OBGYN Block 3 Flashcards
What is the MC form of contraception in the world?
What is the MC form used in the US?
IUD
PO CHCs
What two forms of contraception are not recommended for PTs w/ HTN?
What form is not recommended for PTs w/ migraine and aura?
Depo, CHC
CHCs
What are the 5 tiers of contraception?
What tier would PTs w/ HIV want to avoid?
1: implant, IUD, Sterilization
2: Ring Injection Pill Patch
3: Barrier Behavior
4: Spermicide Sponge Cream/Jelly/Foam
No: Plan-B Abortion
4: spermicide
What are the criteria for being reasonably certain PT is not pregnant?
<7d after start of normal menses
No intercourse since start of last normal menses
Correct/consistent contraception use
<7 days post-abortion
<4wks post-partum
Breastfeeding >85%, amenorrheic and <6mon post-partum
What form of contraception can HIV PTs use?
Breast feeding PTs should not be given COCs if they are post-partum for how long?
All forms, caution w/ spermicide
<1mon PP, no COCs
Use POPs
Tier 1 contraceptives are AKA ?
What are the indications for a PT to receive an IUD?
Long Acting Reversible Contraception (LARCs)
Hormone avoidance Adolescent Nulliparous Dysfunctional bleeds- Levon Stable relationship
What are the 4 brands w/ length of use?
What is their MOA?
? term encompasses the brand names?
Mirena- 5yrs
Liletta- 3yrs
Kyleena- 5yrs
Skyla- 3yrs
Prevention of fertilization
Levonorgestrel
Cu IUD
Endometrial inflammation
No impact on ovulation
Dec sperm/egg viability, motility
Anti-blastocyst action
Good for:
Breast Ca
Anti-phospholipid Ab syndrome
Thromboembolic dz
What are the s/e of Cu IUD?
How long does it take for fertility to return upon d/c of this form?
Menstrual changes- first 3mon
Possible dysmenorrhea or heavier cycles, Tx w/ NSAIDs
Immediately
Levonorgestrel IUDs are used for how long?
The long term progestin release of this form leads to what 3 results?
Used up to 5yrs
Dec sperm motility
Inconsistent ovulation inhibition
Endometrial atrophy prevents implantation
What are the s/e of using Levonorgestrel IUDs?
What is a benefit of using these?
Spot/irregular bleeds x 6mon
1mon post-insertion- device related infections
Improves dysmenorrhea
What do PTs have to do if Levonorgestrel device is placed >7d after menses started?
When do they need to f/u w/ PCM?
What is done if strings can’t be visualized?
Use back up x 7d
6wks
Verify non-pregnancy
Cytology brush to entangle strings and pull into vaginal vault
No strings= US
What are the S/Sxs of PT that has an IUD that has moved into lower uterine segment?
When are IUD expulsions more common?
Continued/new pelvic pain or cramps
First month
Placement <6wks post partum
<25y/o
If PT becomes pregnant w/ IUD in place, there is a higher change of ?
If PT has 2nd trimester miscarriage w/ IUD in place there is a higher likelihood for ?
Ectopic pregnancy
Infection
MOA of Etonogestrel rod implant
How long is this good for?
This form can’t be seen on ? imaging and is not affected by ? PT Hx
Inhibits LH, endometrial atrophy, thickens mucus=
Inhibits ovulation*, implantation and sperm motility
3yrs
Radiopaque
Obesity
What is the MC adverse effect of all progestin-only contraceptives?
What are the two absolute c/is for use?
Irregular/heavy uterine bleeds
Current breast Ca
Pregnancy
Nexplanons are placed w/in ? days of menses onset
What if this time limit is not met and device is still inserted?
5days
Back up x 7d
How long does it take for fertility to return after removal of Nexplanon?
When is Nexplanon use more preferred?
6wks, up to 1yr
Post-partum/abortion
Lactating
How often are Depo shots given?
What is the MOA
150mg q3mon IM- delt/glut
Same as progestin only:
Inhibits LH, endometrial atrophy, thickens mucus=
Inhibits ovulation, implantation and sperm motility
What is the non-contraceptive benefit of Depo?
What are the c/is?
What is the absolute c/i?
Improves dys/menorrhea, endometriosis pain
Dec risk hyperplasia/cancer
Inc risk functional cysts
Recent breast Ca
Progesterone + Ca
Prior ectopic pregnancy
Pregnant
Current breast Ca
What are the adverse effects of Depo use?
How does this effect post-partum status?
