OB/GYN Pt 2 Flashcards
What are the two perineal boundaries
What seperates these two boundaries
? procedure is performed to prevent tearing during delivery
Urogenital (anterior): Symphysis Tuberosities
Anal (posterior): Perineum Anal complex Coccyx Tuberosities Sacrotuberous
Transverse perineal muscles
Perineal body
Episiotomy- perineal body
Labia majora is homologous to ? male structure
? structures are found here and ? structure terminates at the upper boundary
Labia minora is homologus to ? male structure
Scrotum
Sebaceous Exocrine Apocrine glands Venous plexus;
Round ligaments
Ventral shaft of penis
Labia minora contains ? type of glands
What does this join to form
What demarcation line is found here
Sebaceous
Superior: prepuce/clitoris frenulum
Inferior: fourchette
Hart Line- demarcation between skin/mucous membranes (outter: keratinized; inner: non-keratinized)
Glans of clitoris are homologous to ? male structure
This is the principle ? and is made of ? three parts
Define Vestibule and four structures found here and how many openings are found here
Erectile tissue
Female erogenous zone;
Glans, Corpus (body), Crura (x2)
Embryonic urogenital membrane derivative;
6- Vagina, Urethra, Bartholin/Skene glands
Where are the Bartholin glands are AKA and located ? in the vestibule w/ ? function
Define Minor Vestibular glands and where they’re located
Where are the Skene glands located and their function
Which ones are the largest paraurethral glands
Greater Vestibular Glands;
4 and 8- Lubrication
Mucin secreting glands along Hart line
Near urethral meatus, anterior vaginal wall;
Lubricate urethral opening
Skene
Vagina is a tube from ? to ? and contains ? type of cells
What is the name of the collagen elastin layer
Since no glands are found here, how is the structure lubricated
Hymenal ring to Uterus
Non-keratinized, stratified squamous
Adventitia
Sub-epithelial capillary transudate
Define Fornix and which one is used for surgical access to peritoneal cavity
What anatomical changes will be seen w/in the vagina post-menopause
Define Pouch of Douglas
Recess bordering cervix;
Posterior
Loss of rugae
Rectourterine pouch- lowest point of abdominal cavity
? is the lower portion of the uterus called
What is the upper and lower boundary of this called
What is the name of the area above where the vagina attaches to this area
Cervix
Internal os; External os
Portio Supravaginalis
What are three pregnancy induced changes seen on the cervix
Define Ecto/Endocervix
Define Squamocolumnar Junction and two factors that can alter it’s position
Hegar: isthmus softens d/t edema
Chadwick: ectocervical blue tinge d/t inc vascularity
Goodell: outer cervical softening d/t edema
Ecto: stratified squamous
Endo: canal covered by columnar tissue
Where columnar cells meet squamous cells;
Age, hormone status
Define Cervical Transformation Zone
Why is this zone important
What type of cellular changes are seen within the cervix at puberty ages
Area between original and new Squamocolumnar Junction
95% of cervical neoplasms develop here
Inc estrogen causes columnar proliferation onto ectovervix;
Acidified vagina, forces columnar transformation to squamous via glycogen utilization by lactobacilli
Define Uterine Corpus
What joins the Corpus to the Cervix and what does this become during pregnancy
What is the Posterior Wall AKA and why is it important
Muscular upper portion
Isthmus;
Lower uterine segment
Visceral peritoneum;
MC site of implantation
Uterine position is typically ?
Most of the upper uterus is called ? segment
What is the function of this segment
Anteroverted
Myometrium
Hemostasis at placental site during stage 3 of labor
What are the four parts of the fallopian tube from lateral to medial
What structure enclosed the fallopian tubes
What two MCs does the second structure have
Infundibulum Ampulla Isthmus Interstitial/Intramural
Broad ligament
Ampulla: MC site of fertilization and ectopic pregnancy
Ovaries secrete ? and are supplied w/ blood by ?
What is the MC location for ovarian Ca to develop
Where do they drain blood to
E/P; Ovarian/Uterine arteries
Epithelium, outer layer
L: left renal vein
R: IVC
Ovarian ligament holds ovaries to ? and suspensory ligament holds ovaries to ?
What are the two parts of the pelvic anatomy
What two shapes are most favorable for delivery and what two are least favorable
O: ovary to lateral uterus
S: ovary to pelvic wall
True: immobile, constraining to fetus/area of concern
False: above linea terminalis; supports pregnant uterus
+: Gynecoid*, Anthropoid
-: Android, Platypelloid
During delivery, dorsal lithotomy position can increase pelvic outlet size by ? much
Where do arteries supplying superficial abdominal wall arise from
Where do arteries supplying deeper abdominal wall arise from
1.5-2cm
Femoral artery below inguinal ligament
External iliac vessels
What is the name of the cesarean incision and ? structure is lacerated during it
What is the risk of vertical incision
What is the name and benefit of transverse incision
Maylard- inferior epigastric artery, lateral to rectus belly
Higher tension= wider scars
Pfannenstiel- follow Langer lines;
Less scars
What is the risk during low transverse incisions
? structure remains unchanged during pregnancy
What are the 3 tissue sources that develop into gonads
Severing iliohypogastric/ilioinguinal nerve= lost sensation to lateral glute/hypogastric region supplied by L1
Ovaries
Mesothelium- posterior abdominal wall
Mesenchyme- embryotic CT
Primordial germ cells- earliest undifferentiated sex cells
When does gonad differentiation begin and when is it committed by
Testes develop by week ? and ovaries develop by week ?
Mesonephric ducts are AKA ? and paramesonephric ducts are AKA ?
