Associations 6 Flashcards
Precocious puberty
<9 (males)
Tanner level 5 (girls)
Breast: areola recedes to level of breast
Pubic hair: spreads to medial thighs
LH in menstrual cycle
Midcycle surge (induced by estrogen) induces ovulation Stimulates corpus luteum to secrete progesterone (luteal phase)
FSH in menstrual cycle
Stimulates development of ovarian follicle (follicular phase)
Estrogens in menstrual cycle
Stimulates endometrial proliferation (follicular phase)
Secreted by follicle, aids follicle growth
Induces LH surge
High levels inhibit FSH secretion
Progesterone in menstrual cycle
Secreted by corpus luteum (luteal phase); *decrease in levels leads to menstruation
Stimulates endometrial gland development
Inhibits uterine contraction, increases cervical mucus thickness
Increases basal body temperature
Inhibits LH and FSH secretion, maintains pregnancy
hCG in menstrual cycle
Acts like LH after implantation of fertilized egg
Maintains corpus luteum viability and progesterone secretion (no menstruation)
Causes of pseudoprecocious puberty
Exogenous hormones (estrogens)
Adrenal tumor
Other hormone-secreting tumor (eg ovarian)
CAH
Phase of menstrual cycle fixed at 14 days regardless of cycle length
Luteal phase
Diagnostic for menopause
Amenorrhea >1 year in woman
Premature menopause
< 40 years old
Hormones in perimenopause
+LH, +FSH
Estrogen fluctuates
Causes primary amenorrhea
HPO axis dysfunction
Anatomic abnormalities (absent uterus, vaginal septa, imperforate hyman, vaginal atresia)
Chromosome abnormalities
Pregnancy
Causes secondary amenorrhea
Pregnancy
Ovarian failure (menopause)
HPO axis dysfunction, uterine abnormalities, PCOS, thyroid disease
Anorexia, malnutrition
Hypogonadism + anosmia
Kallman syndrome
Initial tests for primary amenorrhea
Physical (anatomic abnl)
B-hCG, prolactin, TSH
Signs of hyperandrogenism -> DHEAS, testosterone
Primary amenorrhea + absent uterus on US
Karyotype + serum testosterone
(Androgen insensitivity syndrome = 46XY)
(Abnl mullerian development = 46XX)
Primary amenorrhea + uterus present
B-hCG + FSH
(Pregnancy = high B-hCG)
(Turner syndrome = high FSH)
(HPO axis disease = low FSH)
Secondary amenorrhea initial tests
B-hCG (always first test)
Prolactin, TSH, FSH
If hyperandrogenism signs -> DHEAS, testosterone
Secondary amenorrhea w/ normal initial tests
Progesterone challenge (normal = anovulation) (abnl = low estrogen or outflow tract abnl) If abnl, progesterone-estrogen challenge (normal = HPO axis abnl, menopause) (abnl = outflow tract obstruction eg Asherman syndrome)
Causes secondary dysmenorrhea
Endometriosis, PID, uterine fibroids, ovarian cysts, adenomyosis
Timing primary vs secondary dysmenorrhea
Primary - beginning of menstruation and resolve over several days
Secondary - midcycle before onset of menstruation and increase in severity until conclusion of menstruation
“Powder-burn” lesions or chocolate cysts on biopsy
Endometriosis
Common symptoms of endometriosis
3Ds - dysmenorrhea, deep dyspareunia, dyschezia
Common causes abnormal uterine bleeding
PALM-COEIN Polyps Adenomyosis Leiomyoma Malignancy/hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Idiopathic Not yet classified
Regular, heavy abnl uterine bleeding
Think fibroid, adenomyosis, polyp
Irregular, heavy abnl uterine bleeding
Think anovulation
MCC abnormal uterine bleeding
Anovulation
Abnl uterine bleeding related to sex
Think cervical polyp/glandular tissue
Abnl uterine bleeding + positive B-hCG + intrauterine pregnancy + closed cervical os
Threatened abortion
Abnl uterine bleeding + enlarged uterus + menometrorrhagia for months
Fibroids, molar pregnancy, adenomyosis
Abnl uterine bleeding + severe menstrual pelvic pain
Endometriosis, adenomyosis
Menorrhagia + perimenopausal
R/o endometrial hyperplasia / cancer
Abnl uterine bleeding that started w/ menarch
R/o coagulopathy
MC coagulopathy associated w/ abnormal uterine bleeding
Von Willebrand disease
Abnl uterine bleeding + positive B-hCG + no fetus in uterus on US
Ectopic pregnancy
Abnl uterine bleeding + depression + constipation
