OB/GYN III Flashcards
How is a molar pregnancy categorized
abnormal proliferation of the placental trophoblastic cells Abnormal cells distend the uterus and secrete hCG, mimicking a normal pregnancy. There are 2 types complete (classic) and partial (incomplete)
What defines a complete mole
Empty ovum fertilized by sperm.
46XX by one sperm occurs 90% of the time
46XX or 46 XY by two sperm occurs 10%
What is the most common clinical presentation of a molar pregnancy
Abnormal uterine bleeding (most common)
Uterine size greater than expected for GA
lack of fetal heart tones
hCG greater than 100,000 and uterine cavity filled with small vessicles
What defines an incomplete mole
a normal ovum is fertilized by two sperm. The resulting karyotype is 69 XXX, XXY, or XYY
A fetus may or may not be present, but will not viable if present
What are the most common clinical presentation of an incomplete molar pregnancy
Abnormal heavy bleeding
hCG is not as elevated as it is with a complete mole
Many spontaneous abortions are the result of a partial mole
How long should a patient wait for reattempting pregnancy following a molar pregnancy
at least 1 year
Gestational Trophoblastic Tumors may become metastatic to what locations
Lung (80%)
Vagina (30%)
Liver (10%)
Brain (10%)
How is a GTT diagnosed
After evacuation of a molar pregnancy
- increase in hCG
- the value of hCG reaches a plateau for 3 weeks
- metastatic disease is identified
What is used to treat non metastatic GTT
Single agent chemotherapy
- Methotrexate
- Actinomycin D
What drug is given with methotrexate to preserve normal cells
leucovorin
What is the mechanism of methotrexate
Anitmetabolite inhibits purine synthesis by blocking the dihydrofolate reductase enzyme required to process folic acid. Results in arrested synthesis of DNA, RNA and proteins
What is the mechanism of actinomycin D
Antibiotic that intercalates DNA strands
How should you monitor a patient with GTT
hCG titers should be taken weekly until normal fro 3 months, then monthly for 6 months
Contraception is preferred for 1 year
What carries a good prognosis with metastatic GTT
Rules of 4
- duration less than 4 months
- less than 40,000 hCG pretreatment
- No foreign metastasis to brain or liver
- no previous chemotherapy
What is the treatment for poor prognosis metastatic GTT
EMA-CO
Etoposide Methotrexate Actinomycin D Cyclophosphamide Oncovin (vincristine)
How long should treatment last for poor prognosis metastatic GTT
Three additional chemo sessions after a negative hCG titer
What are the phases of the menstrual cycle
Follicular
Secretory
What is polymenorrhea
menstrual cycles that last less than 21 days in duration
What is oligomenorrhea
menstrual cycles that last more than 35 days in duration
When are menstrual cycles most irregular
2 years following menarche
3 years preceding menopause
During both times anovulation is common
What is the follicular or proliferative phase
lasts from the first day of menses until ovulation, during which time follicles within the oveary grow in response to FSH and in the uterus enometrial glands proliferate under the influence of estrogen, primarily estradiol produced by the follicle
Characterized by:
Variable length (average of 14 days)
development of ovarian follicles in response to FSH
Secretion of estrogen from the ovary
Proliferation of the endometrium in response to estrogen
Low basal body temperature
What causes ovulation to occur
response to the LH surge
Characterized by:
release of the oocytes from the follicle in response to FSH induction of collagenases
Resumption of meiosis, with oocytes progressing from prophase I to metaphase II
Formation of the corpus luteum with in the follicle
What is the luteal or secretory phase
Begins with ovulation and last until menses
The corpus luteum, stimulated by LH, produces progesterone, which causes secretory changes in the endometrium necessary fro preparing the endometrium for implantation.
What characterizes the luteal phase
Fairly constant duration of 12-16 days
elevated basal temperature in response progesterone production
sustaining of the corpus lute in the ovary
Where is GnRH produced and what is the frequency of release
Produced by hypothalamic neurons from the arcuate nucleus and transported to the portal plexus to the anterior pituitary.
