long-term hormonal methods should be started after the next menstrual period, when it is clear that the patient is not pregnant.
⬢ How can access to emergency contraception be facilitated?
Providing an advance prescription or supply

prescribing it by phone without requiring an office visit
copper IUD for emergency contraception - pregnancy rate of
When is an intrauterine device appropriate for emergency contraception?
women who desire long-term contraception and who are otherwise appropriate candidates for IUD use.
copper IUD for emergency contraception most effective if inserted within ____ after unprotected intercourse
5 days
Emergency contraception progestin-only regimen, which consists of
a total of 1.5 mg levonorgestrel

one 0.75-mg levonorgestrel pill ASAP after unprotected intercourse and to take the second 0.75-mg pill 12 hours after the first dose.

taking both pills at the same time or taking each 0.75-mg pill 24 hours apart is as effective as taking them 12 hours apart and does not increase the risk of side effects.
Emergency contraception combined estrogen–progestin regimen, which consists of
two doses—each containing 100 µg of ethinyl estradiol plus 0.50 mg of levonorgestrel—taken 12 hours apart.
Preliminary Classification Criteria for Antiphospholipid Syndrome in PREGNANCY
Criteria Definition

1) Three or more consecutive spontaneous abortions before the 10th week of gestation
2) One or more unexplained fetal deaths at or beyond the 10th week of gestation

3) Severe preeclampsia or placental insufficiency necessitating birth before the 34th week of gestation
Preliminary Classification Criteria for Antiphospholipid Syndrome*
Criteria Definition
1) Unexplained venous thrombosis
2) Unexplained arterial thrombosis

3) Small-vessel thrombosis in any tissue or organ, without significant evidence of inflammation of the vessel wall
Preliminary Classification Criteria for Antiphospholipid Syndrome*
Criteria Definition

ACA IgG or IgM isotype in medium to high titers, on TWO or more occasions at least 6 weeks apart, measured by standardized ELISA

LA present in plasma, on TWO or more occasions at least 6 weeks apart.
*Definite antiphospholipid syndrome is considered to be present if at least one of the clinical criteria and one of the laboratory criteria are met.
How should antiphospholipid syndrome be managed during pregnancy and the postpartum period? Treatment of women with antiphospholipid syndrome without a thrombotic event
prophylactic heparin and aspirin

6–8 weeks of postpartum thromboprophylaxis

referred to an internist or hematologist
How should antiphospholipid syndrome be managed during pregnancy and the postpartum period? antiphospholipid syndrome who have had a thrombotic event
full/adjusted dose heparin anticoagulation
benefit of adding aspirin is unknown.

continued for a minimum of 6 weeks postpartum to minimize the risk of maternal thromboembolism
can be safely accomplished with coumarin.

referred to an internist or hematologist
Should women with antiphospholipid syndrome have antepartum surveillance?
detection of preeclampsia or IUGR

serial ultrasonographic assessment.

Antepartum testing should be considered after 32 weeks of gestation, or earlier if there are signs of IUGR
Are estrogen-containing oral contraceptives in women with well-characterized antiphospholipid syndrome okay?
Estrogen-containing oral contraceptives in women with well-characterized antiphospholipid syndrome should be avoided.
which mode of misoprostol in regimens with mifepristone results in complete abortion in higher success rates for these gestational ages 50-63 days? vaginal v. oral

better than oral
Medical contraindications to abortion with mifepristone regimens include:
confirmed or suspected ectopic pregnancy or undiagnosed adnexal mass,
intrauterine device in place,
current long-term systemic corticosteroid therapy,
chronic adrenal failure, severe anemia,
known coagulopathy or anticoagulant therapy, and
mifepristone intolerance or allergy.
Misoprostol contraindications:
uncontrolled seizure disorder
allergy or intolerance to misoprostol or other prostaglandins.
Asthma is not a contraindication because misoprostol is a weak bronchodilator.
⬢ Do nonsteroidal antiinflammatory drugs affect the success rates for medical abortion?
⬢ How should a patient be counseled about potential teratogenicity if a medical method fails to lead to abortion?
No conclusions regarding teratogenicity can be drawn
Patients must be informed of the need for a surgical abortion in the event of a continuing pregnancy.
High-risk HPV testing as an adjunct to cervical cytology in women aged 30 years and older
If both test results are negative, combined testing should not be repeated more often than every
3 years
⬢ Normal Pap but HPV positive, what is the appropriate follow-up?
Repeat cytology and HPV test in 6–12 months

Colposcopy is not recommended as further testing after a single HPV-positive, Pap-negative result.
⬢ ASCUS Pap, how should the patient be treated?
Immediate colposcopy
Triage to colposcopy by HPV DNA testing (except adolescents)
Repeat cytology tests at 6 and 12 months.
If HPV testing is elected, those women whose test results are HPV positive should
be referred for colposcopy.
Those women who test negative for HPV can be scheduled for
repeat cytology testing in 1 year.

