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IPAP > OB/GYN Pt 2 > Flashcards

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
Q

Define Meiosis I

Define Meiosis II

What phase are sperm cells stored in during infancy/pre-puberty

A

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

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26
Q

What are the stages of spermatogenesis

A 
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
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27
Q

What are the two components of sperm

A

Head:
Acrosome w/ enzymes
Nucleus

Tail:
Middle Principal End
Middle- mitochondria for ATP production

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28
Q

Define Sperm Capacitation

Prostaglandins found in semen provide what two benefits

Seminal vesicles provide ? nutrient for sperm energy allowing them to survive ? long

A

Sperm acquire ability to fertilize ova d/t nutrients from prostate/seminal vesicles

Uterine motility
Movement

Fructose; 48hrs

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29
Q

What are the four integrated sub-cycles of menstrual cycle

What is the first day of the cycle

How long are the cycles

A

Hypothalamus- GnRH
Anterior pituitary- LH, FSH
Ovary- E/P
Endometrium

First day of shedding

28d +/- 7days

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30
Q

Endometrium is responsive to ? three stimulants

Define Proliferative Phase

Define Secretory Phase

A

Progestin Estrogen Androgen

Estrogen driven; arteries lengthen

Progesterone from corpus lutuem stimulates glycogen/mucus

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31
Q

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

A

High; inc alkaline, dec viscosity (spinnbarkheit)

Ferning

Corona radiata

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32
Q

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

A

Acrosomal: enzymes penetrate zona pellucida
Zona: pellucida becomes impermeable

Est: faciliatates sticking
Pro: inhibits sticking
E: relaxes tubes
F: stimulates tube motility

Morula

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33
Q

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

A

Embryoblast: Amnion Cord Embryo
Trophoblast: Placenta hCG

Apposition Adhesion Invastion

Decidua- maternal component of placenta

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34
Q

What are the 3 parts of the decidua

What part separates conceptus from uterine cavity

On day 8, trophoblast differentiates into ? two structures

A

Basalis Capsularis Parietalis

Casularis

Cytotrophoblast
Synctiotrophoblast

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35
Q

Villous trophoblasts become ? to perform ? function

The other structure formed develop into ?

What is the maternal and fetal surface of the placenta called

A

Chorionic villi- transport nutrients and produces hormones

Extravillous- penetrate into maternal vasculature

Basal: divided into cotyledon
Chorionic: point of umbilical insertion

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36
Q

? layer of placenta maintain maternal/placenta separation

What are three different variants of this layer

What is the RF for these variants to occur

A

Nitabuchs layer

Accreta: adheres to myometrium
Increta: invades myometrium
Percreta: perforated myometrium

Prior uterine surgery

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37
Q

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

A

1mon

Cotyeldon w/ one vein

Week 17;
Term- placenta= 1/6th of fetus

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38
Q

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

A

Synchtiotrophoblast

60-70days

Morning sickness

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39
Q

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

A

Higher O2 affinity
Bohr effect
Higher Hgb

Bohr effect

One vein: oxygenated, pressurized R-side
Two arteries: no O2, flaccid L-side

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40
Q

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

A

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

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41
Q

Tanner stages

A

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

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42
Q

Acronym for sequence of female puberty

? underlying issue can cause early onset puberty initiation

Why is this earlier initiation caused

A 
TAPuP Me
Thelarche
Adrenarche
Pubarche
Peak growth velocity
Menarche

Obesity

Leptin- produced in adipocytes

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43
Q

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

A

48kg/106lbs (Frisch hypothesis)

Pubarche

Pulsatile GnRH causes anterior pituitary to release FSH/LH= onset

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44
Q

Define Precocious Puberty

What are the two types

A

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

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45
Q

What can cause Central Precocious Puberty

What can cause Peripheral Precocious Puberty

A

Idopathic Ischemic Iatrogenic
Tumor
Abnormal CNS
Trauma

Glucocorticoid resistance
Ovarian Cyst
Tumor producing E/T
CAH
Aromatase syndrome
McCune Albright Syndrome
Primary hypothyroidism
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46
Q

What is the first sign of Central Precocious Puberty

What would be seen on lab results

How is it Tx

A

Thelarche

High LH/FSH d/t inc Estrogen

GnRH agonist to inhibit LH/FSH

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47
Q

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

A

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

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48
Q

Females w/ signs of virilization need ? test to differentiate premature thelarche from precocious puberty