Released in a pulsatile manner:
Follicular phase has one pulse every 60-90 minutes
Luteal phase has one pulse ever 2-3 hours
Amplitude and frequency is modulated by feedback of estrogen and progesterone
What is the role of FSH
production of estrogen and growth of the follicle. FSH receptors exist primarily on the ovarian granulosa cell membrane
What is the role of LH
responsible for the initiation of the luteal phase (ovulation) and maintenance of the luteal phase of the menstrual cycle
LH receptors exist primarily on ovarian theca cells at all stages of the cycle and on granulosa cells after the follicle matures under the influence of FSH and estradiol
What is the 2 cell hypothesis of estrogen production
- LH acts on the theca cells to stimulate the conversion of cholesterol to androgens
- Androgens are transported from the theca cells to the granulosa cells
- Under the influence of FSH, androgens are aromatized to form estrogens by the enzyme aromatase in the granulosa cells
What are the key steps in the process of oogenesis
- primordial follicle
- Primary follicle
- Preantral follicle
- Antral follicle
- Preovulatory follicle
- Ovulation
- Early corpus luteum
- Mature corpus luteum
- Corpus Albicans
What is a primordial follicle
contains an oocyte surrounded by a single layer of granulosa cells. Each oocyte is arrested in Prophase I
A woman is born with a finite number of follicles that peaks at 20 weeks gestation. The decline is independent of the menstrual cycle and ovulation
What are the estrogen effects on the preantral follicle
- stimulates preantral follicle growth
- with FSH, increases FSH receptor content of the follicle
- in the presence of FSH, stimulate mitosis of granulosa cells
What are the effects of the follicular increase of estradiol
Negative feedback on FSH
positive feed back on LH
Where is inhibin secreted from
granulosa cells in response to FSH
What are the two types of inhibin
Inhibin A: under the influence of LH suppresses FSH during the luteal phase of the cycle.
Inhibin B: directly suppresses pituitary FSH secretion in the follicular phase of the cycle
What is activin
Augments secretion of FSH and increases pituitary response to GnRH by enhancing GnRH receptor formation on the pituitary
When do estrogens peak
24-36 hours before ovulation
What is the effect of LH on the follicle
initiates luetinization and progesterone production
What effect does a preovulatory rise in progesterone have
causes a midcycle FSH surge by enhancing pituitary response to GnRH and facilitating the positive feedback action of estrogen
When does ovulation occur
10-12 hours after peak of LH
24-36 hours after peak of Estradiol
When can an oocyte become fertilized
only after it has reached metaphase II
What does the LH surge stimulate
Resumption of meiosis in the oocyte
Luteinization of the granulosa cell
Synthesis of progesterone and prostaglandin
When are peak levels of progesterone obtained
7-8 days after ovulation
What happens in the absence of pregnancy to the corpus luteum
will undergo apoptosis and cease to produce progesterone by 12-14 days after ovulation
What effect does the decrease in estrogen and progesterone have on the endometrium
leads to coiling and constriction of the spiral arteries in the endometrium
What causes menstrual cramps
the result of uterine contraction which are stimulated by prostaglandins. Therefore the cramps can be controlled with prostaglandin synthetase inhibitors (NSAIDs)
What is amenorrhea
absence of menses for 6 months or longer
What is primary amenorrhea
Absence of menses by 14 years of age ingirls without appropriate development of secondary sexual characteristics or by 16 years of age regardless of secondary sex characteristics
What are the categories of amenorrhea
Hypergonadotropic: elevated gonadotropins (typically FSH more than 20 IU/L; LH more than 40 IU/L)
Hypogonadotropic: low levels of gonadotropins (FSH and LH less than 5 IU)
Eugonadotropic: normal gonadotropin levels (FISH and LH of 5-20 IU/L)
What are the etiologies of hypergonadotropic amenorrhea
- turner syndrome
- Premature ovarian failure
- Gonadal dysgenesis
- Gonadal agenesis
- Resistant ovary syndrome
- Galactosemia
- Enzyme deficiency
What are the phenotypic characteristics of turner syndrome
Short stature
webbed neck
shield chest
increased carrying angle at the elbow
What are the etiologies of hypogonadotropic amenorrhea
- anorexia
- Female athlete triad
- Kallman syndrome
- Postpill amenorrhea
- Medication or drugs
- Pituitary disease
- Stress
- Delayed puberty
What is the female athlete triad
Syndrome of disordered eating, amenorrhea, and osteopenia or osteoporosis
What percent of body fat is generally needed to initiate menarche and maintain regularity
17% to initiate
22% to maintain
What is kallman syndrome
Deficient secretion of GnRH associated with anosmia or hyposmia.
