OBGYN Flashcards
How long is the average menstrual cycle?
28 days
How many phases are there of the uterus and what are the called?
Mensuration, proliferative, and secretory phase
How many phases are there of the ovum?
Follicular phase and the luteal phase
What is the primary hormone in the follicular phase?
FSH and LH
What does FSH do?
It stimulates growth of the follicle and production of estrogen by stimulating granulosa cells to make aromatase which converts androsteidone (from theca cells) to estrogen.
Why are anovulatory cycles a problem?
They mean that unopposed estrogen is exposed to the uterine lining. Because there is no corpus luteum no progestrone is produced.
What are causes of secondary amenorrhea?
Pregnancy, Prolactinoma, hypothyroidism, menopause (hypergonadotrpic hypogonadism)
What is the criteria in order to diagnose a patient with amenorrhea?
The patient with regular cycles has no periods for greater than 3 months. OR in a person with irregular periods greater than 6 months.
What is oligomenorrhea?
Menstrual cycles greater than 35 days long or less than 9 cycles in a year.
What is menorrhagia?
Heavy and prolonged menstrual bleeding
hypomenorrhea
spotting
Metorrhagia
Bleeding between menstrual periods
What are some of the causes of abnormal uterine bleeding.
Remember the pneumonic PALM. Polyp, adenomyosis, Leiomyata, and Malignancy.
How do we diagnose pregnancy?
urine bHCG and transvagial ultrasound
If a patient has amenorrhea what should work up for this patient look like?
BHCG, prolactin, TSH, FSH, estradiol
If a progestrone withdrawl test is done in a patient with amenorrhea and has withdrawl bleeding what is the reason for amenorrhea?
progesterone deficiency
What is PCOS?
Due to problems of progress and or regression of the follicles the follicles become cystic.
What are common associations of PCOS?
Insulin resistance, acanthosis nigracans, obesity, weight gain, and type 2 diabetes
What is the diagnosis of PCOS?
It’s a diagnosis of exclusion, typically we rule out cushing, 21 hydroxylase, IGF-1 etc
What is treatment for PCOS in a patient that doesn’t currently want children ?
OCP
What is the treatment of PCOS in a patient that wants children?
clomephine or letrzole (usually used in women with a BMI over 30)
what is the mechanism of action of letrozole?
It inhibits aromatase
What are the risks associated with taking OCP’s?
Increased risk of coagulopathies, hypertension, and benign hepatic tumors
Medroxyprogestrone acetate
Hormonal depot or the injection
What are the two types of IUD’s
Levonorgestrel and cooper
What is a vasectomy?
Cut the vas deferens
What is a tubal ligation?
Female sterilization
How do OCP’s work?
They work by inhibiting LH surge due to estrogen feedback to the hypothalamus and pituitary.
How does progesterone work?
By increasing the cervical mucus production
What are the absolute contraindications of OCP’s?
*Patient >35 with smoking history
* History of thromboembolism or
coagulation disorders
* History of liver disease
* history of coronary artery disease
* migrane aura
*breast cancer
* SLE
* Valvular heart disease
This emergency contraception should be inserted 5 days after unprotected sex?
Cooper IUD and uliprastil
This emergency contraception can be used up to 3 days after unprotected sex?
Levenorgestrel
What is primary dysmenorrhea?
Menstrual pain that has lasted a year and usually occurs around the time of menstruation and is typically do to prostaglandin production.
Dysmenorrhea, dyspareunia, urgency frequency, dysuria, constipation. Physical exam shows mass in the left adnexa. What is the most likely diagnosis?
Endometriosis
What is the management for patients with endometriosis?
OCP’s and NSAIDs
What is the diagnostic exam for endometriosis?
Laprascopy
What are Leiomyomas?
Fibroids, masses of the smooth muscle.
cyclic pelvic pain, menorrhagia, dysmenorrhea, urinary frequency, constipation, with an asymetrical large uterus?
Fibroids
Fever, nausea, abnormal vaginal discharge, dysparuneia, with cervical motion tenederness.
PID
How do we diagnose PID?
If you suspect PID, which is a clinical diagnosis. Keep in mind that these patients tend to be sexually active females. Pelvic exam should routinely be performed microscopy of vaginal discharge. NAAT test, pregnancy test, and screen for STD’s.
What are risk factors for PID?
Risky sexual activity, previous infection or STD/STI’s, age <25
What is pre-menstural syndrome?
Either behavioral or physical symptoms that occur around menses
What is post-menstural dysmorphic disorder?
More prominent anger and irritability around mensuration
How we diagnose a women as being in menopause?
It’s a clinical diagnosis and can be confirmed with low levels of estrogen and high levels of and high levels of FSH and LH.
A patient with itching and burning, frequency, dyspareunia. What is the next step in management?
