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OBGYN Lecture Notes Flashcards

1
Q

What are some of the ways of estimating birth weight? (3)

A
  1. USG: by measuring head and abdominal circumference, and femoral bone length
  2. By using the estimated birth date
  3. By measuring Crown-to-rump length (SF: Symphisis-Fundus length) within the first trimester (doesn’t work in the others)
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2
Q

How is the baby usually delivered in according to cardinal movements during vaginal delivery?

A

With head first, then the anterior shoulder (mother’s anterior) right after that if the baby lies on it’s side

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3
Q

What is shoulder dystocia?

A

A life-threating emergency where the head is already out, but anterior shoulder of the baby is stuck behind the the pubic symphysis during delivery and there is need for additional obstetric maneuvers for delivery.

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4
Q

Fetal complications of shoulder dystocia?(4)

A

Fetal:

  1. Erb’s palsy: cause the head is out and the shoulder is stuck, there will be streching and injury to the brachial plexus. (most typical complication)
  2. Phrenic nerve palsy (remember where it’s located)
  3. Fracture of humerus and clavicle
  4. Hypoxic brain injury and death (due to compression on neck and umbilical cord)
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5
Q

Maternal complications of shoulder dystocia?(3)

A
  1. Laceration and uterine rupture
  2. Postpartum hemorrhage
  3. Symphysis Pubis Dysfunction (pelvic discomfort)
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6
Q

Signs of shoulder dystocia? (2)

A
  1. Turtle sign: fetal head retracts into the perineum right after expulsion
  2. Head-to-body expulsion time > 60 seconds
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7
Q

10 Risk facors for shoulder dystocia?

A

Remember, 50% of cases are idiopathic though!

  1. Fetal Macrosomia (when EFW > 4500g)
  2. Tumors
  3. Malformations
  4. DM in mother (babies have often macrosomia or different shoulder-to-head ratio than normal)
  5. Operative vaginal delivery (where forceps or vacuum often are used)
  6. Previous history of shoulder dystocia babies
  7. Postterm pregnancy
  8. Male fetal gender (males have brouder shoulders than females)
  9. Obese (BMI>30) or high gestational weight (>20kg) of mother
  10. Advanced maternal age (>40yerars)
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8
Q

What’s the goal when managing shoulder dystocia and what do?

A

The goal is to deliver the infant before asphyxia occurs, you have 5 mins!

You can try to do the following:

  1. Put mother in dorsal lithiotomy position and tell her NOT to push (might compress the umbilical cord)
  2. Avoid any excessive neck rotation of the baby
  3. Drain the bladder and see if it helps
  4. Do episiotomy or one of the shoulder dystocia maneuvers
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9
Q

What’s an Episiotomy?

A

An incision made in the perineum (the tissue between the vaginal opening and the anus during childbirth)

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10
Q

Name the maneuvers you can try during delivery of child with shoulder dystocia, from best to worst (9)

A

Chronological order from bets to worst:

  1. Mcroberts Maneuver: two people grab each leg of the mather and sharply flex the thigh back against the abdomen (50% effective)
  2. Suprapubic pressure: Fist on pubic symphysis at an oblique angle to dislodge the anterior shoulder (often done at the same time as McRoberts)
  3. Delivery of posterior arm and shoulder first, by directly placing hand into vagina and locating
  4. Rubin Maneuver: pressure on anterior shoulder while rotating infant
  5. Woods Corckskrew Maneuver: pressure on posterior shoulder while rotating
  6. Gaskin all-fours: mother stands on all-four and tries to deliver
  7. Clavicular fracture
  8. Zavanelli Maneuver: One of the last resorts. Head is pushed back into uterus and emergency c-section is done
  9. Symphysiotomy: Very last resort if nothing else works. Incision of pubic symphysis
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11
Q

How many obligatory USGs are done during pregnancy and when are they done?

A

2 obligatory ultrasounds:

  1. First trimester: week 11-14 scan (chromosomal abnormalities)
  2. Second trimester: week 18-22 ( prenatal testing),

Some countries have a 3rd scan in third trimester week 28-30 in some countries (signs of hypertrophy and other pathology)

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12
Q

What is a fetal station?

A

The fetal station is a measurement of how far the baby has descended in the pelvis, measured by the relationship of the fetal head to the ischial spines (sit bones). The ischial spines are approximately 3 to 4 centimeters inside the vagina and are used as the reference point for the station score.