HPV neg expires in 1 year
As an alternative to immediate colposcopy, adolescents with ASC HPV-positive test results may be monitored with
Pap at 6 and 12 months or with a single HPV test at 12 months

with colposcopy for any abnormal cytology result or positive HPV test result.
follow-up of LSIL in adolescents.

think of ASC HPV+ = LSIL
Pap at 6 and 12 months or with a single HPV test at 12 months

That said, although follow-up cytology tests may allow some women to avoid colposcopy, waiting 6–12 months for a definitive diagnosis can create anxiety and will delay the possible diagnosis of cancer.
In addition, the rate of loss to follow-up is substantial
Pap LSIL how should the patient be treated?
colposcopy is recommended for evaluation of LSIL, except in adolescents
Pap ASCUS-H, how should the patient be treated?
colposcopy is recommended for evaluation of ASCUS –H, or triage with HPV for >30yo
Follow-up of a colposcopy result of CIN 1 or normal

Either cytology tests at 6 and 12 months or an HPV DNA test at 12 months,

No excision necessary
⬢ When the results of colposcopy performed for the evaluation of ASCUS, ASCUS-H, or LSIL reveal no dysplasia or CIN 1, how should the patient be treated?
Repeat cervical cytology screening tests at 6 and 12 months or an HPV test at 12 months.
If the follow-up cytology result is ASC or higher-grade cytology or a positive HPV test, what should be done?
colposcopy should be repeated.
Pap HSIL, how should the patient be treated?
Colposcopy and biopsy of visible lesions

ECC should be performed in the nonpregnant patient

entire vagina should be examined, especially when a lesion corresponding to the cytology result is not found.
Pap HSIL, what is an alternative to how this patient should be treated?
An alternative "see and treat" management plan may be used in this patient population in the event that a lesion consistent with CIN 2 or CIN 3 is seen.

In these cases, the cervical biopsy is omitted and an ECC after the LEEP may be considered.
⬢ When the initial evaluation of an HSIL Pap result is Colpo CIN 1 or less, how should the patient be treated?
Review of the cytology/Pap and histology/Colpo results

If review is not undertaken or colposcopy results are not satisfactory, excision is recommended.
For HSIL Pap result is Colpo CIN 1 or less. Who is an exception to excision?
HGSIL Adolescents, follow-up with colposcopy and cytology tests at 4–6 months may be undertaken, as long as the colposcopy results are adequate and the endocervical curettage is negative.
⬢ When the results of Pap AGC or AIS, how should the patient be treated?
Colposcopy and endocervical sampling should be included in the initial evaluation of all women with AGC results, except for those with results that specify “atypical endometrial cells.”
The most common significant lesions associated with AGC are

At least half of AIS and adenocarcinoma results will be accompanied by squamous CIN.
Women with atypical endometrial cells and a normal endometrial sampling should undergo
colposcopy and endocervical sampling
Endometrial sampling is indicated in women with atypical endometrial cells and all women with AGC results who are aged 35 years or older, as well as those younger than 35 years with
abnormal bleeding, morbid obesity, oligomenorrhea, or clinical evaluation suggesting endometrial cancer.
⬢ When the results of the initial evaluation of AGC reveal no neoplasia, how should the patient be treated if original pap was AGC-NOS?
repeat cytology testing and ECC FOUR times at 6-month intervals
Like squamous CIN, HPV is found in more than 95% of AIS and 90–100% of invasive adenocarcinomas of the cervix.

Similar reports suggest that it is reasonable to monitor women with AGC cytology test results, a negative initial evaluation, and a negative HPV test result with a repeat cytology and endocervical sampling in 1 year rather than requiring four visits at 6-month intervals.
For women with reports of
1) AGC favor neoplasia or an AIS cytology result and a negative initial evaluation by colpo, or
2) a SECOND AGC-NOS result and a SECOND negative evaluation what should be done?
excision is warranted

Cold-knife conization is a good choice in this situation because of the prognostic importance in AIS of the pathologic evaluation of margins, which may be obscured by thermal artifact in some LEEP specimens.

complexity may require consultation with gynecologic oncologist.
⬢ When should endocervical curettage be used in the colposcopic examination?
ECC should be performed if colposcopy results are unsatisfactory or if ablative treatment, such as cryotherapy or laser ablation, is contemplated
In women with ASC-H, HSIL, AGC, or AIS cytology results, ECC should be considered as part of the initial colposcopic evaluation, unless
excision is planned.
***If an excision is planned, endocervical sampling may be omitted, although it may be performed at the time of the procedure following the excision to assess the completeness of the procedure.
⬢ How should CIN 1 be managed?
Younger women, observation provides the best balance between risk and benefit and should be encouraged
If observation of CIN I, then how should it be done
two cytology screening tests 6 months apart with colposcopy for an ASC or higher-grade result,

or a single HPV test at 12 months, with colposcopy if the test result is positive.
⬢ How should CIN 2 and CIN 3 be managed?
immediate treatment of CIN 2 and CIN 3 with excision or ablation in the nonpregnant patient is recommended.

The only exception to this recommendation is that follow-up similar to CIN 1 may be considered in the adolescent with CIN 2
⬢ Does management of CIN 2 or CIN 3 differ for women who are HIV positive?
Standard ablative or excisional treatment is recommended for women who are HIV positive with documented CIN 2 or CIN 3, regardless of HIV viral load.
CIN 2 and CIN 3 should be treated similarly in women who are HIV positive regardless of their use of antiretroviral therapy.
⬢ Is excision or ablation the better treatment for CIN for avoiding stenosis?
Rates of cervical stenosis are comparable

Endocervical sampling before ablation is recommended

Ablation should not be performed in patients with dysplasia on endocervical curettage.

