Gyn+OB OME Flashcards
Ultrasound and ca125 indicated to screen for cervical cancer when
Is increased surveillance adequate in these pts
When pt has BRCA1/2 mutation
No ppx hysterectomy oopherectomy mastectomy is superior to surveillance
BRCA1/2 mut predisposes to what cancers
breast ovarian uterine
Risk factor for vaginal and vulvar squamous cell carcinoma
HPV
Vag and vulv scc just like cervical csused by hpv
Endometrial cancer is driven by ______
Estrogen
64 F with maligmant ascites, which gym cancer to suspect
Ovarian cancer
Biggest risk factor for ovarian cancer
Ovulation
Teenage girl has huge obvious cystic teratoma by history and ultrasound, next step cystectomy or CT to better stage and characterize
cystectomy
age of patient and size of tumor make diagnosis clear (serous cystadenoma), no need for radiation exposure
why is TAH + BSO required for breast and uterine carcinomas?
total abdominal hysterectomy and bilateral salpingoopherectomy
estrogen responsive tumors
estrogen comes from ovaries
must take ovaries out in case mets
what % of women with infertility are found to have endometriosis
30%
define preterm labor
v37wks
tf
ovarian torsion often occurs seated not doing anything / at rest
T
often does
tf
treat 3cm simple ovarian cyst with oral contraceptives
f
oral contraceptives don’t affect ovarian cysts – used ot think so but not anymore
for 3cm, just repeat US in 3 mos to check but expecting spontaneous resolution
tubo-ovarian abscess is a complication of
pelvic inflammatory disease
1st and 2nd line tx of endometriosis
far down the line definitive therapy
nsaids
OCPs
laparoscopy
3cm smooth fluid-filled cyst in otherwise normal child-bearing age female, what is it likely, next step
Likely a functional follicular cyst (ovulating ovaries make them every month)… low risk (v10cm smooth thin-walled no septations)
Reassurance, typically regress weeks to months
rectocele causing constipation, surgery planned for next week, how to treat constipation till surgery
transvaginal digital reduction of rectocele - to restore normal alignment of colon and alow expulsion
how do kegel exercises treat vaginismus
contract the pelvic floor, relax the vaginal muscles so they can be gradually dilated
Mittleschmerz pain
Peritoneal pain from rupture / bleed from functional ovarian cyst or follicle
primary causative organism in bacterial vaginosis
gardnerella
choose between gonorrhea and chlamydia for cause of cervicitis on test
choose chlamydia
more prevalent
what kind of incontinence do neurogenic bladder and hypertonic bladder cause
neurogenic - overflow incontinence
hypertonic - spastic/urge incontinence
diabetes
ms
spinal lesion
are risk factors for what kind of urinary incontinence
neurogenic bladder - overflow incontincence
when to get ct scan for urothelial cancer
to stage – CT good at identifying mets, not primary urothelial cancer – get cystoscopy and biopsy for that
oxybutinin moa
use
urinary smooth muscle antispasmotic
also anticholinergic at urinary smooth muscle
tx overactive bladder (hyptertonic, spasmotic)
how does fibroid surgery lead to vesico vaginal surgery
trauma from surgery, or retained stitch, etc…. can lead to epithelialized tract between two epithelia…
when to get urodynamics
eval urinary incontinence when not sure stress vs urgency
overflow incontinence aka aka
hypotonic aka neurogenic bladder
when to use foley vs bethanecol or doxasosin for neurogenic bladder
foley for acute relief of hydronephrosis
bethanecol or doxasosin for long term treatment
When to perform external cephalic version of fetus
When baby is breech after 37 weeks (before 37 weeks the fetus is likely to spontaneously cephalize)
TF
Mom with PPROM and fever and tachy fhm needs betamethasone
F
Abx - broad spectrum pip/tazo or amp/gent/metro
And deliver asap… don’t wait to deliver with evidence of chorioamnionitis
TF
Abx for PROM even if no signs of infection yet
T
Not laboring yet, may take time, ppx against infectiom
When to use cerclage
First trimester presence or historynof cervical incompetence
aka way before labor, mist be removed before cervical changes in labor or else damage
TF
One sac, two placentas is possible
F These are possibe: One sac one placenta Two sacs two placentas Two sacs one placenta
What kind of twinning risks cord entanglement
One sac one placenta
What kind of twinning risks twin-twin transfusion
Two sacs one placenta
What kind of twinning risks malpresentation and premature birh
Two sacs two placentas
Types of twinning according to time of separation
Earlier separation, less shared
Separate eggs - dizy dichor diamn Day 0-3 - monozy dichor diamn Day 4-8 - monozy monochor diamn Day 9-12 - monozy monochor monoamn Day 12+ - conjoined mono mono mono
Each additional gestation pushes the EDD up about…
4 weeks (from mono edd 40 wks)
Quadruplets cooking in there, edd?
