Exam 4 - Chapter 18

Question 1

Pelvic Inflammatory Disease (PID/Salpingitis)

Answer 1

Inflammation of the fallopian tubes, with ovaries at times

Causes: Chlamydia trachomatis (subacute), Neisseria gonorrhoeae (acute), Gardnerella vaginalis, and Trichomonas vaginalis. Occurs in young sexually active women with many partners
Pathology: Edematous tubal serosa, collection of pus forms pyosalpinx, degrading pus forms hydrosalpinx
Symptoms: High fever, lower abdominal pain, cervical motion tenderness, future ectopic pregnancy, infertility
Treatment: Antibiotics

Question 2

Ectopic Pregnancy

Answer 2

Implantation of the ovum in the fallopian tube

Symptoms: Missed period, other signs of early pregnancy, vaginal bleeding 6 -8 weeks after last period. Upon rupture, bleeding may be excessive
Lower abdominal pain may be:
• Sharp unilateral
• Constant
• Diffuse or localized
– May be referred to shoulder

Abdominal pain or unexplained hypovolemia + woman of child-bearing age = Ectopic pregnancy

Question 3

Diethylstilbestrol (DES)

Answer 3

• Known as super-estrogen
• Nonsteroidal estrogens used from 1946–1970 to treat mothers who were prone to spontaneous abortion
• Disorders in daughters of women who received diethylstilbestrol (DES) therapy during pregnancy.
• Precocious Puberty: Puberty before the specified age
• Clear cell adenocarcinoma of the cervix and vaginal adenosis (benign condition characterized by mucosal columnar epithelium-lined changes) in areas normally lined by stratified squamous epithelium (metaplasia), may also occur in these patients

Question 4

Placental Accreta

Answer 4

Deep penetration of the placental villi into the wall of uterus

Causes: Predisposed by previous C-section scars or endometrial inflammation
Pathology: Defective decidual layer allows placenta to attach directly to myometrium
Symptoms: Massive hemorrhage after delivery
Treatment: Hysterectomy to stop bleeding

Question 5

Placental Previa

Answer 5

Implantation of the zygote in the lower section of the uterus

Causes: Predisposed by previous C-section scars
Pathology: Attachment of placenta to lower uterine segment of cervix
Symptoms: Painless bleeding, premature labor
Treatment: C-section, bed rest

Question 6

Abruptio Placentae

Answer 6

Partial/complete premature separation of the placenta which is an obstetric emergency for mother and fetus

Causes: DIC, smoking, cocaine, hypertension
Pathology: Premature separation of the placenta
Symptoms: Painful bleeding with abdominal pain in third trimester. Can result in fetal death
Treatment: Immediate delivary & control bleeding

Question 7

Abortion

Answer 7

Termination of pregnancy before the 22nd week of gestation

Causes: By physician or RU-486
Symptoms: Cramping, abdominal pain, backache, and vaginal bleeding

Question 8

RU-486

Answer 8

RU-486 or Mifepristone competes with progesterone for the progesterone receptors.
• Mechanism of action: Without progesterone, the lining of the women’s uterus breaks down and sheds like normal menstrual cycle. In addition, the drug opens the cervix and influence contractions with help of prostaglandin to dislodge and expel the embryo. Ru-486 works only during the first 9 weeks of pregnancy, or up to 63 days from the start of the women’s last menstrual period. After this time, the level of progesterone goes up in a higher level where RU-486 is not effective

Question 9

Complete Abortion

Answer 9

Spontaneous expulsion of all fetal and placental tissue from uterus prior to 20 weeks gestation. Cervix closed on examination

No further intervention necessary; ultrasound to confirm an empty uterus may be helpful

Question 10

Incomplete Abortion

Answer 10

Passage of some fetal or placental tissue, but not all, prior to 20 weeks gestation. Cervix dilated on examination

IV hydration, type and screen/cross, immediate suction curettage

Question 11

Threatened Abortion

Answer 11

Uterine bleeding prior to 20 weeks gestation, without any cervical dilation or effacement

Ultrasound to document fetal viability; modified activity and pelvic rest until bleeding stops

Question 12

Inevitable Abortion

Answer 12

Uterine bleeding prior to 20 weeks gestation, accompanied by cervical dilation, but no expulsion of fetal or placental tissue through cervical os

