Lectures 2 Flashcards
Define spontaneous abortion
Loss of fetus in less than 20 weeks
Most common organisms responsible for PID
Gonorrhea, chlamydia
Then think of ascending infxns: so anerobes, GN/GB, GBS
Danazol
Indications
Danazol = synthetic steroid/androgen previously used in the tx of endometriosis
-largely replaced by GnRH agonists b/c of their masculinizing/virulizing effects
What time of the month are pts most likely to present w/ PID
Beginning of the cycle (like day 1 aka on first day of menstrual period)
-for some reason when the pain is the worst
How does obesity increase risk of endometrial hyperplasia
-obesity: adipose tissue contains aromatase => increased peripheral conversion of androgens to estrogens
Differentiate appearance of pt w/ PID 2/2 gonorrhea vs. chlamydia
Gonorrhea- more ill appearing, usually more tender, higher fever, thicker discharge
Chlamydia- less severe, discharge thinner/more watery
Prevalence of ectopic pregnancy
(a) How does it change if have previous ectopics?
1% overall
(a) 10% if had one previously
25% if had 2+
Differentiate which part of puberty estrogen and testosterone are responsible for in females
Estrogen = thelarche (breast development) Progesterone = pubarche (pubic hair)
Top 2 things on Ddx for postmenopausal bleeding
60-80% endometrial atrophy
10-15% endometrial cancer => hence all F over 45 w/ AUB get endometrial biopsy
Risk factors for vulvar neoplasms
- smoking
- age
- HPV, h/o abnormal pap
- lichen sclerosis** (thin white patches of skin)
- immunocompromised or immunsuppressed
- Paget’s disease (adenocarcinoma)
Gold standard tx for endometriosis
OCPs, specifically continual OCPs (no progesterone withdrawal bleed part)
Gold standard diagnostic test for endometriosis
Technically gold standard diagnostic tool is laparoscopic exploration w/ tissue biopsy
-but that’s pretty invasive so really just diagnosed clinically
Differentiate the two classifications of delayed puberty
- Hypergonadotropic hypogonadism = elevated FSH
ex: Turners, Mullerian agenesis, imperforate hyman - Hypogonadotropic hypogonadism = arcute nucleus not producing GnRH
- constitutional delay
Location of cervical cancer
Squamocolumnar junction- squamous outside and columnar inside
-squamocolumnar junction receds up the endocervical canal w/ age, as it recedes that’s where you get the transitional zone where metaplasia occurs
Difference in UA interpretation in pregnant women
Pregnant women can have + leukestrase w/o UTI, but nitrates is ALWAYS abnormal
-ketonuria in pregnancy can be 2/2 dehydration
Low threshold for treating UTI in pregnancy b/c pregnant women have higher incidence of asymptomatic UTI
32 yo F1 p/w positive urine pregnancy test at 9 4/7 and painless vaginal bleeding w/ chills
- T 101.5, HR 95, BP 95/60
- cervix closed on exam
- beta-hCG of 6500
- no fetus in gestation sac on US
Dx?
Tx
Septic abortion
= infectioned POCs
Tx- surgery, need to evacuate the uterus
Most common sit of endometriosis
Bilateral Ovaries
-ovarian endometrioma = chocolate cyst
2nd most common = posterior col de sac
Teen w/ ovarian mass
Buzzword for germ cell tumor
List in order the normal process of puberty in girls
Breast development (thelarche) –> Adrenarche –> Growth spurt –> Menarche
-20% of the time adrenarche comes before thelarche
Difference in risk profile from estrogen/progesterone therapy from only estrogen therapy
E/P has increased risk of 4: VTE, stroke, coronary heart disease, breast cancer
While just estrogen: increased risk of VTE and stroke (not of coronary heart disease or breast cancer)
Tx for gonorrohea
Ceftriaxone IM x1
+ Azithromycin to tx common chlamydia coinfection
-also tx partners
Describe the process of a D&C for termination of pregnancy
Paracervical block w/ or w/o mild IV sedation
- serial dilation of cervix
- then curretage out intrauterine material
Lupron- what is it?