28 weeks
Each additional gestation pushes the EDD up about 4 weeks
Major cause of DIC in delivery
Placental embolization
How does amnionic fluid embolism present differently from placental embolism
Amnionic fluid PE w dyspnea amd hypoxia then maybe DIC
Pacental embolism DIC
Blood vessels to edge of delivered placenta implies…
And how to treat…
Retained parts of placenta
If PPH - D&C, then uterine artery ligation, then total abdominal hysterectomy ad needed
Retained placenta has long term complication of this cancer
Choriocarcinoma
How to follow up a DandC of a retained placenta
Serial bHCG’s for about a year to make sure no choriocarcinoma developes
Algorithm for workup of decreased fetal movement
Doppler for fetal heart tones (alive)
NST
NST w vibrioacoustic stim
BPP
CST or repeat BPP 24h if BPP 3-7 and preterm
Deliver if BPP 2 or less or CST abnorm or BPP 3-7 and term
Only go to next one if you get an abnormal… if normal.. can repeat at follow-up to acknowledge mom’s feelings
Act on BPP score
8-10 reassure and repeat weekly to check again
3-7 consider delivery if term, if preterm consider steroids and try to keep cooking a bit longer and do CST or repeat BPP IN 24hrs to help decide whether to deliver
0-2 deliver or else baby is going to die
In which does fetus decompensate faster, placenta previa or vasa previa?
Vasaprevia
What Rh antibody titer would cause you not to give rhogam because Mom already has anti-Rh abs
1:8 or greater
Painless genital ulcer
Think…
Dx by…
Painless genital ulcer
Think syphilis
Dx by dark field microscopy
Dx heamophilis ducrei in painful genital ulcer
Culture
Diffuse intracranial calcifications
Hydrocephalus
Chorioretinitis
Think what congenital infection
Toxoplasma
Saddle nose
Saber shins
Snuffles/rhinitis
Think what congenital infection
Syphilis
Periventricar calcifications
IUGR
Microcephaly
Think what congenital infection
CMV
Labs typically obtained at first prenatal visit
Type and screen CBC HIV HBV HBsAg Pap Rubella Syphillis Gonorrhea/Chlamydia Urine culture
2 blood stuffs, 4 virus stuffs, 3 bacterial stuffs
Labs typically obtained at first prenatal visit
2 blood stuffs, 4 virus stuffs, 3 bacterial stuffs
Type and screen
CBC
HIV
HBV HBsAg
Pap
Rubella
Syphillis
Gonorrhea/Chlamydia
Urine culture
TF
Routinely screen folate levels in preggys
TF
Routinely give folate supplementation to preggys
F - only screen if megaloblastoc anemia
T - always supplement regardless of level
When to screen for gestational diabetes with ogtt
At or after 24 weeks
GDM gets a 2nd-3rd trimester screen
When to stop pap screening if all prior paps have been normal
Age 65
Primary amenorrhea and anosmia think Pathophys Anatomy Karyotype Tx
Kallman syndrome
Pituitary GnRH deficiency
Normal anatomy (uterus, vagina, ovaries, etc)
46XX normal karyotype
Estrogen and Progesterone supplementation
47XXX phenotype
Normal phenotype, may never be diagnosed
47XXY
Syndrome
Phenotype
Klinefelter syndrome
Tall lanky male phenotype with small testes
Leuprolide is a ___ analog
GnRH analogue
TF
Oophorectomy for Kallman’s
F
Just supplement axis with E and P or maybe from the top woth GnRH
(Kallman’s is GnRH insufficiency in setting of normal everything else)
Leaving ovaries in is not a cancer risk like leaving undescended testes in
When is gonadectomy performed for testicular feminization
After completion of puberty
(Testosterone that cannot be converted into active 5-DHT will be converted into estrogen instead and female secondary sex traits will develop – just amenorrhea because no upper vagine uterus or tubes because mullerian inhibiting factor killed those back as a fetus)