Bone loss, reversible (supp E secretion) Irregular bleeding Weight gain Amenorrhea Severe HTN Prolong anovulation/amenses after d/c
No impairment on milk production
What are POPs AKA and what is the only formula?
Norethindrone 0.35mg
Mini-pill
What is the MOA of POPs?
What is a non-contraceptive MOA?
Inhibits LH, endometrial atrophy, thickens mucus=
Inhibits ovulation, implantation and sperm motility
Unreliable ovulation inhibition
POPs are mostly used in ? PT population?
What PT education piece has to go with this Rx?
Breast feeding
Estrogen c/i PTs
Same 4hr window every day of use back up x 48hrs
What are the absolute c/is for Rx POPs?
What are the three forms of CHCs?
Breast Ca
Pregnancy
Ring Patch Pill (CoC)
What is the MOA of CHCs?
Suppress LH/FSH release to inhibit ovulation
P: inhibits LH= suppresses ovulation, dec sperm motility, inhibits implantation
E: inhibits FSH release to suppress ovulation, cycle control to prevent bleeding
CHCs contain ? max amount of estrogen?
Why is this?
Progestin component of CHCs have been modified to provide ? benefits
<35mcg
Dec risk for thromboembolus
Dec androgenic effect (weight acne hair lipids)
When would a 4th Generation progestin like Yaz be preferred?
What is the adverse effect of Yaz?
PTs w/ PMS- breast tenderness,
Inc Na/Water excretion to dec bloat
HyperK+
What are the two types of CHC hormone levels
How does the generation of CHC and amount of progestin differ?
How many days are spent hormone free on this regime?
Monophasic- same amount/pill
Multiphasic- estrogen varies 10-50mcg
Later generation= less androgenic effect, inc PE/VT/MI risk
4-7days
What are the benefits of PO CHCs?
What are the risks?
No risk Ca
Efficacy not impacted by obesity
Dec bleeding, acne, hair
Inc clot risk
What are the non-contraceptive benefits of PO CHCs?
How long does it take for fertility to return?
Dec heavy bleeding/androgen
Improves PMDD Sxs
Improves cycle irregularities
1-2wks for return
6-12mon to regular
What are the PO CHC initiation methods?
1st day: day 1 of menses, no back up needed
Sunday: first Sunday after menses starts, back up x 7d
No weekend withdrawal/bleed
Quick: start day Rx, back up x 7d
What chemical in PO CHCs helps improve PMDD Sxs?
Drospirenone
What are the absolute c/is to CHCs?
CLIMBED UP PAD TV CVA Liver tumor Ischemic heart dz Migraine w/ aura Breast Ca Estrogen dependent tumore Decompensated cirrhosis
UnDx genital bleeding
Pregnancy
Peripartum cardiomyopathy
>35y/o and >15 smokes/day
DM x 20yrs
Thrombogenic states: <21d post partum, DVT/PE, SLE
Vascular dz/uncontrolled HTN
What are the complications that can arise from CHC use?
Benign hepatic tumor Cholelithiasis Post-pill amenorrhea HTN Mood swings Thromboembolism Stroke
What are the s/es in order of prevalence PT experience upon d/c of PO contraceptives?
Irregular bleeds Nausea Weight gain Mood swing Breast tenderness HA
What are the 3 forms of continuous PO OCP
EE 30mcg + Levon .15mg= 84/7, 4 menses/year
EE 10mcg
Levon 90mcg/EE 20mcg
Where is the patch placed on the body?
What is the down side of patch CHC use?
Weekly on butt arm abdomen or torso x 3wks
Not on breast
> 90kg dec efficacy
What is done if patch placement is delayed in 1st wk?
What is done if patch placement is delays in 2nd or 3rd week?
What if the patch becomes detached?
Reapply, back up x7d
<2d, no back up
>2d, back up x 7d
<24hrs- replace same patch, no back up
>24hrs- new patch, back up x 7d
What are the advantages of transdermal CHCs?
What are the disadvantages?
Avoidance of first pass
Constant plasma hormone
Inc compliance
Immediate fertility return
Inc DCT
Skin rash
How long are these used for?
Why are these poor choices for deployments?
3wks in, 1wk out
Refrigeration requirement
Annovera doesn’t require this
When is back up birth control needed w/ CHC rings?
What is done if the ring falls out?
Day 1 start- none
Day 2-5: 7d back up
Reinsert <3hrs, none
Out for >3hrs, back up x 7d
What is a non-contraceptive benefit to CHC rings?
How long does it take for fertility to return?
Lighter/shorter cycles after 6mon
Rapidly
What are the steps if PT misses one pill but is <48hrs total?