Expectant management or evacuation of pregnancy (surgical or medical termination)

Question 13

Missed Abortion

Answer 13

Fetal death before 20 weeks gestation without expulsion of any fetal or maternal tissue for at least 8 weeks thereafter

Suction curettage or medical termination of pregnancy

Question 14

Septic Abortion

Answer 14

Any of the abortions above, accompanied by uterine infection

IV antibiotics, followed by suction curettage

Question 15

Gestational Trophoblastic Disease

Answer 15

Hydatidiform mole (placental abnormality): swelling of the chorionic villi (grapelike clusters). Uterus expands as if a normal pregnancy is present, but the uterus is much larger

Causes: Chromsomal abnormalities
Pathology: Β-hCG much higher than expected for date of gestation. Classically presents in the second trimester as passage of grape-like masses through the vaginal canal. Honeycombed uterus appearance
Diagnosis: Routine ultrasound in the early first trimester. Fetal heart sounds are absent, and a ‘snowstorm’ appearance is classically seen on ultrasound
Two types:
Complete mole: Fetus can not be identified in the ammnotic fluid due to production of androgen. No maternal chromosome only paternal chromosome (46, XX)
Incomplete mole: Some the fetal parts are present. Two sperm fertilize one egg making triploid (69, XXY)

Treatment: Most abort spontaneously, or D&C

Question 16

Gestational Choriocarcinoma

Answer 16

Malignant tumors of germ cells of the placenta. Rare

Causes: 50% develops from hydatidiform mole, 25% develops from placental cells after abortion and 25%, develops from normal placenta
Pathology: High levels of hCG, necrotic tumor
Symptoms: Excessive vaginal bleeding after removal of mole or delivery of fetus/abortant. Hemoptysis
Treatment: Surgery, chemo

Question 17

Toxemia of Pregnancy (Preeclampsia and Eclampsia)

Answer 17

This disorder is characterized by severe hypertension that most often occurs de novo during pregnancy or complicates preexisting hypertensive disease. Toxemia characteristically occurs during the third trimester, most often in the first pregnancy

Preeclampsia: Triad of hypertension, edema, and proteinuria during the 3rd trimester. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets)
Eclampsia: all of the above plus seizures
Treatment:
Preeclampsia: Delivery of the fetus, bed rest, treat hypertension
Eclampsia: Medical emergency, treat with magnesium sulfate and diazepam (anti-epileptics)

Question 18

Supine Hypotensive Syndrome

Answer 18

1. Uterus compresses inferior vena cava
2. Venous return to heart decreases
3. Decreased venous return leads to decreased
   cardiac output
4. BP decreases
   Treatment: Place patient on left side to restore venous return

Question 19

Menorrhagia

Answer 19

Prolonged (>7 days) and or heavy (≥80ml) uterine bleeding occurring at regular intervals

Question 20

Metrorrhagia

Answer 20

Variable amounts of inter-menstrual bleeding occurring at irregular but frequent intervals

Question 21

Polymenorrhea

Answer 21

An abnormally short interval (

Question 22

Oligomenorrhea

Answer 22

An abnormally short interval (

Question 23

Dysmenorrhea

Answer 23

Medical term for pain with menstruation

Question 24

Primary Dysmenorrhea

Answer 24

Common menstrual cramps that are recurrent and are not due to other diseases. Cramps usually begin one to two days after a woman starts getting her period. Pain usually begins 1 or 2 days before or when menstrual bleeding starts and is felt in the lower abdomen, back, or thighs and can range from mild to severe. Pain can typically last 12 to 72 hours and can be accompanied by nausea, vomiting, fatigue, and even diarrhea. Common menstrual cramps usually become less painful as a woman ages and may stop entirely if the woman has a baby

Question 25

Secondary Dysmenorrhea

Answer 25

Pain that is caused by a disorder in the woman’s reproductive organs, such as endometriosis, uterine fibroids, or infection. Pain from secondary dysmenorrhea usually begins earlier in the menstrual cycle and lasts longer than common menstrual cramps. The pain is not typically accompanied by nausea, vomiting, fatigue, or diarrhea. Treatment: Aspirin, other anti-inflammatory drugs and oral contraceptive pills