Define Delayed Puberty

What is the MC cause

A

Leuprolide stim test

Lack of thelarche at 13y/o
No menses by 16y/o

Constitutional (physiologic) delay

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49
Q

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

A

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

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50
Q

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

A

1-2M; <400K oogonium (2n)

Follicular atresia; apoptosis

400

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51
Q

? phase of menstrual cycle is variable in duration

? are the two parts of this cycle

? phase of cycle is usually stable in duration

A

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

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52
Q

Follicular Phase

A

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

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53
Q

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

A

<24hrs

Meiosis 1

Estradiol >200pg/ML x 50hrs

Starts afer LH spike, ends on day 1 of menses
Staple and define duration

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54
Q

? + ? form corpus luteum

If fertilization occurs, trophoblast produces ? hormone similar to ?

If no fertilization occurs, how long does luteum remain

A

Granulosa, Theca interna cells

hCG, similar to LH- maintains placenta

14d, dec progesterone levels cause sloughing

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55
Q

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

A

E: Proliferative; P: Secretory

P: production; O: expression

Primary follicle development
Androstenedione to estradiol conversion in granulosa cell

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56
Q

Define Amenorrhea

Define Secondary Amenorrhea

Functional Amenorrhea can be AKA ? and is d/t ?

A

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

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57
Q

Two MCCs of Secondary Amenorrhea

A

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
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58
Q

Define Dysfunctional Bleeding

Define Heavy Bleeding

Define Inter-Menstrual bleeding

Define dec/shortened menses

A

Dysfunctional bleeds

Menorrhagia

Metrorrhagia

Hypomenorrhea

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59
Q

Time frames:

In/Frequent bleeds

Amenorrhea/Irregular bleeds

Prolonged/Shortened bleeds

Heavy/Light flow

A

<21d, >35d

Absent x 6mon, >20 day variation in cycle

> 8d, <2d

> 80cc, <5cc

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60
Q

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

A

Pad: 20
Tampon: 10
Large: 5
Small: 1

Abnormal uterine bleeding

PALM COEIN
Polyp Adenomyosis Leiomyoma Malignancy
Coags Ovarian dysfunction Endometrial Iatrogenic Not classified

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61
Q

How does age of Pt indicate DDx for abnormal uterine bleeding

A

Prepuberty: bleeding defect

Perimenarchal: immature HPO axis

Reproductive: less cycle variability

Perimenopause: dec ovarian function, follicular atresia

Postmenopause- r/o Ca

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62
Q

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

A

Combined OCPs
Medroxyprogesterone acetate

Unstable/Unrepsonsive in 24hrs: surgery
1st: DnC

Balloon tamponade

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63
Q

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

A

Normalize prostaglandins
NSAIDs

Combined OCPs
Medroxyprogesterone acetate

Levonogestrel IUD*
Progestin only OCPs
Depo

Tranexamic acid

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64
Q

When are Pts w/ abnormal uterine bleeding surgical candidates

Define Dysmenorrhea

What are the two types and causes

A

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

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65
Q

How is dysmenorrhea Tx

Define Endometriosis

What is the MC site for abnormal tissue to be found

A

NSAIDs
Combined OCPs
Progestin only

Endometrial glands/stroma outside of normal location

MC: Pelvic peritoneum
Frequent: ovary, uterosacral ligament

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66
Q

Endometriosis is a ? dependent d/o

What are the four theorized pathogenesis of endometriosis

What are the D’s of endometriosis

A

Estrogen

Retrograde menstruation
Mullerian dysplasia
Lymphatic spread
Stem Cell

Dysmenorrhea
Dyspareunia
Dyschezia

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67
Q

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

A 
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

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68
Q

How is endometriosis definitively Dx and Tx

Mild cases can be managed w/ observation and ?

