OBGYN II 🚺 Flashcards
GENITAL ULCERS DDX
How to DDx AIS and 5æred def
Both very similar. Main difference is that in AIS, the breast buds develop (no T. Action to oppose it). 5 alpha red def the action of T still works and prevents breast buds developing. 5alpha red def will virility at puberty, but AIS patient do not.
What features of a dysmenorrhea can suggest secondary underlying cause
Unilateral, starts above 25 yo, AUB concomitant, no systemic signs
Mx of CINIII, given that margins are negative for dysplasia
Conization/LEEP and then pap/HPV contest every 1-2 years.
If margins are positive, will have to remove again, or even hysterectomy
Risk factors for lactational mastitis
Weaning off milk, fight bra, clogged pore, poor latch, using pump
Breast engorgement vs mastitis symptoms
Similar, but engorgement is usually bilateral and diffuse, whereas mastitis is localised.
How to manage high grade CIN of the cervix in pregnancy
Do colposcopy, and biopsy. But avoid surgery until after birth, unless signs of invasive cervical CA
Out of inflammatory breast Ca and mastitis… which is painful
Mastitis
How does an ENDOMETRIOMA appear on US
which appears on ultrasound as a homogenous ovarian cyst with a ground-glass appearance.
How does TOA present, and how is it seen on US
tuboovarian abscess presents with fever, diffuse lower abdominal pain, and a complex,
multicystic adnexal mass with thickened walls on ultrasound.
How many HPV doses needed in > or < 15 years old. Why the difference?
Individuals age ≥15 require 3 doses of the human papillomavirus (HPV) vaccine to achieve
immunity. In contrast, individuals age <15, such as this patient, require only 2 doses administered 6
months apart to achieve equivalent immunity. This difference is likely attributable to a less mature immune system, which promotes increased antibody production and subsequent immunity with fewer doses.
Annual chlamydia screening for women?
Annual Chlamydia trachomatis screening is indicated for all sexually active women age <25
due to the increased incidence of infection in this patient population.
Different colours that physiological galactorrhea can present
Physiologic galactorrhea is usually bilateral and guaiac negative, as in
this patient; the appearance is typically milky or clear but can also be yellow, brown, gray, or green.
Endometrial biopsy when patient bleeds and endometrium stripe is how thick?
Endometrial biopsy is indicated to evaluate for endometrial cancer in women with
postmenopausal bleeding and an endometrial lining >4 mm on ultrasound.
How to Mx premenopausal women with adnexal mass, which is being appearing on US
If the ultrasound shows a benign cyst, a repeat ultrasound in 6 weeks is performed to
evaluate for cyst resolution. Do relevant conservative Mx
If a patient has a history of cervical intraepithelial neoplasia 2 or higher on histology, screening continues for another ? years after detection (past age 65 if indicated).
20
When is the pain in fibrocytsic changes
Patients with fibrocystic breast changes typically have cyclic, premenstrual breast tenderness
Is costochonritis usually bilateral or unilateral pain
Unilateral
Can endometriosis cause cervical motion tenderness and cervical displacement
Yes
Genito pelvic pain syndrome vs vulvodynia
Genito-pelvic pain/penetration disorder (also called vaginismus) is pain caused by vaginal
penetration only, possibly due to involuntary contraction of pelvic floor muscles.
Vulvodynia can cause painful intercourse; however, patients have pain of the surrounding
external genitalia (eg, vulva) only. Therefore, they do not have dysmenorrhea, cervical motion tenderness, or cervical displacement.
Risk factors and protective factors for ovarian CA
Risk factors
• Family history
• Genetic mutations (BRCA1, BRCA2)
• Age ≥50
• Hormone replacement therapy
• Endometriosis
• Infertility
• Early menarche/late menopause
• Oral contraceptives
Protective factors
• Multiparity
• Breastfeeding
How can size of ovarian mass predict malignancy
Adnexal mass size alone is not predictive of malignancy because benign masses (eg,
mucinous cystadenomas) can also be significantly enlarged. However, rapid interval growth on repeat
imaging may suggest malignancy.
