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Day 10.2 Repro Flashcards

1
Q

How does cardiac output change in pregnancy?

A

Increases 30-50%

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2
Q

How dies blood composition change during pregnancy?

A

Plasma volume increases 50%
RBC vol increases 30%
So have a physiologic anemia of pregnancy (since RBCs don’t incrs as much as plasma)

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3
Q

How does BP change during pregnancy?

A

At first it decreases in early pregnancy (d/t vasodilation)
Lowest at 16-20 weeks
Then normal at term

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4
Q

How does ventilation change during pregnancy

A

There is incrsd minute ventilation
Decreased PACO2 and PaCO2, causing mild respi alkalosis
This means that CO2 is transferred more easily from the fetus to the mom

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5
Q

How does coagulability change during pregnancy?

A

Increased pro-coagulation factors, so hypercoag state.

Bad for blood clots, but ultimately good in case of maternal hemorrhage (will clot faster so won’t die)

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6
Q

How does GFR change in pregnancy?

A

It increases

Also, there is decreased BUN and Cr (bc of the increased plsm vol)

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7
Q

How do TSH and T4 change in pregnancy?

A

They don’t- there is normal TSH and free T4

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8
Q

How does insulin resistance change in pregnancy?

A

There is increased peripheral insulin resistance d/t human placental lactogen. It worsens throughout pregnancy, causing hyperinsulinemia, hyperglycemia, and hyperlipidemia.
Gestational diabetes.
But, once birth takes place and placenta is gone, there is no more placental lactogen and everything goes back to normal.

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9
Q

Why does rifampin (eg for TB prophylaxis) make OCPs less effective?

A

Rifampin revs up Cyt P450 - so increased metabolism of OCPs

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10
Q

What substance is present in high levels in cases of hydatidiform mole?

A

B-hCG

elevated a little in partial mole, elevated a LOT in complete mole

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11
Q

What is a complete mole?

A 
2 sperm + empty egg
so all DNA is paternal. 
either 46 XY or 46XX
B-hCG is majorly elevated
Uterine size is increased
2% convert to choriocarcinoma
No fetal parts
15-20% cause malignant trophoblastic dz
Snowstorm appearance w no fetus
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12
Q

What is a partial mole

A

2 sperm + 1 egg
so 69XXY or XXX
B-hCG is elevated (tho not as much as complete mole)
Fetal parts are present (partial = parts)
Uterine size is normal
Conversion to choriocarcinoma is rare
Low risk of malignancy

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13
Q

What is a hydatidiform mole (molar pregnancy)?

A

Bad pregnancy. (2 sperm + empty egg complete or 2 sperm + 1 egg partial)
Proliferation of placental tsu (trophoblast) w hydropic (swollen) chorionic villi
Px w abn vag bleeding
Most common precursor of choriocarcinoma
Increased B-hCG
Possible pre-eclampsia

Abn enlgd uterus (RAPID growth):
Honeycombed uterus
Cluster of grapes
Snowstorm (complete mole)
Can lead to uterine rupture
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14
Q

Rx for molar prego

A

D&C
MTX if needed
And monitor B-hCG lvls to make sure they fall back to normal.
Recommend no preg for 6-12 mo

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15
Q

Common causes of recurrent miscarriage

A

Low progesterone levels (no response B-hCG rescuing the CL)- esp in 1st wks
Chromosomal abn (robertsonian translocation)- 1st trimester
Uterine/cervical abn (eg bicornate uterus, fibroids or polyps affecting implantation)
Background infections
Maternal health- uncontrolled thyroid, diabetes
Auto-imm: anti-phospholipid Ab, thrombophilia, SLE

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16
Q

What causes a bicornate uterus?

A

Incomplete fusion of the paramesonephric ducts

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17
Q

What kind of ovarian cyst might be found along w a molar pregnancy

A

Molar pregnancy = increased B-hCG

So Theca-Lutein cyst

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18
Q

What are the diagnostic factors of pre-eclampsia?

A 
Increased BP (HTN)
Increased protein in urine (proteinuria)

May also px w edema, but this is not part of the dx.

