Case Files Flashcards
First line of OBGYN presentation
- age
- GP
- LMP
- gestational age if relevant
- chief complaint
Excessive menstrual flow is termed?
Excessive + irregular?
- menorrhagia
- menometrorrhagia
When taking a gynecologic history, in addition to normal history sections (HPI, PMHx, PSHx, etc), what should be included?
- menstrual hx
- contraceptive hx
- STDs
- OB hx
Every pregnant patient greater than 20 weeks gestation should be asked about _____.
symptoms of PreE
headache, visual changes, dyspnea, epigastric pain, face/hand swelling
Murmur considered normal in pregnancy
systolic flow murmur
never diastolic
What is the grey turner sign?
- discoloration at the flank
- indicates intra-abdominal/retroperitoneal hemorrhage
Ddx ulcers at vulva
- HSV (painful)
- syphilis (non-painful)
- vulvar carcinoma
Location of bartholin gland cysts
5 & 7 oclock
Normal ovary size?
about the size of a walnut if palpated at all
Rectal exam finding suggestive of endometriosis
nodularity and tenderness in the uterosacral ligament
What do the vaginal and rectal exams inspect, respectively?
- vaginal: anterior pelvis
- rectal: posterior pelvis
Routine initial prenatal labs
- CBC, blood type
- Urine Culture
- Pap smear
- G&C cultures
- Hep B, HIV, Syphilis, Rubella Titer
When is testing for GDM usually performed in pregnancy? GBS?
- GDM: 26-28 weeks
- GBS 35-37 weeks
Which of the initial prenatal labs are repeated in third trimester?
- HIV in populations with prevalence above 1/1000
- CBC for anemia
- other STDs if indicated based on risk factors
Labs for: threatened abortion
-HCG and progesterone
Labs for: menorrhagia
- CBC
- endometrial biopsy
- pap smear
Ovarian tumor markers (2)
- CEA
- CA125
Thickened endometrial stripe significance:
- premenopause: pregnancy
- postmenopause: endometrial cancer
Test that determines patency of fallopian tubes:
-HSG
Test that determines patency of ureters
-IVP
Test that best evaluates uterine anomalies
-MRI
Top two causes of post partum hemorrhage
- uterine atony
- genital tract laceration
**distinguish by looking for presence of “boggy” vs firm uterus
Multiparous woman with loss of urine when coughing:
- diagnosis
- PE finding
- initial treatment, second treatment option
- stress incontinence
- hypermobile urethra +/- cystocele
- kegel exercises, fix urethra above pelvic diaphragm (urethropexy)
What maintains continence in a healthy individual?
-urethral pressure exceeds bladder pressure (requires that both be located in the intraabdominal cavity)
MC cause overflow incontinence
diabetes/ neuropathy
MC cause stress incontinence
cystocele
hypermobile urethra
Describe mixed incontinence
-urge to void AND loss of urine with Valsalva
Treatments for stress incontinence
-kegels –> urehtropexy –> transvaginal fixation
Treatment of urge incontinence
anticholinergic medication to relax detrusor
Treatment of overflow incontinence
intermittent self cathetherization
What differentiates genuine and urge incontinence
-cystometric/ urodynamic evaluation
Three components of health maintenance
1) cancer screening
2) immunizations
3) addressing common disease in patient group
When are pap smears performed?
every three years 21-65
**may do every 5 years with co-testing ages 30-65
Requirement for stopping pap screening at age 65:
paps negative for CIN2 during last 20 years
What age groups receive HPV vaccine?
9-26
When should tetanus boosters be administered?
q10 years
What age groups receive varicella zoster + pneumonia vaccine?
60+
What two health maintenance screenings begin at age 45?
cholesterol q5 years
fasting blood sugar q3 years
(may start sooner if warranted)
When should TSH screening begin?
q5 years at age 50
When should DEXA scanning begin?
65+
For what age groups is cancer #1 COD? Heart DiseasE?
19-64: cancer
65+ heart disease
(younger = MVA… now probably Overdose is more accurate)
Mammography guidelines
q1 year starting age 40
Four major conditions in women 65+
- depression
- CVD
- osteoporosis
- breast cancer
Signs of placental separation
gush of blood + lengthening of the cord
What defines an abnormally retained placenta
third stage of labor longer than 30 minutes
Cause of uterine inversion
excessive force on the umbilical cord
Risk factors for uterine inversion
1) grand multiparous patient w/ placenta implanted at fundus
2) placenta accreta
1st step in management of uterine inversion
clinicians fist placed inside uterus to maintain structure until surgery can take place
If placenta is not delivered after 30 minutes, what is the next step in management?
manual extraction attempt
What is climacteric?
perimenopausal state
What confirms the diagnosis of perimenopausal state?
