OB-Gyne Flashcards
When does standard HCG test for pregnancy become positive?
2 weeks after conception
What is Heagar’s sign
sofetening and compressivility of the lower uterine segment indicating pregnancy
What is Chadwick’s sign
dark discoloration of the vulva and vaginal walls
What is the significance of linea nigra in preganancy?
normal benign finding
What is melasma?
hyperpigmentation of sun exposed areas; often in pregnancy
When does quickening occur?
primigravida: 18-20 weeks, multi: 16-18 weeks
When during pregnancy do you need a pap smear?
at first visit unless done in last 6 months
When during pregnancy do you need a urinalysis?
at every visit
Urinalysis in pregnancy is used to screen for…
pre-eclamppsia, bacteriuria, diabetes
When during pregnancy do you need a CBC?
at first visit
When during pregnancy do you need a blood type/screen?
at first visit
When during pregnancy do you need a syphilis test?
at first visit, repeat later if high risk
When during pregnancy do you need a rubella titer?
first visit if vaccination history not known
When during pregnancy do you need diabetes screening?
- betwen 24-28 weeks; at first visit if high risk factors
High risk factors for gestational diabetes
obese, family history, age over 30
When during pregnancy do you need a triple screen?
15-20 weeks for older/high risk women
Significance of low AFP on triple screen
Down syndrome, fetal demise, inaccurate dates
Significance of high AFP on triple screen
neural tube defect, ventral wall defect, multiple gestation, multiple gestation
What do you do if triple screen is abnormal.
order an US to check dates and look for anomalies, if US not helpful, order amnio for AFP level and cell culture for chromosomes
When during pregnancy do you need a Group b strep culture?
35-37 weeks
How do you treat group B strep in pregnant mom?
treat with amoxicillin during labor
When can fetal heart tones be heard?
doppler: 10-12 week, stethascope: 16-20 weeks
What is significant for size/date discrepency
uterine size difference of 2-3 cm to dates; get US
What do HCG levels do in the first trimester of pregnancy?
double every 2 days
Ongoing increase in HCG or increase after delivery indicates
hydatiform mole, choriocarcionma
HCG level at 5 weeks
> 2000
Transvaginal US can detect intrauterine pregnancy at
5 weeks
Average weight gain of pregnancy
28 pounds
With extra weight gain in pregnancy think
diabetes
With poor weight gain during pregnancy think
hyperemesis gravidum, psych disorder, major systemic disease
ESR in pregnancy
very elevated
Thyroid tests in pregnancy
free T4 same, overall total T4 and thyroid binding globulin increase
Hematocrit in pregancy
decreased (increased red cells but fluid increases more)
BUN and Cr in pregnancy
decrease (GFR increases)
Alkaline phosphatase in pregnancy
very increased
Mild proteinuiria in pregnancy
normal
Mild glucosuria in pregnancy
normal
Electrolyte in pregnancy
unchanged
Liver function tests in pregnancy
unchanged
BP changes in pregnancy
decreases slightly
HR changes in pregnancy
increased 10-20 beats per minute
Stroke volume and cardiac output in pregnancy
increase, often by 50%
Minute ventillation in pregnancy
increases (increased tidal volume, rate about the same)
Residual lung volume in pregnancy
decreased
Respiratory alkalosis in pregnancy is
normal
Definition of IUGR
below 10th percentile for age
3 classes of causes of IUGR
maternal, fetal, placental
Components of biophysical profile (BPP)
heart rate tracin, amniotic fluid index, fetal breathing movements, fetal body movements
If you are concerned about a fetus, but non-emergent, what is the series of investigations?
