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Clinical Medicine > OB/GYN 2 > Flashcards

OB/GYN 2 Flashcards

1
Q

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

A

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.

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2
Q

The presence of which of the following distinguishes eclampsia from preeclampsia?

A. hypertension

B. proteinuria

C. seizure

D. thrombocytopenia

A

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.

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3
Q

define adenomyosis

indicence

A

endometrial glands and stroma within the myometrium

8-40% of all hysterecyomes

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4
Q

etiology and symptoms of adenomyosis

A

unknown etiology, common in women 35-45 and abates at menopause

dysmenorrhea and menorrhagia

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5
Q

management of adenomysosi

A

diagnosis with MRI or ultrasound

supportive treatment with nsaids, analgesics, or ovarian suppression

surgical treatment with hysterectomy or segmental resection

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6
Q

how do symptoms differ between submucosal and pedunculated fibroids

A

submucus will have menorrhagia and pressure discomfort from the mass

pedunculated will have acute pain due to infarct and dysmenorrhea

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7
Q

fibroid etiology

what determines the symptoms

A

a single myometrial cell mutation found in 20-50% of women that is estrogen dependent

symptoms are depedent on location

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8
Q

are normally dosed birth control pills usually effective for adenomyosis

A

no, they need to be continuously dosed

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9
Q

treatment of fibroids

A

expectant

ovarian suppression

anti-progestational therapy

radiologica embolization

surgery (hysterectomy or myomectomy)

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10
Q

two situations where dysmenorrhea might be caused by outflow obstruction

A

pain at or soon after menarche caused by mullerian fusion or vaginal formation problem

pain after surgical procedure due to cervical stenosis

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11
Q

blind uterine horn (hematometra)

A

trapping of blood in the uterus due to a lack of opening

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12
Q

imperforate hymen

A

a hymen that doesn;t open during development and can trap blood to cause dysmenorrhea

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13
Q

vaginal septum

A

a septum in the uterus that can cause dyspariena or dysmenorrhea

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14
Q

non-communicating uterine horn

A

a malformation of the uterus where one side is closed off from the body of the uterus

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15
Q

cause of uterine prolapse

symptoms

incidence

A

weakening of uterine support caused by congenital causes, obstettrical causes, hypoestrogenism, or increased intraabdominal plressure

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16
Q

uterine prolapse

symptoms

incidence

A

pressure or heaviness, possible bowel and bladder symptoms

common 20-30%

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17
Q

causes for pelvic relaxation leading to uterine prolapse

A

obstetrical deliveries

decreased strength of connective tissue due to age

decreased estrogen

increased abdominal pressure from obesity, chronic cough, constipation

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18
Q

treatment for uterine prolapse

A

reduce intraabdominal pressure

estrogen replacement

kegels

surgical repair

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19
Q

vagina pessaries

A

a plastic ring inserted into the vagina to help support a prolapse uterus

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20
Q

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

A

vaginitis

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21
Q

what is the most common GYN problem in women from 15-45

symptoms

A

cervicitis/vaginitis/vulvovaginitis

vaginal discharge; vaginal or vulvar irritation; odor esp with bacterial vaginosis

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22
Q

big three causes of vaginitis

A

monilia (candida albicans)

trichomonaisis

bacterial vaginosis (gardnerella vaginalis)

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23
Q

three things associated with monilia causing vaginitis

A

hormonal changes, ABx, immune status in frequent infections

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24
Q

which of the vaginitis big three is sexually transmitted

A

trichomonaisis

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25
Q

why does gardnerella vaginalis cause bacterial vaginosis

A

unknown, but the bacteria is associated with sexual activity

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26
Q

diagnosis of vaginitis

A

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

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27
Q

health care issues with the big three vaginitis causes

A

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

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28
Q

treatment of the big three vaginitis

A

oral or topical fungicides for monilia

oral or topical metronidazole for trichomoniasis and bacterial vaginosis

topical clindamycin for bacterial vaginosis

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29
Q

what are the advantages of barrier contraception

three types

A

they are very effective with the right population and they may provide protection against STI

diaphram, cervical cap, condoms

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30
Q

methods of intrauterine contraception

A

IUD (Copper, mirena, Skyla, Liletta)

endometrial ablation

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31
Q

advantages of endometrial ablation

A

it will make conception much less likely and can reduce dysmenorrhea or endometrial pain to managable levels