What is the next step if Sxs persist

A

Laparoscopy w/ ablation for Tx

NSAIDs

Cyclic hormones

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69
Q

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

A

Definitive Dx w/ Gyn referral

Danazol

Leuprolide

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70
Q

Endometriosis can cause ? type of amenorrhea

How is the pain of endometriosis different from dysmenorrhea

Endometriosis also commonly exists w/ ? other two Dxs

A

Secondary

Cyclic pelvic pain peaking 1-2d prior to menses

Adenomyosis
Uterine fibroids

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71
Q

Define PMS

Define PMDD

What do both have in common

A

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

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72
Q

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

A

Luteal, dec serotonin activity

Progesterone- antimineralcorticoid
Estrogen- activates RAAS
Altered E+/fluid balance

2nd half of luteal phase:
E/P neuroactivity

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73
Q

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

A

Sxs during luteal phase
Sx free x 7d in first half of cycle for three consecutive cycles

Sugar, Caffeine

Fatigue, Bloat

Labile mood

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74
Q

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

A

1st: SSRIs- Fluoxetine Sertraline Paroxetine
2nd: anovulatory meds: COCPs Leuprorelin (GnRH agonist)

Tests if false menopause improves Sxs

Acne, hair growth

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75
Q

How are the cramps/HA of PMS/PMDD Tx

How is the swelling/bloat Tx

What non-med intake can reduce cramping

A

NSAIDs

Hctz/Triamterene
Spironolactone

Ca 600mg BID

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76
Q

PMD/PMDD Pts can increase ? intake needed as cofactor for serotonin

What can help reduce anxiety Sxs

Define Menopause

A

Pyridoxine B6

Mg and Vit B6

12mon since LMP

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77
Q

Define Premature Ovarian Failure and is associated w/ ?

Sxs of Menopause

A

Cessation of menses <40y/o;
High FSH

IFLUSH:
Insomnia
Flash/forgetful
Libido decrease
Urinary Sxs
Sad skin
HA/Heart Dz
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78
Q

How is estrogen cardioprotective

By ? age are men and women at equal risk

HT(?) is not cardioprotective if started ?

A

Inc HDL, lower TC

70y/o

> 60y/o, 10yr after FMP

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79
Q

What drug combo is used for meopause Sxs

Why do we not give unopposed estrogen to women w/ uterus

A

Estrogen + Bazedoxifene (if +uterus)

Inc endometrial hyperplasia
Neoplasia
Endometrial Ca

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80
Q

Mnemonic for Osteoporosis RFs

A 
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
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81
Q

All women need DEXA scans at / age or w/ ? RFs

When do perimenopausal women get DEXA scans

What are the DEXA scores

A

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:

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82
Q

Define Z and T Score

How much Ca is used for osteoporosis prevention

When/how much Vit D is used

A

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

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83
Q

When is osteoporosis therapy started

What meds are used to reduce resorption

What meds are used to stimulate bone formation

A

T score

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84
Q

Osteoporosis therapies work more quickly in ? bone and why

MOA of bisphosphonates

What are 4 possible s/e

A

Vertebrae: higher trabecular content

Inhibit osteoclast funtion to dec resporption

Jaw osteonecrosis
Atypical femur Fx
Worse w/ prolonged use >5yrs, consider drug holiday

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85
Q

? 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 ?

A

Dec estrogen= inc activity

Loss of >1.5”

Trabecular: spine, femoral neck

86
Q

Pts w/ early onset primary amenorrhea are at risk for ? Dx later in life

? Tx method offers decent hormonal replacement

A

Osteoporosis induced femoral neck Fx

OCPs

87
Q

? is the MC presenting Sx of vaginal Ca

Vaginal cancer is MC related to ? infection

? is the MC type of vaginal Ca

A

Vaginal bleeding, especially post-menopause/intercourse

HPV

SCC

88
Q

? 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

A

Surgical excision, total abdominal hysterectomy

High dose progestin

Screening mammographys at 50y/o
50-74y/o: biennial, every other year

89
Q

What is the MCC of postpartum hemorrhage

Postpartum hemorrhage is defined as ? amount

What are the mainstays of Tx

A

Uterine atony

> 1000mL or,
Hemodynamic instability <24hrs

Fundal massage, Oxytocin

90
Q

What are the 4 T’s of Post-Partum Hemorrhage

? artery provides the main blood supply to uterus

? is the MC fetal malpresentation

A

Atony
Trauma to birth canal
Tissue retention
Thrombin d/o or coagulopathy

Uterine artery

Breech: buttock adjacent to maternal pelvis, head in fundus

91
Q

What are the 3 types of breech presentation

If presentation has not been self-corrected by ?wks, ? maneuver is performed

A

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
Q

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

A

Cephalic w/ occiput anterior position

Uterus, Fallopian tubes;
G/C*(MC)