Excision offers the advantage of a specimen for histologic examination and the disadvantage of increased surgical complications, primarily bleeding.
⬢ How should AIS pap be managed? How should patients with AIS be monitored after treatment?
Expert consultation

***Hysterectomy is not appropriate until invasive cancer has been excluded.

Cold-knife conization excision is required

LEEP in this situation is associated with an increase in positive cone margins over cold-knife conization and is not recommended
***Endocervical sampling immediately after conization has been reported to have better positive and negative predictive value for residual disease than cone margins.
IN AIS, if the margins of the cone specimen are involved, then what next?
conization should be repeated in AIS.
Why not immediate hysterectomy if margins positive for AIS?
Repeat conization is preferred to immediate hysterectomy so that if invasive cancer is found, the appropriate surgical or radiotherapeutic treatment can be recommended. If no invasive cancer, then hysterectomy is recommended (if undesired fertility).
In AIS, if the margins of the cone specimen are not involved, risk of residual disease is still substantial. Therefore, what is recommended?
recommendation for hysterectomy when fertility is no longer desired.
When fertility is desired and cervical conization margins are clear,
conservative follow-up may be undertaken with Pap and ECC every 6 months, provided that the patient understands the risk of subsequent recognition or development of invasive cancer.
⬢ How should a colposcopic biopsy with inconclusive results for early invasive cancer be managed?
excision to define whether cancer is present and to permit treatment planning.

The management of early invasive cervical cancer depends on the depth of invasion and the presence or absence of LVSI.
Biopsy alone does not adequately provide this information.
• How should a patient’s condition be monitored after treatment for CIN I, if LEEP or cone biopsy reveals a positive margin, how should management proceed?
For CIN 1 with positive margins, cytology screening at 6 and 12 months or HPV testing at 12 months is a reasonable choice before reestablishing routine screening.
Positive margins on a specimen excised for squamous CIN or
ECC positive for squamous CIN performed after excision indicates a risk of persistent disease.
Does this finding require reexcision.
This finding necessitates follow-up, including endocervical sampling until routine screening is reestablished, but it does not require reexcision.
Reexcision may be elected but should be undertaken with the knowledge that the most common outcome is
the absence of residual dysplasia.
By not re-excising and therefore sparing the endocervical mucosa from cautery after the excision does what?
increases subsequent satisfactory colposcopy results and decreases cervical stenosis, but it also may reasonably be expected to increase recurrence rates in the event of positive margins.
What is f/u after TREATMENT of CIN 2 or CIN 3?
cytology screening three to four times at 6-month intervals or

undergo a single Pap and HPV test at 6 months before annual follow-up is reestablished.

Human papillomavirus testing is a powerful predictor of the risk of recurrent CIN 2 or CIN 3 after treatment of CIN.
When is hysterectomy appropriate in women with CIN 2/3+?
may be considered for treatment of persistent or recurrent CIN 2 or CIN 3 or when a repeat excision is indicated but technically unfeasible.
What should always be done before a hysterectomy?
If excision is indicated, it should be performed (where possible) before hysterectomy to rule out invasive cancer.
colposcopic examination during pregnancy should have what as its primary goal
exclusion of invasive cancer.
During pregnancy
may undergo colposcopic evaluation either during pregnancy or at 6–12 weeks postpartum
During pregnancy
ASC-H, HSIL, AGC, or AIS test results should undergo colposcopy. Who should get a biopsy?
colposcopy without endocervical sampling, reserving biopsy for those with visible lesions consistent with CIN 3, AIS, or cancer.
During pregnancy
Why noy biopsy for CIN I impression? You could be wrong, so why take a chance and not biopsy?
Although many women with colposcopic impressions of CIN 1 harbor either normal histology or CIN 2 or CIN 3, the risk of invasive cancer with a colposcopic impression of CIN 1 is low.

may be spared biopsy if the colposcopic impression is CIN 1.
During pregnancy
Excisions should be considered for pregnant women only if a lesion detected at colposcopy is suggestive of
invasive cancer.
Those with unsatisfactory colposcopy results, and those with satisfactory colposcopy results who are not found to have invasive cancer, should be reevaluated with
colposcopy and cytology tests in each trimester until delivery.
⬢ What elements of preoperative evaluation are useful for women with endometrial cancer?
Only a physical examination and a CXR are required for preoperative staging of the usual (type I endometrioid grade 1) histology, clinical stage I patient.
All other preoperative testing should be directed toward optimizing the surgical outcome.
Are CT and MRI necessary?
No because the surgeon should be prepared to resect metastatic disease commonly found in patients with endometrial cancer.
Are preoperative measurement of the CA 125 level appropriate in endometrial CA?
CA 125 is frequently elevated in women with advanced-stage disease.

Elevated levels of CA 125 may assist in predicting treatment response or in posttreatment surveillance.
Exceptions to the need for endo CA surgical staging include
Most women should be surgically staged (ACOG)

young or perimenopausal women with grade 1 endometrioid adenocarcinoma associated with atypical endometrial hyperplasia and women at increased risk of mortality secondary to comorbidities.

