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Low urine 24-hour calcium levels or a low


urine calcium to urine creatinine ratio
is not characteristic of primary
hyperparathyroidism. This finding should
suggest familial hypocalciuric
hypercalcemia (FHH).

**********

All febrile neonates should be


hospitalized and receive intravenous
antibiotics, even when laboratory
screening tests are normal. Treatment
should include IV gentamicin (2.5 mg/kg)
or a third-generation cephalosporin such
as cefotaxime (50 or 100 mg/kg if
meningitis is suspected).

**********

No treatment is indicated for painless


flexible flatfoot. Spontaneous correction
is usually expected within 1 year of
walking.

**********

This child presents with language delay,


echolalia, abnormally large ears, and a
long thin face, which point to a
diagnosis of Fragile X syndrome (FXS),
especially when the history of males with
mental retardation on the maternal side
of the family is also taken into account.

**********

Rotavirus is the most common agent


responsible for infantile diarrhea
throughout the world. In tropical
climates, rotavirus is the etiologic
agent in 15%-50% of cases of acute
diarrhea in children, and in temperate

climates it accounts for 35%-60% of


cases.

**********

Outbreaks of Norwalk gastroenteritis


occur in a wide variety of settings,
involve all ages, and are more likely to
involve high-risk groups such as
immunocompromised patients or the
elderly. Not only does viral shedding of
the Norwalk virus often precede the onset
of illness, but it can continue long
after the illness has clinically ended.
The virus persists on environmental
surfaces and can tolerate a broad range
of temperatures. There are multiple
strains of the virus, so a single
infection does not confer immunity, and
repeated infections occur throughout
life. It is the most common cause of
diarrhea in adults.

**********

The most common cause of acute diarrhea


in Canada is attributed to C. jejuni;
lower GI symptoms are predominant and
begin at least 12-48h after eating.

**********

Although rare in Canada, enterotoxigenic


E. coli is the most common cause of
travelers diarrhea.

**********

Good prognostic factors for ALL: young,


WBC < 30x109/L, T-cell phenotype, absence
of Ph chromosome, early attainment of
complete remission.

**********

Progressive untreated AS ultimately


results in one or more of the classic

triad of syncope, angina, and exertional


dyspnea

**********

Mild intermittent asthma is characterized


by daytime symptoms occurring no more
than 2 days per week, and nighttime
symptoms no more than 2 nights per month.
The peak expiratory flow (PEF), or forced
expiratory volume in 1 second (FEV1) is
80% or more of predicted. Mild persistent
asthma is characterized by daytime
symptoms more than 2 days per week, but
less than once a day, and nighttime
symptoms more than 2 nights per month.
PEF or FEV1 is 80% or more of predicted.
Moderate persistent asthma is
characterized by daytime symptoms daily
and nighttime symptoms more than one
night per week. PEF or FEV1 is 60%-80% of
predicted. Severe persistent asthma is
characterized by continuous daytime
symptoms and frequent nighttime symptoms.
PEF or FEV1 is 60% or less of predicted.

**********

Inhaled beta-adrenergic agents should be


used every 4 hours if needed. Overuse of
these agents has been associated with an
increased mortality rate.

**********

The treatment of choice for occasional


acute symptoms of asthma is an inhaled
2-adrenergic agonist such as albuterol,
terbutaline, or pirbuterol. If symptoms
do not respond to beta-agonists, they
should be treated with a short course of
systemic corticosteroids.

**********

Cromolyn can decrease airway


hyperreactivity, but has no
bronchodilating activity and is useful
only for prophylaxis.

**********

Asthma is the most common chronic illness


of childhood.

**********

>Mild intermittent (choice A) has daily


symptoms <2x/week and nighttime symptoms
<2x/month. Their PEF is >80%.
>Mild persistent (choice B) has daytime
symptoms > 2 days a /week and nighttime
symptoms 3-4x/month. Their PEF is >80%.
>Moderate persistent (choice C) has daily
daytime symptoms with nighttime symptoms
occurring >1 time/week. Their PEF is >60%
and <80%.

**********

Rett syndrome is a neurodevelopmental


disorder of the brain that affects girls
almost exclusively. The clinical features
include small hands and feet and a
deceleration of the rate of head growth.

**********

A post-traumatic air-fluid level in the


sphenoid sinus is associated with basilar
skull fractures.

**********

Conjugated bilirubinemia, shrunken gall


bladder on ultrasonography, and a biopsy
that reveals portal fibrosis and bile
duct proliferation are suggestive of
biliary atresia. Kasai procedure is the
best initial treatment in children with

biliary atresia and is most beneficial


when performed before 60 days of age.