Take late/missed pill ASAP
Continue taking remaining pills on schedule
No back up needed
What are the steps taken if PT misses one pill but is >48hrs total?
Take most recent missed, toss remaining missed
Continue taking remaining pills on schedule
Use back up
If pills were missed on days 15-21: finish hormone pack, start new pack next day
PO COCs decrease the chances/prevalence of ? two cancers?
What is the only physical assessment required prior to starting CHCs?
Ovarian
Endometrial
BP
What are the facts about diaphragms?
How long do cervical caps need to remain in place and what is it AKA?
Require fitting 6hrs prior/post intercourse Inc UTI risk Inc efficacy w/ spermicide Dec risk of STDs
48hrs, higher failure rate
Sailor cap
What are the 4 fertility awareness methods?
Standard days- avoid sex day 8-19; must have cycles q 26-32d
Temp rhythm- every morning, 0.4-0.8* inc x 2d
Cervical mucus- high E= prep for ovulation/implant, inc mucus
High P= white/thick mucus to prevent sperm entrance
Symptothermal methods- combo mucus and body temp; reqs 12-17d of abstinence/mon
What are the two cervical mucus methods?
Two day- safe if no mucus on/day prior to intercourse
Billings- abstain from menses to 4d after identification of watery/slippery mucus
What are the 3 forms of emergency contraception?
PO hormones <72hrs
P only: Levon 1.5mg
COC: EE + Levon 100mcg (Yuzpe regime)
Progesterone antagonist <120hrs (most efficient PO regimen)
Ulipristal 30mg
Cu IUD <120hrs (most effective)
Facts of Lactational Amenorrhea
What form of contraception can be used while breast feeding?
Unlikely ovulation 10wks post-delivery
Switch to back up after 6mon
Must feed >85% of time
POP/mini
When is post-partum contraception recommended to begin?
Do not give E/P contraceptives w/in ? after delivery
Prior to first menses
4wks d/t inc venous thrombus risk
How long after vasectomy is male considered ‘safe’?
Why is this form of sterilization preferred?
3mon/20 ejaculations
Requires confirmation
Safer/more efficacious than tube ligation
What meds are used for elective pregnancy termination and they’re taken on ? day
What are the 3 surgical procedures?
Mifepristone/Methotrexate- 1
Misoprostol- 3
Vacuum: 5-6wks
DnC: 6-13wks
Induction: >16wks
Ovulation can return as quickly as ? wks after pregnancy terminations?
Define Fecundity
Define Fecundability
2wks
Probability of achieving live birth in single menstrual cycle
Ability to conceive; probability of achieving pregnancy per month of exposure (20%/cycle, 50% in 3mon, 85%/year)
Female fertility if reduced by half during what ages?
What is the ‘conception window’?
What can be done to maximize this window?
37-45y/o
5 days prior to day of ovulation
Daily intercourse
Qod 10 days around ovulation
What is the criteria to begin infertility work ups?
How does this change if female is of advanced age?
Failure to conceive w/in 12mon w/ regular coitus and w/out contraception
> 35y/o= 6mon
COCs can prevent ovulation from returning x ?mon
Dep can prevent ovulation from returning x ?mon
12mon
24mon
What are the 5 etiologies of infertility in order of prevalence?
What has more impact on inability to conceive, under/over weight?
Ovulatory Male factors Tubal/uterine Unexplained Other
Under, <19
How does smoking induce infertility?
How does alcohol induce infertility?
Vascular/endothelial dysfunction do to reduced nitric oxide availability
Dec female fertility/sperm count
Inc male sex dysfunction
How does marijuana/coke induce infertility?
Infertility eval consists of ? and encompasses ? triad
M: suppresses HPG axis
C: impairs speratogenesis
Hx/PE both partners
Ovulation
Norm F reproductive tract
Norm semen characteristics
Semen analysis reqs ? days of abstinence?
How many samples are needed?
2 days
2 samples 3wks apart
What presenting female PE indicated ovulation is occurring?
Define Mittelschmerz
How does this present
Menses q25-35d w/ 3-7d duration
Ovulation pain: unilateral mid-cycle pelvic pain w/ ovulation
Breast tenderness
Acne
Mood swings
Food cravings
What are the luteal phase/PMS Sxs?
At home ovulation kits are made to detect ?
Breast heaviness
Dec vaginal secretion
Abdominal bloating
Mild peripheral edema
LH surge prior to fertility window
? test is a more direct and earlier detection of ovulation?
PTs w/ irregular menstrual cycles have ? labs drawn for anovulation work ups?