How does testicular feminization commonly present
Pathophys
Amenorrhea
Testosterone that cannot be converted into active 5-DHT will be converted into estrogen instead and female secondary sex traits will develop – just amenorrhea because no upper vagine uterus or tubes because mullerian inhibiting factor killed those back as a fetus
why tah+BSO for endometrial cancer in PMP woman
because endometrial carcinoma is an estrogen-responsive tumor and there may be mets even if remove uterus, so remove ovaries (a potential source of estrogen even though post-menopausal)
what is the staging process for endometrial cancer in a postmenopausal woman
CT
completed via paraaortic lymph node dissection and peritoneal wash during TAH+BSO
TF
radical hysterectomy includes resection of omentum
T
stages of endometrial cancer and corresponding general tx guidelines
stage I: contained by myometrium - TAH+BSO
stage II: subserosal? TAH+BSO and radiation
stage III: local mets - TAH+BSO and chemo/radiation
stage IV: A - beyond uterus bowel bladder, B - distant – chemo +/- radiation/debulking
which female hormone is protective against endometrial cancer
PROgesterone is Protective against endometrial cancer
when do ovaries pathologically overproduce estrogen enough to increase risk of endometrial cancer
granulosa-theca tumor
POCS (anovulation so less progesterone, more estrogen)
define menometorrhagia
menorrhagia (heavy) plus metrorrhagia (irregular)
prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal. It is thus a combination of menorrhagia (heavy) and metrorrhagia (irregular)
otherwise healthy woman with menometorrhagia and endometrial hyperplasia without atypia on biopsy, tx? hysterectomy? OCP?
cyclical progestin
reserve hysterectomy for atypia… too much risk to surgery for just hyperplasia
OCP prevents hyperplasia, but too late when hyperplasia already present
indication for endometrial ablation
- for endometrial hyperplasia?
- for endometrial atypia?
only in women with uterine bleeding before menopause who are done having kids but in whom the biopsy ins normal
- not for endometrial hyperplasia - can burn in developing cancer such that cancer is hidden on future biopsies
- not for atypia for same reason and also just do hysterectomy for atypia (or cyclical progestin if premenopausal and wants more kids… I think…)
TF
tamoxifen is a treatment for uterine cancer
F
it causes uterine cancer
Irregular periods leading to amenorrhea and positive bleeding with progestin test think…
related pathophys
PCOS
Oligo-anovulation… no luteal/progesterone phase, just estrogen endometrium buildup without differentiation and scheduled sloughing so only sloughs less frequently when outgrows blood supply
chemo regimen for endometrial cancer
pac splat dox
paclitaxel doxorubicin cisplatin
cyclophosphamide doxorubicin 5-fu in setting of OBGYN treats…
breast cancer
Adriamycin bleomycin vinblastine and dacarbazine a the chemo regimen for…
Hodgkin’s lymphoma
ABVD
most common cause of postmenopausal bleeding
most concerning cause of postmenopausal bleeding
vaginal atrophy
endometrial carcinoma
define hyperemesis gravidarum
BMP disturbance
1st 2 staps
severe nausea and vomiting leading to dehydration
hypokalemic hypochloremic metabolic acidosis
IVF and K
beta quant (quant beta hCG) to confirm cause (pregnancy, mole)
pelvic US
most dangerous cause of hyperemesis gravidarum
gestational trophoblastic disease i.e. hydatidiform moleor choriocarcinoma
How do you treat choriocarcinoma of the uterus?