Lupron = GnRH agonist
For hormone-responsive cancers and estrogen-dependent conditions (ex: endometriosis or uterine fibroids)
-can be given pre-op before myomectomy to decrease burden
Inpatient tx for PID
Cefotetan (cephamycin = type of cephalosporin) IV q12
+ Doxy IV q12
Treat until afebrile or clinically improved for 24 hrs, then switch to PO and monitor
Ddx of first trimester vaginal bleeding
spontaneous abortion
ectopic pregnancy
vaginal/cervical lesions or lacerations
extrusion of molar pregnancy
Risk factors for ectopic pregnancy
Fallopian tube scarring/damage
- h/o ectopic
- chlamydial infection
Smoking
ART (assistive reproductive therapy): IVF
Most common subtype of vulvar neoplasm
90% of vulvar neoplasms are squamous cell carcinomas (can be progression from VIN)
- 5% melanoma
- 5% other: Bartholin’s, Pagets (red and scaly)
Explain the mechanism of hypogonadotropic hypogonadism
Delayed puberty b/c arcuate nucleus doesn’t produce GnRH
Describe what it means for a pap smear to show a high-grade squamous intraepithelial lesions
cells on the pap smear suggest an abnormality that will be present from 2/3 to full thickness of the transitional zone
Ddx for acute abdominal pain in 25 yo sexually active female
- R/o ectopic pregnancy
- PID
- Appendicitis
- Torsion
- Ovarian Cyst
- Kidney stone
- R/o ectopic pregnancy
Clear cell adenocarcinoma
Buzzword for DES exposure
DES exposure in utero increased risk for ovarian clear cell carcinoma
Name 4 medication options to tx endometriosis
Want to cause deciduation of the endometrial lining
- OCPs = gold standard
- Progesterone- minipills, depot, IUP
- GnRH agonists (basically induce menopause so use transiently)
- Danazol- synthetic androgen to suppress FSH/LH release
Describe how endometriosis causes
(a) Pain
(b) Infertility
(a) Ectopic endometrial stroma/glands cause inflammation that build into adhesions and scarring
(b) Adhesions and occlusions => infertility
Checking progesterone on what day of the menstrual cycle would help confirm ovluation
Day 21
Name 2 etiologies of GnRH independent precocious puberty
GnRH independent precocious puberty = puberty not due to early activation of HPA axis, instead due to some form of peripheral estrogen production
- McCune Albright syndrome = ovaries producing estrogen w/o stimulation
- Granulosa cell tumor
Buzzword: uterosacral nodularity
Endometriosis
Physical exam findings of ectopic pregnancy
-Abdominal or adnexal tenderness
if ruptured- acute abdomen w/ rebound/guarding
-uterus small for gestational size (aka normal sized)
Etiology of GnRH dependent precocious puberty
GnRH dependent precocious puberty = early activation of the HPA axis
-most often idiopathic
Clinical presentation of ectopic pregnancy
Main features = vaginal bleeding + abdominal pain
Outpatient tx for PID
Ceftriaxone IM x1
+ Doxy PO BID x14 days
then RTC in 3 days for f/u
-need broad spectrum b/c of polymicrobial nature of PID infections 2/2 ascending vaginal infxn
What blood test is essential in every pt w/ any type of abortion
Type and screen!
Prevent autoimmunization if Rh- mother
First steps of management for woman of reproductive age who p/w vaginal bleeding
- beta-hCG
- if pregnant => vaginal ultrasound to determine location of pregnancy (ectopic of IUP)
- pelvic exam etc
56 yo nulligravid post-menopausal F p/w intermittent vaginal bleeding
Next step in workup
Transvaginal ultrasound to look at endometrial stripe- if under 4-5mm that’s thin and believe bleeding is 2/2 atrophy
If endometrial stripe isn’t thin => do endometrial biopsy
Contraindications to medical MTX tx for first semester abortion
- fetal cardiac activity (usually fetal heart beat seen around 6 weeks)
- beta-hCG over 5,000
- impaired renal fxn (MTX is renally cleared)
- elevated LFTs (MTX is directly hepatotoxic)
- HD unstable (b/c they’re ruptured => need surgery)
Surgical tx options for ectopic pregnancy
Salpingectomy vs. salpingostomy
Salpingectomy = removal of fallopian tube Salpingostomy = surgical unblocking of fallopian tube (remove pregnancy w/o removing the tube)- preserves fertility
What is Ashermna syndrome?
