OB/GYN 2 Flashcards
A 30-year-old female who is 32 weeks pregnant begins to experience tremors, heat intolerance, and irritability along with some fatigue, tachycardia, hypertension, and lower abdominal pain.
Labs reveal the following:
Hct 33%;
Hgb 12.8 g/dL;
WBC 14,600/L
am cortisol 42 g/dL (normal 5 to 20 g/dL)
Total thyroxine 13.1 g/dL (normal 5 to 12 g/dL)
Total T3 225 ng/dL (normal 70 to 205 ng/dL)
TSH 0.4 U/mL (normal 2 to 10 U/mL)
Which of the following therapies is the treatment of choice?
A. amiodarone
B. propranolol
C. propylthiouracil
D. radioactive iodine
The answer is C
A. Amiodarone can be a cause of hyperthyroidism and is not used for the treatment.
B. beta Blockers may alleviate symptomatology of hyperthyroidism but may cause fetal growth retardation.
C. Hyperthyroidism results in low TSH and elevated T3 and thyroxine (free T4). It may cause intrauterine growth retardation, prematurity, or transient thyrotoxicosis in the newborn. Propylthiouracil is the only drug recommended for treatment of hyperthyroidism during pregnancy and lactation. This drug does cross the placenta and, although rare, may result in excess TSH secretion and goiter in the fetus. Therefore, the smallest dose possible should be used. Very little is secreted in breast milk; adverse effects in the fetus have not been demonstrated.
D. Radioactive iodine would be harmful to the fetus.
The presence of which of the following distinguishes eclampsia from preeclampsia?
A. hypertension
B. proteinuria
C. seizure
D. thrombocytopenia
The answer is C [Ob/Gyn].
A. Preeclampsia and eclampsia both manifest with hypertension, proteinuria, and thrombocytopenia.
B. See A.
C. When seizure occurs, the patient goes from a diagnosis of preeclampsia to that of eclampsia.
D. See A.
define adenomyosis
indicence
endometrial glands and stroma within the myometrium
8-40% of all hysterecyomes
etiology and symptoms of adenomyosis
unknown etiology, common in women 35-45 and abates at menopause
dysmenorrhea and menorrhagia
management of adenomysosi
diagnosis with MRI or ultrasound
supportive treatment with nsaids, analgesics, or ovarian suppression
surgical treatment with hysterectomy or segmental resection
how do symptoms differ between submucosal and pedunculated fibroids
submucus will have menorrhagia and pressure discomfort from the mass
pedunculated will have acute pain due to infarct and dysmenorrhea
fibroid etiology
what determines the symptoms
a single myometrial cell mutation found in 20-50% of women that is estrogen dependent
symptoms are depedent on location
are normally dosed birth control pills usually effective for adenomyosis
no, they need to be continuously dosed
treatment of fibroids
expectant
ovarian suppression
anti-progestational therapy
radiologica embolization
surgery (hysterectomy or myomectomy)
two situations where dysmenorrhea might be caused by outflow obstruction
pain at or soon after menarche caused by mullerian fusion or vaginal formation problem
pain after surgical procedure due to cervical stenosis
blind uterine horn (hematometra)
trapping of blood in the uterus due to a lack of opening
imperforate hymen
a hymen that doesn;t open during development and can trap blood to cause dysmenorrhea
vaginal septum
a septum in the uterus that can cause dyspariena or dysmenorrhea
non-communicating uterine horn
a malformation of the uterus where one side is closed off from the body of the uterus
cause of uterine prolapse
symptoms
incidence
weakening of uterine support caused by congenital causes, obstettrical causes, hypoestrogenism, or increased intraabdominal plressure
uterine prolapse
symptoms
incidence
pressure or heaviness, possible bowel and bladder symptoms
common 20-30%
causes for pelvic relaxation leading to uterine prolapse
obstetrical deliveries
decreased strength of connective tissue due to age
decreased estrogen
increased abdominal pressure from obesity, chronic cough, constipation
treatment for uterine prolapse
reduce intraabdominal pressure
estrogen replacement
kegels
surgical repair
vagina pessaries
a plastic ring inserted into the vagina to help support a prolapse uterus
24 y/0 gravida 1 para 1 complains of 10 days of progressive symptoms: Vaginal discharge, Vaginal itching and irritation, Good general health, Recently completed antibiotics for strep throat infection
DDx
vaginitis
what is the most common GYN problem in women from 15-45
symptoms
cervicitis/vaginitis/vulvovaginitis
