OB/GYN Flashcards
Amenorrhea primary vs secondary definition
Primary:
*absence of menses by age 15 in the presence of secondary sex characteristics
*absence of menses by age 13 in the absence of secondary sex characteristics
Secondary:
*absence of menses for 3mo w/ previously regular cycles
*absence of menses for 6mo w/ previously irregular cycles
*pregnancy MCC of secondary amenorrhea
Amenorrhea sx
Primary
hypergonadotropic
hypogonadotropic
Kallmanns
Secondary: UPT, prolactin, TSH
*(+) UPT = pregnancy, ↑ prolactin = prolactinemia, ↑ TSH = hypothyroidism
UPT, prolactin, TSH normal 🡪 FSH/LH
Hypergonadotropic (↑ FSH/LH) 🡪 U/S
*(+) follicles = resistant ovarian syndrome
*(-) follicles = age 🡪 <40 = premature ovarian insufficiency, ≥40 = menopause
Hypogonadotropic (↓ FSH/LH) 🡪 MRI: panhypopituitarism (Sheehan, AI), apoplexy, mass
Eugonadotropic (FSH/LH normal)
*progestin challenge (+) menses = PCOS
*hysteroscopy = adhesions, ablation
Amenorrhea tx
Cabergoline/Parlodel (pituitary tumors)
Clomid for individuals desiring pregnancy
Surgery to reconstruct the uterus
Estrogen replacement in women with premature ovarian failure*
Dysfunctional Uterine Bleeding (Abnormal Uterine Bleeding) definition of Menorrhagia, Cryptomenorrhea, Metrorrhagia, Polymenorrhea, Oligomenorrhea, Menometrorrhagia, Postcoital Bleeding
Uterine bleeding of abnormal quantity, duration, or schedule
*avg. blood loss 30-80mL
Menorrhagia: bleed >7d or blood loss >80mL
Cryptomenorrhea: light flow
Metrorrhagia: bleeding between periods
Polymenorrhea: cycle <21d
Oligomenorrhea: cycle >35d
Menometrorrhagia: excessive or prolonged bleeding occurring at irregular intervals
Postcoital Bleeding: bleeding after intercourse
Dysfunctional Uterine Bleeding (Abnormal Uterine Bleeding): anovulatory:
Anovulatory (90%): the ovaries produce estrogen but no ovulation = no corpus luteum formation
*Unopposed estrogen (from no progesterone) 🡪 endometrial growth and unpredictable shedding
Dysfunctional Uterine Bleeding (Abnormal Uterine Bleeding): Luteal Phase Defect
Luteal Phase Defect: ovulation occurs but the corpus luteum does not fully develop to make sufficient progesterone for the 14 days prior to menstruation (never transitions to secretory phase)
*Tissue not favorable for implantation
*Difficulty achieving pregnancy
*Shorter than normal cycles or heavy bleeding mid-cycle
Dysfunctional Uterine Bleeding (Abnormal Uterine Bleeding) dx and tx
dx
hCG to r/o pregnancy – FIRST STEP ALWAYS (in reproductive-age women)
Labs: CBC, TSH, iron studies, PT/PTT, progesterone, prolactin, FSH
First-line imaging: transvaginal U/S
Endometrial bx – alternative for pts w/ risk factors for endometrial cancer
*unopposed estrogen therapy, tamoxifen use, menopause after age 55, PCOS
*all women >35 w/ obesity, HTN, DM
*all women ≥45
*postmenopausal bleeding
tx
Acute Hemorrhage:
*IV high-dose estrogen
*high-dose OCs
Chronic Management:
*estrogen-progestin OCPs
*tranexamic acid (clotting promoter that can treat heavy bleeding)
*IUD
*NSAIDs
*surgery – hysterectomy definitive mgmt.; endometrial ablation alt.
Ectopic Pregnancy defintion, MC location, RF
Implantation of the fertilized ovum outside the uterine cavity
Locations: fallopian tube MC
*others: abdomen, ovary & cervix
MC occur 6-8wks after LMP
Risk Factors:
*previous ectopic strongest RF
*hx of PID (one of the MC)
*IUD use
Ectopic Pregnancy sx, dx, tx
sx
Classic triad: amenorrhea followed by unilateral pelvic or lower abdominal pain + vaginal bleeding
Atypical: vague sxs, menstrual irregularities
Ruptured: severe abdominal, left shoulder pain (Kehr sign)
*dizziness, N/V
*peritonitis: guarding, rigidity, or rebound tenderness)
*signs of shock (from hemorrhage): syncope, tachycardia, hypotension
PE: adnexal mass, cervical motion tenderness, unexplained hypotension
dx
Quantitative beta-hCG: confirms pregnancy – should double every 48-72hrs; in ectopic, serial beta-hCG fails to double
Transvaginal U/S: absence of gestational sac w/ beta-hCG levels >1500 strongly suggests ectopic; adnexal mass w/ free fluid in cul-de-sac
*5.5-6wks earliest it can be detected on U/S
Serum progesterone: <5mg/mL is a nonviable pregnancy; >20ng/mL is most likely a healthy pregnancy
Laparoscopy - most accurate technique of identification of ectopic pregnancy (not often used)
tx
Methotrexate: destroys trophoblastic tissue
*indications: hemodynamically stable pts w/ early gestation (<4cm, hCG <5000, no fetal heart tones) who will be compliant w/ follow up & are immunocompetent
*contraindications: ruptured, abnormalities in hematologic, renal, or hepatic lab values, immunodeficiency, pulm. diseases such as TB, peptic ulcer disease, breastfeeding
*RhoGAM given to Rh (-) women!!!
