1
Q
menstrual cycle - basics and phases
A
length: 21-38 days
menstrual phase: day 1-7
- FSH begins to rise
proliferative/follicular phase: day 7-14
- estrogen (stimulated by FSH) causes proliferation of endometrium and follicular growth
- estrogen triggers LH surge causing ovulation (day 14)
secretory/progestational/luteal phase: day 14-28
- high levels of progesterone
- progesterone converts thickened endometrium to vascularized tissue (preps to host fertilized egg)
2
Q
menorrhagia / heavy menstrual bleeding or prolonged bleeding - causes
A
Von Willebrand’s dz
molar pregnancy
malignant endometrial CA
perimenopause
3
Q
metrorrhagia / irregular bleeding - causes
A
bleeding b/t cycles
polyps
cervical CA
OC pills
4
Q
menometrorrhagia / heavy + irregular bleeding
A
molar pregnancy
malignant endometrial CA
premenopause
5
Q
dysfunctional uterine bleeding (aka abnormal uterine bleeding) - causes (reproductive age v. post-menopausal)
A
bleeding due to an anovulatory cause
Reproductive age:
- pregnancy (and preg complications)
- anovulation/hormone abnormalities
- systemic (PCOS, pituitary, thyroid)
Post-menopausal (think structural vs. non-structural):
- medications (HRT)
- trauma (vaginal atrophy), polyps
- malignancy
6
Q
abnormal uterine bleeding - approach
A
- take a good hx
- bleeding history
- PE: growths, masses, trauma
- Labs: preg test (#1), CBC, TSH, TSH/LH
- Imaging: U/S
- endometrial biopsy: over 35 w/ obesity, HTN, DM or anyone after menopause
- progestin trial
- if bleeding stops, think ovulatory problem!
- investigate pituitary and order prolactin and TSH
7
Q
abnormal uterine bleeding - management
A
Goals:
- must control bleeding
- consider if women wants to maintain fertility or not (depends on age)
treatment:
- hormonal (OCP - progesterone only) - if not trying to get pregnant
- surgery: D&C (can also consider endometrial ablation or hysterectomy if no desire for future fertility)
8
Q
amenorrhea - primary and secondary definition
A
primary:
- no menses by 14 yr and absence of 2ndary sex characteristics
- no menses by 16 yr w/ presense of 2ndary sex characteristics
secondary:
- no menses for 3 mo (previously normal cycle)
- no menses for 6 mo (previous irregular cycle)
9
Q
primary amenorrhea - causes
A
Turner’s Syndrome: no ovaries but pituitary pumps out FSH so see high FSH
- manage w/ OCP (estrogen and progestin)
hypothalamic-pituitary insufficiency: see low FSH and LH
- manage w/ OCP (estrogen and progestin)
Androgen insensitivity: see high testosterone (XY genetically)
- remove testes, start estrogen
Imperforate hymen: dx on PE
- surgically open
Anorexia
- tx eating d/o
10
Q
secondary amenorrhea - causes
A
PREGNANCY (most common cause
androgen excess disordered: PCOS
11
Q
secondary amenorrhea - dx
A
hx and PE: pelvic exam signs of androgen excess
Labs:
- pregnancy test
- TSH and prolactin
- FSH/LH only if TSH and protecting normal
Progestin challenge: Provera 10mg orally for 5 days
- bleed 2-7 days later
- if bleeding: ovulatory issue
- if no bleeding: structural issue
12
Q
secondary amenorrhea - tx
A
NOT desiring pregnancy:
- OCP
Desire pregnant: tx varies by cause
- elevated prolactin - dopamine agonist
- surgery
- fertility specialist
13
Q
primary dysmenorrhea - sxs, cause, PE results, tx
A
sxs: abd pain and cramps, N/V/D, H/A
- most common w/in 2 yrs of menarche
cause: NO PATHOLOGIC CAUSE
- inc. prostaglandins
- inc. leukotriene levels
PE results
- normal
tx:
- NSAIDS - 1st line
- Cox-2 inhibitor (less GI side-effects)
- OCP
14
Q
secondary dysmenorrhea - definition/population, sxs, causes, dx, tx
A
excessive menstrual pain during mid-reproductive yrs
- USUALLY PATHOLOGIC
sxs: pelvic pain related to menstrual cycle
- infertility
- dyspareunia (painful sex)
causes:
- endometriosis
- pelvic adhesions / fibroids (prior surgery)
- polyps
dx:
- pelvic U/S
- laproscopy
tx: depends on cause
15
Q
premenstrual syndrome (PMS) - definition, dx, tx
A
physical and emotional sxs that occur during 2nd half of menstrual cycle
- caused by low serotonin levels
dx: clinical (benign PE)
- only occurs during 2nd half of cycle
- accompanied by bloating, H/A, aches, irritability
tx:
- lifestyle modifications: exercise, small, frequent meals
- SSRI for emotional; NSAIDS for aches
16
Q
endometriosis - definition
A
endometrial tissue outside uterine cavity
- occurs in women of reproductive age