Start week 5, committed by week 7
T: 7wks; O: 12wks
Ovary histologically identified at week 10
M: Wolffian ducts
P: Mullerian ducts
What type of cell replication occurs in female fetus
What stimulates testis to begin to develop and when
Where are the glycoprotein anti-Mullerian hormones made and what is their function
Mitosis of oogonia
HCG peak at 8-12th week
Sertoli/Sustentacular cells- suppress paramesonephric ducts (uterus, fallopian tubes)
How are testis develop
? ducts are male reproductive
? ducts are female reproductive
Undifferentiated cell + TDF=
+ Mullerian inhibiting factor
+ testosterone
+ DHT
Undifferentiated cell w/out TDF=
- MIF, - testosterone
Regression of wolffian ducts
M= Mesonephric/Wolffian F= Paramesonephric/Mullerian
If uterine/vaginal developmental errors are going to occur, when does it happen and why
Define Didelphys
Define Bicornuate Uterus
Define BIcornuate Uterus w/ Rudimentary Horn
Define Septate Uterus
Define Unicornuate Uterus
Arrested development of uterovaginal primordium at week 8
Double Uterus and/or vagina- failed inferior duct fusion
Duplicated upper uterus body d/t slowed growth
Slowed growth of one paramesonephric duct
Failed resorption= thin septum internally
One paramesonephric duct fails to develop; inc risk for preterm delivery/loss
46 XY D/o Sexual Development
46XY S/o Sexual Development
Androgen Insensitivity Syndrome
Partial Androgen Insensitivity Syndrome
Female fetus exposed to excess androgen, causes external genital virilization;
Normal ovary, Clitoral hypertrophy, Partial majora fusion
Chromatin negative nuclei w/ variable in/external genitals d/t insufficient testosterone/MIH production by testis;
Ambiguous genitals
X-linked recessive inheritance, 46XY;
Externally female, blind pouch w/ testis in abdomen/inguinal
Resistance to testosterone= failed masculinization
Point mutation coding for androgen receptors
Define Turner Syndrome
Mullerian dysgeneis is AKA ? syndrome
Define Gamtogenesis
Primary Hypogonadism; 45XO; Hyper Hypo
Inc FSH, LH; Low E
Streak gonads= gonad dysgenesis
Mayer Rokitansky Kuster Hauser, 46XX
Formation and development of ova/sperm precursors into gamets- oocyte/spermatozoa
Define Meiosis I
Define Meiosis II
What phase are sperm cells stored in during infancy/pre-puberty
Diploid 46XY into haploid 23x/23y: primary spermatocyte 46xy into secondary spermatocyte 23x and 23y
2 haploid 23x, 2 haploid 23y
Seminiferous tubules as spermatogonia
What are the stages of spermatogenesis
Primordial germ cell Mitosis Spermatogonia, diploid Mitosis Spermatogonium, diploid Mitosis Primary spermatocyte, diploid Meiosis I 2 Secondary spermatocyte, haploid Meiosis II Four spermatids Spermiogenesis (last phase) Four sperm cells
What are the two components of sperm
Head:
Acrosome w/ enzymes
Nucleus
Tail:
Middle Principal End
Middle- mitochondria for ATP production
Define Sperm Capacitation
Prostaglandins found in semen provide what two benefits
Seminal vesicles provide ? nutrient for sperm energy allowing them to survive ? long
Sperm acquire ability to fertilize ova d/t nutrients from prostate/seminal vesicles
Uterine motility
Movement
Fructose; 48hrs
What are the four integrated sub-cycles of menstrual cycle
What is the first day of the cycle
How long are the cycles
Hypothalamus- GnRH
Anterior pituitary- LH, FSH
Ovary- E/P
Endometrium
First day of shedding
28d +/- 7days
Endometrium is responsive to ? three stimulants
Define Proliferative Phase
Define Secretory Phase
Progestin Estrogen Androgen
Estrogen driven; arteries lengthen
Progesterone from corpus lutuem stimulates glycogen/mucus
Estrogen levels are ? at ovulation making ? changes to cervical mucus
What microscopic changes will be seen
What is the name of the process when sperm pass through egg’s wall
High; inc alkaline, dec viscosity (spinnbarkheit)
Ferning
Corona radiata
What two reactions occur during fertilization
What are the roles of E, P and Prostaglandin E and F after fertilization
Name of the blastocyst prior to entering uterus for implantation
Acrosomal: enzymes penetrate zona pellucida
Zona: pellucida becomes impermeable
Est: faciliatates sticking
Pro: inhibits sticking
E: relaxes tubes
F: stimulates tube motility
Morula
What are the two layers of blastocyst that implant in uterus and what do they form
What are the 3 phases of implantation
What is the name of the structure that establishes implantation
Embryoblast: Amnion Cord Embryo
Trophoblast: Placenta hCG
Apposition Adhesion Invastion
Decidua- maternal component of placenta
What are the 3 parts of the decidua
What part separates conceptus from uterine cavity
On day 8, trophoblast differentiates into ? two structures
Basalis Capsularis Parietalis
Casularis
Cytotrophoblast
Synctiotrophoblast
Villous trophoblasts become ? to perform ? function
The other structure formed develop into ?
What is the maternal and fetal surface of the placenta called
Chorionic villi- transport nutrients and produces hormones
Extravillous- penetrate into maternal vasculature
Basal: divided into cotyledon
Chorionic: point of umbilical insertion
? layer of placenta maintain maternal/placenta separation
What are three different variants of this layer
What is the RF for these variants to occur
Nitabuchs layer
Accreta: adheres to myometrium
Increta: invades myometrium
Percreta: perforated myometrium
Prior uterine surgery
How long after conception does it take for maternal blood to enter the intervillous space
What is the functional unit of placenta architecture
Since the placenta grows faster than fetus during first trimester, when do they match in growth
1mon
Cotyeldon w/ one vein
Week 17;
Term- placenta= 1/6th of fetus
Where is b-hCG produced during first trimester to maintain the corpus luteum
When does this hormone peak then plateau
This hormone is also the cause of ? adverse s/e
Synchtiotrophoblast
60-70days
Morning sickness
What are the three advatages to fetal gas exchange
Chorionic villi drain nutrients and O2 from maternal blood by ? method
How many vessels are in the umbilical cord
Higher O2 affinity
Bohr effect
Higher Hgb
Bohr effect
One vein: oxygenated, pressurized R-side
Two arteries: no O2, flaccid L-side
What are the names of the 3 R to L shunts seen in fetal vasculature
How is the HPO axis suppressed during childhood to prevent puberty
Define Thelarche, Adrenarche, Pubarche, Menarche
Ductus venosus- bypasses hepatic circulation
Ductus arteriosus- diverts blood to brain/heart
Forament ovale- diverts blood from RA to systemic circulation
Estradiol, CNS inhibition of GnRH
The: breast
Adren/Pub: pubic hair
Men: menses
Tanner stages
Elevated Bud Contours 2* Mountains in Adulthood:
1: papilla elevation
2: budding, areola w/ enlargement
3: breast growth w/out contour
4: areola/papilla projection w/ 2* mound
5: adult type contour, papilla projection only
No SCAT:
1: villus hair only
2: sparse hair
3: coarse, curled pigment hair
4: adult hair w/out thigh involvement
5: adult hair spreading to thighs
Acronym for sequence of female puberty
? underlying issue can cause early onset puberty initiation
Why is this earlier initiation caused
TAPuP Me Thelarche Adrenarche Pubarche Peak growth velocity Menarche
Obesity
Leptin- produced in adipocytes
What is the critical body weight for menarche initiation
? can be the first sign of puberty that is out of sequence but considered normal
What starts the onset of puberty
48kg/106lbs (Frisch hypothesis)
Pubarche
Pulsatile GnRH causes anterior pituitary to release FSH/LH= onset
Define Precocious Puberty
What are the two types
Secondary characteristic development <8y/o or 2.5SD below mean age
Central: gonadotropin dependent; characteristics same as phenotype
Peripheral: gnoadotropin independent; characteristics opposite of phenotype
What can cause Central Precocious Puberty
What can cause Peripheral Precocious Puberty
Idopathic Ischemic Iatrogenic
Tumor
Abnormal CNS
Trauma
Glucocorticoid resistance Ovarian Cyst Tumor producing E/T CAH Aromatase syndrome McCune Albright Syndrome Primary hypothyroidism
What is the first sign of Central Precocious Puberty
What would be seen on lab results
How is it Tx
Thelarche
High LH/FSH d/t inc Estrogen
GnRH agonist to inhibit LH/FSH
What would be seen on lab results in Peripheral Precocious Puberty
What is the risk of not treating Precocious Puberty
What are the 3 goals of Tx
Low FSH/LH
Short stature d/t epiphyseal fusion be estrogen dependent
Advanced bone age
Psych distress
Maximize height
Relief of psych distress
Synchronize puberty w/ peers
Females w/ signs of virilization need ? test to differentiate premature thelarche from precocious puberty
Define Delayed Puberty
What is the MC cause
Leuprolide stim test
Lack of thelarche at 13y/o
No menses by 16y/o
Constitutional (physiologic) delay
What are the two causes of Delayed Puberty and what lab results would be seen for each
Average blood loss during menses
When are cycles most irregular
D/t gonad: hypergoadism- high FSH, LH
D/t hypothalamus: 2* hypogonadism- low FSH/LH
Hypo, Hypo; GnRH deficiency
Low FSH/LH
20-60mL
2yrs after menarche, 3yrs before menopause
Females have ? many ova present at birth but only ? at puberty
Why is there a difference in numbers
How many ovulations will occur in life
1-2M; <400K oogonium (2n)
Follicular atresia; apoptosis
400
? phase of menstrual cycle is variable in duration
? are the two parts of this cycle
? phase of cycle is usually stable in duration
Follicular: first day of menses through ovulation d/t estradiol threshold level
Early: day 1-5 w/ dec E/P and shedding
Late: day 6-14 w/ inc E, endometrial growth
Luteal phase
Follicular Phase
Starts on day one of menstruation
Ends at ovulation
Inc FSH causes primary follicle to develop
Follicle increases Estrogen to stim uterine proliferation
Theca cells produce androstenedione d/t LH
Granular cells concert androstenedione to estradiol d/t FSH
Day 14: estrogen surge causes LH spike and oculation
Ovums must be fertilized w/in ? time frame after release
Oocytes are stored in ? phase of development
For ovulation to occur, ? levels must remain at ? for 50hrs or more
Luteal Phase
<24hrs
Meiosis 1
Estradiol >200pg/ML x 50hrs
Starts afer LH spike, ends on day 1 of menses
Staple and define duration
? + ? form corpus luteum
If fertilization occurs, trophoblast produces ? hormone similar to ?