Vaginal discharge analysis (ph), microscopy,
A patient with itching and burning, frequency, dyspareunia. With discharge analysis showing a ph < 4.5 and yeast and hyphae on microscopy has?
Candida
Patient with itching and burning, frequency, dyspareunia with malodorous discharge. With a ph >4.5 with clue cells has?
Gardnerella
Patient with itching and burning, frequency, dyspareunia with frothy discharge and ph >4.5. What is the next step in treatment?
Metronidazole and to treat the partner. Remember trichmonas is a protozoan
Women with PCOS presents to the office with complaint of white discharge (non-odorus), itching. Vaginal exam shows no irritation. What is the cause for the patients white discharge?
leukorrhea
A 2 yo child that presents with vaginal foul, chunky discharge is found to have a retained body in the vaginal canal what is treatment?
irrigation is the first line, but if larger this may require general anesthesia.
What is the treatment for PID?
cephalosporins or (amp and gentamicin in a pregnant woman)
A complication that leads to peri-hepatitis. The patient will present with RUQ and elevated liver function tests.
Fitz hugh curtis is a complication of PID
A patient with abdominal pain in reproductive years what is a diagnosis we should always consider ruling out?
Pregnancy
Pain associated with ovulation. Typical due to a cyst that formed at the corpus luteum.
mittleschmerz, this usually self resolves
Pt. presents to the ED because of severe abdominal pain, fever, and tachycardia. The patient LMP was 7 weeks ago. Palpation of the right adnexa show rebound and guarding?What’s the next step in diagnosis
BHCG
Pt. presents to the ED because of severe abdominal pain, fever, and tachycardia. The patient LMP was 7 weeks ago. Palpation of the right adnexa shows distention and rigidity? What’s the next step in management?
Surgical abortion
Patient with severe unilateral abdominal pain comes to the ED. The doctor orders doppler flow studies, what diagnosis was she trying to rule out?
Ovarian torsion
What is the treatment for stress incontinence?
Kegel exercises, reduce caffiene, if that doesn’t work we can place a pessarry, or urethral sling
What is the treatment for an overactive bladder?
Muscuranic blockers (oxybutinin), mirbageron if not working.
Patient with urinary incontinence complains of constant dribbling and straining to urine, post void volume is >200ml. What is the cause of incontinence?
Overflow incontinence
What is the first step in diagnosis of urinary incontinence?
UA
If a woman is less than thirty with a breast mass what imaging do we use?
Ultrasound
If a woman greater than thirty has a breast mass what imaging do we use?
Mammography
A patient presents to your office with mass on the breasts that she says has been present for a month or so, it doesn’t bother her. Ultrasound finds that is a thin well defined, anechoic septa mass what is the next step in management?
follow up in few months for patients with asymptomatic cysts
What is a complicated cyst?
Complicated cysts are “probably benign” lesions as they contain internal debris which may mimic a solid mass appearance on imaging. The internal debris typically represents proteinaceous or hemorrhagic material which needs to be carefully evaluated in order to differentiate a complicated cyst from a complex cyst
What is a complex cyst?
Has malignant potential . The walls of a complicated cyst are often slightly thicker than that of simple cysts due to inflammation or mild fibrosis which can occur due to the internal proteinaceous or hemorrhagic components.
A 20 year old patient presents to her family medicine doctor because of a breast mass she noticed last month. Her grandmother has a history of breast cancer at the age of 62. on PE the patient has a non-tender, firm, but moblie mass, what is the next step in diagnosis?
US, if this US showed benign features more than likely we’d classify this as a fibroadenoma
What is the most important risk factor for breast cancer?
the most important is age: others include p53 or BRCA mutations, family history , nulliparous women, obese women.
How often should the average women get a mamogram?
every 1-2 years
If a patient has an ER+ breast cancer what treatment can we use?
tamoxifen
If a patient has a HER2+ what medical management can we consider?
Trastuzamab
A 60 yo woman presents to your office because of bloody discharge, what is the next step in diagnosis?
cytology and mammogram
A 45 yo female presents to you office with bilateral milk production, pregnancy test is negative, and patient denies use of ant-dopaminergic medications. TSH is 6, what is the patients most likely cause of milk production?
Hypothyroidism
60 year old woman presents to the clinic with breast mass that she has has for a year. The patient states there is no tenderness. On PE it’s a hard immobile mass located in the upper outer quadrant of the breast. Mammography is suspicious. What is the next best step in management
What is the most common malignant cancer?
infiltrating ductal carcinoma in situ
What are the risk factors for ovarian cancer?
age > 60, family history, BRCA 1/BRCA2, breast cancer, history of smoking.
A 61 yo woman presents to the clinic SOB and ascites. The patient has a history of lynch syndrome what is the next step in managment?