Basically, it’s vasospasm + leaky vessles.

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19
Q

What is eclampsia?

A

Pre-eclampsia + seizures

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20
Q

Clinical features of pre-eclampsia

A 
headache (d/t cerebral edema)
blurred vision
abd pain (RUG)
edema of face, hands
altered mentation
hyperreflexia (pre-seizure)
rapid weight gain

Lab: thrombocytopenia, hyperuricemia

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21
Q

In what pts is pre-eclampsia incidence increased?

A

pre-existing HTN
diabetes
chronic renal dz
autoimmune disorders

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22
Q

HELLP syndrome

A

Pre-eclampsia can be a/w HELLP:
Hemolysis
Elevated LFTs
Low Platelets

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23
Q

What causes pre-eclampsia?

A

Antigenic rxn: immune response from mom reacting to the paternal Ag in the placenta

Prev thought to be caused by placental ischemia d/t impaired vasodilation of spiral arteries, resulting in increased vasc tone.

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24
Q

What causes mortality in pre-eclampsia?

A

Cerebral hemorrhage

ARDS (acute respi distress syndr)

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25
Q

How often does pre-eclampsia occur? and when in pregnancy?

A

7% of pregnant women, from 20 wks gestation to 6 weeks post-partum
(if before 20 weeks, it’s molar prego)

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26
Q

Rx for pre-eclampsia and eclampsia

A

Deliver fetus asap.
If it can’t be delivered yet: bed rest, salt restriction, monitor/treat HTN

Rx: IV Mg2+ sulfate to prevent and treat seizures of eclampsia. Also Diazepam.

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27
Q

Pregnant pt w increased BP, anemic (easy bruising or bleeding gums), jaundice

A

Pre-eclampsia / Eclampsia

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28
Q

Ectopic pregnancy

A

Pain but no bleeding
Pregnancy is usu in fallopian tubes
Suspect if there is high hCG and sudden lower abd pain, confirm w ultrasound. Life threatening.

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29
Q

What is ectopic pregnancy often mistaken for?

A

appendicitis bc of the sudden lower abd pain.

check B-hCG!

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30
Q

Risk factors for ectopic pregnancy

A 
Hx of infertility
Salpingitis, PID
Ruptured appendix
Prior tubal surgery
Pregnancy w IUD
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31
Q

Rx for ectopic pregnancy

A

MTX

or surgery if pt is unstable/bleeding

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32
Q

Abruptio placenta (placental abruption)

A

Painful bleeding in 3rd trimester
Placenta detaches from wall prematurely.
Causes fetal death.
Everything is abrupt- detachement, death, labor is rapid
May be assoc w DIC
Can be caused by trauma (MVA), abuse
Increased risk if smoker, HTN, cocaine use

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33
Q

Placenta accreta

A

Massive bleed after delivery.
Defective decidua basalis layer means placenta attached to myometrium of uterus, and can’t separate after birth.
Must have hysterectomy
Prior C-section (scar is a weak point, faulty decidua basalis), inflam, and placenta previa all predispose.

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34
Q

Placenta previa

A

Painless bleeding in any trimester, but esp 3rd when cervix is changing
Placenta is attached to lower uterine segment, maybe be covering internal os.
Multiparity and prior C-sections can predispose.

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35
Q

Previa vs Accreta

A

Previa PREVents cervical opening

Accreta CREEps into muscular layer

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36
Q

Bleeding during pregnancy- painful vs painless

A

Painful - placental abruption (detaches from wall)

Painless - placenta previa

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37
Q

If there is retained placental tissue after deliver, what can occur?

A

Post-partum hemorrhage.

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38
Q

Polyhydraminos

A

Too much amniotic fluid >1.5-2L
Often d/t fetus swallowing problems
A/w espghl/duodenal atresia (can’t swallow), with anencephaly (no brainstem, so no swallowing center), diabetes, and genetic dz

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39
Q

Oligohydraminos

A

Too little amniotic fluid s syndrome.

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40
Q

Potter’s syndrome

A

Bilateral renal agenesis, causing oligohydramnios –> facial and limb deformities bc not enough space + pulmonary hypoplasia.
Caused by malformation of ureteric bud.