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13
Q

Explain the fetal station numbers

A

The ischial spines are approximately 3 to 4 centimeters inside the vagina and are used as the reference point for the station score. Fetal station is stated in negative and positive numbers with 1cm between each number.

  • -5 station is a floating baby
  • -3 station is when the head is above the pelvis
  • 0 station is when the head is at the bottom of the pelvis, also known as being fully engaged
  • +3 station is beginning to emerge from the birth canal
  • +5 station is crowning
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14
Q

Causes for increasing incidence spontanous abortions these days? (3)

A
  1. More IVF (In Vitro Fertilization) these days
  2. Older women get babies these days
  3. Environmental reasons???
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15
Q

2 instruments commonly used to assist in vaginal delivery?

A
  1. Forceps
  2. Vacuum extractor
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16
Q

4 Types of forceps procedyre?

A
  1. Outlet forceps (best option)
  2. Low forceps. (more complicated)
  3. Midforceps
  4. High forceps
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17
Q

3 indications for Forceps delivery?

A
  1. Poor maternal labor in 2nd phase of labor
  2. Maternal distress
  3. Fetal distress (CTG)
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18
Q

Conditions necessary for forceps delivery? (8)

A
  1. Cervix must be fully dilated
  2. Ruptured membranes
  3. Engaged head
  4. Head of fetus is least at +2 station
  5. Absolute knowledge of fetal position
  6. No evidence of CPD (cephalopelvic disproportion)
  7. Adequate anesthesia
  8. Empty bladder
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19
Q

What’s important to remember when placing the cup of a vacuum extractor? (2)

A
  1. It should be placed over the posterior fontanelle! (head will be abnormally formed if you put it anywhere else)
  2. After placement, take a finger around the cup and be sure that no vaginal wall is in the cup (otherwise may cause vaginal laceration)
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20
Q

Indications for using vacuum extractor during vaginal delivery?

A
  1. Fetal distress in 2nd phase
  2. Dilatation >7 cm
  3. Prolapsed cord (when cord comes out of uterus before baby)
  4. Twin birth were there’s problems of delivering 2nd twin
  5. Maternal indications: physical distress, to avoid maternal effort in patient with hypertension, cardiac and respiratory disease
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21
Q

2 Contraindications of Vacuum extractor?

A
  1. Malpresentation (baby is not in the right position for it)
  2. Cuagulopathy (intracranial hemorrhage or cephalohematoma)
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22
Q
A
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23
Q

Complications from using Vacuum extractor? (3)

A
  1. Scalp laceration
  2. Cephalohematoma
  3. Subgaleal hemorrhage (rupture of emissary veins between dura, sinuses and scalp)
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24
Q

B-hCG: what is normal (no pregancy), what lvl causes a pausitive pregnancy test? When does it peak?

A
  • Negative pregancy test: B-hCG < 5
  • Positive pregancy test: B-hCG > 25 (may already show 8-9 days after ovulation)
  • Peaks between week 8 - 12
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25
Q

What does a B-hCG > 1500 indicate?

A

At that level, you should be able to see a gestational sac in the uerus on USG. If you can’t see it, think about ectopic pregnancy.

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26
Q

Definition of miscarriage?

A

Expulsion of fetus either <500g in weight or <22 weeks old

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27
Q

In what period is the fetus considered viable during the pregnancy?

A

Varies between week 24 - 28

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28
Q

Percentage of normal pregnancies ending in miscarriage?

A

10 - 15%

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29
Q
A
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30
Q

Percentage of EARLY pregnancies ending in miscarriage?

A

45 - 55%

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31
Q

What is a Biochemical pregnancy and what is it caused by?

A

B-hCG positive pregnancy where embryo implants in the uterus but never takes hold ending in a miscarriage (which is why you should wait with a pregnancy test until 1st missed menstruation)

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32
Q

Within what period of trying do most fertile couples get pregnant?

A

Most couples get pregnant within 6 months of trying

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33
Q

How long should a couple try to get pregnant before we start to suspect infertility?

A

>,1year of trying, suspect infertility

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34
Q

In which week of pregnancy should you be able to see the heartbeat of the fetus on USG?