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32
Q

types of tubal contraception

A

surgical

inflammatory occulsion

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33
Q

three types of surgical sterilization for women

A

postpartum “mini-laparotomy” tubal

laparoscopic coagulation or application of occlusive clips/rings

hysteroscopic

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34
Q

describe the process of laparoscopic tubal sterlization

what are the advantages

A

coagulation, cutting, or binding the fallopian tube

no incisions, very effective, can be reversed, IVF still effective

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35
Q

four types of emergency contraception

A

progestin only (plan B)

Yuzpe method

IUD insertion withine 5 days

Progesterone receptor blockers

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36
Q

what drug is in Plan B

when are the best given

what is the method of action

what is the main side effect

A

levonorgestrel pills

best results within 72 hours

blocks ovulation

nausea

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37
Q

how many couples will experience infertility in their lives

how many women

A

8-14%

25%

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38
Q

strategy for dealing with infertility

A

discover the causes

correct the issue if possible

bypass if possible

provide support

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39
Q

causes of infertility along with percent incidence

A

egg/ovulation (25%)

sperm problems (30%)

tubal/pelvic (30%)

unusual problems (5%)

Unexplaned (10%)

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40
Q

what are the three most common causes of infertility

A

egg or ovulation

sperm

tubal or pelvic

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41
Q

what is the source of many idiopathic cases of infertility and treatment failure

A

infertility due to female age

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42
Q

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+

A

less than 35 should try 1 year of unprotected sex before attempting infertility treatment without obvious issues

6 months

immediately

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43
Q

three factors that would warrant infertility evaluation at any time

A

amenorrhea

known tubal Hx

male infertilty Hx

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44
Q

the essential work up for infertility (HEST)

A

health, eggs, sperm, tubes

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45
Q

issues to look for in the health portion of the HEST workup

A

pelvic exam

look for infection (HIV, HepB/C)

changes to immune status (rubella, hepatitis)

TSH

Genetic screening

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46
Q

egg/ovulation test for HEST workup

A

FSH and estradiol (E2) testing on cycle day 2 or 3

serum progesterone

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47
Q

when checking FSH and estradiol for HEST workup, what should the values be

what about serum progesterone

A

FSH <10

E2 <80

SP >9 if taken 7-10 days after LH surge

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48
Q

when evaluating a semen analysis for infertility what are three things to look at

what should happen if the results are abnormal

A

concentration, motility, volume

repeat at 4-8 weeks

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49
Q

what is a normal semen concentration

what is considered mild oligospermia

severe

very severe

A

+20million

10-19 million

5-9 million

<5million

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50
Q

what percent of sperm in semen are normally motile

what is considered mild asthenospermia

severe

very severe

A

+40%

20-39%

10-19%

<10%

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51
Q

in the case of mild oligiospermia or asthenospermia, what action can be taken

what about a severe issue

A

fertility without treatment is possible but intrauterine insemination (IUI) may help

fertility without treatment is very unlikely, IVF is the only option

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52
Q

two ways to evaluate fallopian tubes on a HEST workup

A

hysterosalpingogram

laparoscopy

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53
Q

what other test might be considered for infertility treatment in the presense of oligomenorrhea or amenorrhea

what bout oligospermia

A

serum prolactin

chromosomal analysis

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54
Q

what are fertility drugs used for

two types

A

to cause or enhance ovulation

gonadotropins, clomiphene

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55
Q

T/F fertility drugs are “fertility enhancers”

what conditions are not treatable with fertility drugs

A

false

sperm, tubal, uterine issues

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56
Q

what is in a gonadotropin fertility drug

what are the risks of treatment

A

FSH with or w/o LH

hyperstimulation, multiple births

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57
Q

what is the action of clomphene citrate

what are the possible side effects

A

inhibits estrogen, induces the release of FSH and LH

functional ovarian cysts; decrease cervical mucus; decreased endometrial growth; hot flashes

