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OB/GYN EOR Exam Cards Flashcards

1
Q

Non-endocrine tissue in the body that produces estrogen

A

Fat tissue

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2
Q

Role of LH and FSH

A

Cause secretion of Estrogen, Progesterone and other hormones from ovaries
Stimulate thecal and follicular cells to mature an egg

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3
Q

Roles of estrogen

A

Growth of endometrium
Breast in largement
Induces LH surge
Assists in libido

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4
Q

Roles of progesterone

A

Decreases uterine contractility
Promotes breast development and differentiation
Signals lactation as it falls
Maintaining pregnancy

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5
Q

Activins

A

Stimulate FSH secretion
Involved in WBC production and embryo development

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6
Q

Inhibins

A

Inhibit FSH so we don’t use all out follicles at once

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7
Q

Follistatins

A

Inhibit activins
Regulate gonadotropin secretion

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8
Q

Relaxin

A

Relaxes pubic symphisis and pelvic joints in pregnancy
Inhibits uterine contractions
Mammary and follicular development

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9
Q

Positive feedback on the HPO

A

Estrogen at high levels increases GnRH and LH secretion
Activin promotes gonadotropic cell function

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10
Q

Ad===Thelarche

A

Beginning of breast development
First sign of puberty in females

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11
Q

Pubarche

A

Onset of pubic and axillary hair, after breasts and before menstruation

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12
Q

Day one of a period

A

The first day of bleeding

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13
Q

Normal menstrual cycle

A

28 days on average

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14
Q

Follicular phase

A

Length varies - getting a new follicle ready

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15
Q

Hormones of the follicular phase

A

FSH stimulates a few follicles and then realease inhibin to stop more follicles
One grows and secretes Estrogen
Estrogen causes LH surge, triggering ovulation

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16
Q

Typical ovulation day

A

Day 14

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17
Q

Mittelschmerz

A

Pain upon ovulation

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18
Q

Corpus hemorrhagicum

A

Ruptured follicle fills with blood

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19
Q

Luteal phage

A

consistently 14 days
Corpus luteum forms from corpus hemmorrhagicum

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20
Q

Hormones of luteal phase

A

FSH drops
Corpus luteum produces estrogen which inhibits LH which is stimulating the corpus luteum
CL scars up if no pregnancy

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21
Q

Proliferative phase of the uterus

A

Estrogen forms the stratum functionale about days 5-16 - endometrium growth
Glands are made bu don’t work yet

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22
Q

Secretory phase of the uterus

A

About 14 days
CL is formed
Progesterone from the CL decorates the uterus
Glands become coiled and secrete fluid

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23
Q

Menstrual phase

A

Loss of blood flow results in the death of the stratum functionale

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24
Q

Cervical changes during the menstrual cycle

A

Estrogen makes cervicle mucus thinner and more hospitable to sperm - fern like pattern on slide first half of cycle

Progesterone makes the muscous THICK and impenatrable

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25
Q

Cervical ectopy

A

Caused by opening of cervical opening/unrolling exposing columnar epithelium of the inner cervix
Darker area of tissue - looks like an infection

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26
Q

Birth control and cervical ectopy

A

Stays around longer with birth control

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27
Q

Falopian tube cilia and hormones

A

Estrogen - beat faster
Progesterone - beat slower

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28
Q

Muscle and hormones

A

Progesterone - reduces spasms, relaxes smooth muscle, antagonizes insulin
Estrogen - Improves skeletal muscle contractility

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29
Q

Fat skin and Sodium/Water effect of progesterone

A

Maintains skin
Fat gain in pregnancy
Excretion of sodium and water

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30
Q

Cardiovascular changes of pregnancy

A

Laterally displaced PMI
Supine hypotensive syndrome from uterus compressing IVC
Larger heart and HR increase by 15bpm
Drop in BP w/ increase in volume
May see some murmur, SVT, Left shift, ST depression

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31
Q

Pulmonary changes in pregnancy

A

Congested upper respiratory tract from vasodilation
Higher and wider ribcage
Less dead space in lungs with increased tidal volume
Mild respiratory alkalosis

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32
Q

Renal changes during pregnanacy

A

Transient renal hypertrophy
Dilated ureters, hydronephrosis
Risk of UTI
Increased load on kidneys
Increased GFR
Some leakage of protein and glucose but not to excess
Increased renin

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33
Q

GI changes in pregnancy

A

Increased salivation
Gum hypertrophy
Increased transit times
Slow gallbladder emptying
Increased heartburn
NO worsening dental health is normal

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34
Q

Heme/Onc and Fluid changes in pregnancy

A

Increased in blood volume by 50%
More RBCs
Increased WBCs
More blood clots
Less immune function

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35
Q

When is prolactin highest

A

During pregnancy to help mammary glands develop

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36
Q

Thyroid and pregnancy

A

Increase in production
PTH decreases in 1st trimester and increases in 2 and 3

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37
Q

Eye changes in pregnancy

A

Glaucoma gets better, cornea can thicken

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38
Q

Skin changes in pregnancy

A

Increased skin pigmentation
Linea nigra - black line down midline of abdomen
Melasma - Brown butterfly rash on cheeks
Stretch marks -Red to Brown

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39
Q

Other skin changes that may be seen in pregnancy

A

Spider angiomas
Palmar erythema
Cutis marmorata
Varicosities in legs
Brittle nails
Thickening of hair

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40
Q

Metabolic changes in pregnancy

A

Increased fatigue
Increased appetite, weight, thirst

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41
Q

Weight increase during pregnancy

A

Average increase of 25-35 lbs
Loose about 20 lbs at delivery and thereafeter

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42
Q

Calories per day recommended for pregnancy and lactation

A

300 per day during pregnancy
500 per day during lactation

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43
Q

Protein intake recommendation for pregnancy

A

1g/kg/day
Plus 20 g/d in 2nd half

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44
Q

Pregnancy calcium recommendation

A

1200 mg/d

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45
Q

Iron recommendation for pregnancy

A

60-120 mg/day if defficient

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46
Q

Folic acid supplementation in pregnancy

A

.4 mg/day 1 month before conception and first 3 months
1g/d for insulin dependant diabetics, Valproate, or Carbamazepime
4mg/d if hx of tube defects

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47
Q

B6 for pregnancy

A

Helps with nausea

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48
Q

Placenta

A

Part of the fetus - takes up most of the blood brought to the uterus
Eats into the wall
Uterus needs to contract to prevent bleeding

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49
Q

SUbstances that don’t cross the placenta

A

Only very large
Heparin and Insulin

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50
Q

Initial evolution of fertilized egg

A

Zygote, morula, blastocyst

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51
Q

Week at which organ development begins

A

Weeks 5

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52
Q

Landmarks at weeks 6-7

A

Limb buds and heart beat

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53
Q

Week 9 landmarks

A

All essentail organs have begun to form

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54
Q

Week 10 landmarks

A

Fetal heart tones heard on US
End of embryonic period - fetal period begins

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55
Q

Lanugo development

A

Weeks 15-18

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56
Q

Weeks 19-22 landmarks

A

Fetus can hear
Feel movement of fetus

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57
Q

Threshold of survivability

A

Weeks 23-25 some survive
Week 26+ most survive

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58
Q

Week 26

A

Hands and startle reflex

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59
Q

Weeks 27-30

A

Surfactant production begins to occur

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60
Q

Mesonephric ducts

A

Turn into male structures

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61
Q

Paramesonephric ducts

A

Turn into female structures

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62
Q

Time of testes descending

A

About week 28, should be there by week 32

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63
Q

Term baby

A

Born at 37+ weeks

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64
Q

Preterm baby

A

20-37 weeks

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65
Q

Abortion baby

A

ALL pregnancy losses before 20 weeks

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66
Q

Living children

A

Any infant who lives for 30+ days

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67
Q

Primipara

A

Has delivered once AFTER 20 weeks

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68
Q

1st trimester

A

1-14 weeks

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69
Q

2nd trimester

A

15-28

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70
Q

3rd trimester

A

29-42

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71
Q

Amount of pregnancies that are unplanned

A

Up to half

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72
Q

Pre-conceptual care

A

Help modify risk factors before conception to improve pregnancy outcome

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73
Q

Presentation of pregnancy

A

Amenorrhea - May have conception bleeding
Chadwick sign - Bluish red uterus, soft
Breast enlargement and tenderness
Areolar enlargement

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74
Q

Fetal movement

A

May not feel until 20 weeks first time
May feel 16-18 weeks after first time

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75
Q

Pregnancy diagnosis

A

Urine hCG detectable 8-9 days after ovulation, can also detect in blood

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76
Q

3 hormones similar to hCG

A

LH, FSH, TSH

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77
Q

How rapidly should hCG increase?

A

Value doubles every 1.4-2 days

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78
Q

95% detection level for hCG

A

12.3 mIU/mL

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79
Q

First US evidence of pregnancy

A

4-5 weeks
Gestational sack seen
Transvaginal US

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80
Q

Yolk sac on US

A

Seen at 5-6 weeks
COnfirms location in the uterus (r/o ectopic)
Echogenic ring with anechoic center

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81
Q

Fetal Pole/Embryo

A

Seen after 6 weeks, looks like a hole in the muscle

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82
Q

Crown Rump length

A

Measure from head to butt can be done 6-12 weeks
More reliable estimate of age than LMP
Most accurate at 12 weeks

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83
Q

Naegele’s rule

A

LMP+7 days-3 months

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84
Q

Hx for pregnancy

A

Prior pregnancies
Contraceptive use/desires
Menses interval
Depression
Abuse
Drug/Alcohol use/Drugs

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85
Q

PE for pregnancy

A

Pap smear over 21
Chlamydia and Gonoirrhea testing
Cervical dilation, length, consistency
Bony pelvic architecture

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86
Q

Uterine sizes over time

A

6 week - Small orange
8 week - Large orange
12 week - Grapefruit

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87
Q

When should a Rho gam shot be given

A

at 28 weeks to negative mothers with positive babies
Also for vaginal bleeding intrapartum
Post delivery of neg mothers with positive babies

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88
Q

Kleihauer-Betke

A

Tests for number of fetal RBCs in circulation, in cases of trauma may need to test and give Rho gam

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89
Q

Rh IgG attack rate on fetal RBCs

A

.3 mg will eradicate 15mL Fetal RBCs (eq. to 30 mL fetal blood)

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90
Q

Rubella

A

MCC of fetal growth restriction
Infection in first trimester can cause abortion
Vaccine needs to be taken 1 month BEFORE getting pregnant

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91
Q

Syphillis

A

T. pallidum
Treat with PCN-G - desensitization recommended if allergic

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92
Q

Prenatal counseling recommendations

A

Prenatal vitamin - 400mcg folic acid and Iron
May work but should not do intense or hazardous work

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93
Q

Pregnancy weight gain

A

25-35 lbs if okay weight
Less if they weigh more

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94
Q

Risks associated with obesity while pregnant

A

Hypertension/Preeclampsia
Gestational diabetes
Macrosomia and C section

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95
Q

Additional diet for pregnancy

A

Increase by 100-300 calories per day
Avoid FISH/SEAFOOD

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96
Q

4 risk factors for lead exposure in mothers

A

Immigrant
Remodeling home with lead
Live near lead source
Contaminated water

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97
Q

Air travel and pregnancy

A

Safe up to 35 weeks
Need to ambulate

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98
Q

Dental treatment and pregnancy

A

Okay to get radiographs
Recommended to have done

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99
Q

Caffeine and pregnancy

A

5+ cups of coffee per day can increase risk
Under 200mg/day is okay

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100
Q

Exercise and pregnancy

A

Do not usually need to limit exercise
Encourage mild to moderate exercise - don’t ramp it up
10 lb lifting is the general rule
Don’t scuba dive, etc.

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101
Q

Smoking and alcohol and pregnancy

A

Need to avoid including vaping
Binge drinking is especially problematic

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102
Q

Breastfeeding recommendations

A

6 months is preferred
2 years by WHO (also recommedning ofr Africa)
8-12 times daily with 15 minutes per session
Helps with weight loss, child obesity, chronic disease, bonding

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103
Q

CI to breastfeeding

A

HIV
Drug/Alcohol use
Galactosemia
Hep C with broken skin
Active TB
Medications
Undergoing breast cancer tx
Active herpes lesions on breast

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104
Q

Pregnancy visit spacing

A

Every 4 weeks until 28
Every 2 until 36
Every week until delivery

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105
Q

Prenatal surveillance

A

Fetal HR
Height of the fundus

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106
Q

Fundus height benchmarks

A

12 weeks -emerging from bony pelvis
16 weeks - Between pubic symphysis and umbilicus
20 weeks - Fundus at the umbilicus
20-34 - correlates with gest age
+/- 2cm

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107
Q

Timing of gestational diabetes screening

A

24-28 weeks
50 g glucose with test right after

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108
Q

Lab tests during pregnancy

A

CBC at 28 weeks
Syphillis and HIV 28 weeks for high risk
Rh testing 28-29 weeks
Group B strep testing 35-37 weeks

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109
Q

Vaccines and pregnancy

A

Hep A and B
Flu vaccine
Tdap
RSV between 32 and 36 weeks
COVID

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110
Q

Tx for nausea and vomiting in pregnancy

A

Small meals
BRAT diet
Ginger
B6
Prochlorperazine
Metoclopramide
Odansetron

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111
Q

Hyperemesis gravidarum

A

Vomiting severe enough to produce weight loss, electrolyte disturbances, ketosis, dehydration, etc.