Surgical: laparoscopic salpingostomy or salpingectomy
*mainly reserved for pts w/ contraindications to MTX or if ruptured (unstable, >3-4cm, hCG >5000)
Follow up: serial beta-hCG to see if there is a 15% decrease in 4-7 days – followed until it returns to 0
Endometriosis defintion, locations, RF
Implantation of endometrial tissue (stroma & glands) outside the uterus
Locations:
*ovaries MC site
*posterior cul de sac, broad & uterosacral ligaments, rectosigmoid colon, bladder
Risk Factors:
*prolonged estrogen exposure (e.g., nulliparity, late first pregnancy, early menarche, short menstrual cycles)
*family hx, heavy menstruation
*peak incidence 25-35yrs
Endometriosis sx
sx
Appearance:
*small (1mm) clear or white lesions
*small, dark red (“mulberry”) or brown (“powder burn”) lesions
*cysts filled w/ dark red or brown hemosiderin-laden deposits (“chocolate cysts”)
*dark red or blue “domes” that may reach up to 20mm
Classic Triad: dyschezia + dysmenorrhea + dyspareunia
*abnormal bleeding
*+/- back pain, pre or post menstrual spotting
*asymptomatic in 1/3
*infertility
PE: may have fixed tender adnexal mass, a fixed retroverted uterus or nodular thickening of the uterosacral ligament
*”classic” sign of uterosacral nodularity
*tenderness in posterior vaginal fornix
Endometriosis dx and tx
dx
U/S – initial imaging of choice to r/o other causes
Laparoscopy w/ bx – definitive dx
*raised, patches of thickened, discolored scarred or “powder burn” appearing implants of tissue
*endometrioma – endometriosis involving the ovaries large enough to be considered a tumor, usually filled w/ old blood appearing chocolate-colored (“chocolate cyst”)
dx
Medical Management:
*ovulation suppression – combined OCPs first line
*NSAIDs for pain
*progestins (levonorgestrel-releasing IUD)
*leuprolide (GnRH agonist)
*danazol (an androgen not commonly used)
Surgical Management:
*conservative laparoscopy w/ ablation of ectopic endometrial tissue used if fertility desired (preserves uterus & ovaries)
*total abdominal hysterectomy & bilateral salpingo-oophorectomy if no desire for fertility
ENDOMETRIOMA defintion, sx, dx, tx
ENDOMETRIOMA – adnexal mass that consists of ectopic endometrial tissue in pts w/ endometriosis
S/SXS: dysmenorrhea, dyspareunia, & abdominal pain that is not localized to the uterus during menses
PE: palpable adnexal mass & discomfort on palpation
Transvaginal U/S – smooth walled w/ homogenous internal echoes w/ ground-glass appearance
BX – chocolate-colored
TX: observation w/ serial U/S or surgical removal
*surgical removal: definitive dx, relief of sxs, protection against possible ovarian torsion or rupture
-Risks: intraoperative complications (hemorrhage, infection), slightly decreases fertility
Fetal Distress: FHR baseline, indications of Brady/tachycardia
Monitoring: used to determine if a fetus is well-oxygenated *electronic (EFM) MC method
*Goal is to detect signs of fetal jeopardy in time to intervene before irreversible damage occurs
Baseline FHR: mean bpm (rounded to 0 or 5) over a 10min interval, must be identifiable for 2min during the interval (but not necessarily contiguous 2min)
*110-160bpm = NORMAL
*<110bpm = bradycardia
*>160bpm = tachycardia
Bradycardia: maternal BB therapy, hypothermia, hypoglycemia, hypothyroidism, fetal heart block, interruption of fetal oxygenation
*baseline <80bpm 🡪 non-reassuring fetal status
Tachycardia: chorioamnionitis MCC, maternal fever, infections, medications, hyperthyroidism, elevated catecholamines, fetal anemia, arrhythmia, interruption of fetal oxygenation
*non-reassuring fetal status = tachycardia associated w/ ↓ variability, repetitive late or severe variable decelerations
FHR pattern: variability
VARIABILITY: fluctuations in baseline FHR that are irregular in amplitude & frequency measured in a 10min window
*absent = amplitude undetectable, minimal = 0-5bpm, moderate = 6-25bpm, marked = >25bpm
Moderate FHR variability is a reassuring sign that reflects adequate fetal oxygenation & normal brain function
*in the presence of normal FHR variability, regardless of any other FHR patterns, the fetus is not experiencing cerebral tissue asphyxia