- no matter where it is, it will “plump up” during proliferative phase
- most common on ovary
17
Q
endometriosis - classic triad and most common sxs
A
dysmenorrhea: low sacral backache premenstrually that resolves w/ menstruation
dyspareunia
infertility
most common sx: pelvic pain
18
Q
endometriosis - PE, dx, tx
A
PE:
- retroverted uterus w/ uterosacral ligament nodularity (CLASSIC FINDING)
dx: clinical
- laparoscopy is definitive (cannot se on U/S)
tx:
- observation (1st line)
- medicine (all for women not trying to get pregnant): NSAIDS or OCP, continuous progesterone, danazol-testosterone (bad SE: deep voice)
- surgical (for women who want to get pregnant)
19
Q
pelvic pain - ddx
A
endometriosis: diffuse
ectopic pregnancy: one-sided
acute appendicitis: RLQ
PID: will also have fever, chills
adhesions: hx of prior surgery or infection
IBS: would also have GI sxs
ovarian cyst
psychologic d/o
20
Q
uterine leiomyoma (fibroids) - definition, population, most common type
A
most common benign uterine tumor
- women in 40’s with many babies
- AA women 5x more likely
Types:
- submucous location within the uterine cavity (cause abnormal bleeding)
21
Q
uterine leiomyoma (fibroids) - sxs, exam, tx
A
sxs: abnormal menstrual bleeding, pain, pressure, infertility
exam: enlarged uterus, firm, nontender, asymmetric
dx: U/S is best
tx:
- conservative (most do not require tx)
- GnRH agonists help to shrink fibroids
- endometrial ablation (if not planning on future pregnancy)
- surgery: severe sxs and want to keep fertility
22
Q
endometrial cancer - risk factors, what is protective
A
MOST common Gyn Cancer
- caused by prolonged estrogen exposure
Risks:
- Prolonged estrogen exposure
- nulliparity (no babies)
- early menarche/late menopause
- chronic unopposed estrogen
- tamoxifen (breast cancer tx) - DM, HTN, obesity
- cancer of breast, colon, ovaries
protective: OCP
23
Q
endometrial cancer -tumor type, sxs, exam, dx, tx
A
tumor type: adenocarcinoma (75%)
sxs: post-menopausal bleeding
exam: normal
dx: endometrial biopsy
- curettage is definitive
- stages I-IV
tx:
- total abd hysterectomy and bilateral salpingo-oophorectomy (remove ovary and tubes)
- radiation post-operative (stage I and II)
- radiation, progestins, chemo (stage III and IV)
24
Q
ovarian cysts - population, characteristics
A
common in reproductive years
- due to excess estrogen and progesterone
- most benign and resolve spontaneously
Note: considered malignant in post-menopausal women until proven otherwise
25
ovarian cysts - most common type, dx, tx
most common type: functional (arise from normal function)
- follicular: unilateral, small, resolve on own
dx: U/S (mobile, simple, fluid filled)
tx:
- observe for 30-60 days
- surgical eval if not changing
26
ovarian cysts - nonfunctional, most common, management
do not arise from normal fx
endometrioma: unilateral, blood-filled (hemorrhagic)
- called chocolate cysts
manage: surgical incision
27
PCOS (poly cystic ovary syndrome) - classic triad, how pts present
1. anovulation
2. polycystic ovaries
3. androgen excess
normal menses followed by episodes of amenorrhea that become progressively longer
#1 cause of androgen excess and hirsutism
- most patients present due to hirsutism or infertility
- also have obesity, acne, insulin resistance
- bilateral ovaries affected
28
hirsutism
male pattern hair on females
| - common sign of PCOS
29
PCOS (poly cystic ovary syndrome) - dx, tx
Dx:
- image: U/S (see "oyster ovaries" or "string of pearls"
- labs: inc. androgens, lipid abnormalities, insulin resist
tx:
- OCP, Depo -Provera, wt loss (if not trying to get pregnant)
- Clomid: if trying to get pregnant
- Metformin: w/ Clomid if trying to get pregnant
30
ovarian neoplasm that grows hair and teeth
cystic teratoma
- benign, dermoid cyst
- most common germ cell tumor
- most common ovarian neoplasm in women <30
tx: surgical excision
31
ovarian neoplasm - benign vs. malignant
benign: smooth, regular surface, unilateral, small, simple
malignant: nodular, irregular, fixed, bilateral, large, complex
32
ovarian cancer - population, risk factors, screening
2nd most common GYN cancer
- mean age is 69 y/o
risks: BRCA1 gene, FH, inc. lifetime ovulations (nulliparity, early monarchy/late menopause
screen: bimanual exam
33
ovarian cancer - most common tumor type, sxs, PE
epithelial tumor
sxs:
- early: asymptomatic
- later: abd distention, early satiety, urinary frequency, change in bowel habits