Involves the failure of olfactory axonal and GnRH neuronal migration from the olfactory placode in the nose
How does stress lead to amenorrhea
stress leads to an increased output of corticotropin releasing hormone, which subsequently results indecreased GnRH pulsatile secretion and thus decreased secretion of FSH and LH
What are the etiologies of Eugonadotropic amenorrhea
- Disorders of Androgen excess (PCOS)
- Disorders of the outflow tract or uterus
a. Mullerian agenesis
b. Mullerian anomalies
c. androgen insensitivity syndrome (AIS)
d. Asherman Syndrome
What is the triad assocated with PCOS
- Menstrual irregularity signifying oligo or anovulations
- Appearance of multiple small ovarian cysts on ultrasound “string of pearls”
- Clinical or laboratory evidence of hyperandrogenism
loss of 5-10% body weight may help patients reestablish ovulatory cycles.
When and how may an imperforate hymen present
generally not until 6-12 months after menarche. The vagina maybe distended with more than 1 Liter of old blood
What is the problem with Androgen insensitivity syndrome
The defect is in the androgen receptor and can not respond to the androgen. The individual is phenotypically female and is usually raised female
Testosterone levels will be in the male range, but they will not have any pubic or axillary hair. Normal breast development because the testosterone is converted to estrogen
Gonadectomy is required to prevent gonadoblastoma
What should be suspected if a female patient presents with bilateral inguinal hernia
AIS
What is asherman syndrome
Intrauterine scarring usually a result of viorous curettage during a hypoestrogenic state or in the presence of an intrauterine infection.
Adhesions can develop
What is the goal of hormone replacement for the treatment in patients with hypergonadotropic amenorrhea
prevent bone loss, vasomotor symptoms, urogenital atrophy, and cardiovascular disease due to lack of estrogen
When is it safe to consider an estrogen only treatment
in women without a uterus
Progesterone is needed as it is protective of the uterus
What is the mechanism behind using OCP for the treatment of PCOS
Progestin component suppresses endogenously elevate LH levels, thereby decreasing androgen overproduction
Estrogen component of the pill increases the sex hormone binding globulin levels thereby decreasing the amounts of free estrogens and androgens
What is the rotterdam criteria
It is the criteria established in 2003 that is used to diagnose PCOS. It requires 2 of the following 3:
a. Menstrual irregularities
b. Hyperandrogenism
c. Polycystic ovaries
What are the results of irregular ovulations
lack of adequate progesterone and experience chronic estrogen exposure to the endometrium. Increases risk for endometrial hyperplasia and endometrial cancer
What is the Ferriman-Gallwey score
It is a score used for diagnosing hirsutism.
