6th year Flashcards
HPV vaccines
- Cervarix: 16, 18
- Gardasil: 6, 11, 16, 18
- Gardasil 9: 6, 11, 16, 18, 31, 33, 45, 52, 58
Bethesda system
Squamous cell cc
- ASC-US
- (ASC-H)
- LSIL
- HSIL
- Invasive carcinoma
Adenocc
- ACG
- AIS
- Adenocc
Richard system
- Condyloma
- CIN 1
- CIN 2
- CIN 3
- Invasive carcinoma
Papanicolou system
- P1: negative
- P2: some benign aberration
- P3: pathological cells (inflame vs dysplasia??)
- P4: suspect malignancy
- P5: true malignancy
Reagan system (WHO)
- Normal
- Atypia
- Mild dysplasia
- Moderate dysplasia
- Severe dysplasia
- Carcinoma in situ
- Invasive carcinoma
RMI score
Risk of malignancy index for ovarian masses
- Menopausal status (pre=1p, post=3p)
- US morphology (multiloculated, solid areas, bilateral, ascites, intraabd metastases. Score 0-1 => U=1p, Score 2-5 => U=3p)
- CA-125 absolute value
MxUxCA125 = ? (over 200 is suspicious)
ROMA score ovarian masses
- HE4
- CA-125
- Menopausal status
Treatment ovarian cc
Requires surgical exploration and intraop. frozen section
Stage
- IA: TAH-BSO (pregnancy-wish: USO=>fast pregnancy=>TAH-BSO)
- IB: TAH-BSO
- IC: TAH-BSO + peritoneal radioactive phosphorous
- II-IV: TAH-BSO + omentectomy + debulking (cytoreductive surgery) + chemo (paclitaxel+carboplatin)
*Bevacizumab (anti-VEGF) might be added adjuvantly
Germ-cell tumors and Sex-cord stromal tumors: TAH-BSO + staging +/- adjuvant BEP (bleomycin, etopocide, cisplatin)
Treatment uterine cc
Stage I-II: TAH-BSO (fertility-sparing: medroxyprogesterone acetate)
Stage III-IV: TAH-BSO + radiation + platinums
Treatment cervical cc
Stage Ia1: TAH (fertility-sparing: conization)
Stage IIa: TARH + PLND (fertility-sparing: up to Ib1: radical trachelectomy + PLND)
Stage IIb-IIIb: Radiation + chemo (cisplatin, bleomycin, mitomycin C, methotrexate, cyclophosphamide)
Stage IV: Palliative chemo/radiation/surgery
Types of vaginal prolapse
- Cystocele: weak pubocervical fascia
- Rectocele: weak rectovaginal fascia
- Enterocele:
(4: Urethrocele/urethrocystocele?)
Uterine prolapse defects
- Cardinal ligaments
- Uterosacral ligaments
Treatment vaginal prolapse
- Pelvic floor exercises
- Pessaries - support in vagina
- Colporrhaphy (ant/post)
Treatment uterine prolapse
- Pelvis floor exercises
- Pessaries - support in vagina
- Hysterectomy with repair of pelvic support structures (colporrhaphy) and suspension of top of vagina
Treatment UTIs
Uncomplicated cystitis:
- Nitrofurantoin for 5 days -or- Trimethoprim/Sulfamethoxazole for 3 days
Acute pyelonephritis:
- 1st line: Ciprofloxacin 7 days & Levofloxacin 5 days
- 2nd line: TMP/SMX for 14 days
- Other options if hospitalization: ampi-genta or piperacillin/tazobactam
Treatment PID inpatient
- Lecture: Cefoxitin or Cefotetan + Doxycyclin
Norge: Cefotaxime + doxycyclin +/- metronidazole - Alt: Clindamycin + gentamycin
Treatment PID outpatient
- Lecture: Ceftriaxone + doxycyclin +/-metronidazole
Alkylating agents
Cyclophosphamide
- Ovarian carcinoma
- Germ cell tumors + (Gestational tumor - choriocc)
- Scc
- Breast cc
- Cervix cc
Antimetabolites
- Methotrexate: hydatidiform mole (with D&C), choriocarcinoma, breast, ectopic pregnancy, abortion (with misoprostol)
- 5-FU:
Antibiotics
- Actinomycin D: choriocarcinoma
- Doxorubicin: breast
- Bleomycin: cervix cc
Plant alkaloids
Paclitaxel: breast, ovarian, vaginal/vulvar cc
Platinum chemo
- Cisplatin: cervix cc, vaginal/vulvar cc
- Carboplatin: ovarian cc, uterine cc
Cell-cycle specific chemo
- G1: Actinomycin D
- S: Antimetabolites (mtx, 5-fu), doxorubicin
- G2: Bleomycin, etoposide
- M: taxanes, vinca alkaloids
Normal sperm and semen
- 2-5 ml semen
- > 20 million sperm/microliter
- > 30 % normal morphology
- > 50 % motile
Prenatal visits (GP)
- From gw 4 - 28: once a month
- GW 28 - 35: once every 2 weeks
- From gw 35: every week
Naegles rule
First day of LMP + 7 days - 3 months (+ add a year)
Trimesters
First: gw 1-12
Second: gw 13-26
Third: gw 27-40
*Litt forskjellig overalt
GTPAL
History taking G: Gravidity (total no of pregnancies) Parity (TPAL) T: Term (total no of term deliveries P: Premature deliveries A: Abortions L: Living children
hCG positivity serum and urine + doubling
- Serum: 8-9 days after conception
- Urine: 28 days after first day LMP
- Doubles every 2nd day until 10 weeks
First obstetric visit tests
- Height, weight, BMI
- (BP?)
