OBS/GYNE

Question 1

Causes of vaginal DC in pre-pubertal and post pubertal

Answer 1

a. Pre-pubertal females:

• Physiologic leukorrhea (<3weeks, pre-menarchal)
• Foreign body
• Vaginitis: poor local hygiene, the close proximity to the rectum, more frequent use of bubble baths and other harsh soaps, the use of tight, non-absorbent clothing

b. Postpubertal females

• sexually transmitted infections,
• candidiasis
• bacterial vaginosis
• physiologic leukorrhea

Question 2

DDX for pre-pubertal vaginitis (w/ or w/out DC)

Answer 2

1. VAGINITIS ASSOCIATED WITH VAGINAL DISCHARGE
   (a) Nonspecific vaginitis
   (b) Specific etiology

• (i) Infectious: Respiratory and enteric flora
  
  • (1) Streptococcus pyogenes
  • (2) Staphylococcus aureus
  • (3) Nontypable Haemophilus influenza
  • (4) Streptococcus pneumonia
  • (5) Neisseria meningitides
  • (6) Moraxella catarrhalis
  • (7) Shigella flexneri
  • (8) Yersinia enterocolitica
• (ii) STIs:
  
  • (1) Neisseria gonorrhoeae
  • (2) Chlamydia trachomatis
  • (3) Trichomonas vaginalis
• (iii) Foreign body
• (iv) Congenital Abnormalities
  
  • (1) Ectopic ureter
  • (2) Urethral prolapse

2. OTHER VULVOVAGINITIS WITH OR WITHOUT DISCHARGE

• (a) Sexually transmitted infections
  
  • (i) Herpes simplex
  • (ii) Condyloma acuminate
• (b) Pinworms and other helminths
• (c) Tumors, polyps
• (d) Trauma
• (e) Systemic illnesses
  
  • (i) Kawasaki disease
  • (ii) Crohn disease
  • (iii) Stevens–Johnson syndrome
  • (iv) Scarlet fever
  • (v) Viral infections
• (f) Skin conditions
  
  • (i) Atopic dermatitis
  • (ii) Contact dermatitis
  • (iii) Lichen sclerosis

Question 3

Risk factors for ectopic ?

Common gestational age presentation?

Answer 3

RFs:

• Hx ectopic
• Hx PID /infection
• IUD
• Assisted reproduction
• Anomalies: uterine
• Anomalies: tubal

GA:

• 6-8 weeks

Question 4

Pathogens for pre-pub Vaginal DC

Question 5

Complications of ovarian torsion

Answer 5

COMPLICATIONS
Hemorrhage
Ovarian cyst
Ovarian necrosis
Pelvic adhesions
Peritonitis

Question 6

Causes of PID:

• STI
• Non-STI

Answer 6

STI:

• Chlamydia trachomatis and Neisseria gonorrhoea

Others:

• anaerobes, Gardnerella vaginalis, Strep agalactiae, Bacteroides fragilis, and enteric gram-negative rods

Question 7

RFs for PID

Answer 7

• Young age
• large number of sexual partners
• nonbarrier contraceptive methods
• cigarette smoking
• recent douching
• bacterial vaginosis
• previous gynecologic surgery
• HIV infection.

Question 8

PID: Diagnostic Criteria

(minimum, additional, definitive)

Answer 8

Minimum:

• pelvic or lower abdominal pain (in sexually active)- no cause other than PID identified, + ONE OF:
• Cervical motion tenderness or
  Uterine tenderness or
  Adnexal tenderness

Additional:

• Oral temperature >101°F (>38.3°C)
• Abnormal cervical or vaginal mucopurulent discharge
• High numbers of WBC on saline microscopy of vaginal DC
• ESR >15 mm/hr
• Elevated CRP
• + G/C cervical infection

Definitive:

• Endometrial Bx with histopathologic evidence of endometritis
• Laparoscopic abnormalities consistent with PID
• Transvaginal US or MRI showing thickened, fluid-filled tubes or tuboovarian compler or Doppler studies showing tubal hyperemia

Question 9

PID: complications

Answer 9

• tuboovarian abscesses
• infertility (10x risk)
• chronic pelvic pain (20%)
• ectopic pregnancies (50% due to PID).

Question 10

Define AUB:

Menorrhagia, Metrorrhagia

Menometrrhagia

Answer 10

Abnormal bleeding:

• Menorrhagia = bleeding that occurs at regular intervals but lasts > 7 consecutive days or in excess of 80 mL.
• Metrorrhagia = bleeding that occurs at irregular intervals. Menometrorrhagia denotes heavy and irregular bleeding.

Menometrorrahgia= heavy + irregular bleeding

Question 11

AUB: DDX for causes

Answer 11

Question 12

AUB: investigations

Answer 12

• bHCG
• CBC
• Coags: PTT INR
• Bleeding: VWF, fibrinogen
• STIs
• Endo: TSH, prolactin, dehydroepiandrosterone sulfate (DHEAS), testosterone profile, androstenedione, and 17-hydroxyprogesterone

Question 13

AUB: endocrine causes

Answer 13

1) physiologic: anovulatory cycles (especially in 1st 2 years)
2) OCP
3) PCOS
4) Hypothyroidism

Question 14

Contraindications to Estrogen Rx

Answer 14

1. Migraine with aura
2. Acute VTE or history of VTE
3. Inherited prothrombotic disorders
4. Lupus with positive or unknown antiphospholipid antibodies
5. Hypertension (SBP >160 mm Hg or DBP >100 mm Hg)
6. Current and history of certain heart conditions
7. Certain liver diseases
8. Postpartum (<21 days)
9. Stroke
10. Current diagnosis of breast cancer

Question 15

AUB: Management

Answer 15

Mild (hgb >120)

• Close monitoring, and arrange follow up with PCP
• Anemia should be treated with iron, eg ferrous sulfate 325mg po TID

Mod (Hgb 100-120) or severe (Hgb <100)

1. OCP if no contraindications: (30-35mcg estrogen w/ progesterone, can consider 50mcg estrogen if acute bleeding)

• If no acute bleeding
  
  • 1 pill daily for 6 months
• If active ongoing bleeding, then taper
  
  • 1 pill q6h x 4d
  • 1 pill q8h x 3d
  • 1 pill q12h x 14d
  • Then 1 pill daily
• If estrogen contraindicated
  
  • Active bleeding
    
    • Medroxyprogesterone acetate (MPA) 10mg q6h until bleeding stops
    • Taper afterwards (QID x 4d, TID x 3d, BID x 14d)

Hemodynamic instability

• Admit
• Conjugated estrogen 25mg IV q6h
• Transition to OCP once bleeding stops

Consider:

• Antiemetics for all patient receiving OCP >1/day
• Iron supplementation 65mg elemental BID
• Stool softener

Admit:

• Ongoing, severe blood loss
• Orthostatic changes
• Hgb <80