Greater than 8 is an abnormal score
If a patient experience an rapid onset of hirsutism, what is the most likely etiology
Drug induced or Androgen secreting tumor
Suspect a tumor with levels of testosterone greater than 200 ng/dL
PCOS will likely have a more gradual onset of hirsutism
What defines polycystic ovaries by ultrasound criteria
12 or more antral follicles between 2 and 9 mm in size and peripheral in location in at least one ovary
What is the pathophysiology of LH in PCOS
increased LH pulse frequency and amplitude stimulated by GnRH
LH stimulates production of androgens from the theca cells in the ovary leading to hyperandrogenism
What is the pathophysiology of Insulin resistance in PCOS
With PCOS insulin resistance is present regardless of obesity
Insulin has been shown to increase production of androgens in women with PCOS
a. IGF-I receptor binding
b. Decreases production of sex hormone binding globulin produced by the liver. Increases free metabolically active testosterone
What are the health consequences of PCOS
Diabetes Obesity Metabolic syndrome Cardiovascular disease Endometrial Hyperplasia Infertility
What is the cause of cushings syndrome
Excess cortisol from ACTH
Diagnosed by 24 hour urine collection of free cortisol with the level greater than 100 on two determinations
What is ancanthosis nigricans
Raised, velvety, hyper pigmentation of skin, typically seen on the axilla, neck and intertriginous areas
Marker of insulin resistance
Will go away as insulin resistance improves
How can an insulin and glucose be used to determine insulin sensitivity
Glucose/Insulin Ratio
Ratio less than 4.5 in obese adult women
Ratio less than 7 in adolescents
suggested to diagnose insulin resistance
What is the underlying condition in PCOS and how can it be medically treated
Insulin resistance
Metformin
Thiazolidinediones
What is lanugo hair
soft, short hair covering the fetus that is shed in late gestation and during the neonatal period
What is vellus hair
soft, fine, unpigmented hair that covers apparently hairless areas of the body
What is terminal hair
longer, coarse, pigmented hair that may grow in response to sex hormones or may be sex hormone independent
What is hypertrichosis
excessive growth of androgen independent hair in nonsexual areas such as forearms and legs
What is hirsutism
the presence of terminal hair in androgen dependent sites where hair does not normally grow in women.
What is virilization
hirsutism associated with other signs of hyperandrogenism, such as increased muscle mass, clitormegaly, temporal balding, voice deepening and increased libido
What is the normal level of testosterone in women
less than 70 ng/dL
What are the percentages of free testosterone in women, women with hirsutism and men
women: 1%
hirsutism: 2%
men: 2-3%
Is it possible to have hirsutism with normal testosterone levels
YEP…
The active testosterone is unbound. With a decreased level of SHBG there is an increased level of free or unbound testosterone
What effect does cirrhosis have on SHBG
Increases the plasma levels therefore decreasing free testosterone
What factors may lead to the development of hirsutism
- Increased concentration of serum androgens, especially free testosterone
- Decreased levels of SHBG, resulting in increased bioavailable androgen
- Increased activity of 5a-reductase
What is NCAH
Nonclassic Adrenal Hyperplasia
This is a less severe form of congenital adrenal hyperplasia that is diagnosed in the newborn and is associated with amigos genitalia and salt wasting
What drug exposure may cause hirsutism without virilization
Pheyntoin diazoxide minoxidil danazol corticosteroids cyclosporin
What is the goal of treatment of hirsutism
The major goal is arresting the virilization process, not removing the hair. Once terminal hair has been established, withdrawal of androgens does not affect the established hair pattern
What is the benefit of using Combination hormonal contraceptive for the treatment of hirsutism
Both estrogen and progestin in the hormonal contraceptives cause a decrease in goadotropin secretion with a consequent decrease in ovarian androgen production
a. Estrogen also stimulate an increase in SHBG, causing increased binding of testosterone and decreased free testosterone levels
