Gynae Flashcards
Name the Disorders of Sexual development
Complete AIS
Mullerian a-genesis
Transverse Vaginal Septum
Turner syndrome
Name the Disorders of Sexual development in which breast developed and presence of pubic/axillary hair
Breast developed in all except TURNER syndrome
Pubic /Axillary hair in all except Complete AIS
How to approach Primary Amenorrhea?
Start with checking uterus On Pelvic U/S
-If present——>check FSH—>if increased do karyotype Or it decreased—>MRI
How to approach primary Amenorrhea with absence of uterus on Pelvic U/S?
Check Karyotype and Serum testosterone
- If XY and normal serum level—-> AIS
- If XX—->Mullerian agensis
Important Point of Primary Amenorrhea
- Isolated amenorrhea with well-developed 2* sexual characters may be considered normal up to age 16 yrs
- Amenorrhea without proper development of 2* sexual characters—work-up should not be delayed beyond age 14
Triad of AIS
Management is —->(1) Gender identity and assignment counselling
(2) patient has undescended test for which Removal of GONADs to prevent malignancy
Un descended testis with absence of penis/scrotum
No axillary and pubic hair but breast formation
Increase Testosterone and LH
Why breast developed in AIS?
Due to testosterone aromatisation into oestrogen result breast developmental
Triad of 5-α REDUCTASE DEFICIENCY
Ambiguous genitalia in Male at birth
No abnormality in internal genitalia
No breast development
How does AROMATASE DEFICIENCY present?
virilization In both transient mother and baby with normal internal genitalia
How does LICHEN PLANUS present?
glazed, brightly erythematous lesions on the vulva with erosive (eg, ulcerated) areas.
How does LICHEN SCLEROSIS present on examination?
WHITE vulvar plaque with loss of labia minora
Vulvar dryness with intense pruritus
Perianal figure of 8 involvement
No involvement of VAGINA
How to dx LICHEN SCLEROSIS?
DX::: Clinical but “punch biopsy” of lesion for definitive dx and to rule out malignancy.
It is premalignant for vulvar squamous cell CA
How to manage LICHEN SCLEROSIS?
high potency topical steroids e.g. clobetasol
vulvoperineoplasty (not vulvectomy) If refractory to medication OR developed severe adhesions/scarring
How does ATROPHIC VAGINITIS present on examination?
Painful Sex due to decrease Vaginal diameter
Loss of Vaginal elasticity/Rugae
Thin vulvar skin with loss of minora
Vulvovgainal dryness
How to manage ATROPHIC VAGINITIS(also called GU syndrome of menopause)?
Vaginal Moisturiser and lubricant as first line
Low dose vaginal ESTROGEN as 2nd line
How does CONDYLOMATA LATA present on examination?
Due to 2*Syphilis
Broader base with flatter surface
lobulated or plaque like
How does CONDYLOMATA ACUMINATA present on examination?
Multiple pink Or skin coloured lesion
Exophytic / cauliflower like growth Or smooth flattened papule
How to prevent CONDYLOMATA ACUMINATA ?
Prevention—>Vaccination / Barrier contraception
How to t/m CONDYLOMATA ACUMINATA?
Chemical—>Podophyllin resin /Trichloroacetic acid (for smaller lesion)
Immunologic—>Imiquimod
Surgical—>Cryotherapy/ laser therapy/ Excision (for larger lesion)
How does VULVAR INTRAEPITHELIAL NEOPLASIA present on examination? (DUE TO HPV)
White or erythematous plaques
hyperpigmented lesions or multifocal verruciform lesions
not atrophic changes.
Name the risk factors for Vulvar cancer
Follows HPV infection (e.g. VIN)
OR
vulvar dystrophies (e.g. lichen sclerosis)
How does VULVAR cancer present?
Typically singular, fleshy lesion on labia majora that may bleed
More common in postmenopausal women
Difference B/W SCC AND Clear Cell adenocarcinoma
SCC::
occur above 60 yrs at upper 1/3rd of posterior vaginal wall
Adenocarcinoma
Occur below 20 years at Upper 1/3rd of A nterior vaginal wall
Risk factors of Vaginal Cancer
SCC:::
HPV 16/18
Hx of cervical dysplasia or cancer
Cigarette
Adenocarcinoma:::
DES exposure in utero life
How Vaginal Cancer present?
Malodorous discharge
Irregular mass with plaque OR ulcer on vagina
What are the risk factors of VESICOVAGINAL FISTULA?
