Day 10.2 Repro Flashcards
How does cardiac output change in pregnancy?
Increases 30-50%
How dies blood composition change during pregnancy?
Plasma volume increases 50%
RBC vol increases 30%
So have a physiologic anemia of pregnancy (since RBCs don’t incrs as much as plasma)
How does BP change during pregnancy?
At first it decreases in early pregnancy (d/t vasodilation)
Lowest at 16-20 weeks
Then normal at term
How does ventilation change during pregnancy
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
How does coagulability change during pregnancy?
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)
How does GFR change in pregnancy?
It increases
Also, there is decreased BUN and Cr (bc of the increased plsm vol)
How do TSH and T4 change in pregnancy?
They don’t- there is normal TSH and free T4
How does insulin resistance change in pregnancy?
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.
Why does rifampin (eg for TB prophylaxis) make OCPs less effective?
Rifampin revs up Cyt P450 - so increased metabolism of OCPs
What substance is present in high levels in cases of hydatidiform mole?
B-hCG
elevated a little in partial mole, elevated a LOT in complete mole
What is a complete mole?
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
What is a partial mole
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
What is a hydatidiform mole (molar pregnancy)?
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
Rx for molar prego
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
Common causes of recurrent miscarriage
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
What causes a bicornate uterus?
Incomplete fusion of the paramesonephric ducts
What kind of ovarian cyst might be found along w a molar pregnancy
Molar pregnancy = increased B-hCG
So Theca-Lutein cyst
What are the diagnostic factors of pre-eclampsia?
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.
What is eclampsia?
Pre-eclampsia + seizures
Clinical features of pre-eclampsia
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
In what pts is pre-eclampsia incidence increased?
pre-existing HTN
diabetes
chronic renal dz
autoimmune disorders
HELLP syndrome
Pre-eclampsia can be a/w HELLP:
Hemolysis
Elevated LFTs
Low Platelets
What causes pre-eclampsia?
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.
What causes mortality in pre-eclampsia?
Cerebral hemorrhage
ARDS (acute respi distress syndr)
How often does pre-eclampsia occur? and when in pregnancy?
7% of pregnant women, from 20 wks gestation to 6 weeks post-partum
(if before 20 weeks, it’s molar prego)
Rx for pre-eclampsia and eclampsia
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.
Pregnant pt w increased BP, anemic (easy bruising or bleeding gums), jaundice
Pre-eclampsia / Eclampsia
Ectopic pregnancy
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.
What is ectopic pregnancy often mistaken for?
appendicitis bc of the sudden lower abd pain.
check B-hCG!
Risk factors for ectopic pregnancy
Hx of infertility Salpingitis, PID Ruptured appendix Prior tubal surgery Pregnancy w IUD
Rx for ectopic pregnancy
MTX
or surgery if pt is unstable/bleeding
Abruptio placenta (placental abruption)
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
Placenta accreta
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.
Placenta previa
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.
Previa vs Accreta
Previa PREVents cervical opening
Accreta CREEps into muscular layer
Bleeding during pregnancy- painful vs painless
Painful - placental abruption (detaches from wall)
Painless - placenta previa
If there is retained placental tissue after deliver, what can occur?
Post-partum hemorrhage.
Polyhydraminos
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
Oligohydraminos
Too little amniotic fluid s syndrome.
Potter’s syndrome
Bilateral renal agenesis, causing oligohydramnios –> facial and limb deformities bc not enough space + pulmonary hypoplasia.
Caused by malformation of ureteric bud.
If a woman has a C-section, what placental problems might she have in future pregnancies?
Placenta accreta (into myometrium) Placenta previa (over cervix)
Dinoprostone
PGE-2 analog (“prost”)
Causes cervical dilation and uterine contraction
Induces labor
Ritrodrine/Terbutaline
B2-agonists that relax the uterus
Reduce premature uterine contractions
Ritrodrine - “return to dreams”- prevents early delivery of fetus (so it can dream more?)
List the non-proliferative breast changes (fibrocystic changes)
FIbrosis
Cystic changes
Adenosis- fibroadenoma
What is fibrocystic change of the breast (aka non-proliferative)?
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
What is fibrosis of the breast?
Hyperplasia of breast stroma
What is cystic change of the breast?
Fluid filled, blue domed cysts.
Ductal dilation.
What is adenosis of the breast?
Increased number of acini in the lobules.
It is physiologic during pregnancy
What is a fibroadenoma of the breast?
Small, mobile (non-adherent) firm mass w sharp edges.