Intrauterine adhesions + symptoms (infertility, amenorrhea)
-syndrome 2/2 scar tissue development in the uterine cavity
Infertility if scarring prevents normal implantation
Amenorrhea/AUB when scarring prevents normal endometrial growth/shed
3 theories of the mechanism of endometriosis
- Retrograde menstrual flow (most likely)
- Vascular/lymphatic dissemination
- Coelomic metaplasia (from pleuripotent/undifferentiated cells in the peritoneum)
Name some RF for endometrial hyperplasia/carcinoma
- unopposed estrogen exposure: nulliparity, early menarche, late menopause
- age
- obesity: adipose tissue contains aromatase => increased peripheral conversion of androgens to estrogens
- Tamoxifen
- granulosa cell tumor of the ovary (secretes estrogen)
Overview of tx for ovarian cancer
Surgery, then chemotherapy: surgical b/c almost always diagnosed so late (stage III) so already have peritoneal disease
-often intraperitoneal chemo
Which method of ovarian stimulation is more likely to result in multiple gestations
Clomiphene citrate (SERM); 10% risk
GnRH: 25% risk of multiple gestations
16 yo G1P1 p/w severe lower abdominal pain, F/C/N/V, rebound tenderness
- purulent vaginal d/c
- b/l adnexal fullness
- GC, -RPR, WBC 17.6 w/ left shift
Dx
PID
Major criteria = abdominal/adnexal pain
+
Minor criteria = white count, fever
Explain how giving GnRH can suppress ovulation
FSH/LH respond to pulsatile GnRH, not continuous => if you give continuous GnRH it’ll suppress FSH/LH release
Mechanism of tx in endometriosis
Want to cause deciduation of the endometrial lining => use OCPs, progesterone, GnRH agonist (but only transiently b/c induces menopause)
Describe the staging of cervical cancer
Need to have a way to stage it worldwide (aka also in undeveloped countries) => cervical cancer is staged clinically
-staged w/ palpation: feel for parametrial involvement, CXR for pulm involvement
-in developed countries use CT/MRI to further characterize, but overall its clinical (physical exam) staging
Name 3 etiologies of hypergonadotropic hypogonadism
Hypergonadotropic hypogonadism = elevated FSH but no response => delayed pubrety
- Turners (XO)
- Mullerian agenesis
- Imperforate hyman
Hormone replacement therapy
a) 4 disadvantages (increased risk of…
(b) Decreases risk of 2 things
HRT (referring to both estrogen and progesterone)
(a) Increased risk of
1. breast cancer (only w/ both E/P)
2. stroke
3. VTE
4. coronary artery disease (only w/ both E/P, not E alone)
(b) Decreased risk of
1. colon cancer
2. fractures
Rate of progression of the dif types of endometrial hyperplasias to cancer
quarter, dime, nickel, penny
25% complex w/ atypia => cancer
10% simple w/ atypia => cancer
5% complex w/o atypia => cancer
1% simple w/o atypia => cancer
Differentiate the two classifications of precocious puberty
GnRH dependent (high LH)
vs.