Out: Ceftriaxone, Doxycycline w/ Metro
In: Cefotetan or Cefoxitin w/ Doxy

93
Q

Major criteria supporting PID Dx

Initial step for Pt w/ painless post-menopause bleeding

? is the MCC of postmenopausal bleeding

A

Lower abdominal pain in at risk Pt AND:
Uterine tenderness or,
Adnexal tenderness or,
+ chandalier sign

Endometrial biopsy

Atrophic vaginitis

94
Q

RFs for endometrial Ca

MCC of ovulatory infertility

This MCC is also the MC cause of ? in women

A 
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
Q

How are hot flashes Tx

? alternative is used if primary med is c/i in postmenopausal women for significant hot flashes/sleep disturbances

A

W/ uterus: Estrogen and Progesterone to preevnt endometrial hyperplasia
No uterus: Estrogen

Gabapentin

96
Q

Erythrasma is caused by a infection of ?

How is it Dx on PE

How is it Tx if widespread or localized

A

Corynebacterium

Woods lamp: red

Wide: erythromycin
Local: clindamycin

97
Q

Vaginal mucosa produces ? for vaginal ecosystem stasis

? is the predominant, natural defense microbe

What are the only two categories of non-inflammatory vaginitis

A

Glycogen

Lactobacilli

BV, Candidiasis

98
Q

? 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

A

Candidiasis

Bacterial vaginosis

Profuse, grey milky d/c w/ fishy odor

99
Q

Bacterial vaginitis Sxs develop d/t overgrowth of ? species

What criteria is used for Dx

What lab test can be used for Dx

A

Anaerobics

Amsels w/ three of DPWC:
Homogenous d/c
pH >4.5
Positive whiff test
Clue cells on wet prep

PCR

100
Q

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

A

pH >4.5 turns nitrazine paper blue

KOH added causes amine release

Metronidazole
Clindamycin

101
Q

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

A

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
Q

? is the 2nd MCC of vaginitis

How does this MC present on PE

What two types of microbes are responsible

A

Candidiasis

Burn/itch w/ cottage cheese d/c

Albicans > Glabrata (uncontrolled DMT1)

103
Q

How is Candidiasis Vaginitis Dx

? RFs put Pts at risk for this type of infection

What causes Pts to suffer from chronic candidiasis infections

A

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
Q

Recurrent Fungal Vaginitis is defined as ? episodes/yr

How is recurrent fungal vaginitis Tx

What is used for suppressive Tx

A

4 or more

PO Fluconazole q3d on day 1, 4 and 7

PO Fluconazole 100-200mg/wk x 6mon

105
Q

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

A

PO Fluconazole q3d
Boric acid qd x 2wks

Trichomoniasis

Green/yellow d/c w/ musty odor and dyspareunia/uria; strawberry cervix

106
Q

How is Trichomoniasis Tx

4 etiologies of vulvar pruritus

A

PO Metronidazole
PO Tinidazole

White lesion (dystrophy)
Infestation
Red lesion (dermatoses)
Squamous hyperplasia

107
Q

How does Lichen Sclerosus present

What will be seen on exam

How is it Dx

How is it Tx

A

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
Q

What causes Lichen Simplex Chronicus to develop

What area is MC affected

How can this be Tx/Sxs reduced

When is f/u needed

A

Non-neoplastic alteration d/t chronic itch/scratch cycle

Labia majora

Petroleum jelly
Vegetable oil
PO antihistamine
Topical steroids

3wks, unresolved= biopsy

109
Q

How does atopic dermatitis present

How is it managed/Tx

If psoriasis is found on vulva, ? is suspected in history

A

Scaly patches w/ fissuring

Topical steroids
Tacrolimus

Trauma

110
Q

How is vaginal psoriasis managed

How does Lichen Planus present on PE

What are the 3 variants that can be seen

A

Dovonex (calcipotriene)

Red erosion w/ white border on cutaneous/mucosal surface;
Narrowed introitus

Erosive, MC/difficult to Tx
Papulosquamous
Hypertrophic

111
Q

? form of lichen planus is difficult to Tx

How is the condition Tx

Define Intertrigo

A

Vulvovaginal syndrome

Clobetasol
Vaginal hydrocortisone

Friction between moist skin folds causing burn/itch/hyperpigmentation

112
Q

How is intertrigo Tx based on cause

? is the MCC of vaginal irritation after menopause

How is this MC Dx

A

Drying: corn starch
Inflamed: mild topical steroid
Fungal: nystatin, clotrimazole

Atrophic vaginitis

Friable epithelium w/ loss of rugae and Pap smear changes

113
Q

How is Atrophic Vaginitis Tx

When do bartholin cyst become less common and more concerning

How are these Tx

A

Estrogen topical/PO

> 40y/o- Ca concern

ASx: none unless <40y/o
Word catheter
Cath failure x2 : marsupialize

114
Q

If bartholin cysts occur ? they are painless

? is the sequelae of bartholin cyst

Most sequelaes are polymicrobial but association w/ ?

