Gynecology Flashcards
Describe the difference between nonspecific pediatric vulvovaginitis and foreign body related pediatric vulvovaginitis
Nonspecific - accounts for 75% of cases - irritant, non-purulent w/ vulvar irritation
Foreign body - malodorous, purulent, blood tinged
Define early pregnancy loss. What are the US criteria of early pregnancy loss?
Non-viable intrauterine pregnancy with either an EMPTY gestational sac (anembryonic gestation) or with a fetal pole with no heartbeat before 13 weeks.
US criteria:
- CRL >= 7mm with no FHT
- MSD >= 25mm with no embryo
- Absence of embryo with FHT 11 days after yolk sac + gestational sac
- Absence of embryo with FHT 14 days after gestational sac alone
What are the US findings of a complete abortion
Absence of gestational sac and EMS measuring <30mm (7-14 days after medical management)
What are the screening guidelines regarding discontinuing mammograms?
No universal consensus; talk to your patient. Continue to advise yearly screening if life expectancy >10 years, otherwise reasonable to discontinue after 70-75yo. Should still offer it yearly
What are the different efficacies for emergency contraception? Include BMI cut offs.
- Copper IUD most effective (pregnancy rate <0.1%, no BMI cut off)
- Ulipristal (Ella) - BMI <35 only (pregnancy rate 0.9-2.2%)
- Plan B (BMI < 26), pregnancy rate 0.6-3%
When do patients need an evaluation for primary amenorrhea? When is pubertal development abnormal? What are you first few steps in evaluation?
- No menarche by 15
- No menarche within 3 years of thelarche
- No thelarche by age 13
* *Determine is breasts or any other secondary sexual characteristics are present
* *Check a FSH
* *Determine if a uterus is present
What are the lab criteria for diagnosis of APLS?
- Lupus anticoagulant present
- Anticardiolipin antibody IgG or IgM in 99th percentile
- Anti-B2-Glycoprotein IgM or IgG in 99th percentile
* Need one of the above to be present on two or more occasions, 12wk apart
What are the Amsel criteria? What are they used to diagnose?
Need 3 out of 4 criteria for bacterial vaginosis diagnosis: 1. Abnormal vaginal discharge; 2. Vaginal pH > 4.5; 3. Positive amines or +Whiff test; 4. Clue cells
When do you treat BV?
What are all the treatment options for BV? When do you do suppression therapy
Only when symptomatic OR in pregnancy Flagyl 500mg twice daily x 7 days Metrogel x 5 days Secnidazole 2g x once Treat w/ suppression if more than 3 episodes in 12 months
How do you follow CIN2/3 after a LEEP or excision?
Negative - cotest in 6 months
Positive - colpo/ECC at 4-6 months OR consider re-excision (don’t have to do re-excision right away)
How do you distinguish post-embolization syndrome vs endometritis?
Post-embolization syndrome - pain/fever/nausea/malaise (self limited) after UAE, peak 1-2 days after procedure, resolves within 7 days
Endometritis - 1% of cases after embolization (fever, pelvic pain, purulent vaginal discharge, CMT, uterine tenderness) - can occur days-weeks after procedure
Where is Palmer’s point?
3cm below the middle of the left costal margin
How do you manage an AGC pap?
Colposcopy + ECC
If >= 35 then needs endometrial biopsy
When should HIV positive women get pap smears?
Should get within 1 year of initiating sex OR within 1 year of HIV diagnosis if already sexually active OR by age 21
–> Need 3 consecutive yearly normal cytology and then can increase to q3 years
What is the best way to test for Lynch syndrome on an endometrial cancer?
Direct tumor testing is preferred for Lynch syndrome evaluation because it is inexpensive and helps determine need for further germ line testing
- Lynch syndrome excluded if all 4 mismatch proteins are present
- If MLH1 not present then need to check for promoter methylation
What is the needle stick transmission rate after HIV and Hep C?
Hep C needle stick - 1.8%
HIV needle stick - 0.3%
Who are candidates for thrombophilia screening?
- Personal hx of VTE
- First degree relative with thrombophilia
- First degree relative with VTE before the age of 50 in the absence of other risk factors
What is the definition of recurrent UTIs and how do you manage them?
Recurrent UTIs: 2 or more UTIs in 6 months or 3 or more UTIs in a year
Recommended rx is daily suppression w/ antibiotics OR for post-coital symptoms to only do post-coital ppx
What do you do after a rape trauma? How many times/often should you check HIV? When do you give PEP. What is PEP comprised of?
After a rape - emergency contraception, flagyl 2g, azithromycin 1g, ceftriaxone 250mg x 1, STI testing
Check HIV at 6wk, 3mo, 6mo
Post exposure ppx (PEP) not recommended if >72hr from assault (not effective); if within 72hr, should give for 28 days
PEP includes = emtricitabine, tenofovir, raltegravir
PrEP (pre-exposure) is only emtricitabine and tenofovir
What is bazedoxifene and what is it used for? What is the advantage of it?
SERM with conjugated equine estradiol for vasomotor si/sx but also rx for postmenopausal osteoporosis (progestins are not needed for endometrial protection). Helps w/ hot flashes and bones without the side effect of endometrial hyperplasia
What are examples of electrolyte poor media? What is their max fluid deficit allowed?