GnRH independent (LH doesn’t increase w/ GnRH administration)
Mechanism of visualization in colposcopy
Acetic acid- use dilute acetic acid to make atypical cells turn white
How to equate the cytology and histology findings in cervical cancer
1/3 of the epithelium involved: LSIL, CIN I
2/3 of the epithelium involved: HSIL, CIN II and III
Concept of how to treat TOA
TOA = tubovarian abscess
Want to start w/ aggressive broad spectrum IV abx (cefotetan or cefoxitin + doxy)
-but may be hard for abx to penetrate TOA (b/c no blood supply and capsulated)
=> may need to surgically drain the abscess if abx don’t work
Differentiate the two classification systems used for cervical cancer
- Cytology- this is what you see on pap smears
- LSIL and HSIL - Histology- seen when you take biopsy of colposcopy
- CIN I, II, III
Why does uterine atony cause bleeding post-partum?
Uterine atony = lack of uterine tone
Uterine tone is needed for contractions to clamp down on the spiral arteries- so much vasculature, need to clamp down to stop the bleeding
Briefly describe the IVF process
- ovarian stimulation
- oocyte retrieval, done transvaginally
- fertilization of egg w/ sperm in petri dish (hence the in vitro)
- insertion of fertilized egg into uterus
Age at which you stop needing pap smears?
After 65 you can stop (and never restart!) if never had CIN II or worse
beta-hCG
(a) When does it peak?
(b) Peak level
(c) Level at term
beta-hCG (pregnancy hormone)
rule of 10s
(a) Peaks at abotu 100,000
(b) At 10 weeks of gestation
(c) About 10,000 at time of term fetus
Causes of spontaneous abortion
1st T most common i is spontaneous abortion
2nd T: maternal infection/anatomic abnormality, teratogen exposure, uterine malformation, trauma
-thyroid disease
-diabetes 2/2 poor vascularization
-antiphospholipid syndrome
Relationship btwn BMI and risk of osteoporosis
Low BMI have higher risk of osteoporosis- less body weight = less pressure being put on bones
Medical management of first trimester spontaneous abortion
Prostaglandings such as Misoprostol (cytotec) to
-contract uterus and open the cervix to expel POCs
Describe the details of administering a medical abortion
1-3 tablets of RU-486 (Mifepristone = progesterone antagonist to stop growth of pregnancy) given
Then 6-72 hrs later insert 4 tablets of misopristol (prostaglandin analogue to induce uteirne cramping and POC crampign) transvaginally
-pregnancy passes w/in 4-6 hrs of misopristol
Then F/u apt for US or beta-hCG to confirm completion
Possible consequences of untreated PID
- infertility 2/2 tubal scarring
- TOA
- chronic pain/adhesions
Most common location for ectopic pregnancy
95+% are in the fallopian tubes
-majority of which are located in the ampulla
Discriminatory zone of b-hCG and its relevance
Discriminatory zone 1500-2000
-level above which imaging scan should be able to se gestational sac w/in the uterus
So if b-hCG is >2000 and you don’t see gestational sac = high suspicion for ectopic, but if b-hCG is 1,000 and no gestation sac it’s still pregnancy of unknown location
Indication for continuous GnRH therapy
Continuous GnRH can be given to suppress ovulation in girls w/ precocious puberty
Leading cause of maternal death in the first trimester
Ectopic pregnancy
Buzzword: violin strings
Fitzhugh-Curtis = perihepatitis = adhesions from liver edge to anterior abdominal wall
-inflammation of liver capsule to adjacent periotneal surfaces
Buzzword: cervical motion tenderness
Buzzword for PID
Diagnostic criteria for PID
Need 1 major and 1 minor criteria (at least)
Major criteria: 1 of 2
- Cervical motion tenderness
- Adnexal/uterine tenderness
Minor
- fever
- WBC
- elevated CRP/ESR
Fitz-Hugh-Curtis syndrome
= Perihepatitis = inflammation of the liver capsule and adjacent periotoneal surfaces
- increased risk in PID
- adhesions from liver edge to anterior abdominal wall
‘Chocolate cyst’
Chocolate cyst = ovarian endometrioma
Purpose of HPV testing in pt w/ diagnosis of HSIL
In LSIL and HSIL pt is assumed to be HPV+
-especially if age 21-29: most likely that the patient is + if she’s sexually active, and high probability of clearing it on her own