vaginal discharge; vaginal or vulvar irritation; odor esp with bacterial vaginosis
big three causes of vaginitis
monilia (candida albicans)
trichomonaisis
bacterial vaginosis (gardnerella vaginalis)
three things associated with monilia causing vaginitis
hormonal changes, ABx, immune status in frequent infections
which of the vaginitis big three is sexually transmitted
trichomonaisis
why does gardnerella vaginalis cause bacterial vaginosis
unknown, but the bacteria is associated with sexual activity
diagnosis of vaginitis
wet mount on two slides
one with saline to look for flagellated trichomonads or clue cells (bacterial vaginosis)
one with potassium hydroxide to look for budding yeast
health care issues with the big three vaginitis causes
frequent monilia: immunosuppression
trichomonaiasis: other STDs
bacterial vaginosis: increased risk of premature labor, increased risk of PID with clap, increased risk of post GYN surgery infection
treatment of the big three vaginitis
oral or topical fungicides for monilia
oral or topical metronidazole for trichomoniasis and bacterial vaginosis
topical clindamycin for bacterial vaginosis
what are the advantages of barrier contraception
three types
they are very effective with the right population and they may provide protection against STI
diaphram, cervical cap, condoms
methods of intrauterine contraception
IUD (Copper, mirena, Skyla, Liletta)
endometrial ablation
advantages of endometrial ablation
it will make conception much less likely and can reduce dysmenorrhea or endometrial pain to managable levels
types of tubal contraception
surgical
inflammatory occulsion
three types of surgical sterilization for women
postpartum “mini-laparotomy” tubal
laparoscopic coagulation or application of occlusive clips/rings
hysteroscopic
describe the process of laparoscopic tubal sterlization
what are the advantages
coagulation, cutting, or binding the fallopian tube
no incisions, very effective, can be reversed, IVF still effective
four types of emergency contraception
progestin only (plan B)
Yuzpe method
IUD insertion withine 5 days
Progesterone receptor blockers
what drug is in Plan B
when are the best given
what is the method of action
what is the main side effect
levonorgestrel pills
best results within 72 hours
blocks ovulation
nausea
how many couples will experience infertility in their lives
how many women
8-14%
25%
strategy for dealing with infertility
discover the causes
correct the issue if possible
bypass if possible
provide support
causes of infertility along with percent incidence
egg/ovulation (25%)
sperm problems (30%)
tubal/pelvic (30%)
unusual problems (5%)
Unexplaned (10%)
what are the three most common causes of infertility
egg or ovulation
sperm
tubal or pelvic
what is the source of many idiopathic cases of infertility and treatment failure
infertility due to female age
30 yr old patient attempting to get pregnany comes to the clinic to seek infertility treatment after 1 month of unprotected sex.
how should be cancelled
what if she were 35+
40+
less than 35 should try 1 year of unprotected sex before attempting infertility treatment without obvious issues
6 months
immediately
three factors that would warrant infertility evaluation at any time
amenorrhea
known tubal Hx
male infertilty Hx
the essential work up for infertility (HEST)
health, eggs, sperm, tubes
issues to look for in the health portion of the HEST workup
pelvic exam
look for infection (HIV, HepB/C)
changes to immune status (rubella, hepatitis)
TSH
Genetic screening
egg/ovulation test for HEST workup
FSH and estradiol (E2) testing on cycle day 2 or 3
serum progesterone
when checking FSH and estradiol for HEST workup, what should the values be
what about serum progesterone
FSH <10
E2 <80
SP >9 if taken 7-10 days after LH surge
when evaluating a semen analysis for infertility what are three things to look at
what should happen if the results are abnormal
concentration, motility, volume
repeat at 4-8 weeks
what is a normal semen concentration
what is considered mild oligospermia
severe
very severe
+20million
10-19 million
5-9 million
<5million
what percent of sperm in semen are normally motile
what is considered mild asthenospermia
severe
very severe
+40%
20-39%
10-19%
<10%
in the case of mild oligiospermia or asthenospermia, what action can be taken
what about a severe issue
fertility without treatment is possible but intrauterine insemination (IUI) may help