b. Progestin also may displace active androgens at the hair follicle and may inhibit 5a-reductase activity
What are some androgen receptor blockers that may be used for hirsutism
Spironolactone (5a-reductase inhibitor properties)
Flutamide (nonsteroidal antiandrogen)
Cyproterone acetate
What are some structural causes of abnormal bleeding
fibroids
endometrial polyps
adenomyosis
endometrial or uterine cancer
What is dysfunctional uterine bleeding (DUB)
abnormal bleeding that can be excessive or prolonged, or unpredictable, reflects a disturbance in normal ovulatory function. It is a manifestation of abnormal hormonal stimulation of the endometrium
What is metrorrhagia
bleeding at irregular intervals
What is menometrorrhagia
excessive bleeding at irregular intervals
What is menorrhagia
excessive or prolonged bleeding at regular intervals. Generally not associated with DUB because of the regular cycles
What causes the irregularity associated with DUB
unopposed estrogen stimulation that allows the endometrium to slough off in isolated locations at various times
What is the etiology of DUB
- PCOS
- Immaturity of the hypothalamic pituitary ovarian axis
3 Dysfunction of the hypothalamic pituitary ovarian axis - Abnormalities of the normal feedback signals
What is estrogen withdrawal bleeding
Bleeding that may occur at MIDCYCLE when estrogen levels decline briefly just before ovulation
What are some organic causes of abnormal uterine bleeding
- polyps
- uterine fibroids
- endometritis
- endometrial hyperplasia
- pregnancy
- blood dyscrasia
What increased risk does DUB carry
Increases risk of endometrial hyperplasia and cancer
30% of adolescents who present with severe blood loss will generally have what pathology
associated coagulapathy such as Von Willebrand Disease in which platelets are dysfunctional
What type of sonography is more sensitive in detecting endometrial polyps
Transvaginal
What are the orally administer progestins administered to control bleeding
- Medroxyprogesterone acetate 10mg daily for 10-12 days
- Norethindrone acetate 5 mg daily for 10-12 days
- Oral Micronized progesterone 200 mg daily for 10-12 days
How soon should a response be noted when utilizing OCP for control of bleeding
with in 24 hours of therapy initiation. If no response has occured by this time, another treatment for the DUB should be initiated
Can estrogen be used to stop DUB bleeding
Yes.
Rapidly stops bleeding with in 12-24 hours of treatment
It is effective when bleeding has been prolonged or is secondary to progesterone breakthrough bleeding
What is the mechanism of high dose estrogen to control bleeding
initiation of clotting at the capillary level
What role do NSAIDs have with DUB
limiting menstrual blood loss in women who ovulate, and they reduce excess blood loss by as much as 50%
What is the success rate of endometrial ablation
50% of women will achieve amenorrhea
90% will see a significant reduction
What are some common names for uterine leiomyomas
myomas
fibroids
ibromyomas
What are leiomyomas
porliferative well circumscribed, pseudoencapsulated, benign tumors composed of smooth muscle and fibrous connective tissue. Primarily located in the uterus but may be found in areas outside the uterus
What is the most common uterine mass
leiomyomas
present in 20-40% of women over the age of 35
How are leiomyomas classified
according to location
- Intramural leiomyomas: most common variety. Occurs within the myometrium of the uterus as isolated, ecapsulated nodules of varying size
- Submucous leiomyomas: located beneath the endometrium and can grow into the uterine cavity
- Subserosal leiomyomas: located just beneath the serosal surface and how out toward the peritoneal cavity and causing distortion of the peritoneal surface
How are leiomyosarcomas diagnosed
based on a mitotic count of 10 mitotic figures per 10 high power fields
What are the associated symptoms of leiomyomas
- Abnormal Uterine Bleeding
- Pain
- Pressure (GU and GI problems)
- Reproductive disorders
- Pregnancy related disorders
What should be done initially for treatment of leiomyomas
Expectant management.
Bimanual exam every 3-6 months to determine uterine size and rate of tumor growth
NSAIDs on a regular schedule to limit blood loss
What are the indications for surgery for leiomyomas
When symptoms fail to respond to conservative management.