A

Within duct

Bartholin abscess

G/C infection

115
Q

How are Barthlin Abscess Tx

What are the indications for ABX to be used

What ABX are used

A

Fluctuant: InD w/ word catheter

Pregnant
Recurrent
ImmSupp
Cellulitis
Infection

2nd Gen Cephalosporin
Fluroquinolones
Augmentin
TMP-SMX

116
Q

What causes Toxic Shock Syndrome

What are the classic Sxs of this Dx

What would be seen on PE

A

Exotoxin from Staph A two days after surgery/onset of menses

Fever Malaise Diarrhea

Diffuse macular and erythematous rash

117
Q

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 ?

A 
SBP <90
HOTN
Orthostatic syncope
Temp
Macular erythroderma
Desquamation

Longevity
HIV infection

SCC arising from vestibule at Hart line;
Malignant melanoma

118
Q

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

A

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
Q

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

A

HPV, smoking

Non-smoker w/out STD Hx
Long standing lichen sclerosis

Smoker and HPV genital warts

120
Q

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

A

Vulvoscopy- colpo w/ acetic acid to get thick punch biopsy

Stage 1A, microinvasive

Radical vulvar resection
Chemoradiation

121
Q

How often are vulvar cancers f/u

? recurrence almost always indicates fatal dz

? vaginal carcinomas are rare

A

q3mon x 2-3yrs
q5mon x 5yrs
Annual

Inguinal lymph node recurrence

Primary, most mets to vagina

122
Q

What are the 4 types of vaginal Cas

A

SCC d/t HPV

Adeno: often mets to vagina

Mesenchymal-
Rhabdomyosarcoma- MC <5y/o
Leiomyosarcoma- most rare

Melanoma

123
Q

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

A

Diethylstillbestrol

Clear cell cancer

Vaginal bleeding;
Upper third wall

124
Q

Pts presenting w/ anterior vaginal wall Ca may have ? three Sxs

If posterior wall is involved ? Sxs may be present

A

Hema/Dys-uria
Urgency

Constipation

125
Q

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

A

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
Q

? 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

A

Kleihauer Betke test

Ca Ag 125

Anovulatory Pts taking chronic OCPs

127
Q

? 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

A

FamHx

Epithelial: >50y/o
Stromal: any age
Germ: 15-19y/o

Pain Bleeding Hyperemesis gravidarum

128
Q

? is seen on PE during molar pregnancies

? is first line imaging and what will be seen

How is this condition Tx

A

Uterus higher than gestational age

TV-US: snow storm or bag of grapes

Suction curettage

129
Q

? is the mainstay of Tx for Gestational Trophoblastic Neoplasia

This condition is AKA ?

These are associated w/ ? carcinoma

A

Chemo

Hydatidiform mole

Choriocarcinoma

130
Q

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

A

Vit A

1st: Lube/moisturizer
2nd: Vaginal estrogen

Pale, dry, shiny epithelium

131
Q

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

A

SERM: Ospemifene

50g, 1hr PO glucose challenge; 130/> is failure

100g, 3hr PO challenge and is diagnostic

132
Q

Diagnostic criteria for Dx Gestational Diabetes

A

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
Q

Asthma Tx during pregnancy

What kind of microbe causes chancroids

What is the Tx

A 
Albuterol- class c
Budesonide- class b
Ipratropium- class c
Prednisone- class c/d

H ducreyi- gram neg, coccobaccilus

Azithromycin
Ceftriaxone
Ciprofloxacin
Erythromycin

134
Q

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

A

Syphilis

Treponema pallidum, Syphilis

LARCs- etonogestrol implant
IUD

135
Q

? 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

A

Quant b-hCG

12: pubis
20: umbilicus
36: above xyphoid
40: drops below xyphoid

24hrs/

136
Q

HR is normally increased by ? much during pregnancy and BP may drop during ? trimester