Serum progesterone
>4-6ng during mid-luteal phase
TSH/FSH
Testosterone
Prolactin
DHEA-5
Female PT w/ STI Hx may indicate ? anatomic reason for infertility?
What imaging studies are used for assessing tubal patency?
Tubal for STI/PID issues
HSG
SIS
Laparoscopy
What imaging studies are used for assessing uterine cavity?
What imaging studies are used for assessing ovaries?
All but laparoscopy
All but HSG and Hysteroscopy
What imaging studies are used for assessing for endometriosis/PAD?
What imaging studies are used for assessing for developmental defects?
HSG
Laparoscopy
All
What tests are done for suspected ovulatory dysfunction?
What tests are done for suspected uterine factors?
Ovulation kit
Antral follicle count
FSH AMH TSH PRL Androgen
HSG
Hystero/Laparoscopy
MRI
TVUS/saline sonography
What tests are done for suspected tubal/pelvic dz?
Overall miscarriage risks double by 50% by ? age
HSG
Laparoscopy + chromotubation
> 40y/o
What is the most cost-effective fertility test ordered?
What other test has become standard practice?
An US antral follicle count below ? indicates poor ovarian response?
If any of the above three ovarian reserve tests are abnormal, what is the next step?
Day 3 labs: FSH + Estradiol on cycle day 3
Serum anti-mullerian hormone levels done at anytime, potential earlier predictor
<5-7
Refer
What are the ideal/bad levels of he ovarian reserve tests?
What hormone must be below 100pg for FSH to be valid?
AMH: 2.0 or higher/<0.5
FSH/E2: <10miu/20 or higher
AFC: 20 or higher/below 5
Estradiol
What is the initial Tx for most anovulatory infertile women??
What other medication could be used?
What are two other classes that could be used?
Clomiphene on day 3-5
Metformin- inc spontaneous ovulation
Gonadotropin
Aromatase inhibitors
Hx Test and Therapy for PTs presenting w/ ovulatory infertility
Irregular menses
BBT, LH Progesterone
Clomiphene/metformin
Hx Test and Therapy for PTs presenting w/
Uterine infertility
Fibroids
HSG
Procedure
Hx Test and Therapy for PTs presenting w/
Male infertility
Hernia/varicocele/mumps
SA
Procedure/IVF
Hx Test and Therapy for PTs presenting w/ Tubal infertility
GC/PID
HSG
Laparoscopy/IVF
Hx Test Hx Test and Therapy for PTs presenting w/ Peritoneal infertility
Dyschezia, -pareunia, =menorrhea
Laparoscopy
Ablation
Excision
Pthirus is AKA ?
How is is transmitted and present?
How is it Dx
How is it Tx
Crabs
Contact- pruritis excoriation adenopathy
Microscopy/exam
Permethrin
Pyrethrins
Lindane- not if pregnant/infant
Sarcoptes is AKA ?
How is this transmitted and present?
How is it Dx
How is it Tx
Scabies
Contact- pruritus, dermatitis
Oil scrape/exam
Lindane- not if pregnant/infant
Ivermectin- PO x 2wks
Permethrin
What are the S/Sxs of an initial HSV outbreak?
How is it transmitted?
How is it Dx?
HA Adenopathy Malaise
Saliva/Contact
Culture/PCR/Serum Abs
What causes genital warts?
How is it transmitted?
What is the clinical Dx term
HPV 6, 11
Contact Objects
Birth canal to larynx
Condylomata acuminatum
How are genital warts Dx
How are they Tx by provider
How are they Tx by PT
Acetic acid
Biopsy to test Tx response
Podophyllin T/BCA Cryo
Podofilox Imiquimod- not if pregnant
What bacterial spirochete causes Syphilis?
How is it transmitted?
How is it detected and confirmed?
Treponema pallidum
Contact
Transplacental
RPR/VDRL
FTA-ABS
How does Secondary Syphilis present?
What part of the PT is contagious w/ this Dx?
What other PE finding may be seen?
Bacteremia 6wks-6mon
Maculopapular rash on palm/sole
Exanthem- sheds spirochetes
Condylomata lata- broad pink plaques in moist body areas
What is the criteria for Early and Late Latent Syphilis
What are the 3 areas of the body that untreated syphilis may reappear in?
What two forms are less likely to occur in females compared to males?
Early: <1yr after secondary
Late: >yrs after infection
Cardiovascular CNS MSK
CV/Neuro
What syphilis PTs are more likely to present w/ Jarish-Herxheimer reactions?
