Exam #1 Flashcards
Avg age start of menarche?
12
pubertal delay if no development by what age
13
Avg menstrual cycle length; first yr?
21-35 days; first year 32 days is avg (20-60 day range)
*cycle begins on first day of menstrual bleeding and ends with the last day prior to the beginning of the next menstrual bleed
menstrual flow length on avg; flow amt avg
first yr 2-7 days; typical 4-6 days (<2 or >8 abnormal)
flow amount 20-80ml w/2nd day heaviest
greater than ____ days light or very light spotting prior to onset of heavy flow abnormal
3
endometrial cycle - three parts
menstrual, proliferative, secretory
menstrual portion of the endometrial cycle
Low E and P levels cause disruption of endometrial capillaries; prostaglandins initiate smooth muscle contraction and sloughing
proliferative portion of endometrial cycle
increasing E levels about 4-5 days after onset of menses, endometrium grows and thickens in preparation for implantation (variable time frame)
secretory phase of endometrial cycle
begins at ovulation; progesterone produced by corpus luteum (CL), endometrium dilates (thick, cushiony and nutrient rich); constant time frame; allows for implantation
Ovarian cycle three parts
- follicular
- ovulatory
- luteal
follicular phase of ovarian cycle; effects on cervical mucus? Dominant hormones during this phase?
day 1 of menses to just before ovulation, when follicle mature, usually about 14 days is normal
- effects on cervical mucus: at this stage the follicle secretes estrogen and causes a production of clear mucus that is stretch and lubricative
- days 1-13 of cycle and dominant hormones: FSH + Estradiol
ovulatory phase of ovarian cycle; effects on cervical mucus
LH surge from estrogen levels triggers release of ovum 10-12 hours after peak
- still clear and stretchy until after ovulation
- days 13-15 and dominant hormone: LH
luteal phase of ovarian cycle; effects on cervical mucus?
LH causes ruptured follicle to form corpus luteum “yellow body.” Produces mainly progesterone (w/little estrogen), negative feedback to hypothalamus and AP preventing further ovulation
Starts day 15 and goes until day 28; most commonly lasts 12-14 days
Main hormone: progesterone
*thicker cervical mucus until menstrual bleeding starts
pain that occurs in women during ovulation and characteristics
Mittelschmerz
- one sided
- dull and achy, similar to menstrual cramps
- sharp and sudden
- can be accompanied by slight vaginal bleeding or discharge
- rarely severe
which hormones are released from the hypothalamus, and what do they have an effect on…when do they increase and when do they decreaase
the hypothalamus released GnRH - gonadotropin-releasing hormone and stimulates the anterior pituitary gland to produce FSH and LH (Luteinizing hormone)
GnRH increases mid cycle - think need LH spike for ovulation
GnRH decreases during luteal phase - negative feedback to prevent further ovulation
what hormones does the anterior pituitary produce
the AP produces FSH, LH, prolactin (influences lobular development and milk production), GH (influences lobular development of breasts)
o Ex: Hypothalamus releases GnRH –> stimulates anterior pituitary to release FSH –> follicle stimulates growth of that follicle –> stimulates estrogen –> inc. levels of estrogen –> estrogen levels build-up –> tells anterior pituitary to produce LH –> surge that allows ovulation to occur –> progesterone –> negative feedback –> process occurs again
8All part of a feedback cycle that occurs btwn the gonads (ovaries) – P & E
…
posterior pituitary produces what?
oxytocin (milk ejection in response to suckling)
the ovary produces which hormones
progesterone - prepares endometrium estrogen - produces sudden release LH testosterone - connected to libido inhibin - inhibits secretion of FSH activin - increases FSH binding follistatin -
what is the correct order of a GYN physical exam?
history –> physical assessment –> external pelvic exam –> vaginal/cervical exam with speculum –> cervical smears –> bimanual –> rectovaginal IF needed
primary amenorrhea vs secondary amenorrhea
Primary amenorrhea is the absence of initiation of menses, and secondary amenorrhea is an absence of menses in a previously normal menstruating female
most common causes of primary amenorrhea
primary amenorrhea = at least 15 and haven’t gotten your first period
*most common causes:
Chromosomal or genetic problem with the ovaries (the female sex organs that hold the eggs).
Hormonal issues stemming from problems with the hypothalamus or the pituitary gland.
Structural problem with the reproductive organs, such as missing parts of the reproductive system.
most common causes of secondary amenorrhea
- Pregnancy (which is the most common cause of secondary amenorrhea).
- Breastfeeding.
- Menopause.
- Some birth control methods, such as Depo Provera, intrauterine devices (IUDs) and certain birth control pills.