exam:
- fixed, bilateral pelvic masses
- abd distention/ascites
- sister Mary Joseph's nodule: MET implant in umbilicus
34
ovarian cancer - dx, tumor markers, tx
dx:
- U/S suggests
- biopsy definitive
tumor markers:
- CA-125, CEA
tx:
- total abd hysterectomy and bilateral salpingo-oophorectomy (remove ovary and tubes)
- radiation and chemo
35
PAP smear screening - definition, recommendations
used to diagnose cervical lesions
women < 21: none
21-29: q 3 yrs
30-65: Pap _ HPV q 5 yrs or Pap alone q 3 yrs
> 65:
- previously normal Paps = no testing
- hx of pre-cancer: Paps for 20 yrs post-dx
Note: even if vaccinated (HPV) - follow same PAP schedule
36
PAP results (Bethesda System) - what are you measuring and possible results
sample must have endo-cervical cells
Negative for intraepithelial lesion or malignancy
Squamous Epithelial cell abnormalities:
1. atypical squamous cells (either of uncertain significance (ASCUS) or cannot exclude high-grade lesion (ASC-H))
2. low-grade squamous intraepithelial lesions (LSIL)
- transient HPV infection
3. high-grade squamous intraepithelial lesions (HSIL)
- HPV viral persistence and invasive potential
4. cancer
37
PAP - management of results
ASCUS:
- repeat PAP in 4-6 mo
- if repeat is same or worse = colposcopy (visual examination of cervix)
ASC-H, LSIL, HSIL:
- colposcopy, biopsy, HPV testing
38
grading cervical lesions - cytology vs. histology results
cytology: from PAP
- ASC, LSIL, HSIL, Cancer
histology: from biopsy during colposcopy
- CIN I, 2, 3
39
abnormal PAP - management (depends on biopsy results - histology)
CIN1:
- repeat PAP +/- colposcopy
- HPV DNA testing
CIN2 or CIN3:
- need to remove lesion
- cryotherapy and cold-knife conization (for women who do not want to maintain fertility)
- LEEP: loop electrosurgical excision procedure (for women want to maintain feritlity)
40
cervical cancer - cause and risk factors
3rd most common GYN cancer
- 99% caused by HPV (types 16, 18, 31, 33)
Risks:
- early sex, multiple partners
- smoking
- immunosuppression
- HPV (get vaccine!)
41
cervical cancer - tumor type, sxs, PE, dx, tx
tumor type: squamous cell (90%)
sxs:
- asymptomatic
- post-coital bleeding
PE: friable, bleeding cervical lesion
dx: PAP and biopsy (stage I-IV)
tx:
- hysterectomy
- radiation and chemo (stages III and IV)
42
cystocele, rectocele, uterine prolapse - population, definition
common after menopause
- everything falls down
cystocele: prolapse of bladder into anterior wall of vagina
rectocele: herniation of rectum into posterior wall of vagina
uterine prolapse: prolapse down vaginal canal
43
cystocele, rectocele, uterine prolapse - sxs, tx
sxs:
- vaginal fullness, pressure, incomplete voiding or defecation
tx:
- topical estrogen (cystocele)
- pessary: cork (if not good surgical candidate)
- Kegal exercises
- surgical repair
44
mastitis - sxs and tx
infection that occurs in breastfeeding women
- caused by nipple trauma (S. aureus)
sxs:
- unilateral erythema, edema, tenderness (one quadrant of breast)
- fever and chills
tx:
- dicloxacillin (most common), cefalexin, or erythromycin
- CONTINUE breast feeding
Note: must tx to avoid breast abscess!!
45
breast abscess - sxs and tx
progression from mastitis
sxs: same as mastitis w/ addition of:
- localized mass
- systemic signs of infection
tx:
- I&D
- IV ABX: Nafcillin/oxacillin IV or cefazolin PLUS metronidazole
STOP breastfeeding on affected side
- most pts hospitalized
46
fibrocystic breast disease - sxs, PE, dx, tx
common, benign condition of breast
- women in reproductive age (20-50)
sxs: cyclic (premenstrual), bilateral breast pain
- size of cysts fluctuate during menstrual cycle
PE: bilateral cysts that vary in size
dx: U/S
tx:
- reduce caffeine, inc. PO vit E
- OCP
47
breast fibroadenoma
most common benign breast tumor
- in young women
- PAINLESS
- solid, mobile
- unilateral lumpo
PE: mobile, firm, smooth, rubbery lump
dx: U/S and fine needle aspiration to confirm no fluid
tx:
- observe small masses
- surgically remove large masses
48
breast cancer
MOST COMMON cancer in women; 2nd MC cause of cancer death
risks:
- BRAC1 and 2
- prolonged unopposed estrogen (early menarche, late menopause, over 40, etc.)
- hyperplasia w/ fibrocystic dz
- high fat diet
- obesity
49
types of cancers caused by prolonged, unopposed estrogen
endometrial
ovarian
breast
Not: cervical caused by HPV!!