Criteria for Pre-Eclampsia

Criteria for Severe Pre-Eclampsia

A

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
Q

Pre-eclampsia developing in first trimester suggests ? issue is present

MCC of Primary Amenorrhea

MCC of Secondary Amenorrhea

A

Molar pregnancy

Gonadal dysgenesis

Pregnancy

138
Q

? 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

A

28

Gardnerella vaginalis

Alcohol

Inc FSH
Dec E/P

139
Q

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

A

Dilators; Vaginal estrogen x 4wks

5mm, <2mm= retrograde flow associated

Columnar cells trapped below squamous cells during metaplasia w/ continued mucus secretion

140
Q

How can Cervical Polyps present

Usually arise from ? and are usually ? size

How are these Tx based on size

A

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
Q

Where are the glandular columnar cells in the cervix

When is cervical metaplasia most active

What is the goal for cervical cancer screenings

A

Endocervix

Adolescence/Pregnancy: squamous replaces columnar

Find precance/early cancer lesions for Tx

142
Q

? 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

A

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
Q

? 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

A

6, 11- genital warts, laryngeal papillomas

16, 18- cervical cancer

Type 16- persistence

144
Q

What forms of HPV does Gardasil 9 protect from

What ages can get this

How often is Pap, HPV and CoTesting done

A

6 11 16 18 31 33 45 52 58

9-45y/o

Pap: q3yrs
HPV: q5yrs
CoTest: Pap and HPV, q5yrs

145
Q

What 5 components are needed for Pap exam

When do Paps begin

What are the criteria to d/c Paps

A

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

146
Q

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

A

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

147
Q

HPV screening are done in all women > ? age

Pap results use ? system

What are the 5 sections of results given

A

> 30y/o

Bathesda

Specimen type
Adequacy
Interpretation
Description of ancillary tests
Notes/recommendations
148
Q

Define ACUS

Define LSIL

Define ASC-H

Define HSIL

Define AGC

A

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

149
Q

? 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

A

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
Q

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

A

> 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

151
Q

How are AGC Pap results managed

How are Unsat cytology results managed

A

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
152
Q

What PE finding during Colpo means neoplastic areas

Where are biopsies taken from

What is the next step for colpo if it’s unsatisfactory

A

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
Q

? 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 ?

A

HIV

Cervical

Exo: ectocervix
Endo: endocervix

154
Q

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

A

SCC, ectocervix

Adeno; mucinous

Remain hidden longer, at Dx= further advanced
Worse prognosis than SCC

155
Q

Cervical Ca presenting w/ bleeding can be controlled w/ ?

How often are cervical cancers f/u w/

A

(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
Q

80% of cervical cancers will reoccur in ? time frame

? form of Tx is not considered c/i during cervical Cas

Define Leiomyomata

A

Firs two yrs after radical hysterectomy

Hormone therapy- Ca is not estrogen mediated

Fibroids

157
Q

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

A

Leiomyomata Adenomyosis Endometrial hyperplasia

Leiomyomas (fibroids)- benign, smooth muscle tumor

MRI- differs fibroid from adenomyosis

158
Q

? type of fibroid is often associated w/ infertility

Define Adenomyosis

How does this present to clinic

A

Submucosal

Endometrial glands and stroma in muscular walls;
Endometriosis in myometrium

Heavy, dysmenorrhea in parrous Pt 40-50y/o

159
Q

How are Leiomyomas managed

How are Adenomyosis managed

What medical management can be attempted

A

Mirena
GnRH agonists
Uterine artery embolization
Hysterectomy

Hysterectomy

Progestin IUD
C-OCPs
GnRH agonists
Danazol

160
Q

Define Endometrial polyps

What is the MC c/c

How are these Dx

A

Hyperplastic overgrowth of endometrium on stalks

Metrorrhagis

TV-US, Sonohystergrapy

161
Q

Endometrial Hyperplasia occurs during ? phase

What causes this to occur

What is the MC c/c

How are these Dx

A

Proliferative

Recurrent, chronic anovulation (unopposed estrogen)

Abnormal uterine bleeding in postmenopausal women

Endometrial biopsy or TV-US

162
Q

? 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

A

Endometrial hyperplasia

Most: complex hyperplasia w/ atypia
Least: simple hyperplasia w/out atypia

Post-menopause;
>4mm endometrial stripe need biopsy

163
Q

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

A

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
Q

How is endometrial cancer Tx

Endometrial Ca can be causes by ? syndrome

This sydrome’s Ca is usually ? type and Tx w/ ?