Excessive bleeding Protrusion Rapid growth Repetitive pregnancy loss Infertility Enlarged Uterine size
What are the types of surgical procedures available for leiomyomas
- Myomectomy
a. Abdominal myomectomy
b. Hysteroscopic resection
c. Laparoscopic myomectomy
d. MRI guided focused Ultrasound
e. Laproscopic myolysis or cryomyolysis - Hysterectomy
- Uterine Artery Embolization (UAE)
What is endometriosis
the presence of functioning endometrial glands and stroma outside their usual location within the uterine cavity
Where does endometriosis occur
It is primarily a pelvic disease with implants in or adhesions of the ovaries, fallopian tubes, uterosacral ligaments, rectosigmoid, bladder, and appendix
Less common it can be located outside the pelvis suggesting a metastatic disease
What are the causes of endometriosis
- Retrograde menstrual flow
- Hematogenous or lymphatic spread
- Metaplasia of the coelomic epithelium
- Genetic and immunologic influences
What causes the pain associated with endometriosis
- Irritation or direct ivasion of pelvic floor nerves by infiltrating implants
- Effects of active bleeding from implants
- may result from growth factors, cytokines, prostaglandins, and histamines in endometriotic tissue and peritoneal fluid of women with endometriosis
How is fertility effected with endometriosis
Moderate to sever endometriosis is thought to cause infertility by causing adhesions and scarring of the ovaries and fallopian tubes
What are the signs and symptoms of endometriosis
- dysmenorrhea
- pain with ovulation
- chronic pelvic pain
- dyspareunia
- infertility
- GI and GU disturbances
a. 1/3 will urinary tract involvement
b. up to 1/3 will have bowel involvement
What is dyschezia
pain with defication
How is endometriosis diagnosed
the only way to diagnose the condition is by visualization at surgery or by biopsy of implants
What is a marker for endometriosis
CA-125
Not specific
What pathologies will elevate CA-125
Endometriosis
Ovarian Ca
PID
IBD
What will a typical pelvic exam demonstrate on a patient with endometriosis
- Nodularity and tenderness of the uterosacral ligaments
- Endometriomas
- Uterus is often in a fixed retroverted position
- Usually normal pelvic examination for minimal endometriosis
What are endometriomas
ovarian cysts filled with old blood from endometriosis, forming “chocolate cysts”. Palpated as adnexal masses often fixed to the lateral pelvic walls or to the posterior cull-de-sac
What is the appearance of endometriosis
brown or black pigmentation known as powder burn lesions
Lesions that are clear vesicular, white opacified, glandular excrescences, polypoid or red hemorrhagic vesicles are consider to be “atypical” lesions. May be more metabollically active
White scarring of pelvic peritoneum suggests old burned-out endometriosis
What is the basis of medical therapy for the treatment of endometriosis
hormonal suppression of menses
What are the medical options available for the treatment of endometriosis
- OCP
- GnRH agonist
- Danazol
- Aromatase inhibitors
What is the mechanism of OCP
creates a pseduopregnancy state associated with amenorrhea
What is the mechanism for GnRH agonist
Chemical alteration of the amino acids at positions 6 and 10 produce synthetic derivatives of GnRH that resist cleavage by endopeptidases but retain a high affinity for the pituitary GnRH receptor.
The effect is down regulation and desensitization of the pituitary with resulting lack of ovarian estrogen production
What are the side effects associated with GnRH agonist
- menopausal symptoms
2. Bone loss with prolonged use
What is the mechanism of danazol
adrogenic testosterone derivative that suppresses FSH and LH as well as ovarian estrogen and progesterone production
What are the adverse effects of danazol
Hirsutism
acne
weight gain
decreased breast size
What is the mechanism for aromatase inhibitors
Aromatase enzyme converts androgen precursors suchas androstenedione and testosterone to estrone and estradiol.
Inhibitors such as letrozole and anastrazole will inhibit the production of estrogen within the endometriotic lesion. They will increase FSH and LH by blocking estrogens negative feedback on the pituitary.