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112
Q

Tx for back pain in pregnancy

A

Shoes, maternity belt
Tylenol
Muscle relaxers

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113
Q

Hemorrhoid tx in pregnancy

A

Topical anesthetics
Warm bath
Compression socks for varcosities

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114
Q

Tx for heartburn in pregnancy

A

Antacids
H2 blockers
PPIs

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115
Q

Pica in pregnancy

A

Craving for dirt, ice, starch
Assoc. with iron deficiency

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116
Q

Tx for sleep issues with pregnancy

A

Benadryl and naps

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117
Q

Leukorrhea

A

Increased vaginal discharge during pregnancy - generally not pathologic

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118
Q

2 MC congenital abnormalities

A

Heart and Cleft palate

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119
Q

Threshold for downs risk

A

35years

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120
Q

Marker for neural tube defects

A

Alpha feto protein
May screen 15-18 weeks

Can use a US for it (more common)

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121
Q

Down syndrome screening recommendation

A

Offer to everyone regardless of risk
Screening NOT diagnostic
NUchal translucency and PAPP-A value

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122
Q

Second trimester down screening

A

hCG
AFP
Unconjugated estriol

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123
Q

Cell free DNA

A

Check for genetic abnormalities and gender
99% detection rate
Blood draw at 9-10 weeks

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124
Q

Amniocentesis

A

15-20 weeks
20 cc of fluid
Assess karytype, can be done for comfort
Evaluate for fetal lung maturity
Chance of fetal loss 1 in 300-500

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125
Q

Chorionic villus sampling

A

10-13 weeks
Assess fetal karyotype
Transabdominal or transcervical

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126
Q

CI to CVS

A

Vaginal bleeding
Higher risk of pregnancy loss - 2%
Uterine ante or retro flexion

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127
Q

Fetal blood sampling

A

For fetal anemia
Cord blood sampling
Perfromed at cord insertion

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128
Q

s/s of fetal stress

A

Low HR
Low fetal movement

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129
Q

Recommendations for antepartum testing

A

Every week starting weeks 32-34 (26-28 if high risk)

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130
Q

Factors effecting fetal movement

A

Diminished by increased movement
Sleeping
Placement of the placenta

Should be consistent in its habits

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131
Q

Non-stress test

A

For a baby not moving Measure heartbeat of fetus - should see 2+ accelerations in a 20 minute time span

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132
Q

What to do to wake baby up for a nonstress test

A

Acoustic stimulator up to three times - should have a positive result after

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133
Q

Biophysical profile

A

Score 0 or 2 in five categories
Non stress test
Breathing
Movement
Tone
Amniotic fluid volume (2x2 pocket)

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134
Q

BPP interpretation 8

A

Normal - deliver if abnormal amniotic fluid index

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135
Q

BPP interpretation 6

A

Deliver if over 36 weeks
Repeat within 24 hours
Deliver if still 6 or lower, observe if above 6

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136
Q

BPP interpretation 4

A

Probably asphyxia repeat or deliver

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137
Q

BPP interpretation 2

A

DELIVER!!

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138
Q

Doppler velocitrimetry

A

Looks at fetal blood flow
Umbilical artery - Shows lack of blood to flow to fetus = growth restriction
Middle cerebral artery - Fetal anemia and growth restriction

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139
Q

Complete dilation

A

10cm - max amount

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140
Q

Effacement

A

How thick the cervix is - 0% is 4cm, 100% is no cervix left

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141
Q

Braxton Hicks contractions

A

False contractions - more likely with more pregnancies, dehydration

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142
Q

Bishop score favorable for labor

A

Greater than 8

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143
Q

Diagnoses for labor

A

Water breaking
Ferning
AFI - Amniotic fluid
Nitrazine

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144
Q

Vaginal bleeding in labor

A

A small amount can be okay

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145
Q

Tx for group be strep vaginal colonization

A

PCN
Erythromycin or Clinda for allergies

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146
Q

IV pain medication for labor

A

Usually avoided in later stages of labor to avoid fetal respiratory distress
Epidural anesthesia preferred

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147
Q

Where is an epidural given

A

L3-L4 intercostal space

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148
Q

CI to an epidural

A

Bleeding disorder or recent heparin use
Patient preference
Thrombocytopenia

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149
Q

Regional anesthesia

A

One time dose for C section
Pudendal block - less common for pregnancy today

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150
Q

General anesthesia for deliver

A

Usually only used in emergencies and C sections
Danger of maternal aspiration

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151
Q

Bishop score that indicates likely failure of induction and what can be done

A

Less than 5
Cervical ripening

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152
Q

Cervical ripening medication

A

Prostaglandins - Cervidil or Cytotec Both vaginal, Cytotec is oral as well
Can cause tachysystole, fever, vomiting, diarrhea, uterine rupture
CI - C-section, Hysterotomy, Myomectomy

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153
Q

Induction of labor

A

Pitocin IV infusion that increases over time
Danger of tachysystole and rupture
Stop if fetal distress occurs

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154
Q

Manual induction of labor

A

Balloon catheter or laminaria
More effective with ptosin
Inserted vagnially
Amnio hook to break water

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155
Q

Augmentation of labor

A

Strengthen contractions - Use ptocin

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156
Q

Operative vaginal delivery

A

Forceps or vacuum
Can cause lacerations (forceps - vaginally) (Vaccuum -Perineal)
Use for fetal compromise or if a C section can no longer be done

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157
Q

First stage of labor

A

Onset to complete cervical dilation
1st 6 cms are much slower

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158
Q

Second stage of labor

A

Cervial dilation to fetal expulsion

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159
Q

Third stage of labor

A

Fetal delivery to placental delivery

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160
Q

Fourth stage of labor

A

Placental delivery to one hour postpartum

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161
Q

Adequate labor

A

Over 200 Montevideo unites in 10min as measured by intrauterine catheter
Start ptosin if inadequate

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162
Q

Fetal variabilities that affect labor

A

Fetal size and alignment

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163
Q

Vertex

A

Head first delivery

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164
Q

Breech

A

Butt first delivery

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165
Q

Shoulder/compound

A

Something in front of baby arm

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166
Q

Funic

A

Umbilical cord first - C SECTION!!

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167
Q

Direction baby should be looking when born

A

Down to the floor (posteriorly)

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168
Q

Determinationof fetal position in Uterus

A

Mother lies supine
Leopolds maneuver:
Evaluate fetal lie, weight, position and presentation
Difficult with obesity, multiples, excess amniotic fluid

US is best bet though

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169
Q

C-section indication

A

More than two fetuses
Any non vertex position
5,000+grams
4,500+ grams and diabetic mother

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170
Q

Pelvic shapes

A

Gynecoid - best
Antropoid - Narrow front to back
Android - Triangular
Platypelloid - Narrow side to side

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171
Q

Active phase arrest labor

A

No progression in cervical dilation in 6cm dilated patients despite four hours of adequate contractions or 6 hours of inadequate contraction with augmentation

C-section indicated

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172
Q

Prolonged second stage labor

A

More than 3 hours pushing for nulliparous and 2 hours in multiparous
Indication for C section

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173
Q

IUDC

A

Catheter to measure strength of contractions

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174
Q

Umbilical cord prolapse

A

Emergency if cord get pinched - needs to be propped up manually
Indication for immediate C section while holding baby off the cord

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175
Q

Indications of second stage

A

Pelvic/rectal pressure
Mother has active role in pushing out fetus

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176
Q

Molding

A

Fetal head shaping to shape of pelvis as it works its way out

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177
Q

Perineal laceration first degree

A

Injury to perineal skin and vaginal mucosa only

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178
Q

Second degree perineal laceration

A

Injury to perineal body (space between vagina and rectum)

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179
Q

Third degree perineal laceration

A

Injury through external anal sphincter

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180
Q

Fourth degree perineal laceration

A

Injury through rectal mucosa

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181
Q

Episotomy

A

Intentionally making a perineal laceration
Usually causes problems - not popular
Midline or Mediolateral - more painful to the side

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182
Q

Shoulder dystocia

A

Fetal shoulder impaction on the pubic symphysis
Macrosomia, Diabetes, Obesity, Operative deliver are risk factors

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183
Q

Dangers to the fetus in shoulder dystocia

A

Humerus or clavicle fracture, Brachial plexus injury, Death

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184
Q

Management of shoulder dystocia

A

Episiotomy
Mcroberts maneuver - sharp flexion of maternal hips
Suprapubic pressure
Rubin, Wood’s corkscrew - rotate baby
Symphisiotomy

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185
Q

Delivery of the placenta

A

Done with one hand on the umbilical cord with gentle downward traction

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186
Q

Uterine inversion

A

Uterus is pulled out through the vagina
Replace uterus - use NOX or terbutylline to relax so it can go back inside

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187
Q

Fourth stage of labor risk and definition

A

Postpartum hemorrhage - Uterine atony, Lacerations, retained placental fragments

Defines as 500+cc’s in a vaginal deliver or 1000+cc’s in a c-section

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188
Q

Tx for uterine atony
Four Meds

A

Pitocin, Methergine, Cytotec, Hemabate

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189
Q

Engagement

A

First movement of delivery
Passage of the widest aspect of the fetal presenting part (typically the head) below the plane of the pelvic inlet (level of ischial spines)

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190
Q

Descent

A

Second maneuver of labor
Moving down into the bony pelvis

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191
Q

Flexion

A

Head flexes to fit through the birth canal

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192
Q

Internal rotation

A

Head of baby either rotates from transverse to anterior or posterior position

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193
Q

Extesnsion

A

Head extends out as the baby passes into the vaginal

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194
Q

External rotation / Restitution

A

Head rotates back to its original position prior to internal rotation - aligns with fetal torso

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195
Q

Expulsion

A

Rest of baby comes out

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196
Q

7 Cardinal movements of labor

A

Engagement
Flexion
Descent
Internal rotation
Extension
External rotation/Restitution
Expulsion

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197
Q

Normal fetal HR

A

110-160

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198
Q

Fetal bradycardia

A

Under 110 bpm
May be due to lupus heart block or maternal hypotension

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199
Q

Absent fetal HR variability

A

Absent - worrisome

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200
Q

Minimal fetal HR variability

A

1-5bmp variation
Fetus asleep or inactive

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201
Q

Moderate fetal HR variability

A

5-25bpm variation
Considered normal

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202
Q

Marek fetal HR variability

A

25+ bpm variation
Worrisome

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203
Q

Normal acceleration of fetal HR

A

15bpm for 15s after 32 weeks
10bpm for 10s before 32 weeks

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204
Q

Early decelerations

A

Begin and end with contractions
Result of head compression
No intervention required

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205
Q

Late decelerations

A

Begin at peak of contraction and slowly return to baseline after contraction is finished
Result of compromised bloodflow during contractions - uteroplacental insufficiency

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206
Q

Tx for late decelerations

A

Position, Oxygen, Stop Pitocin, Check cervix, consider C section or assisted vaginal delivery

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207
Q

Variable decelerations

A

V shaped at any time due to cord compression
The deeper and longer, the more concerning
Reposition
Infuse water into the uterus

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208
Q

Sinusoidal fetal HR

A

Most often fetal anemia - always concerning

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209
Q

Category I fetal heart tracing

A

FHR 110-160
Moderate FHR variability
No late or variable decelerations

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210
Q

Category II fetal heart tracing

A

Neither category I or III

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211
Q

Category III fetal heart tracing

A

Absent FHR variability with any of the following
Recurrent late decelerations
Recurrent variable decelerations
Bradycardia
Sinusiodal waveform

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212
Q

Contraction stress test

A

Use pitocin to trigger 3 contractions in ten minutes
Test for poor fetal HR patterns during contractions
Recurrent late decelerations - Positive - Bad
Good looking - Negative test
Equivocal (maybe one deceleration - Wait and see

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213
Q

MC site of ectopic pregnancy

A

Ampulla of fallopian tube

Can also occur in C-section scar (becoming more frequent

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214
Q

Risk factors for ectopic pregnancy

A

Prior
STDs
PID
Endometriosis
IUD
Assistive reproductive technology

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215
Q

Presentation of ectopic pregnancy

A

Vaginal bleeding
Lower abdominal pain
Adnexal mass
Abdominal pain on rupture
Hemodynamic instability

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216
Q

beta hCG at which pregnancy should be visible in the uterus

A

1500-2000mIU/mL
Should be increasing at a steady rate if pregnancy is normal

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217
Q

US for ectopic pregnancy

A

No yolk sac seen in uterus with pseudo gestational sack
Donut sign - thick walls

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218
Q

HCg monitoring if you dont see an intrauterine pregnancy

A

Check every other day

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219
Q

Ectopic pregnancy treatment

A

Methotrexate - Patient needs to be compliant, no fetal cardiac activity, under 3.5 cm, beta hCG under 5000
Check hCG decrease by day 7
Increased abdominal pain afterwards, N/V/D

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220
Q

Surgery for ectopic pregnancy

A

Salpinostomy - open up and remove - creates higher risk of ectopic pregnancy
Salpingectomy - Preferred

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221
Q

Complete abortion

A

Expulsion of all products of conception before 20 weeks - can do analysis of products

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222
Q

Incomplete abortion

A

Not all of the products of conception are expelled
Vaginal bleeding and abdominal cramping
May see protruding POC through cervical os
Curettage, Prostaglandins and removal of tissue for tx

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223
Q

Inevitable abortion

A

No expulsion but vaginal bleeding and dilation of the cervix such that viability is unlikely
Treat with prostaglandins - keep pregnancy if fetal heartbeat

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224
Q

Missed abortion

A

Death of embryo or fetus before 20 weeks with complete retention of products of conception
US shows nonviable pregnancy
Wait to pass or prostaglandins, Curettage, Expectant management

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225
Q

Threatened abortion

A

Any bleeding before 20 weeks
Cervical os closed
Pelvic rest and close monitoring

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226
Q

Complete Molar pregnancy

A

Excessive growth of placenta
Large for dates
2 sets of paternal chromosomes
Very high hcg
Excessive placental tissue
No POC

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227
Q

Incomplete molar pregnancy

A

Two paternal and one half maternal set of chromosomes
Small for dates
Missed abortion
Fetal parts present

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228
Q

Diagnostics for Molar pregnancy

A

Snowstorm appearance on US
Thickened multicystic placenta
Confirm via pathology
Vomiting
preeclampsia before 20 weeks

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229
Q

Management of molar pregnancy

A

CXR for cancer
CBC
Thyroid
EKG
Suction, dilation and curettage
Pitosin to evacuate uterus
Rhogam if Rh negative
Watch for cancer with serial hCG - should decrease - birth control for some time

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230
Q

Questions to ask about Antepartum bleeding

A

Check where it is coming from (could be UTI or hemorrhoids)
Sexual activity - ask

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231
Q

Placental abruption

A

Separation of the placenta either partially or totally from its implantation site
Concealed or revealed
Usually early in pregnancy - monitor
Can cause hypovolemic shock - deliver immediately

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232
Q

Revealed placental abruption

A

Presents with vaginal bleeding

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233
Q

Diagnosis of placental abruption

A

Exclusion diagnosis - pay attention if mother has experienced trauma

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234
Q

Couvelaire uterus

A

Purplr/Blue uterus from blood infiltration

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235
Q

Management of placental abruption

A

Deliver -Vaginal preferred for dead fetus; C-section is quicker with bleed risk

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236
Q

Placenta previa
Four Risk Factors

A

Placenta covering cervix
Increases with age, parity, c-section, smoking

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237
Q

Presentation of placenta previa

A

Painless vaginal bleeding seen after second trimester

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238
Q

Diagnosis of placenta previa

A

Should be excluded in any bleeding patient who presents after the 2nd trimester
Transvaginal US to visualize
NO DIGITAL EXAM ONCE CONFIRMED!!!