- Chemotherapy and radiation therapy for cancer.
- Previous uterine surgery with subsequent scarring (for example, if you had a dilation and curettage, often called D&C).
Other causes of secondary amenorrhea can include:
- Stress.
- Poor nutrition.
- Weight changes — extreme weight loss or obesity.
- Exercising associated with low weight.
- Ongoing illness or chronic illness.
criteria for satisfactory PAP sample
- do it to see changes in endocervical area
- Use the endocervical spatula THEN the brush. Stay in contact with inner surface of the OS
- Liquid cytology sample can be used for pap test, HPV, Gonorrhea, and Chlamydia testing
GTPAL recording system stands for
G: Gravida/pregnancy = total # of pregnancies
T: Term - pregnancies that result in live birth (37-42 weeks)
P: Preterm birth = pregnancies resulting in birth <37 weeks and/or fetal weight <500g
A: Abortion = spontaneous or induced abortion up to 20 weeks gestation
L: Living children (multiples only count toward living children; ex. full term delivery of twins = G1, T1, Po, Ao, L2)
Domestic abuse victim - risks and common history and PE findings
Populations at higher risk: mental and physical disability, depression, low self-esteem, history of abuse/violence in home, lower education/socioeconomic, poverty, AA and American Indian (higher death rates), adolescents in at risk situations, college age, women veterans, pregnancy, elderly
• Affects more women than men (typically adolescent and adult women)
• Women living with IP of same sex had IPV rate nearly twice that of women living with men
o Common History: victimization of a person with whom the abuser is currently or has been in an intimate, romantic, or spousal relationship. All patients presenting with reported assault are survivors!
Most injuries occur on the face, chest, breast, and abdomen
Screening: Universal screening recommended for women of childbearing age, all prenatal visits
Most common causes of cancer death in women
- lung cancer is the leading cause of death in women followed by breast cancer (colorectal and cervical next)
- skin cancer is the most prevalent cancer diagnosis among women, followed by breast cancer
HPV/PAP ACOG screening guidelines
-Starts age 21 and continues every 3 years until age 29. B/w ages 30-65, PAP smears should be performed every 5 years with HPV DNA testing. If no HPV DNA testing, routine PAP smear recommended every 3 years b/w ages 30-65. After age 65, stop if all prior PAP smears have been normal or total hysterectomy
Chlamydia - what bacteria causes? Who is most at risk? What can it cause? Symptoms M vs W? Treatment?
- PID often caused by chlamydia causes scarring of the fallopian tubes, and can increase the risk of tubal pregnancies
- chlamydia is caused by the bacteria Chlamydia trachomatis, and is the MOST COMMON REPORTABLE STI
- often asymptomatic
- s/s in women: vaginal discharge, postcoital bleeding, dysuria, vague lower abdominal pain; mucopurulent (containing mucus and pus) cervical discharge, bimanual tenderness, WBCs wet mount
- s/s men: white, cloudy or watery discharge from the tip of the penis; pain, discomfort or a “burning sensation” when urinating; inflammation, tenderness or pain in and around the testicles
TREATMENT: AZITHROMYCIN 1 G PO single dose OR DOXYCYLINE (preferred) 100mg PO BID for 7 days;
ALT:
ERYTHROMYCIN 500mg QID 7 days
OR LEVOFLOXACIN 500mg PO QD 7 days
Gonorrhea: caused by what bacteria? causes problems with pregnancy how? presenting s/s? treatment?
- Neisseria gonorrhoeae
- 820,000 new N/ gonorrhoeae/year; 2nd most common reported communicable disease
- can cause PT birth and FGR (fetal growth retardation)
- women s/s: asymptomatic or mucopurulent cervical or vaginal d/c, spotting/bleeding, dysuria, frequency, Bartholin’s, Skene’s tenderness, lower abd tenderness (may not notice symptoms until PID and tubal scarring)
- men s/s: dysuria; white, yellow, or green penile d/c; testicular pain/swelling (less common)
Treatment: one dose Ceftriaxone
<150kg 500mg IM injection
> or equal 150kg = 1 gram IM injection
used to recommend also taking azithromycin 1g orally in single dose, but this is no longer recommended unless co-infection w/chlamydia
Syphilis
- caused by what bacteria?
- treatment?
Treponema pallidum
- for primary, secondary, or latent: tx with benzathine PCN G 2.4 million units IM
- for late latent or unknown duration: 3 doses benzathine PCN G 2.4 million units IM each
- for tertiary with normal CSF: Benzathine PCN G 7.2 million units total, admin as 3 doses of 2.4 million units each at 1 week intervals; Requires ID referral
chancroid caused by what organism? presenting exam? diagnosis? tx?