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41
Q

If a woman has a C-section, what placental problems might she have in future pregnancies?

A 
Placenta accreta (into myometrium)
Placenta previa (over cervix)
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42
Q

Dinoprostone

A

PGE-2 analog (“prost”)
Causes cervical dilation and uterine contraction
Induces labor

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43
Q

Ritrodrine/Terbutaline

A

B2-agonists that relax the uterus
Reduce premature uterine contractions
Ritrodrine - “return to dreams”- prevents early delivery of fetus (so it can dream more?)

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44
Q

List the non-proliferative breast changes (fibrocystic changes)

A

FIbrosis
Cystic changes
Adenosis- fibroadenoma

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45
Q

What is fibrocystic change of the breast (aka non-proliferative)?

A

Most common cause of “breast lumps” from age 25 to menopause.
Px: premenstrual breast pain and multiple lesions, often bilateral.
Mass size fluctuates: increases before menstruation (when body is retaining water) and decreases after
Usu does not indicate increased risk of carcinoma

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46
Q

What is fibrosis of the breast?

A

Hyperplasia of breast stroma

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47
Q

What is cystic change of the breast?

A

Fluid filled, blue domed cysts.

Ductal dilation.

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48
Q

What is adenosis of the breast?

A

Increased number of acini in the lobules.

It is physiologic during pregnancy

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49
Q

What is a fibroadenoma of the breast?

A

Small, mobile (non-adherent) firm mass w sharp edges.

Most common tumor in pts - increased # of acini)

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50
Q

List the Proliferative Breast Diseases w/o Atypia (so all cells are normal)

A

Sclerosing adenosis
Epithelial hyperplasia
Complex sclerosing lesion (radial scar)
Papillomas

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51
Q

What is scleroising adenosis of the breast?

A

This is a proliferative dz (vs regular adenosis, which is non-proliferative.
It’s increased acini (so numbers that ducts are compressed/distorted) plus intralobular fibrosis. Assoc/w calcifications.

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52
Q

What is epithelial hyperplasia of the breast?

A

Proliferative breast dz, w/o atypia
Increased number of epithelial cell layers in the terminal duct lobule
Occurs in women >30yo
This is does not have atypia, but if atypical cells do appear, the risk of carcinoma is increased.

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53
Q

What is complex sclerosing lesion (radial scar) of the breast?

A

Proliferative breast dz w/o atypia
Scar w an irreg shape.
Similar to fat necrosis, but no prior trauma or surgery
Can look like invasive cancer on mammogram.

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54
Q

What is a papilloma of the breast?

A

aka intraductal papilloma
Small tumor that grows in the lactiferous ducts, usu beneath areola.
Will have serous (yellow, straw-like) or bloody nipple discharge.
Slightly increased risk for carcinoma.

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55
Q

Most common cause of fluid discharge from the breast

A
  1. Milk

2. Interductal papilloma (serous or bloody discharge)

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56
Q

What is phyllodes tumor?

A 
A breast tumor
Large bulky mass of CT and cysts
Histo: leaf-like projections
most common in 60+yo
some may become malignant
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57
Q

What is acute mastitis?

A

Breast abscess, usu during breastfeeding
Increased risk of bacterial infection thru cracked nipple
Usu S. aureus
Rx: Abx, continue to breastfeed so that it drains (it’s fine for infant)

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58
Q

What is fat necrosis of the breast?

A

Benign painless lump

Forms after injury to breast tsu (but 50% of pts report no trauma)

59
Q

What is gynecomastia

A

Breast growth in males
Results from hyperestrogenism d/t cirrhosis, testicular tumor, puberty, old age;
Kleinfelter (XXY)
Drugs

60
Q

What drugs cause gynecomastia?

A 
Some Drugs Create Awesome Knockers
Spironolactone
Digitalis
Cimetidine (H2 blocker)
Alcohol
Ketoconazole (anti-fungal)

also:
Estrogen
MJ, Heroin, Psychoactive drugs

61
Q

Organization of ducts, sinuses in breast

A

Nipple –> Lactiferous sinus –> Mjr duct –> Terminal duct –> Lobules (—> stroma)

62
Q

What cancers have signet ring cells?