**********

A 12-year-old boy presents to the


emergency room complaining of pain and
swelling at the left mid-femur area for
approximately two weeks. On review of
systems, he has had on/off low-grade
fever for the last month, and the mother
says it looks like he has lost some
weight, but she had attributed this to a
recent growth spurt. You perform an X-ray
and notice a bizarre periosteal reaction,
which the radiologist describes as "onion
skinning." The following day, a biopsy is
performed and shows small, round blue
cells.
Given this history and these findings,
what is the most likely diagnosis?
a) Osteosarcoma
b) Osteoid osteoma
c) Ewing's sarcoma
d) Chondroblastoma
e) Nonossifying fibroma
The correct answer is c.
Topic: bone tumors in children
Subject: Pediatrics
Explanation:
Ewing sarcoma is the correct answer in
this case. It is a malignant, small round
blue cell tumor. It is the second most
common malignant bone tumor (after
osteosarcoma). It tends to peak between
10-20 years of age. Symptoms typically
include pain and swelling, usually

involving the midshaft of long bones,


flat bones of the ribs and
pelvis.Constitutional symptoms or signs,
such as fever, fatigue, weight loss, or
anemia, are present in about 10 to 20
percent of patients at presentation.
Radiograph studies have typical features
of multiple layers of periosteum around
the tumor site described as
"onion-skinning" pattern (see image).

> Osteosarcoma (choiceA), while it is the


most common malignant bone tumor, it
typically does not present with systemic
symptoms and radiographs typically show a
"sunburst" pattern (soft tissue mass with
radial calcifications).
> Osteoid osteoma (choiceB) is a benign
bone-forming tumor, which produces high
levels of prostaglandins (pain typically
responds to NSAIDs).The lower extremity
is most frequently affected; the proximal
femur is the most common site. Boys are
affected two to three times as often as
girls.On plain radiographs, osteoid
osteoma appears as a small, round lucency
(nidus) with a sclerotic margin.
> Chondroblastoma (choiceD) is a benign
cartilage-forming tumor that usually
arises in the epiphyses of long bones
andtypically presents during the teenage
years. On plain radiographs,
chondroblastomas appear as small,
well-defined lesions with a sclerotic
border that may cross the physis (growth
plate).

> Nonossifying fibroma (choiceE) is a


benign fibrous lesion that is also known
as metaphyseal cortical defect. It is a
developmental defect in which areas that
normally ossify are filled with fibrous
connective tissue. On plain radiographs,
nonossifying fibromas appear as small,
well-defined, eccentric, expansile, lytic
lesions located in the metaphysis with
scalloped sclerotic borders.
When benign bone tumors are symptomatic,
they may present with localized pain,
swelling, deformity, or pathologic
fracture.Malignant bone tumors include
the same symptoms,but also
usuallyaccompanied by systemic symptoms
(fever, weight loss, night sweats).

**********
Human breast milk may safely be stored up
to 10 hours at room temperature, up to 8
days in the refrigerator, and up to 12
months when frozen.

**********

>Leukemias account for about 31% of all


cancers in children. Acute lymphoblastic
leukemia is the most common childhood
cancer
>Non-Hodgkin's lymphoma is more common
in children than Hodgkin's disease
>Wilms tumor (nephroblastoma), is the
most common childhood abdominal
malignancy.
>Neuroblastoma is the most common
extracranial solid cancer in childhood
and the most common cancer in infancy.

**********

Endocarditis prophylaxis is recommended


in Coarctation of Aorta

**********

Gastric lavage is not likely to be


beneficial more than 60 minutes after an
ingestion. In order to prevent pulmonary
aspiration, gastric lavage should never
be performed in a comatose patient prior
to placing an endotracheal tube.

**********

21-hydroxylase deficiency accounts for


95% of the cases of congenital adrenal
hyperplasia. It is also the most frequent
endocrine cause of neonatal death. With
severe forms, salt wasting, shock, and
significant virilization occur. The genes
for this enzyme are within the HLA
complex on the short arm of chromosome
6w.

**********

Congenital cataract is the most common


cause of leukocoria in an otherwise
healthy, full term newborn.

**********

Infantile colic is defined as crying for


more than three hours per day, for more
than three days per week, and for longer
than three weeks.

**********

Any child 12 years or younger who


presents with nasal polyps should be
suspected of having cystic fibrosis until
proven otherwise.

**********

The recommended fluid to be infused as


maintenance for well children with normal
hydration is:

0.45% NaCl with 5% Glucose + 20mmol KCl /


Liter.
This is often written as D5 NS + 20KCl
The D5 refers to the glucose (dextrose),
NS refers to Normal saline which is 0.9%
NaCl. NS would refer to 0.45% NaCl.
In this child the potassium is in the
upper limit of normal, since normal range
is 3.5-5.0. So, do not add potassium at
this time. The maintenance treatment
would be with 0.45% NaCl with 5% Glucose.
If giving a bolus, you would use 0.9%
NaCl normal saline.
(0.2 NaCl with 5% glucose + 20KCl - in
the first month of life).

**********

Fluoxetine is the only SSRI approved by


the FDA for the treatment of depression
in children 8-17 years of age.

**********

Dermatomyositis : Electromyography showed


increased insertional activity,
fibrillation potentials, sharp waves and
decreased duration and amplitude of
action potential.