- Pelvic exam
- Labs: Blood type, irregular Ab, infections, fasting glucose
- hCG, urine culture
- Dental examination
Peptide hormones pregnancy
- hCG: 8d-10wk, maintain corpus luteum (pregnancy)
- hPL: glucose availability to fetus (atg to mother insulin)
- CRH: stimulate fetal ACTH => DHEA-S (gives estrogen)
- Prolactin: stimulated by mat. estrogen => milk production
- Relaxin: peak gw 10, promote implantation (and some softening of cervix)
Steroid hormones pregnancy + others
- Progesterone: endometrium for implantation, decidual changes and smooth muscle relaxant (no uterine contr)
- Estrogen: DHEA-S => estrone => testosterone => estradiol. Estriol prod in placenta
- Other: Oxytocin: uterine contractions, milk ejection
Functions estrogen
- Increase uterine blood flow
- Prepare breast tissue for lactation
- Stimulate hormone binding globulin from liver
Phases of parturition
- Phase 1: Quiescence (inactivity, inhibited myometrial contractions, progesterone)
- Phase 2: Activation (last 6-8 wks of pregnancy, myometrial activation from stretch or fetal HPA-axis => ACTH => cortisol => surfactant. Fetal lung: SP-A.)
- Phase 3: Stimulation (fetal cortisol and DHEA-S, increasing maternal estrogen => CAPs (connexin 43, oxytocin and prostaglandin R´s => contractions)
- Phase 4: Involution (puerperium, oxytocin increase => placental separation)
Mississippi class system HELLP
LDH > 600n U/L + ASAT/ALAT > 40 U/L + Platelets: - Class I: < 50000 /microL - Class II: 50000 - 100000 /microL - Class III: 100000 - 150000 /microL
Normal weight gain pregancy
9-14 kg
Estimation of gestational age
- Clinical: Naegle´s rule
- US at first prenatal visit! (gw 11-13+6 og gw 6-7?) - crown-rump length (evt. femur length, biparietal diameter, abd/head circumference)
Lab tests done each trimester
- CBC
- Urine sediment or culture
- Vaginal smear (for bacterial vaginosis)
Triple marker screen test
Gw 15-20 - aFP - Estriol - hCG Screen for Downs, Edwards SY, NT defect
Screening strep B
Vaginal and rectal gw 35-37
Screening chlamydia, gonorrhea
In high-risk patients
- 1st and 3rd trimester
False labor contractions
Braxton Hicks contractions
Contraction freq and intensity in normal labor
Stage 1
- Latent: 60-90 sec every 15 min (50 mmHg)
- Active: 45 sec every 3 min (50 mmHg)
Stage 2
- 45 sec every 3 min (75 mmHg)
Active phase labor abnormalities
Protraction disorder (slower) or active phase arrest (no dilation for 2 hrs)
Second phase labor disorders
- Disproportion of fetus and pelvis
- Maternal pushing efforts
Types of uterine labor dysfunctions
- Hypotonic uterine dysfunction
- Pressure unsufficient to give cervical dilation - Hypertonic uterine dysfunction
- Colicky uterus
- Hyperactive lower segment
Drugs for general anesthesia in emergency c-section
Thiopental + succinylcholine + N2O + O2
Maneuvers shoulder dystocia
- McRoberts maneuver: flex legs and pressure over pubic symphysis
- Rubin maneuver: rocking shoulder back and forth
- Wood corkscrew maneuver: grab posterior shoulder and rotate baby
- Gunn-Zavanellie: push baby head back and -section
- Cleidotomy, symphysiotomy
Maneuvers breech
- Bracth maneuver: pull over symphysis gently
- Müller maneuver: unknown