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58
Q

what is the general strategy for the use of clomid

A

use as much as necessary but as little as possible

expect rapid response (1st 3-4 months)

no effect in continuing beyond 6 months

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59
Q

treatment options for idiopathic infertility

A

IVF

egg donation

surrogate IVF

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60
Q

what is the ultimate goal of infertility treatment

A

prenancy, adoption, or acceptance of life without children

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61
Q

two types of epithelial carcinoma categorized as breast cancer

one special category

A

intermediate type ducts (ductal carcinoma)

terminal lobular ducts (lobular carcinoma)

carcinoma in-situ

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62
Q

how is carcinoma in situ usually diagnosed

A

mammography

63
Q

describe ductal CIS

A

a localized carcinoma with penetration of the basement membrane with 1-3% having + axillary nodes

64
Q

describe lobular CIS

A

localized carcinoma that is not truly malignany but increase the risk of later malignancy by 20%

65
Q

how are breast cancers identified by their hormone receptor

A

estrogen positive or negative

HER-2 positive or negative

basal (“triple negative”)

66
Q

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

A

risk increases with age

40 unless genetically predisposed

60-61

2-8 years

67
Q

what is the male risk of breast cancer

A

1/150 that of women with similar risk factors and treatment

68
Q

rectocele vs cystocele

A

rectocele is posterior vaginal wall weakness

cystocele is anterior vaginal wall weakness

69
Q

Whiff test for vaginosis

A

KOH on a vaginal secretion slide will produce a fishy smell with gardnerella vaginalis

70
Q

how will clue cells look like on a microscope slide

A

epithelial cells with granular bacterial inclusions

71
Q

T/F IUD can be used to treat menorrhagia

A

true

72
Q

complication common with fallope ring for laparoscopic sterlization

A

can cause cramping 12 hts post op

73
Q

primary infertility

A

a couple (particularly the woman) has never been pregnant together

74
Q

what is an effective treatment for HER-2 sensitive breast cancer

A

monoclonal antibodies against the receptors

75
Q

why are triple negative breast cancer the ones with the worse prognosis

A

because they are not receptive to anti-estrogen/progesterone/HER-2 drugs

76
Q

T/F estrogen causes breast cancer

reasoning?

A

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

77
Q

T/F oral contraceptives increase breast cancer risk

A

probably slightly

78
Q

what is the effect of postmenopausal HRT on breast cancer

A

estrogen + progestin increases risk, estrogen alone does not

79
Q

T/F delayed childbearing decreases risk of breast cancer

A

false, pregnancy after 35 increases risk by 1.5x

80
Q

what is the genetic paradox in breast cancer

A

first degree relative with breast cancer increases risk by 3-4x

BUT

85% of patients have no family Hx

81
Q

what percent of breast cancer is associated with BRCA1-2

A

5-10%

82
Q

cancers associated with BRCA1

A

breast cancer

ovarian cancer

pancreatic cancer

fallopian tube

83
Q

cancer associated with BRCA2

A

breast cancer

ovarian cancer

pancreatic cancer

prostate

84
Q

environmental factors associated with breast cancer

A

high rate in developed nations related to fat intake

ETOH slightly increases risk

85
Q

how is breast cancer usually discoved

A

90% are found as a painless lump in the breast

86
Q

three less common presentations of breast cancer

A

nipple erosion or discharge (pagets)

skin dimpling (retraction)

inflammatory breast cancer

87
Q

what type of breast cancer is the most aggresive but uncommon

A

inflammatory breast cancer

88
Q

clinical factors to keep in mind when assessing a breast lump

A

most are benign (90% <20, 60-70>40)

is the mass solid vs cystic

mobile vs fixed

dimpling or nipple erosion

89
Q

DDx for a breast mass

A

benign cyst (fibrocystic disease or cystic duct)

fibroadenoma (benign)

cancer

fat necrosis

lipoma

epidermal cyst

90
Q

three types of breast mass biopsy

A

open (excisional)

fine needle

core needle

91
Q

compare and contrast open, fine needle, and core needle biopsies for breast masses

A

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

92
Q

two step principle as it applies to breast cancer

A

make diagnosis with biopsy first, then treat

93
Q

how is a cysy managed clincially

when should it be biopsied

A

outpatient aspiration

if its the first cyst, it is still present after aspriation, or the fluid aspirated is cloudy

94
Q

when is fine needle biopsy the only reasonable method for breast cancerq

A

when assessing masses that are too small to palpate

95
Q

are self breast exams positively correlated to survival

are they still useful

A

no

useful in a diligent patient using good protocol during cycle day 6-10

96
Q

is there a benefit for performing an annual breast exam

important notes for the exam

A

yes, but a hurried or incomplete exam is useless

palpation supine with arm behind head, extra attention in the upper out quadrant, palpate axilla

97
Q

in what age group does mammography increase survival

is it safe

what is the most common finding

A

50-70

yes there is fairly low radiation with modern equipment

microcalcification

98
Q

what is the only method of breast cancer screening that is capable of finding non-palpable breast cancer

A

mammography

99
Q

is there a value for mammography in ages below 40?