FSH + LH levels (expected to be high)
Mean age of menopause
51
Age at which premature ovarian failure is diagnosed?
less than 40
At 30 or younger: consider AI disease or karotypal abnormality
Four risks associated with Estrogen+ Progestin therapy in menopause
- breast cancer
- stroke
- PE
- heart disease
Two diseases with decreased incidence when using E/P therapy in menopause
1) colon cancer
2) osteoporosis
In addition to estrogen, what drug may be used to treat hot flashses?
clonidine
How are estrogen levels changed in PCOS?
INCREASED
HIGH estrogen + testosterone and poor ovulation
How does hyperprolactinemia effect estrogen levels?
PRL —I GNRG —–I LH/FSH = low estrogen
MC location osteoporosis fracture
thoracic spine
Nectroizing fasciitis buzzword
crepitus
Bacteria responsible for nec fas
anaerobes
First sign of septic shock
decreased urine output –> tachy
Cause of hypotension in shock
vasodilation
Sepsis + sunburn like rash suggests what bacteria?
GAS
What dictates normalcy in labor?
change in the cervix, not contractions
Define: latent phase of labor
stage 1,
time when cervix effaces as opposed to dilating.
less than 4 cm
Define: active phase of labor
dilation occurs more rapidly
greater than 4 cm
Define adequate labor
primigravid: 1.2 cm/ hr
multip: 1.5 cm/hr
Contrast arrest and protaction of labor
arrest: no progress 2 hours
protraction: inadequate cervical dilation
Define the stages of labor:
first: onset to 10 cm dilation
second: complete dilation to delivery of infant
third: delivery of placenta
define adequate acceleration
15 bpm for at least 15 seconds
What should be first evaluated during labor abnormalities?
Three P’s
powers
passenger
pelvis
How long should stage one of labor last?
primi: 18-20
multip: 14
How long should stage two of labor last?
primi: 2, 3 with epidural
multip: 1, 2 with epidural
How long should stage three of labor last?
30 mins
Define clinically adequate contractions
q2-3 minutes lasting at least 40- 60 seconds
or 200 MVUs
How are Montevideo units calculated?
10 minute window, add each contractions rise above baseline
MC cause of early, late, and variable decelerations
early- head compression
variable- cord compression
late- hypoxia
How is normalcy of labor assessed?
cervical change IN ACTIVE STAGE
time in latent phase
When is cesarean delivery considered for abnormal labor?
CP disproportion
arrest of active phase w/ adequate contractions
When should a uterine pregnancy see visible on US
1500-2000 mIU/mL b HCG
25 ng/mL progesterone
What is a normal rise in b-HCG
66% over 48 hours
Who is a candidate for MTX?
women with small ectopics (less than 3.5 cm)
*reliable patient, no heart beat etc
Treatment for patient with suspected ectopic who is acutely symptomatic?
laparoscopy
Common ADR of MTX therapy
mild abdominal pain, can observe these patients with stable vitals
Best treatment for placenta accreta
hysterectomy
Cause of placenta accreta
defect of the decidua basalis layer
Treatment of placenta accreta in young patient who strongly desires further fertility
pack the uterus
excess mortality
Highest risk factors for placenta accreta
previous C-section/ D&C
placenta previa
fetal down syndrome
Placental position most commonly associated with placenta accreta
anterior placenta
Most common complication of placenta accreta treated with uterine artery ligation/ packing
hemorrhage
2nd most common infection
What procedures increase the risk of placenta accreta?
those that penetrate the uterine wall fully (ie cesarean not myomectomy)
Treatment for cervicitis (empiric)
gonococcal protection- ceftriaxone IM single dose
chlamydial protection- azithromycin oral single dose
Alternative to azithromycin for treatment of chlamydia
doxycycline
Where does the “lower genital tract” begin?
cervix and below
Two MC symptoms of cervicitis
post coital bleeding
mucopurulent discharge
What should be offered to patients with cervicitis?
counseling+ testing for other common STDs
MCC septic arthritis in young women?
gonorrhea
MC cause mucopurulent discharge in US women?
chlamydia
Presentation of disseminated gonococcal disease
multiple painful pustules on the skin
Treatment for complete spontaneous abortion
follow hcg levels to zero
How are inevitable abortion and cervical incompetence distinguished
presence or absence of contractions
MC risk factor for shoulder dystocia
maternal diabetes
multiparity, obesity
Sign of shoulder dystocia
turtle sign
Erb’s Palsy involves what nerve roots?