Pelvic surgery / Radiation
GU malignancy
Prolong labour / Childhood trauma
How to dx VESICOVAGINAL FISTULA?
Dye tests
cystourethroscopy
(S’times small area of granulation tissue OR hole may be seen)
How vesicovaginal fistula present?
continuous clear vaginal leakage
dx through bladder dye testing
Triad of Vaginismus / GENITO-PELVIC PAIN/PENETRATION DISORDER
Painful sex and pain occur with any vaginl penetration
Occur due to pelvic muscle contraction
Pain is unrelated to menses
How to manage VAGINISMUS/GENITO-PELVIC PAIN/PENETRATION DISORDER?
Treatment includes relaxation Kegel exercises (to relax the vaginal muscles)
And insertion of dilators with a gradual ↑ in size, fingers, etc. to bring about desensitization
What is the function of HUMAN PLACENTAL LACTOGEN?
insulin antagonist effect
plays an important role in nutrition of the fetus by causing maternal lipolysis and insulin resistance thus increasing delivery of fatty acids and glucose to the fetus.
Define INFERTILITY?
Primary infertility:
failure to conceive after a year of unprotected, timed sexual intercourse in nulliparous woman <35 years.
In >35 years, infertility investigation can begin after 6 mo.
Test to dx infertility due to PID
hysterosalpingogram
laparoscopy with chromotubation to check patency of Fallopian tubes
Triad of PRE-MENSTRUAL SYNDROME OR PRE-MENSTRUAL DYSPHORIC DISORDER
Sx begin 1-2wks prior to menses and regress around the time of menstrual flow.
Sx are then absent until after next ovulation
SSRI such as fluoxetine is the first line treatment
What are the causes of Dysmenorrhea?
F-PEAD
F fibroids
P primary dysmenorrhea / Pelvic Infection
Endometriosis
ADenomyosis
Triad of primary dysmenorrhea
Occur due to Prostaglandins release from endometrium causing contractions
Normal examination findings
NSAIDs OR COCP as a first line agent
Triad of Pelvic congestion syndrome
pelvic pain occur prior to menses
Decrease by end of menses
increase with intercourse OR during long periods of standing
What are the causes of ACUTE ABDOMINAL/PELVIC PAIN IN WOMEN?
PROME night
P PID R ruptured ovarian cyst O ovarian torsion M Mittelschmerz Ectopic pregnancy
How does rupture Ovarian cyst present?
Sudden onset U/L abdominal pain with N/V
Occur following strenuous or sex
U/S shows free fluid near ovarian cyst
How to manage rupture Ovarian cyst?
Uncomplicated cyst rupture:: conservative
-Complicated cyst rupture: Unstable pt or significant hemoperitoneum—>SURGERY
Why Mittelschmerz pain Occur?
Due to enlargement of developing follicle which irritates peritoneum
How to approach ECTOPIC pregnancy?
Check Hemodynamic stability
If unstable—>stat surgery
If stable—>do TV U/S—>shows adnexal mass—>treat Ectopic pregnancy OR intrauterine pregnancy
IF TV U/S is non dx in suspect case of Ectopic pregnancy?
Check B-HCG—>If less than 1500–> re check in 2 days
-If more than 1500 recheck and do TV U/S in 2 days
What are the risk factors for OVARIAN TORSION?
Ovarian mass
Reproductive age female
Infertility t/m with ovulation induction
Triad of OVARIAN TORSION
Severe sudden U/L pelvic pain
with or without signs of peritonitis
Adnexal mass with absent Doppler flow to ovary
How to manage OVARIAN TORSION?
Laparoscopy with de torsion
Ovarian cystectomy
Oophorectomy if necrosis OR malignancy
Lab findings of PCOS
Increase oestrogen and testosterone
Increase LH/FSH ratio
Triad of Functional Hypothalamic Amenorrhea
SxS of oestrogen deficiency
1st line treatment: cut down stressor and exercise intensity
if fails—>pulsatile GnRH considered
Important Point
ANOVULATION IN 1ST YEAR OF MENARCHE normal to have as immature HPO axis
Triad of ANOVULATION SECONDARY TO MORBID OBESITY
Normal FSH and LH level
Ovaries produce oestrogen
No progesterone at normal post ovulation so no menses after
What are the risk factors OR causes of Premature Ovarian failure?