Consider staging all past Grade 1, Ia
⬢ What constitutes appropriate staging for women with endometrial cancer?
Systematic surgical staging, including pelvic washings, bilateral pelvic and paraaortic lymphadenectomy, and complete resection of all disease.

Sampling not enough.
⬢ How are women with endometrial cancer treated postoperatively? Discuss radiation:
radiation should be tailored to sites of known metastatic disease or reserved for recurrence.

there is no benefit to whole pelvic radiation therapy, except local control in the vagina and pelvis.

Patients with surgical stage I disease, postoperative radiation therapy can reduce the risk of local recurrence.
In deciding whether to use radiation, the cost and toxicity should be balanced with the evidence that
the therapy does not improve survival or reduce distant metastasis.

routine lymphadenectomy by avoiding teletherapy and substituting brachytherapy .
⬢ What are the recommendations for women found to have endometrial cancer after a hysterectomy?

options include
no further therapy and surveillance only,

reoperation to complete the surgical staging, or

radiotherapy to prevent local recurrence.
The advent of laparoscopic surgical restaging has resulted in less morbidity using this approach.
consult gyn onc
⬢ What is the mode of therapy for patients with positive pelvic or paraaortic nodes?
Every patient found to have extrauterine disease (stage III, IV) is at significant risk for developing persistent or recurrent disease and should be considered a candidate for additional therapy.
Women with paraaortic nodal disease should have the tumor completely resected and should have postoperative:
postoperative imaging studies (eg, chest computed tomography or positron emission tomography scans) to detect or exclude the presence of occult extraabdominal disease
The addition of paraaortic radiation is associated with
improved survival

benefit of concomitant or sequential systemic chemotherapy.
The use of __________ and ________ in combination, similar to use for ovarian cancer, is favored by some because of the combination’s more favorable toxicity profile.
carboplatin and paclitaxel
It is challenging to differentiate primary cervical adenocarcinoma from stage II endometrial cancer.
When the diagnosis is unclear, what should be done?
radical hysterectomy and lymphadenectomy can be performed, followed by tailored adjuvant therapy based on the pathologic findings.
Which is more predictive of survival; grade or depth of cervical invasion?
grade is more predictive of survival than depth of cervical invasion.
⬢ Is there a role for radiotherapy as an alternative to surgery?
a patient is deemed an exceptionally poor surgical candidate, primary therapeutic radiation may be considered for treating the uterine disease.

use of brachytherapy to control disease offers reasonable results in this ultra-high-risk surgical population
⬢ Is there a role for progestin therapy in the treatment of atypical endometrial hyperplasia and endometrial cancer?
Atypical endometrial hyperplasia and endometrial cancer should be considered part of a continuum.

The diagnosis remains uncertain as long as the uterus is in situ.

Progestational agents have been evaluated as a primary treatment modality of early grade 1 disease in women who wish to maintain their fertility or in those who are extremely poor operative candidates.
For women who do not desire fertility, what is recommended for treatment of atypical endometrial hyperplasia?
because of the high risk of an underlying cancer.
Women who desire to maintain fertility, whether they have a diagnosis of atypical endometrial hyperplasia or grade 1 endometrioid adenocarcinoma, may be treated with
progestins in an attempt to reverse the lesion.
How can progesterone be given in these patients?
Oral, parenteral, or intrauterine device delivery of progestin has been successful, with response rates ranging from 58% to 100%.
Following progesterone therapy, patients should undergo serial complete intrauterine evaluation approximately every _____ to document response.
3 months

Progestin therapy may successfully reverse %50 of atypical endometrial hyperplasia as well as an early endometrial carcinoma; conception may then be attempted.
Beta-thalassemia is associated with elevated Hb F and elevated Hb A2 levels greater than what?
What testing can identify individuals with alpha thalassemia trait;
only molecular genetic testing can identify this condition.
When should alpha thal be tested for/considered?
If the MCV is below normal, iron deficiency anemia has been excluded, and the hemoglobin electrophoresis is not consistent with Beta thalassemia trait (ie, there is no elevation of Hb A2 or Hb F)
If both parents are determined to be carriers of a hemoglobinopathy, what is recommended next?
genetic counseling is recommended
It should be noted that ethnicity is not always a good predictor of risk because
individuals from at-risk groups may marry outside their ethnic group.
Preimplantation genetic diagnosis has been successfully performed for
sickle cell disease and most cases of Beta-thalassemia.
Women with Hb SS have increased risk for maternal complications, such as


antepartum hospitalization,

postpartum infection.
Hb SS are at higher risk for fetal complications, such as
intrauterine growth restriction (IUGR), low birth weight, and preterm delivery.