What causes this reaction and how does it present?
When do these PTs need to f/u w/ PCM?
Secondary
Endotoxin release
Fever Malaise HA
6mon intervals
Re-treat w/ weekly PCN x 3wks
? is intracellular bacteria that is ASx in 70% female/50% males?
How does this present?
How is it Dx?
How is it Tx
Chlamydia
Ureth/Cervicitis
Culture, Ag, PCR
Azithromycin 1g PO x 1
Doxy 100mg BID x 7d
How long do PTs being Tx for G/C need to avoid sex?
What is the only time test for cure is required?
What f/u is needed?
7d during ABX
Pregnant post chlamydia
Re-screen in 3-4mon
What STD are most females ASx but only 5% of males are ASx
How is it Dx
How is it Tx
Gonorrhea
Gram stain
Culture w/ Thayer martin media
PCR
Primary: Ceftriax 250mg IM Azith 1g PO Secondary: IM/PO Cephalosporin Azith 1g PO Teriatry: IM/PO cephalosporin + Doxy 100mg bid x 1wk
Upper PID/genital tract infections are a result of ?
What are the MC microbes
Ascending lower tract infections
Chlamydia
Gonorrhea
BV
Mycoplasmas- M hominis U urealyticum M genitallium
What are the common/unwanted sequels of female STDs?
What is the triad for PID?
Infertility
Chronic pelvic pain
Ectopic
CMT Dysparunia Fever that develop at/soon after menstruation
How are inpatient PIDs Tx?
Parentaral IV Tx*
Cefotetan or
Cefoxitin w/ Doxy
Clinda w/ Gentamicin
Alt:
Ampicillin/Sulbactam and Doxy
Define Tuboovarian abscess
How does it Present
If left untreated, ? occurs
How is it Dx and Tx
Infection/inflammation of tube or ovary
PID Sxs + Fever Leukocytosis Abd pain Mass
Rupture and peritonitis
US
Broad IV ABX
What causes TSSyndrome
When does it present?
What are the classic Sxs
Staph A Exotoxin
2days post surgery or menstruation
Fever Malaise Diarrhea
Non-painful/itchy macular rash
What causes TSSyndrome
When does it present?
What are the classic Sxs
Exotoxin from Staph A
2days after surgery/menstruation
Fever Malaise Diarrhea
Non-painful/itchy macular rash
What are the major criteria needed to Dx TSS
What are the minor criteria that only require 3 for Dx
HOTN Orthostatic syncope BP <90 Macular erythroderma Temp >38.8 Late skin desquamation
Myalgia/Cr 2x inc AMS D/V Elevated bili Platelets <100K Mucous membrane erythema
What are the major criteria needed to Dx TSS
What are the minors that need 3 for Dx
HOTN Orthostatic syncope BP <90 Macular erythroderma Temp >38.8 Late skin desquamation
D/V Mucous membrane erythema Platelets <100K AMS Myalgia/Cr 2x inc Elevated bili
What is a normal life cycle for breast epithelial cells?
Young premenopausal women w/ breast growths are usually ?
What is the sequence of working up a suspected breast growth
Proliferate in LUTEAL phase
Inc water retention/fullness week preceding menses
Benign
Exam Image Cytology
How do fibroadenomas present?
How are these managed?
How are breast cysts Dx?
Mobile, well circumcised, non-tender rubbery growth in adolescent/pre-menopause
Biopsy to Dx, if stable/ASx, leave in place
Unstable/growing- excise
Sonography
What are the 3 categories of breast cysts and how do they appear?
Simple:
Sonolucent/smooth
No special management
Recurrent= Excision
Complicated: Aspirate Culture Cytology Core needle
Complex: Co Ex
Core needle
Excise
Fibrocycstic breast changes
Nodular tissue from dilated ducts/acini w/ dense collagen
Ropy/tender from exaggerated stromal response to hormone/Gfs
No breast Ca risk if alone
Hyperplasia from low progesterone
Fibrocycstic breast changes
Nodular tissue from dilated ducts/acini w/ dense collagen
Ropy/tender from exagerated stromal response to hormone/Gfs
No breast Ca risk if alone
Hyperplasia from low Progesterone
What is the MC benign breast tumor
What is the MC benign breast d/o
Fibroadenoma
Fibrocystic changes
PTs w/ green nipple d/c indicates ? issue?
What does multi duct d/c after manual expression indicate?
What does serous/spontaneous bloody discharge indicate?