**********

At 3 - 4 months of age, a normal term


baby will smile at almost anyone. By 9
months of age, there is a developmentally
normal anxiety over separation from the
mother (Or primary care giver), as well
as anxiety at the sight of an unfamiliar
face. Coincident with the increased
mobility gained by walking (usually at
12-15 months of age), these anxieties
normally abate.

**********
Sensorimotor stage is the correct answer.
This stage encompasses birth to 2 years
of age and consists of children learning
by activity, explanation, and
manipulation of the environment.
B. Preoperational stage, ages 2-7: the
child engages in symbolic representation
of the world.
C. Concrete operations, ages 7-11: the
child is capable of limited, logical
thought process.
D. Abstract operations is not a stage of
Piagets cognitive development.
E. Formal operations, ages 12 to adult:
the child can reason logically and
abstractly.

**********

Head banging has been estimated to be


present in 3%-15% of normal children and
usually begins between the ages of 5 and
11 months. The vast majority of these
children will engage in this activity for
only a few months, and most will stop by
age 3.

**********

Which of the following is not part of the


normal developmental milestones for a 24
month old child?
a) Builds tower of four blocks or more
b) Begins to run
c) Scribbles spontaneously
d) Begins to copy some capital letters
The correct answer is d.
Topic: Developmental Milestones

Subject: Pediatrics
Explanation:
Choices a), b) and c) are part of the
developmental milestones up to the age of
2. Choice d) is part of the developmental
milestones by the end of 4 years.
Two-year-old children usually produce 2-3
word phrases, may follow 2-step commands,
and be understood by a stranger about 50%
of the time.
2-year-old infants are able to walk up
and down stairs, but not hop, may remove
pants and shoes, but does not exhibit
fully developed language usage or
parallel play.

**********

4 years old. Gross motor skills at 4


years of age include hopping, skipping,
and alternating feet going downstairs.
Visual motor skills at 4 years of age
include buttoning clothing fully and
catching a ball. Language skills at 4
years of age include knowing colors,
singing songs from memory. Social skills
at 4 years of age include cooperative
play.
A. 2-year-old infants are able to walk up
and down stairs, but not hop, may remove
pants and shoes, but does not exhibit
fully developed language usage or
parallel play.
B. 3-year-old infants may alternate feet
going up steps, dress and undress

partially, use 3-word sentences, and


begin group play.
D. 5-year-old infants may skip
alternating feet, tie shoes, print their
first name, and play competitive games.
E. 6-year-old children are in
kindergarten to 1st grade and know their
ABCs, may count up to ten, form
friendships, and do household chores.

**********

At 15 months a child should be able to


walk backwards, creep up stairs,
scribble, build a tower of two blocks,
and use 4-6 words.
A. At 9 months, the average child can
neither walk nor talk.
B. An average 1-year-old knows 1-3 words
and cannot walk backwards.
D. At 2 years, a child should know about
100 words and be able to walk up and down
stairs.
E. At 3 years, a child should be able to
use 3-word sentences, dress himself, and
draw a circle.

**********

Developmental milestones
At 12 months, a child should be able to
walk with support, pincer grasp, throw
objects and speak in single words.
6 months: tripod sit, object transfer
from hand to hand, babble, stranger
anxiety
2 years: 2 word sentences, understands 2
step commands, up/down steps
3 years: 3 word combos, 3 digit repeat,

rides tricycle
4 years: Counts 4 objects, knows 4
colours, draws 4 sided object (square)
Developmental red flags:
Not smiling at 3 months
No peek-a-boo at 9 months
Exhibits handedness < 10 months
Not walking and < 3 words at 18 months

**********

a febrile neonate temperature >38C


undergoes a full sepsis workup, which
includes a CBC count, urinalysis, blood
culture, urine culture, chest
radiography, and diagnostic LP.

**********

Any child younger than 29 days old with a


fever, and also any child,regardless of
age,who appears toxic, should undergo a
complete sepsis workup and be admitted to
the hospital for observation until
culture results are known or the source
of the fever is found and treated.
Observation only, with close follow-up,
is recommended for nontoxic infants 3-36
months of age with a temperature <39.0C
(102.2F). Children 29-90 days old who
appear to be nontoxic and have negative
screening laboratory studies, including a
CBC and urinalysis, can be sent home with
precautions and with follow-up in 24
hours. Testing for neonatal herpes
simplex virus infection should be
considered in patients with risk factors,
including maternal infection at the time
of delivery, use of fetal scalp
electrodes, vaginal delivery,

cerebrospinal fluid pleocytosis, or


herpetic lesions. Testing also should be
considered when a child does not respond
to antibiotics.

