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OB/GYN > Lectures 2 > Flashcards

Lectures 2 Flashcards

1
Q

Define spontaneous abortion

A

Loss of fetus in less than 20 weeks

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2
Q

Most common organisms responsible for PID

A

Gonorrhea, chlamydia

Then think of ascending infxns: so anerobes, GN/GB, GBS

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3
Q

Danazol

Indications

A

Danazol = synthetic steroid/androgen previously used in the tx of endometriosis

-largely replaced by GnRH agonists b/c of their masculinizing/virulizing effects

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4
Q

What time of the month are pts most likely to present w/ PID

A

Beginning of the cycle (like day 1 aka on first day of menstrual period)
-for some reason when the pain is the worst

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5
Q

How does obesity increase risk of endometrial hyperplasia

A

-obesity: adipose tissue contains aromatase => increased peripheral conversion of androgens to estrogens

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6
Q

Differentiate appearance of pt w/ PID 2/2 gonorrhea vs. chlamydia

A

Gonorrhea- more ill appearing, usually more tender, higher fever, thicker discharge

Chlamydia- less severe, discharge thinner/more watery

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7
Q

Prevalence of ectopic pregnancy

(a) How does it change if have previous ectopics?

A

1% overall

(a) 10% if had one previously
25% if had 2+

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8
Q

Differentiate which part of puberty estrogen and testosterone are responsible for in females

A 
Estrogen = thelarche (breast development)
Progesterone = pubarche (pubic hair)
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9
Q

Top 2 things on Ddx for postmenopausal bleeding

A

60-80% endometrial atrophy

10-15% endometrial cancer => hence all F over 45 w/ AUB get endometrial biopsy

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10
Q

Risk factors for vulvar neoplasms

A
  • smoking
  • age
  • HPV, h/o abnormal pap
  • lichen sclerosis** (thin white patches of skin)
  • immunocompromised or immunsuppressed
  • Paget’s disease (adenocarcinoma)
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11
Q

Gold standard tx for endometriosis

A

OCPs, specifically continual OCPs (no progesterone withdrawal bleed part)

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12
Q

Gold standard diagnostic test for endometriosis

A

Technically gold standard diagnostic tool is laparoscopic exploration w/ tissue biopsy
-but that’s pretty invasive so really just diagnosed clinically

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13
Q

Differentiate the two classifications of delayed puberty

A
  1. Hypergonadotropic hypogonadism = elevated FSH
    ex: Turners, Mullerian agenesis, imperforate hyman
  2. Hypogonadotropic hypogonadism = arcute nucleus not producing GnRH
    - constitutional delay
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14
Q

Location of cervical cancer

A

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

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15
Q

Difference in UA interpretation in pregnant women

A

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

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16
Q

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

A

Septic abortion
= infectioned POCs

Tx- surgery, need to evacuate the uterus

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17
Q

Most common sit of endometriosis

A

Bilateral Ovaries
-ovarian endometrioma = chocolate cyst

2nd most common = posterior col de sac

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18
Q

Teen w/ ovarian mass

A

Buzzword for germ cell tumor

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19
Q

List in order the normal process of puberty in girls

A

Breast development (thelarche) –> Adrenarche –> Growth spurt –> Menarche

-20% of the time adrenarche comes before thelarche

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20
Q

Difference in risk profile from estrogen/progesterone therapy from only estrogen therapy

A

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)

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21
Q

Tx for gonorrohea

A

Ceftriaxone IM x1
+ Azithromycin to tx common chlamydia coinfection

-also tx partners

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22
Q

Describe the process of a D&C for termination of pregnancy

A

Paracervical block w/ or w/o mild IV sedation

  • serial dilation of cervix
  • then curretage out intrauterine material
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23
Q

Lupron- what is it?