chemotherapy / radiation,
mumps/ oophoritis
autoimmune ovarian failure (associated with autoimmune conditions like DM1 Hashimoto’s thyroiditis, Addison’s disease and pernicious anemia),
Turner’s syndrome /fragile X syndrome
Important Point Premature Ovarian failure
Markedly increase FSH in menopausal range (defined by lab assay) in a woman under 40 with >/=3 mo of amenorrhea confirm diagnosis of premature ovarian failure—
no need to wait for 1 year to make dx to prevent osteoporosis at young age
Define AUB
Menstrual bleeding that is prolonged (>5 days) and heavy (>1 pad every 2 hours) with an irregular frequency
T/m of Acute AUB
High dose Oral OR IV oestrogen
High dose COCP
High dose progestin pills
Tranexamic acid
Emergency dilation and curettage may be needed if medical treatment fail after 24-36 hours
What are the causes of AUB?
If post menopausal—> endometrial Ca or hyperplasia—>do TV U/S or bc
If pre menopausal—>Fibroids / ADenomyosis/ endometrial Ca or hyperplasia
Physical Examination findings of ENDOMETRIOSIS
Immobile uterus with normal size non tender
Cervical motion tenderness with adnexal mass
Uterosacral ligament nodules
US finding of Endometriosis
Unilocular hypoechoic adnexal mass
low level echoes
How to manage ENDOMETRIOSIS?
Medical—>NASIDS with or without COCP
Surgery—>if medical CI then laparoscopy or removal of uterus if family completed
How to dx and manage fibroids?
SxS signs depends on position
Dx-> U/S
T/m—> if Asymptomatic do nothing
If symptomatic—>COCP or myomectomy, uterine artery embolization /hysterectomy
Important Point of ADenomysis
Typically in multiparous women > 40 years
-Repeat endometrial biopsy after 3 mo to assess response to rx (IN ENDOMETRIAL HYPERPLASIA)
How to Approach AUB due to ENDOMETRIAL HYPERPLASIA?
Take bx
-If shows—>hyperplasia without atypia—->progestin therapy
-if shows—> hyperplasia with atypia—->progestin therapy if desire of pregnancy
OR no desire/fail medical t/m—-> remove uterus
What are the indications of HPV vaccine?
Not indicated in pregnant female
Women age 9-26 years
Immunocompromised patient age 9-26 years
Boy age 9-21 years (upto 26 years men who are homosexual)
Cervical Cancer screen approach
Start at age 21
-Cytology every 3yrs age —>21-29 and 30-65years
Cytology + HPV testing every 5 years—>30-65 years
Cervical Cancer screening in Immunocompromised
Onset of sexual intercourse
Every 6 months * 2 then annually
What are the result of PAP smear?
Cytology= PAP smear
atypical squamous cells
low grade squamous intraepithelial lesion LGSIL)
high grade squamous intraepithelial lesion (HGSIL)
overtly malignant cells (squamous cell CA)
How to MANAGED ATYPICAL SQUAMOUS CELLS OF UNDETERMINED SIGNIFICANCE OR
LOW GRADE SQUAMOUS INTRAEPITHELIAL LESION IN WOMEN 21-24 YEARS?
Repeat PAP smear at 12 months
Shows—->If ASC-H OR AGC OR HSIL——> colposcopy
How to MANAGED ATYPICAL SQUAMOUS CELLS OF UNDETERMINED SIGNIFICANCE OR
LOW GRADE SQUAMOUS INTRAEPITHELIAL LESION IN WOMEN 21-24 YEARS?
PART 2
Repeat PAP smear at 12 months
If shows—->negative OR ASC-US OR LSIL
-Repeat Pap smear again at 12 months—>if shows—->ASC—->do colposcopy
If negative PAP smear negative—-> routine screening
How to MANAGE ATYPICAL SQUAMOUS CELLS OF UNDETERMINED SIGNIFICANCE OR
LOW GRADE SQUAMOUS INTRAEPITHELIAL LESION IN WOMEN >25 YEARS (Pap smear showed)
ASC-US—>HPV testing—> if positive—->do colposcopy
If negative—-> repeat PAP smear and HPV testing in 3 years
How to MANAGED HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION (HGSIL)?
If age 21-24 years—->do colposcopy
- if shows CIN 2/3 or NO CIN 2/3 age above 25—->manage per guidelines
- if shows no CIN 2/3 age 21-24—>repeat colposcopy and cytology 2times up-to 2 years
How to MANAGED HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION (HGSIL)?