Cholesterol, not infection/Ca
Physiologic
Pathological, concerning if only one duct invovled
What is the MC cause of mastitis
On top of warm compresses and continuing to feed, what meds can be added for Tx?
Staph
Dicloxacillin Cephalexen Augmentin PCN Allergy- erythromycin MRSA: TMP/SMX, Clinda, Vanc
How is cyclic mastalgia Tx
How is noncyclic mastalgia Tx
No eval, Sx Tx w/ NSAID
Exam Image Biopsy
How are breast tumors annotated/recorded in records?
What imaging modality is used for focal mass in in PTs <30 or pregnant?
What image is preferred if PTs are older?
Left breast, 2.5cm mass, 10:00, 6cm FN
US, differentiates cyst from solid
Mammograms
How are neoplasms Dx
Biopsy- minimally invasive
Open biopsy: excision
FNA- small masses for cytology
Core needle- Dx w/out excision
What eval technique is used for the following:
Palpable cyst
Recurrent cyst/blood fluid
Non-Dx FNA
Solid mass
Non-Dx CNB
Needle drainage
Excision
Core/excision biopsy
Core biopsy
Excision biopsy
Nulliparous PTs w/ tender, red, hot breast and adenopathy not responding to ABX, what is the next best step?
What are the 4 muscles of the Levator Ani
US/Biopsy
Pubococcygeus
Puborectalis
Iliococcygeus
Coccygeus
Dx criteria for chronic pelvic pain
Non-cyclic pain persisting x 6mon
Pain localized to pelvis, anterior abdominal wall, lumbrosacral back/butt
Pain severe enough to cause functional disability
Chronic pelvic pain can be that cause for ? mental dx?
CPP can be comorbid w/ ? 4 somatic syndromes?
Depression
Fibromyalgia
Chronic fatigue
Temporomandibular d/o
Migraine
Define Allodynia
Define Hyperalgesia
Painful response to normally innocuous stimuli
Extreme response to painful stimulus
What MSK issues can cause CPP?
How does Pelvic Congestion Syndrome present
Kyphodosis
Lorodosis
Worse Sxs pre-menstrual
Ache, pressure, heaviness
Hormone suppression
Ovarian vein embolization
Hyst w/ BSO
How is CPP managed?
Define Vulvodynia
How does it present
Acetaminophen/NSAIDs
Neuro Pain= SSRI/SNRI Gabapentin
3-6mon vulvular discomfort w/ot visbile/neuro findings
Burning Stinging Itching Pain
How is Vulvodynia Tx
Rates of dyspareunia have been linked w/ ?
10% spontaneously resolve
TCAs w/ topical lidocaine/gabapentin
CPPs
What are the different types of dyspareunia
Primary: onset at coitarche
Secondary: after pain free sex
Generalized: all intercourse
Situations: partners/positions
Define Myofascial Pain Syndrome
How is Levator Ani Syndrome Tx
Hyperirritable area of muscle due to trigger point of taught/ropy bands
Primary- MSK
Secondary- visceral
Local anesthetic injections
Botulinum A injection
Define Pudendal Neuralgia
Where does it present?
What makes it better/worse?
Sharp severe pain in pudendal nerve distribution area:
Perineal- vulva
Inferior rectal
Dorsal clitoris
Unilateral pain worse sitting
Better standing/sitting on toilet
How is Pudendal Neuralgia Dx
How is it Tx
Nantes Criteria: Pain follow innervation Worse w/ sitting No sensory loss No awakening from sleep Relieved w/ nerve block
TCA, Gabapentin
What are the 4 types of pelvic organ prolapse?
This issue is the 3rd MC cause for ?
Cystocele Rectocele Enterocele Procidentia- uterus
Hysterectomy
Define prolapse splinting
Define prolapse digitization
Manual bolstering of prolapse to improve Sxs
Manual pressure to aid stool evacuation
What are the RFs for developing prolapses?
How are prolapses Tx/Managed?
Vaginal births, 1.2x/delivery
Forcep delivery
Episiotomy
Post-meno/atrophy- estrogen
ASx/Mild Sxs- kegels
Non-surgical candidate or prolapse w/ urine incontinence- pessary
Surgery
Interstitial cystitis and painful bladder syndrome both present w/ ? 3 Sxs
How are they different
Frequency Urgency Pain
IC: mucosal changes, dec bladder capacity
PBS: no bladder pathology
What PT presentation indicates interstitial cystitis/painful bladder syndrome?
What do these PTs need to avoid?
Unexplained chronic pain/voiding Sxs
Dyspareunia/postcoital ache
Cranberry juice
How is interstitial cystitis/painful bladder syndrome Tx
What is the only FDA approved med for Tx?