low risk: methotrexate
high risk: EMA/CO (etoposide, methotrexate, and dactinomycin, cyclophosphamide and vincristine (Oncovin))
what distinguishes hyperemesis gravidarum from normal morning sickness
and what causes them
degree of metabolic and vital sign derangement
vomiting likely caused by elevated b-HCG
snowstorm on US and no fetal parts suggests what kind of molar pregnancy
complete mole
when to perform suction curettage vs dilation and curettage for mole/abortion
suction curettage for early gestation moles and abortions
dilation and curettage for second trimester
what is the role of CT scan in molar pregnancy
staging CHORIOCARCINOMA to inform surgical decision / therapy if this cancer arises AFTER the molar pregnancy is removed
what is the role of MTX in molar pregnancy
a treatment for CHORIOCARCINOMA if it arises AFTER the molar pregnancy is removed
incomplete mole is caused by how many sperm and how many eggs
2 sperm
1 egg
(Dispermy)
what type of molar pregnancy is caused by dispermy
incomplete mole
2 sperm, 1 egg
TF
karyotype of molar pregnancy is necessary to guide management
F
not necessary, but often obtained
how does dispermy occur
rarely, when two sperm enter egg at exactly the same time
how do incomplete moles present vs complete moles
just the same for the most part
-B-HCG too elevated for dates +/- hyperemesis gravidarum, size/date discrepancy, US shows snowstorm
but some fetal parts in snowstorm in incomplete mole
what is the cause of a complete mole
how many sperm, how many eggs
dyfunctional oocyte
1 sperm meets 1 dysfunctional egg (absent nucleus), sperm doubles own genetic content, can grow but non-viable
absence of barr bories is associated mostly with
Turner syndrome 46XO
maternal nondisjunction is associated mostly with
downs trisomy 21
high b-HCG with molar pregnancy makes high risk for ___ after removal
high risk of choriocarcinoma
molar pregnancy with bHCG 150,000 now 3,600 8weeks s/p suciton curettage lost to follow-up in interim no symptoms no period not compliant with OCPs
what is the risk to worry about
next step
next next step
management if risk becomes reality
risk for choriocarcinoma s/p gestational trophoblastic disease
repeat bHCG in a week, it has downtrended, make sure of this with 1 week repeat bHCG
repeat US if 1 week not downtrending
CT, suction curettage vs ex-lap, chemo
choriocarcinoma diagnosed, manage
CT, suction curettage vs ex-lap, chemo
choriocarcinoma with mets but no mass effect after normal pregnancy spontaneously aborted, treat
methotrexate, actinomycin D (standard)
+ cyclophosphamide (after pregnancy, elevated bHCG, or brain mets)
standard chemo for choriocarcinoma
additional agent and indications
standard methotrexate and actinomycin D
add cyclophosphamide if follows a normal pregnancy, bHCG elevated, or brain mets
indications for cyclophosphamide in chemo for choriocarcinoma
if follows a normal pregnancy, bHCG elevated, or brain mets
what is a positive GnRH stimulation test and what does it tell you in the setting of precocious puberty, e.g. tanner stage II axillary hair pubic hair and breast development with bone age 2 years ahead of stated age. Next step after positive GnRH stim test in this patient, differential, treatment, why treat
positive if exogenous GnRH elevates LH
tells you its a central issue
get MRI
- pituitary adenoma - resect
- “constitutional” if negative – aka idiopathic but maybe caused by diet or urban environement factor that stimulates axis early – continuous leuprolide (GnRH agonist) to stifle axis
treat to stave off early menarche which will compromise growth spurt
cause of “constitutional” precocious puberty
idiopathic but maybe caused by diet or urban environement factora that stimulates hormonal axis early
when to get abdominal ultrasound in workup of precocious puberty
what have your ruled out already
what are you looking for now
after negative GnRH stim test rules out central lesion (pituitary mass vs “constitutional” issue)
looking for peripheral lesion – ovarian or adrenal gland tumors