If no fertilization occurs, how long does luteum remain
Granulosa, Theca interna cells
hCG, similar to LH- maintains placenta
14d, dec progesterone levels cause sloughing
Estrogen has ? effect on endometrium while
progesterone has ? effect on endometrium
Prolactin has ? effect on breast tissue while oxytocin has ? effect
Two effects of FSH on ovary
E: Proliferative; P: Secretory
P: production; O: expression
Primary follicle development
Androstenedione to estradiol conversion in granulosa cell
Define Amenorrhea
Define Secondary Amenorrhea
Functional Amenorrhea can be AKA ? and is d/t ?
16y/o w/ secondary characters, no meneses
14y/o w/out secondary or menses
No menses w/in 3yrs of thelarche
Cessation of menses x 3mon
Non-structural hypothalamic amenorrhea;
Abnormal GnRH d/t stress, low weight, celiac dz
Two MCCs of Secondary Amenorrhea
1: pregnancy
2: anovulatory cycles
Pregnancy, TSH, Prolactin labs
Progesterone challenge test:
+ bleed= anovulatory, PCOS
- bleed= E/P challenge test
+ bleed= FSH levels
>40= menopause/premature ovary failure
<5: stress, tumors, radiation, Sheehans
- bleed:
Outflow obstruction
Ashermans Syndrome
Define Dysfunctional Bleeding
Define Heavy Bleeding
Define Inter-Menstrual bleeding
Define dec/shortened menses
Dysfunctional bleeds
Menorrhagia
Metrorrhagia
Hypomenorrhea
Time frames:
In/Frequent bleeds
Amenorrhea/Irregular bleeds
Prolonged/Shortened bleeds
Heavy/Light flow
<21d, >35d
Absent x 6mon, >20 day variation in cycle
> 8d, <2d
> 80cc, <5cc
How many points are assigned for bleeding through pad, tampon and for clots
? is the MC complaint seen in Gyn
What acronym is used for DDxs
Pad: 20
Tampon: 10
Large: 5
Small: 1
Abnormal uterine bleeding
PALM COEIN
Polyp Adenomyosis Leiomyoma Malignancy
Coags Ovarian dysfunction Endometrial Iatrogenic Not classified
How does age of Pt indicate DDx for abnormal uterine bleeding
Prepuberty: bleeding defect
Perimenarchal: immature HPO axis
Reproductive: less cycle variability
Perimenopause: dec ovarian function, follicular atresia
Postmenopause- r/o Ca
How is Acute Menorrhagia Tx in stable Pts
How long until re-eval is needed and what is the next step
What is the next step if the above option is unavailable
Combined OCPs
Medroxyprogesterone acetate
Unstable/Unrepsonsive in 24hrs: surgery
1st: DnC
Balloon tamponade
How is Chronic Recurrent Menorrhagia Tx
What can be done one time in attempt to reset the cycle
What is the third step that most Pts will need
? is used in Pts w/ excessive fibrinolytic therapy
Normalize prostaglandins
NSAIDs
Combined OCPs
Medroxyprogesterone acetate
Levonogestrel IUD*
Progestin only OCPs
Depo
Tranexamic acid
When are Pts w/ abnormal uterine bleeding surgical candidates
Define Dysmenorrhea
What are the two types and causes
Underlying structure cause
Medical therapy failure
Completed child bearing
Cyclic pain w/ menstruation; cramping w/ backache, HA, N/V/D
Primary: begins after menarche
Secondary: underlying pathology w/ less prostaglandin involvement
How is dysmenorrhea Tx
Define Endometriosis
What is the MC site for abnormal tissue to be found
NSAIDs
Combined OCPs
Progestin only
Endometrial glands/stroma outside of normal location
MC: Pelvic peritoneum
Frequent: ovary, uterosacral ligament
Endometriosis is a ? dependent d/o
What are the four theorized pathogenesis of endometriosis
What are the D’s of endometriosis
Estrogen
Retrograde menstruation
Mullerian dysplasia
Lymphatic spread
Stem Cell
Dysmenorrhea
Dyspareunia
Dyschezia
What signs of endoetriosis may be sen on exam
What signs may be seen if tissue is w/in thoracic cavity
What is the perferred imaging modality and how are they Tx
Tender adnexa: ovarian endometriomas (chocolate cyst) Retroverted uterus Rectovaginal septum nodules Barbed uterosacral ligament Posterior fornix tenderness
Right sided, cyclic Sxs including pain, hemoptysis and pneumothorax
CT;
Hormones, surgery
How is endometriosis definitively Dx and Tx
Mild cases can be managed w/ observation and ?
What is the next step if Sxs persist
Laparoscopy w/ ablation for Tx
NSAIDs
Cyclic hormones
What is the next step in endometriosis Tx if NSAIDs and OCPs fail to control Sxs
What androgen analog can be used to inhibit FSH/LH
What GnRH agonist can be used to dec estrogen and induce pseudomenopause
Definitive Dx w/ Gyn referral
Danazol
Leuprolide
Endometriosis can cause ? type of amenorrhea
How is the pain of endometriosis different from dysmenorrhea
Endometriosis also commonly exists w/ ? other two Dxs
Secondary
Cyclic pelvic pain peaking 1-2d prior to menses
Adenomyosis
Uterine fibroids
Define PMS
Define PMDD
What do both have in common
Premenstrual Syndrome;
Numerous Sxs not associated w/ significant impairement
Premenstrual Dysphoric D/o:
5Sxs w/ psychosocial or functional impairment
Imbalance of E/P w/ excess prostaglandins
Sxs of PMS/PMDD occur during ? phase d/t ?
Why do Pts complain of bloat
What is the theory behind PMDDs physical and behavioral Sxs
Luteal, dec serotonin activity
Progesterone- antimineralcorticoid
Estrogen- activates RAAS
Altered E+/fluid balance
2nd half of luteal phase:
E/P neuroactivity
How is PMDD Dx
Diets high in ? two ingredients can increase Sxs
What are the top two PE Sxs of PMS
What is the top behavioral health Sx of PMS
Sxs during luteal phase
Sx free x 7d in first half of cycle for three consecutive cycles
Sugar, Caffeine
Fatigue, Bloat
Labile mood
How is PMS/PMDD Tx first and second line
Why does the second line Tx need to be attempted prior to surgical intervention
Why is Danazol poorly tolerated by PTs
1st: SSRIs- Fluoxetine Sertraline Paroxetine
2nd: anovulatory meds: COCPs Leuprorelin (GnRH agonist)
Tests if false menopause improves Sxs
Acne, hair growth
How are the cramps/HA of PMS/PMDD Tx
How is the swelling/bloat Tx
What non-med intake can reduce cramping
NSAIDs
Hctz/Triamterene
Spironolactone
Ca 600mg BID
PMD/PMDD Pts can increase ? intake needed as cofactor for serotonin
What can help reduce anxiety Sxs
Define Menopause
Pyridoxine B6
Mg and Vit B6
12mon since LMP
Define Premature Ovarian Failure and is associated w/ ?
Sxs of Menopause
Cessation of menses <40y/o;
High FSH
IFLUSH: Insomnia Flash/forgetful Libido decrease Urinary Sxs Sad skin HA/Heart Dz
How is estrogen cardioprotective
By ? age are men and women at equal risk
HT(?) is not cardioprotective if started ?