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239
Q

Point before which previa is unlikely to persist

A

23 weeks

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240
Q

Management for placenta previa

A

Delivery via C-section as late as possible
Deliver sooner if persistently bleeding
Goal to keep pt pregnant as long as possible

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241
Q

Placenta accrete

A

Abnormally adhered
Accreta - Attached to myometrium
Increta - Attached into myometrium
Percreta - Goes through myometrium

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242
Q

Risk factors for placenta accrete syndromes

A

C section or placenta previa

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243
Q

Presentation of pracenta accrete

A

Found on US
Hard to deliver placenta
Recommended early delivery at 34-36 weeks
May consider leaving placenta insode or hysterectomy -MC

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244
Q

Cervical insufficiency

A

Painless cervical dilation during the second trimester
d/t prior cervical trauma

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245
Q

Eval and management of cervical insufficiency

A

US to confirm
Swab for infection
Trendelenburg psoition
Pelvic rest
Cerclage - stitch in the uterus kept in until week 36
Delivery

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246
Q

Tx of cervical insufficiency for next pregnancy

A

US to measure
Preventative Cerclage - Rescue (wait) or Elective (don’t wait)

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247
Q

Cerclage

A

Stitch in the uterus - what Mary Crawley got

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248
Q

Preterm birth - 4 reasons

A

Delivery of infant before 37 weeks
Spontaneous
Idiopathic
Maternal or fetal indication
Twins+

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249
Q

Fetal fibronectin and early labor

A

Sensitive but not specific for preterm labor - can rule it OUT

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250
Q

Workup for preterm labor

A

Tocolysis - Stops contractions for 48 hours max
Administer steroids for fetal development
Nifedipine
Mag Sulfate
Prostaglandin inhibitors
Beta agonists - Terbutaline

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251
Q

Management for preterm labor

A

Steroid for fetal lung maturation
Betamethazone indicated 24-34 weeks
Cerclage to help prevent
Progesterone NOT helpful unless vaginal

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252
Q

Reason for magnesium sulfate in preterm labor

A

Prevents neonatal intercranial hemorrhage weeks 24-32 for at least 12 hours

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253
Q

Preterm premature rupture of membranes

A

Check for pooling, nitrazine swab, ferning of vaginal mucosa to confirm
Risk of cord prolapse - don’t send home

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254
Q

Managementof preterm premature rupture of membranes

A

Patient hospitalized for remainder of pregnancy
Corticosteroids for fetal lung maturity
Tocolysis
Ampicillin or Erythromycin can extedn time before delivery

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255
Q

Intrauterine growth restriction

A

Stick with original due date
May be due to alcohol, smoking, young patients, TORCH infections

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256
Q

Dangers with IUGR

A

Stillbirth
Encephalopathy
Palsy
Still monitor even if parents are small

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257
Q

Diagnosis for IUGR

A

Less then 10th percentile overall growth OR less than 10th percentile abdominal circumference is indicative
US

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258
Q

Management of IUGR

A

Amiotic fluid volume management
US for circumference and weight
Umbillical artery doppler monitor
Serial growth scans
Plan for delivery at 38 weeks

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259
Q

Fetal death risk factors

A

Age
AA race
Smoking diabetes

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260
Q

Dx and management of fetal death

A

Usually incidental - US
Plan for delivery
Karyotyping, Autopsy

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261
Q

Management for future pregnancies after a fetal death

A

Control modifiable risk factors
Offer genetic testing
Anatomy scan at 18 weeks growth US at 32 weeks
Begin antepartum surveillance 1-2 weeks prior to when stillbirth happened
Elective induction or C section at 39 weeks

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262
Q

Hypertension in pregnancy

A

Over 140/90 on two occasions at leat 2 hours apart

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263
Q

Chronic hypertension and pregnancy

A

Present before 20 weeks or persistent 12 weeks after delivery is an underlying chronic HTN
ACEIs and Angiotensin receptor agonists are CI

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264
Q

Prenatal care for chronic HTN

A

EKG, Echo (at risk for cardiomyopathy)
Baseline labs

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265
Q

Medications for HTN in pregnancy

A

Labetolol or Calcium channel blockers
Aspirin reduced preeclampsia risk

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266
Q

Management for chronic hypertension in pregnancy

A

Close observation
Deliver early at 37-39 weeks

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267
Q

Gestational HTN

A

After 20 weeks BP becomes 14/90+
Resolves by 12 weeks postpartum
Treat and manage like chronic HTN in pregnancy

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268
Q

Preeclampsia

A

Hypertension and proteinuria after 20 weeks gestation
0.3g+ urine protein on dipstick
Can also present with: Thrombocytopenia, Renal insufficiency, Liver disease, Pulm edema

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269
Q

Risk factors for preeclampsia

A

Young age
First pregnancy
Multifetal
Obesity
Other vascular disorders

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270
Q

Dx of preeclampsia

A

140/90+ BP
Proteinuria dipstick of 2+
300mg or more in a 24 hour urine collection
Could also be with thrombocytopenia

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271
Q

Eclampsia

A

Occurence of generalized convulsion and or coma in the setting of preeclampsia with no other neuro condition
Before, during, or after labor - hold in hospital after birth

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272
Q

Preeclampsia superimposed on chronic HTN

A

Need to have close monitoring of labs and home blood pressure so that it can be caught

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273
Q

HELLP

A

Hemolysis, Elevated Liver Enzymes, and Low Platelet Count
RUQ pain because liver bleeds and distends capsule
Risk of hepatic hematoma and rupture
Indicates SEVERE preeclampsia

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274
Q

Tx for preeclampsia

A

Delivery
Monitor closely if mild
HTN therapy if 160/110 or greater
Labetolol (IV), Hydralazine (IV), or nifedipine (PO) can be used

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275
Q

Magnesium sulfate and preeclampsia

A

To prevent seizure, NOT BP
Continued after delivery until the patient diureses

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276
Q

Pregestational diabetes

A

Check hemoglobin A1c first trimester
A1c over 6.5%
Higher A1c = More fetal anomalies - significant risk over 12%
Fasting glucose over 125, nonfasting over 200

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277
Q

Complications of pregestational diabetics

A

Spontaneous abortion
Preterm birth
IUGR
Cardiac defects
Hydramnios
Macrosomia

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278
Q

Neonatal effects of pregestational diabetes

A

Baby born with overproduction of insulin - hypoglycemia
Hypocalcemia
Diabetes and Obesity later in life

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279
Q

Preconception care for diabetes

A

Glucose 70-110 mg/dL
A1c 7% or lower
Folic acid supplementation

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280
Q

First trimester care for DM

A

Careful glucose monitoring
HGA1c under 6
81 mg Aspirin for preeclampsia prevention
24 hour urine

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281
Q

Second and third trimester care for diabetic mothers

A

US at 18-20 weeks
Fetal echo at 20-24
Antepartum testing at weeks 32-34
Deliver 36-40 weeks
Vaginal or C section delivery

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282
Q

Postpartum diabetes management

A

Insulin may need to be decreased - mom needs more insulin during gestation

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283
Q

Gestational diabetes

A

Commonly recurrence
Diabetes after the first 20 weeks
Ethnic populations are at higher risk
Increased risk of DM later in life

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284
Q

Screening for Gestational Diabetes

A

50g one hour glucose challenge followed by 100g 3 hour test - fasting

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285
Q

Limits for 3 hour GTT

A

Fasting 95
1 hour 180
2 hours 155
3 hours 140

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286
Q

Management of rgestational diabetes

A

Keep fasting BS under 95 and postprandial under 120
Diet modification - 40-20-40 diet
Insulin - First line
Metformin - also good
May consider early induction or not with vaginal delivery depending on size

Same risk factors as pregestational diabetes

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287
Q

Postpartum management of gestational diabetes

A

All should receive a 75g 2 hour OGTT at 6-12 weeks postpartum

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288
Q

Vanishing twin

A

Twin vanishes or is lost before the second trimester
10-40% of all twin pregnancy

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289
Q

Diagnosis of multifetal gestation

A

Uterus larger than expected
Determine chorionicity in the first trimester with US

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290
Q

Dichorionic twins

A

Two separate placentas with a thick 2mm+ dividing membrane
Twin peak sign aka lambda or delta sign

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291
Q

Monochorionic twins

A

Thin under 2mm dividing membrane
T sign on US - right angle relationship between membranes

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292
Q

Monoamniotic twins

A

One amniotic sac - the later the split the more the twins share
High risk of fetal death - deliver 32-24 weeks, steroids at 24-28 weeks with antepartum testing

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293
Q

Complications of multifetal pregnancies

A

Congenital malformations
Spontaneous abortions
Low birth weight
HTN
Size dischordance

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294
Q

Twin-Twin Transfusion syndrome

A

In monochorionic twins
One twin gets all the nutrients, one gives all the nutrients
May be able to ablate vascular abnormalities causing TTTS
May need selective abortions
Harms both twins -One anemic, one congested

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295
Q

Weight gain expectation for multifetal pregnancies

A

37-54lbs. weight gain

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296
Q

Labor management for DD twins

A

38 weeks, can be vaginal - first twin should be vertex!!

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297
Q

Labor management for MD or MM twins

A

Usually C section at 34-37 weeks and 32-34 weeks respectively - first twin should be vertex!!

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298
Q

Maternal hypothyroidism

A

Fetus does not produce own thyroid before 12 weeks
Check TSH every trimester
Cold, Fatigue, Muscle Cramps, Hair loss
MC - Hashimotos thyroiditis
Treat with levothyroxine

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299
Q

Screening for maternal depression

A

Screen for in patients in initial visit and at every visit if at risk

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300
Q

Tx for depression during pregnancy

A

Counselling
SSRI or SNRI are first line
If mother is stable on current antidepressant - don’t change

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301
Q

Zuranlone

A

For post partum depression with and SSRI or SNRI

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302
Q

Substance abuse among pregnant women

A

7.2% abused pain relievers
12% Drank
25+% Smoked including marijuana

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303
Q

Screen for substance abuse in pregnancy

A

Try to screen all patients if possible - tend to use for those with risk factors

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304
Q

Opioid substitution for pregnancy

A

Methadone, Suboxone, Subutex
All associated with neonatal withdrawal
Subutex does not cross the placenta as early

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305
Q

UTI dx and tx in pregnancy

A

Always do a urine screen when first presenting as pregnant
Can cause preterm birth
Macrobid or Keflex and recheck urine a week after

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306
Q

Suppressive UTI therapy in pregnancy

A

Macrobid 100mg PO daily

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307
Q

Pyelonephritis in pregnancy

A

Flank pain
Admit w/ IV abx and prophylaxis
Assess for kidney stone

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308
Q

Definition of infertility

A

1 year of unprtected intercourse of reasonable frequency in under 35
6 months for those over 35

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309
Q

Primary v. Secondary infertility

A

Primary no prior pregnancies
Secondary - prior pregnancy

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310
Q

How often is reasonable to have sex for fertility

A

Once every other day
Make sure you’re having it during the right time

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311
Q

Workup for many pregnancy losses

A

Do genetic testing to see if there is a problem
Look for uterine septum on US

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312
Q

Dx for ovulatory dysfunction

A

Use menstual hx as a predictor
Ask about mittleschmirtz
TSH, Weight over or under
Basal body temperature
US to look at ovarian reserve
Urine LH sticks

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313
Q

Serum progesterone

A

Check around 21 days for ovulation
Relatively cheap

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314
Q

Serum FSH

A

Predictor of ovarian reserve - less inhibin
Check on day 3 of cycle
Estradiol compensation (elevation) indicates a depleated ovarian reserve

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315
Q

Antimullerian hormone testing

A

Expressed by granulosa cells
Possible role in dominant follicle recruitment
Under 1ng/mL can indicate depleated ovaries
High in PCOS

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316
Q

Tx for ovulatory dysfunction

A

Check hyperprolactinemia
Treat any adenoma
Levothyroxine for hypothyroid
Ovulation induction

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317
Q

Clomiphene for ovulation dysfunction

A

Clomiphene - Estrogen antagonist results in increased FSH given around day 3 of cycle
PO

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318
Q

Aromatase inhibitors for ovulation induction

A

Letrozole
Inhibits estrogen and increases FSH
PO
High BMI and PCOS

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319
Q

Gonadotropins

A

Variety of IM formulations
Expensive

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320
Q

COmplications of ovulation induction

A

Multifetal gestation
Ovarian hyperstimulation syndrome - enlarged ovary with cysts - causing abdominal pain, distention

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321
Q

Intrauterine insemination

A

Sperm washed and concentrated and inserted into the uterus - less expensive than and tried before IVF

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322
Q

IVF

A

Sperm and ova combine seperately and inserted into uterus

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323
Q

Tubal and pelvic factors that can lead to infertility

A

Endometriosis
Surgery such as appendectomy
Pelvic infection

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324
Q

Dx for tubal issues

A

Hyerosalpingogram on days 5-10 - uses radio-opaque medium in uterus
Chromopertubation - Methylene blue for tube patency with laparoscopy