A

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

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24
Q

Inpatient tx for PID

A

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

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25
Q

Ddx of first trimester vaginal bleeding

A

spontaneous abortion
ectopic pregnancy
vaginal/cervical lesions or lacerations
extrusion of molar pregnancy

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26
Q

Risk factors for ectopic pregnancy

A

Fallopian tube scarring/damage

  • h/o ectopic
  • chlamydial infection

Smoking
ART (assistive reproductive therapy): IVF

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27
Q

Most common subtype of vulvar neoplasm

A

90% of vulvar neoplasms are squamous cell carcinomas (can be progression from VIN)

  • 5% melanoma
  • 5% other: Bartholin’s, Pagets (red and scaly)
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28
Q

Explain the mechanism of hypogonadotropic hypogonadism

A

Delayed puberty b/c arcuate nucleus doesn’t produce GnRH

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29
Q

Describe what it means for a pap smear to show a high-grade squamous intraepithelial lesions

A

cells on the pap smear suggest an abnormality that will be present from 2/3 to full thickness of the transitional zone

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30
Q

Ddx for acute abdominal pain in 25 yo sexually active female

A
      1. R/o ectopic pregnancy
        • PID
        • Appendicitis
        • Torsion
        • Ovarian Cyst
        • Kidney stone
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31
Q

Clear cell adenocarcinoma

A

Buzzword for DES exposure

DES exposure in utero increased risk for ovarian clear cell carcinoma

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32
Q

Name 4 medication options to tx endometriosis

A

Want to cause deciduation of the endometrial lining

  1. OCPs = gold standard
  2. Progesterone- minipills, depot, IUP
  3. GnRH agonists (basically induce menopause so use transiently)
  4. Danazol- synthetic androgen to suppress FSH/LH release
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33
Q

Describe how endometriosis causes

(a) Pain
(b) Infertility

A

(a) Ectopic endometrial stroma/glands cause inflammation that build into adhesions and scarring
(b) Adhesions and occlusions => infertility

34
Q

Checking progesterone on what day of the menstrual cycle would help confirm ovluation

A

Day 21

35
Q

Name 2 etiologies of GnRH independent precocious puberty

A

GnRH independent precocious puberty = puberty not due to early activation of HPA axis, instead due to some form of peripheral estrogen production

  1. McCune Albright syndrome = ovaries producing estrogen w/o stimulation
  2. Granulosa cell tumor
36
Q

Buzzword: uterosacral nodularity

A

Endometriosis

37
Q

Physical exam findings of ectopic pregnancy

A

-Abdominal or adnexal tenderness
if ruptured- acute abdomen w/ rebound/guarding
-uterus small for gestational size (aka normal sized)

38
Q

Etiology of GnRH dependent precocious puberty

A

GnRH dependent precocious puberty = early activation of the HPA axis
-most often idiopathic

39
Q

Clinical presentation of ectopic pregnancy

A

Main features = vaginal bleeding + abdominal pain

40
Q

Outpatient tx for PID

A

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

41
Q

What blood test is essential in every pt w/ any type of abortion

A

Type and screen!

Prevent autoimmunization if Rh- mother

42
Q

First steps of management for woman of reproductive age who p/w vaginal bleeding

A
  • beta-hCG
  • if pregnant => vaginal ultrasound to determine location of pregnancy (ectopic of IUP)
  • pelvic exam etc
43
Q

56 yo nulligravid post-menopausal F p/w intermittent vaginal bleeding

Next step in workup

A

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

44
Q

Contraindications to medical MTX tx for first semester abortion

A
  • 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)
45
Q

Surgical tx options for ectopic pregnancy

A

Salpingectomy vs. salpingostomy

Salpingectomy = removal of fallopian tube
Salpingostomy = surgical unblocking of fallopian tube (remove pregnancy w/o removing the tube)- preserves fertility
46
Q

What is Ashermna syndrome?

A

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

47
Q

3 theories of the mechanism of endometriosis

A
  1. Retrograde menstrual flow (most likely)
  2. Vascular/lymphatic dissemination
  3. Coelomic metaplasia (from pleuripotent/undifferentiated cells in the peritoneum)
48
Q

Name some RF for endometrial hyperplasia/carcinoma

A
  • 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)
49
Q

Overview of tx for ovarian cancer

A

Surgery, then chemotherapy: surgical b/c almost always diagnosed so late (stage III) so already have peritoneal disease
-often intraperitoneal chemo

50
Q

Which method of ovarian stimulation is more likely to result in multiple gestations

A

Clomiphene citrate (SERM); 10% risk

GnRH: 25% risk of multiple gestations

51
Q

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

A

PID
Major criteria = abdominal/adnexal pain
+
Minor criteria = white count, fever

