OBGYN Flashcards
Her2+ Tx and screening?
Trastuzumab (Herceptin). ECHO beforehand to check for cardiotox
Detect oncogene via FISH
Breast Feeding OCP
Progesterone Only
Post partum Breast Engorgement. Presentation? What to do?
Bilateral tenderness. Peaks at 3-5 days. Resolves spontaneously.
Physiological galactorreha. What to do
Test prolactin. TSH
Breast Exam Screening
Mammo every 2 years from 50-75
US before 30 if concerned. Mammo after 30 for imaging.
Pagets DIsease gross appearance. Type of CA? Hitology?
Eczematous rash near nip
AdenoCA
Large cells surrounded by clear halos
Elderly female w/ erythematous edematous plaque over a mass + discharge/bloody or nonbloody.
What is dx + tx?
Inflammatory Breast CA.
Pagets WONT have a mass.
Biopsy
Tx based off of histo
Presentation of Mammary Duct Ectasia?
histology?
Inflam/dilation w/ green/brown nipple discharge. May feel mass.
Chronic inflame w/ plasma cells.
Usu in multiparous postmenopausal women (ducts have been dilated multiple times)
Histo: Plasma Cells
Contraindications to breast feeding
TB, HIV (untreated), active breast HSV, chemo, DRUGS
Hep B, C, not contraindicated
Stress incontinence vs urge incontinence?
Etiology/ Dx/ Tx
Stress - Weak pelvic floor. Swab Test (urethral straining over 30 degrees). Tx Kegels + Urethropexy
Urge incontinence - Detrusor Hyperactivity. Tx Oxybutynin
DES leads to? Where?
AdenoCA of vagina+cervix. Hooded cervix.
T shaped uterus
Type of CA causes by HPV?
Squamous Cell CA of vagina and cervix
CHlamydia and Gonorrhea screening?
Annual screening in sexually active women less than 26 y.o.
26+ w/ risk factors (new, multiple contacts, sx contact)
1st and 3rd trimester preg
How to distinguish chlamydia vs gonorrhea cervicitis
Indistinguishable. Both purulent, friable cervix. Gram stain not reliable. CHlamydia is more common.
Primary Syphilix dx testing?
Darkfield microscopy.
False negatives in VDRL/RPR due to lack of ab in Primary.
Genital Warts. Description. Causes. Tx.
Multiple teardrop shapes.
HPV.
Tx Acetic Acid or Podophyllin
Cervical mucous findings in ovulatory phase
Clear, stringy, pH 6.5 (more hospitable for spermies)
pre/post ovulation is thick and opaque
OCP side effects
Contraindications
HTN, NOT weight gain.
Contra:: Migrains w/ aura. Smoking .uncontrolled HTN
Persistent uterine bleeding in premenopausal? WOrkup?
Preg Test.
US + EMB
Adenomyosis s/sx + physical findings
boggy, enlarged uterus
Dysmenorrhea, pelvic pain
Endometriosis s/sx
Dx + Tx
Dyspareunia, dysmenorrhea, dyschezia
US to rule out CA
May see endometrioma.
Tx. OCP, NSaids. Lap if refractory.
Tx for erbs palsy post-birth
80% resolve spontaneously in 3 month.
Surg if no improvement in 3-6 months.
Lichen sclerosis. Apperanace. Tx.
Vulvar pruritis, porcelain white atrophy cigarette paper.
Biospy to rule out vulva SS CA.
Tx Steroids
EMB findings..
Tx for?
EMB -
Without Atypia: Progestin
With Atypia: Hysterectomy
PID Tx
2 reg
Clinda gent
Cefetetan + doxy.
Adnexal torsion vs Ruptured cyst presentation
Torsion has n/vv
Cyst rupture usu after exercise/sex
BV vs Trich
Both have pH > 4.5
BV - thin, white, fishy +Whiff test. No inflam. DONT tx partner
Trich - Thin yellow/green, malodorous, inflam, erythema. Tx partner
ASCUS Age grouping Screen
ASCUS
21-24 - repeat annually. Colpo if 3 consecutive + reading
25+ HPV test. If negative, revery to pap every 3 years.