50
mammogram screening
average risk:
- begin at 40 y/o
- 40-49: q 1-2 yrs
- >50 - every year
genetic risk factors:
- start b/t 25-35
- consider MRI
51
breast cancer - 4 types
infiltrating ductal: most common (80%)
- painless, stony, hard, unilateral mass
- begins as ductal carcinoma in situ (DCIS)
```
infiltrating lobular (10%):
- often bilateral
```
inflammatory (2%):
- peau d'orange
Paget's disease (1%): - pruritic, scaly rash on nipples
52
breast cancer - sxs, dx
sxs:
- painless mass (upper, outer quadrant)
- nipple d/c
- itching of nipple
- skin dimpling or pulling in of nipple
dx:
- exam, U/S (solid vs. cystic), mammogram (screen for non-palpable mass), fine needle aspiration (blood = malignancy)
- open biopsy: definitive
53
breast cancer - management
surgery: lumpectomy v. mastectomy
radiation and chemo
hormone therapy: for estrogen and progesterone positive receptor tumors
- Tamoxifen
- aromatase inhibitor (1st line if METS)
54
menopause - age, definition, sxs
mean age = 51 y/o
all sxs are associated with estrogen deficiency
Immediate sxs:
- cessation of menses
- hot flashes
- dec. vaginal lubrication
- depression/mood swings
Late changes:
- osteoporosis
- CVD
55
menopause - signs and labs
signs:
- everything shrinks and dries up
- dec. size of uterus, ovaries, breasts
cystocele, rectocele, and uterine prolapse occur
labs: FSH > 30mlU/mL is diagnostic
- FSH keeps pumping out telling ovaries to work but they are shut down
56
menopause - tx with HRT (benefits, drawbacks, and contraindications)
hormone replacement therapy
- mainly for hot flashes, vaginal dryness
- benefits: promotes good lipid profile
- drawbacks: inc. risk for CHD, breast cancer, stroke, pulmonary embolism
contraindications:
- liver dz
- thrombosis
- CA of endometrium or breast
57
menopause -alternative tx
Hot flashes:
- DepoProvera - IM
- SSRI
- Yoga, acupuncture
- Soy, black cohost
Osteoporosis:
- Ca++ w/ vit. D
Vaginal dryness
- topical estrogen
58
vaginitis - 3 main types
Candida (yeast)
Bacterial vaginosis (BV)
Trichomonas
59
candida - risk factors, sxs, d/c, micro findings, tx
risk: immunocompromised (HIV, DM), ABX
sxs: itchy, red, odorless
d/c: "cottage cheese"
micro: pseudohyphe in KOH prep
tx:
- PO fluconazole (single dose)
- "azole" creams (3-7d)
60
bacterial vaginosis (BV) - sxs, d/c, micro findings, tx
sxs: malodorous d/c
d/c: fishy grey, scant, thin, sticky
micro: clue cells
tx:
- metronidazole PO (multiple doses)
61
trichomonas - risk factors, sxs, d/c, micro findings, tx
risks: sexual activity
sxs: copious, malodorous d/c
- "strawberry cervix"
d/c: green/yellow, "frothy"
micro: motile flagellated protozoa
tx:
- metronidazole PO (single dose)
62
metronidazole (Flagyl) warning
MUST avoid ETOH (severe N/V) and sun exposure
63
chlamydia - definition, risk factors, sxs, labs, tx
most common bacterial STI in women
risks:
- sex <20 y/o
- multiple partners
sxs:
- asymptomatic
- mucopurulent cervical d/c
- cervical motion tenderness
labs:
- nucleic acid amplification test (NAAT)
tx:
- azithromycin (single dose)
- doxycycline (BID x 7d); use AMOX in pregnancy
Note: must also tx sexual partners
64
gonorrhea -definition, risk factors, sxs, labs, tx
STI; often co-infection w/ chlamydia
sxs:
- asymptomatic
- vaginal itching and burning, dysuria
- purulent cervical d/c
- cervical motion tenderness
labs:
- nucleic acid amplification test (NAAT)
tx: treat for both gonorrhea and chlamydia
- cefixime PO (single dose)
- ceftriaxone IM (single dose)
Note: must also tx sexual partners
65
gonorrhea - disseminated
can be disseminated
- #1 cause of septic arthritis in young, sexually active adults
sxs:
- GU sxs of gonorrhea (itch, burn, purulent d/c)
- if disseminated: lesions on hand/feet, tenosynovitis, endocarditis, meningitis
66
human papillomavirus (HPV) - definition, sxs, dx, tx
most common VIRAL STI in women
- subtypes 6 and 11: genital warts
- subtypes 16, 18, 31, 33: cervical and penile cancer
sxs: cauliflower-like warts on external genitalia, anus, cervix, or perineum
dx:
- HPV DNA testing
- direct visualization (PAP)
tx:
- small lesions: burn off
- large lesions: cryosurgery, laser ablation, surgical excision
67
HPV prevention
Gardasil vaccine
- recommended for girls and boys 9-26
- protects against HPV 6, 11, 16, 18
- 3 doses: 1st, 2nd 2 mo later, 3rd 6 mo later
68
pelvic inflammatory disease (PID) - definition, pathogens, risks, sxs, PE findings
pathogens (bacteria) travel up vaginal canal and into tubes / ovaries / pelvis
pathogens:
- chlamydia (most common)
- gonorrhea
- E. coli
risks: young, multiple partners, douching
sxs: DIFFUSE, bilateral abd and pelvic pain (gradual or sudden onset)
- back pain
- fever (+/-)
PE:
- mucopurulent cervical d/c
- cervical motion tenderness; bilateral adnexal tenderness
- rebound tenderness on abd exam
69
pelvic inflammatory disease (PID) - dx, tx
Dx:
- cervical cultures
- elevated WBC, ESR, C-reactive protein
- WBC on wet prep
Tx:
Outpatient:
- Ceftriaxone IM (single dose) PLUS doxycycline PO (x 14 d)
Inpatient (if access, high fever, pregnant, OP tx failure):
- IV ABX
70
condoms - what two things can it prevent
only contraception method that prevents pregnancy and STI!!