Hypothyroidism
Diagnostic criteria for PCOS
2/3
Oligo or anovulation
Androgen excess
Polycystic ovaries (“string of pearls”) by US
Labs for PCOS
+LH
LH:FSH ratio >2:1
+DHEA, androstenedione, testosterone
+progesterone challenge (anovulatory)
Complications of PCOS
Infertility
DM
Endometrial cancer (+unopposed estrogen)
Also HTN, ischemic heart disease, ovarian torsion
“Dew drops on rose petals” rash
Varicella zoster (chicken pox)
MCC postmenopausal bleeding
Atrophic vaginitis (but must r/o endometrial cancer)
Indications for endometrial biopsy
AUB >35 yo or <35 w/ risk factors
Postmenopausal bleeding
Pap smear recommendations
Start at age 21
Every 3 years (21-29)
Every 3 years or every 5 years w/ HPV testing (>30)
Stop at age 65 if multiple normal results
ASCUS Pap - next step
21-24: repeat Pap in 12 months
25+: HPV testing
Colposcopy if either is positive
AGUS Pap - next step
Colposcopy + ECC +/- endometrial biopsy
ASC-H Pap - next step
Colposcopy
LSIL (CIN 1) Pap - next step
21-24: repeat Pap in 12 months
25-29: colposcopy
30+: HPV testing or colposcopy
HSIL (CIN 2 or 3) Pap - next step
21-24: colposcopy
25+: excision (LEEP, conozation or laser)
Thin anogenital skin w/ ivory or porcelain-white macules and plaques w/ pruritis or pain, usu postmenopausal
Lichen sclerosis (need to r/o SCC)
Functional benign ovarian tumors (physiological)
Follicular cyst, Corpus luteum cyst
Often regress on their own
Psammoma bodies
Concentric calcifications
Assoc w/ ovarian serous cystadenocarcinoma (or cystadenoma), papillary thyroid cancer, melanotic schwannoma
Benign ovarian tumor + chocolate cyst
Endometrioma
Benign ovarian tumor + multiple dermal tissues
Benign cystic teratoma (dermoid cyst)
Benign ovarian tumor + estrogen secretion (precocious puberty)
Granulosa theca cell tumor (stromal cell tumor)
Benign ovarian tumor + androgen secretion (virilization)
Sertoli-Leydig cell tumor (stromal cell tumor)
Characteristics of benign and malignant ovarian tumors on US
B - cystic, smooth edges, few septa
M - irregular, nodular, multiple septa, pelvic extension or adhesions
Drugs that cause gynecomastia
STACKED Spironolactone THC (marijuana) Alcohol (chronic) Cimetidine Ketoconazole Estrogens Digoxin
Multiple, bilateral small tender breast masses that vary in size with menstrual cycle
Fibrocystic changes
MC breast tumor <30 yo
Fibroadenoma
Bloody or nonbloody (serous) discharge with or without stimulation
Intraductal papilloma (nonbloody discharge only on stimulation is consistent w/ noncancerous)
Solitary, solid, mobile breast mass w/ well defined edges in young woman
Fibroadenoma
Large, bulky breast mass w/ leaf-like projections w/ patient in 50s
Phyllodes tumor
Embryonic age 1 week (3 weeks GA)
Implantation, B-hCG production starts
Embryonic age 2 weeks (4 wks GA)
Beginning of maternal-fetal circulation
B-hCG high enough to detect in urine (~30-40)
CNS starts to develop
Embryonic age 3 weeks (5 wks GA)
Heart starts to form
Embryonic age 4, 5 weeks (6, 7 wks GA)
GI tract start to form; lungs start to form
Embryonic age 6, 9 weeks (8, 11 wks GA)
Limbs, genitalia start to form; kidneys start to function
Embryonic age 15-20 weeks (17-22 wks GA)
Early detectable fetal movement
Embryonic age 24 weeks (26 wks GA)
Surfactant production begins
Earliest chance of viable premature birth
Embryonic age 32 weeks (34 wks GA)
Fetus usually survives premature birth
Embryonic age 37 weeks (39 weeks)
CNS fully developed
Fetus considered full term
37-42 weeks GA (35-40 EA)
Biggest effect of teratogens on organ systems
2-12 weeks (esp 3-8 weeks) EA
CV effects of pregnancy
CO increases 40% (SV and HR)
BP decreases slightly weeks 20-24, back to base by term
Respiratory effects of pregnancy
O2 consumption increases 20%
Tidal volume increases 40% w/ minute ventilation increase
PCO2 decreases to ~30 (respiratory alkalosis)
Endocrine effects of pregnancy
Nondiabetic hyperinsulinemia w/ mild glucose intolerance (HPL hormone contributes)
TG, cortisol increase
TSH decreases slightly; TBG and total T4 increase (free T4 stays the same)