**********

Hypochondriasis is the major differential


of somatization. Be careful! The
hypochondriatic patient will also
complain of multiple symptoms; however,
she will name only one disease and will
try to convince you with this diagnosis.
In other words, the patient will tell you
I think I have brain tumor, heart
attack

**********

Somatization disorder is characterized


by:
unexplained physical symptoms manifested
before age 30
symptoms last for several years
symptoms include two gastrointestinal,
four pain, one pseudoneurologic, and one
sexual

**********

La belle indiffrence is considered a


classic feature of conversion disorder.
It is characterized by the inappropriate
and paradoxical absence of distress
despite the presence of an unpleasant
symptom.

**********

In addition to the regular use of


emollients, the mainstay of maintenance
therapy, topical corticosteroids have
been shown to be the best first-line
treatment for flare-ups of atopic
dermatitis.

**********
Which of the following is not true of
Erbs palsy?
a) It affects the fourth and fifth
cervical spinal nerves
b) It can result from traction on the
head, neck, and arms of large infants
during a vaginal delivery
c) The grasp reflex is intact
d) The Moro, biceps, and radial reflexes
are absent on the affected side
e) The affected arm is adducted and
internally rotated with the elbow
extended, the forearm is in pronation,
and the wrist is flexed

**********

This infant has the typical flea-bitten


rash of erythema toxicum neonatorum
(ETN).

**********

The most common cause of poor weight gain


is inadequate caloric intake.
-Up to 10% of birth weight is lost in the
first 7 days of life.
-A term newborn should then regain their
weight by 10 days of age and should gain
20-30 grams/day.
-The energy requirements of a 0-10 kg
child are 100 Kcal/kg/day.
-Signs of inadequate intake are:
< 6 wet diapers/day;
< 7 feeds /day;
lethargy, jaundice.

**********

Ovarian cancer affects mainly


perimenopausal and postmenopausal women.
Nulliparity, delayed childbearing, and

delayed menopause increase risk. A


personal or family history of
endometrial, breast, or colon cancer
increases risk. Probably 5 to 10% of
ovarian cancer cases are related to
mutations in the autosomal dominant BRCA
gene.
Studies find that birth control pills can
help reduce a woman's risk of developing
ovarian cancer.

**********

The most common cause for a cystic


enlargement of the ovary in a
reproductive age woman is a functional
cyst (follicular or corpus luteum).

**********

The vast majority of ovarian cysts


diagnosed in early pregnancy represent a
physiological cyst known as the corpus
luteum (cystic or hemorrhagic). This is a
normal finding in early pregnancy. The
corpus luteum supports the lining of the
womb and in turn the pregnancy itself.
The corpus luteum does this by producing
the pregnancy hormone progesterone which
helps nurture the pregnancy. Once the
pregnancy gets beyond the 1st trimester,
the corpus luteum is no longer needed and
therefore this resolves spontaneously,
not causing any harm whatsoever to the
mother or baby.

**********

While dysgerminomas are the most frequent


ovarian malignancy in young women, they
are not as frequent as corpus luteum and
follicular cysts.

**********
In premenarchal patients, most neoplasms
are germ cell in origin and require
surgical exploration

**********

The Pap is a screening test used to


detect premalignant and malignant
processes in the ectocervix.It may also
detect infections and abnormalities in
the endocervix and endometrium

**********

The Canadian Task Force on Preventive


Healthcare (CTFPHC) recommends that a
Pap test should be done every 3 years in
women 30-69 years of age, if a womans
previous test results were negative

**********

The category of atypical glandular cells


not otherwise specified (AGC-NOS) has a
benign sound to it, although it is
associated with a 17% rate of cancer (8%
carcinoma in situ, and 9% invasive
carcinoma). High-grade squamous
intraepithelial lesion (HSIL), which
would seem worse intuitively, has only a
3% associated cancer rate.

**********

Because AGUS is associated with


significant clinical disease, all women
found to have AGUS should have colposcopy
as the next step in management. For women
older than 35 years,endocervical
sampling should be done in addition
tocolposcopy(choiceE). This is
particularly encouraged in women with any
unexplained vaginal bleeding,history of
amenorrhea, or use of oral contraceptive

pills.

**********
Repeat Pap smear at 6 and 12 months
(choiceA) may be done for atypical
squamous cells of undetermined
significance or low grade squamous
intraepithelial lesions with few risk
factors but it is not sufficient for the
management of AGUS. Unlike women with
atypical squamous cells of undetermined
significance, a significant percentage of
women with AGUS will have more serious
lesions, such as high-grade preinvasive
squamous disease, adenocarcinoma in situ,
adenocarcinoma or invasive cancers from
sites other than the cervix.

**********

All women with atypical glandular cells


of undetermined significance (AGUS)
should have colposcopy. In women >35
years old, endocervical curettage is also
recommended.

**********

All women who have a pap smear that shows


moderate to severe dysplasia should have
a colposcopy with biopsy done.

**********

HPV infection is common and transient in


most adolescent women (20 years and
younger) in their first few years of
sexual activity. With careful follow-up,
they can be observed rather than treated
for HSIL.