71
hormonal methods of contraception (combined estrogen and progestin) - 3 types
Oral Contraceptive Pills (OCP)
- combo pills most common
- 3 weeks on, 1 week off
Patch (orthoEvra)
- change 1/week
- failure higher if >200lbs
Vaginal Ring (NuvaRing)
- lasts for 3 weeks
- good for women who have not had vaginal delivery in past
72
hormonal methods of contraception (combined estrogen and progestin) -mechanism of action
estrogen suppresses FSH so no follicle/ovulation
progesterone suppresses LH surge, so no ovulation
Thicker cervical mucus - hostile to sperm
Endometrial atrophy - unfavorable to implantation
73
estrogen-containing hormonal methods - benefits, contraindications
Benefits:
- Dec. risk of endometrial and ovarian cancer, ovarian cysts, endometriosis, dysmenorrhea, fibrocystic breasts
- Regulates menses
Absolute Contraindication:
- pregnancy
- hx of thromboembolism, CVA, CHD, breast or endometrial cancer, melanoma, abnormal LFTs
Relative Contraindications:
- DM, chronic HTN, hyperlipidemia, smoker over 35 yrs
74
hormonal methods of contraception (progestin only pills) - use, indications for use
progestin-only pills (called "mini pills")
- take every day (no week off)
- high incidence of break-through bleeding
indications:
- breast feeding
- overe 40
- women who cannot take estrogen
75
hormonal methods of contraception (progestin only shot) - use, side effects, warnings
IM injection (Depo-Provera)
- IM shot q 3 months
- side effects: break-through bleeding, weight gain, mood changes
Warnings:
- return of ovulation can take up to 18 months!
- Black Box: calcium loss, bone weakness --> ONLY use for 2 yrs or less
76
hormonal methods of contraception (progestin only implant)
subcutaneous rod inserted under upper arm skin (Jadelle, Implanon)
side effects:
- break-through bleeding
- scaring at insertion site
Note: ovulation returns promptly after removal
77
hormonal methods of contraception (progestin only) - mechanism of action and contraindications
mature follicle is formed but not released
- suppresses LH surge
- NO effect on FSH (that is estrogen driven)
contraindications:
- breast carcinoma
- liver tumors
78
IUD - population, two types, mechanism of action
best for women who have had kids (multiparous)
- Levonorgestrel (Mirena) (5 yrs); dec. cramping and bleeding
- Copper-banded (ParaGuard) (10yrs); may inc. cramping and bleeding
mechanism of action:
- alters endometrial environment
- ovum transport altered - changes tubal ciliary action
79
IUC - complications
uterine perforation
salpingitis
ectopic pregnancy
prolonged or irregular bleeding
80
sterilization - avoid pregnancy
tubal sterilization (female) - most common
vasectomy (male )
81
emergency contraception
Plan B levonorgestrel (progesterone)
- 1st dose within 72 hrs after unprotected sex
- 2nd dose 12 hrs later
Efficacy: >95%
82
infertility - definition, primary vs. secondary, causes
inability to conceive w/in 12 months of unprotected sex
primary: absence of previous pregnancy
secondary: after previous pregnancy
causes:
- anovulation (most common)
- tubal dz
- male factor
- unexplained
83
infertility from anovulation - causes, dx
polycystic ovaries
high prolactin levels
hypothalamic-pituitary dysfunction
hypothyroidism
dx:
- menstrual diary
- luteal-phase (day 21) progesterone level < 3ng/ml
- no mid-cycle basal body temp elevation
84
infertility from tubal dz - causes, dx
causes:
- scarring/adhesions
- hx of surgery, PID, endometriosis, ruptured appendix
dx:
- hysterosalpingogram: shoot dye up tubes to see if blocked
- laparoscopy
tx:
- surgery or lysis of adhesions
85
infertility from male factors - causes, dx
abnormal semen analysis resulting from:
- inc. scrotal temp
- smoking
- ETOH ingestion
- epididymitis
- varicocele
dx: semen analysis
tx:
- tx etiology if identified
- intrauterine insemination
- sperm injection
- donor insemination
86
infertility - general approach
Phase I (inexpensive / non-invasive)
- detailed hx, type of intercourse
- ovulation tracking
- semen analysis
- TSH, prolacting, LH
- FSH in women > 35 (high in menopause)
Phase II (expensive/invasive)
- hysterosalpingogram
- laparoscopy
- IVF if no cause found
87
Pregnancy - trimesters, weeks for "term", GPTPAL
Trimesters:
1st: 1-12 weeks