If HPV+ w/ ASCUS = Colpo
ASC-H - always colpo
Postmenopausal adnexal mass workup
- Transvags US
- CA 125
DONT biopsy (seeing)
CA125…
If + lap
If - periodic US
Atrophic vaginiits
USU sx. Odd sx/
Tx
Dryness. Scare pubic hair, pruritis, dyspareunia
Dysuria+ frequency (seems almost like a UTI)
Tx local estrogen
Anovulation secondary to morbid obesity hormonal findings
Normal FSH, LH
Low progesterone (and thus no withdrawal sloughing.
Maternal Graves Disease ->
Neonatal thyrotoicosis
Mech and tx?
Transplacental passage of anti-TSH receptors
.
Tx - Methimazole + b blocker in child.
Resolves in a few weeks/months.
In preg, what STi do we ALWAYS screen for.r
Which STI do we screen for if high risk?
Always - HIV, Syph, Hep B (blood tests)
Risk: GC/CT, Hep C
Thyroid levels in preg.
INC total T4, Free T4,
Dec/Normal TSH.
Estrogen INC TBG
Major mech of fat production of estrogen?
Fat has aromatase. COnverts adrenal androgens to estrogen
At what bHCG can we see preg?
bhCG 1500-2000.
Doubles every 2 days.
Premature Ovarian failure - Age?
hormonal levels. Assoc. Tx for Preg
40 y.o
HIGH FSH /LH
Assoc w/ autoimmune (Hashi, DM1, pernicious anemia)
ONLY option is IVF. Clomiphene does not work here.
Chorioamionitis s/sx
Tx
Maternal fever, fetal tachy, malodorous fluids, purulent discharge. WBC > 15k.
Polymicrobial. Tx broad (Amp, Gent, Clinda) and DELIVER IMMEDIATELY.
s/SX RUPTURED ectopic preg
Tx algorithm is based off of what?
Cervical motion tenderness, palpable adnexal mass. May have urge to defecate (blood in posterior cul de sac)
Tx Methotrexate or surgical (IF UNSTABLE VITALS.
When to correct breech?
Attempt leopold if it persists past 37 wk. Be ready for induce labor/c section
UTI in preg.
Nitrofurantoin, amox, cephalexin.
Hep C in preg. How to deliver?
2-5% vertical transmission.
Ribavarin is teratogenic. No Tx.
immunize against Hep A/B
Antihypertensives in preg
Methyldopa, labetalol, hydralazine. CCB
Avoid, ACEi ARB, etc
Cause of hyperandrogenism during pregnancy.
Sx/sx
New onset hirsutism and acne during pregnancy.
LLuteomas and theca luteum cysts
Can be BILATERAL masses. BENIGN.
Regress after delivery
Intense pruritis. Worse at palms/soles. No jaundice.
lab kfindings?
Biliary stasis/sludge
INC total bile acids. LFT may be over 1000, must rule out viral hep. INC alk phosph
Tx Ursodeoxycholic acid to INC bile flow.
Gestation HTN criteria
Pre Eclampsia
SEvere Pre Eclampsia
Gestation - Over 140 after 20 wk.
Pre Ec 140+ proteinuria
Severe Pre EC 160+ proteinuria
Eclampsia: seizures
Toxo signs
Rubella signs
Toxo: Chorioretinitis, Hydrocephalus, Intracranial calcifications
Rubella: CATARACTS, Hearing loss, PDA. Must vaccinate prior to preg (not during)
Emergency Contraceptive options
Copper IUD (lastsup to 5 days)
Levonorgesterl (Mirena (3 days)
Ulipristal (Anti-Progestin) 5 days
Oral levonorgestrel (PLAN B 3 DAYS)
HIV tx in preg?
During birthing>
HAART during preg REGARDLESS of viral levels.
Zidovudine for 6wk + after delivery.
If viral laod over 1000, Zidovudine + C section.
Painless antepartum hemorrhage w/ fetal vital deterioration
Vasa previa.
Maternal vitals unchanged.
RhoGam - When admistered?
Up to 32 wk. Within 7 2 hr/bleeding.
Fetal Growth Restriciton
Symetrical vs Asymmetric (examples)
Symmetric: Fetal (infection, genetic )
Asymmetric - Maternal (Vascular, APA, SLE, Substance abuse)
Fetal hydrantoin syndrome
Phenytoin/Carbamazepine ->
hypoplasia of distal phalanges, hirsutism, cleft palate.