Hematologic effects of pregnancy
Hypercoagulable
Increased RBC production, increased blood volume = physiologic anemia of pregnancy (Hct still decreases)
GI effects of pregnancy
Increased salivation
Decreased gastric motility (increased GERD)
Labs at initial prenatal visit
CBC Blood type and cross UA Pap smear, G/C screening RPR/VDRL, Rubella antibody titer, Hep B surface antigen, HIV screening (w/ permission)
Labs at 16-18 weeks GA
Quad screen
Labs at 18-20 weeks GA
US dating and anatomy screen
Labs at 24-28 weeks GA
1 hr glucose challenge (screen for gestational DM)
Labs at 32-37 weeks GA
Cervical culture for G/C in high risk GBS screening (36 weeks)
Quad screen
Maternal serum aFP Estriol B-hCG Inhibit Must be done at 16-18 weeks (aFP requires this time) Assesses for NTD, trisomy 18 and 21
Full integrated test
Nuchal translucency and PAPP-A in first trimester + quad screen in second trimester
Lowest false-positive rate for non-invasive tests
Amniocentesis
After 16 weeks
NTD and chromosomal abnormalities
0.5% miscarriage
Chorionic villi sampling
9-12 weeks
Chromosomal abnormalities
1% miscarriage
PUBS
After 18 weeks
Fetal anemia, Rh sensitization, possible transfusion
Increased nuchal translucency
Trisomy 21, 18, 13
Turner syndrome
Congenital heart defects (+fluid)
Maternal serum aFP
High in NTD and multiple gestations
Low in trisomy 21, 18
Quad screen, trisomy 21 vs 18 (doesn’t see trisomy 13)
21 = low aFP, estriol; high hCG, inhibin-A 18 = low aFP, estriol, hCG
B-hCG levels during pregnancy
Double every 48 hours until ~10 weeks, ~100K
Slowly return down to ~10K, stay there til end of pregnancy
Timing of diagnosis for gestational diabetes, preeclampsia vs pre-existing conditions
Diabetes >24 weeks
HTN >20 weeks
Pre-gestational diabetes early fetal complications
Sacral and renal agenesis, cardiac (TGA, tetralogy of Fallot), neural tube defects
HTN + edema in hands or face + proteinuria (>300 g/24 hrs) in pregnancy >20 wks
Preeclampsia
HELLP syndrome
Hemolysis
Elevated Liver enzymes
Low Platelets
Maternal N&V timing
Worst in first trimester, usu resolves by 12-16 weeks
Congenital infection w/ hydrocephalus, intracranial calcifications, chorioretinitis
Toxoplasmosis or CMV
Congenital infection w/ blueberry muffin rash
Rubella
Congenital infection w/ high rate of neonatal death
Rubeola, HSV
Congenital infection w/ rash w/ hand and foot desquamation
Syphilis
Congenital infection w/ progressive unilateral hearing loss + neuro abnl
CMV
Congenital infection w/ halo sign on CT of brain
Toxoplasmosis
Congenital infection w/ IUGR, deafness, cataracts/glaucoma
Rubella
Congenital rubella cardiovascular problems
PDA
Pulmonary artery stenosis
Congenital infection w/ temporal lobe encephalitis
HSV
Congenital infection w/ dermatomal skin scarring, chorioretinitis, microcephaly, intellectual disability, hypoplasia of hands and feet, early death
VZV (new infection)
Leading cause of congenital blindness
Chlamydia
Congenital infection w/ PNA, sepsis (early) or meningitis (late)
GBS
Congenital infection w/ decreased RBC production + hemolytic anemia = hydrops fetalis, high output cardiac failure
Parvovirus B19
MC site of ectopic pregnancy
Ampulla of fallopian tube (95%)
US can see intrauterine pregnancy
Intraabdominal: B-hCG >6500
Intravaginal: B-hCG >1500
<20 weeks + uterine bleeding + closed cervical os + viable IUP
Threatened spontaneous abortion
<20 weeks +/- uterine bleeding or pain + closed cervical os + non-viable IUP
Missed spontaneous abortion
<20 weeks + uterine bleeding + pain + open cervical os +/- viable IUP
Inevitable spontaneous abortion
<20 weeks + uterine bleeding + open cervical os + some uterine contents expelled
Incomplete spontaneous abortion
<20 weeks + uterine bleeding + open or closed cervical os + all uterine contents expelled
Complete spontaneous abortion
> 20 weeks + nonviable IUP w/o fetal movement or heart activity
Intrauterine fetal demise
Cause of 1st trimester spontaneous abortion
Chromosomal abnl (usu trisomies, trisomy 16 is common)
Cause of 2nd trimester spontaneous abortion
