6. Reproductive Flashcards
Basic PathoPhysiology of Mense cycles
Day 1-12
- GnRH -> FSH, LH -> Estrogen
- FSH increase cause follicle & egg matruation
- LH stimulates the maturing follicle to produce estrogen to build endometrium (preparing pregenancy environment)
Ovulation 12-14
- LH surge cause release egg
Day 14-28
- Estrogen decrease and Progesterone increase
1st day of mensteration
- fall of estrogen and progesteron cause lose of endometrium (shed tissue and bleed)
Type of amenorrhea explain
- Amenorrhea
- Cryptomenorrhea
- Menorrhea
- Metrorrhea
- MenoMetrorrhagia
- Oligomenorrhea
- Polymenorrhagia
- not bleeding
- light bleeding
- Large bleeding
- Irregular bleeding
- Large irregular bleeding
- Prolonged cycle length >35 days
- Frequent cycle interval <21 days
US normal, normal pep, but irregular bleeding
Name/Etio/Dx/Tx
Name: DUB (dysfunctional uterine bleeding)
Etio: Anovulation(high estrogen), Ovulation
Dx: Diagnosis of exclusion
Tx
- OCP
- Progesterone
- Surgery
- Hysterectomy (definitive)
- Endometrial ablation (pt who wants keep productive)
Diffuse pelvic pain right before or with the onset of menses
Name/Tx
Name: Dysmenorrhea
Tx: NSAID
Physical, behavioral & mood change with cyclical occurence during luteal phase (1-2 weeks before mense)
Name/Other type/Tx/Workup differentiate
Name: Premenstural syndrome
Other type: Premenstrual dysphoric disorder (PMDD)
- additional sx: Anger & irritabillity
Tx: SSRI, OCP
Workup: Hyper/hypothyroidism check (may mimic)
Failure of mense before 15y or no second sex characteristic by 13y
Name
- Uterine present + breast absent=?
- Uterine absent + breast present=?
Name: Primary amenorrhea
- 2type
- FSH, LH low - hypothalamus
- FSH, LH high - Turner
- Mullerine, androgen
Not bleeding but no genetic issue
Possible 5 dz/Dx/Tx
- MC cause pregnancy
- Hypothalamus
- Dx: low LH, FSH
- Tx: Clomephen
- Pituitary dysfunction
- Dx: low FSH, LH, + Prolactin high
- Tx: TSS
- Ovarien failure
- Dx: high FSH, LH + low estrogen
- Uterine disorder
- Dx: Pelvic US, hysteroscopy
- Tx: estrogen tx
age of 50y women + has not bleeding for a year
+ hot flashes and mood change
Name/Risk/PE/Dx/Complication/Tx
Premanopause vs perimanopause Term?
Name: Menopause
Risk: 50-52y
PE: bone density low, Vaginal atropy
Dx: FSH (1st) -> FSH high LH high but estrogen low
Complication: Osteoporosis
Tx: HRT
- Estrogen only
- Benefit: good for sx
- Risk: endometrial cancer, thromboembolism
- Often use this for nonintact uterus
-
Estrogen + progesterone (best option often)
- Benefit: protect against endometrial cancer
- Often use this for intact uterus
Vaginal atrophy: estrogen cream
Premanopause - no sx
Perimanopause - estrogen drop and shows sx
leiomyoma vs adenomyosis
Leiomyoma
- Benign smooth muscle tumor
- MC AA
- PE: Asymetric, firm, nontender mass
- Dx: US
- Tx: Observe + leuprolide (GnRH inhibitor)
- Definitive: hysterectomy, myodectomy for preserve inferility
Adenomyosis
- Ectopic endometrial hypetrophy within muscle layer of uterine
- PE: Symetric, soft, tender mass
- Dx: MRI
- Tx: Total abdominal hysterectomy
infection post C-section + fever, tachycardia
Name/Pathogen/Tx
Name: Endometritis
Pathogen: GBS
Risk: C-section
Tx: Clinda + gentamycin
Prophylaxis: 1st gen cephalosporin
nulliparty + pelvic pain + painful intercourse