A

Gastric adenocarcinoma

Lobular carcinoma in situ (breast)

63
Q

What are the in situ breast carcinomas?

A

DCIS - ductal carcinoma in situ (intraductal carcinoma)

LCIS - lobular carcinoma in situ

64
Q

What is DCIS

A

Ductal carcinoma in situ
Arises from ductal hyperplasia and fills the ductal lumen.
Early malignancy without basement mbr penetration (bc in situ!)

65
Q

What are the subtypes of DCIS?

A 
Cornedocarcinoma - ductal, caseous necrosis
Solid
Cribiform
Papillary
Micropapillary
66
Q

What is Paget’s dz of the breast?

A

Eczematous patches on nipple, suggests underlying carcinoma. Can also be seen on vulva.
Paget cells - large cells in epidermis w clear halo
This is not a subtype of DCIS, but it’s a way that DCIS can present.

67
Q

LCIS

A

Lobular carcinoma in situ (breast)
Confined in lobules.
See signet ring cells on histo
LCIS is always estrogen receptor positive and progesterone receptor positive (so therapy can be targeted)

68
Q

What are the types of invasive carcinoma of the breast?

A 
Invasive ductal carcinoma (aka infiltrating ductal)
Invasive lobular carcinoma
Tubular/cribiform carcinoma
Mucinous carcinoma
Medullary carcinoma
Papillary carcinoma
69
Q

What is Invasive Ductal Carcinoma of the breast?

A

Firm, fibrous, rock-hard mass w sharp margins and sml, glandular, duct-like cells.
Worst and most invasive
Most common breast cancer (76%)

70
Q

What is the precursor to invasive ductal carcinoma of the breast?

A

DCIS

71
Q

What is Invasive Lobular Carcinoma of the breast?

A

Orderly row of cells
Often multiple, bilateral.
Inactivates the E-cadherin gene
Metastasizes to the peritoneum (!)

72
Q

What is the precursor to invasive lobular carcinoma of the breast?

A

LCIS

73
Q

What is medullary carcinoma of the breast?

A

A type of invasive carcinoma
Fleshy, cellular lymphatic infiltrate
Good pgx.

74
Q

What is inflammatory carcinoma

A

This is a way that invasive carcinoma can present.
Dermal lymphatic invasion by breast carcinoma.
Peau d’orange (breast skin resembles orange peal, d/t the edema caused by lymph blockage)
50% survival at 5 years

75
Q

Breast changes in cancer (outward appearance)

A

Orange peel
Dimple (cancer involves suspensory ligaments)
New nipple retraction/inversion (cancer involves lactiferous duct)

76
Q

T/F Gynecomastia does NOT increase the risk for breast cancer

A

True

77
Q

Most common breast tumor for women <25yo

A

Fibroadenoma

78
Q

Most common breast mass in post-menopausal women

A

Invasive ductal carcinoma

79
Q

Most common breast mass in pre-menopausal women

A

Fibrocystic change of the breast

80
Q

Most common form of breast cancer

A

Invasive ductal carcinoma (the worst kind)

81
Q

Small firm mobile mass w sharp edges in 24yo woman’s breast

A

Fibroadenoma (benign)

82
Q

Breast tumor w leaf-like projections on histo

A

Phyllodes tumor

83
Q

Breast tumor w signet ring cells

A

Invasive lobular carcinoma (or its precursor, LCIS)

84
Q

Breast tumor causing loss of e-cadherin cell adhesion gene on chr 16

A

Invasive lobular

85
Q

Breast tumor that is always ER+ and PR+

A

LCIS
ER = estrogen receptor
PR = progesterone receptor

86
Q

Tumor that presents w nipple discharge

A

Intraductal papilloma

87
Q

Eczematous patches on nipple

A

Paget’s dz of breast

88
Q

Multiple bilateral fluid-filled lesions w diffuse breast pain

A

Fibrocystic chg of breast

cysts- blue domed

89
Q

Firm fibrous breast mass in 55yo woman

A

Invasive ductal carcinoma (the bad kind)