RARE in US
- organism: Haemophilus ducreyi (gram - bacteria)
- presenting exam: painful genital ulcers + suppurative (pus) inguinal adenopathy
-No FDA approved test, so diagnosis by exclusion. Ask about recent travel to Africa/Caribbean.
Diagnose by exclusion:
-1 or more painful genital ulcers
-with regional lymphadenopathy
-NO evidence of T. pallidum at least 7 days after onset
-HSV PCR or HSV culture of exudate negative
Tx: Azithromycin 1 g PO single dose, OR Ceftriaxone 250 mg IM single dose, OR Cipro 500 mg PO BID 3 days, OR Erythromycin 500 mg PO QID 7 days
Trichomoniasis
- organism?
- presenting exam?
- diagnostic results
- tx?
- organism: Trichomonas vaginalis (anaerobic one-cell protozoan with flagellae)
- S/s: many asymptomatic (70%)
- Men: itching/irritation inside the penis, burning after urination or ejaculation, penile d/c
- Women: STRAWBERRY SPOTS on cervix. Itching, burning, redness, soreness. Elevated vaginal pH & fishy odor w/ KOH.
- Dx: NAAT - GOLD STANDARD PCR TEST (vag swab women, 1st catch urine in men); +Whiff test - d/c + KOH = fishy odor
- Tx: metronidazole 2 g PO in 1 dose OR metronidazole 500mg orally twice a day for 7 days (preferred)
HSV-1 & HSV-2 diagnosis and tx?
-Diagnosis with HSV PCR is the gold standard, but cell culture can be used if active lesions are present
-Tx FIRST EPISODE: 7-10 tx
Acyclovir: 400 mg three times daily or 200 mg five times daily
OR
Famciclovir: 250 mg three times daily
OR
Valacyclovir: 1000 mg twice daily
Episodic therapy — When prescribing episodic therapy, the provider needs to determine which antiviral agent to use. In addition, patients need to be counseled regarding the optimal timing of when to initiate treatment.
●Acyclovir: 800 mg three times daily for two days; or 800 mg twice daily for five days; or 400 mg three times daily for five days
●Famciclovir: 1000 mg twice daily for a single-day duration; or 125 mg twice daily for five days; or 500 mg once, followed by 250 mg twice daily for two days
●Valacyclovir: 500 mg twice daily for three days or 1000 mg once daily for five days
HPV - which types cause cancer, which types cause genital warts?
- most common STI in US
- 40 types infect genital area
- HPV types 6 and 11 cause genital warts and do not cause cancer
- HPV types 16 & 18 cause most uro-anal-genital-oral cancers
Prevent with Gardasil vaccine given around 11-12 for strains 6,11,16,18 - now 2-dose recommendation, but used to be 3
Most people clear infection spontaneously with otherwise no associated symptoms
PID
- caused by?
- occurs where?
- s/s?
- tx?
- diagnosis?
- occurs in upper genital tract
- caused by: N. gonorrhoeae, C. Trachomatis, Garnerella vaginalis (BV), H. flu, Mycoplasma genitalium
- Sequelae: abscessed tubes and ovaries, ectopic pregnancy, infertility, chronic pelvic and abdominal pain, dyspareunia, dysuria, burning w/urination, discharge w/foul odor, fever, low back pain
- **abrupt onset of lower abdominal pain after menses characteristic presentation
-tx: early diagnosis and tx is critical but difficult d/t non-specific s/s that mimic other common GI and GU problems
Outpatient:
-CEFTRIAXONE 500mg IM (single dose) PLUS DOXYCYCLINE 100mg PO BID 14 days PLUS METRONIDAZOLE 500mg BID x 14 days
Diagnosis: should undergo bimanual exam to evaluate for cervical motion, uterine, or adnexal tenderness. Additionally, speculum exam should be performed to evaluate for cervical mucopurulent d/c.
POC test: pregnancy test, microscopy of vaginal d/c, NAATs for chlamydia and gonorrhea, and mycoplasma genitalium, HIV testing, and serological testing for syphilis (looks for Ab)
BV
- most commonly caused by?
- presenting exam?
- diagnostic results?
- tx?
- most commonly caused by Gardnerella vaginalis and an overgrowth of this bacteria that naturally occurs in the vaginal area
- presenting: vaginal pH >4.5; discharge thin, homogeneous, gray-white, adherent; amine (fishy) odor with KOH “whiff” test, vulvar pruritis mild or negative, negative genital ulceration, negative pelvic pain, occasional dysuria, occasional dyspareunia; CC: asymptomatic, vaginal discharge or odor worse after intercourse; +PID risk
- diagnosis: wet prep (saline) + clue cells, decrease in lactobacilli
- Tx: metronidazole 500mg PO BID 7 days or can use it intra-vaginally w/0.75% gel
Vulvovaginal candidiasis
- most common cause
- presenting exam?