C5-6
What is the Zavanelli maneuver?
cephalic replacement –> cesarean delivery
How might bony diameter from shoulder to axilla be decreased in the case of shoulder dystocia?
delivery of posterior arm
How can anterior rotation of the pubic symphysis be achieved in the case of shoulder dystocia?
mcroberts maneuver
How might fetal shoulder axis switch from AP –> oblique?
suprapubic pressure
What should be avoided in the case of shoulder dystocia?
fundal pressure
Symptoms of pyelonephritis post op suggest _____
ureteral injury –> need IVP or CT
Through which ligament do the uterine arteries traverse?
cardinal
IVP images what structures?
KUB
MC surgery injuring the ureter
abdominal hysterectomy
When the ureter is “dissected” during surgery, what risk is posed to the patient?
ureteral ischemia
In addition to surgery, what may cause a fistula leading to incontinence?
radiation therapy
Postmenopausal bleeding always warrants a __________
endometrial biopsy
risk factors for endometrial cancer
- late menopause, nulliparity, early menarche
- obesity, diabetes, htn, pcos
In the case of negative biopsy in the face of PM bleeding and many risk factors, the next best step in management is?
direct visualization, hysteroscopy vs hysterectomy
MC cause post menopausal bleeding
friable tissue, only 20% will have endometrial cancer
Normal thickness of the endometrial stripe
5 mm
When do we worry about endometrial cancer in a 30 year old patient
history of anovulation (ie PCOS= unopposed estrogen)
MC female genital tract malignancy
endometrial cancer
Endometrial cancer in thin patients is _____
more aggressive
When is a patient with placenta previa delivered?
cesarean at 36-37 weeks with stable vitals
Three types of placenta previa
complete, partial, marginal
Placenta previa causes a risk of placenta _____
accreta
Risk factors for placenta previa
multips
surgeries
history
Order of appropriate examinations in case of placenta previa
U/S –> speculum –> digital
Treatment of stable placenta previa diagnosed early in pregnancy?
repeat US at second trimester
Three major risk factors for placental abruption
cocaine
trauma
HTN
Bleeding that occurs behind the placenta in an abruption
concealed abruption
What is couvelaire uterus?
bleeding into the myometrium that discolors the uterus
How is placental abruption diagnosed?
clinical picture, not US
What lab is critical in case of suspected coagulopathy secondary to abruption?
fibrinogen levels (less than 150)
What tests for fetal-maternal hemorrhage in case of abruption?
kleihauer betke test
Desried hematocrit and urine output in placental abruption?
hct 25-30%
urine 30 ml/hour
post cotial bleeding
odorous discharge
suggestive of….
cervical cancer
Mean age of presentation for cervical cancer
51
Risk factors for cervical cancer
STDs
early sex/ many partners
cigarettes
multiparity
Ages during which HPV vaccine is given
9-26
Which strains of HPV cause cervical cancer? warts?
cancer: 16,18
warts: 6,11
1 location cervical cancer
squamocolumnar junction
Appearance of CIN lesions on colposcopy
aceto-white changes
Best test for visible cervical lesion
biopsy, not pap smear
Treatment of early versus late cervical cancer
early: surgical vs chemo/radiation
late: radiation + chemo gold standard
Contrast brachytherapy and teletherapy
brachy: implants
tele: full pelvic radiation
MC chemo drug used in cervical cancer
cisplatin
Most common cause of death in cervical cancer
bilateral ureteral obstruction leading to uremia
Followup post hysterectomy for cervical cancer
hysterectomies of the vaginal cuff
What populations with ASCUS may be observed?
adolescents and pregnant women
Sheehan syndrome is _______ pituitary necrosis
anterior
Symptoms of Sheehan
amenorrhea
failure to breast feed
hypothyroid
adrenocortical insufficiency
Asherman syndrome is caused by damage to _____
the decidua basalis layer
How are Sheehan and Asherman distinguished?
determine whether the uterus is responsive to hormonal therapy
How is Ashermans definitively diagnosed?
hysterosalpingogram
Amenorrhea is formally defined as
lack of cycles for 6 months
Definition of PPH
500+ mL vaginal
1000+ mL cesarean
MCC amenorrhea in reproductive years
pregnancy
What hormones need to be replaced in Sheehan syndrome?
- thyroxine
- cortisol
- mineralocorticoids
- estrogen, progestin
Treatment asherman syndrome
hyperoscopic resection
Temperature chart associated with PCOS
monophasic
Treatment of cord prolapse
immediate cesarean delivery
Risk factors for cord prolapse
rupture of membranes with transverse fetal lie or unengaged presenting part
AROM should be avoided without ______
engagement of the presenting part ! `
Position that must be maintained while preparing patient for cesarean delivery in case of cord prolapse
trendelenburg + physicians hand maintains cord inside
Define engagement
largest diameter of the head has negotiated the fetal pelvic inlet
Initial triage steps in case of fetal bradycardia
1) patient on side
2) fluid bolus
3) 100% O2 by face mask
4) stopping oxytocin
How does hyperstimulated labor present?