Name/Patho/Risk/Dx/Tx
Name: Endometriosis
Patho: ectopic endometrial tissue (MC ovaries)
Risk: Nulliparty, <35y
Dx: Laparoscopy w/ biopsy
Tx: OCP + NSAID, Danzol, leuprolide
- Surgical
- Keep fertility -> abalation
- Not keep fertility -> total abdominal hysterectomy
Precursor to endometrial cancer + Post menopausal bleeding
Name/Patho/Dx/Tx
Name: Endometrial hyperplasia
Patho: estrogen high by hyperplasia
Dx: Transvaginal US (1st) - endometrial stripe >4mm -> Endometrial bx (definitive)
Tx
- Hyperplasia w/o atypia - progestin
- Hyperplasia w/ atypia - hysterectomy
Manopausal bleeding + hx of use estrogen
Name/Risk/Dx/Tx
Name: Endometrial Cancer
Risk: hx of use estrogen
Dx: Transvaginal US (1st) - endometrial stripe >4mm ->endometrial bx
Tx: Hysterectomy
Uterine prolapse
3 type/Grade/Sx/PE/Tx
3 type
- Cystocele: Posterior bladder herinating into Anterior vagina
- Enterocele: Small bowel herniate into Upper vagina
- Rectocele: sigmoid colon(rectum) herniate into Posterior distal vagina
Grade
- descent into upper 2/3 of the vagina
- cervix approaches introitus
- outside introitus
- entire uterus out
Sx: pevic or vaginal heaviness, fullness, falling out sensation
PE: Bulging mass when introabdominal pressure (valsalva)
Tx
- Prophylactic - kegel exercise
- Nonsurgical - pessaries
- Surgical - hysterectomy (grade 4)
Unilateral RLQ or LLQ pain + otherwise normal
Name/Dx/Tx
Name: Functional ovarian cysts
Dx: Pelvic US
Tx: Supportive
- Cyst <8cm - rest, NSAID
- if 8cm< - laparoscopy or laparotomy
- Repeat US after 6 weeks
Palpable overain mass + postmenopausal bleeding
Name/Risk/Dx/Tx/Protective factors
Name: Overian cancer
Risk: hx of fx, BRCA
Dx: Biopsy 90% Epithelial, CA 125 serum
Tx
- TAH-BSO
- Chemo + surgery
Protective factors: OCP
Amenorrhea + Obesity + Hirsutism + hx of DM
Name/Dx/Tx
Name: PCOS (polycystic overian syndrome)
Dx: LH:FSH >3:1, Labs - testosterone
- Pelvic US: string of Pearls
Tx: OCP (main)
- Hirsutism: spironlactone
- Infertility: clomiphene
Cervical test result/bx - tx
- Negative - Normal pap -> NO HPV test
- ASC-US - if >25y
- HPV test
- neg -> 3y
- POS -> colposcopy
- HPV test
- ASC-H - Colposcopy
- LSIL
- 25-29 -> colposcopy
- >30 - HPV test
- Neg -> Pap 1y
- POS -> colposcopy w/ bx
- HSIL - Colposcopy
Biopsy result
- CIN 1 - mild -> Observe or leep
- CIN2,3 - Moderate(1/3 - 2/3 thick), severe -> leep or abalation
Bleeding after sex, Non-menstrual bleeding
Name/Risk/Dx/Tx
Name: Cervical carcinoma
Risk: DES exposure (estrogen), HPV 16/18
- MC Squamous
Dx: Colposcopy w/ bx
Tx: early - leep, abalation
- Stage 1 - 2a - TAH-BSO
- Stage 2a above - TAH-BSO + Chemo
HPV vaccination recommendation
Age/type of vaccine/schedule
HPV vaccination: 11-26y
- Gardasil: HPV 6,11,16,18
- Gardasil 9: 5 more then regular
Schedule
- <15y 2 dose HPV 6month apart
- >15y 3 dose 2,4month apart
Cervical cancer screening
Age initiate/Discontinue/Recommendation pap
Age: 21
Discontinue: 65
Test
- 21-29: Pap test
- >30: Pap 3y HPV 5y
Painless cervical dilation in 2nd trimester
Name/Risk/Tx
Name: Cervical insufficiency
Risk: DES exposure
Tx: cerclage + bed rest (may add 17 alpha-hydroxyprogesterone)
Tender vulvar 4 or 8 o’clock
Name/Dx/Tx
Name: Bartholin cyst/abscess
Patho: bartholin duct obstruction
Sx