CAH with female masculinization what will be elevated in urine what is functional hormone is overproduced what hormone is upregulated in blood how to treat and reasoning
17-OH-progesterone elevated in urine
androgens overproduced
ACTH upregulated to try to get cortisol going
give prednisone (adrenalcorticoid) to suppress ACTH which is driving androgen production
T/F
prednisone and fludrocortisone for CAH with female masculinization or precocious puberty, why
F
prednisone only - suppress ACTH which is driving androgen production
prednisone + fludrocortisone for renal failure (AI, TB, Neisseria) with hypotension and electrolyte abnormalities, to support sugar and salt… not for precocious puberty
TF
bilateral adrenalectomy for CAH
F
would force hormone dependence when can be treated by prednisone to suppress the upregulated ACTH driving androgen production
why is ACTH elevated in CAH
no cortiosol negatively inhibitin
all the 17-OH-progesterone shunted into androgen production by 21-hydrozylase deficiency
risk factors, lab abnorms, radiologic findings in dysfunctional uterine bleeding
1st line treatment
2nd line addition
none – no risk factors, lab abnorms, radiologic findings in dysfunctional uterine bleeding, diagnosis of exclusion
OCPs
NSAIDS - vague prostaglandin effect on uterus reduces bleeding
TF
get coags for irregular periods that do not provoke anemia
F
not likely to be a bleeding/clotting disorder, those look more like menorrhagia (heavy but regular), not metorrhagia (irregular)
-give OCPs and add NSAID if necessary
when to get coags for uterine bleeding
if bleeding and can’t stop it
if menorrhagia suspicious of acquired bleeding disorder
how to NSAIDS treat uterine bleeding
a mysterious prostaglandin effect
when to give leuprolide for fibroids
routine?
to shrink Large fibroids prior to myomectomy
not routine, not necessary if fibroids small
how is endometriosis most commonly definitively diagnosed
ex-lap
typically clinically suspected but not usually evident on imaging and unconfirmed till ex-lap
classic physical exam finding in adenomyosis
next step
smooth, symmetric, enlarged uterus with soft consistency on bimanual exam
rule out cancer with a biopsy, though exam reassuring
leiomyosarcoma
common presentation and diagnosis
presents like fibroids and commonly diagnosed surgically while treating fibroids or if MRI distinguishes irregular invading borders on a fibroid-like mass
painful irregular heavy periods in 14yo, otherwise healthy normal doing well, most likely cause, pathogenesis
next step
if hemodynamically stable
if anemic
ddx if persists, next steps
anovulaiton - just common at extremes of menarche / menopause, FSH and LH getting their levels figured out (but no need to draw levels)
reassurance with follow-up if hemodynamically stable
coags if symptomatic anemia looking for von willebrand and hemophilia
consider endometrial pathology eg fibroids or cancer if persists – imaging, endometrial biopsy
DES exposure increases risk of
endometrial cancer
chemical risk factor
2 common presentations of endometrial cancer
DES exposure
obese woman with heavy periods
post-menopausal bleeding
fibroids are ___-responsive and get better with ____ ____ and ____
estrogen-responsive
better with OCPs, pregnancy, menopause
how to check if advanced maternal age mom has ovarian reserve to ovulate
check inhibin-B level – decreases with age
38yo w enlarged uterus that has a prominent smooth posterior mass on bimanual exam
likely dx? next step(s)?
likely fibroids
(smooth… not symmetric)
pelvic ultrasound to decrease supsicion of cancer, followed by biopsy if ultrasound equivocal or if pt age ^45
when to get endometrial biopsy for large uterus with assymetric smooth mass on bimanual exam
after ultrasound if ultrasound equivocal for fibroid vs cancer
or in any woman ^45yo… cancer risk high
bimanual exam in endometriosis
normal typically
TF
CT with IV contrast is good for GYN pathology
general use indications
F
not usually for GYN - uterus bladder ovaries etc small and tight down there in pelvis, and radiation to these organs not great for young patients
maybe used for staging cancer once found
much better for abdominal pathology