Most common tumor in pts - increased # of acini)
List the Proliferative Breast Diseases w/o Atypia (so all cells are normal)
Sclerosing adenosis
Epithelial hyperplasia
Complex sclerosing lesion (radial scar)
Papillomas
What is scleroising adenosis of the breast?
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.
What is epithelial hyperplasia of the breast?
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.
What is complex sclerosing lesion (radial scar) of the breast?
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.
What is a papilloma of the breast?
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.
Most common cause of fluid discharge from the breast
- Milk
2. Interductal papilloma (serous or bloody discharge)
What is phyllodes tumor?
A breast tumor Large bulky mass of CT and cysts Histo: leaf-like projections most common in 60+yo some may become malignant
What is acute mastitis?
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)
What is fat necrosis of the breast?
Benign painless lump
Forms after injury to breast tsu (but 50% of pts report no trauma)
What is gynecomastia
Breast growth in males
Results from hyperestrogenism d/t cirrhosis, testicular tumor, puberty, old age;
Kleinfelter (XXY)
Drugs
What drugs cause gynecomastia?
Some Drugs Create Awesome Knockers Spironolactone Digitalis Cimetidine (H2 blocker) Alcohol Ketoconazole (anti-fungal)
also:
Estrogen
MJ, Heroin, Psychoactive drugs
Organization of ducts, sinuses in breast
Nipple –> Lactiferous sinus –> Mjr duct –> Terminal duct –> Lobules (—> stroma)
What cancers have signet ring cells?
Gastric adenocarcinoma
Lobular carcinoma in situ (breast)
What are the in situ breast carcinomas?
DCIS - ductal carcinoma in situ (intraductal carcinoma)
LCIS - lobular carcinoma in situ
What is DCIS
Ductal carcinoma in situ
Arises from ductal hyperplasia and fills the ductal lumen.
Early malignancy without basement mbr penetration (bc in situ!)
What are the subtypes of DCIS?
Cornedocarcinoma - ductal, caseous necrosis Solid Cribiform Papillary Micropapillary
What is Paget’s dz of the breast?
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.
LCIS
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)
What are the types of invasive carcinoma of the breast?
Invasive ductal carcinoma (aka infiltrating ductal) Invasive lobular carcinoma Tubular/cribiform carcinoma Mucinous carcinoma Medullary carcinoma Papillary carcinoma
What is Invasive Ductal Carcinoma of the breast?
Firm, fibrous, rock-hard mass w sharp margins and sml, glandular, duct-like cells.
Worst and most invasive
Most common breast cancer (76%)
What is the precursor to invasive ductal carcinoma of the breast?
DCIS
What is Invasive Lobular Carcinoma of the breast?
Orderly row of cells
Often multiple, bilateral.
Inactivates the E-cadherin gene
Metastasizes to the peritoneum (!)
What is the precursor to invasive lobular carcinoma of the breast?
LCIS
What is medullary carcinoma of the breast?
A type of invasive carcinoma
Fleshy, cellular lymphatic infiltrate
Good pgx.
What is inflammatory carcinoma
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
Breast changes in cancer (outward appearance)
Orange peel
Dimple (cancer involves suspensory ligaments)
New nipple retraction/inversion (cancer involves lactiferous duct)
T/F Gynecomastia does NOT increase the risk for breast cancer
True
Most common breast tumor for women <25yo
Fibroadenoma
Most common breast mass in post-menopausal women
Invasive ductal carcinoma
Most common breast mass in pre-menopausal women
Fibrocystic change of the breast
Most common form of breast cancer
Invasive ductal carcinoma (the worst kind)
Small firm mobile mass w sharp edges in 24yo woman’s breast
Fibroadenoma (benign)
Breast tumor w leaf-like projections on histo
Phyllodes tumor
Breast tumor w signet ring cells
Invasive lobular carcinoma (or its precursor, LCIS)
Breast tumor causing loss of e-cadherin cell adhesion gene on chr 16
Invasive lobular
Breast tumor that is always ER+ and PR+
LCIS
ER = estrogen receptor
PR = progesterone receptor
Tumor that presents w nipple discharge
Intraductal papilloma
Eczematous patches on nipple
Paget’s dz of breast
Multiple bilateral fluid-filled lesions w diffuse breast pain
Fibrocystic chg of breast
cysts- blue domed
Firm fibrous breast mass in 55yo woman
Invasive ductal carcinoma (the bad kind)
Clomiphene
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
Tamoxifen
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.