- BPP, if abnormal then contractile stress test. If decels, usually go to c-section
What is the contraction stress test
looks for uretroplacental dysfunction,
Define oligohydramnios
<300-500 ml
4 major causes of oligohydramnios
IUGR, premature rupture of membrane, postmaturity, renal agenesis (Potter disease)
4 complications of oligohydraminios
pulmonary hypoplasia, cutaneous problems (compression), skeletal problems (compression), hypoxia (cord compression)
Define polyhydramnios
> 1700-2000ml
5 major causes of polyhydramnios
maternal diabete, multiple gestation, neural tube defects, GI anomolies, hydrops fetalis
Maternal complications of polyhydramnios
uterine atony, dyspnea from large uterus
At term normal fetal heart rate is
110 to 160 bpm
Discuss early decelerations
low point of fetal HR and high point of uterine contraction coincide, from head compression, normal
Discuss varible decelerations
most common, variable occurance with contractions, signifies cord compression
Treatment of variable decelerations
mom in lateral decub., give O2 by facemask, stop oxytocin, if brady (t resolve measure fetal O2
Discuss late decelerations
fetal HR nadir occurs after contraction, uteroplacental insufficiency, worrisome
Treatment in late decelerations
lateral decub, O2, stop oxytocin, give tocolytic, give IVF if BP not optimal, if persist, measure fetal O2
Examples of tocolytic agents
ritodrine, magnesium sulfate
Discuss the loss of fetal variability if heart rate in labor
check fetal scalp pH, if associated with variable or late decels, likely need to deliver
In labor, what are the scalp pH parameters that indicate need for delivery?
fetal scalp pH < 7.2 or abnormal O2
How can you distinguish true labor
regular contraction (every 3 minutes), associated with cervical changes
Describe “false labor”
aka Braxton-Hicks contraction, irregular, no cervical changes
Desribe the stages of labor
1st- true labor to full dilation, 2nd- full dilation to dirth, 3rd- delivery of baby, 4th- placenta to stabilization
1st stage of labor lasts how long?
nuligravida: < 20 hours, multigravida: < 14 hours
In the active phase of 1st stage of labor, how fast does the cervix dilate?
nuligravida: >1cm/hr, multigravida: >1.2 cm/hr
Time from full cervical dilation to start delivery of baby
nuligravida: 30min - 3 hrs, multigravida: 5-30 min
Time to delivery baby
0-30 minutes
Time to delivery placenta and maternal stabilization
up to 48 hours
What is protraction disorder
Labor takes long than expected
What is labor arrest disorder?
No change in cervical dilation occurs over 2 hours and no change in fetal descent after 1 hour
Treatment of arrest disorder
check fetal lie, check for cephalopelvic disproportion, augment labor
Name 3 ways to augment labor
oxytocin, prostaglandin gel, amniotomy
Most common cause of “failure to progress” in labor
cephalopelic disporoprtion (labor augmentation contraindicated)
Half life of oxytocin
less than 10 minutes
Side effects of oxytocin
uterine hyperstimulation, uterine rupture, fetal heart deccelerations, hyponatremia
Side effects of PGE2 used for ripening cervix
uterine hyperstimulation
Decision of vaginal delivery with HSV based on…
if active lesions during labor, opt for c-section
Orientation of “classic” c- section incision
vertical
Signs of placental separation
fresh blood from vagina, umbilical cord lengthens, fundus rises and becomes firm and globular
What is the first step during delivery with shoulder dystocia
McRobert maneuver: mother sharpely flexes thighs against abdomen
List the order of labor positions
descent, flexion, internal rotation, extension, external rotation, expulsion
Postpartum discharge
red the first few days, usually white by day 10
Foul smelling lochia is concerning for
endometritis
What is the underlying likely cause when new mom develops PE
PE from amniotic fluid
Definition of post-partum hemorrhage
> 500 cc with vaginal, >1000cc with c-section
Most common cause of post-partum hemorrhage
uterine atony
Complication of severe post-partum hemorrhage
Sheeham sydrome
Risk factors for retained placenta after delivery
previous uterine surgery, previous c- section
Risk factors for uterine atony
overdistended, prolonged labor, oxytocin, more than 5 deliverie, precipitous labor (<3h)
Treatment of uterine atony
- uterine massage with low dose oxytocin, 2. ergot drug or PGF2-alpha, 3. hysterectomy
Treatment of retained products of conception
remove placenta manually to stop bleeding, curettage in or, if placental accreta, likely to need hysterectomy
Most common cause of uterine inversion
iatrogenic; pulling too hard on the cord
Treatment of uterine inversion
manually replace uterus may need anesthesia
Definition of post-partum fever
fever for 2 days
5 most common causes of post-partum fever
breast engorgement, UTI, endometritis, puerperal sepsis, endomyometritis
Risk factors for endometritis
C-section, PROM, prolonged labor, frequent vaginal exams, manual removal of placenta
Treatment of endometritis
obtain cultures of endometrium, vagina, blood and urine, treat with broad spectrum antibiotics
If endometritis doesn’t resolve, what’s likely going on?