40-50

70+

A

no because the breast is more dense

maybe

no proven value after 70

100
Q

T/F screening is strong correlated with breast cancer survival

A

false, there is only a small increase in survival, a lot what we are picking out are not aggressively malignant similar to prostate cancer

101
Q

what is the trade off from mammography

A

reduce mortality by 8 per 100,000

increase false positives by 122 per 100,000

102
Q

breast cancer treatments

A

surgery

radiation

chemo

endocrine modulation

immune modulation

103
Q

when is MRI mammography useful

A

high risk patients (BRCA1, 2, FHx)

104
Q

what is the goal of primary breast cancer treatment

intial recurrence

after that

A

surgical or medical therapy for a cure

still hope with endocrine, chemo, occasional surgical follow up

eventually palliative care

105
Q

TNM

A

Tumor: size, Node: lymph node involvement, Metastasis: presence of distant metastasis

106
Q

general prognostic factors for breast cancer

A

best age is 40-70

preexisting conditions can limit treatment

staging

receptor status and genetic profile

107
Q

breast cancer prognosis divided by receptor status

A

good: estrogen and progesterone receptors
neutral: HER-2
poor: tipple negative, HER-2 without monoclonal antibodies

108
Q

primary surgical treatment for breast cancer

A

conservative (lumpectomy)

mastetctomy

axillary nodes

109
Q

compare and contrast lumpectomy vs mastetcomy

A

similar survival studies with post op radiation

lumpectomy is under utilized, but not everyone is a candidate (small breast and large tumor size)

110
Q

adjunctive therapy associated with breast cancer

what is the goal

types

is chemo needed?

A

improve long term survival

endocrine modulation for estrogen sensitive patients (anti-estrogen and aromatase inhibitors)

chemo is not necessary for early stage cancer

111
Q

immunologic therapy associated with breast cancer

A

trastuzumab for HER-2 sensitive cancer

trastuzumab emtansine is a chemo drug bonded to trastuzumab

112
Q

types of breast reconstructuve surgery

A

saline implants

trans-rectus abdominis muscle flap

113
Q

what is the long term survivability of lung cancer

two big take aways to maximize survival

A

old standard is 5 years

most studies are showing 10 years

early diagnosis is crucial and long term surveillance is needed

114
Q

factors that increase risk for ovarian cancer

A

age

genetics (familial, BRCA1-2, ashkenazi)

high fat diet

PCOS

115
Q

factors that lower ovarian cancer risk

A

pregnancy (-15% per pregnancy)

oral contraceptives (-50%)

116
Q

three ovarian cancer origins

A

epithelial (90%)

germ cell origin

stromal/sex cord

117
Q

types of epithelial ovarian cancer

A

serous cystadenocarcinoma

mucinous cystadenocarcinoma

118
Q

types of germ cell ovarian cancer

A

dysgerminoma

choriocarcinoma

embryonal cell carcinoma

119
Q

stromal/sex cord ovarian cancer

A

granulosa cell tumor

120
Q

what is the usual presentation of ovarian cancer

screening tests

conclusion?