Inc HDL, lower TC
70y/o
> 60y/o, 10yr after FMP
What drug combo is used for meopause Sxs
Why do we not give unopposed estrogen to women w/ uterus
Estrogen + Bazedoxifene (if +uterus)
Inc endometrial hyperplasia
Neoplasia
Endometrial Ca
Mnemonic for Osteoporosis RFs
SHATTERED Family Steroids Hyper-thyroid, Ca, parathyroid Alcohol, tobacco T, low Thin, low BMI Early menopause Renal/liver dz Erosive bone dz Diet low in Ca/DMT1 FamHx
All women need DEXA scans at / age or w/ ? RFs
When do perimenopausal women get DEXA scans
What are the DEXA scores
65/> or
One or more RF or
Sustained Fxs
RFs
BMI <18.5
Meds w/ accelerated bone loss
Normal: +2.5 - -1
Penia: -1 - -2.5
Porosis:
Define Z and T Score
How much Ca is used for osteoporosis prevention
When/how much Vit D is used
T: score compared to healthy, young adult
Z: score compared to Pt same age/gender
31-50y/o: 1g/day
51/>: 1200mg/day
Post-menopause w/out Fx/Fall risk;
600 IU/qd
When is osteoporosis therapy started
What meds are used to reduce resorption
What meds are used to stimulate bone formation
T score
Osteoporosis therapies work more quickly in ? bone and why
MOA of bisphosphonates
What are 4 possible s/e
Vertebrae: higher trabecular content
Inhibit osteoclast funtion to dec resporption
Jaw osteonecrosis
Atypical femur Fx
Worse w/ prolonged use >5yrs, consider drug holiday
? effect does estrogen have on osteoclasts
Pts losing ? much height need a Dx of compression Fx considered
Most Ca is lost from ? type of bone located ?
Dec estrogen= inc activity
Loss of >1.5”
Trabecular: spine, femoral neck
Pts w/ early onset primary amenorrhea are at risk for ? Dx later in life
? Tx method offers decent hormonal replacement
Osteoporosis induced femoral neck Fx
OCPs
? is the MC presenting Sx of vaginal Ca
Vaginal cancer is MC related to ? infection
? is the MC type of vaginal Ca
Vaginal bleeding, especially post-menopause/intercourse
HPV
SCC
? is the main Tx for endometrial carcinoma
What is the first line therapy for recurrent endometrial carcinomas
Per USPSTF, when are breast Ca screenings started
Surgical excision, total abdominal hysterectomy
High dose progestin
Screening mammographys at 50y/o
50-74y/o: biennial, every other year
What is the MCC of postpartum hemorrhage
Postpartum hemorrhage is defined as ? amount
What are the mainstays of Tx
Uterine atony
> 1000mL or,
Hemodynamic instability <24hrs
Fundal massage, Oxytocin
What are the 4 T’s of Post-Partum Hemorrhage
? artery provides the main blood supply to uterus
? is the MC fetal malpresentation
Atony
Trauma to birth canal
Tissue retention
Thrombin d/o or coagulopathy
Uterine artery
Breech: buttock adjacent to maternal pelvis, head in fundus
What are the 3 types of breech presentation
If presentation has not been self-corrected by ?wks, ? maneuver is performed
Frank: MC; hips flexed, knees extended w/ feet next to head
Complete: hips and knees flexed, feet next to buttocks
Incomplete: one/both hips not completely flexed, one/both feet near cervix
38wks,
External cephalic version
What is the MC presentation at delivery and associated w/ the least risk for adverse outcomes
MC areas infected during PID w/ ? microbes
How is PID Tx outpatient and inpatient
Cephalic w/ occiput anterior position
Uterus, Fallopian tubes;
G/C*(MC)
Out: Ceftriaxone, Doxycycline w/ Metro
In: Cefotetan or Cefoxitin w/ Doxy
Major criteria supporting PID Dx
Initial step for Pt w/ painless post-menopause bleeding
? is the MCC of postmenopausal bleeding
Lower abdominal pain in at risk Pt AND:
Uterine tenderness or,
Adnexal tenderness or,
+ chandalier sign
Endometrial biopsy
Atrophic vaginitis
RFs for endometrial Ca
MCC of ovulatory infertility
This MCC is also the MC cause of ? in women
Early menarche Nulliparity Late menopause Obesity FamHx
PCOS, Dx w/ two of three: Oligo/Anovulatory Hyperandrogenism Polycystic ovaries US criteria: >10cm or 12 antral follicles
Infertility
How are hot flashes Tx
? alternative is used if primary med is c/i in postmenopausal women for significant hot flashes/sleep disturbances
W/ uterus: Estrogen and Progesterone to preevnt endometrial hyperplasia
No uterus: Estrogen
Gabapentin
Erythrasma is caused by a infection of ?
How is it Dx on PE
How is it Tx if widespread or localized
Corynebacterium
Woods lamp: red
Wide: erythromycin
Local: clindamycin
Vaginal mucosa produces ? for vaginal ecosystem stasis
? is the predominant, natural defense microbe
What are the only two categories of non-inflammatory vaginitis
Glycogen
Lactobacilli
BV, Candidiasis
? is the only etiology of vaginitis to cause both inflammatory and non-inflammatory vaginitis
? is the MCC of vaginal d/c
What will be seen on PE during this MC
Candidiasis
Bacterial vaginosis
Profuse, grey milky d/c w/ fishy odor
Bacterial vaginitis Sxs develop d/t overgrowth of ? species
What criteria is used for Dx
What lab test can be used for Dx
Anaerobics
Amsels w/ three of DPWC: Homogenous d/c pH >4.5 Positive whiff test Clue cells on wet prep
PCR
What type of response is seen on paper when diagnosis bacterial vaginitis
Why is there a fishy odor w/ this Dx
How is Acute Bacterial Vaginitis Tx
pH >4.5 turns nitrazine paper blue
KOH added causes amine release
Metronidazole
Clindamycin
How is recurrent bacterial vaginitis w/out prior extended treatment managed
How are these cases manged if Pt does have Hx of prior extended Tx
2wk Tx w/:
Vaginal metrogel/Clindamycin
PO Metronidazole/Tinidazole
Initial Tx x 2wks:
Vaginal metrogel/Clindamycin
PO Metronidazole/Tinidazole
Then add suppression therapy:
Metronidazole gel 1/wk or
PO MetronidazoleTinidazole 2/wk for 6mon
? is the 2nd MCC of vaginitis
How does this MC present on PE
What two types of microbes are responsible
Candidiasis
Burn/itch w/ cottage cheese d/c
Albicans > Glabrata (uncontrolled DMT1)
How is Candidiasis Vaginitis Dx
? RFs put Pts at risk for this type of infection
What causes Pts to suffer from chronic candidiasis infections
Erythema
pH <4.5
Budding yeast w/ pseudohyphae
DMT1 OCPs Pregnant ImmSupp
Dec concentration of mannose binding lectin and
Inc concentration of IL-4
Recurrent Fungal Vaginitis is defined as ? episodes/yr
How is recurrent fungal vaginitis Tx
What is used for suppressive Tx
4 or more
PO Fluconazole q3d on day 1, 4 and 7
PO Fluconazole 100-200mg/wk x 6mon
How is non-albican species vaginitis that is unresponsive to topicals Tx
? is the 3rd MCC of vaginal d/c
How does this 3rd MC present on PE
PO Fluconazole q3d
Boric acid qd x 2wks
Trichomoniasis
Green/yellow d/c w/ musty odor and dyspareunia/uria; strawberry cervix
How is Trichomoniasis Tx
4 etiologies of vulvar pruritus
PO Metronidazole
PO Tinidazole
White lesion (dystrophy)
Infestation
Red lesion (dermatoses)
Squamous hyperplasia
How does Lichen Sclerosus present
What will be seen on exam
How is it Dx
How is it Tx
Post-menopausal women w/ inflammed dermis; MC perianal
Cellophane/cigarette paper appearance
Biopsy; f/u q12mon
Topical clobetasol
Sev/unremitting: retinoids
Sev: phototherapy, Aminolevulinic acid
What causes Lichen Simplex Chronicus to develop
What area is MC affected
How can this be Tx/Sxs reduced
When is f/u needed
Non-neoplastic alteration d/t chronic itch/scratch cycle
Labia majora
Petroleum jelly
Vegetable oil
PO antihistamine
Topical steroids
3wks, unresolved= biopsy
How does atopic dermatitis present
How is it managed/Tx
If psoriasis is found on vulva, ? is suspected in history
Scaly patches w/ fissuring
Topical steroids
Tacrolimus
Trauma
How is vaginal psoriasis managed
How does Lichen Planus present on PE
What are the 3 variants that can be seen
Dovonex (calcipotriene)
Red erosion w/ white border on cutaneous/mucosal surface;
Narrowed introitus
Erosive, MC/difficult to Tx
Papulosquamous
Hypertrophic
? form of lichen planus is difficult to Tx
How is the condition Tx
Define Intertrigo
Vulvovaginal syndrome
Clobetasol
Vaginal hydrocortisone
Friction between moist skin folds causing burn/itch/hyperpigmentation
How is intertrigo Tx based on cause
? is the MCC of vaginal irritation after menopause
How is this MC Dx
Drying: corn starch
Inflamed: mild topical steroid
Fungal: nystatin, clotrimazole
Atrophic vaginitis
Friable epithelium w/ loss of rugae and Pap smear changes
How is Atrophic Vaginitis Tx
When do bartholin cyst become less common and more concerning
How are these Tx
Estrogen topical/PO
> 40y/o- Ca concern
ASx: none unless <40y/o
Word catheter
Cath failure x2 : marsupialize
If bartholin cysts occur ? they are painless
? is the sequelae of bartholin cyst
Most sequelaes are polymicrobial but association w/ ?