A

At around week 6

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35
Q

Name the different classifications of misscarriages (6)

A
  1. Threatened miscarriage
  2. Inevitable miscarriage
  3. Incomplete miscarriage
  4. Complete miscarriage
  5. Missed miscarriage
  6. Septic miscarriage
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36
Q

Threatened miscarriage: How does it present and what can we do about it?

A
  • Presents as a vaginal bleeding with lower abdominal pain, and closed cervical os on examination.
  • Do a USG, if fetal cardiac activity is present, put her on high dose progesterone and follow.up in a week (though 1/3 of women progress to inevitable miscarriage)
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37
Q

Inevitable miscarriage: How does it present and what can we do about it?

A
  • Presents as lower abdominal pain with heavy bleeding and an open cervical os
  • Need to quickly hospitalize and give analgesia
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38
Q

Incomplete miscarriage: How does it present (3) and how is it managed?

A

Presents as:

  1. Always > 8 week
  2. History of blood with fleshy masses (bleeding may cause shock)
  3. History of pain

Managed by Curettage

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39
Q

What is Curettage?

A

Is the use of a curette (a scoop) to remove tissue by scraping or scooping. Used after a miscarriage to remove remaining tissue.

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40
Q

Complications of a courettage procedure? (4)

A
  1. Uterus perforation
  2. Asherman’s syndrome (adhesions of the uterus)
  3. Lack of menstruation
  4. Infertility
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41
Q

Complete miscarriage: How does it present? (5) Management?

A
  1. Occurs within the first 6-8 weeks
  2. History of passage of products followed by stop in pain and bleeding
  3. Closed cervical os
  4. Small uterine size
  5. On its own symptoms of pregnancy start to dissappear and tests become negative

Always do USG to double check!

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42
Q

What’s a Missed miscarriage and how does it present?

A

When the embryo has died but is retained in the uterus without miscarriage symptoms. Presents with small uterine size with little to no bleeding.

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43
Q

USG dinding of a Missed miscarriage? (2)

A

Either….

  1. Empty gestational sac with absent embryonic pole (blighted ovum) or…
  2. Gestational sac with embryonic pole without cardiac activity
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44
Q

A patient presents with Missed miscarriage, what do we do? (3)

A
  1. USG and order B-hCG to confirm (decreasing lvls should be seen)
  2. Coagulation test (these patients are at risk of DIC)
  3. Give prostaglandins to dilate the cervix then do courettage
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45
Q

What’s a Septic miscarriage and how is it managed?

A
  • A miscarriage with an infection of uterus and sorrounding area. The infection is either the cause of the miscarriage or occur as a result of a spontanous miscarriage.
  • Management: Metronidazole of Levofloxacin (remember this is miscarriage not pregnancy), then prostaglandins, then curettage.
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46
Q

When do we consider a patient to have recurrent miscarriages, and what has to be done right after?

A
  • Patient has recurrent miscarriages when they have 3 or more consecutive miscarriages
  • Do a chromosomal testing of both parents!
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47
Q

Most common cause of a spontanous abortion?

A

Chromosomal abnormality

48
Q

Causes for 1st trimester miscarriages? (5)

A
  1. Uterine abnormalities (fibroids etc…)
  2. Endocrine causes (DM, Thyroid, PCOS etc..)
  3. Autoimmune causes (Antiphospholipid syndrome, SLE etc…)
  4. Infections
  5. Chromosomal abnormalities in parents
49
Q

Differential diagnosis of 1st trimester vaginal bleeding? (6)

A
  1. Spontaneous abortion (main suspect)
  2. Postcoital bleeding
  3. Ectopic pregnancy
  4. Vaginal or cervical lesions
  5. Extrusion of molar pregnancy
  6. Other, nonpregnancy causes
50
Q

Causes for 2nd trimester miscarriages? (6)

A
  1. Cervical incompetence
  2. Uterine abnormalities (septate or subseptate).
  3. PCOS
  4. Infection (HIV, syphilis, chlamydia, listeria)
  5. Endocrine (DM thyroid)
  6. Immune problems
51
Q

What do you do if you have an Rh- mother with vaginal bleeding?

A

Give anti-D Rh immunoglobulin within the first 72h of bleeding

52
Q

Antiphospholipid syndrome: What is it?

A

Autoimmunity agains patient’s own blood cells, causing among other things, blood clots. Often seen in women with recurrent miscarriages.