Glycine, sorbitol, mannitol (maximum deficit is 1000mL)
*Good to use with monopolar energy, but have to be careful with fluid overload. Can cause hyponatremia/cerebral edema quickly
Can you use HRT on a patient who is HIV+
Should avoid simultaneous use of HRT and patient on HAART therapy (the estrogen can inactivate the anti-retroviral meds)
**Same is true for CDC MEC criteria for combined hormonal contraception for women who are HIV+ on anti-retrovirals
How do you treat PID (outpatient)? What is the recommended treatment in someone who is PCN allergic?
When do you consider INPATIENT treatment and what is it? When do you consider IR consultation?
Ceftriaxone IM + doxy/flagyl x 14 days
PCN allergic: Levofloxacin daily + flagyl BID for 14 days
Inpatient: cefotetan OR cefoxitin with doxycycline
Consider if: pregnancy, TOA, severe nausea/vomiting, failed outpatient treatment, severe clinical status
IR consult for drainage if TOA and no clinical improvement in 48hr (then high risk for rupture and sepsis)
What is the myoma classification system?
Submucosal fibroids - Type 0 (pedunculated intracavitary), Type 1 (<50% intramural), Type 2 (>50% intramural)
Other - Type 3 (100% intramural but contacts endometrium), Type 4 (intramural), Type 5 (<50% subserosal), Type 6 (>50% subserosal), Type 7 (subserosal pedunculated)
What are alternatives to estrogen replacement therapy to treat hot flashes (what are MOA, which ones are FDA approved)
Clonidine - centrally acting alpha 1 agonist (<40% reduction in hot flashes compared to placebo; adverse effects of dry mouth/insomnia/drowsiness)
Gabapentin - reduces by 45-70%, anticonvulsant, can cause somnolence/drowsiness. Good if patient has sleeping disturbance and nighttime awakening.
Paxil - FDA approved (7.5mg), SSRI, 40% reduction. Good for those with concurrent mood disorders. AVOID IF ON TAMOXIFEN.
Venlafaxine (SNRIs) - Effexor - also good if concurrent mood problem
What are criteria for screening for hemostatic disorders?
- Heavy menstrual bleeding since menarche
- One of the following - hx of postpartum hemorrhage, surgery related bleeding, bleeding associated w/ dental work
- Two or more of the following - bruising 1-2x per month, epistaxis 1-2x per month, frequent gum bleeding, family hx of bleeding symptoms
What is VWD? How do you test for it? How do you treat it?
What are the different types of von Willebrand disease and their inheritance patterns?
Inherited bleeding abnormality where platelets cannot stick together and cannot form clot (vWF is a carrier protein for factor VIII)
Test with vWF antigen, vWF activity, factor VIII level
CONFIRMATORY TEST - ristocetin platelet aggregation test
Type 1 - autosomal dominant, quantitative
Type 2 - autosomal dominant, qualitative
Type 3- autosomal recessive, severe disease
Treat w/ desmopressin (DDAVP) synthetic analog of vasopressin which promotes release of vWF from storage sites
What is the mechanism of action of Lysteda?
Binds to the lysine binding site on tissue plasminogen activator (TPA); reduces plasma lysis of fibrin (anti-fibrinolytic), stabilizes intrauterine clot, reduces bleeding by 50%
What are the diagnostic clinical criteria for precocious puberty? What is on your differential diagnosis? How do you determine central vs peripheral cause?
<6 years old with breast development OR pubic hair development
<8 years old with BOTH
Central - idiopathic/constitutional (75%), CNS pathology
Peripheral - ovarian tumor, adrenal disease, McCune-Albright syndrome, exposure to estrogen (meds)
You test with the GnRH stim test (give lupron and if LH rises >6 it confirms central cause
If Central cause - do brain imaging
If peripheral cause - test for adrenal or ovarian cause (CT abdomen/pelvis) and test DHEA-S and 17-OHP
What is McCune Albright syndrome? What is the genetics of it?
Trifecta syndrome of cafe au lait spots, precocious puberty, and fibrous dysplasia of bones causing easy fracture
Caused by a DE NOVO mutation of GNAS1 gene (NOT passed down, no inheritance pattern)
What is the definition of primary amenorrhea?
13yo with no period and no secondary sexual characteristics
15yo with secondary sexual characteristics but no period
When is outright referral to REI indicated?
- 35yo and trying for 6 months
- Age > 40yo
- Known infertility conditions
- Patient with known/suspected tubal disease or peritoneal disease; stage 3-4 endometriosis
- Known/suspected male factor
- Oligomenorrhea
What are the normal semen analysis parameters?
> 1.5mL ejaculate, >15mil concentration
4% morphology, 40% motility
Absent agglutination
32% progressive motility
When do you do salpingectomy INSTEAD of a salpingostomy (aka salpingostomy is contraindicated)
Ruptured ectopic, tube severely damaged, other tube appears normal, future fertility is not desired, the ectopic pregnancy is in a setting of a failed sterilization, prior ectopic in same tube (aka damaged tube), hemorrhage