If age more than 25 years ——> LEEP OR Cryotherapy
But not in postmenopausal and pregnant patients
What to do if the colposcopy result is unsatisfactory Or un-visualise T-junction?
Do endocervical curettage
but not done in pregnancy as risk of miscarraige and preterm delivery
What are the pap smear results which need endometrial evaluation?
VERY HY HY
Atypical glandular cells favor neoplastic-»> in all females
Atypical glandular cells-»> at age 35 years OR at risk for endometrial hyperplasia OR postmen female
Benign appearing endometrial cells-»> if premen female with AUB or risk for endometrial hyperplaisa
How to approach CIN3?
if no pregnancy-»> LEEP or conization or cryoablation
follow up with PAP smear and HPV co-testing
What is the indication of the cervical conization?
CIN 2 OR 3
What are the complications of cervical conization?
Cervical stenosis
Preterm birth or PPROM
2nd trimester pregnancy loss
Cervical incompetence
How to approach non invasive cervical cancer?
if negative surgical margins-»> f/u with PAP smear and HPV co-testing
if positive surgical margins-»> repeat Conization if pregnancy desire OR remove uterus if no pregnancy desire
What are the factors which decreases the ovarian cancer?
BSO
Breastfeeding
Oral COCP use
Tubal ligation
Age less than 30 at first live birth
U/S findings of EPITHELIAL OVARIAN CANCER
Solid mass
Thick septations
Ascites
Physical examination findings of Ovarian cancer
may present with firm, non-mobile pelvic mass with nodularity
Important point of ovarian cancer
Image guided biopsy is CONTRAINDICATED—>can cause spread of cancerous cells to entire abdominal cavity
How to evaluate adnexal Mass in post menopausal patients?
If ovarian mass on U/S—->check CA-125
-if elevates—->CT/MRI check mets
-if no elevated——>check malignant features—>if present—> CT/MRI check mets otherwise serial US and CA-125
Define Epithelial ovarian Cancer
Epithelial ovarian cancer:
refers to malignancy involving ovary, fallopian tube and peritoneum epithelium.
Abnormality can begin at any of these sites—>presents with hallmark large ovarian mass, and widespread pelvic and abdominal mets regardless of primary origin
How to manage Ovarian cancer?
Exp-laparotomy
After —>Chemotherapy with platinum based agents
US finding of serous ovarian Ca
complex mass with solid component
No calcification
hyperechoic
Emergency contraception in terms of efficacy
COPPER IUD»>Ulipristal pill»» LEVONORGESTREL pill»»OCP
MOA of Ulipristal
Antiprogestin—> delay ovulation
Important point of COPPER IUD
MOST EFFECTIVE emergency and long-term contraception
Used in breast cancer patient as copper is hormone free
What are the benefits of ORAL CONTRACEPTIVE PILLS (OCPS)?
Prevention of pregnancy/ ovarian and endometrial cancer
Reduce benign breast diseases
Menstrual regulation with reduction in iron deficiency anaemia
What are the CI of Oral COCP?
Migraine with aura
Past hx of Stroke / IHD / venous thromboembolism
Chain smoker and age above 35
Cancer Of Breast / liver
Cirrhosis
Major surgery with protracted immobilisation
Less than 3wk postpartum
What Contraception can be used in lactating mothers?
Sterilization OR Barrier method
Intra-uterine devices
Progestin only pills
Important Point of contraception in lactating mothers
Combined OCPS: ↓ milk production and pass in milk—effect on infant unknown
What are the adverse effects of SELECTIVE ESTROGEN RECEPTOR MODULATOR?
Hot flashes
Venous thromboembolism
Ca or hyperplasia if tamoxifen use
Important point Tamoxifen
Post-menopausal: 2nd line—prescribed to those who cannot use aromatase inhibitors.
What SIDE EFFECTS OF DIETHYLSTILLBESTROL if USE IN PREGNANCY?
Clear cell adenocarcinoma of the vagina and cervix
Ectopic pregnancy and pre term delivery
Infertility
Structural abnormalities of female reproductive tract
What complications occur in Male if DES is used?
Complications in boys exposed to DES in utero:
cryptorchidism,
microphallus,
hypospadias,
and testicular hypoplasia
How to approach NIPPLE DISCHARGE?