Expensive

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325
Q

Tx for tubal and pelvic factors

A

Cannulation to create patency
Reconstruction post op
Removal if dyfunctional tube causing issues
IVF with removal of adhesions

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326
Q

Uterine factors that cause infertility

A

Polyps, Uterine septum, Fibroids
Dx with US or Hysteroscopy, endometrial biopsy before IUI or IVF

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327
Q

Asherman’s syndrome

A

Intrauterine adhesions that can resemble a fetus on US
Form after dilation and curettage

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328
Q

Cervical factors that cause infertility

A

Infection
Thick mucous d/t high estrogen

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329
Q

Dx and tx for cervical factors

A

Postcoital test - how many sperm got through
Bypass with IUI

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330
Q

Male hx for infertility

A

Testosterone use!!
Get a semen analysis
Mumps, ED, Hx of infection

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331
Q

Lag time for sperm to be impacted

A

Takes 3 months for effects to be felt - look at that in hx

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332
Q

Semen analysis

A

Refrain from ejaculation for 2-3 days
Too much sex can reduce sperm count per time
f/u analyze for antisperm antibodies
f/u low volume with urology

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333
Q

Tx for low sperm count

A

IUI - Under 20 million per mL

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334
Q

Azoospermia

A

Congenital absence of vas deferens d/t cystic fibrosis

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335
Q

Asthenospermia

A

Decreased sperm motility
Prolonged abstinence
Infection
Varicocele
IUI to treat

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336
Q

Antisperm antibodies

A

Can be d/t vasectomy, infection, testicular torsion

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337
Q

Hormonal evaluation of male infertility

A

Look for low FSH and or Testosterone
Giving testosterone can actually suppress sperm production

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338
Q

PMDD

A

Premenstual dysphoric dysorder

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339
Q

Premenopause

A

Erratic hormones, menses begin to be irregular

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340
Q

Postmenopause

A

No menses for a year

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341
Q

Dysmenorrhea

A

Painful menstrual bleeding

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342
Q

Metorrhagia

A

Menstrual bleeding between periods

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343
Q

Menometorrhagia

A

Irregular, unpredictable bleeding

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344
Q

Oligomenorrhea

A

Periods more than 35 days apart

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345
Q

BSO

A

Bilateral salpingo-oophorectomy

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346
Q

TAH

A

Total abdominal hysterectomy - through abdomen

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347
Q

TVH

A

Total vaginal hysterectomy - comes out through vagina

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348
Q

Radical hysterectomy

A

Takes out uterus and additional tissue including the cervix

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349
Q

Term pregnancy

A

37-42 weeks

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350
Q

Preterm

A

20-36 weeks

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351
Q

Abortion

A

Before 20 weeks

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352
Q

Puerperium

A

Birth to 6 weeks postpartum

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353
Q

3 trimesters

A

1 - 0-14
2 - 15-28
3 - 29-42

Each is 2 Weeks

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354
Q

FHT

A

Fetal Heart Tones

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355
Q

Grand multigravida

A

More than 5 times pregnant

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356
Q

GTPAL

A

Gravida
Term
Preterm
Abortions
Lived 30 days

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357
Q

Para

A

Pregnancies carried to term

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358
Q

Recommended age for 1st reproductive health visit

A

Age 13-15
Only screen if STD suspected or symptomatic

359
Q

Age to begin pelvic exams and pap smear

A

21 years old
Frequency of pelvic depends on risk factors with pap every 3-5 years

360
Q

General breast exam screening

A

Every 1-3 years 20-39, yearly after 40 with mammograms done starting at 40

361
Q

Speculum lubrication for pap smear

A

Use warm water (officially)

362
Q

Two ways to do pap smear

A

Use scraper and brush, or use the combo tool

363
Q

General breast exam method

A

Palpate 4 quadrants and 4 positions
Palpate for regional lymphadenopathy
Palpate tail of spence

364
Q

Bimanual exam

A

One hand in vagina and one on lower abdominal wall
Test for size shape, mobility, and consistency of organs

365
Q

Skin exam recommendations

A

Q3 years 20-40 and then yearly 40+
Same as pap smears!!

366
Q

Pap screening recommendations

A

21-29 every 3 years
30-65 every 3 years or HPV with pap every 5 years
Stop screening at 65

367
Q

Reasons to stop pap smears after 65

A

No hx of dysplasia/cancer
3 negative smears or 2 negative Pap+HPV in a row

368
Q

When do pap smear guidelines NOT apply

A

Hx of cervical cancer, HIV+, Immunedeficient, DES exposure

369
Q

STD screenings for ALL pregnant women

A

Hep B, HIV, Syphillis

370
Q

STD screenings in all women under 25

A

Gonorrhea and Chlamydia

371
Q

STD to screen for in high risk sexual behavior women

372
Q

STD screening for all sexually active women

A

HIV - One time screen
Gonorrhea and Chlamydia - Yearly if under 25

373
Q

STD screenings for High risk sexual behavior women

A

Annual for All:
HIV
Syphillis
Trichomoniasis
Hep B and C
G/C
HSV

374
Q

Breast cancer screening

A

Depends on agency - start yearly 40-50 years old - definitely by 50
Clinical breast exam optional, Mammogram required

375
Q

When to stop mammograms

A

When you wouldn’t treat cancer if you found it
74 per official guidelines

376
Q

Colon cancer screening recommendations

A

FOB, FITm CT Colonoscopy 45-75 - recommended against after 75

377
Q

Bone density screening recommendations

A

65 years old
Or any woman who’s risk is equal to a 65 year old woman

378
Q

Bethesda system

A

Pap smear evaluation - grades pap cells for cancer

379
Q

Atypical squamous cells

A

ASC - Lowest concern abnormal pap smear cells, can see in infection or atrophy
Undetermined significance = ASC-US
Cannot exclude High Grade = ASC-H

380
Q

Low grade squamous intraepithelial lesion

A

LGSIL or LSIL
Corresponds to CIN-I

381
Q

High grade squamous intraepithelial lesion

A

HGSIL or HSIL
Corresponds to CIN II or CIN III

382
Q

Atypical glandular cells

A

Do not match normal cervical glandular cells but are also not cancer
Associated with adenocarcinoma of endocervix or of endometrium

383
Q

CIN I

A

Disordered growth of lower 1/3 of epithelial lining - mild

384
Q

CIN II

A

Disordered growth of lower 2/3 of epithelial lining - moderate

385
Q

CIN III

A

Disordered growth of over 2/3 of epithelial lining of cervix - considered full thickness

386
Q

CIN

A

Cervicle Intraepithelial Neoplasia

387
Q

Treatment for CIN stages

A

Always treat CIN II or III
Except for in pregnant women (wait till after birth) or in adolescents with CIN II we can observe

388
Q

Risk factors for cervicle dysplasia

A

Multiple sexual partners
High risk partner
HPV hx
Other STIs
Immune suppressed
Contraceptive use long term
Multiparous

389
Q

Management for ASC-US

A

Repeat pap in 6 months and then again in 6 more months
Second abnormal smear - refer for colposcopy
Test for HPV - colposcopy if positive
Colposcopy

390
Q

Colposcopy

A

Like a cervicle exam - use a magnifying light as well as acetic acid
Curette or brush endocervical canal

391
Q

Indications for coloposcopy

A

Abnormal cervicle cytology
CLinically abnormal cervix
Unexplained intermenstrual or postcoital bleeding
Vulvar or vaginal neoplasia
In utero DES exposure

392
Q

CIN I on colposcopy management

A

Expectant management
2 pap q6 months as with ASC-US
Repeat colpscopy if positive or +HPV

393
Q

CIN II-III or cancer on colposcopy management

394
Q

Cervix surgery

A

Take out part of the cervix for cancer

395
Q

3 estrogens in women

A

Estrone (E1) - Order when worried that thye have little estrogen
Estradiol (E2) - What we are usually talking about when talking about estrogen - ordered to monitor menopause, etc.
Estriol (E3) - Screen for fetal pathology and assess preterm labor risk

396
Q

Where progesterone is produced

A

Corpus luteum
Placenta
Biotin - causes flase elevation
Should not be present post menopause

397
Q

Percent of pregnancies that are unintended

398
Q

Percent of pregnancies that were unwanted but women not using birth control

399
Q

Coitus Interruptus

A

Pull out method
Very ineffective - very high failure rates
Semen can leak out before orgasm
Not recommended

400
Q

Postcoital Douche

A

Fluch semen out of vagina
Not reliable - sperm are fast
Not recommended

401
Q

Lactational amenorrhea

A

Suckling to reduce GnRH to suppress ovulation
Pregnancy rate of 7.4% after 12 months - less effective with time
Need to be amenorrheic
Start other birth control at 3 months postpartum

402
Q

Periodic abstinence

A

Calendar methods - 11-25% failure rate
May be related to birth defects

403
Q

Most effective determinant for ovulation

A

serum LH - not practical

404
Q

Fertile period for periodic abstinence

A

2 days before and after ovulation - not very reliable

405
Q

Temperature method of birth control

A

Check temp in the morning
first three days of elevated temperature after drop are the fertile period

406
Q

Failure rate of combined temp/calendar method

A

5 per 100 couples per year - if consistent, need to be consistent

407
Q

Cervical mucous method

A

Billings method
Check cervical mucus - when its thin, patient is fertile

408
Q

Symptothermal method

A

Notice ovulation symptoms and be aware - most effect natural method

409
Q

2 types of OCP

A

Combo or Progestin only pills

410
Q

Combination OCPs

A

Include estrogen and a progestin -some kind of both

411
Q

3rd or 4th generation progestins

A

Better to avoid male secondary sex characteristics
Worse for risk of clotting - DVT, etc.

412
Q

Monophasic COC

A

Same hormones daily

413
Q

Multiphasic COC

A

Different doses during the cycle
May give placebo at some points

414
Q

Administration of COC

A

Ideally start on first day of cycle or just start the day you pick it up and your body will adjust

415
Q

Single missed dose COC

A

Single high monophasic - makeup on the next day

416
Q

Multiple missed doses for COC

A

Double dose and use added barrier contraceptive for 7 days

417
Q

Tx for missed COC w/ coitus in past 5 days,

A

consider emergency contraception

418
Q

MOA of COCs

A

Suppress LH and FSH
Alter cervical mucus
Make endometrium less receptive to implantation

419
Q

Drug interactions with COCs

A

Antibiotics, Anticonvulsants, NSAIDs, SSRIs

420
Q

Benefits of COC

A

Lower risk of ovarian and endometrial cancer
MSK benefits
Lower ectopic pregnancy
Less menstrual pain

421
Q

Major side effects of COCs

A

Increased thromboembolic risk
MI risk increases
Stroke
Liver disease
Cervical and Breast cancer increase

422
Q

Cautions for COCs

A

No use in migraine HAs with aura
May impair breast milk

423
Q

Four Minor SEs for COCs

A

Nausea, dizziness, fatigue
Weight gain 2-5lbs
Abnormal menses
Melasma

424
Q

8 Contrindications for COCs

A

Pregnancy
Undiagnosed vaginal bleeding
Migraine with Aura
Prior history of thromboembolic event
Uncontrolled HTM DM, or SLE
Smokers over 35
Breast cancer hx
Active liver disease

425
Q

Progestin only contraceptives

A

Does not suppress ovulation
Thicken cervical mucous and make endometrium unsuitable
Need to be very compliant

426
Q

Disadvantages of POCs

A

Must take at same time of day daily
Higher bleeding and pregnancy rates
Cancer is still a risk

427
Q

CI to POCs

A

Unexplained uterine bleeding
Breast cancer
Hepatic neoplasms
Pregnancy
Active severe liver disease

428
Q

Three ,method of emergency contraception

A

Yuzpee method
Levonorgestrel
Copper IUD

429
Q

Yuzpee method of contraception

A

Emergent
COC with levonorgestrel
1st dose within 72 hours of intercourse - sooner is better
Causes nausea

430
Q

Levonorgesterol alone

A

Plan B - OTC
Single dose of 1500mcg
Within 72 hours ideally, stops LH surge - not useful if already ovulated

431
Q

Ulipristal

A

Ella - OTC
Single dose of 30mg
Within 72 hours recommended
Prevents LH surge - slightly better than plan B

432
Q

Emergent Copper IUD

A

May inhibit implantation or interfere with sperm function
Insert up to 5-7 after
OTC
Emergency contraception

433
Q

Levonorgestrel IUD for emergency contraception

A

52 mg for emergency contraception
Insert up to 5 days post intercourse

434
Q

Vaginal ring

A

Combination contraception
3 weeks per month
No fitting, can remove for three hours and still work

435
Q

Failure rate of vaginal ring

A

0.65 per 100 women per year

436
Q

Transdermal patch contraception

A

New patch weekly for 3 weeks a month, not directly on breast - rotate sites
Less than 1% failure with less efficacy in obese patients

437
Q

CI of transdermal patch and detachment

A

Have to restart if it has been off for 24 hours

438
Q

Depot Medroxyprogesterone Acetate

A

SepoShot
Progesterone Q3 months
3% failure rate for typical (imperfect) use
0.3 - Ideally

439
Q

Benefits of Depot Medro shot

A

Lower risk of ectopic pregnancy
Lower risk of endometrial cancer
Lower sickle cell crises
May help endometriosis

440
Q

Side effects of Depot Medroxyprogesterone Acetate Shot

A

Decreased bone density
Irregular menses
Takes 10 months to return to baseline and get pregnant

441
Q

Levonorgestrel implant

A

Implanted in arm
Contains a progesterone - etonogesterol
Almost 100%
Up to 3 years - some studies is 5

442
Q

SE of implants (nexplanon)

A

Minor bruising, swelling, and itching at insertion site
Irregular menses
Weight gain
HA

443
Q

Copper IUD non-emergent

A

FDA approved for 10 years
Uncertain MOA
0.6-0.8 per 100 woman-years

444
Q

Risks/SEs of Copper IUD

A

Ectopic pregnancy
Spontaneous abortion
Uterine perforation
Menstrual irregularities, cramping, vaginitis