**********

The cervical cytology category of


atypical squamous cells of undetermined
significance (ASC-US) is one that is

poorly reproducible, having been shown to


be frequently downgraded to negative or
upgraded to a low- or high-grade squamous
intraepithelial lesion on review.
Recommended management strategies women
with ASC-US include repeat cytology at
4-6 months, immediate colposcopy, and
reflex DNA testing for oncogenic HPV
types. Should two repeat cytologic
examinations at 4- to 6-month intervals
prove negative, the patient can safely
return to routine cytologic screenings.
Should any repeat examination detect
ASC-US or more significant cytology,
colposcopy is indicated.

**********

Cervical cancer screening is recommended


every three years for all women starting
at age 21 who are or ever have been
sexually active.
Sexual activity includes intercourse, as
well as digital or oral sexual activity
involving the genital area with a partner
of either gender.
Women who are not sexually active by 21
years of age should delay cervical cancer
screening until sexually active.
Regardless of sexual history, there is no
evidence to support screening women under
21 years of age.
Based on the latest clinical evidence,
cervical cancer screening every three
years is effective.
Pap tests can stop at age 70 in women who
have had three or more normal tests in
the prior 10 years.
Immunocompromised women should receive
annual screening.

Women who have undergone subtotal


hysterectomy and retained their cervix
should continue screening according to
the guidelines.

**********

Clinical practice guidelines recommend


that all patients with atypical glandular
cells of undetermined significance (AGUS)
be evaluated by colposcopy and
endocervical curettage; endometrial
sampling is recommended in women 35 years
of age or older, and in those with AGUS
favouring neoplasia or suggesting an
endometrial source. Cervical
intraepithelial neoplasia is the most
common histologic diagnosis found in
patients evaluated for AGUS.

**********

Any cervical dysplasia (formerly cervical


intraepithelial neoplasia IIII, now
low-grade and high-grade squamous
intraepithelial lesion) necessitates
colposcopy for definitive diagnosis.

**********

Conization of the cervix is always


preceded by a colposcopy, and is
indicated for unsatisfactory colposcopy,
inconsistency of colposcopic findings
with Pap smear findings, an endocervical
curettage with abnormal cells, or a
lesion on colposcopy extending into the
endocervix.

**********

CIN is graded as 1 (mild cervical


dysplasia), 2 (moderate dysplasia), or 3
(severe dysplasia and carcinoma in situ).

CIN I (LSIL) treatment:


-observe with regular cytology (every 6
months)
-many lesions will regress or disappear
(60%)
-colposcopy if positive on 2 consecutive
smears
-lesions which progress should have area
excised by either LEEP, laser,
cryotherapy or cone biopsy (with LEEP,
tissues obtained for histological
evaluation)
CIN II and CIN III (HSIL) treatment:
-colposcopy referral
-ablation or excision therapy: LEEP,
laser, cryotherapy, cone excison, cautery
-hysterectomy, only if no desire for
future childbearing

**********

Human papillomavirus (HPV) DNA testing is


useful for determining whether colposcopy
is needed in patients whose Papanicolaou
(Pap) test shows aytpical squamous cells
of undetermined significance (ASCUS).
Women with a negative result for
high-risk HPV can be safely followed
without colposcopy.

**********

The CDC recommendations for the treatment


of PID with intravenous medications
include (A) cefoxitin and doxycycline,
(B) clindamycin and gentamicin. In
treating an abscess, it is necessary to
have anaerobic coverage by agents such as
clindamycin or metronidazole. Quinolones
with clindamycin can also be used.
Aminoglycosides do not cover against

anerobes

**********
The criteria for hospitalizing patients
with pelvic inflammatory disease include
failure to improve after 3 days of oral
therapy, inability to tolerate
antibiotics, suspicion that the patient
will not comply with therapy,
tubo-ovarian abscess, severe illness with
high fever, vomiting, pain, pregnancy,
and the underlying possibility of a
surgical problem such as appendicitis.

**********

Pelvic inflammatory disease (PID) results


from microorganisms ascending from the
vagina and cervix into the endometrium
and fallopian tubes. Infection of the
cervix (cervicitis) causes mucopurulent
discharge. Infection of the fallopian
tubes (salpingitis) and uterus
(endometritis) tend to occur together. If
severe, infection can spread to the
ovaries (oophoritis) and then the
peritoneum (peritonitis). These
infections are called salpingitis even
though they involve other structures.

**********

With genital herpes, if a woman does have


a lesion or prodromal symptoms at
delivery, the safest practice is a
cesarean delivery

**********

Current guidelines recommend treatment


with antiviral agents for primary HSV
infection in pregnancy.

**********

Zidovudine and nevirapine have the most

well-established track record.

**********

If a woman is nonimmune to rubella, then


the risk of congenital rubella syndrome
is 20% for a primary infection in the
first trimester. Cataracts, patent ducuts
arteriosus, and deafness are the most
common findings.