↓ variability: associated w/ fetal hypoxia, acidemia, drugs that may depress the fetal CNS (maternal narcotic analgesia, should recover as medication wears off after D/C), fetal tachycardia, fetal CNS & cardiac anomalies, prolonged uterine contractions, prematurity, & fetal sleep (if due to fetal sleep, should recover in 20-60min)
FHR pattern: deccelerations
DECELERATIONS: ↓ in FHR from baseline (nadir = lowest point)
Early Decelerations: mirror contractions in timing & shape, not associated w/ fetal hypoxia or acidemia, benign
Late Decelerations: nadir after peak of contraction; gradual*
*most often a reflex fetal response to transient hypoxemia during a contraction, non-concerning if there is +baseline variability or accelerations
recurrent late decelerations w/ absent/minimal variability & NO accelerations can be a sign of uteroplacental insufficiency 🡪 severe hypoxemia & metabolic acidemia
Variable Decelerations: abrupt decline & return to baseline that vary in timing w/ contraction, only cause for concern if repetitive/severe (<60bpm)
Prolonged Deceleration: ↓ in FHR ≥15bpm lasting ≥2min but <10min, same causes as late/variable decelerations
*prolonged deceleration ≥10min considered change in baseline
FHR patterns: accelerations
ACCELERATIONS: ABRUPT ↑ in FHR, frequently associated w/ fetal movement, +accelerations indicate absence of hypoxia & acidemia
*<32wks: peak ≥10bpm above baseline for ≥10s
*≥32wks: peak ≥15bpm above baseline for ≥15s
FHR patterns: sinusoidal
SINUSOIDAL PATTERN: smooth, sine wave-like undulating pattern in FHR baseline w/ a cycle frequency of 3-5/min of regular amplitude of 5-15bpm that persists ≥20min, associated w/ fetal anemia, rare
FHR: category 1-3
Category I: intermittent or continuous fetal monitoring based on clinical status & underlying risk factors, review q30min in first stage of labor & q15min in second stage
Category II/III: prepare for delivery
*reposition mom in left lateral decubitus, administer IVF bolus
*D/C any uterotonic drugs to ↓ uterine contraction
*scalp stimulation to provoke FHR acceleration
(+)acceleration: fetus not acidotic
*no improvement after conservative measures + scalp stimulation does not result in acceleration 🡪 delivery advised
Intrauterine Pregnancy vaginal/cervical changes (Chadwick, goodells, ladin, haegars sign), amenorrhea, breast changes, skin changes
Vaginal/Cervical Changes
*Chadwick: mucosa appears dark bluish red & congested
*Goodells sign: cervical softening
*cervical mucus: thick due to P
*uterine change:
*Haegers sign: isthmus soften (6-8)
*Ladin sign: uterus softens (6wk)
Amenorrhea
*cessation of menses in a health
*not reliable until 10d + after menses
*can have “implantation bleeding” for blastocyst
Breast Changes
*tenderness & paresthesia
*increase in breast & nipple
*thick yellowish fluid 🡪 colostrum
*areola becomes deeply pigmented
Skin Changes ~16th wk
*increased pigmentation, linea nigra
*pruritic papules 🡪 steroids
*chloasma 🡪 “mask”
*striae (stretch marks)
Fetal Movement 16-20 weeks
*Primigravida ~20wk
*Multigravida ~16-18wk
Heart Tones: 10-12 weeks
Intrauterine Pregnancy dx
*urine beta-hCG – can detect pregnancy 14d after conception
*serum beta-hCG – can detect pregnancy as early as 5d after conception
Transvaginal U/S structures during the 1st TM
*gestational sac – can be seen at 4.5-5wks
*yolk sac – can be seen at 5-6wks; first structure to appear within gestational sac & confirms intrauterine pregnancy
*fetal pole w/ cardiac activity – around 5.5-6wks
Estimated Due Date:
*Naegele’s Rule
-LMP + 9mo + 7d
-assumes pregnancy begun
2wk before ovulation
*Ultrasound
1st trimester crown rump is MOST ACCURATE
Intrauterine Pregnancy tx
Nulligravida: currently not pregnant, never been pregnant
Primigravida: currently pregnant, never been pregnant before (aka first pregnancy)
Multigravida: currently pregnant, has been pregnant before (aka ≥2nd pregnancy)
Nullipara: never completed a pregnancy beyond 20wks
Primipara: given birth 1 time after 20wks
Multipara: ≥2 births after 20wks
G&P (TPAL)
G – number of pregnancies
P – number of actual deliveries
*T – term (>37wks)
*P – preterm (>20wks, <37wks)
*A – abortions/miscarriages (<20wks)
*L – living children