Molar Preg US findings
Can see bilaterally enlarged, MULTILOCULAR cystic ovaries secondary to HYPERSTIMULATION and ovarian cysts (theca luteal cysts)
Preg Women over 35? Offer? When?
Cell Free DNA tests for Downs.
10+ wks
Placenta Previa vs Placenta Abruptio vs Uterine Rupture
Previa - Painless 3rd Trim bleeding. Dx - US. Pelvic Rest.
Abruptio - Painful, HYPERTONIC. If over 34 wk, trial vaginal birth (unless baby unstable)
Uterine rupture - Painful. Past Hx C section. Recession of fetal station. Contractions STOP (opposed to hypertonic. Fetal hands/etc.
Post term and late term preg complications
Oligohydramnios
Meconium aspiration. Macrosomia
Definition of false labor
Contractions w/.o cervical changes
80% cause of postpartum bleeding.
Uterine Atony
Soft, boggy, poorly contracted uteurs.
Tx Fundal massage. IV fluids + Oxytocin
When to give
GBS ppx?
Steroids?
Tocolysis
Mag Sulf
Rho Gam
GBS - before 37 wk. ROM > 18hr. Past GBS+ birth.
Steroids - before 34wk
Tocolysis - before 34wk
Mag SUlf - Before 34/32 for neuroprotection
Rho Gam - before 28-32 wk + bleeding.
Ovarian CA - most common?
- 3 types
Eptihelailn , 70%
Stroma
Germ Cell
Ovarian CA
Epithelial:
70% of ovarian cA - if 30-40 bening, 60-70 concern.
Benign cystado - single flat lining (30-40)
CystadenoCA - complex, shag, 60-70 - PSAMOMMA
Borderline
Endometroid Surface CA - Malig, ~Endometriosis + Endometrial CA
Stromal Ovarial CA
Fibroma - Benign, white fibrotic bands. Meigs (pleural effusion, ascites)
Granulosa Theca - INC Estrogen, Call Exner. Uterine bleeding
Sertoli Leydig - Androgen - Leydig : Renke crystals
Ovarian Germ Cell CA
Endodermal (Yolk) - INC AFP, Schiller Duval
ChorioCA - INC HCG, hemorrhagic, lung
Dysgerminoma - HCG, LDH - clear cytoplasm w/ centrla nuceli. Fried egg - responds to RTX
Embryonal (fetal)- large primitive cells. early mets
Cystic teratoma - mature - benigni -> struma ovarii
Imamature - maligant neuroectoderm
parital move
vs
Total mole
Partial - egg + 2 sperm (69) Fetal parts. Inc HCG.
total - 2 sperm (46) - REALLY INC HCG - Cluster of grapes, snw storm. ENLARGED UTEUR, MULTILOCULAR BILT CYSTS. ChorioCA risk factor.
HIV in preg - tx? delivery?
Intrapartum HAART, regardless of load.
Postnatal ZIDOVUDINE
If viral load >1000, C section + Zidovudine
Fetal presentation
syph
rubella
CMV
toxo
syph - hsm, ULCERS ON HANDS AND FEET, anemia, rhinorrhea, JAUNDINCE
Rubella - hsm - cataracts, hearing, skin
CMV - hsm - chorioretinitns, hearing, skin
toxo - intracranial Calcifications, chorioretinints, hydrocephalus
Thyroid lab findings in preg
DEC TSH, INC Free T4, BIG INC in Total T4
When to give oral glucose tolerance test?
End of 2nd trimester (24-28)
Threatened abortion (blood, closed cervix) - What to do?
If fetal monitoring norml - reassure with 1 wk followup
Mechanism of HTn in preeclampsia?
Generalized arterial vasospasm. ICN bp can lead to pulm edema
Small for gestational age have risk to go on to develop what metabolic abnormalities?
Polycythemia, hypoxia, hypothermia, hypoglycemia, hypocalcemia,
OCP associate ICN and DEC risk of CA
DEC endometrial and ovaria. INC breast and cervical.
When do perform amniotomy
After 6 hr of labor w/o complete dilation.