2nd: weeks 13-27
3rd: weeks 28-40
Term: 37-42 weeks
```
G: # of pregnancies
P: # of vaginal births
T: # of full-term pregnancies
P: # of preterm pregnancies
A: # of abortions b/f 20 weeks
L: total # of living children
```
88
Chadwick's sign
bluish discoloration of vagina and cervix due to estrogen and progesterone during pregnency
89
skin changes during pregnancy
melasma/cholasma: dark patches on face
linea nigra: line on abdomen
90
uterine growth during pregnancy
12 wks: at symphysis pubis
20 wks: at umbilicus
after 20 wks: 1 cm for every week gestation
- way to monitor fetal growth
91
normal labs in pregnancy
normal to have high cholesterol - do not need to treat
- f/u 6 wks after birth
renal: normal to have dec. in BUN, Cr, uric acid
- if high/normal, can be signs of pre-E
92
Pre Natal Labs
Blood type (Rh factor, antibodies to blood group antigens)
Glucose tolerance test
Hep B, syphylis, HIV, rubella, GC/CT
Group B strep (can be part of women's normal vaginal flora)
93
pregnancy - screening tests and timing
first visit (7-9 wks): dating sonogram; discuss optional screening tests
10-13 wks: nuchal translucency
15-18 wks: alpha-fetoprotein / quad screen
18-22 wks: anatomical U/S
24-28 wks: glucose tolerance test
28 wks: Rhogam (if mom is Rh-)
32 wks: repeat CBC, VDRL/PRP (syphylis), chlamydia, gonorrhea, GBS
94
pregnancy - screening blood tests (quad screen) - what is measured and levels for chromosomal abnormalities
Quad screen:
- AFP
- estriol
- beta HCG
- inhibin A
Note:
- PAPP-A: low in preg; elevated in trisomy 21
- nuchal translucency (seen on U/S) - back of neck measured
Trisomy 21 (Down's): AFP and Estriol down; PAPP-A, inhibin A, BHCG, nuchal translucency up
Trisomy 18 (Edward's): AFP, Estriol, BHCG and Inhibit A down; nuchal translucency up
Neural tube defect: AFP up, rest normal
95
pregnancy - optional diagnostic tests
chorionic villus sampling (CVS): 10-13 wks
amniocentesis: 15-20 wks
Not: these give you a definitive answer based on baby's DNA
96
stages of labor
stage 1: onset of labor to full dilation (10cm)
stage 2: full dilation to birth
stage 3: delivery of infant to delivery of placenta
97
signs of placental separation
fresh show of blood - BRB
cord lengthening
fundus rises
uterus firm and globular (contracts down)
98
dystocia
difficult birth: inadequate pelvis, position of baby, inadequate contractions / dilation
99
labor induction - common indications and absolute contraindications
Indications:
- prolonged pregnancy (>42 wks)
- DM
- Pre-eclampsia
- Suspected intrauterine growth retardation
Contraindications:
- cephalopelvic disproportion
- placenta previa
- uterine scar from previous C-section
- transverse lie
100
labor induction - medications and "surgical"
prostaglandins (cervidil):
- given vaginally
- "ripens" cervix
oxytocin (Pitocin)"
- causes uterine contractions
- given IV
amniotomy: breaking membranes
101
antepartum fetal monitoring (close to or during labor)
non stress test:
- most common
- monitor fetus HR from outside
- postive test: 2 accelerations in 20 minutes
- positive test is a GOOD THING
contraction stress test (CST):
- observe baby's HR in response to contractions
- positive test: decelerations with each contraction
- positive test is a BAD things
102
induced abortion - medications and surgical options
mifepristone and misoprostol:
- medication
- up to 1st 7-9 wks LMP
suction curettage
- surgical procedure
- safest and most effective method for 12 wks or less
- local anesthesia for cervix
```
surgical curettage (D&C): aspiration
- surgical abortion up to 16 wks LMP
```
dilation and evacuation (D&E):
- up to 18 wks
Past 18 wks
- induce labor
103
spontaneous abortion (e.g. miscarriage) - definition and risks
Any pregnancy that ends before 20 wks gestation
- most occur in 1st 12 wks
- most due to chromosomal abnormalites
Risks:
- parity (more births)
- Inc. maternal and paternal age
- conception w/in 3 mo of term birth
104
spontaneous abortion - classifications
threatened:
- vag bleed: yes
- cervix open: no
- POC passed: no
inevitable:
- vag bleed: yes
- cervix open: yes
- POC passed: no
incomplete:
- vag bleed: yes
- cervix open: yes
- POC passed: partial
complete:
- vag bleed: yes
- cervix open: yes
- POC passed: yes