Trans-vaginal ultrasound and check serum CA-125
A female patient that is 70 yo presents to the office because of vaginal bleeding. What is the next step in diagnosis?
biopsy (endometrial lining thickness) or ultrasound
What is the most common risk factor for cervical cancer?
HPV
How often should women get a pap smear?
Every 3 years
How often should women get HPV testing?
Co-testing of HPV and pap smear should occur every 5 years?
This is a chronic inflammatory disease in the anogenital area that presents with itching, it’s associated with a high risk of SCC and is more prevent in older women?
Lichen sclerosis
Bartholin’s cyst are typical found in what positions?
The 4 and 8 in the posterior portions of the labia
When is drainage of a bartholin cyst indicated?
when the cyst is greater than 3 cm
A 30 year old female presents to your office with her husband because difficulties with conceiving. The husband semen analysis is normal. What is the next best step in work up for this patient?
to r/o ovulatory issue check prolactin, TSH, FSH, and LH. If there is suspicion of structural changes of the uterus and fallopian tubes consider a hysterosalpingogram.
When a patient is planning to become pregnant what supplement should they start?
Folic acid
How do you date a pregnancy?
LMP - 3 months +7 days
Pregnancy dating in the first trimester is most accurate via ?
US
After the first trimester, use _____ for dating of the fetus.
combination of head and abdominal circumference and femur length
What test should be done on the initial visit?
-Blood type; ABO/ Rh
-CBC (complete blood count) to rule out anemia
-Rubella and varicella antibody,
-VDRL/ Rapid Plasma Reagin (RPR),
-Hepatitis panel
-HIV
-Pap smear
-Influenza
-Urine protein and culture
-N.G testing only in women age < 25 or those at risk (multiple sex partners, history of sexually transmitted disease [STD], illicit drug use, etc.)
What test should be done at 24-28 weeks?
If Rh(D) -ve, repeat antibody screen, glucose tolerance test
When should we screen for Group B strep?
35-37 weeks
What are the drugs of choice for urinary tract infections in a pregnant woman?
amoxicillin-clavulanate, cephalexin, cefpodoxime (an oral third-generation cephalosporin), or single-dose fosfomycin.
What patient population is offered chromosomal abnormality screening?
women who are >35 years old
Can be used for the detection of chromosomal abnormalities a t 10 weeks, least invasive.
cell free fetal DNA
Test used to detect chromosomal abnormalities at 10-14 weeks as a confirmatory test following cell free fetal DNA
Chorionic villus sampling
Test used to detect chromosomal abnormalities at 15- 18 weeks?
Amniocentesis
What test measures maternal serum alpha-fetoprotein (AFP), β-hCG, estriol, and inhibin-A levels?
Quadruple screen
Fetus loss of < 20 weeks’ gestation
spontaneous abortion
The (MCC) spontaneous abortion in the first trimester is _____________.
Chromosomal abnormalities.
POC completely evacuated from the uterine cavity with a closed cervix?
complete abortion
Death of fetus in utero, with a closed cervix and no passage of uterine contents.
Missed abortion
Passage of some POC, with some POC remaining in the uterine cavity. With open cervix.
Incomplete abortion
Vaginal bleeding and cramping with dilated open cervix, without passage of POC (products of conception).
Inevitable abortion
When are uterine contractions considered to be tachysystolic?
greater than 5 contractions in 10 mins
What is a normal fetal heart rate?
110-160
What is variability?
The difference between the trough and the peak. 6-25 is a normal variability. If there is no variability or if there is a difference greater than 25 it’s abnormal
Category 1
Everything is all good. HR (110-160), variability is good, no decelerations
Category 3
Absent variability, recurrent late decelerations, variable decelerations or bradycardia. Or a sinusoidal pattern
What are some strategies that may improve a category 3 situation?
Position change, tocolytics, stop oxytocin, vasopressor if mom is hypotensive
What is an adequate montivedo unit
> 200
Why is uterine tachysystole an issue?
Because there is a comprimise to placental blood flow.
When is amnioinfusion indicated?
When the patient has variable decelarations
What is the most common cause of immune hydrops fetalis
Anti- D alloimmunization
What is the most common type of non-immune hydrops fetalis?
Parvovirus
What’s the target glucose for a pregnant female?
What is the most common cause of a non-reactive fetal stress test?
baby is asleep
Normal variability ranges from?
6-25
In order to be considered an acceleration the duration must be..
at least 15 seconds
Non-reactant test may be pathologic for?
Hypoxemia or acidemia
Antiphosholipid anntibodies can cross react with what other infectious etiology?
syphillis (+ VDRL)
What are the etiologies of stress incontinence?
Hyper mobility of the urethra and decreased urethral sphincter tone
What are the etiologies of obstrictive incontinence?
Poor detrusor contractility or obstruction
What is a normal position of the uterus?
Anteverted and anti-flexed
Is rectus abdominus diastisis a true hernia?
No, and thus only requires observation