3rd Trimester bleeding, dx algorithim/ 2 dx concerns –
Previa, abruption. Must rule out w/ abd ultrasound BEFORE SPECULUM OR BIMANUAL.
Screening test proven to lower mortality?
Mammo after 50
Most beneficial to asx pt w/ multiple 1st degree relatives w/ breast CA?
SERMS (Tamoxifen or Raloxifene)
First physical signs of preg?
Goodells sign - softeningof the cervix
Postpartum fever unersponve to broad spectrum antibiotics
septic pelvic thrombophlebitis.
TVUS vs TA-US in regards to beta HCG
– TVUS as low as 1500. TA-US – Over 6500.
breast Cyst drainage in young women, clear fluid
What next? – Observe 4-6 wk . No cytology first tiem.
Chorio! Algorithim?
Oxytocin and deliver. NOT an indication for C section
Chorio tx
vs
Endometritis tx?
Chorio - amp gent clinda
Endometritis - clinda gent
Arrest of labor definition and algorith
After greater or equal to 6cmand ROM : If NO CERVICAL CHANGE A in 4 hr w/ adequate contractinos; No cervical changes in 6 hr with inadequate contractions -» C section.
oxytocin is not in the picture sinc eif they had adequate contractions you wouldnt need oxytocin
Abnormal uterine bleeding in young female w/ anovulation, t
in hemodynamically stable – High dose Estrogen (or High dose OCP). In unstable, dilation and curettage.
Eclampsia/HELP delivery Labor or Csection?
Labor or Csection? If stable, labor+ augmentation. If fetal distress, then C section. Almost always try to deliver unless fetal distress.
Breast feeding dec risk of which cancers?
Ovarian and breast. Does not affect endometrial CA.
Placental abruption/previa delivery alogirthm
Abruption if stable can trial delivery. If not C section. Previa always C section.
PID tx
clinda/gent or cefotetan doxy
No movemetns felt and fetal heart sounds not heard.
What next? – US. NOT nonstress test (pointless, no heart sounds heard)
Fibrinogen in stillbirth
– higher is better. Lower suggest consumption. Remember lower than 200 is concern!
De Quervain tenosynovitis
inflame of abductor pollicus longus and extensor pollicis brevis. Tenderness at radial side of wrist. “MOMMY THUMB!!” Not ulnar side.
Constant pain with no bleeding, frequent contractions
– Placenta previa. Labor should not be constant pain. 20% have
no bleeding. Blood is uterotonic -> frequent contractions every 1-2 minutes.
Tamoxifen CA risk
INC endometrial/uterine CA. No INC ovarian, or cervical or breast.
During preg, pap smear with HIGH GRADE SIL, wath to do ?
– Pap and COLPO after delivery
MTB said do colpo..
Hgih grade SIL in 21-24 and 25+ algorithm.
Colpo everyone.
GBS meningitis transmission?
– not vertically transmitted and from hospital acquire dinfection. GBS pneumo/sepsis is from momma.
Tx of infiltrating ductal breast CA
– lumpectomy and RTX. Standard of care. Add hormonal if receptor fpositive.
When do you give tamoxifen vs aromatise
? Standard of care in POSTMENOPAUSAL is AromataseI – more effective than tamoxifen (duh!)
When is chemo added to lumpectomy and RTX
(always screen for receptor positive. If positive give hormonal therapy)? Tumor size >1cm or lymph node positive.
Prolonged bleeding -> EMB shows adenoCA, then what?
Surgical staging. Hysterectomy. RTX if LN mets, Chemo if mets.
Physical findings in Mulleraian Agenesis
– Absence of uterus cervix and upper vagina. Ovaries intact. Normal E.
When do you do a progesterone challenge test?
? Secondary amenorrhea after TSH, FSH, Prolactin
Guidelines for Hormone Replacment Therapy, recommendations
Only for hot flash, GU atrophy, dyspareunia. Reevauate annually, and do NOT exceed 4 ye therapy (INC breast CA risk)
Differnetiating postpartum blues from depression and tx
Blues care about baby. Depression may have htoughts about hurting baby/depressive sx. Baby blues self liminited. Depression is SSRI.
Postpartum psychosis in breastfeeding pt tx
ECT