pelvic abscess OR pelvic thrombophlebitis ( get a CT)
Treatment of post-partum pelvic thrombphlebitis
heparin
3 major things to think of with postpartum shock and no evident bleeding
amniotic fluid embolus, concealed hemorrhage, uterine inversion
Mastidis after delivery usually occurs
within 2 months
Usual organism of mastidis
staph aureus
Treatment of mastidis
keep breast feeding, analgesia, warm compresses, antibiotics if more than mild (cephalexin, dicloxacillin)
Contraindications to breast feeding
maternal HIV, illicit drug use, sedatives, stimulants, lithium, chemotherapy
Define abortion
termination of pregnancy before 20 weeks or fetus less than 500 grams
Define threatened abortion
uterine bleeding without cervical dilation and no expulsion of tissue
Treatment of threatened abortion
pelvic rest
What percentage of pregnancies with threatened abortion go on to be normal?
50%
Define inevitable abortion
uterine bleeding with cervical dilation, crampy pain and no tissue
Treatment of inevitable abortion
follow, D&C of uterine cavity
Define incomplete abortion
passage of some products of conception through cervix
Treatmetn of incomplete abortion
observation, often need D&C
Define complete abortion
expulsion of all products of conception from the uterus
Treatment of complete abortion
Serial HCGs to be sure returns to zero. D&C if pain or opeen cervical os
Define missed abortion
fetal death without expulsion of fetus
Treatment of missed abortion
most women go on to have spontaneous miscarriage but D&C often performed
Define induced abortion
intentional temination prior to 20 weeks (elective or therapeutic)
Define recurrent abortion
two or three successive unplanned abortions
4 infectious causes of recurrent abortion
syphilis, Listeria, Mycoplasma, Toxoplasma
3 environmental causes of recurrent abortion
alcohol, tobacco, drugs
2 metabolic causes of recurrent abortion
hypothyroidism, diabetes
3 autoimmune causes of recurrent abortion
lupus, anitphospholipid antibodies, lupus anticoagulant
3 anatomic causes of recurrent abortion
cervical incompience, congenital female tract abnormalities, fibroids
Classic cause of painless recurrent abortions in the second trimester
cervical incompetence
Treatment of cervical incompetence
cerclage at 14-16 weeks
Typical time when ectopic pregnancy presents
4-10 weeks.
Definitive diagnosis and treatment of ectopic pregnancy in unstable patient
laparoscopy
Major risk factors for ectopic pregancy
history of PID, previous ectopic, history of tubal ligation, pregnancy with IUD in place
In 3rd trimester bleeding always do a ______ before a ______
always do an UTZ before a pelvic exam
Ddx of 3rd trimester bleeding
placenta previa, abruptio placentae, uterine rupture, fetal bleeding, cervical/vaginal lesions, cervical/vaginal trauma, bleeding disorder, cervical cancer
In all patients with 3rd trimester bleeding, what do you do?
order CBC w/ coags, do UTZ, setup maternal and fetal monitoring, tox screen if suspected, give Rh immune globuline if mother Rh negative
Risk factors for placenta previa
multiparity, older age, multiple gestation, prior previa
Why do you do an US before a pelvic exam in 3rd trimester bleeding
because of placenta previa.
