Gynecology Flashcards
1
Q
Painful menstruation that affects normal activities
A
Dysmenorrhea
2
Q
Primary dysmenorrhea is not due to ________ but is due to increased ___________
A
Not due to pelvic pathology
Due to increased prostaglandins
Painful uterine muscle wall activity
3
Q
Secondary dysmenorrhea is due to __________, such as
A
Pelvic pathology Endometriosis Adenomyosis Leiomyomas Adhesions PID
4
Q
Most common secondary cause of dysmenorrhea in younger patients. Most common secondary cause of dysmenorrhea in older pts
A
Endometriosis - younger
Adenomyosis - older
5
Q
Diffuse pelvic pain right before or with onset of menses. May be associated with HA, n/v. Cramps usually last 1-3 days
A
Dysmenorrhea
6
Q
Management of dysmenorrhea
A
NSAIDs first line
Local heat and vitamin E
Ovulation suppression - OCPs, etc.
Laparoscopy if medication fails to ro secondary causes
7
Q
Absence of menstrual periodd
A
Amenorrhea
8
Q
Light flow or spotting
A
Cryptomenorrhea
9
Q
Heavy or prolonged bleeding at normal menstrual intervals
A
Menorrhagia
10
Q
Irregular bleeding between expected menstrual cycles
A
Metorrhagia
11
Q
Irregular, excessive bleeding between expected menstrual cycles
A
Menometrorrhagia
12
Q
Infrequent menstruation with a prolonged cycle length > 35 days but < 6 mo
A
Oligomenorrhea
13
Q
Frequency cycle interval (< 21 days)
A
Polymenorrhagia
14
Q
Two etiologies of dysfunctional uterine bleeding (DUB)
A
- Chronic anovulation
2. Ovulatory
15
Q
Cause of chronic anovulation
A
Unopposed estrogen
Seen especially with extremes of age
16
Q
Workup of dysfunctional uterine bleeding includes:
A
- pelvic exam
- Hormone levels
- Transvaginal US
17
Q
Management of acute severe bleeding with DUB
A
High dose IV estrogens or high dose OCPs
18
Q
Management of anovulatory DUB
A
OCPs first line
Progesterone if estrogen CI
19
Q
Definitive treatment for DUB
A
Hysterectomy - done if not responsive to medical treatment
Endometrial ablation - can be done if hysterectomy not wanted
20
Q
Workup for amenorrhea
A
Pregnancy test
Serum prolactin
FSH, LH, TSH
21
Q
Primary amenorrhea
A
Failure of menarche onset by age 15 y/o in the presence of secondary sex characteristics or 13 y/o in the absence of secondary sex characteristics
22
Q
Secondary amenorrhea
A
Absence of menses for > 3 months in a pt with previously normal menstruction
23
Q
Etiologies of secondary amenorreha
A
- Pregnancy (MC)
- Hypothalamus dysfunction
- Pituitary dysfunction
- Ovarian dysfunction
- Uterine disorder
24
Q
Presence of endometrial tissue (stroma and gland) outside the endometrial (uterine) cavity. The ectopic endometrial tissue responds to cyclical hormonal changes
A
Endometriosis
25
Most common site for endometriosis
Ovaries
| Also: posterior cul de sac, broad and uterosacral ligaments, rectosigmoid colon, bladder
26
Risk factors for endometriosis
Nulliparity
Family history
Early menarche
27
Signs/Symptoms of endometriosis
1. Cyclic premenstrual pelvic pain
2. Dysmenorrhea (painful menstruation)
3. Dyspareunia (painful intercourse)
4. Infertility
+/- low back pain
28
Diagnosis of endometriosis
Physical exam: normal, +/- fixed tender adnexal masses
| Laparoscopy with biopsy - definitive treatment
29
Endometriosis involving the ovaries large enough to be considered a tumor, usually filled with old blood appearing chocolate-colored
Endometrioma (chocolate cyst)
30
Management of endometriosis
1. Medical - ovulation suppression
OCPs + NSAIDs as needed
Leuprolide
Danazol (testosterone)
2. Surgical - laparoscopy with ablation or hysterectomy if no desire to conceive
31
Occur when follicles fail to rupture and continue to grow
Follicular ovarian cysts
32
Occurs when corpus luteum fails to degenerate after ovulation
Corpus luteal ovarian cysts
33
Excess hCG causes hyperplasia of the theca interna cells
Theca Lutein ovarian cyst
34
Signs/symptoms of ovarian cysts
Most are asymptomatic until they rupture, undergo torsion or become hemorrhagic
Menstrual changes, dyspareunia
35