Dx the gynae abd pain
Recurrent mild & unilateral mid-cycle pain priorto ovulation
• Pain lasts hours to days
Mittelschmerz
Dx the gynae abd pain
Amenorrhea, abdominal/pelvic pain & vaginalbleeding
No intrauterine pregnancy on US
• Positive B-hCG
Ectopic pregnancy
Dx the gynae abd pain
Sudden-onset, severe, unilateral lower abdominal pain; nausea & vomiting
Enlarged ovary with decreased or absent BF on US
Unilateral, tender adnexal mass on examination
Ovarian torsion
Dx the gynae abd pain
Sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous activity or excersize
Pelvic free fluid on US
Ruptured ovarian
cyst
Dx the gynae abd pain
Fever/chills, vaginal discharge, lower abdominal
‡ Tuboovarian abscess
pain & cervical motion tenderness
PID
Two hormones high in granulosa cell tumour
• 1 Estradiol
• 1 Inhibin
When should intimate partner violence screening be done
that screening be performed in all women of childbearing age and appropriate patients be given referral for support services. Do open and specific questions
When does breast cancer screening begin
Breast cancer screening with mammography should begin at age 40-50 for women of average
risk. Earlier screening should be considered for certain high-risk patients (eg, BRCA1 mutation, history of radiation therapy in the chest) but is not routinely advised.
Primary amenorrhea classification
Primary amenorrhea is the lack of menses without secondary sex characteristics at
age ≥13 or with secondary sex characteristics at age ≥15.
Why might patients have back pain in placenta abruption
If the placenta is posterior
Why does uteroplacental insufficiency and maternal malnutrition cause asymmetrical FGR
Because the blood redirects to the vital organs like the brain
Two main causes of symmetrical FetaL growth restriction
Congenital infection and trisomy. There are more however
Absolute CI to do excersize in preg
Amniotic fluid leak
• Cervical insufficiency
• Multiple gestation
• Placenta abruption or previa
• Premature labor
• Preeclampsia/gestational hypertension
• Severe heart or lung disease
Which sports and excisize cannot be done in pregnancy
- Contact sports (eg, basketball, ice hockey, soccer)
• High fall risk (eg, downhill skiing, gymnastics, horseback riding)
• Scuba diving
• Hot yoga
PID likely in pregnancy
No. Because cervical mucus plug protective
Third trimester patient with appendicitis. Where is the pain usually
RUQ, due to FetaL occupying space
First trimester US measurement for gestational age prediction
CRL
Second trimester US measurements for gestational age prediction
BPD, FL, AC.If differ from first trimester, then we consider macrosomia or FGR. NEVER CHANGE FIRST TRIM PREDICTION (most accurate)
Third trimester measurement for gestational age prediction
Fundal height
Name two things that can mess up the fundal height measurement to predict gestational age
Obesity and fibroids
When is the kleihauer betke test done
In RhO mums who bleed, to check if alloimmunisation has occured
Can you do endometrial biopsy during pregnancy
No
Post partum hemorrhage after c sec. What’s that all about
Usually due to artery damage, either bleeding out into abdomen or retroperitoneal. If stable to CTAP, if unstable do lap
Post term (after 40 weeks), what two things should we check
AFI and deepest pocket. And non stress test. Since late term is associated with placenta issues (causing our late decel).
Fetal HR monitoring. What are the three classes
1, 2, 3 and 1 is good, 3 is bad. In between is on the fence
Category Ill fetal HR signs
At least 1 of the following characteristics:
• Absent variability + recurrent late decelerations
• Absent variability + recurrent variable decelerations
• Absent variability + bradycardia
• Sinusoidal pattern
CTG decels. Early, late and variable
What is a class 1 fetal heart rate?
Requires all the following criteria:
• Baseline 110-160/min
• Moderate variability (6-25/min)
• No late/variable decelerations
‡ Early decelerations
‡ Accelerations
What is this CTG pattern?
Sinusoidal
FHR:
Increased HR
Hypoxia, fever, infx, anemia
FHR:
Decreased HR
Hypoxia, cord prolapse, CHD
FHR:
Variability absent
Academia
FHR:
Variability minimal
Hypoxia, opioids, Mg
FHR:
Variability sinusoidal
Anemia
FHR:
Variability increased
Early hypoxia
Uterine incarceration
Uterine incarceration, entrapment of the uterus between the pubic symphysis and sacral promontory,
is a rare condition typically occurring at <20 weeks gestation. Patients have constant lower abdominal pain that radiates to the back and urinary retention due to bladder obstruction.