Accuracy of US in dx placenta previa
95-100%
Characteristics of bleeding in placenta previa
painless, may be profuse
Treatment of placenta previa
if premature, can try rest and tocolysis if stable, otherwise needs c-section
Risk factors for abruptio placentae
HTN, cocaine, trauma, polyhydramnios with rapid decompression with membrane rupture, tobacco, preterm PROM
3rd trimester bleeding where blood may not be visible
abruptio placentae
Woman in 3rd trimester with uterine pain/tenderness and hyperactive contraction pattern and fetal distress is concerning for
abruptio placentae
Use of US in diagnosing abruptio placentae
may be falsely normal
Complication of abruptio placentae
maternal DIC if fetal products enter blood stream
Treatment of abruptio placentae
rapid delivery (vaginal preferred)
Risk factors for uterine rupture
previous uterine surgery, trauma, oxytocin, grand multiparity, excessive uterine distention, abnormal fetal lie, CPD, shoulder dystocia
Sudden onset of abdominal pain in 3rd trimester with sudden materal hypotension most concerning for
uterine rupture
Treatment of uterine rupture
laparotomy for delivery, usually requires hysterectomy
2 major causes of 3rd trimester fetal bleeding
vasa previa, velamentous insertion of the cord
Major risk factor for 3rd trimester fetal bleeding
multiple gestation (higher # of fetuses = higher risk)
3rd trimester bleeding with painless bleeding, stable mom and fetal distress
from fetal bleeding
How do you differentiate maternal from fetal blood (such as in 3rd trimester bleeding?)
The Apt test
Treatment of fetal bleeding in 3rd trimester
c-section
Define preterm labor
labor between 20-37 weeks
List the more common contraindications to tocolysis in preterm labor
herat disease, HTN, DM, hemorrhage, pre-eclampsia, chorioamnionitis, IUGR, ruptured membranes, cervical dilation >4cm, fetal demise, =- fetal abnormalities incompatible with survival
What action for the fetus must be taken in a stable patient with possible pre-term labor and positive fetal fibronectin?
measures for lung maturity
Amniocentesis results that indicate immature lungs
lecithin : sphingomyelin (L:S) ration less than 1:2
At what age in premature labor do you give steroids to hasten lung maturity
between 26 and 34 weeks
Define premature rupture of membrance
ruputre of amniotic sac prior to onset of labor
3 critera for premature rupture of membranes
pooling of amniotic fluid, ferning pattern, positive nitrazine test
What test should be done in confirmed premature rupture of membranes
US
How long do you give a mom at full term with PROM before inducing labor?
6-8 hours
Mom with PROM, fever and tender uterus likely has
chorioamnionitis
Classic cause of chorioamnionitis
premature rupture of membranes
Complications of chorioamnionitis in mom and fetus
neonatal sepsis, maternal sepsis, maternal endomyometritis
Empiric treatment of chorioamnionitis
ampicillin
Define preterm PROM
premature rupture of membranes before 36-37 weeks
What do you need to test for with preterm PROM
culture fluid for group B step and treat mom with ampicillin if positive culture
If placenta is monochorionic then twins are
monozygotic
4 major maternal complications of multiple gestations
anemia, HTN/pre-eclampsia, postpartum uterine atony, postpartum hemorrhage
9 major fetal complications of multiple gestations
polyhydramnios, malpresentation, placenta previa, abruptio placentae, velamentous cord/vasa previa, umbilical cord prolapse, IUGR, congenital anomalies, increased morbidity/mortality
When can you try to delivery twins vaginally?
When they are BOTH vertex; any other combo, do c-section
Define post-term pregnancy
after 42 weeks
If dates for pregnancy are known and reach 42 weeks, what do you do?
induce labor
If dates for pregnancy are unknown and reach 42 weeks, what do you do?
twice weekly BPP
Post post-maturity for fetus increase risk of morbidity and mortality?
yes
Prolonged gestation is classically associated with what congenital anomaly?
anencephaly
Fetus with “frog-like” appearance on US likely has
anancephaly
Hyperemesis gravidarum presents in which trimester?