**********

Rubella infection during pregnancy can


result in miscarriage, fetal death, or
congenital rubella syndrome. If a
pregnant woman is exposed to rubella,
testing for rubella antibody should be
performed as soon as possible. Positive
rubella IgG antibody means that the
patient is immune and not at risk. If
serum IgG is not detectable, a second
blood specimen should be obtained in 2-3
weeks; evidence of seroconversion
indicates recent infection.

**********

Congenital rubella syndrome is most


commonly associated with the following
types of anomalies: ophthalmologic
(cataracts, retinopathy, congenital
glaucoma), cardiac (patent duct
arteriosus, peripheral pulmonary artery
stenosis), auditory (sensorineural
hearing impairment), and neurologic
(behavioral disorders,
meningoencephalitis, and mental
retardation).

**********

Syphilis in pregnancy is associated with


mental retardation, stillbirth and sudden
infant death syndrome;

**********
Viral hepatitis is the most common cause
of jaundice in pregnancy

**********

Newborns who are exposed to hepatitis B


have more than a 90% chance of becoming
chronically infected. This means the
virus stays in their blood and liver for
possibly a lifetime. They can pass the
virus on to others. They will also live
with a greater chance of developing liver
failure or liver cancer later in life.

**********

The most common cause of perinatal


mortality is Prematurity.
The perinatal period is defined as the
period that commences at 22 completed
weeks (154 days) of gestation and ends
seven completed days after birth.
Perinatal mortality refers to the number
of stillbirths and deaths in the first
week of life (early neonatal
mortality).Perinatal and maternal health
are closely linked. During this time the
top causes of death in the fetus are (in
order): prematurity, congenital
abnormalities, infections and
Intra-uterine growth retardation (IUGR).

**********

For women affected with PKU, it is


essential for the health of their child
to maintain low phenylalanine levels
before and during pregnancy. Though the
developing fetus may only be a carrier of
the PKU gene, the intrauterine
environment can have very high levels of
phenylalanine, which can cross the

placenta. The result is that the child


may develop congenital heart disease,
growth retardation, microcephaly and
mental retardation.

**********

Beginning in the midluteal phase,


progesterone is secreted in a pulsatile
fashion, occurring immediately following
an LH pulse. Prior to ovulation,
progesterone levels are less than 1
ng/ml, but reach a midluteal level of
10-20 ng/ml.
A. FSH stimulates the production of
estrogen as well as the production of FSH
receptors.
C. When peak levels of estradiol are
achieved, the onset of the LH surge then
occurs.
D. FSH stimulates secretion of inhibin
from granulose cells and, in turn, is
suppressed by inhibin.
E. Activin is related to inhibin, but has
an opposite effect (stimulates FSH
release and GnRH receptor number).

**********

Progesterone released by the corpus


luteum, stimulates proliferation of
gladular tissue by increasing the
development of milk producing alveolar
cells.

> Oxytocin via the suckling reflex


causes the contraction of the
smooth-muscle cells in the ducts to eject
the milk from the nipple.
>Prolactin is the primary hormone

responsible for stimulating alveolar


cells to produce milk. During pregnancy,
high levels of progesterone inhibit
prolactin from milk synthesis. Therefore
the role of progesterone and prolactin
should not be confused as the first
stimulates to development of glands while
the latter make the glands produce milk.
The expulsion of the placenta at delivery
initiates milk production and causes the
drop in circulating estrogen and
progesterone.
> Estrogen released from the ovarian
follicle, promotes growth ducts. During
pregnancy estrogen antagonizes the
positive effect of prolactin on milk
production.
> Human placental lactogen is chemically
similar to the growth hormone and
prolactin. It antangonizes the cellular
action of insulin, decreasing insulin
utilization, thereby contributing to the
predisposition of pregnancy to glucose
intolerance and diabetes.

**********

Complications of placenta previa :


Hemorrhage
Preterm delivery
Congenital malformations
Abnormal fetal presentation
Placental abruption
Higher rates of blood transfusion
Increased incidence of postpartum
endometritis
Hemostasis

**********

The classical clinical presentation of


placenta previa is painless, bright red

vaginal bleeding.

**********

Abruption of the placenta is the most


common cause of intrapartum fetal death

**********

Postcoital bleeding should be assumed to


be a gynecologicalmalignancy until
proven otherwise. Malignant causes of
postcoital bleeding include cervical
malignancy (squamous cell carcinoma (95%)
and adenocarcinoma (5%))and vaginal
atrophy.

**********

Any post menopausal woman who has vaginal


bleeding should have an endometrial
biopsy.

**********

Amoxicillin is preferred for the


treatment of Lyme disease in children, as
well as for pregnant or lactating women.
Doxycycline is effective, but should not
be used in pregnant women.

**********

Premature ovarian failure is


characterized by the triad of amenorrhea,
hypergonatropinism, and hypoestrogenism.

**********

factors that may be linked to PROM


include the following: multiparity, low
socioeconomic conditions (as women in
lower socioeconomic conditions are less
likely to receive proper prenatal care),
sexually transmitted infections such as
chlamydia and gonorrhea, previous preterm
birth, vaginal bleeding, cervical
incompetence, cigarette smoking during
pregnancy.