- tx?
- The fungus Candida albicans is responsible for most vaginal yeast infections. Your vagina naturally contains a balanced mix of yeast, including candida, and bacteria. Certain bacteria (lactobacillus) act to prevent an overgrowth of yeast. But that balance can be disrupted. An overgrowth of candida or penetration of the fungus into deeper vaginal cell layers causes the signs and symptoms of a yeast infection.
- presenting: vaginal pH < 4.5, discharge thick or thin, white, curd or cottage cheese like, adherent, NEGATIVE amine odor (Whiff test), + vulvar pruritis with swelling, excoriation, and erythema, + ulceration if severe, negative pelvic pain, + dysuria if severe, occasional dyspareunia; CC: vaginal itching, burning, and/or discharge; negative PID risk
- treatment: fluconazole 150mg PO single dose (MR second dose 72 hours after initial treatment if severe)
- rx vaginal creams (-azoles)
- OTC -azole vaginal cream or suppositories OK w/pregnancy
which vaccines are live and can’t be given during pregnancy
MMR and varicella - so it should be given a month or more before pregnancy
prior to pregnancy which immunity titers should be drawn?
rubella, varicella, hepatitis
Nagele’s rule
calculates EDB
- count back 3 months from the date of LMP
- add 7 days
- adjust the year +1 if the delivery will occur the following year
probable sign: Jacquemier’s sign + when does it occur
Chadwick’s sign (also referred to as Jacquemier’s sign when the vaginal tissue appears bluish in color
-usually occurs b/w 6-8 wks
probable sign: Goodell’s sign
cervical softening that occurs b/w 6-8 wks
probable sign: Ladin’s sign
softening in the midline of the uterus anteriorly at the junction of the uterus and cervix
probable sign: Hegar’s sign
Softening of the lower portion of the uterus normally occurs b/w 6-12 weeks gestation
probable sign: McDonald’s sign
ease of flexing the body of the uterus against the cervix
other probable signs
- increase in basal body temperature 0.4-0.8 degrees above 98 usually
- positive pregnancy test (endocrine pregnancy test)
- skin pigment changes (think seen by examiner)
- Ballottement
- enlargement of uterus or abdomen
- Braxton Hicks (remember false labor - does not result in dilation)
Positive sign: Leopold’s maneuver and when can it be performed?
- Detection of fetal movement by examiner - usually not done until after 24 weeks of gestation when fetal outline can be already palpated. Determines the direction and degree of flexion of the head/presentation and position of baby, done in 4 steps/maneuvers
- visible movements seen by examiner = positive sign
Fundal ht by weeks gestation
12, 16, 20, 28, & 36 weeks
o Fundal ht. by wks. Gestation:
12 wks. = symphysis pubis
16 wks. = halfway btwn symphysis pubis & umbilicus
20 wks. = at umbilicus
28 wks. = halfway btwn umbilicus & xiphisternum
36 wks. = at xiphisternum
first trimester
week 1-14
second trimester
week 15-28
third trimester
29-birth
when can embryo and fetal heart activity be OBSERVED on U/S, uterus is the size of an orange, + Chadwick’s, Goodell’s, Ladin’s, Hegar’s, McDonald’s
6 weeks
uterus size of naval orange at this gestational age?
8 weeks
when are FHS heard with doppler
notes say 10-12 weeks
but online says 8-14 weeks
At what stage can quickening occur?
16 weeks (range 15-22 weeks)
Pre-pregnancy BMI and ideal weight gain (lbs.)
BMI
- underweight < 18.5 optimal gain 28-40lbs
- normal wt BMI 18.5-24.9 optimal gain 25-35lbs
- overweight BMI 25-29.9 optimal gain 15-25lbs
- obese BMI > or equal 30 optimal gain 11-20lbs
v/s during pregnancy: what happens to HR?
louder s1, 3rd heart sound may be detected, systolic murmur may be heard; increased HR by 15-20 bpm @32 weeks
v/s during pregnancy: RR
increase of 1-2 bpm
BP during pregnancy
1st trimester normal; 2nd trimester systolic BP decreases 2-8 and diastolic decreases 5-15; 3rd trimester back to normal
Online says that it drops up to 5-10mmHg systolic and 15mmHg diastolic
recommendation for folic acid intake during pregnancy
-what risk factors require an increased dose?