1st
With all high risk pregnancies, consider weekly _____ during the third trimester
biophysical profiles
Can chorionic villi sampling detect neural tube defects?
no
When can chorionic villi sampling be done?
at 9-12 weeks (earlier than amniocentesis)
chorionic villi sampling is generally reserved for
testing of genetic diseases
What is the miscarriage rate of chorionic villi sampling compared to amniocentesis
higher with chorio
How do you know if a woman has pre-eclampsia if she already had HTN?
Increased greater than 30/15
What does HELLP syndrome stand for?
H- hemolysis, EL-elevated liver enzymes, LP-low platelets
S/s for pre-eclampsia
HTN, 2+ proteinuria, oliguria, facial/hand edema, headache, visual changes, HELLP syndrome
Pain in what location often does with HELLP syndrome?
RUQ or epigastric pain
When does pre-eclampsia usually occur?
3rd trimester
Treatment of pre-eclampsia
Definitive treatment is termination of deliver
Treatment for pre-eclampsia if fetus is not full term
hydralazine or labetalol, magnesium sulfate (seziure prophylaxis), bedrest, hospital observation
Indications in pre-eclampsia to delivery baby regardless of gestational age
BP > 160/110, oliguria, mental status change, headache, blurred vision, pulmonary edema, cyanosis, HELLP, ecclampsia (seizures)
Is severe ankle edema normal in pregnancy?
No, look for pre-ecclampsia
HTN + proteinuria in pregnancy = ______ until proven otherwise
pre-eclampsia
Complications of pre-eclampsia and eclampsia
uretoplacental insufficiency, IUGR, fetal demise, increased maternal morbidity and mortality
Does pre-eclampsia during pregnancy mean higher risk for HTN later in life?
No, not generally
Pre-eclampsia prior to the third trimester is likely
molar pregnancy
Best way to prevent eclampsia?
routine prenatal care
Initial treatment of choice for eclamptic seizures?
magnesium sulfate wthich also lowers blood pressure
Toxic effects of magnesium sulfate
hyporeflexia (1st sign), respiratory depression, CNS depression, coma, death
3 maternal complications of gestational diabetes
polyhydramnios, pre-eclampsia, complications of DM
2 difference is fetus for gestational DM vs. pre-existing DM
gestational: macrosomia, pre-existing: IUGR
What is caudal regression syndrome?
lower half of body incompletely formed (risk with gestational DM)
Use of oral hypoglycemics in pregnancy
contraindicated (use insulin)
Infants born to DM mothers are classically at risk for what right after birth?
postdelivery hypoglycemia
Why do babies of DM mother’s get hypoglycemic after delivery?
fetal islet cell hypertrophy
Only maternal antibody category to cross the placenta
IgG
Meaning of elevated neonatal IgM concentration?
never normal
Meaning of elevated neonatal IgG concentration
often represents maternal antibodies
When does Rh incompatilbity occur
mom Rh negative, baby Rh positive
At what time do you give Rh immune globulin
28 weeks, within 72 hours of delivery, after any procedures which may cause transplacental hemorrhage (amnio)
What type of prevention is Rh immune globulin?
primary
IS Rh immune globulin effective if maternal Rh antibodies are strongly postiive?
no
What is hydrop fetalis
edema, ascites, pleural/pericardial effusions
Undetected Rh incompatability can lead to
hemolytic disease of newborn (hydrops fetalis)
Who do you test the severity of fetal hemolysis
Amniotic fluid spectrophotometry
Treatment of hemolytic disease of the fetus
delivery if mature, intrauterine blood transfusion, phenobarbital (helps fetal liver break Down bilirubin)
Mother with type O blood and baby with any other type, baby at risk for
hemolytic disease of the newborn
Snow storm pattern on US =
hydatiform mole
grape like vesicles with 1st or 2nd trimester bleeding
hydatiform mole
uterine size/dates discrepancy brings concerns for
hydatiform mole
Karyotype of complete moles
46XX or 46 XY (all from father)
Do complete moles contain fetal tissue?