- Tender - infected
- Nontender - not infected
Dx: CBC, culture
Tx: I & D w/ abx
significant pruritus + red/white ulcerative
Name/Risk/Tx
Name: Vulvar cancer
Risk: 90% squamous (HPV 16,18,31)
Tx: Surgical remove + Chemo
Vagnial dryness, dyspareunia (painful sex)
Name/Tx
Name: Vulvovaginal atrophy
Tx: Vaginal estrogen cream
Unilateral breast pain
Name/Risk/Tx
Name: Mastitis/breast abscess
Pathogen: S. Aureus
Sx
- Unilateral - infected
- Bilateral - congestive
- Breast Abscess - induration with fluctuance
Tx
- Infected - dicloxacillin, Continue breast pump
- Congestive - ice pack, tight-fitting bras
- Breast abscess - I & D, discontinue breastfeeding from the affected breast
Cyst become bigger or smaller in size with menstrual hormonal change
Name/Dx/Tx
Name: Fibrocystic breast disorder
Dx: US(1st), FNA (straw-colored fluid)
Tx: Most spontaneously
Smooth, well circumscribed Non tender freely mobile fixed mass + No change in size
Name/Tx
Name: Fibroadenoma of the breast
Tx: Observe
breast mass painless hard fixed + blood discharge from nipple (unilateral)
Name/Risk/Type/PE/Dx/Tx
Name: Breast cancer
Risk: BRCA, fx hx
Type: ductal carcinoma MC
PE: Itchy scaling rash on the nipple + Peau d’orange (peel of an orange looking)
Dx: US (1st) -> Mammogram, Biopsy (def)
Tx: Lumpectomy (save breast), Mastectomy (remove breast)
- Medication - tamoxifene, raloxifene
Mammogram
- ACS screening recommendation
- ACOG screening recommendation
- USPSTF screening recommendation
Clincal Breast exam recommendation
When to start self breast exam?
Mammogram
- 45-54y annually, 55 above q2y
- 40 above annually
- 50-74y q2y
Breast Exam in clinic - q3y in women age 20-39, 40 above annually
Self exam should start age of 20 monthly
abd tenderness + cervical motion tenderness + adnexal tenderness
Name/Infection site/pathogen/Dx/Tx
Name: Pelvic inflammatory disease
Infection site: upper reproductive region
Pathogen: Gonorrhea & chlamydia
Dx: Clinical, maybe used US for abscess
Tx
- Outpatient - doxy + ceftx
- Inpatient - IV doxy + cefo
hx of tampon use + fever + skin macular rash + hypotension
Name/Pathogen/Dx/Tx
Name: Toxic shock syndrome
Pathogen: S. Aureus
Dx: CBC
Tx: Admission
- Vanco + clinda + fluid replacement
Grey white fish rotten smell
Name/Pathogen/Dx(results)/Tx/Prevention
Name: Bacterial vaginosis
Pathogen: Gardnerella vaginallis
Dx
- PH 5<
- Fish smell
- Wiff test POS with 10% KOH
- Microscopic: clue cell
Tx: Metronidazole
Prevention: avoid douching, NO need tx partner
FROTHY yellow green discharge + strawberry cervix
Name/Pathogen/Dx/Tx/Prevention
Name: Trichomoniasis
Pathogen: Trichomonas vaginalis
Dx
- PH 5<
- Wiff test may POS
- Wet Mount (Flagellated)
Tx: Metronidazole 2g oral
Prevention: Must tx partner
Thick curd like/cottage cheese like discharge
Name/Pathogen/Dx/Tx
Name: Candida
Pathogen: Candida albicans
Dx
- PH normal acidic (3.8-4.2)
- Wiff test (neg)
- Microscopic (hyphae, yeast)
Tx: Fluconazole
Cauliflower like lesion (flesh colored growths)
Name/Dx/Tx
Name: HPV infection
Dx: whitening with 4% acetic acid
Tx: Acetic acid, podofilox, imiquimod
- which meds approve for PMDD?
- Which meds last 3 years and S/E?
- Which meds last 3 month and S/E
- What is OCP S/E?
- Safe OCP for lactation?
- 5 year long OCP?
- 10 year long OCP?