Hb SC disease also are at risk for the aforementioned complications but to a lesser extent
Do sickle cell mothers need more folate?
1 mg per day of folic acid should be prescribed due to the continual turnover of red blood cells.
painful crisis.
precipitating by factors such as
cold environment, heavy physical exertion, dehydration, and stress should be avoided.
Painful crises in pregnancy should focus on detection of serious medical complications requiring specific therapy, such as
acute chest syndrome (fever tachypnea, chest pain, and hypoxia),
severe anemia,
cholecystitis, and
Goal of transfusion or prophylactic exchange transfusion for pregnancies complicated by sickle cell anemia?
Objective is to lower the percentage of Hb S to approximately 40%

while simultaneously raising the total hemoglobin concentration to about 10 g/dL.
⬢ Is fetal surveillance useful in pregnancies complicated by sickle cell anemia?
serial ultrasound examinations and antepartum fetal testing is reasonable.
Beta-thalassemia minor usually causes
mild asymptomatic anemia.
Are large bladder capacities always pathologic
Limited data support the need for cystometric testing in the routine or basic evaluation of urinary incontinence. It is indicated as part of the evaluation of more complex disorders of bladder filling and voiding, such as the presence of
neurologic disease and other comorbid conditions.
No studies have determined whether the addition of multichannel cystometry or video assessment over simple filling cystometry improves diagnostic accuracy or outcomes after treatment.
When surgical treatment of stress incontinence is planned, urodynamic testing often is recommended to confirm the diagnosis, unless
the patient has an uncomplicated history and compatible physical findings of stress incontinence and has not had previous surgery for incontinence.
⬢ When are urethral pressure profilometry and leak point pressure measurements useful for evaluation of incontinence?
it does not meet the criteria for a useful diagnostic test.

Leak point pressure measures the amount of increase in intraabdominal pressure that causes stress incontinence, although its usefulness also has not been proved.
⬢ When is cystoscopy useful for evaluation of incontinence?
sterile hematuria or pyuria;
irritative voiding symptoms, such as frequency, urgency, and urge incontinence, in the absence of any reversible causes;

bladder pain;
recurrent cystitis;

suburethral mass;

and when urodynamic testing fails to duplicate symptoms of urinary incontinence.
⬢ Are pessaries and medical devices effective for the treatment of urinary incontinence?
objective evidence regarding their effectiveness has not been reported.

Replacement of the prolapsed anterior vaginal wall with a pessary may unmask incontinence by straightening out the urethrovesical kinking that may have been responsible for either continence or some degree of urinary retention.
"Potential incontinence"
⬢ Are behavior modifications (eg, bladder retraining, biofeedback, weight loss) effective for the treatment of urinary incontinence?
improves symptoms of urge and mixed incontinence

combining drug and behavioral therapy in a stepped program can produce added benefit for patients with urge incontinence.
⬢ Are pelvic muscle exercises effective for the treatment of urinary incontinence?
effective treatment for adult women with stress and mixed incontinence,
Which is better, Kegels or cones or electrical stimulation?
Pelvic muscle exercise appears to be superior to electrical stimulation and vaginal cones in the treatment of stress incontinence.
The most typical side effect of anticholinergic therapy is
dry mouth
blurred vision
⬢ Is there a role for bulking agents in the treatment of urinary incontinence?

How long are symptoms relieved after injections?
For women with extensive comorbidity precluding surgery or anesthesia or both, injection of bulking agents may provide a useful option for relief of symptoms for a 12-month period.
When is surgery indicated for urinary incontinence?
when conservative treatments have failed to satisfactorily relieve the symptoms

the patient wishes further treatment in an effort to achieve continence.
Is retaining fertility potential is a contraindication for incontinence surgery?
which patients with urinary incontinence do NOT need urodynamic testing before surgery.
women who lose urine only with physical exertion;

have normal voiding habits (<8 voiding episodes per day, <2 per night);

have no associated findings on neurologic or physical examination;

have no history of antiincontinence or radical pelvic surgery;

possess a hypermobile urethra, pliable vaginal wall, and adequate vaginal capacity on physical examination;

have a normal postvoid residual volume;

are not pregnant.
Retropubic colposuspension procedures are indicated for women with the diagnosis of
urodynamic stress incontinence and a hypermobile proximal urethra and bladder neck.
Selection of a retropubic approach (versus a sling) depends on many factors, such as:
the need for laparotomy for other pelvic disease,

the amount of pelvic organ prolapse and

whether a vaginal or abdominal procedure will be used to suspend the vagina,

the age and health status of the patient, and

the preferences of the patient and surgeon.
Does hysterectomy add to the efficacy of Burch colposuspension in curing stress incontinence

Hysterectomy should be performed only for specific uterine pathology or for the treatment of uterine prolapse.
⬢ For patients with both prolapse and urinary incontinence, what surgical procedures are appropriate?
If the prolapse is to be repaired abdominally
sacral colpopexy, a retropubic colposuspension may be appropriate.
For patients with both prolapse and urinary incontinence, what surgical procedures are appropriate? If transvaginal approach
may include a sling placed at the time of repair to treat stress incontinence.
Women who have severe pelvic organ prolapse but “potential stress incontinence” present a unique challenge.
After hysterectomy and support of vaginal apex,
Suburethral plication of the bladder neck to stabilize a hypermobile urethra is probably appropriate in many cases
Combination of cervical cytology and HPV DNA screening is appropriate for women aged 30 years and older.
If this combination is used, women who receive negative results on both tests should be rescreened no more frequently than
every 3 years.