no
Karyotype of incomplete moles
69 XXY
Do incomplete moles contain fetal tissue?
yes
Treatment of moles
D&C, follow HCG levels to zero
What happens if patient treated for hydatiform mole and HCG doesn’t return to zero
invasive mole or choriocarcinoma and patient needs chemo
Chemo options for invasive mole or choriocarcinoma
methotrexate, actinomycin D
Source of choriocarcinoma
complete mole
Can choriocarcinoma develop from incomplete mole?
no
Prevention of aborption in when with antiphsophlipid antibodies and previous pregnancy problems
Low dose ASA and heparin
How do you treat TB in a pregnant patient
same treatment
Drug to avoid if need to treat pregnant patient for TB
streptomycin
Streptomycin given during preganancy risks causing ____ and ____ in the fetus
deafness & nephrotoxicity
Fetal defect caused by thalidomide
phocomelia
Fetal defect caused by tetracycline
yellow/brown teeth
Fetal defect caused by aminoglycoside
deafness
Fetal defect caused by valproic acid
spina bifida, hypospadias
Fetal defect caused by progestersone
masculinization of females
Fetal defect caused by cigarettes
IUGR, low birth weight, prematurity
Fetal defect caused by llithium
Ebstein anomalies (atrialization of right ventricle)
Fetal defect caused by aminopterin
IUGR
Fetal defect caused by radiation
IUGR, CNS/face defects, leukemia
Fetal defect caused by phenytoine (diphenyhydantoin)
craniofacial defects, limb defects, mental retardation, cardiac defects
Fetal defect caused by trimethadione
craniofacial defects, cardiovascular defects, mental retardation
Fetal defect caused by warfarin
craniofacial defects, CNS defects, IUGR, stillbirth
Fetal defect caused by carbamazepine
fingernail hypoplasia, craniofacial defets
Fetal abnormalities caused by iodine
goiter, cretinism
Fetal abnormalities caused by cocaine
cerebral infarcts, mental retardation
Fetal abnormalities caused by diazepam
clef lip/palate
Fetal abnormalities caused by diethylstilbestrol
clear cell vaginal cancer, adenosis, cervical incompetence
Is acetaminophen safe in preganancy?
Yes
Is penicillin safe in preganancy?
Yes
Is cepahlosporins safe in preganancy?
Yes
Is erythromycin safe in preganancy?
Yes
Is nitrofurantoin safe in preganancy?
Yes
Is H2-blocker safe in preganancy?
Yes
Is antacid safe in preganancy?
Yes
Is heparin safe in preganancy?
Yes
Is hydralazine safe in preganancy?
Yes
Is methyldopa safe in preganancy?
Yes
Is labetalol safe in preganancy?
Yes
Is insulin safe in pregnancy?
yes
Is docusate safe in pregnancy?