A

Hysterectomy w/ BSO and node staging

Lynch: Pt 20-50y/o w/ multiple Ca RFs

Sentinel; prophylactic hysterectomy

165
Q

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

A

Tamoxifen- upregulates progestin receptors

5-15 follicles stimulated each cycle and considered functional when >3cm

Pain Dullness Heaviness
Hemorrhagic > Sxs

166
Q

What is the MC benign epithelial ovarian neoplasm

What is the largest benign epithelial ovarian neoplasm

What are the three stromal neoplasms

A

Serous cystadenoma

Mucinous cystadenoma

Granulosa Theca: estrogen; fetal ovaries
Sertoli-Leydig: testosterone; fetal testis
Fibroma: no hormone/function

167
Q

? is the MC ovarian neoplasm

What would be seen on lab results

What is the risk of these growths

A

Germ Cell- cystic teratoma

Mature forms of all 3 germ cells: ecto/meso/endo-derm

Ovarian torsion

168
Q

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

A

Ascites

Unilocular;
F/u US 6-12wks

Adnexa- ovary and fallopian tube;
6-10cm

169
Q

Ovarian torsions MC occur on ? side and why

? finding suggest necrosis has begun

What are the 4 androgens that can cause “maleness”

A

Right, left is limited by sigmoid colon

Fever

Dehydroepiandrosterone- weak
Androstenedione- weak
Testosterone- potent
Dihydrotestosterone- most potent

170
Q

What happens in theca cells

What happens in granulosa cells

Define Hypertrichosis

A

Cholesterol + LH= Androsterodione, Testosterone

Androsterodione, Testosterone + FSH= estrone, estradiol

Non-sexual hair, not d/t androgens
Vellus Lanugo Normal

171
Q

Define Hirsutism

Define Virilization

Ovarian androgen production w/in granulosa/theca cells is controlled by ?

A

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

172
Q

Peripheral conversion of androstenedion within adipocytes creates ?

Peripheral conversion of testosterone w/in hair follicles/genital skin creates ?

Nearly all androgens circulate attached to ?

A

Testosterone then estradiol
Estrone

Dihydrotestosterone
Estradiol

80% Sex Hormone Binding Globulin
19% Albumin
1% Free, bioactive

173
Q

Sex Hormone Binding Globulin levels are increased or decreased by ?

Ovarian causes of hyperandrogenemia

Adrenal causes of hyperandrogenemia

A

Inc: Estrogens
Dec: Androgen/Insulin= obesity

Neoplasm, PCOS

Neoplasm, Cushing Syndrome, Congenital Adrenal Hyperplasia

174
Q

MC cause of adrenal hyperandrogenemia is ?

PCOS has ? increased lab values

What are the MC c/c in order

A

21 hydroxylase

Androgen, Estrogen

Hirsutism AUB Polycystic ovaries Infertility Obesity

175
Q

Define Ovarian Hyperthecosis

Define HAIRAN Syndrome

Idiopathic Hirsutism is considered a mild form of ? d/t ?

A

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
Q

How is PCOS Tx

How is the hirsutism Tx

When are Pts f/u w/

A

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

177
Q

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

A

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
Q

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

A

Tumor suppressing genes that repair proteins to preserve chromosomal structure

Done w/ child bearing or by 40y/o

90% effective preventing epithelial cancer

179
Q

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

A

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
Q

? 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

A

BRCA mutation; inc susceptibility to chemo

Ruptured ectopic pregnancy

Vestibular bulb veins torn creating hematoma

Pudendal nerve/vessel

181
Q

Done w/

What two muscle groups are found in the pelvic diaphragm

Where does the Pudendal Nerve originate, pass through and it’s purpose

A

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
Q

What are the 3 transmitters of the ovaries

Where are they secreted from

These 3 transmitters respond to ?