fertility without treatment is very unlikely, IVF is the only option
two ways to evaluate fallopian tubes on a HEST workup
hysterosalpingogram
laparoscopy
what other test might be considered for infertility treatment in the presense of oligomenorrhea or amenorrhea
what bout oligospermia
serum prolactin
chromosomal analysis
what are fertility drugs used for
two types
to cause or enhance ovulation
gonadotropins, clomiphene
T/F fertility drugs are “fertility enhancers”
what conditions are not treatable with fertility drugs
false
sperm, tubal, uterine issues
what is in a gonadotropin fertility drug
what are the risks of treatment
FSH with or w/o LH
hyperstimulation, multiple births
what is the action of clomphene citrate
what are the possible side effects
inhibits estrogen, induces the release of FSH and LH
functional ovarian cysts; decrease cervical mucus; decreased endometrial growth; hot flashes
what is the general strategy for the use of clomid
use as much as necessary but as little as possible
expect rapid response (1st 3-4 months)
no effect in continuing beyond 6 months
treatment options for idiopathic infertility
IVF
egg donation
surrogate IVF
what is the ultimate goal of infertility treatment
prenancy, adoption, or acceptance of life without children
two types of epithelial carcinoma categorized as breast cancer
one special category
intermediate type ducts (ductal carcinoma)
terminal lobular ducts (lobular carcinoma)
carcinoma in-situ
how is carcinoma in situ usually diagnosed
mammography
describe ductal CIS
a localized carcinoma with penetration of the basement membrane with 1-3% having + axillary nodes
describe lobular CIS
localized carcinoma that is not truly malignany but increase the risk of later malignancy by 20%
how are breast cancers identified by their hormone receptor
estrogen positive or negative
HER-2 positive or negative
basal (“triple negative”)
describe the relationship between breast cancer and age
before what age is breast cancer less likely
what is the mean age at diagnosis
what is the time from origin to dianosis
risk increases with age
40 unless genetically predisposed
60-61
2-8 years
what is the male risk of breast cancer
1/150 that of women with similar risk factors and treatment
rectocele vs cystocele
rectocele is posterior vaginal wall weakness
cystocele is anterior vaginal wall weakness
Whiff test for vaginosis
KOH on a vaginal secretion slide will produce a fishy smell with gardnerella vaginalis
how will clue cells look like on a microscope slide
epithelial cells with granular bacterial inclusions
T/F IUD can be used to treat menorrhagia
true
complication common with fallope ring for laparoscopic sterlization
can cause cramping 12 hts post op
primary infertility
a couple (particularly the woman) has never been pregnant together
what is an effective treatment for HER-2 sensitive breast cancer
monoclonal antibodies against the receptors
why are triple negative breast cancer the ones with the worse prognosis
because they are not receptive to anti-estrogen/progesterone/HER-2 drugs
T/F estrogen causes breast cancer
reasoning?
false, it opens the door to allow for breast cancer to form
women without esstrogen have a low risk, men with estrogen do, early menses + late menopause increases risk
T/F oral contraceptives increase breast cancer risk
probably slightly
what is the effect of postmenopausal HRT on breast cancer
estrogen + progestin increases risk, estrogen alone does not
T/F delayed childbearing decreases risk of breast cancer
false, pregnancy after 35 increases risk by 1.5x
what is the genetic paradox in breast cancer
first degree relative with breast cancer increases risk by 3-4x
BUT
85% of patients have no family Hx
what percent of breast cancer is associated with BRCA1-2
5-10%
cancers associated with BRCA1
breast cancer
ovarian cancer
pancreatic cancer
fallopian tube
cancer associated with BRCA2
breast cancer
ovarian cancer
pancreatic cancer
prostate
environmental factors associated with breast cancer
high rate in developed nations related to fat intake
ETOH slightly increases risk
how is breast cancer usually discoved
90% are found as a painless lump in the breast
three less common presentations of breast cancer
nipple erosion or discharge (pagets)
skin dimpling (retraction)
inflammatory breast cancer
what type of breast cancer is the most aggresive but uncommon
inflammatory breast cancer
clinical factors to keep in mind when assessing a breast lump