yes
3 important features of PID
abdominal pain, adnexal tenderness, cervical motion tenderness
4 supporting features of PID
elevated ESR, leukocytosis, fever, purulent cervical discharge
3 biggest organisms in PID
Neiseria gonorrhoeae, chlamydia, e. coli
Organism causing PID in patient with IUD
actinomyces israeli
Most common preventable cause of infertility
PID
Likely cause of infertility in woman under 30 with regular menstrual cycles
PID
Treatment of PID
more than 1 antibiotic, oupt: ceftriaxone/doxycycline, Inpt: clinda/gent
Unusual feature of tubo-ovarian abscess
may resolve with antibiotics alone
Vaginal discharge like cottage chees
candida
Vaginal discharge with pseudohypahe on KOH
candida
Vaginal discharge with history of diabetes
candida
Vaginal discharge with history of antibiotic treatment
candida
Vaginal discharge with during pregancy
candida
Treatment of candidal vaginitis
oral or topical antifungal
Vaginal discharge with organisms seen swimming under microscope
trichomonas
Vaginal discharge that is pale green, frothy, watery
trichomonas
Vaginal discharge with strawberry cervix
trichomonas
Treatment of trichomonas
metronidazole
Vaginal discharge with fishy smell on KOH prep
Gardnerella
Vaginal discharge with clue cells
Gardnerella
Vaginal discharge that is malodorous
Gardnerella
Treatment of Gardnerella
Metronidazole
Venereal warts are caused by
human papillomavirus
Koilocytosis on pap smear =
human papillomavirus venereal warts
Multiple shallow painful vaginal ulcers =
herpes
Treatment of vaginal herpes
acyclovir, valacyclovir
Most common sexually transmitted disease
Chlamydia
STD that often causes dysuria
Chlamydia
Treatment of chlamydia
doxycycline, azithromycin
One time oral treamtment option for chlamydia
- 1 gram of azithromycin
Treatment of chlamydia in pregnant patient
erythromycin or amoxicillin
STD for mucopurulent cervicitis
Neisseria gonorhoeae
Gram negative STD
Neisseria gonorhoeae
Treatment of Neisseria gonorhoeae
ceftriaxone, cipro
STD with intracellular inclusions
molluscum
If a patient has gonorrhea, what should you also treat for?
chlamydia
Typical treatment for fonorrhea
ceftraizone and doxycycline (assume also chlaymdia infection)
STDs where the partner does NOT need to be treated
candida, Gardnerella
Test to do in primary amenorrhea
- if basic overview normal, administer progesterone; if no bleeding, likely no estrogen or anatomic abnormality
If patient with primary amenorrhea bleeds with progesterone test, this means
estrogen is present, normal uterus
If patient with primary amenorrhea has normal breasts but no pubic/axillary hair, likely
androgen insensitvity syndrome
Secondary amenorrhea with + progesterine challenge and HIGH leutinizing hormone
polycystic ovarian syndrome
In polycystic ovarian sydrome, LH is
high
Ddx for secondary amenorrhea with + progesterine challenge and LOW leutinizing hormone
pituitary adenoma, hypothyroidism, low gonadotropin hormone
Test to check is patient has secondary amenorrhea that you think is from pituitary adenoma
prolactin
Patient with secondary amenorrhea with normal prolactin, normal TSH and low gonadotropin likely has
anorexia nervosa
A patient with secondary amenorrhea with + progesterone bleeding test can likey become pregnant by using which drug?
clomiphene
Secondary amenorrhea with no bleeding on progesterine challenge has (generally)
insuffecient estrogen
Secondary amenorrhea with no bleeding on progesterine challenge with elevated FSH has
premature ovarian failure/menopause
FSH is _____ in premature ovarian failure
elevated
Secondary amenorrhea with no bleeding on progesterine challenge with low/normal FSH may have
neoplasm of hypothalamus (get MRI of brain)
First test to order in amenorrhea
pregnancy test
Nulliparous 35 yr woman with dyspareunia and dyschezia
endometriosis
Most common site for endometriosis
ovaries
Tender adnexa WITHOUT evidence of PID =
endometriosis
Endometriosis may be associated with this uterine position
retroverted
Gold standard for diagnosis of endometriosis
laparoscopy with visualization
Mulberry spots
endometriosis
flat brown colored powder burns
endometriosis
chocolate cysts
endometriosis
Most likely cause of infertility in menstruating woman over 30
endometreosis
Treatment of endometriosis
1st: birth control pills, 2nd/3rd: danzol, GnRH agonists
Effect of surgery for endometriosis on fertility
often improves it
Define adenomyosis
ectopic endometrial glands within uterine musculature
Typical characteristics of adenomyosis
dysmenorrhea, large boggy uterus
Woman over 40 with large boggy uterus and dymenorrhea
adeomyosis
Treatment of adenomyosis
D&C to r/o endometrial cancer, consider hysterectomy, may try GnRH agonists
Define dysfunctional uterine bleeding
abnormal uterine bleeding not associated with tumor inflammation or pregnancy
70% of dysfunctional uterine bleeding is associated with
anovulatory cycles
When is dysfunction uterine bleeding common and physiologic?