Currently only indicated for Breast cancer and this treatment option is considered investigational
What is the treatment choice for adhesions associated with endmetriosis
Surgery
What is the physiology of splanchnic pain
occurs when an irritable stimulus is appreciated in a specific organ secondary to tension, peritoneal irritation or inflammation, hypoxia or necrosis of viscera, or production of prostanoids
What is the physiology of referred pain
Occurs when autonomic impulses arise from a diseased visceral organ, eliciting an irritable response within the spinal cord. pain is sensed in the dermatomes corresponding to cells receiving those impulses
When is laparoscopy indicated for pelvic pain
cases that are unresponsive to medical therapy or when an organic cause of the pain is suspected
What should be included as differential for ACUTE pelvic pain
Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion PID GI disorders Urologic causes
what is mittleschmerz
pain the lower abdomen noticed at or near the time of ovulation. May be associated with a ruptured ovarian cyst
What should be included as differential for CHRONIC pelvic pain
Dysmenorrhia Pelvic Adhesions Endometriosis Adenomyosis Mullerian anomalies
What is the success rate of laporascopic separation of adhesions
75% report improvement in pain that is sustained at least 6-12 months
What is adenomyosis
a condition characterized by the presence of ectopic foci of endometrium within the myometrium, may also cause chronic pelvic pain and dysmenorrhea
What are the locations of ectopic pregnancies
- Tubal (99%) and most common sight is the ampulla
- Ovarian
- Abdominal
- Cervical
- Heterotropic
What is a heterotropic ectopic pregnancy
both intrauterine and ectopic pregnancy occurring simultaneously
What is the prevalence of ectopic pregnancy
2%
What are the signs and symptoms of an ectopic pregnancy
Vaginal bleeding
Abdominal pain
Other symptoms related to hypotension
Pregnancy status
How does smoking effect ectopic pregnancy
smoking causes tubal ciliary dysfunction
What approach is needed to diagnose an ectopic pregnancy
- Transvaginal ultrasound to rule out an intrauterine pregnancy
- hCG
- D&C
- Serial hCG if below discriminatory zone
- Laparoscopy
- Serum progesterone levels: Levels less than 5 ng/mL are considered nonviable
What is the discriminatory zone
the quantitative hCG level above which all viable intrauterine pregnancies are visible by ultra sound. Generally this is 2000 IU/mL
What are the surgical approaches available for treatment of an ectopic pregnancy
- Salpingectomy
- Linear Salpingotomy
- Operative laparoscopy
- Laparotomy
- Cornual resection
What are the medical approaches available for treatment of an ectopic pregnancy
Methotrexate
folic acid antagonist that interferes with DNA synthesis
how is infertility defined
no conception after 1 year of unprotected intercourse.
what is fecundability
monthly probability of pregnancy. Which is rough 20% among fertile couples. The cumulative probability of pregnancy after 1 year reaches 85%
How can hypothyroidism induce oligo/anovulation.
increased thyrotropin-releasing hormone (TRH) secretion stimulates prolactin secretion
High levels of prolactin cause thalamic dysfunction and lack of progesterone, leading to miscarriage
What is the treatment for ovulatory dysfunction
- Correcting the underlying problem
2. clomiphene citrate: Most commonly prescribed fertility drug and is indicated for the treatment of anovulation
What is the mechanism of clomiphen citrate
estrogen antagonist and works best in women with functioning hypothalamic pituitary ovarian axis
It triggers endogenous release of FSH, which then stimulates follicular development
How is a decreased ovarian reserve diagnosed
- Elevated menstrual cycle day 3 FSH is a marker for decreased number and quality of oocyte.
What is the definition of ovarian failure
FSH greater than 40 mIU/mL associated with amenorrhea.