- Progestin + estrogen
- Implane, Osteoprosis
- Depo shot, weight gain
- Imgraine or smoker >35 should avoid
- Progestin only
- Mirena
- Paragard
Uncomplicated pregnancy
Dx/PE/Timeline(fetal movement/pelvic US/heart tone)
Dx
- Serum HCG - detect pregnancy 5 days after conception
- Urine HCG - 14 days after conception
PE
- Uterus (soften)
- Ladin - 6 weeks
- Hegar - 6-8 weeks
- Piskacek - 7-8 weeks
- Cervix
- Goodell - cervix soften
- Chadwick - blue color cervix 8-12hr
Timeline
- Fetal heart tone - 10-12 weeks
- Pelvic US - detect fetus 5-6 weeks
- Fetal movement - 16-20 weeks
GPA and Fundal height measurement
GPA classification/timeline for height explain
GPA
- Gravida - # of pregnancy
- Para - # birth
- Abortus - # of loss
Fundus height
- 12 weeks - pubix symphysis
- 20 weeks - at ubilicus
- 38 weeks - below xiphoid process
Estimated date of delivery (EDD)
Naegele’s rule
- (1st day of last mense + 7 days) - 3month
First trimaster visit tests (1-12wks)
- Maternal blood screening test for down syndrome
- HCG(high or low), PAPP-A(low), Nucal translucency (thick abnormal)
- US
- Feter heart tone - 10-12wks
- heat beat check - 5-6 wks
- Chorionic villus sampling (CVS)
- age >35 at risk option to test chromosomal abnormality
Second trimaster visit test (13-27 weeks)
- Triple screening test (15-20wks)
- beta hCG high - down syndrome (trisomy 21)
- Alpha fetoprotein high - Neural tube defect
- everything low (trisomy 18) - usually die in 1st year of life
- US
- In 15-18 wks, Aminocentesis offered to check chromosomal abnormality (maternal 35y)
- Gestational diabetes screening 24-28wks
Third trimaster visit test (28 wks - till birth)
- RhoGAM - 28 wks and within 72 hours after child birth
- GBS screening to prevent endometritis 32-37 wks
- Non stress test - 2 acceleration in 20 min, if no acceleration -> contraction stress test - NO late deceleration (no problem), if late deceleration present -> delivery
Failure to conceive after 1 year trial
Name/RIsk/Dx/Tx
Name: Infertility
Risk: Male (40%), Female (30%)
Dx: check male sperm first and Hysterosalpingography
Tx: Clomephene (induce ovulation), Intrauterine insemination
- if fallopian tube defect - vitro ferilization
Unilateral pelvic pain + amennorrhea
Name/Risk/MC site/Dx/Tx
Name: Ectopic pregnancy
Risk: hx of abd surgery or tubal (due to adhesions)
MC site: Fallopian tube MC
Dx
- Beta hCG - 2000< or doubling in 24-48hrs
- Transvaginal US - absence of sac
Tx
- MTX
- lararoscopic salpingostoy (unstable)
- RhoGAM if mother is RH negative
Abortion cases tx
- NO POC expelled + Cervical close
- some POC expelled + Cervical close
- some POC expelled + Cervical open
- NO POC shown + Cervical closed
- NO POC expelled + Cervical close + fetal demise (death)
- Some POC expelled + cervical tenderness + cervical closed
Basic Tx: D&E except for threatened
- Threatened
- Inevitable
- Incomplete
- Complete
- Missed
- Septic
Medical vs surgical
Medical
- MTX
- Misoprostol
- Mifepristone
Surgical
- D & C - 4-12 wks
- D & E - 12wks <
No proteinuria + HTN + Pregnancy 20 wks
Name/Tx
Name: Gestational HTN
Tx: Hydralazine
ProteinUrea + HTN + Pregnancy
Name/Complication/Tx
Name: Preclampsia
Complication: HELLP syndrome
Tx
- 37wks< - delivery NOW
- 34wks> - admission tx w/ mag sulfate + hydralazine
Seizure or coma + HTN + Pregnancy
Name/type of seizure/Tx
Name: Eclampsia
Type: Tonic-clonic 1,2 min -> postictal state
Tx: ABCD 1st, Mag sulfate + hydralazine or labetalol
- Once stable - DELIVERY (life thretening)
HTN before 20 weeks pregnancy
Name/Tx
Name: Chronic HTN
Tx: Methyldopa
3rd trimaster + Painless bleeding (bright red)
Name/Patho/Fetal HR/Dx/Tx
Name: Placenta previa
Patho: abnormal place for placenta
Fetal heart rate: Normal
Dx: Pevic US
Tx: hospotalization
- tocolytic (mag sulfate)
- if less than 34 wks give steriod for surfactant