Diagnosis of ovarian cysts
Pelvic US
| Order hCG to r/o pregnancy
36
Smooth, thin-walled unilocular ovarian cyst on ultrasound
Follicular
37
Complex, thicker-walled with peripheral vascularity ovarian cyst on ultrasound
Luteal
38
Management of ovarian cysts
Most < 8 cm are functional and spontaneously resolve
NSAIDs, repeat US after 6 weeks
OCPs
Surgical intervention if > 8 cm or cysts found postmenopause
39
Two etiologies of vaginitis
1. Infectious (bacterial, trichomoniasis, candida, cytolytic)
2. Atrophic (postmenopausal, allergic rxn)
40
Copious discharge, watery grey-white "fish rotten" smell from vagina
Bacterial vaginosis
41
Malodorous discharge, frothy yellow green vaginal discharge, strawberry cervix
Trichomoniasis vaginosis
42
Thick curd-like/cottage cheese vaginal discharge
Candidiasis vaginosis
43
Non odorous vaginal discharge that is white to opaque
Cytolytic vaginosis
44
Diagnosis of bacterial vaginosis
```
Whiff test (fishy odor)
Microscopic: epithelial cells covered with bacteria
```
45
Diagnosis of trichomoniasis vaginosis
Mobile protozoa on wet mount, WBCs
46
Diagnosis of candidiasis vaginosis
Hyphae, yeast and spores on KOH prep
47
Diagnosis of cytolytic vaginosis
Copious lactobacilli, large number of epithelial cells
48
Management of:
1. Bacterial vaginosis
2. Trichomoniasis
3. Candidiasis vaginosis
4. Cytolytic vaginosis
1. Metronidazole or Clindamycin
2. Metronidazole or Tinidazole
3. Fluconazole, intravaginal antifungals
4. Discontinue tampon usage, sodium bicarbonate (sitz baths)
49
Ascending infection of the upper reproductive tract (may lead to sepsis, ectopic pregnancy or infertility)
Pelvic inflammatory disease
50
Most common causes of PID
N gonorrhea
| Chlamydia
51
People at increased risk of PID
```
Multiple sex partners
Unprotected sex
Prior PID
Age 15-29
Nulliparous
IUD placement
```
52
Pelvic/lower abdominal pain, dysuria, dyspareunia, vaginal discharge, nausea, vomiting
PID
53
Lower abdominal tenderness, fever. Purulent cervical discharge, +/- bleeding
PID
54
Cervical motion tenderness to palpation and rotation so severe they seem to rise off the bed
Chandelier sign
| PID
55
Diagnosis of PID
1. Primarily clinical
2. Obtain hCG to r/o pregnancy
3. Gram stain, WBC > 10,000
4. Pelvic ultrasound if abscess suspected
5. Laparoscopy if uncertain, severe disease or if no improvement with antibiotics
56
Management of outpatient PID
Doxycycline + IM ceftriaxone
57
Management of inpatient PID
IV doxycycline + cefoxitin or cefotetan
58
Complications of pelvic inflammatory disease
```
Fitz-Hugh Curtis Syndrome
Infertility
Tubo-obarian abscess
Ectopic pregnancy
Chronic pelvic pain
```
59
Hepatic fibrosis/scarring and peritoneal involvement. RUQ pain due to perihepatitis. May radiate to right shoulder. Often have normal LFTs. Violin string adhesions on anterior liver surface
Fitz-Hugh Curtis Syndrome
| Complication of PID
60
Inflammation of the breast
Mastitis
61
Seen mostly in lactating women secondary to nipple trauma
Infectious mastitis
62
Most common bacterial etiologies of infective mastitis
Staph aureus
Strep
+/- Candida
63
Signs/Symptoms of infective mastitis
```
Unilateral breast pain
Tenderness
Warmth
Swelling
Nipple discharge
```
64
Signs/Symptoms of congestive mastitis
Bilateral breast pain and swelling
Low grade fever
Axillary lymphadenopathy
65
Management of infective mastitis
Supportive measures (warm compresses, breast pump)
Anti-staphylococcal abx: Dicloxacillin, nafcilllin, cephalosporin
Fluconazole if fungal
Mothers may continue to nurse/breast pump
66
Management of congestive mastitis
If woman does not want to breastfeed: ice packs, tight fitting bras, analgesics, avoid breast stimulation
If women wants to breastfeed, manually empty breast after baby is done, local heat, analgesics
67
Management of breast abscess
I&D
| Discontinue breastfeeding from affected breast
68
Termination of pregnancy before __________ is classified as spontaneous abortion. Most commonly during first ________ weeks.