How is it managed?
fetal bradycardia
B-agonists (terbutaline)
What most commonly causes fetal bradycardia during labor?
epidural, give fluids, it will resolve
Position that most strongly predisposes to cord prolapse
footling breech presentation
Ddx for bradycardia
1) epidural
2) hyperstimulation of labor
3) cord prolapse
4) uterine rupture
FIRST step in assessing fetal bradycardia
distinguish maternal and fetal pulse + look for cord prolapse
MC finding assc with uterine rupture
fetal HR abnormality
Treatment for uterine rupture
STAT cesarean
How do thyroid hormone levels alter prolactin levels?
TRH increases PRL levels
How does elevated PRL cause amenorrhea?
^^ PRL –I GnRH
How is galactorrhea definitively diagnosed
fat droplets under the microscope
Differential diagnosis of pruritis in pregnancy
cholestasis
herpes gestationalis
PUPPP
what does PUPPP stand for?
pruritic urticarial papule and plaques of pregnancy
Cholestasis of pregnancy:
- most common location of pruritis
- most common time of onset
- extremities
- third trimester, at night
What confirms the dx of cholestasis in pregnancy?
increased bile acids
Treatment of cholestasis of pregnancy?
antihistamines
Cause of herpes gestationis
IgG autoantibodies against basement membrane (not virus”)
dx and Treatment of herpes gestationis
IgG levels, corticosteroids
Where does PUPPP typical start?
abdomen –> thighs and buttocks
Treatment of PUPPP
topical steroids and antihistamines
Effect of cholestatis, PUPPP, and HG on pregnancy
- cholestatis: increased neonatal mortality
- PUPPP: none
- HG: will see transients neonatal lesions
Pelvic inflammatory disease is AKA
acute salpingitis
2 longterm sequelae of PID
infertility
ectopics
The best method for diagnosing PID is?
laparoscopy
Perihepatic lesions in the presence of PID is termed:
Fitz-Hugh Curtis syndrome
What is required to manage PID outpatient?
absence of peritoneal signs
low fever
tolerance of oral meds
not pregnant or at extremes of age
Most common cause and treatment of tuboovarian abscess
anaerobes
metronidazole/clinda
Most common culture findings in PID
multiple organisms
gonorrhea, chlamydia, anaerobes, gram -
Sulfur granules are classic for infection with what bacteria?
actinomyces
Is multiparity or nulliparity assc with higher PID risk?
nulliparity
vital sign changes assc with PE
tachycardia
tachypnea
classic test for PE
Spiral CT or MRA
What predisposes pregnant women to DVT?
venous stasis (vena cava) + hypercoagulable state (estrogen) of pregnancy
How does estrogen cause hypercoagulable state?
increases fibrinogen levels
“Rales” on exam in a patient woman are suggestive of:
1) pneumonia
2) CHF
3) ARDS
4) atelectasis
Normal pH, pCO2, HCO3 in a pregnant woman?
7.45 28 CO2 (higher tidal volume) 19 bicarb (higher renal excretion to compensate for respiratory changes)
How is peripartum cardiomyopathy treated in pregnancy?
diuretics
ionotropic therapy
How is PE treated?
IV heparin 5-7 days followed by subQ therapy to maintain PTT 1.5-2.5 for at least 3 months
What tests should be done to detect clotting disorders?
- Protein S/C levels
- Factor V levels
- AT levels
- homocysteinuria/ APL syndrome
MCC maternal mortality
PE
What PO2 is concerning in a pregnant woman?
less than 80 mmHg
Painful vaginal lesions + inguinal adenopathy =
chancroid (haemophilus ducreyi)
MC symptom of leiomyomata
heavy bleeding/ anemia
what medication is used to shrink the size of fibroids?
GnRH agonist
Change seen in leiomyoma during pregnancy?
red degeneration
What types of leiomyomata exist?
- subserosal
- submucosal
- intramural
- pedunculated
MC reason for hysterectomy
fibroids (30%)
Risk factor for leiomyosarcoma
pelvic radiation
When should an asymptomatic leiomyomata be removed?
rapid growth
ureteral compression
How might pre-eclampsia lead to blood loss/ severe hypotension?
hepatic rupture
Proteinuria + BP diagnostic for PreE
300+ mg over 24 hour period
140/90+
Underlying pathogenesis of PreE
vasospasm and leaky vessels
What labs are included in the PIH panel?
ULAC PP
- uric acid
- ldh
- AST/ALT
- Creatinine
- Platelet
- Protein/creatinine ratio
How is magnesium sulfate excreted?
kidneys, monitor urine output +reflexes
Treatment for severe PreE
deliver, regardless of gestational age
When are platelets transfused?