- PNV with 0.4mg-1mg folic acid daily for 2-3 months prior to conception and throughout pregnancy
- supplement with 4mg daily 2-3 months PTC until 12 weeks then reduce to 0.4mg/day of pregnancy if expectant mother has: epilepsy, IDDM, BMI >35, FH NTD, Mexican born Hispanic
how much iron is needed during pregnancy
- twice what is normal
- supplement of 27g/day should be taken (amt in prenatal)
- heme iron sources increase bioavailability: meat, poultry, fish, vit c increases absorption of non-heme sources (legumes, veg, grains, nuts)
how much iron does an iron deficient pregnant woman need to take?
Iron replacement of 60‐120 mg elemental iron
o Ferrous gluconate= 34mg per 300mg tab
o Ferrous sulfate= 65mg per 325mg tab
o Ferrous fumarate= 106mg per 325 tabs
*Take with meals or bedtime, increased fiber, water, and activity; stool softeners as
Rh factor - what does it mean and what to do if incompatible blood types b/w mom and baby
*when is pregnant woman first screening for this
Rh- mother and Rh+ baby = problem. Mother needs Rhogam at week 28 + second dose given w/i 72 hours post delivery
-screen in first trimester
when do they screen for GDM with OGTT?
24-28 weeks
- screen w/hgbA1c at first visit and if it’s greater than or equal to 6.5 at this time then undiagnosed type 2 diabetes is the likely the diagnosis
- if hgbA1c is b/w 5.7-6.4 these pts have impaired glucose tolerance and are more likely to develop GDM
what treatment of asymptomatic bacteriuria and cystitis is safe in all trimesters of pregnancy
Cephalexin
macrobid problems with it during pregnancy
does not reach therapeutic levels in the kidneys, so do not use if pyelonephritis is suspected; avoid use during first and at term (39+ weeks) if other options are available
most common lung disease in pregnancy
asthma - may improve in early pregnancy, worsens in about 1/3 women
-if well-controlled no increase in maternal fetal risk
what things can make asthma worse
emotional stress, exercise, allergens (animal dander, dust mites, cockroach, mold, SULFITES, pollen), cigarette or wood smoke, cold air, URI, meds (NSAIDS, beta blockers)
- continue current meds if well controlled to prevent exacerbation during pregnancy
- Albuterol and budesonide have most pregnancy data available but majority of asthma medications are considered safe during pregnancy
diagnosis of ectopic pregnancy
- US best way to confirm
- Pregnancy test
- CBC
- B-HCG levels (blood)
risk factors for ectopic pregnancy
MAJOR: IUD, previous ectopic pregnancy, PID (>50%), previous tubal surgery, termination of pregnancy
MINOR: smoking, age greater than 35, tuberculosis salpingitis, many sexual partners, congenital anomalies of the fallopian tubes, ovum transmigration
HepB - diagnostic tests and interpretation: HBsAg +
- hepatitis b surface antigen
- indicates pt has acute or chronic Hep B virus infection and can transmit to others
What is Anti-HBs
- hepatitis B surface antibody
- if positive indicates pt has immunity resulting from vaccination or previous infection
Anti-HBc
- total HepB core antibody
- Indicates that pt has previous or ongoing infection in an undefined time frame
IgM anti-HBc
- immunoglobulin M antibody to HepB core antigen
- Indicates pt has had an acute infection within past 6 months
Women who have - HBsAg, anti-HBc, and anti-HBs tests…
should be vaccinated as they are at risk!
Women who have positive anti-HBs test with negative HBsAg and anti-HBc…
has immunity from vaccination
Negative HBsAg and positive anti-HBc and anti-HBs has…
has immunity from prior infection that has resolved
+HBsAg, anti-HBc, and IgM anti-HBc tests;
negative HBs
acute hep B infection
+HBsAg and anti-HBc; -IgM anti-HBc and anti-HBs
chronic hep B
+anti-HBc and -HbsAg and -anti-HBs should
be referred for further evaluation
Medications/substances to avoid in pregnancy:
statins, ACE-I, TCAs, lithium, tetracycline, warfarin, iodine, carbamazepine, barbiturates, thalidomide, DES, cocaine, ethanol, tobacco)
ATBs not to give (FYI)
Tetracyclines (including doxycycline and minocycline)
Medications/substances to avoid in pregnancy:
statins, ACE-I, TCAs, lithium, tetracycline, warfarin, iodine, carbamazepine, barbiturates, thalidomide, DES, cocaine, ethanol, tobacco)
ATBs not to give (FYI)
Tetracyclines (including doxycycline and minocycline)