HPV neg expires in 1 year
Why test HPV only in women > age 30?
The decreasing prevalence of HPV DNA positivity in women older than 30 years and the improved specificity of HPV DNA testing in predicting CIN 2 and CIN 3 makes it a more practical screening test, combined with cervical cytology screening, in that age group.
Does HPV penetrate condoms?
Particles the size of HPV virions do not penetrate an intact latex condom
warts on moist or mucosal surfaces are more responsive to topical treatment than are warts on
drier surfaces
When should warts be reevaluated after treatment?
Warts that do not respond to a particular treatment modality after three provider-administered treatments and warts that are not cleared completely after six treatments should be re-evaluated.
The mechanism of action includes

damage to vessels within the wart

stimulation of macrophage proliferation

production of interleukin-1 and interleukin-2.
podophyllin is applied
BID for 3 consecutive days followed by 4 days of no therapy

4 cycles

leave on 8 hours
The total area of warts that should be treated with podophyllin should be limited to
10 cm2
Imiquimod MOA
ACTIVATES macrophages

imiquimod treatment area should be limited to no more than
20 cm2.
which is more effective, Podophyllin or Imiquimod?

Can they be used inside vagina?
no single treatment for external genital warts can be recommended over another.

Not for use inside vagina/anus.
When should provider-applied medication or procedures for genital warts be considered?
anatomic location of the warts (inside vagina)
the number and character of the external genital warts

co-existing medical conditions, such as pregnancy and immune deficiency
Cryotherapy is effective for
both dry and moist warts;
Drawback of cryo for warts
when treating large warts or large areas, wound care problems can occasionally be encountered.
Trichloroacetic acid and bichloracetic acid more appropriate for which characteristic of warts
small warts on moist surfaces.
Trichloroacetic acid and bichloracetic acid in concentrations of 80–90%
low viscosity, they can run onto adjacent normal tissue if over-applied, causing damage.

should be applied sparingly and allowed to dry before the patient is allowed to sit or stand.
Surgical removal of external genital warts may be advantageous because
the patient often is cured in one visit.
Surgical removal is probably most appropriate when .
the patient has only a few small warts or

large numbers of warts over a large surface area that require surgical debulking.

The former generally is done in the office using a local anesthetic, whereas the latter requires general anesthesia
Laser ablation requires specialized training and equipment and generally is reserved for
extensive and recalcitrant disease.
Pain following laser vaporization is dependent on the area being treated.

Laser ablation of large areas can result in severe pain that peaks after 5–7 days and can last up to how long?

What should be applied post ablation?
3 weeks.

Laser ablation drawback
Vitiligo and hyperpigmentation are possible

scarring is a potential complication of laser vaporization that is very extensive or too deep.
. Rarely, infants exposed to HPV may develop warty growths in the throat called laryngeal papillomatosis.

Is CD useful in preventing the transmission of HPV?
pregestational DM, in response to a report of an increased stillbirth rate in patients with a reactive nonstress test within 1 week of delivery, ____ testing has been widely adopted.
twice weekly
Contraindications to Intrauterine Device Use
Pelvic inflammatory disease (current or within the past 3 months)
⬢ Sexually transmitted diseases (current)
⬢ Puerperal or postabortion sepsis (current or within the past 3 months)
⬢ Purulent cervicitis
⬢ Undiagnosed abnormal vaginal bleeding
⬢ Malignancy of the genital tract
⬢ Known uterine anomalies or fibroids distorting the cavity in a way incompatible with intrauterine device (IUD) insertion
⬢ Allergy to any component of the IUD or Wilson's disease (for copper-containing IUDs)
If a patient had PID or POSTABORTAL/POSTPARTUM SEPSIS, how long must she wait until IUD can be inserted?
3 months
IUD Uterine perforation, the most concerning complication, is estimated to occur in approximately how many per 1000 insertions?
1 in 1,000 insertions.
If either the copper T380A or the levonorgestrel intrauterine system perforates into the peritoneal cavity, the location of the IUD should be confirmed by ultrasonography, and then
IUD should be removed by laparoscopy or laparotomy.
when removing IUDs is the lack of visible strings, what may be helpful in the office?
If the cytobrush maneuver is not helpful, what should be done?
ultrasonography should be performed to ensure intrauterine location of the IUD.
What next if can't get with cyto brush and IUD is intrauterine confirmed by u/s?
attempt to remove the IUD with an "IUD hook" under sterile conditions in the outpatient setting or may elect to remove the IUD in the operating room, where hysteroscopic guidance may be helpful.
⬢ Is routine screening for STDs (eg, gonorrhea and chlamydia) required before insertion of an IUD?
women at high risk of STDs may benefit from screening.
number of new cases in a period of time

NEW POrT (period of time)
If GC/Chl cultures are not done before IUD placement, and pt later found to have chlamydia infection, should IUD be pulled?
Clinical judgment should be used to determine whether the IUD should be removed

look for purulent discharge
abdominal pain
incidental finding
multiple partners
⬢ Is the presence of bacterial vaginosis a contraindication to IUD insertion?
Does antibiotic prophylaxis before IUD insertion decrease the risk of subsequent pelvic infection?
unlikely to be cost-effective in populations with a low prevalence of STDs.
SBE px for IUD insertion or removal needed?
Not recommended for insertion or removal.
asymptomatic patient with an IUD who has actinomyces identified on a Pap test:
Management of the asymptomatic IUD user whose Pap test shows actinomyces is not clearly established.