A

pelvic mass with ascites

pelvic exams, CA-125 assays, ultrasound

there is no cost effective protocol

121
Q

what types of patient would warrant vaginal ultrasounds and CA-125 assays every 6 months

A

BRCA1-2 positive patients with a first degree relative who had premenopausal ovarian cancer

122
Q

what is the most common germ cell ovarian cancer

A

dysgerminoma

123
Q

what type of ovarian cancer can secrete steroid hormones

A

granulosa cell tumors

124
Q

treatment for ovarian cancer

A

surgery to cure stage 1-2, or debulk stage 3-4 for better chemo

chemo

125
Q

when is conservative treatment of ovarian cancer warranted

A

young people with no children or those with stage one disease with low malignany potential

126
Q

sources of morbidity associated with ovarian cancer

A

intra-abdominal spread

obstruction or malabsorption in the GI tract

distant mets (liver, lung, bone)

127
Q

why isn’t US used to screen for ovarian cancer

A

increased survival by 50% but lead to many false positives

128
Q

ovarian cancer stagin

A

stage one: tumor only in ovaries

stage II: tumor limited to pelvis

stage III: tumor limited to abdomen

Stage IV: distant mets

129
Q

what is prognosis of ovarian cancer dependent on

A

stage, age, health, tumor type, tumor grade

130
Q

what is the main cuase of cervical cancer

two synergistic factors

A

HPV

smoking and immunosuppression

131
Q

HPV types 6, 11, 42, 43 are low risk for HPV but are asociated with what

A

condlyomata and CIN I

132
Q

HPV 16, 18, 33, 35, 45 are high risk and are associated with what

A

CIN II, III, cervical cancer

133
Q

prevention of cervical cancer

A

HPV vaccine

pap smear to detect cervical intraepithelial neoplasia

134
Q

gardasil is most effective when

potential benefit

A

girls and boys 11-12, reccomended 9-26

prevent 70% of cervical cancer

90% genital warts

135
Q

differentiate between CIN and CIS

A

CIN = cervical intrepithelial neoplasia, can be mild, moderate, or severe dysplasia

CIS = carcinoma in situ

136
Q

screening protocol for cervical cancer

A

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

137
Q

bethesda system to classify pap smears

A

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)

138
Q

prognosis of intraepithelial lesions

A

50% will regress to normal

25% will persist

25% will progress to invasive cancer

139
Q

evaluating abnormal pap smears (ASC-US, LGSIL, HGSIL)

A

ASC-US: treat any vaginal infections and repeat in 3-6 months

for any others colposcopy with directed biopsy

140
Q

treatment of CIN

A

loop electrosurgical excision procedure (LEEP)

cervical cryotherapy

cold knife cone biopsy

141
Q

morbidity associated with cervical cancer

A

local spread and destruction of ureters, bladder, rectum

lymphatic spread

rare distant metastasis

142
Q

treatment of invasive cervical cancer

A

radiacl hysterectomy with lymph node dissection

radiation therapy

chemo (adjunctive)

143
Q

factors the increase risk of endometrial cancer

decrease risk

A

estrogen exposure, genetic factors

oral contraceptives, progestin use

144
Q

three types of endometrial hyperplasia

A

hyperplasia without atypia

hyperplasia with atypia

carcinoma in situ

145
Q

what is the prognosis of endometrial hyperplasia w/o atypia

with atypia

carcinoma in situ

A

80% regress, 1% progress to cancer

considered premalignant, 8-29% progress to CA

considered the same as CA

146
Q

advantages/disadvantages of radiation treatment in cervical cancer

A

advantage: able to use direct appliation of radiation
disadvantage: can damage the vaginal tissue so is reserved for older women

147
Q

what is the most common symptom of endometrial cancer

A

abnormal uterine bleeding or postmenopausal bleeding

148
Q

postmenopausal bleeding DDx

A

postcoital (cervical polyp or carcinoma)

ovulatory

abnormal (endometrial hyperplasia/carcinoma)

149
Q

evaluation of post menopausal bleeding

A

TV US to measure endometrial thickness, biospy if <3mm

endometrial biopsy >3mm

dilation and curettage in the case of cervical stenosis

150
Q

treatment of endomettrial cancer

A

radiation therapy adjuct to surgery or primary

surgery (TAH, BSO)

progestin, tamoxifen

chemotherapy

151
Q

primary radiation therapy for endometrial cancer

A

implants in the endometrium or vagina

lymph nodes irradiation for mets

152
Q

when would leiomyosarcoma be high on the DDx

how are they treated

A

when there is a rapidly growing uterine mass or suspected fibroid

excision

153
Q

other types of GYN cancer

vulvar

vaginal

A

vulvar: squamous carcinoma, malignant melanoma
vaginal: clear cell adenocarcinoma (DES) esxposure

Clinical Medicine (11 decks)

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