missed: fetal demise on U/S
- vag bleed: no
- cervix open: no
- POC passed: no
105
normal B-hCG levels during pregnancy
urine (home preg test): positive 10-14 days after ovulation
serum: positive 8-9 days after ovulation
levels should DOUBLE every 48 hrs during 1st trimester if normal, intrauterine pregnancy
106
ectopic pregnancy - definition, cause, sxs
implantation of blastocyst anywhere outside uterine cavity
- most common in tube
cause:
- hx of salpingitis (results in scarring and blocking of tube)
sxs (unruptured):
- amenorrhea (pos preg test)
- unilateral pain
- vaginal bleeding
- adnexal mass
sxs (ruptured):
- above sxs
- hypotension
- tachycardia
- abd guarding
107
ectopic pregnancy - dx
labs:
- B-hCG positive in urine or serum but NOT doubling appropriately (q 48 hrs)
imaging:
- U/S shows absence of intrauterine gestational sac
presumptive dx:
- B-hCG titer > 1500 w/ no intrauterine gestational sac
108
ectopic pregnancy - tx
MUST end pregnancy - dangerous for mom
Medical:
- methotrexate (folic acid inhibitor)
- Criteria for use: serum B-hCG < 5,000, ectopic <3.5cm, no pulmonary, renal or hepatic dz, stable and compliant patient
Surgery:
- salpingostomy: if unruptured (open tube and remove ectopic preg) - best to preserve fertility
- salpingectomy: if ruptured and tube destroyed (complete removal)
109
gestational trophoblastic disease
neoplasms from an abnormal proliferation of the placenta or trophoblast (cells that make placenta)
benign: hydatidiform mole (molar preg)
- more likely to ask about on PANCE
malignant: choriocarcinoma
110
hydatidaform mole (aka molar pregnancy) - characteristics of complete
Positive pregnancy test with...
```
grape-like vesicles or "snow storm" (on U/S)
empty egg
paternal X's only
fetus ABSENT
20% progress to malignancy
```
Studies:
- b-hCG is higher than it should be
111
hydatidaform mole (aka molar pregnancy) - hx, PE, studies, tx
Hx/PE:
- vaginal bleeding
- pre-eclampsia-like sx b/f 20 wks
- severe hyperemesis
- new onset hyperthyroidism
- uterus larger than gestational age
- no fetal heart tones
Studies:
- B-hCG: excessively high
- U/S: sack of grapes or snowstorm pattern
tx:
- D&C, serial b-HCG, OC's for 1 yr
112
preterm labor - definition, triad, risk factors
labor occurring b/t 20 weeks and 37 weeks
Triad:
- gestation < 37 wks
- uterine contractions (at least 3 in 20 min)
- dilation and effacement
Risks:
- GBS, PROM (premature), short cervix (<4cm), previous preterm birth, cocaine, nicotine
113
fetal fibronectin testing
cervical swab used to predict risk of delivery w/in 2 weeks
114
preterm labor - management
observation:
- 30-60 min
- hydration
ABX: tx for possible infection
Glucocorticoids (betamethasone)
- enhance fetal lung maturity (if < 34 wks)
- inc. levels of surfactant
Tocolytics (Tocolysis Mg Sulfate): dec. contractions/slow labor
- inhibits myometrial contractility mediated by Ca++
- SE: nausea, fatigue, dec. reflexes, resp distress)
- antidote: calcium gluconate
115
premature rupture of membranes (PROM) - definition, risks, dx, tx
rupture of membranes b/f labor begins
- most common dx leading to NICU admit
Risks:
- infection (GBS, STI)
- smoking
- cervical incompetence
Dx:
- nitrazine paper
- ferning test: on slide
- speculum exam (sterile)
Tx:
- before 34 wks: bed rest and attempt to prolong to 35 wks
- at least 35 wks: induce
116
maternal Rh Isoimmunization (incompatibility)- definition, risk
mom produces antibodies against foreign red blood cell antigens in maternal circulation
- most common antigen is D
risk is present only if mom is Rh- and dad is Rh + and baby is Rh+
- risk is larger for subsequent pregnancies since mixing occurs at birth
117
Rh incompatibility - tx
RhoGAM
- binds and hemolyzes any D-positive RBC in maternal circulation so mom does not mount her own antibody response
- given at 28 wks
- also given at other high risk times (potential for fetal and mom's blood to mix): after delivery of Rh+ infant, ectopic preg, amnio, D&C, trauma
118
multiple gestation - sxs and office visit frequency
all sxs of pregnancy are usually more severe
prenatal office visits more often
additional risks to mom (spontaneous abortion, premature labor) and fetus
119
gestational diabetes - definition, population at higher risk, material risks, fetal risks