Education/behavior mods
Pelvic PT
Amitriptyline Cimetidine Hydroxyzine
Elmiron but takes months to take effect
What medication can sometimes help with incontinence?
What are the two main types of incontinence?
Topical estrogens
Stress: involuntary leakage w/ inc intraabdoinal pressures
Urge: involuntary leakage followed by urge to void
What are the DDxs for transient causes of incontinence?
DIAPPERS Delerium Infection Atrophic vagin/urethritis Pharmaceuticals Psych Excess urine output Restricted mobility Stool impaction
What is the MC cause of transient incontinence in hospitalized PTs?
What meds can cause transient incontinence by gender
Derlirum
A-blockers: women
A-agonists: men
What part of the NS controls the inferior/superior parts of the bladder?
What muscle helps counteract increased pressure from the abdomen?
Inferior: SNS, A adrenergic
Superior: PNS, B/Muscarinic
Levator ani
Vaginal CT
What are the characteristics of stress urinary incontinence?
What causes this?
What are the 3 degrees of this issue
Cough laugh sneeze causing dribbles, no bladder contraction
Pelvic/urethral weakness- change in urethral angles
HypoEstrogen
1: only w/ severe stress
2: rapid movement, stairs
3: mild stress, standing
What are the characteristics of urge urinary incontinence?
What causes this issue?
Urgency w/ dec volume
Detrusor instability but not impaired or weak
What are the characteristics of incomplete bladder emptying?
What can cause this?
Frequency w/ hesitation
Over distension of detrusor
Restricted outlet
CCBs/A-agonists need to be avoided, cause retention
What PE test is done to Dx stress incontinence?
How are most cases Tx
Q-tip test- change of >30*= hypermobility
Kegels for both
Ca glycerosphate to dec urge/frequency by buffering urine pH
What meds are used for managing incontinence
Anticholinergics- inhibits muscarinic receptors to dec detrusor contractions
Imipramine- TCA w/ A-adrenergic and anticholinergic effects for Mixed Incontinence
Mirbegron- anti-spasmotic; relaxes smooth muscles and inc bladder capacity for Urge Incontinence
Botulism Injection- Idiopathic detrusor over activity/urge incontinence
Sexual expression is determined by ?
What is the sexual response cycle
Psych Social Environment Spiritual Learned factors
Excite Plateau Orgasm Resolution
What part of the sexual response cycle holds the most weight?
What hormones modulate, excite or suppress libido
What are the two forms of d/os?
Motivation/emotional willingness to engage
Mod: testosterone
Ex: dopamine
Sup: serotonin
Hypoactivity
Aversion
Arousal signals come from what part of the spine?
What part of the NS controls
excitement/arousal?
This part is modulated by ? hormone and is the cause of ?
T11-L2, S2-S4
PNS
Estrogen
Sex flush
What is the MC cause of excitement/arousal dysfunction?
What is the most treatable sexual phase d/o?
What part of the NS controls this phase?
Estrogen deficit
Orgasmic phase
SNS
What optimizes orgasmic phase dysfunction
What are the RFs for dyspareunia?
Afferent concentration
<50y/o
Hx of abuse
Hx of PID
Depression/Anxiety
What age groups are more likely to experience sexual violence?
What ages are least likely?
16-24y/o
> 65
What is the leading cause of death during pregnancy?
What area of the female genitalia is MC injured during assault?
How long after attack can evidence be collected from PT?
Homicide
Posterior fourchete
5days
VEAL CHOPS
Which ones require intervention?
Variable - Cord compression (MC)
Early - Head compression
Accelerate - OK
Late - Placental insufficiency
Late/Variable
Normal fetal heart rate
Reassuring patterns for moderate variability and weeks of gestation
110-160
Moderate: 6-25
Two acceleration/20min of:
>32wks: 15bpm x 15sec
<32wks: 10bpm x 10sex
Non reassuring patterns
Brady <100bpm
Recurrent late/variable
Absent/Minimal variability w/ late/variable Dcells
Sinusoidal
How do early Dcells appear on a strip?
What is the most frequent abnormal pattern?
What is the criteria for severe?
Mirror image of contraction
Variable Declls
60 FHR decel x 60sec
How do variable Dcells appear on a strip?
How are non-assuring FHR patterns managed?