actinomyces found via a Pap test is not diagnostic of actinomycosis infection, nor is it predictive of future disease.

options for management of asymptomatic IUD users with actinomyces on Pap test are expectant management, an extended course of oral antibiotics, removal of the IUD, and both antibiotic use and IUD removal.

history of ectopic pregnancy considered a contraindication to IUD use?
Pregnancy with IUD. What to do:
FDA recommends that IUDs be removed from pregnant women when possible without an invasive procedure.
Do most women continue to ovulate while using the levonorgestrel intrauterine system?
Which intrauterine system resulted in a substantial reduction in menstrual blood loss
The levonorgestrel intrauterine system

may be an acceptable alternative to hysterectomy in women with menorrhagia.
When should an IUD be removed in a menopausal woman?
Awaiting 1 year of amenorrhea to ensure menopausal status is advisable before removing the device.

it seems prudent to remove the IUD placed for contraception from a menopausal woman.
in the perimenopausal period, unexpected bleeding in women with an IUD should prompt
an endometrial biopsy evaluate the possibility of endometrial pathology.
Which IUD is appropriate for emergency contraception in women who meet standard criteria for IUD insertion and is most effective if inserted within 5 days after unprotected intercourse.
The copper T380A
Ultrasonography should be performed only when there is a valid medical indication, and the lowest possible ultrasonic exposure setting should be
as low as reasonably achievable (ALARA) principle.
Is a physician is not obligated to perform ultrasonography in a patient who is at low risk and has no indications?
However, if a patient requests ultrasonography, it is reasonable to honor the request. The decision ultimately rests with the physician and patient jointly
⬢ What gestational age represents the optimal time for an obstetric ultrasound examination?
16–20 weeks
fetus found to have IUGR. What should one look for?
detailed ultrasound survey for the presence of fetal structural and functional defects may be indicated.
is an important diagnostic and prognostic parameter in fetuses with IUGR.
Amniotic fluid volume
is highly suggestive of growth failure and indicates an increased risk of fetal death.

the absence of oligohydramnios should not diminish the importance of the diagnosis of IUGR.
In pregnancies at risk for IUGR. Doppler velocimetry has been shown to both
reduce interventions
and improve fetal outcome
Identification of IUGR is improved by
recording growth velocity or through 2 sets of examinations generally 2–4 weeks apart.
Macrosomia implies growth
beyond a specific weight, usually 4,000 g or 4,500 g,

regardless of gestational age.
is the test of choice in the diagnosis of herpes-related infections of the central nervous system (meningitis and encephalitis.
More sensitive than viral culture for diagnosis of herpes
The problem with viral culture for dx herpes
not sensitive
The incubation period for HSV is
short (approximately 4 days),
Antibodies to HSV-2 are detected how long after acquisition of infection and persist indefinitely.
2–12 weeks
⬢ Is there a role for testing an asymptomatic patient who reports possible exposure?
type-specific antibody testing is more accurate than assessment of infection based on symptoms or past sexual behavior.
knowledge of infection may result in decreased distress
⬢ Is there a role for postexposure prophylaxis in an asymptomatic patient?
some physicians offer antiviral therapy in the setting of unanticipated known high-risk exposure (for example, rape or intercourse without a condom with a partner who had an unnoticed recurrence).
Acyclovir MOA
interrupt viral DNA synthesis
Acyclovir is not activated unless
HSV is actively replicating.
Suppressive therapy (in which the medication is taken daily) for genital herpes prevents approximately ___% of recurrences.

who gets suppression?

recurrences >6 times/year
In those taking daily HSV antiviral therapy:

viral shedding from the genital area is markedly decreased,

the breakthrough shedding contains reduced amounts of viral DNA.

This reduction in shedding translates into what
Women in whom a first episode genital HSV infection is diagnosed should be told
they are likely to have recurrences and that these will be milder than the first episode
Do they still shed even if don't have HSV symptoms?

they may have viral shedding with or without symptoms and that they are infectious at that time.