50,000 or less
How do ecclamptic seizures lead to maternal mortality?
intracranial hemorrhage
Treatment for mild pre-eclampsia:
expectant management before term at term (37 weeks) deliver
When are monochorionic twins delivered?
35 weeks
When are PPROM patients delivered?
34 weeks
HTN that persists beyond 12 weeks postpartum is deemed
chronic HTN
Difference between fine and core needle biopsies
core needle biopsies preserve cellular architecture
What is a “triple assessment” of a breast mass?
clinical exam
imaging
FNA/CNB
What are the five main causes of infertility?
1) ovarian
2) uterine
3) tubal factor
4) semen
5) peritoneal factor (endometriosis)
Define fecundability
probability of achieving viable pregnancy during one menstrual cycle (20-25% is normal)
Ovulation occurs _____ hours after the LH surge
36
Gold standard for diagnosis of endometriosis
laparoscopy
When is temperature highest during the menstrual cycles?
after LH surge (luteal phase)
HSG revealing blocked tubes should be followed up with ______
laparoscopy
Most common time of ovarian torsion during pregnancy?
14 weeks when uterus rises or immediately post partum
What distinguishes ovarian torsion from appendicitis and cholecystitis?
absence of fever/ anorexia/ leukocytosis
Timing of appendicitis vs cholecystitis in pregnancy ?
appy: any trimester
cholecystitis: after first trimester
What predisposes women to gall stones?
increases size of gallbladder
increased biliary sludge
Ddx of abdominal pain in pregnancy
cholecystitis appendicitis placental abruption ectopic torsion
MCC pancreatitis in pregnancy
gallstones
Labs assc with pancreatitis:
amylase
lipase
How is cholelithiasis/ cholecystitis treated in pregnancy?
lowfat diet
observe until post partum
**not to be confused with choleCYSTITIS (treat with cholecystectomy)
1 cause maternal mortality in the first twenty weeks of pregnancy
ruptured ectopic
Gold standard for diagnosis of ectopic
laparoscopy
After giving MTX, what should raise suspicion of rupture?
hypotension and low Hct
*abdominal pain is normal
What progesterone level denotes a normal IUP
25 ng/mL
Most common cause of anemia in pregnancy women
iron deficiency, fetus has increased need for iron
Sickle Cell anemia mutation
glutamic acid –> valine on B globin chain
B-thal presentation at birth
normal, until Hb F falls
life expectancy in third decade
Which is more common in pregnancy: folic acid or B12 deficiency?
folic acid, B12 stored for years
Three common causes of hemolysis in patients with G6Pd deficiency?
nitrofurantoin
antimalarials
sulfa drugs
Elevated A2 Hb suggests ______.
Elevated Hb F suggests ______.
A2: B thal
F: A thal
What test of vaginal fluid determines risk of preterm delivery?
fetal fibronectin assay
What steps should be taken to manage preterm labor?
- abx for GBS px
- steroids
- tocolysis
- cause of labor?
What is needed to diagnose preterm labor in a nulligravida
2cm dilated, 80% effaced
At what week gestational age are steroids/tocolytics no longer necessary in face of preterm delivery
34
What are common tocolytic agents?
CCBs
terbutaline
indomethacin
How does MgSO4 work to maintain a pregnancy?
competitively inhibits calcium
How does 17 a hydroxyprogesterone caproate work to stop labor?
(progesterone) inhibits pituitary gonadotropin release; maintains pregnancy
Nifedipine should never be combined with _____
MgSO4
Terbutaline/ Ritodrine ADRs
pulmonary edema
hyperglycemia
hypokalemia
tachy
MgSO4 ADRs
pulmonary edema and respiratory distress
How often are steroids given when mother is at risk of preterm delivery?
17aOHprogesterone caproate?
steroids: once
17aOHPC: weekly to maintain pregnancy
What infection is strongly linked to preterm delivery?
gonorrhea
What is a contraindication to tocolytic therapy?
suspected abruption
Dyspnea in a woman given tocolysis is generally caused by ______
pulmonary edema, give furosemide
E .coli = MC etiology of simple UTI.
What abx are known to treat e coli?
SCQN super cocks never quit sulfa cephalosporins quinolones nitrofurantoin
1 cause urethritis
chlamydia
Why does female sex predispose to UTIs?
Why do pregnant women have high risk UTIs?
women- shorter urethra
pregnancy- incomplete emptying of bladder
What abx is e coli commonly resistant to?
ampicillin
DOC for chlamydia? gonorrhea?
chlamydia- azithromycin, doxy
gonorrhea- ceftriaxone
Which two drug classes cover e coli AND penetrate kidney for treatment of pyelo?