If U/L—>patho—>U/S or Mammography if above 30yrs
or
If bloody Or serous discharge—-> patho—>U/S or Mammography if above 30yrs
How to approach Milk non bloody nipple discharge?
Check palpable lump OR skin changes——>if yes—-> patho—>U/S or Mammography if above 30yrs
If NO—->physiologic discharge
Important Point of physiologic Galactorrhea
Typically milky or clear but can be yellow, brown, gray or green
What are the causes of PHYSIOLOGIC GALACTORRHEA?
HP MC
H hyperprolactinemia / Hypothyroidism
P Pit-prolactinoma / Pregnancy
M med
C Chest wall/nipple stimulation
How to approach PALPABLE BREAST MASS in age above 30 years?
Start with mammogram/US—->if malignant features—->Core biopsy
How to approach PALPABLE BREAST MASS in age less than 30 years?
Start with U/S first/mammogram
-If simple cyst—> needle aspiration
-If complex cyst/mass (solid mass)—-> image guided core biopsy
US findings of SIMPLE BREAST CYST
USG: shows acoustic enhancement (indicative of fluid)
and no echogenic debris or solid components
What type of biopsy use in breast masses?
Core biopsy if solid / acellular (stromal)
Excisional bx if large Or suspicious mass
FNA if suspected cystic or small mass
What are the d/f BENIGN BREAST DISEASES ?
3F B
Breast cyst
Fibrocystic changes
Fibroadenoma
Fat necrosis
Name the benign breast diseases which shows U/L single mobile well circumscribed mass
- Fibroadenoma if tenderness prior to menses
- Breast cyst-> could be tenderness
Describe Fibrocystic changes on Ex Ian bases
Nodulocystic masses
Multiple and diffuse
With tenderness prior to menses
Triad of Fibroadenoma
Seen in less than 30 yrs of age
U/L single mobile well
circumscribed mass
Painful prior to menses
How to manage fibroadenoma?
How to manage fibroadenoma?
Re-examine in next cycle—size decreases in adolescents—>observations and reassurance
U/S if persistent mass Or seen in old age
Triad of Fat necrosis
Seen post trauma / surgery
Fixed irregular mass
Mammography / US and Bx findings of Fat necrosis
Mammography —>calcifications
US—-> hyperechoic mass
Biopsy—> fat globules and foamy histiocytes
Breast biopsy shows fat globules and foamy histiocytes in which condition?
Fat necrosis
What are the risk factors for breast cancer?
Modifiable:::
Nulliparity / HRT
Alcoholic / Increase age at first birth
-Non modifiable:::
Cancer in 1st degree relative / white race
Increase age / Early menarche Or late menopause
Important point of breast cancer t/m
Echo before proceeding for Trastuzumab
Triad of Inflammatory breast cancer
Itching and palpable mass with nipple changed
edematous cutaneous thickening
peau d’orange appearance
How to manage OCP induced HTN?
Discontinued the meds—->still persist—->diet and exercise—->still on —>low dose thiazides
MOA of OCP induced HTN
estrogen mediated increase in hepatic angiotensinogen synthesis or other effects on renin-angiotensin system
How theca lutein cyst present?
B/L multilocular cyst in ovaries
U/S FINDING OF TUBO OVARIAN ABSCESS
multiloculated cystic adnexal mass
How urethral diverticulum present?
Due to outpouching which collect urine
Palpable tender mass on the anterior vaginal wall
Associated with purulent discharge
Risk factor of the Pelvic organ prolapse
Obesity
Removal of uterus
Multiparity
Postmenopausal age
How bartholin abscess present?
Abscess located at the b/l posterior vulvar vestibule
At the base of labia majora (4’ and 8’ clock)
How to manage bartholin duct cyst / abscess?
if symptomatic-» I and D followed by word catheter placement
otherwise no treatment if asymptomatic
How skene gland cyst present?
located at lateral to urethral meatus
How urethral prolapse present?
Inflamed friable tissue
Donut shaped at the urethral meatus
Triad of Ovarian Hyperthecosis
virilization seen in postmenopausal female
sign of insulin resistance
Normal or decrease LH and FSH
U/S presentation of Ovarian
Hyperthecosis
Solid appearing enlarged ovaries
What is the in hospital treatment of PID?
1) IV Cefotetan OR Cefoxitin with docxi
or
2) IV Clindamycin with gentamicin
Important point
Evaluate renal tract if patient has mullerian agenesis
How to dx turner syndrome?