52
Q

Explain how giving GnRH can suppress ovulation

A

FSH/LH respond to pulsatile GnRH, not continuous => if you give continuous GnRH it’ll suppress FSH/LH release

53
Q

Mechanism of tx in endometriosis

A

Want to cause deciduation of the endometrial lining => use OCPs, progesterone, GnRH agonist (but only transiently b/c induces menopause)

54
Q

Describe the staging of cervical cancer

A

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

55
Q

Name 3 etiologies of hypergonadotropic hypogonadism

A

Hypergonadotropic hypogonadism = elevated FSH but no response => delayed pubrety

  1. Turners (XO)
  2. Mullerian agenesis
  3. Imperforate hyman
56
Q

Hormone replacement therapy

a) 4 disadvantages (increased risk of…
(b) Decreases risk of 2 things

A

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

57
Q

Rate of progression of the dif types of endometrial hyperplasias to cancer

A

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

58
Q

Differentiate the two classifications of precocious puberty

A

GnRH dependent (high LH)

vs.

GnRH independent (LH doesn’t increase w/ GnRH administration)

59
Q

Mechanism of visualization in colposcopy

A

Acetic acid- use dilute acetic acid to make atypical cells turn white

60
Q

How to equate the cytology and histology findings in cervical cancer

A

1/3 of the epithelium involved: LSIL, CIN I

2/3 of the epithelium involved: HSIL, CIN II and III

61
Q

Concept of how to treat TOA

A

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

62
Q

Differentiate the two classification systems used for cervical cancer

A
  1. Cytology- this is what you see on pap smears
    - LSIL and HSIL
  2. Histology- seen when you take biopsy of colposcopy
    - CIN I, II, III
63
Q

Why does uterine atony cause bleeding post-partum?

A

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

64
Q

Briefly describe the IVF process

A
  1. ovarian stimulation
  2. oocyte retrieval, done transvaginally
  3. fertilization of egg w/ sperm in petri dish (hence the in vitro)
  4. insertion of fertilized egg into uterus
65
Q

Age at which you stop needing pap smears?

A

After 65 you can stop (and never restart!) if never had CIN II or worse

66
Q

beta-hCG

(a) When does it peak?
(b) Peak level
(c) Level at term

A

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

67
Q

Causes of spontaneous abortion

A

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

68
Q

Relationship btwn BMI and risk of osteoporosis

A

Low BMI have higher risk of osteoporosis- less body weight = less pressure being put on bones

69
Q

Medical management of first trimester spontaneous abortion

A

Prostaglandings such as Misoprostol (cytotec) to

-contract uterus and open the cervix to expel POCs

70
Q

Describe the details of administering a medical abortion

A

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

71
Q

Possible consequences of untreated PID

A
  • infertility 2/2 tubal scarring
  • TOA
  • chronic pain/adhesions
72
Q

Most common location for ectopic pregnancy

A

95+% are in the fallopian tubes

-majority of which are located in the ampulla

73
Q

Discriminatory zone of b-hCG and its relevance

A

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

74
Q

Indication for continuous GnRH therapy

A

Continuous GnRH can be given to suppress ovulation in girls w/ precocious puberty

75
Q

Leading cause of maternal death in the first trimester

A

Ectopic pregnancy

76
Q

Buzzword: violin strings

A

Fitzhugh-Curtis = perihepatitis = adhesions from liver edge to anterior abdominal wall
-inflammation of liver capsule to adjacent periotneal surfaces

77
Q

Buzzword: cervical motion tenderness

A

Buzzword for PID

78
Q

Diagnostic criteria for PID

A

Need 1 major and 1 minor criteria (at least)

Major criteria: 1 of 2

  1. Cervical motion tenderness
  2. Adnexal/uterine tenderness

Minor

  • fever
  • WBC
  • elevated CRP/ESR
79
Q

Fitz-Hugh-Curtis syndrome

A

= Perihepatitis = inflammation of the liver capsule and adjacent periotoneal surfaces

  • increased risk in PID
  • adhesions from liver edge to anterior abdominal wall
80
Q

‘Chocolate cyst’

A

Chocolate cyst = ovarian endometrioma

81
Q

Purpose of HPV testing in pt w/ diagnosis of HSIL

A

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

OB/GYN (10 decks)

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