Within duct
Bartholin abscess
G/C infection
How are Barthlin Abscess Tx
What are the indications for ABX to be used
What ABX are used
Fluctuant: InD w/ word catheter
Pregnant Recurrent ImmSupp Cellulitis Infection
2nd Gen Cephalosporin
Fluroquinolones
Augmentin
TMP-SMX
What causes Toxic Shock Syndrome
What are the classic Sxs of this Dx
What would be seen on PE
Exotoxin from Staph A two days after surgery/onset of menses
Fever Malaise Diarrhea
Diffuse macular and erythematous rash
To Dx Toxic Shock Syndrome all major criteria must be met including ?
Vulvular Ca increases in incidence w/ ? two factors
90% of these Cas are ? type and the remaining are ?
SBP <90 HOTN Orthostatic syncope Temp Macular erythroderma Desquamation
Longevity
HIV infection
SCC arising from vestibule at Hart line;
Malignant melanoma
How does Verrucous Carcinoma present
How does BCC vulvular Ca present
How does Vulvar Sarcoma present
How does Bartholin gland Ca present
How does Vulvar Paget Dz present
Cauliflower shaped mass w/ pruritus/pain; radiotherapy resistant
Common in elderly women arising from L Majora w/ poor pigment and pruritus
Rare but w/ broader age range of incidence
Peaks in mid-60s
Intraepithelial neoplasias w/ eczemoid, red weeping area
What are the vulvar Ca RFs for women <55y/o
What are the RFs for women >55y/o
? duo makes Pts 35x increased risk for vulvar cancer
HPV, smoking
Non-smoker w/out STD Hx
Long standing lichen sclerosis
Smoker and HPV genital warts
How are vulvar cancers evaluated
What is the only time this cancer is Tx w/ wide, local excision
What are the other two Tx options
Vulvoscopy- colpo w/ acetic acid to get thick punch biopsy
Stage 1A, microinvasive
Radical vulvar resection
Chemoradiation
How often are vulvar cancers f/u
? recurrence almost always indicates fatal dz
? vaginal carcinomas are rare
q3mon x 2-3yrs
q5mon x 5yrs
Annual
Inguinal lymph node recurrence
Primary, most mets to vagina
What are the 4 types of vaginal Cas
SCC d/t HPV
Adeno: often mets to vagina
Mesenchymal-
Rhabdomyosarcoma- MC <5y/o
Leiomyosarcoma- most rare
Melanoma
Adenocarcinoma of the vainga is linked to ? exposure
? type of adeno cancer is caused
What is the MC c/c of vaginal cancer and ? is the MC region affected
Diethylstillbestrol
Clear cell cancer
Vaginal bleeding;
Upper third wall
Pts presenting w/ anterior vaginal wall Ca may have ? three Sxs
If posterior wall is involved ? Sxs may be present
Hema/Dys-uria
Urgency
Constipation
Indication to give Rhogam
When does father’s blood type come into consideration
Women w/ Rh? status or unknown father blood type need Rh immunoglobulin at ? mile marker
Rh- mother w/ Rh+ baby
Mother makes Abs against Rh+ Ag
Rh- mother= fathers blood
Rh- = no chance of Rh immunoglobulin
Rh+: recommend giving Rhogam
Rh+; 28wks or <72hrs of end of pregnancy
? is the name of test run on maternal blood to identify fetal blood cells
? Ca marker is used to screen/monitor for ovarian Ca
? combo decreases the risk for ovarian cancer development
Kleihauer Betke test
Ca Ag 125
Anovulatory Pts taking chronic OCPs
? is the biggest RF for ovarian cancer
What are the three layers of ovarian Ca and prevalence of each
? are some of the MC c/c of molar pregnancies
FamHx
Epithelial: >50y/o
Stromal: any age
Germ: 15-19y/o
Pain Bleeding Hyperemesis gravidarum
? is seen on PE during molar pregnancies
? is first line imaging and what will be seen
How is this condition Tx
Uterus higher than gestational age
TV-US: snow storm or bag of grapes
Suction curettage
? is the mainstay of Tx for Gestational Trophoblastic Neoplasia
This condition is AKA ?
These are associated w/ ? carcinoma
Chemo
Hydatidiform mole
Choriocarcinoma
Dietary deficiency of ? is associated w/ increased risk for complete mole pregnancy
What is first and second line Tx for atrophic vaginitis
What key terms may be used to describe PE findings
Vit A
1st: Lube/moisturizer
2nd: Vaginal estrogen
Pale, dry, shiny epithelium
What medication can be used for atrophic vaginitis in Pts that don’t want vaginal route delivery
? is initial lab study for gestational diabetes and w/ ? result failing
What is the next step for Pts that fail the initial test
SERM: Ospemifene
50g, 1hr PO glucose challenge; 130/> is failure
100g, 3hr PO challenge and is diagnostic
Diagnostic criteria for Dx Gestational Diabetes
50g, 1hr challenge at 24-28wks gestation; glucose 130-140 after 1hr go to 3hr test
100g, 3hr challenge w/in one week of first challenge
Two criteria met= Dx >95mg fasting >180mg at 1hr >155 at 2hrs >140 at 3hrs
Asthma Tx during pregnancy
What kind of microbe causes chancroids
What is the Tx
Albuterol- class c Budesonide- class b Ipratropium- class c Prednisone- class c/d
H ducreyi- gram neg, coccobaccilus
Azithromycin
Ceftriaxone
Ciprofloxacin
Erythromycin
When Tx H Ducreyi, consider empiric Tx for ? other STD
What microbe causes Condyoma Latum
? is first line recommended birth control for adolescents requesting contorl
Syphilis
Treponema pallidum, Syphilis
LARCs- etonogestrol implant
IUD
? is the best method to identifying persistent/recurrent gestational trophoblastic disease
Where should the fundus be at week 12, 20, 36, and 40wks
Where is the fundus <24hrs postpartum
Quant b-hCG
12: pubis
20: umbilicus
36: above xyphoid
40: drops below xyphoid
24hrs/
HR is normally increased by ? much during pregnancy and BP may drop during ? trimester
Criteria for Pre-Eclampsia
Criteria for Severe Pre-Eclampsia
10-15bpm; 2nd
HTN after 20wks and >140/90 taken >4hrs apart w/ proteinuria (>300mg/24hrs)
BP >160/110
AMS
Pulm edema
Epigastric pain
Pre-eclampsia developing in first trimester suggests ? issue is present
MCC of Primary Amenorrhea
MCC of Secondary Amenorrhea
Molar pregnancy
Gonadal dysgenesis
Pregnancy
? is the MC bacteria detected in bacterial vaginosis
Pts taking metronidazole for Tx need to avoid ? to prevent a disulfiram-like reaction
What are the classic hormone level alterations seen during menopause
Stopped
28
Gardnerella vaginalis
Alcohol
Inc FSH
Dec E/P
How is cervical stenosis Tx in pre and post-menopausal women
How big does an os need to be for sufficient flow of menses
Define Nabothian Cyst
Dilators; Vaginal estrogen x 4wks
5mm, <2mm= retrograde flow associated
Columnar cells trapped below squamous cells during metaplasia w/ continued mucus secretion
How can Cervical Polyps present
Usually arise from ? and are usually ? size
How are these Tx based on size
Leukorrhea, post-coital spotting
Endocervical canal during reproductive years;
<3cm
Small and pedunculated: grab w/ forceps, twist
Sessile: remove w/ biopsy forceps and cauterize
Where are the glandular columnar cells in the cervix
When is cervical metaplasia most active
What is the goal for cervical cancer screenings
Endocervix
Adolescence/Pregnancy: squamous replaces columnar
Find precance/early cancer lesions for Tx
? is a surrogate for cervical cancer
What are the 4 categories of severity
? is the MC STI in USA and where does it hide in the body
Cervical Intraepithelial Neoplasia 3
Mild: abnormal cells in lower 1/3 of epithelium; regress
Mod: abnormal cells in mid 1/3, possible regression
Severe: abnormal cells extend to upper 1/3, risk of invasive cancer
Adenocarcinoma in situ: full thickness involvement
Human Papilloma Virus- basal cells
? HPV types are rarely oncogenic but can cause ?