53
Q

Antiphospholipid syndrome: Diagnostic criteria? (2)

A

In pregnancy, one or more of the following:

  • Thrombosis or unexplained death of normal fetus at >10 weeks
  • >3 consequtive spont.abortions < 10 weeks + 2 positive blood tests spaced 3 months apart

Blood test: anti-cardiolipin IgG and/or IgM, antibeta2 glycoprotein IgG and/or IgM, lupus anticoagulant

54
Q

Pregnant lady with several miscarriages and signs of thrombosis, you’ve ruled out antiphospholipid syndrome, but you’re still considering a coagulation disorder. What other blood tests should you take? (3)

A
  1. Factor V leiden
  2. Factor II gene mutation
  3. Factor S
55
Q

Treatment for pregnant patient with antiphospholipid syndrome? (2)

A
  1. Low dose aspirin in early pregnancy
  2. Heparin injection if fetal heart rate is detected by scan
56
Q

You suspect a genetic problem to be the cause of the miscarriage, what can you do to be sure? (2)

A
  1. Tissue test from the miscarried fetus (only clear in 50%)
  2. Blood test from parents to check for balanced translocation
57
Q

Explain the 7 congenital mullerian abnormalites:

A
58
Q

When are congenital mullerian abnormalities usually seen, and what tests can be done to confirm? (2)

A

Noted on 1st pelvic usg.

  1. Hysteroscopy + laparoscopy (usually done in the same procedure)
  2. 3D pelvic ultrasound scan.
59
Q

What congenital mullerian abnormality of the uterus can be fixed and what cannot?

A

If the problem is that there’s a septum, it can often be removed. But if there’s a cornuate, nothing can be done

60
Q

What is cervical incompetence?

A

When the cervical tissue is weak and therefore causes or contributes to premature birth or the loss of an otherwise healthy pregnancy

61
Q

Treatment for cervical incompetence?

A

Do a Cerclage (suture the cervix to close it) at 14 weeks, the sutures stay until patient reaches term date or starts having contractions.

62
Q

Most common location of ectopic pregnancy?

A

Fallopian tube

63
Q

Signs of ectopic pregnancy? (4)

A
  1. >1500 B-hCG, but gestational sac can’t bee seen on transvaginal usg
  2. Thin endometrium (if it’s thick, B-hCG should be 2000- 3000 and no gestational sac to consider ectopic pregnancy)
  3. > 5000 B-hCG, but gestational sac can’t be seen on transabdominal usg
  4. Fluctuating B-hCG in early pregnancy where instead of doubling every 48h, it may even decrease from day to day

Remember: serum B-hCG is more reliable than urine B-hCG

64
Q

When should you suspect miscarriage instead of ectopic pregnancy?

A

If B-hCG < 1500 and there’s no gestational sac on transvaginal usg

65
Q

Symptoms of ectopic pregnancy? (7)

A
  1. Bleeding 7- 14 weeks after missed menstruation (not heavy unless ruptured, usually spotting),
  2. Abdominal pain
  3. Adnexal mass
  4. Rebound tenderness (if ruptured)
  5. Shoulder pain
  6. Acute abdomen
  7. Pain on palpation of cervix
66
Q

Other than ectopic pregnancy, what else can cause pain on palpation of cervix?

A

Pelvic Inflammatory Disease (PID)

67
Q

USG findings during ectopic pregnancy?

A

Visible fallopian tubes are an abnormality on usg (can’t be seen in normal pregnancy).

68
Q

Oher than ectopic pregnancy, what else can cause visible fallopian tube on usg?

A

Hydrosalpinx - a block in the fallopian tube causing it to be distended.

69
Q

Most serious complication in ectopic pregnancy and signs for it? (3)

A

Rupture of the fallopian tube! Signs include:

  1. Hevay vaginal bleeding (–> hypotension –>dizziness/palpitations/fainting)
  2. Rebound tenderness
  3. Acute abdominal pain and shoulder pain
70
Q

Risk factors for ectopic pregnancy? (9)

A
  1. Salpingitis - inflammation of fallopian tube
  2. PID - Pelvic Inflammatory Disease
  3. IUD - Intrauterine Devices (birth control)
  4. History of ectopic pregnancy or tubal inflammation
  5. Priot tubal surgery, (or any surgery of the pelvis –> adhesions)
  6. Previous Appendectomy
  7. IVF and infertility
  8. DES exposure (Dietylstilbestrol, estrogen drug, not used anymore)
  9. Smoking
71
Q

3 Most common locations of ectopic pregnancy?

A
  1. Oviduct ampulla 85%
  2. Oviduct infudibulum 9%
  3. Oviduct isthmus 5%
72
Q

What do ectopic pregnancy and c-sections have in common?