**********
Offer all women screening for group B
streptococcal disease at 35 to 37 weeks'
gestation since it appears that
identifying and treating asymptomatic
baceteriuria decreases the risk of
preterm delivery.It has been specifically
demonstrated that treatment of group B
streptococcal bacteriuria decreases the
risks of neonatal septis.

**********

Escherichia coli is the most common


infectious agent responsible for
asymptomatic bacteriuria in pregnant
women. It is recommended that screening
be done at 12-16 weeks of gestation or at
first prenatal visit if patient initial
presentation is later than the
recommended gestational age for
screening.

**********

Triple marker: 15-18 weeks gestation


Amniocentesis: if necessary, usually15-18
weeks
Screen for gestational diabetes: 24-28
weeks gestation
Group B strep: 35-37 weeks gestation

**********

Crown-rump length is a very accurate


parameter in the first trimester, but the
biparietal diameter is the most accurate
parameter during the second trimester.

**********

PEARL: Chorionic Villus Sampling is


performed between 10 and 12 weeks
gestation.

**********

Routine blood work during the first


trimester includes CBC, Rubella titer,
ABO and RH, antibody screen, UA, urine
culture, HBsAg, RPR.

**********

Maternal serum triple marker screening is


done between 15-18 weeks. Post partum
visit happens 6 weeks after delivery. CVS
can be done between 10-12 weeks. Oral
glucose challenge test is done between
24-28 weeks. Rhogam is given at 28 weeks
to RH negative women.

**********

Preterm delivery (20-37 weeks gestation)


is three to four times more likely in
women who have had a prior preterm
delivery (choice A). Multiple gestation
also makes preterm delivery more likely.
There are some known risk factors for
premature birth:

Second- or third-trimester bleeding


Some chronic conditions, such as high
blood pressure and diabetes
Being underweight or overweight before
pregnancy, or gaining too little or too
much weight during pregnancy
Cigarette smoking, alcohol use, or
illicit drug use during pregnancy.

**********

Preterm birth applies to delivery


occuring after the 20th week of gestation
but before the 37th week.

**********

Lichen schlerosus is associated with


vulvar cancer in older women.

**********
The classic triad of Vasa Previa are
membrane rupture followed immediately by
painless vaginal bleeding and fetal
bradycardia.

**********

Common risk factors for Vasa previa are


multiple pregnancies, bilobed placenta,
velamentous cord insertion, in vitro
fertilization, low-lying placenta or
placenta previa, uterine surgery, and
succenturiate-lobed placenta.

**********

Absolute contraindication to VBAC are


include prior classical (vertical)
uterine incision

**********

Contraindications to vaginal delivery


include footling breech, large fetus
(>3800 grams), hyperextended fetal head,
inadequate pelvic size, medical/obstetric
contraindications to labour and vaginal
delivery, abnormal fetus, previous
classical cesarean (classical uterine
incision), total placenta previa,
transverse lie presentation, and herpes
simplex virus with active genital lesions
or prodromal symptoms

**********

If a patient is a gestational diabetic


with a macrosomic fetus and a prior
shoulder dystocia, a cesarean delivery is
indicated.

**********

Maternal factors associated with IUGR are


high blood pressure, chronic kidney
disease, advanced diabetes, heart or

respiratory disease, malnutrition,


anemia, infection, substance abuse
(alcohol, drugs) and cigarette smoking.
Factors involving the uterus and placenta
are: decreased blood flow in the uterus
and placenta, placental abruption,
placenta previa, and infection in the
tissues around the fetus.
Factors related to the developing fetus
are: multiple gestation, infection, birth
defects and chromosomal abnormality.

**********

Atenolol and propranolol are associated


with intrauterine growth retardation

**********

Treatment of premature labor with


betamethasone or dexamethasone has been
associated with up to a 65% reduction in
necrotizing enterocolitis in the neonate.
> Weekly treatment is not generally
accepted. Increasing reports of adverse
consequences with repeated courses of
treatment has caused most experts to
recommend a single course of antenatal
corticosteroids for women at risk of
preterm birth at 24-34 weeks gestation.
> Reported benefits of antenatal steroid
therapy for preterm labor include reduced
rates of intraventricular hemorrhage and
persistent patent ductus arteriosus.
> Both neonatal mortality and the
incidence of respiratory distress
syndrome are also reduced.

**********

It should take 5 to 30 minutes for a

multipara to transition through this 2nd


stage (as opposed to 30 minutes to 3
hours for a nullipara).

**********

Misoprostol is valuable for labor


induction or cervical ripening. It should
not be used in a woman with a history of
uterine surgery and is not indicated
during active labor.

**********

Leiomyomas are much more common in women


of African-American descent.

**********

Lichen sclerosus is a chronic,


progressive, inflammatory skin condition
found in the anogenital region. It is
characterized by intense vulvar itching.
The treatment of choice is high-potency
topical corticosteroids.