445
Q

Contrindication to copper IUD

A

Pregnancy
Active infection
Wilson disease
Cancer or unknown bleeding
PID

446
Q

Levonorgestrel IUD

A

Good for people having heavy periods and cramping
8 year lifespan
Very low failure
Bleeding as a SE, helps with cramping, breast pain
52 mg

447
Q

Low dose levonorgestrel IUD

A

Kylea - 5
Skylea - 3
Not for cramps or menorrhagia

448
Q

IUD expulsion

A

Check for strings
Happens in up to 5% in first year of use
Test for pregnancy if expelled

449
Q

Spermicides

A

Most based on Nonoxynol-9
Phexxi - More natural
Most OTC
Placed in vagina and last around an hour
High pregnancy due to non-compliance

450
Q

Contraceptive sponge

A

Nonoxyl-9 impregnated disk
Inserted up to 24 hours before and keep in 6hrs post coitus
Less effective than condom

451
Q

Lamb skin condoms

A

Don’t protect against STD’s - latex DO

452
Q

Female condom

A

May prevent STDs, not as effective as a male condom

453
Q

DIaphragm and Spermicide

A

Rubber dome over cervix
Must use the spermicide
6 hours before and 24 hour max placement
6 per 100 with perfect use
15-20 per 100 with typical use

454
Q

Cervical cap

A

Smaller than a diaphrage -can stay in up to 48 hours
Just on cervix
May be hard to place

455
Q

Regret frequency for sterilization contraception

A

20% for women under 30 6% for women over 30

456
Q

Legal limitations to sterilization

A

Federal won’t pay for under 21 - some states may
None for incompetent patients

457
Q

4 types of female tubal sterilization

A

Electrocoagulation
Mechanical occlusion
Ligation with suture material
Salpingectomy

458
Q

Concerns with tubal sterilization

A

Tubal pregnancy
Chronic pelvic pain - tubal ligation syndrome
Irregular menses
Decreased ovarian cancer when removed

459
Q

Tubal occlusions

A

No longer done, used a hysteroscopic precedure

460
Q

Chemical tubal occlusion

A

Usually not done in US, never approved - seen in immigrants

461
Q

Vasectomy

A

30x less failure, 20x less post-op complications
Need 1-2 consecutive sperm counts of zero to confirm it is working
Easier reversal

462
Q

Suction curettage

A

Elective abortion performed 12 weeks for earlier
90% of US abortions
Cervical dilation and suction catheter insertion

463
Q

Surgical curettage

A

Scrape out fetal parts - more bleeding less common than suction

464
Q

Phamraceutical abortion

A

(Mifepristone OR methotrexate) and/or Misoprostol
Used in first trimester
SE of cramping/bleeding
CI in active liver/renal disease, anemia, bleed risk, IBF -may not expel everything

465
Q

Intraamniotic instillation

A

Hypertonic solution put into uterus to kill the fetus - lots of side effects

466
Q

Vaginal prostaglandins

A

For elective abortions - suppository containing misoprostal etc. to trigger preterm delivery
Can cause GI side effects, live abortion

467
Q

MOA of misoprostol

A

Causes uterine contractions and cervicle ripening
Used for abortions and induction

468
Q

Dilation and evacuation

A

Most common elective abortion for 2nd trimester
Cervical ripening agents used and forceps to break up tissue
Infection and blood loss - does not feel like a delivery

469
Q

Post abortion follow up

A

Rho-Gam
Avoid anything intravaginal for 2 weeks
Birth control
2+ elective abortions lead to higher risk of miscarriage

470
Q

Climacteric

A

Phase of aging from reproductive to non-reproductive age, before actual menopause occurs

471
Q

Average langth of per menopausal transition

A

1-3 years
Part of climacteric period

472
Q

Average age of final menstrual cycle

473
Q

Premature menopause

A

Menopause at 40 or younger

474
Q

Perimenopausal

A

Going through menopause but still having periods

475
Q

Change in follicles over time

A

Ones most responsive to FSH are ovulated first

476
Q

Estradiol of menopause

A

May see bursts of estradiol because follicles are not responding as well

477
Q

Predisposing factors for menopause

A

Smoking advances by 2 years
Reproductive tract disease
GU infections
Chemo or radiation
Surgical impairment to ovarian blood supply

478
Q

Artificial menopause

A

We do something that destroys the ovaries or take them out
May be due to endometriosis, cancer

479
Q

Postmenopausal androgens

A

Decreased production, but still have androgenic symptoms because ovaries make some testosterone and binding protein is not produced

480
Q

Gonadotropins in menopause

A

Increase because no estrogen - can be used for diagnosis

481
Q

Common classic menopause symptoms

A

Irregular bleeding
Irritability and mood swings
Vaginal dryness
Decreased libido
Hot flashes
Hair loss
Hirsutism
Weight gain

482
Q

Physical changes of menopause

A

Atrophy of cervix, uterus, tubes
Flattening of vaginal rugae

483
Q

Urinary and mammary changes of menopause

A

Urgency, frequency, dysuria
Urethral prolapse
Regression and flattening of mammary glands

484
Q

Atrophic vaginitis

A

Epithelium becomes thinner and rugae flatten out
Painful intercourse and friability
Smooth pale and shiny late
Diffuse patchy and red early
Increased pH

485
Q

Diagnosis of atrophic vaginitis

A

Clinical dx - may see atrophic cells in cytology

486
Q

Initial tx for atrophic vaginitis

A

Conservative first
Vaginal moisturizers AND lubricants - not the same thing
Moisturizers daily - not just for sex

487
Q

Treatment for moderate/severe atrophic vaginitis

A

Vaginal estrogen, restores pH and microflora
Fewer UTIs and overactive bladder symptoms
Can go systemic
DOn’t need a vaginal estrogen if systemic

488
Q

Ospemifene

A

For atrophic vaginitis
Only targets vaginal estrogen receptors, MC MC SE is hot flashes

489
Q

Prasterone

A

Vaginal DHEA that turns into estrogen for estrogen sensitive individuals

490
Q

Presentation of hot flashes

A

Elevated HR - normal rhythm and BP
Night sweats, Insomnia
Cutaneous dilation - flushing

491
Q

Risk factors for hot flashes

A

Obesity, Lower physical activity, Smoking, African american race

492
Q

Normal hot flash length

A

seconds to 10 minutes

493
Q

Tx for hot flashes

A

Estrogen = mainstay, give progestin if they cannot take it alone

494
Q

Reasons to take eastrogen with progestin

A

Intact uterus due to endometrial cancer risk

495
Q

First line for patients who don’t want hormones for hot flashes

A

SNRI/SSRI
Citalopram or Venlafaxine, Paroxetine but it reacts with tamoxifen
Gapapentin, Clonidine can also be used

496
Q

Protections of estrogen alone

A

CHD
Fractures
Diabetes
Not used to treat these conditions

497
Q

Risks of MHT (Hormone therapy

A

Estrogen causes endometrial cancer - add progestin to prevent
Increased risk of breast cancer with combo therapy - d/t progesterone!!

498
Q

Non-cancer risks of MHT

A

Thromboembolic diesease
Gallbradder disease

499
Q

MHT contraindication

A

Hx of breast cancer
Unknown bleeding
Endometrial cancer
Thromboembolic disease
Liver dysfunction
Pregnancy

500
Q

1st line MHT for vasomotor symptoms of menopause

A

Patch before pill - less risk of blood clots but insurance doesn’t like to pay so oral is often used

501
Q

Starting MHT

A

Increase at one month intervals if still symptomatic
Recommended not to use for more than 5 years - taper

502
Q

Progesterone only therapy for menopause

A

Can be oral or IM if we don’t want estrogen

503
Q

Tissue selective estrogen complex

A

SERM and estrogen
Reduces some of the risk of using a progesterine

504
Q

Oral estrogen and levonorgestrel IUD

A

May or may not help reduce risk of breast cancer - dubious

505
Q

Alternative hot flash pharm and GU symptoms

A

Doesn’t really help except oxybutynin

506
Q

CAM for menopause

A

Isoflavone/Phytoestrogens - soy, lentils, etc.
Black Cohosh
Vitamin E
Weight loss
CBT
Supplements can still have problematic effects

507
Q

Preparations for atrophic vaginitis

A

Ring, cream or tablet - every night for two weeks then two times per week
May use testosterone if estrogen is contraindicated

508
Q

Lobes per breast

A

12-20 lobes

509
Q

Apex of breast

A

Contains major excretory duct

510
Q

Base of breast

511
Q

Montgomery glands

A

Sebacecous glands of the areola - help the breast stay healthy while breastfeeding

512
Q

Percent of the breast that is adipose tissue

A

80-85% adipose tissue

513
Q

Coopers ligaments

A

Hold the breast to the chest wall - deeper

514
Q

Beginning age for breast deveopment

A

Ages 10-13

515
Q

Breast changes during menstrual cycles

A

Premenstrual - Epithelial cells proliferate - increased size by a little
Post menstrual - Epithelial cells die off, decreased turgor with some tenderness

516
Q

When does the breast reach full development

A

End of a full term pregnancy only

517
Q

Pregnancy changes of breast

A

Darkened areola - bulls eye for infant
Increased lubrication and milk ducts
Fatty tissue almost completely replaced by glands and ducts

518
Q

Trigger and regulator of breast milk production

A

Progesterone drop triggers and prolactin maintains

519
Q

Menopausal breast changes

A

Atrophy and loss of functional breast tissue

520
Q

Fluids from breast commonality

A

40% of premenopausal women
55% of parous women
75% who have lactated in the past 3 years

521
Q

Physiologic breast discharge

A

Expressed when pressure is applied and from multiple ducts/ both breasts

522
Q

Causes of physiologic breast discharge

A

Normal lactation
Galactorrhea
Benign phys discharge
Can be an intraductal papilloma

523
Q

Classical presentation of galactorrhea

A

Bilateral multiductal milky discharge, otherwise normal PE - may want to test for pregnancy

524
Q

Classic pathologic discharge

A

Unilateral spontaneous bloody for serous discharge from a single duct
Bloody is more suggestive of cancer but also more likely due to benign papilloma

525
Q

Cytology of breast discharge

A

Very los sensitivity - usually skip to imaging

526
Q

Ductography

A

May show a filling defect in cancer - flush contrast into ducts

527
Q

Ductoscopy

A

Use tiny endoscope for viewing

528
Q

Definitive diagnostic for pathologic discharge

A

Microductectomy - excise ducts below areola and send to pathology

529
Q

Gynecomastia

A

Glandular breast tissue in a biologic male
Normal in 60% of pubertal boys - usually resolves in a year
Anabolic steroids

530
Q

Psudogynecomastia

A

Fat tissue that looks like gynecomastia - should not seem a firm tender area beneath the areola - firm
Glandular tissue not enlarged

531
Q

Dx for gynecomastia

A

Elevated PRL or hCG
Can also chack testosterone, estradiol
Thyroid

532
Q

Tx for gynecomastia

A

If painful and persistent for 9-12 months
SERM - raloxifine or tamoxifen
Anastrozole - not recommended long term in teens

533
Q

When would we give testosterone to a male

A

Only for true hypogonadism

534
Q

MCC of mastitis

A

Staph areus

535
Q

Risk factors for mastitis

A

Seen in lactation and nursing in primiparous patients, rare before fifth day postpartum

536
Q

Presentation of mastitis

A

Painful, erythematous lobule in the outer quadrant of the breast 2nd or 3rd week after birth
Systemic signs of infection - high fever not due to simple breast engorgement
Antibody coated bacteria in breast milk

537
Q

Presentation of breast abcess

A

Pitting edema and fluctuation

538
Q

Tx for mastitis

A

Keep draining breast - feed or pump
Local heat, warm compress
Well fitted bra
Instruct on techniques
Acetominophen/ibuprofen

539
Q

Antibiotics for mastitis

A

Dicloxacillin of Keflex
Clinda or Bactrim (not for under 1 month old infants)

540
Q

Abx for severe mastitis

A

Van and Ceftriaxone OR Zosyn

541
Q

Tx for breast abcess

A

I&D with abx tx - oral abx usually not sufficient without draining

542
Q

Non nursing breast abcess - peripheral

A

On side is often because of folliculitis or infected cyst
I&D and mastitis abx

543
Q

Subareolar breast abcess

A

Due to keratin plugged milk ducts behind nipple
Simple I&D not enough
Requires duct excision with biopsy to rule out cancer

544
Q

Breast fat necrosis presentation

A

Presents with nipple and skin retraction
May have signs or hx of trauma
Indistinguishible from breast cancer clinically
Biopsy if persistent

545
Q

Fibrocystic breast changes

A

MCC of cyclic breast pain or mastalgia in women 30-50
Epithelial cells become cystic
May be increased in drinkers and estrogen users
Worsened by caffeine

546
Q

Age of fibrocystic breast changes

A

30-50 - correlated with reproductive age, goes away with menopause

547
Q

Presentation of fibrocystic breast changes

A

Pain or tenderness with lump
Present or worse during the premenstrual phase (later half of cycle)
Multiple lesions that change in size

548
Q

Discharge of fibrocystic breast changes

A

Green or brown

549
Q

Dx for fibrocystic breast changes

A

Mammogram for over 30
US and aspiration -US can be better than an ultrasound to see if lesions are cystic
Be on the lookout for odd one out

550
Q

Tx for fibrocystic breast changes

A

Avoid trauma, well fitting bra
Avoid caffeine
Low fat diet may help

551
Q

Tx for severe fibrocystic breast changes

A

Danazol and Tamoxifen
Surgery for most refractory cases

552
Q

Prognosis for fibrocystic breast changes

A

Will subside with menopause
Usually not associated with breast cancer

553
Q

Fibroadenoma

A

Enlarged lobule in young women - early and mid 30s
Larger with hormones and usually solitary

554
Q

Presentation of fibroadenoma

A

Round, smooth, and nontender mass, discrete
Can dx clinically but usually get image to be sure

555
Q

Fibroadenoma on imaging and def dx

A

Well defined solid mass with benign features
Def. dx is core biopsy or mass excision

556
Q

Phyllodes tumor

A

Can become malignant - similar to a fibroadenoma

557
Q

Tx for fibroadenoma or phyllodes tumor

A

Unclear or rapid growth -surgical excision with wide margins
Can monitor/follow-up fibroadenoma if asymptomatic with biopsy or US breast exam

558
Q

Inheritance pattern of BRCA1 and 2

A

Autosomal dominant
Also causes risk in MEN!!