- once stable - delivery
3rd trimaster + severe sudden painful bleeding
Name/Patho/Risk/fetal HR/Dx/Tx
Name: Abruptio placenta
Patho: seperation of placenta from uterine wall
Risk: HTN, Smoking
Fetal HR: Brady
Dx: Pelvic US
Tx: Delivery NOW
Painless vagnial bleed + 3rd trimaster bleeding
Name/Patho/Fetal HR/Dx/Tx
Name: VASA Previa
Patho: fetal vessel traverse the fetal membrane over cervical os
Fetal HR: Brady
Dx: Pelvic US
Tx: C-section NOW
Pregnancy + obesity + hx of DM
Name/Risk/Dx/Tx
Name: Gestational DM
Risk: Obesity, hx of DM, 4g over baby birth
Dx
- 50g glucose challenge at 24-28 wks
- if >140 after 1 hour -> 3 hr test
- 3 hour 100g glucose tolerence test (GTT)
- Overnight fast and test in the morning
- Fasting >95, 1hr >180, 2 hr >155, 3 hr >140
Tx: Insulin
Postpatum blues vs depression
Blue - do not think of harm baby 2-4 days onset
- No need tx resolve in 10 days
Depression - 2 wks - 2 month onset and THINK OF HARM BABY
- May need antidepressant, may last 3-14 month
beta hCG more than 100,000 + Snowstorm shown in US
Name/Dx/Tx
Name: Molar pregnancy
Patho: Neoplasm growth due to abnormal placental development (Hidaform Mole)
Dx: US, hCG
Tx: Surgical uterine evacuation (Suction curettage)
- MTX can be used if METS
Pregnancy + hepatosplenomegaly + jaundice
Name/Patho/Dx/Tx
Name: RH allomunization
Patho
- 1st pregnancy (Mom RH-, Baby RH+) develop antibody
- 2nd pregnancy (Mom RH-, Baby RH+) developed antibody from 1st pregnancy will cross to attack baby RBC
Dx
- Pt must be RH- abo and 2nd pregnancy
Tx
- given at 28 weeks
- within 72 hrs of delivery
- anytime bleeding during pregnancy
- if bleed less than 12 weeks - 50 RoGAM
- if bleed more than 12 weeks - 300 RoGAM
Severe emesis during pregnancy
Name/Tx
Name: Motion sickness or HEG (hyperemesis Gravidarum)
Tx
- Fluid, electrolyte repletion
- Pyridoxine (Vit B6) + Doxylamine
Stage of Labor explain
Contraction but no Cervial dilation called?
- Stage 1 - dilation of cervix (10 cm)
- Stage 2 - delivery of fetus
- Stage 3 - delivery of placenta
- Stage 4 - 1-2 hr after delivery and assessed for complication
- Called as Braxton-hicks contraction
APGAR score category
- Appearance - pink
- Pulse - 100<
- Grimace - pull away, sneeze, or cough
- Activity - arm, leg flex and resists extension
- Repiratory - strong, crying
Postpartum Physical difference 4 things
- Uterus - shrink in 2 days, decends back to 2 weeks, Normal size in 6 weeks
- Lochia serosa - bleeding 4-10 days, Resolves 3-4 weeks
- Breast - milk in 3-5 days
- Mense - restart if no breast milk, usually restart in 6-8 weeks
loss of blood more than 500ml during delivery
Name/Risk/Patho/PE/Dx/Tx
Name: Postpartum hemorrhage
Risk: 500ml vaginal, 1000ml C-section
Patho: Uterine atony (uterus unable to contact to stop bleeding)
PE: soft boggy uterus
Dx: CBC, type & cross
Tx
- Bimanual uterine massage
- IV fluid + oxytocin
hx of smoking + sudden pooling of secretion in vagina (pregnacy)
Name/Dx/Tx
Name: Premature rupture of membrane
Risk: STD, SMOKING
Dx
- Nitrazine paper test - turn blue PH 6.5<
- Fern test - fern pattern crystalization
Tx: Labor + monitor for infection
Any delivery before 37 wks
Name/Dx/Tx
Name: Premature Labor
Dx
- Fern test - crystal
- Nitrazine paper test - blue (ph 6.5<)
- Presence of FETAL FIBRONECTIN
Tx
- Beclomethasone (premature lung)
- Tocolytic - It’s Not My Time
- Indomethacin
- Nifedipine
- Meg sulfate
- Terbutaline
- ABX for GBS infection (ampicilin + amox)
During delivery baby head is out but shoulder stuck at mother pubis
Name/Tx
Name: Shoulder dystocia
Tx
- Nonmanipulation - McRobert maneuver (lift leg up and push w/ hand on mother suprapubis) 1stline
- Manipulation - Wood “Corkscrew” Maneuver (180 should rotation)
Induction of labor medication
- Oxytocin IV - 1cm dilation with some effacement
- Prostaglandin gel - unfavorable cervice