A

The scar after the C-section may sometimes not heal correctly and there might be a risk of perforation of uterus and it’s vessels. It is often monitored and treated vere similarly to how we treat ectopic pregnancy??? (laporascopy or surgery) Sometimes the scar can also cause increased risk of bladder perforation, as it is so close to it.

73
Q

What is Culdocentesis and what is it used for?

A
  • Extracting fluid from the pouch of Douglas with a needle
  • Used in PID and in ruptured ectopic pregnancies which cause hemoperineum
74
Q

Laporascopy is a diagnostic option in ectopic pregnancy, when does it have to absolutely be done as fast as possible?

A

If the ectopic pregnancy ruptures!!

75
Q

Treatment options for ectopic pregnancy? (6)

A
  1. Methotrexate (given as either 1 dose and check B-hCG week later (should be 20% down) og given as 3 doses spaced within a week then check B-hCG in 2 weeks)
  2. Methotrexate with mifeprostone and misoprostol therapy (used to induce abortion)
  3. Laparoscopy - we have to operate if there is rupture
  4. Laparotomy - if there is problems with laparoscopy
  5. Cornual resection if there’s interstitial pregnancy (not responsive to methotrexate)
  6. General surgery - if it hasn’t ruptured, we can remove the pregnancy without removing the oviduct with it
76
Q

What is Methotrexate?

A

A chemotherapeutic agent that can be used in small doses to induce abortion in ectopic pregnancies.

77
Q

2 Pros and 2 Cons of using Methotrexate for ectopic pregnancies?

A
  • Pros:
  1. Patient avoids surgery
  2. Tube will be patent after treatment = can get a normal pregnancy later
  • Cons:
  1. Even if we give methotrexate, the pregnancy can rupture and we might need surgery still
  2. For next 6 months she can not get pregnant (methotrexate is teratogenic), needs to use contraceptives
78
Q

If a woman has a spontanous abortion, how fast and by how much will the B-hCG decrease?

A

hCG levels should fall 21-35% in 2 days

79
Q

Causes for abnormally HIGH B-hCG? (4)

A
  1. Multiple gestation (most common cause)
  2. Hydatidiform mole
  3. Choriocarcinoma
  4. Down Syndrome (B-hCG is the most sensitive marker marker for it during the 2nd trimester)
80
Q

Which parts are included within the term “Adnexa”? (3)

A
  1. Ovaries
  2. Fallopian tubes
  3. Broad uterine ligament
81
Q

Explain the normal menstrual cycle

A

Begins with the first day of bleeding of one period and ends with the first day of the next. In most women, this cycle last 28 +/- 7 days (21-35 days)

Remember: the follicular phase varies, while the luteal doesn’t!

82
Q

When does the menstrual bleeding actually occur during the menstrual cycle?

A

At the end of the luteal phase, around the first week of the follicular phase.

83
Q

Definition of an abnormal utering bleeding (AUB)?

A

An abnormality in quantity, volume or duration of menstruation. Pretty much an abnormality that isn’t tied to normal physiology and can be considered a pathology.

84
Q

Menorrhagia, what is that?

A

Prolonged and excessive bleeding that occurs at regular intervals (heavy bleeding)

85
Q

Metrorrhagia, what is it?

A

Bleeding at irregular intervals (often called “intermenstrual bleeding”)

86
Q

Polymenorrhea, what is it?

A

Bleeding that occur more often than every 21 days

87
Q

Oligomenorrhea, what is it?

A

Bleeding that occurr les often than 35 days

88
Q

Abnormal Uterine Bleeding: difference betwen acute and chronic?

A
  • Acute: one episode of heavy bleeding that is so much that it requires immediate intervention to prevent further blood loss.
  • Chronic: may occur at the last 6 months, doesn’t require immediate intervention
89
Q

What is the Palm-Coein Classification?

A

A system for reproductive-age non-pregnant women wutj Abnormal Uterine Bleeding.

90
Q

What does the Palm-Coein classification stand for?