If these findings are before the age of 40, it is considered premature ovarian failure
What is the treatment for decreased ovarian reserve
- Donor oocytes
2. Adoption
What are the common causes of tubal disease
Pelvic inflammatory disease
tubal ligation
endometriosis
How is tubal disease diagnosed
- HSG: hysterosalpingography - fluoroscopic view of the uterine cavity
- Laproscopy
What is the treatment for tubal disease
- IVF
- Surgery
a. Tubal reanastomosis
b. Lysis of peritubal adhesions
What are the WHO standards for a semen fertility sample
- Volume: 1.5 - 5.0mL
- Concentration greater than 20 million sperm/mL
- Total sperm greater than 40 million per ejaculate
- Percent motility greater than 50%
- Progression greater than 2
- Morphology more than 30% normal
- WBC less than 1 million/mL
what is azoospermia
absence of sperm in the ejaculate
What karyotype is associate with azoospermia
kleinfelter syndrome
what is CBAVD
congenital bilateral agenesis of the vas deferens
2/3 with CBAVD will have Cystic Fibrosis.
When is a woman’s most fertile days
up to 4 days prior to ovulation and the day of ovulation
What are the assisted reproductive technology options
- IVF (in vitro fertilization)
- ICSI (intracytoplasmic sperm injection)
- PGD (preimplantation genetic diagnosis)
- GIFT (famete intrafallopian transfer)
- ZIFT (zygote intrafallopian transfer)
What is RPL
Recurrent pregnancy loss
What defines recurrent pregnancy loss
two to three or more CONSECUTIVE spontaneous abortions of clinically recognized pregnancies prior to 15 weeks gestation
What is the incidence of RPL
5%
What are the etiology of miscarriages in the general reproductive population
Advanced age Chromosome anomaly Congenital anomaly Structural anomalies of the uterus Hormonal conditions
What is the etiology of RPL
50% is idiopathic Genetic/parental chromosomal abnormality Antiphospholipid syndrome Anatomic cause Endocrinologic factors
What is a robertsonian translocation
occurs when genetic information is exchanged between two acrocentric chromosomes.
What are acrocentric chromosomes
13, 14, 15, 21, 22
unique because their centromeres are near the end of the chromosome and their short arms encode redundant genes
How is APS (Antiphospholipid Syndrome) diagnosed
1 of the 2 clinical criteria
a. Thrombosis
b. Pregnancy morbidity
1 of the 2 laboratory criteria
a. Anticardiolipin antibodies, IgM or IgG in medium or high titers
b. Lupus anticoagulant antibodies
What do the muellarian ducts develop into
fallopian tubes and fuse to form the uterus, cervix and upper third of the vagina
What are the common muellarian anomalies associated with RPL
Uterine septum
Unicornuate uterus
Bicornuate uterus
Uterin didelphys
What is a uterine septum
results when fusion of the paired mullerian duct has occurred normally but the medial septum between the ducts has not been completely resorbed. Most common uterine abnormality diagnosed with RPL
What is a unicornuate uterus
occurs when one of the paired mullerian ducts fails to develop. A uterus with a limited cavity results
What is a bicornuate uterus
arises due to the incomplete fusion of the mulllerian ducts resulting in two separate uterine cavities joined at a common cervix
What is a uterine didelphys
the result of complete failure of the mullerian ducts to fuse, but normal differentiation of each duct system. The final out come is two separate uteri and cervices, with each uterine horn a smaller than normal uterus
How are uterine abnormalities diagnosed
- HSG hysterosalpinogography
- Ultrasound
- Saline sonohysterography
- MRI
- Hysteroscopy
At what point will DM become a significant risk for inducing RPL
A1C above 8%. Well controlled diabetes has little effect on RPL
What is the treatment for APS
heparin injections and low dose aspirin throughout pregnancy
The benefit is in its prevention of placental microthrombi and possible treatment of inflammation
What is a metroplasty
a surgical procedure to unify the cavities and reconstruct the uterus and can be performed when pregnacy outcomes have been particularly poor despite excellent and aggressive prenatal care in previous pregnancies
Can be done for bicornuate uterus and uterine didelphys
What is the treatment option for a unicornuate uterus
cerclage