90
Q

Clomiphene

A

SERM - estrogen partial agonist
Partial agonist at estrogen receptors in they hypothalamus.
Prevents normal feedback inhibition and increases rls of LH and FSH from the pituitary, so ovulation is stimulated.
Used to treat infertility and PCOS

Can cause hot flashes, ovarian enlgmt, multiple simultaneous pregnancies, and visual disturbances

91
Q

Tamoxifen

A

Antagonist on breast tsu
Used to treat and prevent recurrences of ER-positive breast cancer, e.g. LCIS.
It’s also an agonist on endometrial tsu, which means it increases risk of uterine cancer.

92
Q

Raloxifene

A

SERM
Agonist on bone- reduces resorption of bone
Used to treat osteoporosis
Unlike tamoxifen, does not have increased risk of uterine cancer.

93
Q

Anastrozole/Exemestane

A 
Aromatase inhibitors (so inhibit the production of estrogen)
Used in post-menopausal women w breast cancer
94
Q

Two cell theory of estradiol production

A

LH stimulates Theca cells, they make androstenidione, it travels to the Granulosa cells, which are stimulated by FSH and turn the androstenodione into estradiol.
FSH cells don’t have 17a-hydroxylase, so they can’t make the androstenodione by themselves. Theca cells don’t have aromatase so they can’t convert it.

95
Q

What hormone causes production of thick mucus that inhibits sperm entry into uterus?

A

Progesterone

96
Q

What hormone induces the LH surge?

A

Estrogen

97
Q

What hormone causes uterine smooth muscle relaxation?

A

Progesterone

98
Q

What hormone causes follicle growth?

A

Estrogen

99
Q

What hormone maintains pregnancy; withdrawal leads to menstruation?

A

Progesterone

100
Q

What drug would you give to inhibit prolactin secretion?

A

Bromocriptine (Dopamine analog)

(also used for parkinson’s

101
Q

Rx for PCOS

A 
OCPs
weight loss
metformin
clomiphene
leuprolide
spironolactone for hirsutism
102
Q

Ovarian tumor that produces AFP

A

yolk sac tumor aka endometrial sinus tumor (a germ cell tumor)

103
Q

Ovarian tumor that secretes estrogen, causes precocious puberty

A

Granulosa-Thecal cell tumor (a stromal tumor)

104
Q

Ovarian tumor w psamomma bodies

A

Serous cystadenocarcinoma (epthelial tumor)

105
Q

Ovarian tumor w intraperitoneal accumulation of mucinous material

A

Mucinous cystadenocarcinoma (epithelial tumor)

106
Q

Ovarian tumor that can cause virilization bc it secretes testosterone

A

Sertoli-Leydig cell tumor (stromal tumor)

107
Q

Ovarian tumor w multiple different tsu types

A

Teratoma

108
Q

Ovarian tumor + ascites + hydrothorax (pulm effusion)

A

Meigs’ syndrome (the ovarian tumor is a fibroma, which is a stromal tumor)

109
Q

Ovarian tumor w Call-Exner bodies

A

Granulosa-Theca cell tumor (stromal)

110
Q

Ovarian tumor that resembles bladder epithelium

A

Brenner tumor (benign, epithelial tumor)

111
Q

Ovarian tumor w high B-hCG

A

Choriocarcinoma (germ cell tumor)

if also high LDH- dysgerminoma

112
Q

The risk for endometrial carcinoma is increased by any disease that causes an increase in which hormone

A

Anything that causes increased estrogen.

113
Q

How are the extraocular muscles innervated?

A

SO4 LR6 everything else is 3

SO - 4
IO - 3
MR - 3
LR - 6
SR - 3
IR - 3
Lev palp - 3
Pupillary constriction - 3 (PNS)
114
Q

What does the superior oblique muscle do?

A

It abducts, intorts, and depresses while adducted.

115
Q

What happens to the eye if there is CN III dmg?

A

Eye looks down and out
Down bc of unopposed SO (CN 4)
Out bc of unopposed LR (CN 6)
Also,
there is ptosis d/t loss of levator palpibrae,
there is pupillary dilation and loss of accomodation, bc CN 3 also carries PNS

116
Q

What nerves and vessles enter the eye socket from the back?