CHO intolerance of variable severity only present during pregnancy
Risks:
- obesity
- > 25 y/o
- ethnicity: AA, Asian, Hispanic, Indian
Maternal risks:
- pre-eclampsia
- traumatic birth
Fetal risks:
- macrosomia
- delayed fetal lung maturity
120
gestational diabetes - screening
b/t 24-28 weeks:
1. glucose challenge test (GCT):
- non fasting 50 g glucose load
- check glucose after 1 hr
- > 140 mg/dl, move to GGT
2. glucose tolerance test (GTT):
- 100 g oral glucose load after overnight fast
- check plasma glucose at fasting, after 1 hr, 2 hr, and 3 hr
- 2 or more abnormal values - gestational diabetes
121
gestational diabetes - tx
1. diet and exercise
2. check glucose (finger stick) 4 times daily
- fasting
- 2 hr post meal
3. insulin: if not controlled by diet
Also:
- weekly check-ups and NST (non-stress test) at 32-34 wks
- induce labor at 40 wks (if good control) and 38 wks (if bad control or signs of macrosomia)
122
HTN in pregnancy - first step
determine is this is a chronic issue from before pregnancy, if brought on due to pregnancy, and if any end organ damage (pre-E)
123
chronic HTN - tx in pregnancy
monthly U/S: check of IUGR
serial BP and urine protein
medication:
- METHYLDOPA
124
pre-eclampsia and eclampsia - definitions and timing
pre-E:
- classic triad of HTN, proteinuria, and edema
- mild: BP>140/90, proteinuria, no other sxs
- severe: above + sxs (h/A, visual disturbance, RUQ pain)
Eclampsia:
- all of the above + seizures
Note: can occur anytime after 20 wks station, but common near term
- no inc. risk of HTN later in life
125
preeclampsia - predisposing factors
```
NULLIPARITY (most common)
extremes of age: <20, >35
multiple gestation
DM
chronic HTN
```
126
preeclampsia - complications and prevention
```
progression to eclampsia
renal failure
pulmonary edema
HELLP syndrome
DIC
```
prevent: 1gm calcium during pregnency
127
HELLP syndrome
complication of pre-eclampsia
Hemolysis
Elevated Liver enzymes
Low Platelets
128
preeclampsia - management (mild v. severe)
cure = delivery of fetus
mild:
- <37wks: bed rest, testing, betamethasone (if < 34 wks)
- > 37 wks: induce delivery
severe:
- hospitalize
- <34 wks: monitor in ICU, betamethasome for fetal lung development
- >34 wks: deliver vaginally or c-section and watch for HELLP
- meds: Magnesium sulfate (MgSo4) for seizure prophylaxis
129
placental abruption - definition and risks
separation of placenta from sit of uterine implantation before delivery of fetus
- most common cause of 3rd trimester bleeding
- most common obstetric cause of DIC
- more serious if blood is confined within uterine cavity (and does not come out of cervix)
Risks:
- HTN, smoking, cocaine, trauma
130
placental abruption - sxs, dx, tx, complications
vaginal bleeding
abdominal and back PAIN
fetal distress
dx: clinical
tx: emergent c-section
complications:
- fetal demise
- maternal hemorrhage
- maternal DIC and death
131
placenta previa - definition, sxs,
placenta is implanted over os (partial or complete)
- common cause of 3rd trimester bleeding
sxs:
- PAINLESS vaginal bleeding
- cramping, contractions
DO NOT DO VAGINAL EXAM!!
- must first do U/S to confirm no placenta previa
tx:
- ALWAYS deliver by C-section
132
post partum hemorrhage - causes
1. uterine atony (loss of tone)
- most common
- risks: short or long labor, infected uterus
- PE: soft, "boggy" uterus
- Tx: uterine massage, oxytocin
2. genital laceration
- uncontrolled vaginal delivery
- PE: visual laceration
- Tx: suture
3. retained placenta:
- non-contracted uterus
- PE: missing cotyledon on placenta
- Tx: manual exploration
133
endometritis - definition, sxs, dx, tx
infection of endometrium of uterus
- most common after c-section, prolonged ROM
sxs:
- post partum fever
- uterine tenderness
- presents 2-3 days post-partum
dx:
- high WBC, U/A, shows bacteria
tx:
- clindamycin plus gentamicin
PANCE Review
flashcards
Decks in class (16)
# Cards
-
Infectious Disease99
-
Dermatology74
-
Cardiology120
-
Cardiology II90
-
Cardiovascular Pharmacology17
-
Pulmonary99
-
Musculoskeletal System107
-
Gastroenterology134
-
Eyes41
-
Ear, Nose, and Throat41
-
Reproductive System133
-
Genitourinary86
-
Psychiatry70
-
Neurologic System60
-
Endocrine System50
-
Hematology36