A

Estrogens: estradiol estrone estriol

Theca interna/granulosa
After ovulation- corpus luteum w/ progesterone

Gonadotropins

183
Q

Estrogens two main functions

Progesterone’s main function

? is the Athletic Triad

A

Maintains endometrium, converts it to secretory structure

Endometrial proliferation

Amenorrhea
Eating d/o
Osteoporosis/penia

184
Q

What is done at each appointment:

10wks

18-20wks

24-28wks:

36wks

A

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
Q

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

A

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
Q

? 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

A

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
Q

Define Biochemical Pregnancy

Majority of conceptions lost are w/in ? time frame

A

hCG in blood after conception but w/ spontaneous loss that doesn’t prolong cycle

14days of conception

188
Q

Define Threatened Abortion

Define Inevitable Abortion

Define Incomplete Abortion

A

Bleeding <20wks w/ closed os

Bleeding w/ dilated os, non-viable pregnancy

Bleeding w/ dilated os and passage of some tissue

189
Q

Define Complete abortion

Define Missed Abortion

Define Recurrent abortion

A

Conception products passed, os closed; rare medical Tx needed

Fetal demise but retained in uterus

3 successive spontaneous abortions

190
Q

? is the MCC of early pregnancy loss

Fetus are susceptible to maternal stress prior to ? age

How is the fetus protected from stress

A

Genetic abnormalities

22wks

Enzyme 11b-hydroxylase- converts cortisol into inactive corticosterone

191
Q

How are Threatened, Incomplete, Missed abortions managed

A

Threat: reassure, 94% have live births

Imcomplete: Type and Cross, evacuate uterus

Missed: Misoprostol

192
Q

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

A 
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
Q

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

A

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
Q

Normal fetal HR ranges

? name of maneuver is done to verify fetal positioning

These maneuvers are used to verify ? three things

A

110-160bpm

Leopolds at 28wks

Lie, Presentation, Position

195
Q

How is edema during pregnancy defined

This is used as a marker for ?

When are fetal kick counts incorporated into daily monitoring

A

Greater than +1 after 12hrs of bed rest
5lbs gained in one week

Pre-eclampsia

After 28wks

196
Q

How are kick counts conducted

How long are sleep/wake cycles

How is Rh Alloimmunization tested for

A

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
Q

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

A

28wks and,
<72hrs of delivery for all pregnancies

Neonatal encephalopathy
Kernicterus

Kernicterus- cerebral palsy, SNHL

198
Q

When/why would a quant test be used for fetal-maternal hemorrhage

What is the above quant test named and how is it completed

A

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
Q

How much Rhogam is administered

How much coverage is provided

Screening for fetal aneuploidy is looking for ? MC

A

300mcg IM

30cc of hemorrhage

Down Syndrome

200
Q

What Fetal Aneuploidy tests are done in the first trimester

What Fetal Aneuploidy tests are done in the second trimester

A

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
Q

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

A

Cystic Fibrosis
Sickle Cell
Tay-Sachs

Trisomy 21 (Downs) 18 (Edwards) 13 (patau)

Nuchal translucency

202
Q

What US finding decreases likelihood of Down being present

Quad screen results

Non-invasive cell-free fetal DNA testing is available at ? week

A

Nasal bone

21- dec MSAFP/Estriol, inc b-hCG/inhibin
18- dec all
13- depends

Starting- 9wks

203
Q

Indications for cffDNA testing

When are genetic testing ages changed

Amniocentesis is conducted at ? week while CVS is done at ?

A 
>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

204
Q

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

A

Jaw/Limb abnormalities

AFP levels= no NTD info

> 20wks

205
Q

When is antenatal testing started

How is electronic fetal monitoring results interpreted if fetus is healthy

? is the first line tool for fetal surveillance

A

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
206
Q

? 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

A

Moderate: 6-25bpm

High negative predictive value;
Pos= high risk for fetal death d/t hypoxia

Labor

207
Q

Amniotic fluid is similar to ? fluid

When does fetal urine production begin

Fetal kidney become main contributor to amniotic fluid by ?

A

Extracellular

8-11wks

18wks

208
Q

Why do premature babies lose more water than term babies

What is a normal amniotic fluid index

What result mean Polyhydramnios or Oligohydramnios

A

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

209
Q

What are the 5 fetal variables used for determining Biophysical Profile

What do the scores mean and the next step associated with each

A 
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

210
Q

BPP score of 8-10 means

Score equivocal to 6 or poor predictor means ?

Score of 4 or less means

A

Normal fetal pH, reassuring

Retest in 12-24hrs or deliver

Non-reassuring, poor outcome- eval and consider delivery

211
Q

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

A

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

212
Q

1st Trimester precautions

2nd/3rd Trimester precautions

A

Pain UTI Sxs Bleeding

Bleeding Ab pain Contraction HA Fetal movement
Vision change Loss of fluid
Cadidiasis UTI Sxs Regular contractions F/u

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