? are the high risk forms
? is the most oncogenic worldwide and what is the key to it’s oncogenic factors
6, 11- genital warts, laryngeal papillomas
16, 18- cervical cancer
Type 16- persistence
What forms of HPV does Gardasil 9 protect from
What ages can get this
How often is Pap, HPV and CoTesting done
6 11 16 18 31 33 45 52 58
9-45y/o
Pap: q3yrs
HPV: q5yrs
CoTest: Pap and HPV, q5yrs
What 5 components are needed for Pap exam
When do Paps begin
What are the criteria to d/c Paps
LMP Abnormals Menopause Pregnancy Hormones
21-29y/o: q3yrs
30-65y/o: HPV/Cotest- q5yrs or Pap only q3yrs
> 65y/o w/ no CIN2+ Hx >20yrs and:
Two consecutive negative HPV in 10yrs, most recent <5yrs
Two consecutive negative co-tests in 10yrs, most recent <5yrs,
Three consecutive negative Paps in 10yrs, most recent in <5yrs
Pts >65y/o need to continue receiving Paps if ? is present and for ? long
When are Pap smears continued after hysterectomys
How long are they then continued for
Inadequate/Unknown screening;
Cotest annually x 3yrs; then q5yrs
Hx of CIN2+ in last 20yrs- perform vaginal cuff cytology
20yrs past CIN2 Dx/Tx even if past 65y/o
HPV screening are done in all women > ? age
Pap results use ? system
What are the 5 sections of results given
> 30y/o
Bathesda
Specimen type Adequacy Interpretation Description of ancillary tests Notes/recommendations
Define ACUS
Define LSIL
Define ASC-H
Define HSIL
Define AGC
Atypical Squamous Cells of Undetermined Significance
Low Grade Squamous Intraepithelial Lesion; no HPV reflex testing
Atypical Squamous Cells; cannot exclude HSIL
High Grade Squamous Intraepithelial Lesion
Atypical Glandular Cells
? is the MC cytologic abnormality reported on Pap results that often precedes CIN2 or 3
What are the next steps for Pts >30, 25-29 or <25y/o
ACUS
> 30y/o w/ +HPV: colpo
30 w/ -HPV: HPV testing in 3yrs
25-29y/o w/ +HPV: colpo
25-29y/o w/ -HPV: HPV testing in 3yrs
25-29 unknown HPV status: repeat Pap in 12mon, if abnormal- colpo
<25y/o- repeat Pap in 12mon
Reflex HPV Pos- Repeat Pap in 12mon
Reflex HPV Neg- Routine screening
What are the next steps for LSIL Pts > or < 25y/o
What is the management for ASC-H Pts regardless of age
How is HSIL managed
> 25 w/ +HPV: colpo
25 w/ -HPV: repeat HPV in 12mon
25 w/ unknown HPV: colpo
<25y/o- repeat Pap in 12mon
Reflex HPV Pos- Repeat Pap in 12mon
Reflex HPV Neg- Routine screening
Colposcopy
> 25: Colpo or Immediate LEEP
<25: Colpo
How are AGC Pap results managed
How are Unsat cytology results managed
Atypical Endometrial Cells: endometrial and endocervical sample w/ colpo
All others or >35y/o: Colpo + Endoervical sampling (unless pregnant= no samples)
No HPV status/>25 -/+HPV= repeat screen in 2-4mon Abnormal: manage Negative: manage Unsat: Colpo HPV 16/18+= Colpo
What PE finding during Colpo means neoplastic areas
Where are biopsies taken from
What is the next step for colpo if it’s unsatisfactory
Acetowhite staining w/ 3% acetic acid; accentuated w/ green filter/Lugol iodine solution
Acetowhite and Endocervical curreatge
Loop Electrosurgical Excision Procedure
Cold Knife Cone
? population is less likely to have successful Txs of cervical pre-cancer
? is the MC Gyn Ca worldwide
Exophytic Ca arises from ? while Endophytic arises from ?
HIV
Cervical
Exo: ectocervix
Endo: endocervix
Most cervical cancer is ? type and arises from ?
The rest are composed of ? type and ? is the MC type of this type
What is the down side of the more rare type Dx
SCC, ectocervix
Adeno; mucinous
Remain hidden longer, at Dx= further advanced
Worse prognosis than SCC
Cervical Ca presenting w/ bleeding can be controlled w/ ?
How often are cervical cancers f/u w/
(Monsol paste) Ferric subsulfate and packing
q3mon x 2yrs then,
q6mon for 5yrs post-Tx then
Annual
Full body lymph node check
Cuff Pap annually x 20yrs
80% of cervical cancers will reoccur in ? time frame
? form of Tx is not considered c/i during cervical Cas
Define Leiomyomata
Firs two yrs after radical hysterectomy
Hormone therapy- Ca is not estrogen mediated
Fibroids
What 3 uterine growths are estrogen dependent
? is the MC pelvic tumor in women
? image is used to differ the different types of uterine growths
Leiomyomata Adenomyosis Endometrial hyperplasia
Leiomyomas (fibroids)- benign, smooth muscle tumor
MRI- differs fibroid from adenomyosis
? type of fibroid is often associated w/ infertility
Define Adenomyosis
How does this present to clinic
Submucosal
Endometrial glands and stroma in muscular walls;
Endometriosis in myometrium
Heavy, dysmenorrhea in parrous Pt 40-50y/o
How are Leiomyomas managed
How are Adenomyosis managed
What medical management can be attempted
Mirena
GnRH agonists
Uterine artery embolization
Hysterectomy
Hysterectomy
Progestin IUD
C-OCPs
GnRH agonists
Danazol
Define Endometrial polyps
What is the MC c/c
How are these Dx
Hyperplastic overgrowth of endometrium on stalks
Metrorrhagis
TV-US, Sonohystergrapy
Endometrial Hyperplasia occurs during ? phase
What causes this to occur
What is the MC c/c
How are these Dx
Proliferative
Recurrent, chronic anovulation (unopposed estrogen)
Abnormal uterine bleeding in postmenopausal women
Endometrial biopsy or TV-US
? is the only known direct precursor of invasive uterine dz
? classification of endometrial hyperplasia has the greatest and least malignant potential
When can TV-US be used to Dx endometrial hyperplasia and w/ ? criteria
Endometrial hyperplasia
Most: complex hyperplasia w/ atypia
Least: simple hyperplasia w/out atypia
Post-menopause;
>4mm endometrial stripe need biopsy
How is endometrial hyperplasia w/ atypia Tx
How is endometrial hyperplasia w/out atypia Tx
? is the MC Gyn Ca in the US and w/ ? c/c
Post-menopause/child bearing: hysterectomy and BSO
Premenopause: progestin w/ endometrial biopsy q3mon
Postmenopause: progestin w/ endometrial biopsy q3mon
Premenopause: progestin x 3-6mon w/ endometrial biopsy
Endometrial; vaginal bleeding
How is endometrial cancer Tx
Endometrial Ca can be causes by ? syndrome
This sydrome’s Ca is usually ? type and Tx w/ ?