**********

For nausea and vomiting, however, vitamin


B 6 is considered first-line therapy,
sometimes combined with doxylamine.

**********

Among women taking estrogen alone, the


risk of breast cancer increased only when
duration of use was 5 years.

**********

Hormone replacement therapy that includes


estrogen has been shown to decrease
osteoporosis and bone fracture risk. The
risk for colorectal cancer also is
reduced after 5 years of estrogen use.
The risk for myocardial infarction,
stroke, breast cancer, and venous
thromboembolism increases with long-term
use.

**********
Estrogen is
flashes but
alone as it
endometrial

**********

effective in treating hot


generally should not be given
increases the risk for
cancer.

Hormone Replacement Therapy:


-helps with symptomatic relief of
estrogen deprivation
-decreases risk of osteoporotic
fractures, colorectal cancer
-increases risk of breast cancer,
coronary heart disease, stroke, and
pulmonary embolism

**********

Hormone replacement therapy (HRT) is


considered the first line treatment for
symptoms of vasomotor instability (hot
flushes, night sweats, sleep
disturbances).

**********

Selective serotonin reuptake inhibitors


(SSRIs) have been proposed as an
alternative to hormonal therapy for
breast cancer survivors.

**********

Hypercoagulable states are


contraindications to HRT or OCPs.

**********

Absolute contraindications to HRT


include:
Severe liver disease
Undiagnosed vaginal bleeding
Venous thrombosis
Known/suspected breast/uterine cancer
Relative contraindications include:

Hypertriglyceridemia (a)
Uncontrolled hypertension (b)
Migraine headaches (c)
History of uterine fibroids (d)
History of breast cancer
Atypical ductal hyperplasia of the
breast
Active gallbladder disease

**********

Menstrual migraine is usually not


associated with aura and often lasts
longer than nonmenstrual migraine. The
headaches occur just before or during
menses as a result of estrogen
withdrawal, mediated by prostaglandins.
NSAIDs are effective first-line
treatment, because they inhibit
prostaglandin synthesis or block
prostaglandin receptors. If the initial
NSAID is ineffective, other classes of
NSAIDs should be tried. When headaches
cannot be controlled with NSAIDs, a 5-HT
agonist (triptan) may be used.

**********

This patient has metrorrhagia, or


bleeding intermenstrual, characterized
by bleeding heavy enough to require the
use of multiple pads; the heavy bleeding
occurs between normal menstrual bleeding.
It is important to evaluate metrorrhagia
because potential causes include cervical
disease, problems with IUDs,
endometritis, polyps, submucous myomas,
endometrial hyperplasia, and cancer.
-Mid-cycle spotting, as the term implies,
refers to light spotting, and is often
caused by a decline in estrogen levels.

-Polymenorrhea is bleeding occurring at


intervals of less than 21 days.
-Menorrhagia is very heavy bleeding
during a regular period or prolonged
bleeding (> 8 days)

**********

Migraine sufferers usually have


improvement of symptoms in pregnancy and
many have complete remission.

**********

Ergotamines are abortifacients and are


absolutely contraindicated in pregnant
women and women of childbearing age who
are not using reliable
contraception.Prolonged vasoconstriction
of uterine vessels with increased
myometrial tone may lead to reduced
myometrial and placental blood flow and
contribute to fetal growth retardation
seen in animal studies.

**********

Complete mole, paternal diploid, 95%


46XX, 5% 46XY.
Incomplete mole: triploid, with two sets
of paternal origin, 69 XXX, etc.
A complete mole does not have a fetus.
Due to the high levels of HCG, it can be
associated with hyperthyroidism, theca
lutein cysts, and hyperemesis gravidarum.
It can also be associated with
preeclampsia in the first trimester.

**********

Serotonin syndrome is characterized by


hyperthermia, tachycardia, hyperreflexia,
and altered mental status. It is caused
by drug interactions, especially drugs

that may cause increased serotonin


levels.

**********

Symptoms of serotonin syndrome include


altered mental status, agitation,
myoclonus, hyperreflexia, diaphoresis,
tremor, diarrhea, incoordination, muscle
rigidity, and hyperthermia.

**********

Trazodone can cause priapism. Only


bupropion is relatively free of sexual
side effects.

**********

Bupropion is the antidepressant least


likely to cause weight gain, and may
induce modest weight loss. Among SSRIs,
paroxetine is associated with the most
weight gain and fluoxetine with the
least. Mirtazapine has been associated
with more weight gain than the SSRIs.

**********

Etiology of Female Infertility


a)
b)
c)
d)
e)

Ovulatory disorders (25%)


Endometriosis (15%)
Pelvic adhesions (12%)
Cervical pathology (5%)
Uterine pathology (<5%)

PEARL: Ovulatory disorders are the most


common cause of female infertility.

**********

Infertility affects about 1 of 5 couples


in the Canada.