Start with karyotype—-»if negative but high suspicion—»FISH
How vulvodynia (vestibulodynia) is present?
Painful sex due to sharp burning
pain on the vulvlar vestibule
Triggered by touch
Show redness in vestibule
Name the test done in vulvodynia?
Q tip test
US finding of Mature cystic teratoma
Partially calcified
Thin echogenic band
US finding of endometrioma
Homogeneous cystic mass with no solid component
US finding of serous ovarian Ca
complex mass with solid component
No calcification
hyperechoic
US doppler finding of ovarian hyperstimulation syndrome
B/L enlarged ovaries with increased vascular permeability
US finding of complex cystic breast mass
echogenic debri
thick septa
solid component
How Recurrent cystitis is present in females?
More than 2 infections in 6 months OR more than 3 infections in year
Risk factors of Recurrent cystitis
Sex active postmenpausal?
First UTI <15 years
spermicide use
How to manage Recurrent cystitis?
Take prophylactic ABx after coitus
Triad of Vaginismus
Painful sex and pain occur with any vaginal penetration
Occur due to pelvic muscle contraction
Pain is unrelated to menses
What to evaluate in sexual assault?
physical and forensic Ex
Psychological assessment
What are the consequences of sexual assault?
PTSD
Unintended pregnancy
STI
How to manage sexual assault?
Emergency contraception
Post exposure ABx to prevent STI
Psychosocial counselling
What are the pap smear results which need endometrial evaluation?
VERY HY HY
Atypical glandular cells favor neoplastic-»> in all females
Atypical glandular cells-»> at age 35 years OR at risk for endometrial hyperplasia OR postmen female
Benign appearing endometrial cells-»> if premen female with AUB or risk for endometrial hyperplaisa
What to do if the colposcopy result is unsatisfactory Or un-visualise T-junction?
Do endocervical curettage
but not done in pregnancy as risk of miscarraige and preterm delivery
How to approach CIN3?
if no pregnancy-»> LEEP or conization or cryoablation
follow up with PAP smear and HPV co-testing
What is the indication of the cervical conization?
CIN 2 OR 3
What are the complications of cervical conization?
Cervical stenosis
Preterm birth or PPROM
2nd trimester pregnancy loss
Cervical incompetence
How to approach non invasive cervical cancer>
if negative surgical margins-»> f/u with PAP smear and HPV co-testing
if positive surgical margins-»> repeat Conization if pregnancy desire OR remove uterus if no pregnancy desire
Triad of Ovarian Thecoma
seen in postmenopausal females
Thickness of endometrium due to estrogen
no virilization
Important point
actinomycosis which colonizes intrauterine devices
may cause PID
What are the contraindications of COPPER IUD?
Acute pelvic infection
wilson diseases
complicated organ transplant failure
severe uterine cavity distortion
Important point
medroxyprogesterone avoided in female who doesn’t want weight gain
Important point
Unexplained AUB is contraindication to IUD
Name the IUD avoided in anemia
Copper IUD
Name the IUD which given in anemic patient and also not causing weigh gain
Progesterone IUD
What contraceptives are given in postpartum?
Non hormonal viz copper and progesterone IUD preferred in less than 1 month postpartum and breastfeeding
Name the contraceptive given in breast cancer patient
Copper IUD
rest are all contraindicated
Treatment approach of menopause
If mild vasomotor sx-»behavioral modification
severe vasomotor sx-»give non hormonal therapy SSRI if estrogen is contraindicated
How to give estrogen in postmenopause female if its not contraindicated?
Intact uterus—> give Estrogen and progesterone
no uterus—> only estrogen
How Gartner duct cyst present?
appear along the lateral aspect of the upper vagina anterior
Don’t involve vulva
COMMON PROBLEMS RELATED TO LACTATION
Remember MEAN PG
M mastitis
E engorgment
A abscess
N nipple injury
P plugged duct
G galactocele
Name the COMMON PROBLEMS RELATED TO LACTATION
MEAN PG
M Mastitis
E Engorgement
A Abscess
N Nipple Injury
P plugged duct
G Galactocele
Triad of Breast Engorgement
B/L symmetrical fullness
without fever and erythema
Tender and warm
Triad of Mastitis
U/L breast tenderness
With fever and erythema
Firm red swollen quadrant
How to manage lactational Mastitis?