Question 26

Seasonal Oral Contraceptive Pill

Answer 26

It contains two female hormones, an estrogen called ethinyl estradiol, and a progestin called levonorgestrel

Question 27

Amenorrhea

Answer 27

An abnormal absence of menstruation

Question 28

Primary Amenorrhea

Answer 28

Failure to have a period during puberty. Patients usually have birth defects like Turner Syndrome or other congenital defects

Question 29

Secondary Amenorrhea

Answer 29

When a woman has normal menstrual cycles but stopped having her period for 6 months or longer. Exception-women who are pregnant, breastfeeding or in menopause. Common factors contributing are: drugs (chemotherapy), anti-depressants, low body weight, hormonal problems

5 types:
Psychogenic Amenorrhea
Lactational Amenorrhea
Anorexia Nervosa
Exercise Amenorrhea
Runner's Amenorrhea

Question 30

Psychogenic Amenorrhea

Answer 30

Menstrual cycle stops in young female (non-pregnant) without any evidence of abnormalities with pituitary or ovaries. Common with college freshmen (stress) or usage of opiates

Question 31

Lactational Amenorrhea

Answer 31

Increased of PRL due to nursing a baby

Question 32

Anorexia Nervosa

Answer 32

Decreased body weight (body fat)&raquo_space; decreased FSH and LH&raquo_space; decreased estrogen production

Question 33

Exercise Amenorrhea

Answer 33

Delayed menarche, luteal phase dysfunction and amenorrhea are known as female athletic triad (decreased FSH & LH)

Question 34

Runner’s Amenorrhea

Answer 34

Long distance female runners produce Beta endorphins which inhibit GnRH production. Treatment: diet, decrease exercise and birth control pills

Question 35

Turner’s Syndrome

Answer 35

Pubertal delay in girls due to low estrogen

Causes: An absent or structurally abnormal second chromosome characterizes Turner Syndrome (45 or 46 XO chromosomes)
Pathology: In absence of second functional X chromosome, oocyte degeneration happens because of primary gonadal failure, which causes FSH and LH rise and are elevated at birth and again at puberty
Symptoms: 10 – 20% Turner girls, some ovarian functions at puberty that allow for slight breast development, short stature, neck, webbed neck, abnormal upper to lower segment ratio, primary amenorrhea
Treatment: Estrogen and progesterone and height with Growth hormone

Question 36

Endometriosis

Answer 36

Deposits of endometrium outside its normal location, most often located on the ovary and pelvic peritoneum

Causes: Idiopathic, affects 10% of women, especially between 20-30
Pathology: Retrograde flow of endometrial fragments (non-neoplastic) through fallopian tubes during menstruation, with implantation on the ovary or other peritoneal structures
The condition is characteristically responsive to hormonal variations of the menstrual cycle. Menstrual-type bleeding occurs into the ectopic endometrium, resulting in blood filled, or so-called “chocolate,” cysts
Symptoms: Severe menstrual-related pain (dysmenorrhea), pelvic pain, and pain during intercourse (dyspareunia). Infertility
Diagnosis: Visualizing the ectopic deposits within the pelvis with a laparascope
Treatment: Birth control pills, and drugs that suppress output of gonadotropins from the pituitary gland

Question 37

Endometritis

Answer 37

Inflammation of the endometrium or uterine lining by bacterial infection

Causes: Acute - trauma, STDs, Staphylococcus and Streptococcus, after delivery or miscarriage. Chronic - PID, TB
Symptoms: Malaise, fever, constipation. Chronic - abnormal vaginal bleeding, pelvic pain, discharge, infertility
Treatment: Antibiotics

Question 38

HPV

Answer 38

Sexually transmitted DNA virus that infects the lower genital tract, especially the cervix

• Infection is usually eradicated by acute inflammation & persistent infection leads to an increased risk for cervical dysplasia (cervical intraepithelial neoplasia, CIN).
• Risk of CIN depends on HPV type (determined by DNA sequence).
• High-risk—HPV types 16, 18, 31, and 33
• Low-risk—HPV types 6 and 11
• High-risk HPV produce E6 and E7 proteins which result in increased destruction of p53 and Rb (tumor suppressor proteins) which increases the risk for CIN
Treatment: Vaccines like Gardasil (for types 6, 11, 16, 18)