FQs
TMP-SMX
Most simple difference in presentation of lower UTI vs pyelo?
fever
What are contraindications to IUD placement?
recent infection (STD) scandalous sexual behavior. give them condoms. abnormal size/shape uterus
Does hormonal IUD increase risk of DVT/PE?
no. its progesterone, not estrogen.
ADR assc with hormonal patch for contraception
nausea and vomiting
How does the levonorgestrel IUD work?
thickens cervical mucus, thins endometrium
**doesn’t prevent ovulation
How does the copper IUD work?
inhibits sperm migration/viability
damages ovum
What patients cant have copper IUD?
wilsons disease
How long should a diaphragm be left in?
put in 1-2 hours before sex and leave in for 8 hours after
must also use spermicide
MOA compination OCPs
progresterone inhibits ovulation and thickens cervical mucus
estrogen stabilizes endometrium to prevent breakthrough bleeding
Three risks OCPs
1) clotting (stroke, MI, PE)
2) benign hepatic tumors
3) cholelithiasis
What is the preferred method of oral emergency contraception and why?
progestin only, as opposed to combination…..
less nausea
when must emergency contraception be initiated?
within 72 hours of intercourse
For what conditions is contraception with IMPA indicated?
SCA, epilepsy
What may occur after initiation of abx therapy for treatment of gram negative infection?
ARDS
endotoxin release after bacteria are lysed
What is the pathogenesis of ARDS?
leaky capillaries
CT finding in case of ARDs
patchy infiltrates
MC cause septic shock in pregnancy
pyelo
Proper evaluation test for DVT
Doppler ultrasound
How common is PE in untreated DVT?
40%
Which anticoagulant leads to osteoporosis?
heparin
What chromosomes are assc with the BRCA genes?
What types of genes are they?
What is the inheritance pattern?
- BRCA1 17
- BRCA2 13
- tumor supressors
- AD
Any palpable dominant mass requires _____
histologic diagnosis regardless of imaging findings
FNA for young women
Excisional biopsy for women 50+
MC type of breast cancer
intraductal carcinoma
Tumor producing TH
struma ovarii
MC type ovarian neoplasm + type assc with CA 125
epithelial tumor in ages 30+
younger than 30 dermoid more common
U/S features of mature/benign cystic teratoma
hypoechoic area, cystic structures, fat fluid level
What are the five types of epithelial ovarian neoplasms?
1) serous
2) mucinous
3) endometroid
4) brenner
5) clear cell
What epithelial tumor is most rapidly growing?
mucinous, assc with pseudomyxoma peritonei
What size ovarian cyst warrants operation in:
- prepubertal girls
- reproductive age girls
- menopausal girls
- prepuberty: 2+ cm
- reproductive 8+
- menopausal: 4+
Appearance of ovarian neoplasms on US:
- granulosa cell
- dermoid
- follicular
- granulosa cell: solid
- dermoid: complex
- follicular: simple cyst
Treatment of surgical site infection
immediate surgical closure and abx
Contrast wound dehiscence, fascial disruption, and evisceration
dehiscence: separation of surgical incision
fascial disruption: communication of the perionteal cavity with the skin
evisceration: disruption of all layers, bowel protruding through
MCC post op fascial breakdown
suture tearing through fascia
How can urine vs lymphatic drainage be distinguished?
creatinine
Copious amounts of serosanguinous fluid from abdominal incision suggest _____
fascial disruption
Risk factors for fascial disruption
- obesity
- malnutrition
- chronic cough
Endometrial tissue floating with a frond pattern is diagnostic of _____
IUP
Hemoperitoneum in the presence of a viable IUP is likely caused by
ruptured corpus luteum cyst, less commonly co-existing ruptured ectopic + IUP
Symptoms of hemoperitoneum:
hypovolemic symptoms peritoneal signs (pain)
What part of pregnancy requires progesterone from the corpus luteum
first 10 weeks
Symptoms of degenerating leiomyomata in pregnancy:
localized tenderness over the site of the mass
What percentage of blood volume must be lost before hypotension is seen?
30-40%
How is ashermans syndrome diagnosed?
HSG, trial of progesterone withdrawl bleeding
Treatment for ashermans
operative hysteroscopy
Classic finding suggestive of breast cancer on mammography
Small cluster of calcifications around a mass.
Mass with spiculated borders
Annual mammograms age 40-90 exposes patients to how many rads?
10; safe.
Tx for palpable breast mass with normal imaging
Biopsy; false negative up to 10% of cases
Lesion caused by trauma to breast + it’s mammogram appearance
Fat necrosis
Mimics breast cancer
** Still must excise lesion to confirm
At what age is primary amenorrhea diagnosed?