A

Palm = structural changes , Coein = Non-structural changes

  • P: polyps
  • A: adenomyosis
  • L: leiomyoma
  • M: malignancy
  • C: coagulopathy
  • O: ovalutory dysfunction
  • E: endometrial causes
  • I: iatrogenic causes
  • N: not yet classified
91
Q

Abnormal Uterine Bleeding causes NOT included in palm-coein classification? (5)

A
  1. Endocrine system factors: Hyperthyroidism, hypothyroidism, PCOS, stopping or changing birth control pills or menopausal HRT (withdrawl bleeding)
  2. Infections; cervicitis, PID, endometriosis, gonorrhea, vaginitis, chlamydia/ureaplasma
  3. Fertility and reproduction factors: ectopic pregnancy, pregnancy, sexual intercourse, perimenopausal period, vaginal atrophy
  4. Medical conditions: kidney, liver, celiac disease
  5. Trauma: sexual abuse, trauma
92
Q

Polyps in AUB

  • Where are they found?
  • How to diagnose them? (4)
A
  • Found in uterus or cervix, often asymptomatic
  • Diagnosed usually by:
  1. Transvaginal USG (most common method)
  2. Hysterosonography
  3. Hysteroscopic imaging
  4. Histopathology (of tissue sample)
93
Q

Adenomyosis

  • How does it present?
  • How is it diagnosed? (3)
A
  • People with Adenomyosis have endometrial-type glands and stroma within the myometrium –> bleeding (you can’t have glands and stroma growing inside muscles!)
  • Diagnosed by:
    1. Transvaginal USG, veins on doppler
    2. MRI
    3. Histopathology
94
Q

Leiomyomas

  • What are they?
  • The 3 types?
  • Prevelance?
  • Other names? (2)
  • How to diagnose it? (2)
A
  • Abnormal growth within the wall of uterus
  • Submucosal, subserosal and intramural. Most important: submucosal (especially in AUB and infertility)
  • Prevalence in women: 70-80%
  • Also called fibroids or myoma
  • Pelvic examination and pelvic imaging
95
Q

Malignancy in AUB:

  • How does it present?
  • Where can it be found? (4)
A
  • Usually as endometrial hyperplasia with cytological atypia (dysplasia, carcinoma, sarcoma etc…), but can be due to cancer in other places as well
  • Can be due to cancer in:
    1. Endometrium
    2. Cervix
    3. Ovaries
    4. Vaginal canal
96
Q

How to diagnose malignancy in AUB?

A

Start with pap-smear as the following methods may cause metastasis of cervical cancer if the malignancy stems from there!

Afterwards do one of the following:

  • Endometrial biopsy with papilla
  • Dilation and courettage
97
Q

Coagulopathy in AUB:

  • How common are they?
  • Most common cause?
  • Test?
  • What about post-mature or post-miscarriage women?
A
  • In 24% of women with heavy menstrual bleeding
  • Von Willebrand Disease
  • Coagulation test
  • If the patient is after delivery or miscarriage, wait at least 12 weeks to ask for coagulation test (although best is to wait 6 months)
98
Q

Iatrogenic causes of AUB? (4)

A
  1. Gonadal steroids
  2. Anticoagulants
  3. IUD’s or changing birth control pills
  4. Tamoxifen side effects (often given for 5-6 years to breast cancer patients)
99
Q

Menopause definition?

A

The last menstruation after which you do not have any bleeding for 12 months

100
Q

Endometrial thickness in postmenopausal women, and thickness in menopausal hypertension?

A
  • Normal post-menopausal thickness: 5mm
  • Menopausal HTN: 8mm
101
Q

Patient comes in with AUB, what do you ask about (4) and consider (3) during interview?

A

Ask about:

  1. Is bleeding is from genital sores - is she sure the bleeding is from the vagina
  2. Bleeding only during urination/defecation?
  3. Bleeding only when she wipes with toilet tissue
  4. Bleeding while using tampon?