Question 39

Cervical Intraepithelial Neoplasia (CIN)

Answer 39

Most physicians regard cervical dysplasia and in situ carcinoma as very closely related, constituting different stages in a progressive spectrum of epithelial abnormalities, classifying them under the general term, cervical intra-epithelial neoplasia (CIN). Disordered epithelial growth manifested by loss of polarity and nuclear hyperchromasia, beginning at the basal layer and extending outward, is characteristic. It is graded into three categories:
• Grade I: CIN 1Mild dysplasia
• Grade II: Moderate dysplasia
• Grade III: Severe dysplasia (carcinoma in situ)

• The goal of screening is to catch dysplasia (CIN) before it develops into carcinoma
• Progression from CIN to carcinoma, on average, takes 10-20 years. Screening begins at age 21 and is initially performed yearly
• Pap smear is the gold standard for screening
• Cells are scraped from the transformation zone using a brush and analyzed under a microscope
• Dysplastic cells are classified as low grade (CIN I) or high grade (CIN II and III)

High-grade dysplasia is characterized by cells with hyperchromatic (dark) nuclei and high nuclear to cytoplasmic ratios
• Hybrid Capture 2 Technology: new test based on RTPCR
• Treatment: Dysplasia and in situ carcinoma: cryocautery (freezing), surgical excision of abnormal area, hysterectomy (removal of uterus)
• Invasive carcinoma: radiation or radical hysterectomy (resection of uterus, fallopian tubes, ovaries, and adjacent tissues)

Question 40

Uterine Myometrial Tumors (Leiomyoma)

Answer 40

Leiomyoma (benign, common): This is the most common uterine tumor and the most common of all tumors in women; the incidence is increased in women of African lineage. The tumor is a benign neoplasm; malignant transformation is rare
• Leiomyomas occur in multiple separate foci in most cases. The tumors are estrogen-sensitive. They often increase in size during pregnancy, and they almost always decrease in size following menopause
• Leiomyosarcoma (malignant, rare)

Staging 5-Year Survival Rates:
I (Localized to cervix): 85%
II (Body of the uterus): 75%
III (Ovaries): 35%
IV (Other sites): 10%

Question 41

Endometrial Carcinoma

Answer 41

Endometrial hyperplasia leads to adenocarcinoma in endometrium. Most common gynecological malignancy. Affects women 55-65

Causes: Unopposed estrogen use, obesity, diabetes, HTN
Symptoms: Postmenopausal vaginal bleeding, pyometra (pus in cervix), hematometra (blood in cervix)
Treatment: Variable prognosis - depends on the stage and to a lesser extent on the grade of the tumor. Sometimes total hysterectomy

Staging 5-Year Survival Rates:
I (Localized to endometrium): 90%
II (Cervix): 50%
III (Pelvic spread): 20%
IV (Other sites): 5%

Question 42

Ovarian Cancer

Answer 42

Malignant neoplasm (abnormal growth) located on the ovaries

• 5th Leading cause of cancer death in ♀ and leading cause of death from gynecological malignancies
• Older ♀ @ higher risk (post-menopasual)
• Ovarian cancer prognosis is poor. Symptoms are vague and non-specific conditions
• Symptoms: Pelvic heaviness, abdominal discomfort, vaginal bleeding, weight gain or loss, abnormal menstrual cycles
• Thus, 50% of ♀ with ovarian cancers are diagnosed in the advanced stages of the disease
• Factors protecting ♀ from ovarian cancer: Early age pregnancy, use of oral contraceptives (birth control pills)
• Risk Factors: Presence of BRCAI and BRCAII (mutated) genes increase breast and ovarian cancers, higher dietary fat content, smoking
• Testing: Blood chemistry, CA 125, ultrasound, CT, MRI, pelvic exam, and PAP smear (♀ over 20 yrs old). If diagnosed in early stages, survival rate is higher
• Treatment: Taxol (yew tree derivative) Regression of ovarian cancer by disrupting the cellular structures of tumor. Anti-estrogens