May shed for 7 days
Women who have partners with genital herpes should be .
tested with type-specific serology to assess the woman's risk of infection
If the partners have discordant HSV types, the couple should be counseled about
consistent use of condoms or dental dams, although condoms do not offer total protection from acquisition of HSV-2 infection.
, use of suppressive antiviral therapy in the potential source partner has been shown to decrease transmission of HSV-2 by ___%to susceptible partners
What is strongly predictive of preterm delivery in twin pregnancies.
shortened cervix identified by endovaginal ultrasonography
How do digital exams compare to u/s of cervical length?
digital examination may be less objective than ultrasonographic measurement and does not allow assessment of the internal os.
Has FFN been studied with multiple gestations?
Px cerclage in twins?
does not prolong gestation or improve perinatal outcome
tocolytics in multiples...
should be used judiciously.
Steroids in multiples?
National Institutes of Health recommends that all women in preterm labor who have no contraindications to steroid use be given one course of steroids, regardless of the number of fetuses.
How is the death of one fetus managed?
if the death is the result of an abnormality of the fetus itself rather than maternal or uteroplacental pathology, and the pregnancy is remote from term, expectant management may be appropriate.
The most difficult cases are those in which the fetal demise occurs in 1 fetus of a monochorionic twin pair.
By the time the demise is discovered, the greatest harm has most likely already been done, and there may not be any benefit in immediate delivery, especially if the surviving fetuses are very preterm and otherwise healthy.
How to manage fetal demise of 1 twin?
Fibrinogen and fibrin degradation product levels can be monitored serially until delivery, and delivery can be expedited if DIC develops.
⬢ Is there a role for routine antepartum twin fetal surveillance?
Multiple gestations are at increased risk of stillbirth.
Twin–Twin Transfusion Syndrome A variety of therapies have been attempted, but what is most frequently used?
serial therapeutic amniocenteses of the recipient twin's amniotic sac
More aggressive therapies, include abolishing the placental anastomoses by endoscopic laser coagulation or selective feticide by umbilical cord occlusion usually are considered only for
very early, severe cases,
IN TTT, death of one fetus has been reported to result in the sudden transfusion of blood from the viable fetus to the low pressure system of the dead fetus, resulting in exsanguination of the viable twin.
If the gestational age is such that surviv
immediate delivery should be considered, recognizing that damage to the remaining viable fetus may already have occurred.
Beyond ____ weeks of gestation, the biochemical markers of pulmonary maturity (lecithin/sphingomyelin ratio or fluorescence polarization immunoassay) are higher in twin pregnancies than in singleton pregnancies at comparable gestational ages.
The nadir of perinatal mortality for twin pregnancies occurs at approximately ___ completed weeks of gestation
⬢ For a postterm patient with a favorable cervix, does the evidence support labor induction or expectant management?
generally is induced in postterm pregnancies in which the cervix is favorable because the risk of failed induction and subsequent cesarean delivery is low.
⬢ For a postterm patient with an unfavorable cervix, what are options of management?
The introduction of preinduction cervical maturation has resulted in fewer failed and serial inductions, reduced fetal and maternal morbidity, reduced medical cost, and possibly a reduced rate of cesarean delivery
Prostaglandin (PG) is a valuable tool for improving cervical ripeness and inducing labor.
changes in Bishop scores,

shorter durations of labor,

lower maximum doses of oxytocin, and a

reduced incidence of cesarean delivery among postterm patients who received PGE2 gel?
For women with 2 prior cesarean deliveries, only those with what should be considered candidates for a spontaneous trial of labor.
a prior vaginal delivery
Women who attempt VBAC who have interdelivery intervals of less than 24 months have a ____x increased risk of uterine rupture when compared with women who attempt VBAC more than 24 months after their last delivery.
A second-trimester hysterotomy is associated with its own risks, and the decision to attempt a trial of labor in the midtrimester should probably be based on
individual circumstances, including but not limited to the

number of previous cesarean deliveries,

gestational age, placentation, and the

woman's desire to preserve reproductive function.
⬢ What are contraindications for VBAC?
⬢ Previous classical or T-shaped incision or extensive transfundal uterine surgery
⬢ Previous uterine rupture
⬢ Medical or obstetric complication that precludes vaginal delivery
⬢ Inability to perform emergency cesarean delivery because of unavailable surgeon, anesthesia, sufficient staff, or facility
⬢ Two prior uterine scars and no vaginal deliveries
Does epidural analgesia masks the signs and symptoms of uterine rupture?
Rarely. So, no.
internal better than external monitoring for TOLAC?
No data suggest monitoring with intrauterine pressure catheters is superior to external monitoring
Should scar dehiscences after SVD that are stable be repaired?
***Most asymptomatic scar dehiscences heal well, and there are no data to suggest that future pregnancy outcome is better if the dehiscence is surgically repaired
If the site of the ruptured scar is confined to the lower segment of the uterus, the rate of repeat rupture or dehiscence in labor is
If the scar includes the upper segment of the uterus, the repeat rupture rate is
How are patients with hydatidiform moles managed?
⬢ Complete blood count with platelet determination
⬢ Clotting function studies
⬢ Renal and liver function studies
⬢ Blood type with antibody screen
⬢ Determination of hCG level
⬢ Preevacuation chest X-ray
Medical complications of hydatidiform moles



pregnancy-induced hypertension, and

Women with signs and symptoms of these complications will need more intensive evaluation (ie, thyroid-stimulating hormones and coagulopathy studies).

Moles should be evacuated when?
as soon as possible after stabilization of any medical complications
To manage potential complications of molar evacuation in a woman with a large uterus, consideration should be given to performing the evacuation in a facility with:
an intensive care unit, a blood bank, and anesthesia services.
After serial dilation of the cervix, uterine evacuation is accomplished with what size cannula?
the largest cannula that can be introduced through the cervix.
What should you have in the OR to assist with suction D&C of mole?
ultrasound guidance may facilitate complete evacuation of the uterus.
This sequelae/sydrome has been emphasized as an underlying cause of respiratory distress syndrome following molar evacuation:

There are many other potential causes of pulmonary complications in these women.
the syndrome of trophoblastic embolization (deportation)
in moles, respiratory distress syndrome can be caused by
high-output congestive heart failure caused by
iatrogenic fluid overload

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