Right are menarche and before menopause
If dysfunctional uterine bleeding that doesn’t appear simple, think
polycystic ovarian syndrome
What needs to be done in woman over 35 with dysfunctional uterine bleeding?
D&C to r/o endometrial cancer
Why should you get a CBC in patient with polycystic ovarian syndrome?
excess blood loss
4 uncommon causes of dysfunctional uterine bleeding
infections, end, ocrine disorders, coagulation defects, estrogen producing neoplasms
First line treatment for idiopathic dysfunctional uterine bleeding
NSAIDs or OCPs
First line treatment for dysmenorrhea
NSAIDs
Treatment of severe bleeding with dysfunctional uterine bleeding
progesterone
Overweight woman with infertility and amenorrhea
polycystic ovarian syndrome
Most common cause of infertility in woman under 30 with ABnormal menstruation
polycystic ovarian syndrome
LH:FSH in polycystic ovarian syndrome
greater than 2:1
Cancer risk in polycystic ovarian syndome
unopposed estrogen causes increased risk for endometrial hyperplasia and enodmetrial carcinoma
Treatment of polycystic ovarian syndrome
OPCs, cyclic progesterone, Metformin, if wants pregnancy, use clomiphene
Treatment of premenstrual dysphoric disorder
NSAIDs; antidepressants
Increase parabasal cells on vaginal cytology indicates
menopause
Fibroids aka
leimyoma
Are leiomyomas malignant or benign?
benign
Most common indication for hysterectomy
leiomyoma
Rate of malignant transformation of leimyoma
<1%
When do leiomyomas often grow rapidly?
During pregnancy or high estrogen (OCPs)
Anemia with fibroids is an indication for
hysterectomy
Test that should be done in woman over 40 with leiomyoma
D&C to r/o endometrial cancer
Polyp protruding through cervix is likely
leiomyoma
If a patient has bilateral non-bloody breast discharge, what are the chances that it’s cancer?
very low
Unilateral breast discharge is concerning for
cancer
Most common breast disorder
fibrocystic disease
Treatment of fibrocystic breast disease if under 35
if symptoms are very severe can do progesterone or danazol for a week at the end of each month
Features of fibrocystic breast disease
under 35, bilateral, multiple cystic lesions, tender
A painless, shaprly circumscribed, rubbery, mobile breast mass is likely
fibroadenoma
Most common benign tumor of the female breast
fibroadenoma
Age when you become more concerned about breast cancer
35
Treatment of fibroadenoma of the breast
excision is curative but often not needed
Fibroadenoma of the breast often growns quickly in the setting of
OCPs or pregnancy (estrogen)
Is mammogram useful under the age of 35?
No. Breast tissue too dense. Proceed directly to biopsy
This potentially malignant tumor often masquerades as a rapidly growing fibroadenoma of the breast
phylloides tumor
In a woman over 35 with a breast mass, when in doubt…
get a biopsy
A new breast mass in a postmenopausal woman…
is breast cancer until proven otherwise
Pelvic heaviness that is worse with standing and improves with lying down may be
vaginal prolapse
A bulge into the upper vaginal wall is likely
a cystocele
Symptoms of cystocele
urianry urgency, frequency and incontinence
A bulge into the lower posterior vaginal wall is likely
a rectocele
Symptoms of rectocele
difficultly defecating
What is an enterocele
bulding of loops of bowel into upper posterior vaginal wall
Treatment of -celes (cystocele, etc)
pelvic strengthening
1st step in eval of infertility (after based H&P)
semen anlysis
Risk factor for uterine synechiae
D&C
What radiographic test do you order to look for uterine structural abnormalities?
hysterosalpingogram
Clomiphene can be used to stimulate ovulation in what setting
need adequate estrogen