most are benign (90% <20, 60-70>40)
is the mass solid vs cystic
mobile vs fixed
dimpling or nipple erosion
DDx for a breast mass
benign cyst (fibrocystic disease or cystic duct)
fibroadenoma (benign)
cancer
fat necrosis
lipoma
epidermal cyst
three types of breast mass biopsy
open (excisional)
fine needle
core needle
compare and contrast open, fine needle, and core needle biopsies for breast masses
open is the most reliable
fine needle is the least invasive but has a higher false negative rate and needs US or Xray guidance
core needle has fewer false negatives
two step principle as it applies to breast cancer
make diagnosis with biopsy first, then treat
how is a cysy managed clincially
when should it be biopsied
outpatient aspiration
if its the first cyst, it is still present after aspriation, or the fluid aspirated is cloudy
when is fine needle biopsy the only reasonable method for breast cancerq
when assessing masses that are too small to palpate
are self breast exams positively correlated to survival
are they still useful
no
useful in a diligent patient using good protocol during cycle day 6-10
is there a benefit for performing an annual breast exam
important notes for the exam
yes, but a hurried or incomplete exam is useless
palpation supine with arm behind head, extra attention in the upper out quadrant, palpate axilla
in what age group does mammography increase survival
is it safe
what is the most common finding
50-70
yes there is fairly low radiation with modern equipment
microcalcification
what is the only method of breast cancer screening that is capable of finding non-palpable breast cancer
mammography
is there a value for mammography in ages below 40?
40-50
70+
no because the breast is more dense
maybe
no proven value after 70
T/F screening is strong correlated with breast cancer survival
false, there is only a small increase in survival, a lot what we are picking out are not aggressively malignant similar to prostate cancer
what is the trade off from mammography
reduce mortality by 8 per 100,000
increase false positives by 122 per 100,000
breast cancer treatments
surgery
radiation
chemo
endocrine modulation
immune modulation
when is MRI mammography useful
high risk patients (BRCA1, 2, FHx)
what is the goal of primary breast cancer treatment
intial recurrence
after that
surgical or medical therapy for a cure
still hope with endocrine, chemo, occasional surgical follow up
eventually palliative care
TNM
Tumor: size, Node: lymph node involvement, Metastasis: presence of distant metastasis
general prognostic factors for breast cancer
best age is 40-70
preexisting conditions can limit treatment
staging
receptor status and genetic profile
breast cancer prognosis divided by receptor status
good: estrogen and progesterone receptors
neutral: HER-2
poor: tipple negative, HER-2 without monoclonal antibodies
primary surgical treatment for breast cancer
conservative (lumpectomy)
mastetctomy
axillary nodes
compare and contrast lumpectomy vs mastetcomy
similar survival studies with post op radiation
lumpectomy is under utilized, but not everyone is a candidate (small breast and large tumor size)
adjunctive therapy associated with breast cancer
what is the goal
types
is chemo needed?
improve long term survival
endocrine modulation for estrogen sensitive patients (anti-estrogen and aromatase inhibitors)
chemo is not necessary for early stage cancer
immunologic therapy associated with breast cancer
trastuzumab for HER-2 sensitive cancer
trastuzumab emtansine is a chemo drug bonded to trastuzumab
types of breast reconstructuve surgery
saline implants
trans-rectus abdominis muscle flap
what is the long term survivability of lung cancer
two big take aways to maximize survival
old standard is 5 years
most studies are showing 10 years
early diagnosis is crucial and long term surveillance is needed
factors that increase risk for ovarian cancer
age
genetics (familial, BRCA1-2, ashkenazi)
high fat diet
PCOS
factors that lower ovarian cancer risk
pregnancy (-15% per pregnancy)
oral contraceptives (-50%)
three ovarian cancer origins
epithelial (90%)
germ cell origin
stromal/sex cord
types of epithelial ovarian cancer
serous cystadenocarcinoma
mucinous cystadenocarcinoma
types of germ cell ovarian cancer
dysgerminoma
choriocarcinoma
embryonal cell carcinoma
stromal/sex cord ovarian cancer
granulosa cell tumor
what is the usual presentation of ovarian cancer
screening tests
conclusion?