559
Q

Risk factors for breast cancer

A

Nulliparity
First full term pregnancy after age 30
Early menarche or late menopause (reverse decreases risk)
Combo HRT
Hx of uterine or breast cancer

560
Q

Usual presentation of breast cancer

A

Painless breast mass
Hard, fixed, irregular margins, nonmobile
May see metastatic symptoms first
May also see pain, discharge, erosion, retraction

561
Q

MC site of breast cancer

A

Upper outer quadrant

562
Q

4 positions for breast exam

A

Arms over head
Laying on back with arms up
Arms on hips
Leaning forward

563
Q

Concerning PE findings for breast cancer

A

New unilateral side change in size, contour
Unilateral retraction of nipple
Edema or erythema
Firm, non mobile, matted lymph nodes

564
Q

Main lymph nodes for breast drainage

A

85% goes to axillary but palpate everything

565
Q

Paget’s disease of the breast

A

Eczematoid eruption and ulceration - arises from nipple areola
Pain itching, burning discharge and superficial erosion or ulceration
Biopsy
Excision/Mastectomy to treat

566
Q

Inflammatory carcinoma

A

Diffuse, brawny edema with erysipeloid border
Orange peel skin may be seen
No mass
Aggressive but rare - rule out in refractory or unexplained mastitis

567
Q

BIRAD 1 and 2 on mammogram

A

Okay, anything higher is concerning

568
Q

Definitive diagnosis for breast cancer

A

Biopsy
Fine needle - less invasive but less sensitive
Core needle - MOre invasive better
Can also excise

569
Q

Hormone receptor sites for cancer

A

Can have estrogen, progesterone, and HER2 receptors - change how the cance will metastasize
Triple neg goes to lungs/liver

570
Q

Indication for hormonal therapy

A

Positive for ER/PR/HER2 hormone receptors

571
Q

Tamoxifen

A

Historically drug of choice for hormonal breast cancer - can cause clotting and endometrial cancer

572
Q

Newer treatment for hormonal breast cancer

A

Anastrozole - aromatase inhibitor, more effective than tamoxifen

573
Q

Therapy for non hormonal (triple neg) breast cancer

A

Consider an adjuvant -pembrolizumab (keytruda)

574
Q

Selective estrogen receptor modulators

A

Bind to estrogen receptors and block estrogen SERMs -selective for tissues, tamoxifen is specific to breast tissue
Roloxifene blocks in breast and uterus

575
Q

SEs of SERMs

A

Hot flashes, thin hair, thrombosis
Can stimulate OR inhibit estrogen

576
Q

Aromatase inhibitors

A

Anastrozole, exemastane, letrozole
Inhibit aromatase which produces estrogen
Menopausal symptoms - hot flash, brain fog, thinning hair
Newer for breast cancer

577
Q

Fulvestrant

A

Little brother elacestrant
Destroys estrogen receptors
Used for metastatic breast cancer
No blood clots or cancer
Need receptors to work

578
Q

Breast cancer follow ups

A

Q4 months for 2 years
then Q6 for 3 years for PE
Mammogram in 6 months then yearly

579
Q

Median time of breast cancer recurrence

A

At 4 months

580
Q

Percent of those trafficked who are female and minors

A

55-70% female
About half minors

581
Q

Warning signs of human trafficking

A

Social withdrawal
Physical abuse
Neglect
Practiced hx
Living in unsuitable conditions

582
Q

What to do if you suspect human trafficking

A

Send tip to national hotline
Give resources to patient
DOCUMENT

583
Q

Percent of domestic violence victims who are female

584
Q

Women killed by male partner or ex 2001-2012

A

11,766, more than died in the iraq war in the same period

585
Q

DV

A

Domestic violence
Controlling with disregard for wellbeing

586
Q

Risk factors for DV/IPV

A

Race - AA
Pregnancy is a huge risk factor - DV is the leading cause of death in pregnant women
Younger age (16-24)
Childhood exposure to violence

587
Q

Presentation of domestic violence

A

Often vague
Chronic pelvic pain
Sexual dysfunction
Recurrent vaginitis
Anxiety and tearfulness during breast and pelvic exam

588
Q

Body complaints of DV

A

HA
Fatigue
Sleep disturbance
Seems like a somatoform disorder

589
Q

Percent of pregnancies with violence

590
Q

Cycle of abuse

A

Tension building
Incident
Reconciliation
Calm “Honeymoon” phase

591
Q

Screening for domestic violens

A

Screen everybody at all checkups, especially in pregnancy screen at least once per trimester and postpartum

592
Q

Bestway to screen for domestic violence

A

Do it in person
Say something universal first: Because so many people are abused…..I want to ask
Ask about specific behaviors - not general like “rape” or “abuse”

593
Q

Mandatory report events in WV for abuse

A

Gunshot, Stab, Burn

594
Q

After dx tx for DV

A

Acknowledge trauma
Document with photographs - flag to withold
Assess safety and lethality, substance abuse
Create safety plan

595
Q

What to do if patient does not want to leave abusive situation

A

Don’t place blame
Document
Support patient
Follow up with patient

596
Q

Majority of teenage rapes

A

Acquaintance rape - by someone they know

597
Q

Presentation of sexual assault

A

May say they were mugged, May be asking AIDS or STD screening
60-70% have no obvious physical injury
May have bleeding and vaginal irritation, few have major injuries

598
Q

Rape trauma syndrome

A

Detached shock like state
Acute phase - hours to days, tired, HA, startled abates after about two weeks
Delayed phase - Months to years, chronic anxiety, mistrust, depression, sexual dysfunction

599
Q

PE for sexual assault

A

Have a trained person do a sexual assault assessment kit
Sexual assault nurse examiner - take care not to tamper with evidence

600
Q

Hx for sexual assault

A

Describe what happened
Any consensual sex
What happened between
Any infections
State “Use of Force”

601
Q

Tx for sexual assault

A

Emergency contraception after pregnancy test - IUD
Ceftriaxone and potentially metronidazole or Doxycycline
Hep B and HIV prophylaxis
HPV vaccine

602
Q

Psych tx for sexual assault

A

Refer to counseling even if they appear calm, admit if unstable

603
Q

Follow up for sexual assault

A

2 weeks - for psych and other issues

604
Q

3 things we need for intact menses

A

Intact HPO axis
Endometrial response to stimulation
Way for blood to exit

605
Q

Primary amenorrhea

A

Have never had a period
Often due to a genetic abnormality

606
Q

Secondary amenorrhea

A

Misses 3 cycles or 6 consecutive months
MCC is pregnancy

607
Q

2nd MCC od secondary amenorrhea

608
Q

Sheehan’s syndrome

A

Blood loss during birth leads to pituitary necrosis

609
Q

Mullerian dysgenesis

A

No internal female sex hormones except for ovaries

610
Q

Asherman’s syndrome

A

Uterine fibroids cause unable evacuation of blood

611
Q

Anatomical blockages causing amenorrhea - 2

A

Transverse septum
Imperforate hymen

612
Q

Dx for asherman’s syndrome

A

Hyerosalpingogram

613
Q

Progesterone challenge test

A

Give progesterin - if they bleed afterwards they are anovulatory

614
Q

Estrogen and Progesterone challenge test

A

No bleed afterwards means blockage
Bleading afterwards = hypogonadism

615
Q

Secondary dysmenorrhea

A

Casued by something demonstrable

616
Q

Membranous dysmenorrhea

A

Due to passage of a cast of the uterus through the cervix

617
Q

Primary dysmenorrhea

A

No known cause - MC type of dysmenorrhea

618
Q

First line tx for dysmenorrhea

A

NSAID - 400-800 with no more than 1200mg per day
May take prophylactically
Acetaminophen less effective
Continuous heat helps - need a break

619
Q

Erythema ab igne

A

Rash associated with chronic heat pad use

620
Q

2nd line tx for dysmenorrhea

A

Hormonal contraceptives
Lyletta, Morena - Progesterone IUD

621
Q

Percent of women with PMS or PMDD

A

75%
Highest in 20s to 30s

622
Q

Tx for mild to moderate PMS/PMDD

A

Dietary changes - caffeine, alcohol, sodium
Exercise - aerobic
Chasteberry, Calcium carbonate - OTC
NSAID for pain
Spironolactone for bloating
Bromocryptine for breast pain

623
Q

Tx for severe PMS/PMDD

A

SSRI - 1st line with 50% helped, can be used periodically
2nd line - Hormonal therapy
May consider alprazolam
GnRH agonist - put pt in menopause

624
Q

Transvaginal US taking

A

Need an empty bladder - see pelvic organs

625
Q

Transabdominal US taking

A

Full bladder, less visualization of pelvic organs

626
Q

Sonohysterography

A

Saline injected into intrauterine cavity - increased sensitivity

627
Q

Gold standard for uterine pathology evaluation

A

Hysteroscopy - camera in the uterus

628
Q

Tx for Dysfunctional Uterine Bleeding

A

r/o pregnancy or cancer - oral contraceptives, observation if asymptomatic and no cancer
Levonorgestrel IUD, D&C for short term ablation

629
Q

Postmenopausal DUB

A

MCC - exogenous hormones
Always investigate
May actually be bleeding from vagina

630
Q

Workup to r/o tumors of reproductive tract in DUB

A

Endometrial sampling

631
Q

Endometrial ablation

A

Need to take birth control, not want to be fertile
Reduces flow in 70-80%

632
Q

Pretreatment for endometrial ablation

A

Abx NOT needed
GnRH agonist or D&C to thin out endometrium

633
Q

CI to endometrial ablation

A

Pregnancy, Desire to have children, Endometrial hyperplasia, Postmenopause, IUD in place

634
Q

Vaporization endometrial ablation

A

Nd-Yag laser
Early method
Scar endometrium

635
Q

Roller ball

A

Similar to vaporization
Old method

636
Q

Endometrial resection

A

Old method - caused a lot of perforation

637
Q

Hysteroscopic thermal endometrial ablation

A

2nd generation
Heated saline put in uterus
Good for anatomic abnormalities
Higher burn risk

638
Q

Radiofrequency thermal ablation endometrial ablation

A

2nd gen
No D&C or progesterin needed
Uses a heasted mesh

639
Q

Thermal + RF Endometrial ablation

A

Brand - Minerva
Silicone contours to shape of cavity
Balloon filled with RF heated Argon gas
Endometrial prep not needed
Higher success rates
2nd gen

640
Q

Water vapor termal endmetrial ablation

A

Seal with baloons and fill with water
2nd gen
Safer

641
Q

Cryoablation endometrial ablation

A

Less pain but less effective
2nd gen

642
Q

Theraml balloon endometrial ablation

A

Use balloon to conform to contours of uterus
No longer done in US - too much burning

643
Q

Sites of endometriosis

A

Other sites in the abdomen
Or distant site outside of the abdomen - can be anywhere

644
Q

Risk factors for endometriosis

A

Fam hx
Early menarchy
Nulliparity
LOng flow
Heavy periods
Shorter cycles
IE. anything that increases menstrual bleeding

645
Q

Presentation of endometriosis

A

Dysmenorrhea
Pelvic pain
Dyspareunia
Infertility
May worsen with period
Severity does not corespond to amount of ectopic tissue

646
Q

PE for endometriosis

A

Tender nodules in posterior vaginal fornyx
Pain with uterine motion
Tender adnexal masses may be felt
May have no findings

647
Q

Dx for endometriosis

A

Imaging is usually not helpful
Laparoscopy to diagnose definitively

648
Q

Lesions of endometriosis

A

Powder burns
Chocolate cysts
Red/Purple raspberry spots

649
Q

Tx for mild/moderate endometriosis

A

NSAID
Progesterone contraceptives

650
Q

Tx for moderate to severe endometriosis

A

Hormonal - GnRH agonists or antagonists - ie. danazole, letrozole
Gabapentin
TCAs
Surgery

651
Q

Reason to use surgery for endometriosis

A

Do it when they are wanting to have children b/c they can come back

652
Q

Danazol

A

Testosterone derivative that acts like progestin
Inhibits gonadotropic release
SE - Oily skin, acne, deep voice

653
Q

Anastrozole/Letrozole

A

Aromatase inhibitors
Can be used as an adjuvant to Danazol

654
Q

GnRH agonists

A

Leuprolide, Goserelin, Nafarelin
For endometriosis
Use for max 6 months
Menopause like symptoms

655
Q

GnRH antagonists

A

Elagolix (Orlissa)
Most studied
Max 6 months at high or 24 months at low dose
Menopause like symptoms

656
Q

Pelvic inflammatory disease presentation

A

Lower abdominal pain - insidious or acute usually for 2 ish weeks
Oral temp > 101F
Bilateral lower quadrant tenderness
Skene or Bartholin glands around introitus

657
Q

Fitz-Hugh-Curtis syndrome

A

Liver inflammation with PID

658
Q

Classic sign of pelvic inflammatory disease

A

Cervical motion tenderness (chandelier sign

659
Q

Dx for PID

A

Pregnancy test to r/o
WBCs in vaginal fluid
ESR/CRP may be elevated

660
Q

Imaging for PID

A

May see thickening, tubo-ovarian complex, may be normal

661
Q

Tx for pelvic inflammatory disease

A

Outpatient abx if they are not too sick and compliant, IV for inpatient
3 Drugs at same time:
Rocephin shot
Doxy
Metronidazole
14 day course overall

662
Q

Presentation of tubo-ovarian abcess

A

Tenderness and guarding
Mass in abdomen
Multi-loculated lesion on US

663
Q

Tx for unruptured tubo-ovarian abcess

A

Same abx as PID (Metro, Doxy, Rocephin) but for 4-6 weeks

664
Q

Tx for ruptured tubo-ovarian abcess

A

Life threatening emergency
TAH (total abdominal Hysterectomy) and BSO (bilateral salpingo-oophorectomy) with aggressive fluid resuscitation

665
Q

Cystocele

A

Prolapse of the bladder d/t anterior vaginal wall weakness. Visualized through the vagina and better seen when bearing down

666
Q

Rectocele

A

Rectal prolapse d/t posterior vaginal weakness
Seen in bearing down

667
Q

Uterine prolapse

A

Uterus slides down towards the introitus

668
Q

Pelvic organ prolapse stages 0-4
Halfway system

A

0 - Normal
1 - Halfway to hymen
2 - To hymen
3 - Halfway past hymen
4 - Maximal descent

669
Q

Presentation of pelvic organ prolapse

A

Feeling of heaviness in vagina, urinary symptoms with cystocele
Talk about putting fingers in vagina to brace it when urinating/defecating

670
Q

Dx for pelvic organ prolapse

A

Pelvic exam with bearing down
Imaging only if worried about secondary problem

671
Q

Tx for pelvic organ prolapse

A

Pessary - reexamine in 1-2 weeks for first one, then every 2-3 months after that

Kegal exercises

672
Q

Surgical tx for POP

A

May use mesh or other surgery - mesh can cause irritation

673
Q

Adenomyosis

A

Endometrial tissue implants in the myometrium
Focal or diffuse

674
Q

Risk factors for adenomyosis

A

Parity and age

675
Q

Presentation of adenomyosis

A

More areas of invasion = more s/s
Menorrhagia, dysmenorrhea
Global uterine ENLARGEMENT with uterine softening

676
Q

Imaging for adenomyosis

A

TVUS
Focal thickening of myometrium on US
Heterogenous texture on US

677
Q

Tx for adenomyosis

A

NSAIDs for pain
Combo oral contraceptives
Endometrial ablation/resection may help somewhat

678
Q

Definitive tx for adenomyosis

A

Hysterectomy
Symptoms also get better after menopause - ride out

679
Q

Leiomyoma

A

Benign neoplasm of the female genital tract - uterine fibroids

680
Q

Submucous leiomyoma

A

Directly beneath endometrial lining - on the inside!!