A

Optic nerve
Opthalmic artery is right above it

Superior opthalmic vein is a little farther up

117
Q

What nerve comes out right below the eye socket on the face?

A

Infraorbital nerve

118
Q

What happens to the eye w CN IV dmg?

A

Diplopia w a defective downward gaze
SO4 is gone- SO usu does down and in.

Pt adjusts by tilting head downward toward lesion, and tucking in chin

119
Q

What happens to the eye w CN VI dmg?

A

LR6 dmg means eye will be medially directed, bc LR causes outward gaze (straight out horizontally)- if don’t have it, will look inward.
Also will have horizontal diplopia.

120
Q

Testing extraocular muscles- draw the diagram

A

p419

121
Q

Which way does inf oblique make you look?

A

Up and In

IOU: IO makes you look Up

122
Q

Which way does lateral rectus make you look?

A

Out (straight out horizontally)

123
Q

Which way does superior oblique make you look?

A

Down and In

124
Q

Which way does superior rectus make you look?

A

Up and out

125
Q

Which way does medial rectus make you look?

A

In (horizontally)

126
Q

Which way does inferior rectus make you look?

A

Down and out

127
Q

Where are the maxillary sinuses?

A

On either side of the nose

128
Q

Where are the frontal sinuses?

A

Above the eyebrows

129
Q

Where are the ethmoidal air cells?

A

Between the eyes

130
Q

Where are the sphenoid sinuses?

A

Between the eyes, but further inward (more posterior) than the ethmoidal air cells
Above the nasopharynx

131
Q

Where is the cavernous sinus?

A

right above the sphenoid sinus, around the pituitary gland

132
Q

What things pass through the cavernous sinus?

A

Nerves: 3,4,6, V1 opthalmic division, V2 maxillary division
Internal carotid artery
Postganglionic sympathetics
Pituitary gland and optic chiasm are also there.

133
Q

What kind of pathologies can occur in the cavernous sinus?

A 
Cavernous sinus thrombosis
Infection from the venous drainage of the face into the cavernous sinus (eg lesion on philtrum)
Mass effect (pit tumor)
134
Q

What is the danger triangle of the face?

A

Bridge of nose to corners of mouth, includes nose and maxilla
Retrograde infections can spread from here to the brain bc of the venous communication (via the ophthalmic veins) between the facial vein and the cavernous sinus.

135
Q

What is the cavernous sinus?

A

Collection of venous sinuses on either side of the pituitary. Blood from the eye and the superficial cortex drain to the cavernous sinus, and then to the IJV.

136
Q

What is cavernous sinus syndrome?

A

opthalmoplegia (3, 4, 6) plus opthalmic and maxillary sensory loss (V1, V2)
Often d/t mass effect

note: can get hypo or hyperasthenia (decreased or increased sensation) bc of V1 and V2 when there is cav sinus dmg.

137
Q

Where do malignant breast tumors arise from

A

Mammary duct epithelium or lobular glands

138
Q

Overexpression of which receptors is common in malignant breast tumors?

A 
estrogen receptors (ER)
progesterone receptors (PR)
erb-B2 (HER-2, an EGF receptor)

these affect the choices of drugs used- can actually be helpful bc can use drugs that target these receptors specifically.

139
Q

Most imp prognostic factor for malignant breast tumors?

A

Axillary lymph node involvement

140
Q

Rx for cancer w overexpression of estrogen receptors

A

Tamoxifen, Raloxifene

141
Q

Rx for cancer w overexpression of erb-B2 (HER-2)

A

Tratuzimab

142
Q

Risk factors for developing malignant breast tumors

A 
Increased estrogen exposure
Increased total # of menstrual cycles
Older age at 1st live birth
Obesity (adipose is mjr source of estrogen)
Fam Hx
Prior breast cancer
143
Q

What breast condition presents w premenstrual breast pain and multiple, often bilateral lesions that fluctuate in size and mass?

A

Fibrocystic change of the breast.

* DIT each session (34 decks)

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