Infection, cervical incompetence, uterine abnl, drug use…
MCC symmetric IUGR
Congenial infection, chromosomal abnormalities
Familial
MCC asymmetric IUGR
Poor maternal health, placental insufficiency, multiple gestations
MC initial finding in IUGR
Abdominal circumference <10% for GA
AFI in oligohydramnios
2 cm
AFI in polyhydramnios
> 25 cm or one pocket >8 cm
MCC first trimester oligohydramnios
Often results in spontaneous abortion
MCC second trimester oligohydramnios
Fetal renal abnl
Maternal HTN/CVD
Placental thrombosis
MCC third trimester oligohydramnios
PROM, abruption
Preeclampsia
Idiopathic
MCC polyhydramnios
Insufficient fetal swallowing (GI abnl) Increased fetal urination (maternal DM) Multiple gestation Fetal anemia Chromosomal abnl
Complications oligohydramnios
Spontaneous abortion / IUFD
Abnl limb/face/lung/abdomen from compression
PROM vs PPROM
Spontaneous ROM before onset of labor (PPROM = before 37 weeks)
Labs for PROM
“Ferning” on slide
Nitrazine paper turns blue (non-specific)
Signs of fetal lung maturity
L:S ratio >2 + presence of phosphatidylglycerol (PG) in amniotic fluid
Signs of chorioamnionitis
Fever +
Maternal HR >100, fetal HR >160, maternal WBC >15K, uterine tenderness or foul smelling discharge
2 OB complications that can lead to DIC
IUFD (if fetus remains for extended time)
Abruptio placenta
Preterm labor
<37 weeks
MCC vaginal bleeding after 20 weeks
Placenta previa (painless) and abruptio (painful)
Higher B-hCG than expected
Molar pregnancy
Multiple gestations
Painless heavy or irregular vaginal bleeding during first or second trimester + hyperemesis gravidarum
R/o molar pregnancy
Preeclampsia <20 weeks gestation
Molar pregnancy
Expulsion of “grape-like” vesicles from vagina
Molar pregnancy
“Snow-storm” appearance on US w/o gestational sac
Molar pregnancy
Uterine mass on US w/ mix of hemorrhagic and necrotic areas and possible parametrial invasion
Choriocarcinoma
MC sites of mets for hydatidiform mole or choriocarcinoma
Lungs
Liver and brain = worse prognoses
Kidney, GI for choriocarcinoma
Workup for infertile couple
1) Semen analysis (30-40%)
2) Anovulation workup (20%)
3) Hysterosalpingogram to r/o anatomic issue (30%)
Normal non-stress test
15 bpm accelerations x 15 sec x 2 in 20 min
BPP scoring
NST AFI Fetal movement Fetal breathing Fetal tone 8-10 is reassuring, under that suggests fetal distress
Decelerations that begin and end w/ uterine contractions, rounded
Early (usu head compression)
Decelerations that begin any time and last different amounts of time, v-shaped
Variable (usu cord compression)
Decelerations that begin after uterine contraction starts and end after it finishes, check mark-shaped
Late (possible sign of uteroplacental insufficiency and fetal hypoxia)
Stage 1 of labor, latent phase
Start until 4 cm dilation and complete effacement
Stops and starts, gradual, variable
Stage 1 of labor, active phase
4 cm to complete 10 cm dilation w/ constant progression
>1.2 cm/hr (null) or >1.5 cm/hr (multi)
Stage 2 of labor
Fetal descent through birth canal
<1 hr (multi) (add 1 hr for epidural)
Stage 3 of labor
Neonatal delivery until placental delivery, <30 min
Stage 4 of labor
1 hr after lab, monitor mom hemodynamically
Induction of labor, Bishop score
3 has 15%
Fetal station, cervical dilation, effacement, consistency and position
Apgar scores
1 and 5 minutes, 0/1/2 points each
>7 (1 min) and >9 (5 min) reassuring
Appearance (blue/pink + blue extremities/pink)
Pulse (none/100)
Grimace (none/grimace/strong cry to pain)
Activity (none/some/active)
Respirations (none/poor weak cry/good strong cry)
Small, red, tender area on breast during breastfeeding
Galactocele
Larger, circumscribed area of redness and warmth on breast during breastfeeding + fever and +WBC
Mastitits
Uterine tenderness postpartum day 1-7 w/ fever, foul lochia
Postpartum endometritis
Immediately postpartum or during labor sudden-onset hypoxia, cardiogenic shock, DIC
Amniotic fluid embolism
Postpartum bleeding >500 cc + anemia + lack of breast milk when attempting to breastfeed
Sheehan syndrome