20 weeks
| 7 weeks
69
__________ is the only type of spontaneous abortion that is associated with possible fetal viability
Threatened
70
Most common cause (50%) of all cases of spontaneous abortion
Fetal chromosomal abnormalities
71
Most common cause of first trimester bleeding
Threatened spontaneous abortion
72
Signs/symptoms of threatened spontaneous aboriton
No products of conception expelled
Cervical os is closed
Bloody vaginal discharge, spotting progressing to profuse blood
73
Signs/symptoms of inevitable spontaneous abortion
No products of conception expelled
Progressive cervix dilation > 3 cm
+/- rupture of membranes
Moderate bleeding > 7 days, cramping
74
Signs/symptoms of incomplete spontaneous abortion
Some products of conception expelled, some retained
Cervical os dilated
Heavy bleeding, cramping, boggy uterus
75
Signs/symptoms of missed spontaneous abortion
No products of conception expelled
Cervical os closed
Loss of pregnancy symptoms, +/- brown discharge
76
Signs/symptoms of septic spontaneous abortion
Cervical os closed
Cervical motion tenderness
Foul brownish discharge, fevers, chills, uterine tenderness, spotting progressing to heavy bleeding
77
Abruptio placenta is premature separation of the placenta from the uterine wall after __________ gestation
20 weeks
78
Signs/symptoms of abruptio placenta
Mild: slight bleeding
Partial: moderate bleeding
Complete: heavy bleeding and increased risk to fetus and mother
Severe abdominal pain, painful contractions, rigid uterus
79
Fetal signs during abruptio placenta
Fetal bradycardia - fetal distress due to interference with fetal oxygenation
80
Diagnosis of abruptio placenta
Pelvic ultrasound
| DO NOT perform pelvic exam
81
Management of abruptio placenta
Hospitalization - for hemodynamic stabilization
| Immediate delivery - C section preferred
82
Complications of abruptio placenta
May lead to DIC (disseminated intravascular coagulation)
83
Risk factors for abruptio placenta
```
Maternal HTN (MC)
Smoking
EtOH
Cocaine
Increased age, trauma
```
84
Implantation of fertilized ovum outside of the uterine cavity
Ectopic pregnancy
85
Most common location of ectopic pregnancy
Fallopian tube (98%)
86
Risk factors for ectopic pregnancy
```
Previous abdominal or tubal surgery (due to adhesions)
PID
Previous ectopic
History of tubal ligation
Endometriosis
```
87
Signs/Symptoms of ectopic pregnancy
Unilateral pelvic/abdominal pain
Vaginal bleeding
Amenorrhea (pregnancy)
Severe abdominal/shoulder pain (peritonitis)
88
Signs/Symptoms of ruptured ectopic pregnancy
Severe abdominal pain, dizziness, nausea, vomiting
| Signs of shock: syncope, tachycardia, hypotension
89
Physical exam signs of ectopic pregnancy
Cervical motion tenderness
Adnexal mass
Mild uterine enlargement
90
Diagnosis of ectopic pregnancy
1. hCG (serum)
2. Transvaginal ultrasound
3. Culdocentesis - nonclotted blood present (not done often)
4. Laparoscopy
91
hCG trends
Should double q 24-48 hours
92
Absence of gestational sac with hCG levels > _________ strongly suggests ectopic or nonviable intrauterine pregnancy
> 2000
93
Management of unruptured/stable ectopic pregnancy
Methotrexate
| Used if hCG < 5000, no fetal tones
94
Contraindications for methotrexate
```
Ruptured ectopic
History of TB
hCG > 5000
+ fetal heart tones
Noncompliant
```
95
Management of ruptured/unstable ectopic pregnancy
Laparoscopic salpingostomy
Laparotomy in severe cases
RhoGAM administration if mother Rh negative and unsensitized
96
Most common 2 causes of third trimester bleeding
Abruptio placentae
| Placenta previa
97
```
Abruptio = ____________
Previa = ____________
```
```
Abdominal pain (usually severe)
Painless
```
98
Abdominal placenta placement on or close to the cervical os
Placenta previa
99
Partial placenta previa
Covering of cervix ahead of fetal presenting part
100
Complete placenta previa
total coverage of cervical os
101
Sudden onset of painless bleeding (bright red) at 20-30 weeks. Resolves within 1-2 hours
Placenta previa
102
Fetal heart rate with placenta previa
Usually normal - no fetal distress
103
Diagnosis of placenta previa
Pelvic ultrasound to localize placenta - DO NOT perform pelvic exam
104
Management of placenta previa
Hospitalization - for stabilization
Stabilize fetus - magnesium sulfate - inhibits uterine contraction
Amniocentesis - to fetal lung maturity. Steroids given between 24-34 weeks
Delivery when stable
105
Risk factors for placenta previa
Multiparity
Increasing age
Smoking
106