pelvic mass with ascites
pelvic exams, CA-125 assays, ultrasound
there is no cost effective protocol
what types of patient would warrant vaginal ultrasounds and CA-125 assays every 6 months
BRCA1-2 positive patients with a first degree relative who had premenopausal ovarian cancer
what is the most common germ cell ovarian cancer
dysgerminoma
what type of ovarian cancer can secrete steroid hormones
granulosa cell tumors
treatment for ovarian cancer
surgery to cure stage 1-2, or debulk stage 3-4 for better chemo
chemo
when is conservative treatment of ovarian cancer warranted
young people with no children or those with stage one disease with low malignany potential
sources of morbidity associated with ovarian cancer
intra-abdominal spread
obstruction or malabsorption in the GI tract
distant mets (liver, lung, bone)
why isn’t US used to screen for ovarian cancer
increased survival by 50% but lead to many false positives
ovarian cancer stagin
stage one: tumor only in ovaries
stage II: tumor limited to pelvis
stage III: tumor limited to abdomen
Stage IV: distant mets
what is prognosis of ovarian cancer dependent on
stage, age, health, tumor type, tumor grade
what is the main cuase of cervical cancer
two synergistic factors
HPV
smoking and immunosuppression
HPV types 6, 11, 42, 43 are low risk for HPV but are asociated with what
condlyomata and CIN I
HPV 16, 18, 33, 35, 45 are high risk and are associated with what
CIN II, III, cervical cancer
prevention of cervical cancer
HPV vaccine
pap smear to detect cervical intraepithelial neoplasia
gardasil is most effective when
potential benefit
girls and boys 11-12, reccomended 9-26
prevent 70% of cervical cancer
90% genital warts
differentiate between CIN and CIS
CIN = cervical intrepithelial neoplasia, can be mild, moderate, or severe dysplasia
CIS = carcinoma in situ
screening protocol for cervical cancer
begin 3 years after sexual activity or 21-25
q3yrs as long as results have been normal
q5yrs after 50
stop at 65 (or 70) with 5 normal paps
bethesda system to classify pap smears
normal: negative for CIN, CIS, cancer
atypical squamous cells, undetermined or cannot exclude (ASC)
low grade squamous intraepithelial lesion (LGSIL)
high grade squamous intraepthelial lesion (HGSIL)
prognosis of intraepithelial lesions
50% will regress to normal
25% will persist
25% will progress to invasive cancer
evaluating abnormal pap smears (ASC-US, LGSIL, HGSIL)
ASC-US: treat any vaginal infections and repeat in 3-6 months
for any others colposcopy with directed biopsy
treatment of CIN
loop electrosurgical excision procedure (LEEP)
cervical cryotherapy
cold knife cone biopsy
morbidity associated with cervical cancer
local spread and destruction of ureters, bladder, rectum
lymphatic spread
rare distant metastasis
treatment of invasive cervical cancer
radiacl hysterectomy with lymph node dissection
radiation therapy
chemo (adjunctive)
factors the increase risk of endometrial cancer
decrease risk
estrogen exposure, genetic factors
oral contraceptives, progestin use
three types of endometrial hyperplasia
hyperplasia without atypia
hyperplasia with atypia
carcinoma in situ
what is the prognosis of endometrial hyperplasia w/o atypia
with atypia
carcinoma in situ
80% regress, 1% progress to cancer
considered premalignant, 8-29% progress to CA
considered the same as CA
advantages/disadvantages of radiation treatment in cervical cancer
advantage: able to use direct appliation of radiation
disadvantage: can damage the vaginal tissue so is reserved for older women
what is the most common symptom of endometrial cancer
abnormal uterine bleeding or postmenopausal bleeding
postmenopausal bleeding DDx
postcoital (cervical polyp or carcinoma)
ovulatory
abnormal (endometrial hyperplasia/carcinoma)
evaluation of post menopausal bleeding
TV US to measure endometrial thickness, biospy if <3mm
endometrial biopsy >3mm
dilation and curettage in the case of cervical stenosis
treatment of endomettrial cancer
radiation therapy adjuct to surgery or primary
surgery (TAH, BSO)
progestin, tamoxifen
chemotherapy
primary radiation therapy for endometrial cancer
implants in the endometrium or vagina
lymph nodes irradiation for mets
when would leiomyosarcoma be high on the DDx
how are they treated
when there is a rapidly growing uterine mass or suspected fibroid
excision
other types of GYN cancer
vulvar
vaginal
vulvar: squamous carcinoma, malignant melanoma
vaginal: clear cell adenocarcinoma (DES) esxposure