–Methicillin sensitive S. aureus: dicloxacillin or cephalexin
–If MRSA risk factors exist (e.g. recent antibiotic therapy, residence in long-term care facility, incarceration): clindamycin, TMP-SMX, or vancomycin
Triad of Galactocele
Afebrile
Mobile Non tender mass well circumscribed
Subareolar
Triad of Plugged duct
No fever
Focal tenderness
Firmness and erythema
Clinical features of Nipple Injury
Abrasion, cracking, bruising blistering from poor latch
Triad of Breast abscess
features of mastitis
fluctuant, tender, palpable mass
needle aspiration of breast abscess under ultrasound guidance and antibiotics as first line t/m —>if not resolved—->incision and drainage (eg surgical drainage) with packing are recommended
Why PID is uncommon in pregnancy?
Cervical mucus plug protect the uterus from ascending infection
How to approach cyclic breast Pain which is b/L and diffuse?
If mass on examination–>Imaging
-If no mass on examination—->observed
How to approach non cyclic breast Pain which is U/L and focal?
If mass on examination—>bx and surgery consult
If no mass O/E—>imaging—>mass do bx and if no mass just observed
Important point of cyclic breast pain
Due to hormonal changes and pain occurs 2 week before menses and subsides with the onset of menses
How to manage Cyclic breast pain?
Reassurance in most cases
If symptomatic—> supportive bra And NSAIDs
D/f b/w Simple and complex Breast cyst findings
Simple—>Thin wall fluid filled (anechoic) without solid or echogenic debri
Complex—>Thick wall sepated with solid and cystic component
How to manage Complex Breast cyst?
Biopsy
How to manage SIMPLE breast cyst?
If Asymptomatic—> Obs
If sxs FNA
How to manage Symptomatic SIMPLE breast cyst?
Do FNA
A) If bloody aspirate—> Bx and imaging
B) If non-bloody aspirate—>if cyst resolve—>no management further OR if persist or Recurrent—> bx and imaging
How to approach Pre menopausal Adenxal mass?
(1) Start with U/S and pregnancy test —-> if negative rule out ectopic pregnancy
(2) Malignant features on U/S???—-> Yes then surgery
If not —->Conservative management and repeat U/S after 6 wks
How to Manage Migraine In pregnancy?
NI—-> no improvement
Non pharma like rest —->NI—-> Acetaminophen
Still NI—->Antiemetics/codeine/caffeine
Still NI —-> NASID like naproxen only in 2nd trimester
Still NI —-> Opioid
Important point of Treatment of migraine in pregnancy
Metacolon used only acutely
Ergotamine is not used due to hypertonic uterine contractions and Vasoconstriction
Triptans Also not used due to above reason and LBW / Preterm birth.
What are the complications of Oligohydramnios?
Preterm delivery
Umbilical cord compression
Meconium aspiration
What are the causes of Polyhydraminos?
C MADE
C congenital infection M multiple gestation A anencephaly D duodenal atresia / DM E esophageal atresia
What are the complications of Polyhydraminos?
PPROM
Preterm labor
Umbilical cord prolapse
Fetal malposition
How to Approach HSV infection in pregnancy?
(a)Past hx of HSV?—-> No —-> Cont prenatal care
If yes—->Give antiviral at 36 wk
(B) If active lesion /prodromal sxs during labor??—> Yes —-> do C/sec
If no —-> Vaginal delivery
What are the causes of Hirsutism?
N-PICA
Non classic 21-hydrox deficiency
P PCO
I Idiopathic Hirsutism
C Cushing syndrome
A androgen secreting ovarian tumor / ovarian hyperthecosis
Triad of Idiopathic Hirsutism
Hirsutism
Normal menstruation
Normal androgen level
Triad of Non classic 21-hydrox deficiency induced Hirsutism
Hirsutism
Increase 17 hydroxy Progesterone
Sxs mimic like PCO
Name the cause of Hirsutism which also show virlization
Cushing syndrome
A androgen secreting ovarian tumor / ovarian hyperthecosis
What are the features of Virlization?
Male pattern baldness viz temporal hair loss
Increase muscle bulk
Clitoromegaly
Change of voice
Define 2nd stage of Labor arrest
No fetal descent after pushing for more than 3 hrs in nulliparous
Or
More than 2hrs in multiparous
T/m is C-sec Or operative vaginal delivery
What factors would lead to 2nd stage of Labor arrest?