- Maurice-Smellei-Veit: grab face right hand and other hand hook shoulders/push occiput
Tests ROM
- Nitrazine paper: turn blue (alkaline)
- Fern test: NaCl cryztallize (microscope) in a fern pattern in the presence of estrogen (as in amniotic fluid or before ovulation - not after when progesterone predominates)
- AmniSure test: measure PAMG-1 (placental alpha-microglobulin a)
TORCHeS
- Toxoplasmosis: cat, intracerebral calcifications, chorioretinitis, hydrocephalus
- Other (VZV, Parvovirus B19, HIV, zika)
- Rubella: cataract, deafness, PDA, (rash, jaundice, mental)
- CMV: Microcephaly, IUGR, mental ret, Periventricular calcifications, Sensoryneural hearing loss
- Syphilis: Hutchinsons triad: hutchinsons teeth, deafness and interstitial keratitis
Infectious diseases in pregnancy, not TORCHes
- Listeria monocytogenes
- Chlamydia
- Gonorrhea
- Strep B (agalactie)
TORCH syndrome
In utero transmission of congenital infection
- Hepatosplenomegaly, Jaundice
- Fever, Lethargy, Difficulty feeding
- Anemia, petechiae, purpura
- Chorioretinitis
- Hearing impairment
Biophysical profile
- NST: over 2 good accellerations in 20-40 min
- Breathing: one or more rhythmic episodes lasting over 30 sec within 30 min
- Movements: more than 2 movements in 30 min
- Tone: 1 episode of extension + flexion (eg opening+closing of hand)
- AFI: One or more pockets of at least 2 cm
Uterine and cervical changes puerperium
- Uterine involution: 1000 gr to 50-100 gr (6 wks pp)
- Endometrial lining degenerates day 16
- Lochia 4-8 wks pp (rubra, serosa, alba)
- Eschar sloughs off 1-2 wks pp (blood loss ca 250 ml)
- 1 wk pp, cervix is back to normal
Endometritis puerperium
- Foul-smelling lochia
- Wash with iodine
3 reasons for puerperial fever
- Mastitis
- UTI
- Thrombosis
Perineum, abdominal wall puerperium
- Perineum: swelling down after 1-2 wks, muscle tone after 6 wks
- Abdominal wall soft and poor tone for many weeks
Urinary tract puerperium
Ureters and pelvis return to normal after 2-6 wks pp
Cardiovascular system puerperium
- Immediately after delivery increase in peripheral vascular resistance
- CO and plasma volume return in 2 wks
- Leukocytosis and thrombocytosis occur during and after labor
Return of menstruation after delivery
- Not breast feeding: 6-8 wks pp
- Breast feeding: longer due to prolactin
Treatment genital warts (HPV)
- Imiquimod cream
- Podophyllotoxin
- Cryotherapy
Non-treponemal tests (non-specific)
- RPR: rapid plasma reagin
- VDRL: Venereal disease research laboratory
- TRUST: Toluidine red unheated serum test
Treponemal tests (specific)
- FTA-ABS: fluorescent trep antibody absorption
- MHA-TP: microhemagglutination test for ab t.pallidum
- TPPA: t.pall particle agglutination assay
- TP-EIA: t.pall enzyme immunoassay
- CIA: chemiluminescence immunoassay
Sexually transmitted diseases du ikke kan navnet på
- Lymphogranuloma venereum: L1-L3 chlamydia, painless ulcer, painfull LN, Tx: doxycyclin or erythromycin (som chlamydia)
- Granuloma inguinale: klebsiella granulomatis (donovan), painless ulcer, Tx: azithromycin, ciprofloxacin, or erythromycin
- Chancroid/ulcus molle: H. Ducreyi, painfull ulcer, Tx: azithromycin and ceftriaxone (som gonorrhea)
- Pediculosis pubis, Tx: permethrin scrub