Hysterectomy w/ BSO and node staging
Lynch: Pt 20-50y/o w/ multiple Ca RFs
Sentinel; prophylactic hysterectomy
If endometrial cancer is not Tx w/ hysterectomy and BSO, what meds can be used
Define Functional Cyst
What can Pts present w/ c/c
Tamoxifen- upregulates progestin receptors
5-15 follicles stimulated each cycle and considered functional when >3cm
Pain Dullness Heaviness
Hemorrhagic > Sxs
What is the MC benign epithelial ovarian neoplasm
What is the largest benign epithelial ovarian neoplasm
What are the three stromal neoplasms
Serous cystadenoma
Mucinous cystadenoma
Granulosa Theca: estrogen; fetal ovaries
Sertoli-Leydig: testosterone; fetal testis
Fibroma: no hormone/function
? is the MC ovarian neoplasm
What would be seen on lab results
What is the risk of these growths
Germ Cell- cystic teratoma
Mature forms of all 3 germ cells: ecto/meso/endo-derm
Ovarian torsion
Ovarian masses w/ ? PE finding have higher malignancy potential
What finding on US is reassuring and what is the next step
Ovarian torsions occur at ? structure and are at higher risk when ? size
Ascites
Unilocular;
F/u US 6-12wks
Adnexa- ovary and fallopian tube;
6-10cm
Ovarian torsions MC occur on ? side and why
? finding suggest necrosis has begun
What are the 4 androgens that can cause “maleness”
Right, left is limited by sigmoid colon
Fever
Dehydroepiandrosterone- weak
Androstenedione- weak
Testosterone- potent
Dihydrotestosterone- most potent
What happens in theca cells
What happens in granulosa cells
Define Hypertrichosis
Cholesterol + LH= Androsterodione, Testosterone
Androsterodione, Testosterone + FSH= estrone, estradiol
Non-sexual hair, not d/t androgens
Vellus Lanugo Normal
Define Hirsutism
Define Virilization
Ovarian androgen production w/in granulosa/theca cells is controlled by ?
Terminal thick hair in a male distribution d/t androgens
Clitomegaly Male pattern baldness Acne Inc libido/strength Deep voice; d/t androgens
LH from pituitary
Peripheral conversion of androstenedion within adipocytes creates ?
Peripheral conversion of testosterone w/in hair follicles/genital skin creates ?
Nearly all androgens circulate attached to ?
Testosterone then estradiol
Estrone
Dihydrotestosterone
Estradiol
80% Sex Hormone Binding Globulin
19% Albumin
1% Free, bioactive
Sex Hormone Binding Globulin levels are increased or decreased by ?
Ovarian causes of hyperandrogenemia
Adrenal causes of hyperandrogenemia
Inc: Estrogens
Dec: Androgen/Insulin= obesity
Neoplasm, PCOS
Neoplasm, Cushing Syndrome, Congenital Adrenal Hyperplasia
MC cause of adrenal hyperandrogenemia is ?
PCOS has ? increased lab values
What are the MC c/c in order
21 hydroxylase
Androgen, Estrogen
Hirsutism AUB Polycystic ovaries Infertility Obesity
Define Ovarian Hyperthecosis
Define HAIRAN Syndrome
Idiopathic Hirsutism is considered a mild form of ? d/t ?
Severe PCOS w/ nests of luteinized theca cells in ovarian stroma
PCOS variant;
HyperAndrogenic Insulin Resistant Acanthosis Nigricans
PCOS w/ greader 5-a reductase activity
How is PCOS Tx
How is the hirsutism Tx
When are Pts f/u w/
1st: progestin only OCP to dec androgen production or,
Climiphene
Metformin
Combined OCPs to inhibit LH secretion
Estrogen will inc synthesis of SHBG
6mon, add another anti-androgenic agent
What anti-androgenic agents are used for suppressing hirsutism progression but w/ ? s/e
What med can be used for topical control
What are some ovarian cancer protective factors
Spironolactone- NSAID/ACEI will inc K levels
Flutamide- hepatotoxicity
Finasteride- teratogenic
Eflornithine- inhibits enzyme for follicle division/growth
Breast feeding
Long term OCP use
Tubal ligation/hysterectomy
High fiber, low fat diet
What are the function of BRCA 1 and 2 genes
Carriers of the mutations can elect to have ovaries removed at ? time frame
Removing ovaries is ? effective at preventing ? cancer
Tumor suppressing genes that repair proteins to preserve chromosomal structure
Done w/ child bearing or by 40y/o
90% effective preventing epithelial cancer
What labs can be drawn for suspected ovarian cancer
? is the most useful initial test for ovarian Ca
What 4 findings are suggestive of Ca
CBC: thrombocytosis >400
HypoNa 125-130
CA-125, especially useful post-menopause
Human epididymal protein 4
TV-US then CT
Multiloculated, solid, echogenic >5cm Thick septa w/ area of nodularity Papillary projection Neovascularization
? Pt population have better prognosis for ovarian Ca Txs and why
Fluid found in Pouch of Douglas means ? Dx is suspected
Traumatic birth can cause ? issue to develop in urogenital triangle?
? nervous/vasculature structure is found in Anal Triangle
BRCA mutation; inc susceptibility to chemo
Ruptured ectopic pregnancy
Vestibular bulb veins torn creating hematoma
Pudendal nerve/vessel
Done w/
What two muscle groups are found in the pelvic diaphragm
Where does the Pudendal Nerve originate, pass through and it’s purpose
Deck 6/7
Lavator ani- damaged by labor
Coccygeus muscle
Anterior ramus of S2-4
Between piriformis and coccygeus muscles;
Nerve block for vaginal deliveries
What are the 3 transmitters of the ovaries
Where are they secreted from
These 3 transmitters respond to ?