Shoulder/deep drop off
D/c oxy/pitocin
Put PT on L side/all 4s
Cervical exam, r/o entrapment
O2/Fluids
6 cardinal movements of labor
Descent Flexion Internal rotation Extension External rotation/restitution Expulsion
Define Caput Succedaneum
Define Cephalohematoma
Define Subgaleal hemorrhage
Boggy head, crosses suture lines
Does not cross sutures, associated w/ jaundice
Crosses sutures, jaundice and blood loss
Indications to do vaginal operative delivery
As soon as baby is delivered, what is given to mother and when/why?
Breech- forcep only
Compromise
Prolonged 2nd stage
Shorten 2nd stage for maternal benefit
Placental delivery=
Oxytocin/Pitocin- PPH
ABX x 24-48hrs
Define Chorioamnionitis
This is not an indication for ?
Infection of membrane/fluids around fetus
C-section
Define Turtle Sign
Define HELPERR acronym
Retraction/recoiling of fetal head toward perineum despite pushing
Help Eval for episiotomy Legs hyperflexed: McRoberts Pressure Enter: rotation/remove Roll onto all 4s- Gaskin maneuver
What part of HELPERR acronym has the highest success rate?
4 severity of episiotomy
Step 5: removal of posterior arm
1: skin
2: skin, subcutaneous
3: skin, sub-cutaneous, anal sphincter
4: All and rectal mucosa
How long are post-MVA PTs monitored to r/o abruption?
They can only be d/c if ? criteria is met?
4hrs
Contracting <1 q10min
No bleeding/abdominal pain
FHR reassuring
No visible bruising
4 causes of PPH
Why is this so scary
Tone Tissue Trauma Thrombin
P/BP don’t change until large amounts have been lost
What PE finding indicates lack of uterine atony/possible PPH
MC cause of mortality from PPH
Boggy/soft uterus on bimanual exam
Atony
What two drugs will be pushed during PPH Tx
Oxy/Pitocin 10U IM
Methergine 0.2mg IM- not if pre-clamptic/HTN
Hemabate- not if asthma, cardiac/renal/liver dz, seizure
Failure/c/i- mesoprostol
What happens to the brain if too much blood is loss?
What are the different types of PID
Sheehan Syndrome- pituitary failure/infarct causing hypothyroid issues
Silent- ASx woman
Dx PT w/ tubal infertility w/out Hx of UTIs
Acute: Sxs develop after menstruation
CMT/Dysparunia/Fever
What happens to the brain if too much blood is loss?
What is the ‘classic’ hemorrhage disaster?
Sheehan Syndrome- pituitary failure/infarct causing hypothyroid issues
Uterine inversion
Mastitis may be AKA
What are 3 DDx for mastitis in non-pregnant/feeding woman
Puerperal breast infection
Inflammatory Ca- image and biopsy
Peripheral abscess- drain, ABX
Subareolar abscess- duct/tract excision and biopsy
What are the names of the lesions seen on cystoscopy of IC/PBS?
These findings are indicative of ? Dx
Hunner ulcers
Interstitial cystitis
Urgency incontinence Tx
Stress incontinence Tx and medication avoidance
Schedule
Anticholinergics Detro/Ditro
Kegels
Collagen injection
Topical estrogen
Imipramine/Duloxetin
Pessary/Kegels
Avoid: AAntagonists
What meds are avoided in overflow incontinence
What is a normal sexual response during pregnancy and menopause?
AAgonists
Anticholinergics
CCBs
Preg: dec desire
Meno: inc dysfunction
What are the 3 phases of sexual response?
What is the most intense reaction experienced during sexual assault?
Desire- libido
Excitement- arousal
Orgasm- climax
Fear of dying
What are the two phases of Sexual Trauma Syndrome
Acute disorganization: shock disbelief shame blame anger
Reoganization: vulnerable, despair guilt shame
Somatic Sxs Anxiety Depression
How long do narcotics affect fetal respiration?
What sedatives are used during false labor?
Fentanyl 20-60min
Morphine 1-2hrs
Meperidine 4-6hrs
Promethazine
Hydroxyzine
Zolpidem
What is the regional analgesia procedure of choice?
Microbes associated w/ chorioamnionitis
Lumbar epidural
Bacteroides E Coli Anaerobes Mycoplasma Strep
RFs for shoulder dystocia
Risks to mother and baby
Hx Macrosomia DM Obesity
Mother: PPH Atony 4th* lacs
Fetus: Hypoxic Erbs Fx
Criteria for high risk atony
Criteria for mod risk atony
Prolonged labor
Over distended uterus
Grand multiparity
Multiple gestations
Polyhydrammnios
Fetal macrosomia
PPH management
Help/examine Uterine massage Meds IV fluids Bimanual compression