Question 43

Serous Cystadenoma

Answer 43

Fallopian tube-like epithelium

Question 44

Serous Cystadenocarcinoma

Answer 44

Malignant cysts with psammoma bodies

Question 45

Mucinous Cystadenoma

Answer 45

Tumor epithelium resembles mucus-secreting epithelium of endocervix

Question 46

Mucinous Cystadenocarcinoma

Answer 46

Malignant tumor with mucus-secreting epithelium

Question 47

Brenner Tumor

Answer 47

Benign tumor resembling bladder transitional epithelium

Question 48

Endometroid Tumor

Answer 48

Malignant tumor resembling endometrium

Question 49

Clear Cell Tumor

Answer 49

Rare, malignant tumor composed of sheets of clear cells

Question 50

Ovarian Tumors (Germ Cells)

Answer 50

Occur in women younger than 25 years old
• Common germ cell tumor: Teratoma (Mature: benign)
• Contain teeth or calcified parts
• Mature teratoma presents a hairy structure and teeth: it is known as dermoid cyst
• Malignant tumors (immature teratoma: rapidly metastasize) may secrete AFP and hCG

Question 51

Ovarian Tumors (Other Tumors)

Answer 51

1. Granulosa cell tumor: Hormonally inactive and may produce estrogen which cause mentrual irregularities
2. Theca cell tumor: are solid tumors and produce estrogen. They are benign in nature and often cause endometrial hyperplasia
3. Sertoli-Leydig cell tumor: are solid tumors and produce androgens which cause masculine characteristics

Question 52

Metastatic Ovarian Tumors

Answer 52

• Tumors metastatic to the ovary account for approximately 5% of all ovarian tumors
• These tumors are frequently of gastrointestinal tract, breast, or endometrial origin
• They are called Krukenberg tumors when ovaries are replaced bilaterally by mucin secreting signet ring cells and the site of origin is often the stomach

Question 53

Polycystic Ovary Syndrome (PCOS)

Answer 53

• Involves enlarged ovaries, which contain many fluid-filled sacs (cysts), and a tendency to have high levels of male hormones (androgens). Not all women with PCOS have cysts
• A main underlying problem with PCOS is a hormonal imbalance. In women with PCOS, the ovaries make more androgens than normal. High levels of these hormones affect the development and release of eggs during ovulation
• Researchers also think insulin may be linked to PCOS. Many women with PCOS have too much insulin in their bodies because they have problems using it. Excess insulin appears to increase production of androgen. High androgen levels can lead to: acne, hirsutism, weight gain and ovulation problems
• Blood tests to measure levels of LH and male hormones are performed, and ultrasonography of the ovaries may be performed

Question 54

PCOS Treatment

Answer 54

• No ideal treatment is available. The choice of treatment depends on the type and severity of symptoms, the woman’s age, and her plans regarding pregnancy
• Women who do not wish to become pregnant may take a progestin by mouth or a combination oral contraceptive (which contains estrogen and a progestin)
• The medicine metformin (Glucophage) is used to treat type 2 diabetes. It also has been used in PCOS, but not approved by FDA for this use. Metformin affects the way insulin controls blood glucose (sugar) and lowers testosterone production. It slows the growth of abnormal hair and, after a few months of use, may help ovulation to return. Recent research has shown metformin to have other positive effects, such as decreased body mass and improved cholesterol levels. Metformin will not cause a person to become diabetic
• Lack of ovulation is usually the reason for fertility problems in women with PCOS. Several medications that stimulate ovulation can help women with PCOS become pregnant. For example Clomiphene, gonadotropins. In vitro fertilization (IVF) offers the best chance of becoming pregnant in any given cycle. It also gives doctors better control over the chance of multiple births. IVF is very costly
• “Ovarian drilling” is a surgery that may increase the chance of ovulation. It’s sometimes used when a woman does not respond to fertility medicines. The surgeon punctures the ovary via laparoscopy with a small needle carrying an electric current to destroy a small portion of the ovary. This procedure carries a risk of developing scar tissue on the ovary. This surgery can lower male hormone levels and help with ovulation. But, these effects may only last a few months

Question 55

Toxic Shock Syndrome

Answer 55

• Estimated 10-15 cases per 100,000 menstrual age women per year
• This condition was initially associated with the use of highly absorbent tampons. It is caused by exotoxin produced by Staphylococcus aureus, which grows in the tampon
• Use of tampons promotes development
• Characteristic features include skin peeling, fever, vomiting, and diarrhea, sometimes followed by renal failure and shock. A generalized rash often seen in patients.