Factor which increase women BMI
Like DM / Excessive Wt gain / Obesity
What are the causes of 2nd stage of Labor?
MIC
M malposition of fetus // Maternal exhaustion
I insufficient contractions
C cephalopelvic disproportion
Triad of Ovarian Thecoma
AUB due to Estrogen
Seen in post menopausal
Do not cause virlization
Define Secondary Amenorrhea
1) No menses for more than 3 month with prior “REGULAR” Menses
OR
2) No Menses for more than 6 months with Prior “IRREGULAR” Menses
How to approach Secondary Amenorrhea/AUB?
Regardless of Age Do B-Hcg
If age below 45 —>Do FSH, TSH and prolactin if pregnancy test came out negative
If age above 45 —>no need of FSH, TSH and prolactin if pregnancy test came out negative
What are the risk Factor of Vulvovaginal candidasis ?
DM
Increase estrogen
Immunosuppression.
Menopause Decrease the risk due to low estrogen
Important point of Benign breast disease
Both fibrocystic and fibroadenoma have cyclic pre menstrual tenderness
but former have multiple nodulocystic mass and later have single firm mobile solitary mass
How to manage polyhydraminos?
1) Severe symptomatic preterm polyhydraminos—->aminoreduction as there is chance of preterm labor and PPROM
2) mild asymptomatic term doesn’t need treatment
What is the category 3 FHR?
delivery the baby stat
If CTG shows:
1) Sinusoidal pattern
2) absent Variability with late or variable decelerations
3) absent Variability with bradycardia
How to approach category 3 FHR?
Initial step is re-position mother with O2, IV fluid and stop utero tonic agents
Failed—–> C-sec stat or Vaccum assisted delivery if Cervix is 10 cm dilate.
Important point of BPP
It is not useful in Intra partum period as BPP will not change the status of patient
It would delay the intervention
Triad of Candidal mastitis
Seen in Diabetic 2 and Obesity patient
Shiny flaky areolar rash
Shooting pain
Dx via KOH skin scraping
How Intertrigo present?
1) Macerated plaques b/w inflammatory fold
2) Satellite lesion
3) Seen in DM2 AND Obesity
Triad of Acute fatty liver of Pregnancy
RUQ pain
Low PLT with deranged LFT
Low glucose
How to manage acute fatty liver of Pregnancy?
Immediate delivery
Triad of Pseudocyesis
Sxs like pregnancy
-Ve pregnancy test in hospital though!!
US shows empty uterus with thin endometrium
How to manage Pseudocyesis?
Kinda somatization so need psychiatric evaluation
Patient had hx of infertility and pregnancy loss
Name the condition which shows abscess located at the posterior vulvar vestibule Or at the base of labia majora (4th and 8th clock)
Bartholin abscess
Name the condition which shows cyst along the lateral aspect of the upper vagina without involvement of VULVA
Gartner duct cyst
Name the condition which shows vulvar white plaque worth dryness and intense pruritus with loss of labia minora
No involvement of vagina
Lichen sclerosis
Name the condition which shows painful sex with decrease vaginal diameter
Loss of vaginal elasticity or Rugae
Atrophic vaginitis
Name the condition which shows Exophytic Or cauliflower like growth Or smooth flattened papule
Condylomata acuminata
Name the condition which shows fleshy lesion in vulva which may bleed and seen in post menopausal female
Vulvar cancer
Name the condition which shows white or reddish plaques and Hyper-pigmented lesion Or multi focal verruciform lesions
Without atrophic changes
Vulvar intra epithelial neoplasia due to HPV
What are the indications for hospitalisation for PID?
If patient unable to tolerate oral meds or non compliant to meds
Very severe presentation or developed complications of PID like TOA or perihepatitis
Pregnancy
Failed outpatient treatment
What are the Risk factors of Endometrial hyperplasia / cancer?
KTONE (K = C)
All due to early Oestrogen
Chronic Ovulation Or PCOS
T tamoxifen use
O obesity
N Nulliparity
E early menarche or Late menopause
What does meant by FHR tracing category 1?
Baseline HR (110-160) with moderate variability (6-25/min)
No late / variable deceleration
With or without (early decelerations)
With or without (acceleration)
What are the contraindications of progestin IUD and copper IUD?
U-PAGED
U unexplained vaginal bleeding
P pregnancy
A acute pelvic Infection like PID of cervicitis
G GTD
E endometrial and cervical cancer
D distorted endometrial cavity