681
Q

Subserous leiomyoma

A

Directly beneath serosal lining - on the outside!!

682
Q

Intramural leiomyoma

A

Completely within the myometrium

683
Q

Presentation of leiomyomas

A

Most are asymptomatic
MC symptoms are - Abnormal bleeding, pelvic pressure/pain
May torse - causing pain
May compress nearby organs

684
Q

PE for leiomyomas

A

Enlarged uterus with irregular contour

685
Q

Dx for leiomyomas

A

Iron deficiency on labs
US can detect
MRI for more detail
Hysterography/Scopy can also help

686
Q

Tx for asymptomatic leiomyomas

A

Can monitor with a yearly US - not a big threat to health

687
Q

Tx for sympomatic leiomyomas

A

NSAIDs or hormonal therapy depending on sx
Regress spontaneously during menopause - menopausal hormone therapy may bring it back

688
Q

Surgical tx for leiomyomas

A

Total hysterectomy
Myomectomy - just remove fibroid
Embolization - Clot it up - good results

689
Q

Peak onset for endometrial cancer

A

70s - many cases can occur younger
Obestity increases risk

690
Q

Precursor to endometrial cancer

A

Endometrial hyperplasia
Excess estrogen!!

691
Q

MCC of endogenous over production of estrogen

A

Obesity - From the fat!

692
Q

Other risk factors for endometrial cancer

A

PCOS
Exogenous unapposed estrogen therapy (w/o progestin and no hysterectomy)
More peiords (ie. early menarche, less pregnancies)

693
Q

Risk reduction for endometrial cancer

A

Progestin or combination contraceptives

694
Q

MC symptoms of endometrial hyperplasia

A

Abnormal uterine bleeding
Simple or complex atypia (complex more likely to become cancer but progesterone cures both)

695
Q

Endometrial hyperplasia with atypia

A

More concerning that simple/complex
Progesterone will not cure

696
Q

Type I endometrial cancer

A

Not as aggressive
YOunger patients
Better prognosis

697
Q

Type II endometrial cancer

A

Less common
Poorer prognosis
Independant of estrogen

698
Q

Classic endometrial cancer patient

A

Obese
Nulliparous
Infertile
HTN
DM
White

699
Q

MC type of endometrial cancer

A

Adenocarcinoma

700
Q

Presentation of endometrial cancer

A

Abnormal bleeding in 80% of patients - postmenopausal bleeding may be an indicator
Vaginal discharge
Cervical os stenosis

701
Q

Tx for endometrial cancer WITHOUT atypia

A

Progesterone

702
Q

PE for endometrial cancer

A

May feel inguinal lymph nodes
Normal in early stages

703
Q

Imaging for endometrial cancer

A

US with endometrial thickness over 4 mm is high suspicion for cancer
DDx - Biopsy

704
Q

Other tests that may pick up endometrial cancer

A

D&C - even better than biopsy
Sometimes picked up on pap smear

705
Q

Tx for endometrial cancer

A

Surgery is mainstay - total hysterectomy with BSO - curative in low risk

706
Q

Adjuvant pharm for endometrial cancer

A

Radiation, Progesterone, Chemo - Doxyrubicin and Cisplatin

707
Q

Tx for excess bleeding in endometrial cancer

A

NO IV estrogen like we would with other bleeding
Tamponade and Packing

708
Q

Functional ovarian cysts

A

Due to cyclic ovarian changes - do not always cause symptoms
Can rupture causing peritonitis
Impinge organs

709
Q

Dx for ovarian cyst

A

Pelvic US is MC way to dx

710
Q

Follicular cyst

A

MC type of ovarian cyst
Follicle doesn’t rupture appropriately
Usually asymptomatic
May cause irregular menstual bleeding

711
Q

Management of follicular cyst

A

Usually resolve in 2 months
OCP can keep cysts from forming
May aspirate or surgically remove - usually not necessary

712
Q

Corpus luteum cyst

A

Corpus luteum did not regress
Progesterone abnormalities may lead to late period
Torsion, pain, can look like ectopic pregnancy

713
Q

Tx for corpus luteum cyst

A

Manage symptomatically
OCP questionable
Surgery if problematic
Ring of fire on US

714
Q

Theca Lutein cyst

A

Caused by elevated hCG
Often bilateral and multiple
Resolve once hCG goes down
May aspirate in pregnancy

715
Q

Endometriomas

A

Implant of endometrial tissue on the ovary
Endometriosis symptoms - chocolate cysts

716
Q

Dermoid cyst

A

Filled with improper tissue - fat, teeth, etc.
Not cancer
May rupture

717
Q

Cystadenomas

A

Cysts that get massive - pain and discomfort
Pop, drain, remove

718
Q

PCOS

A

Stein Leventhal syndrome
Enlarged ovaries with multiple cysts
Anovulaotry, amennorheic
Obese, overweight patients

719
Q

Diagnosis of PCOS

A

Pt. with variable periods, obesity, hirsutism, oligomenorrhea
Polycystic ovaries on US - Oyster ovaries

720
Q

Presentation of PCOS

A

Menstural abnormalities, early pregnancy loss, Pelvic pain/pressure, T2DM
Young endometrial cancer dx
Acanthosis nigricans

721
Q

Hormones in PCOS

A

Mild elevation of androgens
Lower sex hormone binding globulin
Increased LH:FSH ratio

722
Q

US of PCOS

A

Ovary with many cysts in it - look like dark pockets

723
Q

Tx for PCOS - conservative

A

Observe symptoms - should be having at least 8 periods a year
Lifestyle changes -loose weight, well balanced diet

724
Q

PCOS moderate therapy

A

Pregnancy test
COC - if not trying to conceive or ring patch if eligible, helps with hyperandrogenism
Progesterone alone - second line

725
Q

PCOS insulin sensitization

A

Metformin is MC drug - safe in pregnancy
May also use GLP-1 agonist

726
Q

Tx for PCOS hirsutism

A

Takes 6-12 months to work
COC or GnRH agonist
Laser removal, etc.
Spironolactone - androgen antagonist
5 alpha reductase inhibitors - finasterid/dutasteride

727
Q

Vaniqua

A

Expensive hair removal medicine

728
Q

Novel PCOS therapies

A

Myo-inositol
NK34 antagonist

729
Q

PCOS tx for patients who want to get pregnant

A

Weight loss and lifestyle
Letrozole on days 3-7 of period
Not safe once pregnant
(Clomid used to be first line - SERM - blocks estrogen in hypothalamus)

730
Q

MOA of letrozoleand 4 SEs

A

Inhibits aromatoase
SE - hot flashes, dizziness, fatigue, pain

731
Q

Clomid for PCOS

A

causes ovarian enlargement, hot flashes, bloating
Not great

732
Q

FLuid retention of PCOS tx

A

Can be extreme - present with hypovolemia and swelling
MC with Clomid, FSH
LC with Letrozole

733
Q

Surgery for PCOS

A

Ovarian drilling - laparoscopic laser biopsies jump start the ovaries

734
Q

Ovarian torsion

A

Emergent condition like testicular torsion
Often due to enlarged ovaries
May occur in early pregnancy

735
Q

Presentation of ovarian torsion

A

Sudden onset severe, one sided unilateral abd pain
Painful adnexal mass
May radiate to thigh, flank, or groin
Women may be used to abdominal pain!!

736
Q

Dx for ovarian torsion

A

Sonography - dx of choice
Bull’s eye, whirlpool, snailshell pattern
Doppler flow disruption
Do pregnancy test
Transvaginal US may be better

737
Q

Tx for ovarian torsion

A

Laparoscopic detorion ( can do laparotomy)
Remove cyst causing problem
Remove if 12+ hours - obvious necrosis

738
Q

MC source of ovarian cancer

A

Epithelial ovarian cells

739
Q

Ovarian cancer

A

CA-125 marker - from serous cystadenomas
Typical in menopausal patients

740
Q

Other types of ovarian cancer

A

Germ cell tumor - younger patients
Sex cord stromal tumors

741
Q

Risk factors for ovarian cancer

A

Anything that increases cell turnover
Talcum powder

742
Q

Presentation of ovarian cancer

A

Vague early symptoms
Early satiety
Fatigue, back pain
Late - abdominal pain, ascites, solid irregular adnexal mass

743
Q

Sister Mary Joseph nodule

A

Belly button nodule due to ovarian cancer

744
Q

CA-125 marker for ovarian cancer

A

Elevated in 50% of ovarian cancer
Associated with many other things - fibroids, endometriosis
More specific for postmenopausal women

745
Q

Dx for ovarian cancer

A

Various markers
Pelvic US w/ solids, separation, ascites
CT/MRI for more exact
Bx for definitive

746
Q

Tx for ovarian cancer

A

Remove omentum, ovaries, uterus
Watch CA-125 to see if cancer resolved

747
Q

Tx for germ cell ovarian cancer

A

Often try to save the uterus - not as aggressive

748
Q

MC GYN malignancy

A

Uterine cancer

Ovarian - 2nd

749
Q

Sexual response stages - 4

A

Desire
Arousal
Orgasm
Resolution

750
Q

Hormones that increase libido

A

Estrogen
Testosterone - uspraphysiologic
Dopamine
Norepinephrine
Oxytocin
Melanocortins

751
Q

Hormones that inhibit libido

A

Serotonin - at high levels
Prolactin
Opioids
Endocannabinoids

752
Q

Average female puberty onset

A

8-13 years old

753
Q

MC sexual dysfunction in women

A

Low sexual desire - 39% of disorders

754
Q

Female arousal/interest disorder

A

Low desire or abnormal arousal - must occur 75%+ of the time, lasts for 6+ months
Causes distress

755
Q

6 criteria for female interest arousal disorder

A

Must report 3:
Absent interest in sex
Reduced fantisizing
Reduced initiation
Reduced interest/arousal to stimuli
Reduced excitment/pleasure
Reduced sensation

756
Q

Genitopelvic pain/Penetration disorder

A

Pain majority of time with sex
TIghtening of muscles
Avoid vaginal sex
Common hx of trauma or abuse

757
Q

Female orgasmic disorder

A

Don’t feel like they finish the way they want to
May be due to neuropathy, partner issues, etc.

758
Q

Medications related to sexual disorders

A

SSRI!
TCA
Benzos
Lithium
Anticholinergic
HTN meds - BB
SERM/Aromatise inhibitors

759
Q

Estrogen for sexual disorders

A

Increases libido, vaginal lubrication, blood flow to genitalia
CI - Blood clots, endometrial cancer
Recommended if more than just libido

760
Q

Androgens for sexual disorders

A

Generally not recommended - may be used in menopause
Cause hirsutism, acne, liver disease
Last line

761
Q

Dosing testosterone for women

A

Much lower dose than used for men

762
Q

Serotonin/Dopamine for sexual disorders

A

Flibanserin - post menopause serotonin agonist/modulator helps with SE of SSRI
CI with alcohol, hypotension

763
Q

Bupropion for sexual dysfunction

A

Helps with norepi and dopamine
Helps with arousal response, etc.
CI in seizures, anorexia, MAOI use

764
Q

PDE-5 inhibitors in womens sexual dysfunction

A

Slidenafil
Most helpful with physiologic problems - ie. vascular, neuro
CI with nitrates

765
Q

Bremelanotide

A

Agonist of melanocortin receptors for sexual dysfunction
New drug -PRN injection stop if no benefit in 6 weeks
CI in liver disease, pregnancy

766
Q

Other tx for female orgasmic disorder

A

Sexual devices
Directed masturbation - usually best for partner not to participate at first
No scientific evidence for genital cosmetic precedures

767
Q

Tx for sexual pain disorders

A

Lubricants and estrogen for vaginal atrophy
PT for pelvic floor if estrogen fails

768
Q

Tx for vaginismus

A

PT, Counseling, Gabapentin/Botox

769
Q

Tx for vulvodynia

A

Lidocaine, TCA, Remove irritants, PT

770
Q

MC symptom of cevicitis

A

Discharge -many are asymptomatic

771
Q

Cervicitis v. Vaginitis

A

Discharge see from cervcle os in cervicitis

772
Q

Strawberry cervix

A

Indicates trichomoniasis

773
Q

Presentation of chronic cervicitis

A

Often asymptomatic
Discharge - less than acute
Vaginal bleeding
Cervical tenderness
Proximal vagina may look okay
Urethritis, pelvic pain

774
Q

Microscopic analysis for cervisitis

A

Gram stain, Wet mounts - clue cells
KOH prep
PCR

775
Q

Pap smear/ Colposcopy for cervicitis

A

Double hairpin capillaries for trichomonas
Excess leukocytes
Cell enlargement - HPV
Multinucleated cells with ground glass cytoplasm - HSV

776
Q

Biopsy where cell properties have changed

A

Indicative of a virus!!