Estrogens: estradiol estrone estriol
Theca interna/granulosa
After ovulation- corpus luteum w/ progesterone
Gonadotropins
Estrogens two main functions
Progesterone’s main function
? is the Athletic Triad
Maintains endometrium, converts it to secretory structure
Endometrial proliferation
Amenorrhea
Eating d/o
Osteoporosis/penia
What is done at each appointment:
10wks
18-20wks
24-28wks:
36wks
10: heart tone w/ doppler
18: quickening
18-20: anatomy scan
20: fundal height at umbilicus
24-28: glucose tolerance
28: Rhogam
36: GBS screening
How fast does hCG increase during pregnancy
That viability determinants can be made w/ TV-US at 5,6 and 7 wks
What are indications of demise
Doubles q2.2 days for first month
5wk: sac w/ hCG of 1500
6wk: fetal pole w/ hCG of 5200
7wk: cardiac motion w/ hCG of 17500
Gestational sac w/out yolk
No FCM
CRL >5mm
? is the first ultrasound evidence of pregnancy
How does a normal pregnancy appear differently from an ectopic pregnancy
What is another sign used to indicate early intrauterine pregnancy
Gestational sac at 4-5wks
Sac implants eccentrically in endometrium
Pseudosac is midline of endometrial cavity
Double/Intradecidual sign: anechoic center surrounded by single echogenic ring
Define Biochemical Pregnancy
Majority of conceptions lost are w/in ? time frame
hCG in blood after conception but w/ spontaneous loss that doesn’t prolong cycle
14days of conception
Define Threatened Abortion
Define Inevitable Abortion
Define Incomplete Abortion
Bleeding <20wks w/ closed os
Bleeding w/ dilated os, non-viable pregnancy
Bleeding w/ dilated os and passage of some tissue
Define Complete abortion
Define Missed Abortion
Define Recurrent abortion
Conception products passed, os closed; rare medical Tx needed
Fetal demise but retained in uterus
3 successive spontaneous abortions
? is the MCC of early pregnancy loss
Fetus are susceptible to maternal stress prior to ? age
How is the fetus protected from stress
Genetic abnormalities
22wks
Enzyme 11b-hydroxylase- converts cortisol into inactive corticosterone
How are Threatened, Incomplete, Missed abortions managed
Threat: reassure, 94% have live births
Imcomplete: Type and Cross, evacuate uterus
Missed: Misoprostol
Fundus height at 12, 14-16, 20, 20-38 and 38-40wks
When is ‘quickening’ felt by mothers
How big of a discrepancy between age and fundus height needs US assessment
12: above pubic symphysis 14-16: midway between symphysis and umbilicus 20: umbilicus 20-38: corresponds to age 38-40: below xyphoid
Primi: 18-20wks
Multi: 16-18wks
> 3cm discrepancy
How much weight gain is expected during pregnancy
How many calories should be consumed
When is the lowest BP seen in pregnancy and what levels are dangerous
1st-T: 3-6lbs
After 20wks: 1lb/wk
Overall: 25-35lbs gain
300-400/day during pregnancy (1lb/wk during 2nd/3rd trimester)
500cal/day during breast feeding
Lowest at 26wks;
>140/90
Normal fetal HR ranges
? name of maneuver is done to verify fetal positioning
These maneuvers are used to verify ? three things
110-160bpm
Leopolds at 28wks
Lie, Presentation, Position
How is edema during pregnancy defined
This is used as a marker for ?
When are fetal kick counts incorporated into daily monitoring
Greater than +1 after 12hrs of bed rest
5lbs gained in one week
Pre-eclampsia
After 28wks
How are kick counts conducted
How long are sleep/wake cycles
How is Rh Alloimmunization tested for
After 28wks, on left lateral recumbent,
10 kicks per hour,
<10- drink sugar fluid and repeat for 1hr
If still <10 after 2hrs, go to LnD
20-75min
Indirect Coombs Ab screen
When is Rhogam administered
High levels of bilirubin seen during acute hemolysis attacks can cause ? issues
Before the use of Rhgam, one of the above issues was the leading cause of ? two adverse outcomes
28wks and,
<72hrs of delivery for all pregnancies
Neonatal encephalopathy
Kernicterus
Kernicterus- cerebral palsy, SNHL
When/why would a quant test be used for fetal-maternal hemorrhage
What is the above quant test named and how is it completed
Need for higher dosage of Rhogam after trauma
Kleihauer-Batke test-
Citric acid w/ pH of 3.2 dissolves maternal Hgb
Eosin stains fetal Hgb causing maternal cells to ‘ghost’
Manual count of 500 cells to calculate % of fetal cells
How much Rhogam is administered
How much coverage is provided
Screening for fetal aneuploidy is looking for ? MC
300mcg IM
30cc of hemorrhage
Down Syndrome
What Fetal Aneuploidy tests are done in the first trimester
What Fetal Aneuploidy tests are done in the second trimester
Maternal age
Nuchal Translucency
b-hCG
Pregnancy associated plasma protein A
Triple screen w/ reflex quad screen at 16-18wks:
hCG, Uncon estriol, MSAFP
MSAFP
Total hCG
Uncon estriol
Inhibin A*- differs triple from quad
What are the single gene d/os seen during pregnancy
What are the aneuploidys seen
? is the 1st trimester US marker and the earliest screening available for Downs
Cystic Fibrosis
Sickle Cell
Tay-Sachs
Trisomy 21 (Downs) 18 (Edwards) 13 (patau)
Nuchal translucency
What US finding decreases likelihood of Down being present
Quad screen results
Non-invasive cell-free fetal DNA testing is available at ? week
Nasal bone
21- dec MSAFP/Estriol, inc b-hCG/inhibin
18- dec all
13- depends
Starting- 9wks
Indications for cffDNA testing
When are genetic testing ages changed
Amniocentesis is conducted at ? week while CVS is done at ?
>35y/o at delivery US findings of inc aneuploidy Prior 21/18/13 pregnancy Robertsonian translocation Abnormal combined/screening results
32y/o if w/ twins
A: 16-20wks
C: 10-12wks
What is the risk of conducting CVS testing <9wks EGA
No data pertaining to ? is provided w/ CVS testing
Antenatal testing unit becomes pregnancy ER after ? wk
Jaw/Limb abnormalities
AFP levels= no NTD info
> 20wks
When is antenatal testing started
How is electronic fetal monitoring results interpreted if fetus is healthy
? is the first line tool for fetal surveillance
Typical: 32-34wks
High risk: 26-28wks
Accelerations in response to movement w/out decelerations
Non-stress test- reactive= normal HR 110-160bpm Two HR accelerations in 20min: Inc 10bpm x 10sec (10x10) <32wks EGA Inc 15bpm x 15sec (15x15) 32/>wks EGA
? type of HR variability seen on Non-Stress Testing is reassuring
What is a Contraction Stress Test performed
When is this test c/i to be done
Moderate: 6-25bpm
High negative predictive value;
Pos= high risk for fetal death d/t hypoxia
Labor
Amniotic fluid is similar to ? fluid
When does fetal urine production begin
Fetal kidney become main contributor to amniotic fluid by ?
Extracellular
8-11wks
18wks
Why do premature babies lose more water than term babies
What is a normal amniotic fluid index
What result mean Polyhydramnios or Oligohydramnios
Water transfer across fetal skin- continues until keratinzation occurs at 22-25wks
5-24cm at deepest vertical pocket in each of 4 quadrants
Poly: >24cm
Oligo: <5cm
What are the 5 fetal variables used for determining Biophysical Profile
What do the scores mean and the next step associated with each
NST+US: NST- HR accelerations Breathing movement- 1 or more Movement- 3 or more Tone- one or more AF index- 2 or more
10:
normal, repeat weekly unless diabetic/post-term pregnancy- then twice weekly
8:
normal AFI= follow protocols
decreased AFI= suspect chronic fetal asphyxia, deliver
6:
Dec AFI- deliver
Normal AFI- if 36wks and favorable cervix- deliver
Repeat test 6 or less- deliver
Repeat test 7 or more- protocol
4:
repeat test same day, 6 or less- deliver
0-2: almost certain fetal asphyxia- deliver
BPP score of 8-10 means
Score equivocal to 6 or poor predictor means ?
Score of 4 or less means
Normal fetal pH, reassuring
Retest in 12-24hrs or deliver
Non-reassuring, poor outcome- eval and consider delivery
How often are BPPs conducted in intrauterine restricted infants
How often are BPPs conducted in diabetics
When/why would Doppler US of umbilical artery be done
Mild: weekly
Mod: twice a week
Class A, 37-40wks: weekly
Class A, 40wks or >: twice weekly
Class B- start at 34wks, twice weekly
Post term pregnancy- start 42wks, twice weekly
Intrauterine growth restrictions
1st Trimester precautions
2nd/3rd Trimester precautions
Pain UTI Sxs Bleeding
Bleeding Ab pain Contraction HA Fetal movement
Vision change Loss of fluid
Cadidiasis UTI Sxs Regular contractions F/u