16
Ddx of painless primary amenorrhea with normal breast development
Androgen insensitivity vs mullerian agenesis
Treatment of androgen insensitivity
Removal of intra-abdominal gonads after puberty
Anomaly commonly assc with mullerian anomalies
Renal anomalies
What explains breast development in androgen insensitivity syndrome?
Peripheral conversion of androgens
Treatment for septic abortion:
IV broad spectrum abx
D&C
Also monitor BP/O2/urine output
MC etiology of septic abortion
Usually polymicrobial
Pockets of gas on pelvic CT suggest what diagnosis?
What was the treatment?
Metritis
Treatment = urgent hysterectomy
Ergot alkyloid used to treat atony
Methergine
What vessels are ligated to treat uterine atony?
Uterine artery
Internal iliac artery
Late post partum hemorrhage cause
Subinvolution of the placenta
MCC sexually infantile delayed puberty
gonadal dysgenesis, chromosomal abnormality
kallman v turners
Contrast Kallman and Turners
FSH, LH increased in Turners
Four stages puberty
thelarche –> adrenarche –> growth spurt –> menarche
MC health concern in Turners Syndrome
osteoporosis
No menses at age 15 is diagnosed as?
delayed puberty (no sex characteristics at 14-15) –> primary amenorrhea not diagnosed until 16 years
______ determines gonadotropic state, _____ determines gonadal state.
FSH-gonadotropic
estrogen- gonadal
breast fluctuating lesion:
dx:
tx:
etiology:
abscess
drain
staph aureus, from infants nose and throat
**continue breast feeding
What vitamin is absent in breast milk?
Vitamin D, supplement by 2 months
What proteins are in breast milk?>
whey + casein
What immunogenic compounds are found in breast milk?
lactoferin
secretory IgA
lysozyme
Treatment of thyroid storm in pregnancy
- Bber
- corticosteroids
- PTU
Rare but serious ADR of PTU
bone marrow aplasia
check white cell count before giving
Changes to thyroid panel in pregnancy
- normal free T4/TSH
- increased TBG, total T4
MC cause hyperthyroidism in the postpartum patient
destructive lymphocytic thyroiditis
antimicrosomal antibodies
Manifestations of chlamydial infection in pregnancy
- neonatal conjunctivitis and pneumonia
- late postpartum endometritis
- mucopurulent urethritis/cervicitis
MCC neonatal conjuncitivits
chlamydial
erythromycin given at birth prevents gonococcal conjunctivitis
Manifestations of gonococcal infection in pregnancy
- PPROM/premature labor/SAB/chorio
- disseminated gonococcal disease
- postpartum endometritis
- neonatal sepsis, conjuncitivits
MC mode of transmission of HIV
heterosexual intercourse
How long after infection are HIV ab’s detectable
by three months
How should delivery be handled in HIV+ patient?
scheduled cesarean prior to rupture of membranes
**If PPROM just go ahead and deliver vaginally, baby already exposed
Chlamydia prefers what tissue type?
transitional and columnar epithelium
Treatment of chlamydia in pregnancy
ORAL azithro/amox
How does parvovirus B19 lead to hydrops?
inhibits bone marrow erythrocyte production –> anemia –> hydrops
(aplastic anemia)
Describe adult rash associated with parvo
“lacy”/reticular
What ab is assc with past parvo infection? current?
How long after infection might it take for ab’s to become evident?
IgG-past
IgM- current
20+ days after infection
Describe fetal hydrops
fluid in multiple body cavities
What fetal heart tracing is assc with fetal hydrops?
sine wave with cycles of 3-5/minute
Describe the viral structure of parvo
small single stranded DNA
What are some causes of fetal hydraminos?
- CNS, GI, chromosomal anomalies
- maternal DM, multiple gestation
- syphilis, parvo
- Rh isoimmunization
Fetal findings assc with ITP
thrombocytopenia
IUGR
Abx for postpartum endometritis should cover what bugs?
- anaerobic, gram -
cesarean: clinda +gent
vaginal: amp + gent
Ddx of postpartum fever, most common causes (4)
- mastitis
- wound infection
- endometritis
- pyelo
Postpartum fever persisting beyond 72 hours after abx treatment warrants _____
CT of abdomen
Best treatment of wound infection
open the wound.
Greatest risk factor for endometritis?
cesarean
MC bacteria assc with endometritis
bacteroides (anaerobes)
Treatment for septic thrombophlebitis
heparin + abx
Exam finding assc with syphilis
nontender lesion + lymphadenopathy
What test is more specific that RPR/ VDRL for syphilis?
FTA-ABS
2 MC infectious causes of ulcers in the US
syphilis + herpes
What are the stages of syphilis infection?
primary (painless ulcer)
secondary (rash on hands and feet)
latent (1+ year)
tertiary (ocular, CNS,CV findings)
How is neurosyphillis diagnosed?