777
Q

Cervicitis prevention and screening

A

Barrier contraception
Routine screening in 19-25
Remove cervix with hysterectomy

778
Q

Incompetent cervix

A

Cervix shortens before 28 weeks gestation
Painless

779
Q

Risk factors for cervicle insufficiency

A

Cervical conization or Hx of previous episode

780
Q

Presentation of cervical insufficiency

A

2+ cm dilation with minimal contractions
2nd trimester

781
Q

Screening for cervical insufficiency

A

US at 14-16 weeks
Look for funneling and shortening abnormalities
No way to predict

782
Q

4 cervical insufficiency abnormalities

A

TYVU - Trust Your Vaginal Ultrosound
Shape of cervix -increasing risk and progression from T to U

783
Q

Tx for cervcal insufficiency

784
Q

3 things to look for before circlage -Contraindications

A

Make sure fetus is still viable 1st
Rupture of membranes
Look for infection - treat first

785
Q

Pharm tx for cervical insufficiancy

A

Adjunct to circlage - progesterone

786
Q

Nabothian cysts

A

Blocked glands on the cervix
Smooth rounded, whitish area that does not hurt
Benign!!

787
Q

CIN I-III

A

I - 1/3
II - 2/3
III - In theory entire cervix

788
Q

When do we NOT treat CIN I and II

A

Pregnant women - wait for delivery
Adolescents - observe at first

789
Q

Main risk factor for cervicle dysplasia

790
Q

Pap smear screening

A

Start at 21 3 years
Every 3 years or PAP+HPV every 5 years 30-65

791
Q

Pap screening after 65

A

Stop screening if:
No hx of mod-severe dysplasia/cancer
3 negative Pap or 2 neg PAP+HPV

792
Q

ASC-US cells on pap smear

A

Undetermined significance

793
Q

ASC-H cells on pap smear

A

Cannot exclude a high grade lesion

794
Q

LGSIL/LSIL on pap smear

A

Corresponds to CIN I

795
Q

HGSIL or HSIL on pap smear

A

Corresponds to CIN II or III

796
Q

Atypical glandular cells

A

Rare - cells from endocervix - MAY indicate cancer, may not

797
Q

Management for ASC-US

A

2 pap smears over 6 months - send for colposcopy if abnormal
Might try vaginal estrogen

798
Q

Management for anything that is NOT ASC-US

A

Send for colposcopy

799
Q

Colposcopy

A

Low power magnification of cervix - uses camera
Add acetic acid to light up abnormal areas
Bx abnormal areas

800
Q

Indications for colposcopy - 5

A

Abnormal pap smear
Clinically abnormal cervix
Unexplained bleeding
Vulvar/Vaginal neoplasia
Hx of in utero DES exposure

801
Q

Tx for CIN II-III after biopsy

A

Surgery with evaluation afterwards

802
Q

Management of cervical dysplasia - cryotherapy

A

Probe to blanch tissue in cervical os - 7mm margin
Makes it hard to visualize for later colposcopy

803
Q

Carbon dioxide laser for cervical dysplasia

A

More often in operating room
Very precise
More depth of excision
Can biopsy

804
Q

Loop electrosurgical excision procedure

A

LEEP - Small wire loop to remove with electrical generator
Can biopsy
Best procedure
For cervical dysplasia

805
Q

Cold knife

A

Cervical displasia
For large areas
No risk to being able to biopsy

806
Q

Prognosis for cervical dysplasia

A

80-90% success rates for any method

807
Q

Risk factors for cervical dysplasia recurrence -4

A

Large lesions
Gland involvement
Positive margins
Positive endocervical curretage

808
Q

MC type of cervical cancer

A

Squamous cell carcinoma

809
Q

Presentation of cervical cancer

A

MC symptom = Abnormal vaginal bleeding
Bloody leukorrhea, spotting, postcoital

810
Q

Late signs of cervical cancer

A

Fistula to recum or bladder leading to incompetence
Radiating pain
Weight loss, fever

811
Q

Signs of cervicle cancer

A

Cervix appears abnormal
Ulceration

812
Q

Endophytic cervix

A

Barrell shape, enlarged - cancer

813
Q

Exophytic cervix

A

Friable, bleeding, cauliflower lesions

814
Q

Dx for cervical cancer

A

Cancer may be present despite negative cytology - if the cervix look suspicious, still suspect

815
Q

Tx for cercal cancer

A

Radical hysterectomy with lymphadenectomy
Chemo is mostly palliative

816
Q

Normal vaginal flora

A

Aerobes, anaerobes, yeast
Lactobacilli that make it acidic

817
Q

Normal vaginal pH before and after menopause

A

Before - 4-4.5
After - 6.5-7

818
Q

Things that can alter vaginal flora

A

Low estrogen - decrease
Menses - Increase
Abx
Pregnnacy, Hysterectomy
Foreign substances
DM/Poor diet - worse

819
Q

Candidal vulvovaginitis presentation

A

Often in DM
Pruritis
THick white cottage cheese discharge
Minimal odor

820
Q

Dx for vulvovaginal candidiasis

A

Normal pH
Branching filaments and psudohyphae on wet prep/KOH

821
Q

Pharm tx for vulvovaginal candidiasis

A

Azole - 1st line ie. fluconazole
May extend therapy for recurrent cases

822
Q

Alternative vulvovaginal candidiasis tx

A

Boric acid
Gentian violet

823
Q

Vaginal antifungal administration

A

Administer at night

824
Q

MOA of azoles

A

Inhibit enzyme for cell membrane synthesis

825
Q

MOA of nystatin

A

Increase permeability of cell walls

826
Q

Ibrexafungerp MOA

A

Inhibits glucan synthesis - cell wall production
DO NOT TAKE with an azole

827
Q

MOA of boric acid

A

Interferes with metabolism
CI in pregnancy

828
Q

Gentian Violet MOA

A

May inhibit protein synthesis
Not many drug interactions

829
Q

Presentation of bacterial vaginosis

A

Milky, homogenous, malodorous discharge
No inflammation
Malodorous esp. after intercourse - fishy

830
Q

Dx of bacterial vaginosis

A

Vaginal pH 5.5-7
Clue cells - covered in bacteria
Fishy odor on KOH prep - wiff test

831
Q

Tx for Bacterial vaginosis

A

Metronidazole or Clinda

Can also use an expensive -azole

832
Q

MOA of metronidazole

A

Bind to and deactivate enzymes
Dizziness, HA, Fatigue
Disulfiram reaction

833
Q

Clindamycin MOA

A

Binds to ribosomes
C diff - and not with imodium

834
Q

Vaginal douche

A

Washing out of vagina - only for bacterial vaginosis - NOT for regular cleaning

835
Q

Presentation of trichomonal vaginitis

A

Frothy, copious green, foul smelling vaginal discharge
Strawberry cervix

836
Q

Dx for trichamoniasis

A

pH 5-5.5
Motile wet prep - look at right away before they die
Culture = Best test

837
Q

Tx for trichomonal vaginitis

A

Metronidazole or other ~idizole’s
Cross reactivity to alcohol
Liver disease

838
Q

Presentation of gonorrhea

A

80-85% asymptomatic
Copious mucopurulent discharge

839
Q

Dx for gonorrhea

A

Nucleic acid probe
Or culture of discharge

840
Q

Tx for gonorrhea

A

One shot IM rocephin
Treat partners

841
Q

CHlamydia presentation

A

Cervicitis, dysuria, bleeding
May progress to PID or lymphogranuloma venereum

CERVIX MAY LOOK NORMAL

842
Q

Dx for chlamydia

A

Culture
Immunoassay
Pap smear

843
Q

Tx for chlamydia

A

Doxycycline
ALT: Zmax

844
Q

Noninfectious vaginitis

A

Irritants, Allergens (latex), Atrophic, Excess sexual behavior

845
Q

Presentation of noninfectious vaginitis

A

Itching with no bacteria detectable - get a good hx

846
Q

Tx for noninfectious vaginitis

A

Lubricants
SERM
Sitz bath
Steroid if very painful/inflamed

847
Q

Alternitive tx for vaginitis

A

White vinegar - better option
Herbals
Iodine
Tea tree oil

May kill of good bacteria!

848
Q

Presentation of genital herpes

A

Vescicles that become painful erosions or ulcers
My have a buringing prodrome with inguinal lymphadenopathy

849
Q

Dx for genital herpes

A

Most often clinical
Tzank smear

850
Q

Initial tx for herpes outbreak

A

7-10 days valacyclovir, Famcyclovir, Acyclovir
1-5 days for recurrent
Same drugs for prophylaxis

851
Q

Condyloma acuminatum MC strains

A

MC HPV 6-11

852
Q

Presentation of condyloma

A

Culiflower growths - can be anywhere
May also be flat with rough surface

853
Q

Before tx analysis for condyloma

A

PAP smear and biopsy

854
Q

Tx for condyloma

A

Cryotherapy
Podofilox, Imiquimod, Interferon

855
Q

Molluscum contagiousum cause

856
Q

Presentation of molluscum contagiosum

A

Up to 1cm sized umbilicated papules
Inclusion bodies in cell cytoplasm

857
Q

Tx for molluscum contagiosum

A

Dessication, Freezing, Imiquimod
May observe - can cause scarring when removed

858
Q

Presentation of syphillis - 3 stages

A

1 - Painless sore
2 - Palm and sole rash
3 - Involves heart, brain, etc.

859
Q

Tx for Syphillis

A

PCN 1st line
ALT: Doxy

860
Q

Bartholin gland disease

A

Glands near vaginal orifices get infected or plugged
Red flag post menopause

861
Q

Presentation of bartholin gland disease

A

Tenderness - have to duck waddle
Fluctuant tender mass
Systemic signs of infection

862
Q

Tx for bartholin gland disease

A

Draining won’t help
Catheter inflation
Marsupialization - create a pouch
Check for cancer post menopause

863
Q

Abx for Bartholin gland disease

A

Usually not needed - may still use for prophylaxis

864
Q

Lichen sclerosis

A

MC non-neoplastic epithelial vulvar disorder
Usually women over 60

865
Q

Presentation of lichen sclerosis

A

Pruritis is MC sx
May see pain, white lesions, dyspareunia

866
Q

Progression of lichen sclerosis

A

Erythema w/ no response to yeast tx
White plaques develop
Scratching worsens and inflammation does

867
Q

Chronic presentation of lichen sclerosis

A

Ciggarette paper
Phimosis of clitoral hood
Labial fusion
General loss of structure

868
Q

Complication of lichen sclerosis

A

SCC - send for biopsy

869
Q

Tx for lichen sclerosis

A

Potent steroid - Clobetasol with a taper BID to QD eventually PRN for life

870
Q

Adjuncts for lichen sclerosis

A

Antihistamine, Tacrolimus, Methotrexate

871
Q

Lichen Simplex Chronicus

A

Due to a specific trigger or chrinic irritation
No loss of structure like in Lichen Sclerosis
Lots of itching

872
Q

Dx of LSC

A

Biopsy of lesion

873
Q

Tx for LSC

A

Hygeine and Sitz bath
Medium potency steroid - fluocinolone, triamcinolone)

874
Q

Lichen planus

A

Flat white plaques on vagina
Papules on skin
Send to GYN for biopsy
Steroids

875
Q

Dark non cancer vulvar lesions

A

Melanosis lentigo, etc.

876
Q

Vulvar varicosities

A

Common in pregnancy, concerning in elderly or non-pregnant
Sclerosing agent to tx

877
Q

Preinvasive vulvar disease

A

Strong association with HPV
White hyperkeratotic papules with pruritis
Dx through biopsy

878
Q

Tx for preinvasive vulvar disease

A

More aggressive for higher grade
Excision, ablations, laser

879
Q

Paget’s disease - vulvar

A

Itching, soreness
Red velvet cake presentation with white plaques
Can cause structural breakdown

880
Q

Tx for paget’s disease

A

WIDE local excision - need to recheck
Stop as soon as possible
Very poor prognosis if mets to lymph nodes

881
Q

Vulvectomy

A

Partial or radical
Removes area of skin +/- lymph nodes
Not great - last resort for cancer

882
Q

Vulvar cancer

A

90% SCC
Older patients with chronic inflammation or HPV

883
Q

Presentation of vulvar cancer

A

Itching or macerous skin lesion
May just be a “weird spot” w/ no sx

884
Q

Tx for vulvar cancer

A

Remove tumor - excise
Rad vulvectomy - may radiate to reduce
Pelvic exenteration if widespread

885
Q

Pelvic exenteration

A

Removal of everything in the pelvis - diversion of GI and GU tracts

886
Q

Vaginal Intraepithelial Neoplasia

A

Vagina rather than vulva
Colposcopy andbx to dx
Condylomatous lesions or flat and granular

887
Q

Tx for Preinvasive vaginal disease

A

Resection, 5FU not as effective
Difficult to get everything out

888
Q

True vaginal cancer

A

Not spread from the cervix
HPV, Smoking are RF

889
Q

Vaginal SCC

A

Exophytic or ulcerative lesions in the upper 1/3 of vagina

890
Q

Vaginal adenocarcinomas

A

MC vaginal primary tumor in young patient

891
Q

Vaginal sarcoma

A

Highly aggressive with grape like masses
Older pts -upper vaginal wall

892
Q

Vaginal melanoma

A

Usually towards the distal vagina

893
Q

Tx for vaginal cancer

A

Exenteration, Radiation
Poor prognosis

EOR Exams (7 decks)

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