OB/GYN Pt 2 Flashcards

1
Q

What are the two perineal boundaries

What seperates these two boundaries

? procedure is performed to prevent tearing during delivery

A

Urogenital (anterior): Symphysis Tuberosities
Anal (posterior): Perineum Anal complex Coccyx Tuberosities Sacrotuberous

Transverse perineal muscles
Perineal body

Episiotomy- perineal body

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2
Q

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

A

Scrotum

Sebaceous Exocrine Apocrine glands Venous plexus;
Round ligaments

Ventral shaft of penis

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3
Q

Labia minora contains ? type of glands

What does this join to form

What demarcation line is found here

A

Sebaceous

Superior: prepuce/clitoris frenulum
Inferior: fourchette

Hart Line- demarcation between skin/mucous membranes (outter: keratinized; inner: non-keratinized)

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4
Q

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

A

Erectile tissue

Female erogenous zone;
Glans, Corpus (body), Crura (x2)

Embryonic urogenital membrane derivative;
6- Vagina, Urethra, Bartholin/Skene glands

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5
Q

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

A

Greater Vestibular Glands;
4 and 8- Lubrication

Mucin secreting glands along Hart line

Near urethral meatus, anterior vaginal wall;
Lubricate urethral opening

Skene

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6
Q

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

A

Hymenal ring to Uterus
Non-keratinized, stratified squamous

Adventitia

Sub-epithelial capillary transudate

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7
Q

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

A

Recess bordering cervix;
Posterior

Loss of rugae

Rectourterine pouch- lowest point of abdominal cavity

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8
Q

? 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

A

Cervix

Internal os; External os

Portio Supravaginalis

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9
Q

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

A

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

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10
Q

Define Cervical Transformation Zone

Why is this zone important

What type of cellular changes are seen within the cervix at puberty ages

A

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

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11
Q

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

A

Muscular upper portion

Isthmus;
Lower uterine segment

Visceral peritoneum;
MC site of implantation

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12
Q

Uterine position is typically ?

Most of the upper uterus is called ? segment

What is the function of this segment

A

Anteroverted

Myometrium

Hemostasis at placental site during stage 3 of labor

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13
Q

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

A

Infundibulum Ampulla Isthmus Interstitial/Intramural

Broad ligament

Ampulla: MC site of fertilization and ectopic pregnancy

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14
Q

Ovaries secrete ? and are supplied w/ blood by ?

What is the MC location for ovarian Ca to develop

Where do they drain blood to

A

E/P; Ovarian/Uterine arteries

Epithelium, outer layer

L: left renal vein
R: IVC

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15
Q

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

A

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

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16
Q

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

A

1.5-2cm

Femoral artery below inguinal ligament

External iliac vessels

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17
Q

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

A

Maylard- inferior epigastric artery, lateral to rectus belly

Higher tension= wider scars

Pfannenstiel- follow Langer lines;
Less scars

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18
Q

What is the risk during low transverse incisions

? structure remains unchanged during pregnancy

What are the 3 tissue sources that develop into gonads

A

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

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19
Q

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 ?

A

Start week 5, committed by week 7

T: 7wks; O: 12wks
Ovary histologically identified at week 10

M: Wolffian ducts
P: Mullerian ducts

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20
Q

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

A

Mitosis of oogonia

HCG peak at 8-12th week

Sertoli/Sustentacular cells- suppress paramesonephric ducts (uterus, fallopian tubes)

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21
Q

How are testis develop

? ducts are male reproductive
? ducts are female reproductive

A

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
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22
Q

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

A

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

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23
Q

46 XY D/o Sexual Development

46XY S/o Sexual Development

Androgen Insensitivity Syndrome

Partial Androgen Insensitivity Syndrome

A

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

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24
Q

Define Turner Syndrome

Mullerian dysgeneis is AKA ? syndrome

Define Gamtogenesis

A

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

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25
# 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
26
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 ```
27
What are the two components of sperm
Head: Acrosome w/ enzymes Nucleus Tail: Middle Principal End Middle- mitochondria for ATP production
28
# 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
29
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
30
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
31
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
32
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
33
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
34
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
35
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
36
? 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
37
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
38
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
39
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
40
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
41
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
42
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
43
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
44
# 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
45
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 ```
46
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
47
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
48
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
49
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
50
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
51
? 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
52
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
53
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
54
? + ? 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
55
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
56
# 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
57
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
58
# Define Dysfunctional Bleeding Define Heavy Bleeding Define Inter-Menstrual bleeding Define dec/shortened menses
Dysfunctional bleeds Menorrhagia Metrorrhagia Hypomenorrhea
59
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
60
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
61
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
62
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
63
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
64
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
65
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
66
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
67
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
68
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
69
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
70
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
71
# 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
72
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
73
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
74
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
75
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
76
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
77
# 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 ```
78
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
79
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
80
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 ```
81
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:
82
# 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
83
When is osteoporosis therapy started What meds are used to reduce resorption What meds are used to stimulate bone formation
T score
84
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
85
? 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
86
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
87
? 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
88
? 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
89
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
90
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
91
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
92
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
93
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
94
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
95
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
96
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
97
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
98
? 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
99
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
100
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
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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
102
? 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)
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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
104
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
105
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
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How is Trichomoniasis Tx 4 etiologies of vulvar pruritus
PO Metronidazole PO Tinidazole White lesion (dystrophy) Infestation Red lesion (dermatoses) Squamous hyperplasia
107
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
108
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
109
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
110
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
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? 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
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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
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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
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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
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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
116
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
117
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
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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
119
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
120
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
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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
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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
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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
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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
125
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
126
? 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
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? 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
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? 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
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? is the mainstay of Tx for Gestational Trophoblastic Neoplasia This condition is AKA ? These are associated w/ ? carcinoma
Chemo Hydatidiform mole Choriocarcinoma
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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
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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
132
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 ```
133
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
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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
135
? 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/
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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
137
Pre-eclampsia developing in first trimester suggests ? issue is present MCC of Primary Amenorrhea MCC of Secondary Amenorrhea
Molar pregnancy Gonadal dysgenesis Pregnancy
138
? 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
Gardnerella vaginalis Alcohol Inc FSH Dec E/P #28
139
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
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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
141
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
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? 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
143
? 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
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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
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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
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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
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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 ```
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# 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
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? 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
150
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
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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 ```
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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
153
? 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
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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
155
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
156
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
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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
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? 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
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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
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# Define Endometrial polyps What is the MC c/c How are these Dx
Hyperplastic overgrowth of endometrium on stalks Metrorrhagis TV-US, Sonohystergrapy
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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
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? 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
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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
164
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
165
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
166
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
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? 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
168
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
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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
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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
171
# 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
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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
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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
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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
175
# 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
176
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
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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
178
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
179
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 ```
180
? 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
181
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
182
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
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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
184
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
185
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
186
? 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
187
# 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
188
# 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
189
# 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
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? 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
191
How are Threatened, Incomplete, Missed abortions managed
Threat: reassure, 94% have live births Imcomplete: Type and Cross, evacuate uterus Missed: Misoprostol
192
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
193
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
194
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
195
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
196
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
197
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
198
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
199
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
200
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
201
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
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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
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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
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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
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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 ```
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? 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
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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
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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
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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
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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
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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
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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