Abruption signs…. But no bleeding
Concealed abruption
In abruption, when blood builds up between placenta and uterus…. What occurs
Rigidity and increase contractions
When do we test for HIV, RPR, HBV, CHLAM, GON
In first trim (usually on first visit). If patient is high risk (<25, previous STD, promiscuous)
Theca luteal cysts…. Cause and Mx
Due to high HCG. so seen in molar preg, twins, Choriocarcinoma. Will regress with decreasing hcg
What is the staircase sign on tocodynamtery
Sign of uterine rupture…. Where the contractions slowly decrease like a downward staircasen
Normal post partum findings
Transient rigors/chills
• Peripheral edema
• Lochia rubra
• Uterine contraction & involution
• Breast engorgement
Routine care for mum post partum
Rooming-in/lactation support
Serial examination for uterine atony/bleeding
• Perineal care
Voiding trial
• Pain management
Why do we see transient chills and rigors after birth
Drop in E. and P.
Normal palpable uterus findings after birth
Firm, and roughly 1-2 cm above or below umbilicus
When do all the placenta issues occur. Abruption and previa
Above 20 weeks. Unlike abortions, which are before 20 weeks,
THIS FAFT CAN HELP YOU
Fetal decel and pain and more contractions….. more abruption or previa
Abruption
Complications of Oligo and polyhydramnios
OLIGO
Meconium aspiration
Preterm delivery
• Umbilical cord compression
POLY
• Fetal malposition
• Umbilical cord prolapse
• Preterm labor
• Preterm premature rupture of me
Why does prior c section with current anterior placenta cause accreta risk
That it where the scarring is from the c sec
Why do we see hypothyroid or large thyroid in high HCG states
HCG shares subunit with TSH
Benign looking cyst above 5cm
Should remove if above 5cm
HIV or immunocomp patients Pap test routine
Every year until 3 negatives
Ovulatory bleed first line Mx
COCP
Anovulatory bleed first line
Levo IUD
If patient has Ovulatory bleed and isn’t controlled on COCP or other hormonal stuff/non hormonal stuff. Do what preocidure
DandC
When do we do NSAID or tranexamic acid instead of COCP/P for Ovulatory bleed
Do if patient doesn’t want hormones, or is CI
Patient has AUB. Consider what makes you biopsy the endometrium if above or below 45
If below 45. Can biopsy if patient has significant RF (tamoxifen, obese, failed COCP)
If above 45. Obvs biopsy if RF, or if TVUS shows thick endometrial stripe. But also if Tx not working
If patient has mullerian agenesis…. Check what else
Renal issues
PCOS Tx plan
1st: weight loss and lifestyle Mx (mainly if obese)
No conception right now: COCP, SpirinoL, both help Acne too
Conception plan: letrozole (1st line), clomiphene (2nd line)
Associated insulin resistance: metformin
Patient has tested positive for chlamydia, and is negative for Gonorrhoea, and the patient is somewhat hey symptomatic how do we manage
Doxycycline only. If symptomatic would give empiric Doxy Foxy
Compare the weight gain effect of progesterone IUD versus intramuscular progesterone
The IUD does not cause weight gain, where the intramuscular does
First medication to give if PCOS patient wants to conceive
Letrozole (aromatse inhibitor
Benign endometrial cells are normal premenopausally. What should we do if a patient has this post menopause
Consider biopsy in the endometrium. It’s not normal to be shedding endometrial cells at that point
Other than sharp dilation and curettaged, what else is a big risk factor for Asherman syndrome
The presence of concurrent endometritis
Other than Karyo type, two main ways to tell between mullarain agenesis and AIS
AIS Does not have pubic hair, and there will be testes inside. Agensus will have pubic hair and will have ovaries inside
If last mense was two weeks ago. Ultrasound shows ovary cyst of around 3 cm and a couple of smaller ones. And a little three fluid in the posterior cul-de-sac. Is this normal
Yes this is normal
Went to start discussing contraception with girls
After menarche, and either before or when started having sex. Around 14-15 is okay
 How many HPV doses are needed is less than 15 and receiving them versus if more than 15 and receiving them
Less than 15, two doses needed. 15 of older three doses needed
If somebody has signs of physiological galactorrhoea, what sort of lab tests shall I order
TSH and prolactin
I’m early preg… we should see what increase in HCG
Double every 48 hours
In pregnancy, which increases. Vital capacity or tidal volume
Total vol only. Also RR doesn’t change