Risk factors for premature rupture of membrarnes
STDs
Smoking
Prior preterm delivery
Multiple gestations
107
Diagnosis of premature rupture of membranes
1. Sterile speculum exam: visual inspection, pooling of secretions
2. Nitrazine paper test - if turns blue (pH > 6.5) - PROM likely
3. Fern test - amniotic fluid - fern pattern - PROM
4. Ultrasound - avoid digital exam
108
Management of premature rupture of membranes
Await spontaneous labor
| Monitor for infection (chorioamnionitis or endometritis)
109
During pregnancy, hCG should _______ every __________ days and will plateau at __________ gestation
Double
2-3 days
10 week gestation
110
Intrauterine pregnancy is seen after hCG quantity reaches about ________ (or at about _______ weeks gestation)
2,000
| 5 weeks gestation
111
Gravida
Total number of pregnancies (including abortions)
112
Parity
Total number of births (over 20 weeks gestation)
113
Naegele Rule
First day of LMP - 3 months + days + 1 year = conception date
114
If pt has irregular menstrual periods, Naegele's Rule should not be used, instead a __________ should be obtained for correct dating
US
115
Increase in plasma levels during pregnancy may lead to:
```
Hypotension
Increased cardiac output
Increased urinary frequency
Anemia
Increased GFR (decreased creatinine)
Edema
```
116
Increased progesterone levels during pregnancy may lead to:
Relaxes smooth muscles
GERD
Constipation
Hyperventilation
117
Increased levels of estrogen, fibrinogen, and procoagulation factors during pregnancy lead to:
Hypercoagulable state
118
Increased blood flow to nasopharynx during pregnancy leads to
Rhinorrhea
119
Frequency of scheduled visits for pregnancy
Every 4 weeks until 30 weeks gestation
Every 2 weeks until 36 weeks gestation
Every week until delivery
120
Each pregnancy visit should include (4)
1. BP check
2. Urine dipstick
3. Fundal height
4. Fetal heart rate (110-160 bpm)
121
Pts who are AMA (> 35) and/or those with abnormal genetic screening are at increased risk for fetal aneuploidy
Testing can be done with (3):
1. Chorionic villus sampling
(10-12 wks)
2. Amniocentesis (15-17)
3. Cell-free fetal DNA (mother blood - done after 10 wks)
122
First trimester is defined as __________ wks gestation
1-12
123
If uterine size on physical exam does not correlate with last menstrual period
US should be obtained
124
The fundal height (cm) should correlate to the number of weeks between:
20-36 weeks gestation
125
Fetal heart rate may be heard at _________ with transvaginal ultrasound
6 weeks
126
Fetal heart rate can be heard with hand held doppler at ________ gestation
12 weeks
127
All first trimester pregnant patients need:
1. Rhesus type and screen
2. CBC
3. Pap smear (only if due)
4. Rubella titer
5. Urinalysis
6. Urine culture
7. RPR
8. Hepatitis B antigen
9. Chlamydia screening
10. Gonorrhea screening
11. HIV
12. HgA1c
13. hCG quant
128
Pregnant pts with a HgA1c > ________ are diagnosed with DM
6.5%
129
Nuchal translucency ultrasound should be done from ________ wks gestation to r/o chromosomal abnormalities. This should be combined with first trimester serum testing (2)
11-13.6
PAPP-A (pregnancy associated plasma protein A)
hCG quant
130
Second trimester of pregnancy is defined as:
13-27 wks gestation
131
A quadruple screen should be done between 15-20 weeks gestation to screen for chromosomal abnormalities, including:
1. AFP
2. Unconjugated estriol
3. hCG
4. Inhibin A
132
Most common cause for an abnormal quad screen
Incorrect dating
133
Quickening (sensation of fetal movement) occurs between:
16-20 weeks gestation
134
Diabetes and anemia screening (CBC) should be done between __________ wks gestation. 2 DM screening options:
24-28 weeks
1. 75 g 2 hour (fasting) oral glucose tolerance test: only one abnormality is needed for diagnosis
2. 50 g 1 hour oral glucose tolerance test - not done fasting
If positive, over 140, pt should have 100 g 3 hour oral glucose tolerance test. Two abnormalities needed in 3 hour glucose challenge
135
Third trimester is defined as
28-40 wks gestation
136
If pt was found to be Rh negative, Rhogam prophylaxis should be administered at
28 weeks gestation (3rd trimester)
137
Vaccination that should be given to all pregnancies during third trimester
Tdap
138
If pt was found to have STD during initial screening, repeat testing is done during
Third trimester
139
GBS screening should be done at _________ wks gestation using a vaginal and rectal swab. If positive, prophylactic abx are given intrapartum
35-37 weeks gestation