What are the manifestations of neurosyphilis?
LP
-argyl Robertson pupil, unsteady balance
Gram stain finding of chancroid
“school of fish”
What causes false + RPR
SLE
T pallidum:
-organism type
Thin spirochete
Alternatives to penicillin in the treatment of syphilis
erythromycin, doxycycline
How long after PPROM does labor occur?
50% within 48 hours
90% within a week
Risk factors for PPROM
- cigarettes, STDs, low SES
- multiple gestation
- cone
- cerclage
MC acute complication of PROM
labor
How to definitively diagnose infection during PPROM
gram stain of amniotic fluid (amniocentesis)
Cause of intra-amniotic infection WITHOUT PROM
listeria via transplacental spread
Treatment for trich resistant to metronidazole
tinidazole
What vaginal bug may be isolated from a wet surface up to 6 hours after inoculation?
trich
Both BV and trich are assc with ____ and ____
alkaline pH and + whiff test
What are the three phases of hair growth and which determines length/ stability of hair?
anagen- length
catagen
telogen- strength
Diagnostic test for cushings
dexamethasone suppression test
Molecule elevated in adrenal tumor? sertoli leydig?
adrenal: DHEA
sertoli: testosterone
Molecule elevated in CAH
17 OH progesterone
Treatment of CAH
replace cortisol/ mineralocorticoid
Changes in LH/FSH assc with PCOS
^^ LH:FSH ratio (ie 2:1)
Cause of high AFP? low?
high- multifetal gestation, open defect
low- downs
*or incorrect dating
PAPPA/hcg/NT assc with downs in early pregnancy?
low hcg/papp-a thick NT
Trisomy 18 vs Downs findings 2nd trimester
all markers low in trisomy 18
hcg,inhibin high/afp, estriol low in downs
First step in management of abnormal triple screen
ultrasound
Risks assc with amnio
death, chorio, prom
When does window for serum screening end?
21 weeks
Cystic masses in left + right abdominal region suggests
duodenal atresia- assc with downs
Unexplained elevated AFP puts babies at risk of what conditions?
- stillbirth
- IUGR
- preE
- abruption
Definition of PCOS
hyperandrogenic chronic anovulation + excess estrogen
Define BMI
kg/height in m2
Treatment of young patients with endometrial cancer (stage 1)
hysterectomy and surgical staging …or high dose progesterone + repeat sampling if child bearing is desired. Hysterectomy indicated after childbirth
Patient with PCOS should be screened for ____ and ____.
glucose intolerance
lipid abnormalities
What organs prolapse anteriorly through vagina? posteriorly? centrally?
anterior: cystocele
posterior: rectocele
central: enterocele
The vagina may be fixed to ______ to prevent prolapse
sacrospinous ligament
What muscles make up the pelvic diaphragm?
- pubococcygeus
- puborectalis
- levator ani
What organ sits on the pelvic diaphragm?
bladder
Define procidentia
uterus prolapses beyond the introitus
To what structure should the vaginal cuff be fixed after a hysterectomy?
cardinal or uterosacral ligament
How might prolapse be prevented in patient with deep culdesac?
culdoplasty
Bleeding with ROM suggests what diagnosis? treatment?
vasa previa
stat cesarean
What is vasa previa?
fetal vessel overlies the os
Risks assc with twin pregnancies
1) congenital anomalies
2) preterm labor
3) preE
4) PPH
5) maternal death
How are OCPs related to twinning?
slow tubal motility
Best treatment of twin twin transfusion syndrome
laser ablation of shared vessels
Why are tocolytics relatively contraindicated in multifetal gestations?
^^ pulmonary edema risk
What screenings should be offered early for women over age 30?
cell free DNA
glucose tolerance
PCO2 and bicarb are both _____ in pregnancy
decreased, increased tidal volume + urinary output
In patient with a history of unexplained abruption, how might future pregnancies be managed?
induce slightly before GA of previous abruption
What are the consequences of anti-Lewis and anti-Kell ab’s in pregnancy?
Lewis Lives
Kell Kills
Duffy Dies
(Lewis is IgM and doesn’t cross placenta)
Treatment of neonate after birth from HbS+ mom
HBIG
HB vaccine
Three infectious diseases in which fetal well being can be dramatically improved
HIV
syphilis
HepB
Biopsy findings assc with lichen sclerosis (3)
thinned epidermis
hyperkeratosis
elongation of the rete pegs
Second most common type of vulvar cancer
melanoma
Treatment of Bartholin gland abscess
marsupialization
Lichen sclerosis shows predilection for _____
anus and vulva
Uncontrolled vaginal candidiasis may lead to
fissures in the labial folds = pain on urination