Consider:

  1. Is the bleeding uterine or extrauterine?
  2. Is she pre- or post-menopausal?
  3. Is she pregnant or not??
102
Q

Patient comes in with AUB, lab tests? (10)

A
  1. B-hCG (to exclude pregnancy, although may be false-positive in malignancy)
  2. General blood test andCBC
  3. Blood smear (morphology)
  4. Coagulation test
  5. Thyroid function test
  6. Estrogen lvl
  7. Prolactin (if there’s anovulatory bleeding, amenorrhea, galactorrhea or take meds that increases it)
  8. Androgen level (if there’s irregular menses, acne or hirsutism)
  9. FSH (if there’s ovarian insufficiency)
  10. LH (if hypothalamic dysfunction is suspected as a cause of anorexia)
103
Q

Patient comes in with AUB, additional tests? (3)

A
  1. Test for cervicitis
  2. Cervical cancer screening
  3. Imaging and other tests that exclude cervical screening
104
Q

Causes for Postmenopausal uterine bleeding? (8)

A
  1. Benign tumors or cancer (endometrial most common postmenopausal, but also cervical and ovarian)
  2. Endometrial hyperplasia
  3. Postmenopausal HRT
  4. Disease in adjacent organs (urethritis, bladder cancer, UTI, IBD, hermorrhoids)
  5. After radiation-therapy (may lead to vaginal bleeding)
  6. Infection - endometritis is an uncommmon cause of postmenopausal bleeding.
  7. Medicines: anticoagulant therapy
  8. Herbal and dietary supplemets - soy and other phyoestrogens may stimulate endometrium)
105
Q

When does menstruation usually start in life and when does it end?

A
  • Starts at 13 years of age
  • Ends at 45 - 50 years of age
106
Q

Average menstrual flow in ml?

A

30-80ml

107
Q

What’s important to remember when you diagnose someone with PCOS.

A

Do not diagnose it until 2-3 years after onset of menstruation

108
Q

What does the menstrual fluid contain? (4)

A
  1. Blood
  2. Mucus
  3. Vaginal secretions
  4. Endometrial tissue.
109
Q

Explain the endocrine signaling involved in stimulating menstruation:

  • From the hypothalamus?
  • From the pituitary?
  • From the ovaries?
A
  • From the hypothalamus: GnRh
  • From the pituitary: FSH and LH
  • From the ovaries: Progesterone and Estrogen (estriol in pregnant, and estradiol in non-pregnant)
110
Q

Explain the negative feedback loop of estrogen and FSH?

A

FSH causes increased estrogen release, and high estrogen lvls causes in return decreased FSH release (negative-feedback loop)

111
Q

Name the 3 phases within the menstrual cycle

A
  1. Follicular phase
  2. Ovulation
  3. Luteal phase
112
Q

What happens in phase 1 of the menstrual cycle?

A

Follicular phase:

  1. 2 days before this phase the FSH lvl has increased and caused follicles to mature and also release estradiol (non-pregnant)
  2. Menstruation at the start of this phase: endometrium is shed in response to withdrawal of progesterone from previous cycle
  3. The high estradiol lvl causes in a feedback loop decreased FSH release and increased LH release + also causes new endometrial proliferation after the previous was shed in menstruation
113
Q

What happens during phase 2 of the menstrual cycle?

A

Ovulation:

  1. LH rises sharply by day 11-13 of the cycle due to increasing estradiol
  2. This causes the dominant follicle to rupture and release an oocyte (many have flank pain in during this)
114
Q

What happens during phase 3 of the menstrual cycle?

A

Luteal Phase:

  1. Corpus Luteum starts to develop from the ruptured follicle
  2. Corpus Luteum starts to release progesterone and keeps releasing it for 11 days after ovulation
  3. If fertilization of the oocyte takes place, the Corpus Luteum continues to make progesterone throughout the first trimester of pregnancy. If fertilization does not occur, the Corpus Luteum will regress and the progesterone withdrawl wil cause menses to happen
115
Q

2 types of ovulation disorders?

A
  1. Oligoovulation: infrequent or irregular ovulation (cycles of >36 days or <8 cycles per year)
  2. Anovulation: absence of ovulation when it would be normally expected (in post-menarchal, premenopausal women). Usually manifests as irregularity of menstrual periods.
116
Q

Does PCOS manifest as oligoovulation or anovulation?

A

PCOS patients can either have oligoovulation or anovulation

117
Q

3 ways to check if a patient has ovulation:

A
  1. Interview - ask about irregular menses
  2. USG: done twice during the menstrual cycle to evaluate if there’s a dominant follicle and see if it grows (sign of ovulation)
  3. Progesterone lvl > 35ng/ml during day 20-22

6 MD (8 decks)

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