Raloxifene
SERM
Agonist on bone- reduces resorption of bone
Used to treat osteoporosis
Unlike tamoxifen, does not have increased risk of uterine cancer.
Anastrozole/Exemestane
Aromatase inhibitors (so inhibit the production of estrogen) Used in post-menopausal women w breast cancer
Two cell theory of estradiol production
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.
What hormone causes production of thick mucus that inhibits sperm entry into uterus?
Progesterone
What hormone induces the LH surge?
Estrogen
What hormone causes uterine smooth muscle relaxation?
Progesterone
What hormone causes follicle growth?
Estrogen
What hormone maintains pregnancy; withdrawal leads to menstruation?
Progesterone
What drug would you give to inhibit prolactin secretion?
Bromocriptine (Dopamine analog)
(also used for parkinson’s
Rx for PCOS
OCPs weight loss metformin clomiphene leuprolide spironolactone for hirsutism
Ovarian tumor that produces AFP
yolk sac tumor aka endometrial sinus tumor (a germ cell tumor)
Ovarian tumor that secretes estrogen, causes precocious puberty
Granulosa-Thecal cell tumor (a stromal tumor)
Ovarian tumor w psamomma bodies
Serous cystadenocarcinoma (epthelial tumor)
Ovarian tumor w intraperitoneal accumulation of mucinous material
Mucinous cystadenocarcinoma (epithelial tumor)
Ovarian tumor that can cause virilization bc it secretes testosterone
Sertoli-Leydig cell tumor (stromal tumor)
Ovarian tumor w multiple different tsu types
Teratoma
Ovarian tumor + ascites + hydrothorax (pulm effusion)
Meigs’ syndrome (the ovarian tumor is a fibroma, which is a stromal tumor)
Ovarian tumor w Call-Exner bodies
Granulosa-Theca cell tumor (stromal)
Ovarian tumor that resembles bladder epithelium
Brenner tumor (benign, epithelial tumor)
Ovarian tumor w high B-hCG
Choriocarcinoma (germ cell tumor)
if also high LDH- dysgerminoma
The risk for endometrial carcinoma is increased by any disease that causes an increase in which hormone
Anything that causes increased estrogen.
How are the extraocular muscles innervated?
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)
What does the superior oblique muscle do?
It abducts, intorts, and depresses while adducted.
What happens to the eye if there is CN III dmg?
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
What nerves and vessles enter the eye socket from the back?
Optic nerve
Opthalmic artery is right above it
Superior opthalmic vein is a little farther up
What nerve comes out right below the eye socket on the face?
Infraorbital nerve
What happens to the eye w CN IV dmg?
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
What happens to the eye w CN VI dmg?
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.
Testing extraocular muscles- draw the diagram
p419
Which way does inf oblique make you look?
Up and In
IOU: IO makes you look Up
Which way does lateral rectus make you look?
Out (straight out horizontally)
Which way does superior oblique make you look?
Down and In
Which way does superior rectus make you look?
Up and out
Which way does medial rectus make you look?
In (horizontally)
Which way does inferior rectus make you look?
Down and out
Where are the maxillary sinuses?
On either side of the nose
Where are the frontal sinuses?
Above the eyebrows
Where are the ethmoidal air cells?
Between the eyes
Where are the sphenoid sinuses?
Between the eyes, but further inward (more posterior) than the ethmoidal air cells
Above the nasopharynx
Where is the cavernous sinus?
right above the sphenoid sinus, around the pituitary gland
What things pass through the cavernous sinus?
Nerves: 3,4,6, V1 opthalmic division, V2 maxillary division
Internal carotid artery
Postganglionic sympathetics
Pituitary gland and optic chiasm are also there.
What kind of pathologies can occur in the cavernous sinus?
Cavernous sinus thrombosis Infection from the venous drainage of the face into the cavernous sinus (eg lesion on philtrum) Mass effect (pit tumor)
What is the danger triangle of the face?
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.
What is the cavernous sinus?
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.
What is cavernous sinus syndrome?
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.
Where do malignant breast tumors arise from
Mammary duct epithelium or lobular glands
Overexpression of which receptors is common in malignant breast tumors?
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.
Most imp prognostic factor for malignant breast tumors?
Axillary lymph node involvement
Rx for cancer w overexpression of estrogen receptors
Tamoxifen, Raloxifene
Rx for cancer w overexpression of erb-B2 (HER-2)
Tratuzimab
Risk factors for developing malignant breast tumors
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
What breast condition presents w premenstrual breast pain and multiple, often bilateral lesions that fluctuate in size and mass?
Fibrocystic change of the breast.
