Obs/Gyne Focus Flashcards
Define meconium
first intestinal discharge of a newborn infant
when does meconium stained amniotic fluid occur? (Green)
fetus looses sphinter control bc (1) hypoxia stimulating vagus nerve
Preterm labor occurs btw which weeks? Signs of it?
20-37 weeks
Uterine contraction
Effacement of cervix and dilation
4 causes of preterm labor
uterine distension (if multiple gestation e.g. triplets or polyhydramnios)
stress
infection/inflammation
placental abruption
Tests for preterm labor
fetal fibronectin
CBC
urinalysis
Digital cervix check
US of cervix lenght
Preterm labor general TX
corticosteroids for sufactant production in baby lungs
tocolytics (to supress contractons) - nifedipine
MgSO4 - to help baby brain
Antibiotics - ampicillin/gentamicin (to avoid group B strep)
What are leopold manuvers
4 abdominal assessment maneuvers to determine position of fetus
What are the stages of labor
Stage 1 (latent, active, transition phases) - goal is to dilate and efface cervix
Stage 2 (complete cervical dilation finished and delivery of fetus)
Stage 3 (baby is out and delivery of placenta)
Stage 4 (placenta out, 2 hours of observation)
What is an umbilical cord prolapse?
umbilical cord prolapses through cervix - EMERGENCY
uterine rupture lineage of development
window - myometrium thinned
dehiscence: endo and myo are ruptured
rupture: endo, myo and perimetrium are ruputred
what is abruptio placentae
premature detachment of the placenta from the uterine wall
DX of ectopic pregnant
urine HCG
serum progesterone
TX for ectopic pregnancy
methotrexate (inhibits growth of embryo)
salpingostomy (salvage fallopian tubes if unruptured)
salpingectomy (removal of tube)
Define HELLP syndrome
is a form of pre-eclampsia that develops in 3rd trimester
Hemolysis Elevated liver enzymes Low Platelets
T/F GnRH is released by the hypothalamus in a pulsatile manner
T
What is the Graffian follicle
the one dominant follicle that becomes chosen for ovulation
The graffian follicle, once stimulated by FSH, releases what and to what effect?
It releases estrogen.
Estrogen goes back to the adenohypophysis and inhibits the release of more FSH.
The estrogen also stimulates the increase in LH to peak.
Estrogen causes proliferation of the endometrium.
once the dominant follicle has ovulated, the remaining cells in the ovary are called? They release what and why?
Corpus luteum
releases progesterone.
Tells endometrium to stop proliferate, and to differentiate instead into softer/be more nutritious
main risk for endometrial carcinoma?
Overproduction of estrogen
what triggeres menses?
fall in progesterone levels and consequent ischemia of endometrial layer
before the placenta can produce progesterone on its own (at 8 weeks), who keeps up the progesterone levels necessary to maintain the pregnancy?
the trophoblastic cells in the embryo produce hCG
days of follicular phase in menstrual cycle
day 1 - 14
LH stimulated the teca cells to do what?
to activate production of androgens
FSH acts on granulosa cells to do what?
to take the androgens produced by the teca cells and activate aromatase to change androgens into estrogens
T/F the ovary can produce cholesterol ex novo
T
Where is AMH produced? What does it signify in females?
is produced by granulosa cells in women and sertoli cells in men.
It signifies the reserve of ovarian follicles
Progesterone secretion causes firm mucus or soft, permeable mucus?
Firm
Inhibin A is only in women, and its purpose is to stop the further release of FSH from the hypophysis when a dominant follicle has already been selected
T
accorciate cycle is called
polimenorrhea (cycle <21 days)
allungato cycle is
oligomenorrhea (>35 days)
Metrorragia means?
hemorrage irregular outside of the cycle
Metrorrhagia examples according to ages
Before menarcha: lesions from external bodies or abuse
Menopause: endometrial cancer (<= 5mm is the cut off width for not cancer)
First trimester: ectopic pregnancy, aborto, mola
Third trimester: placental detachment and placenta previa
Primary amenorrhea defintion
lack of menses at 14 y/o + no secondary characteristics
secondary amenorrhea definition
loss of menses for 6 months in a woman that previously had a normal cycle
causes of primary amenorrhea
Cromosomico: Turners syndrome (X0 - female-ish), Klinfelters syndrome (XXY - male-ish)
Gonadico: Sawyer syndrome (gonadic disgenesis pura - appears female-ish)
Fenotipici: Pseudohermapfroitisim; Morris syndrome (XY - insensibile to androgens), Rokistansky (XX - congential aplasia of uterus and 2/3 superior of vagina)
if a woman has PCOS and is amenorrhoic, will she have her mensis if you administer progesterone only?
yes
Asherman syndrome
occurs when scar tissue forms inside the uterus and/or the cervix. These adhesions occur after surgery of the uterus or after a dilatation and curettage with tuberculosis and schistosomiasis being a less common cause
PCOS hormone elevated is
LH
How to diagnose PCOS?
prove : (1) ovarian dysfunction (amenorrha/oligomenorrhea, echo)
(2) hyperandrogenism (hirsutism, acne, calvizia or increase testosterone in blood)
PCOS issue is?
doesnt have aromatase enzymes.
Give metformin, give estrogen and progesterone pills
what is the scale of hirsutism?
Score of Ferrimana nd Gallwey
if >8 points its positive
metaplastic theory of endometriosis
in the presence of an inflammatory estrogenic stimulus it produces endometrial tissue
Chocolate cysts for endometriosis is seen on
not on echo (is seen ground glass)
on laparoscopy
right and left ovarian arteries originate from
aorta
the uterine arteries originate from
anterior visceral branch of the internal iliac artery
the lymphatic vessels of the superior third of the vagina drain directly into
iliac lymph nodes
order of incidence of gynecological tumors
MECOV
mamella
endometrium
cervix
ovary
vulva
Types of endometrial cancer
Type 1: adenoK, 85% of cases, hormone dependant, has endometrial hyperplasia, good prognosis
Type 2: most commonly serous or serous papillary, bad prognosis
risk factors for endometrial cancer
estrogens (precocious puberty, late menopause)
obesity
tamoxifene
levels of prevention
priamry: vaccinations (avoid entire pop from encountering the RF)
Secondary: screening (for the pop already exposed to the RF)
Third: follow up
Does endometrium cancer have screening? How to diagnose?
no screening
DX: hysteroscopy with biopsy
stages of endometrial cancer
Stage 1: only uterus
- 1a: with myometrium infiltration <50% (ONLY STAGE WHERE YOU CAN GIVE CONSERVATIVE TX)
-1b: >50%
Stage 2: uterus and cervix
Stage 3: local invasion
Stage 4: metastatis to bladder and rectum
what histotype of ovarian tumor is most frequently correlated to ovarian endometriosis
clear cell tumor and endometriod tumor
most common RF for cervical cancer
HPV 16 18
E6 E7 virus changes
screening of cervical cancer
from 25 years - 30 years: pap test ogni 3 anni
above 30 -65: HPV test ogni 5 anni
If HPV positive: PAP test next. PAP positive: go to colposcopia with biospy
LSIL or CIN1 regrades by itself or HSIL (CIN2/CIN3) needs conisation. – Bethesda systme for reading
most common ovarian cancer
epithelial
what is IOTA
international ovarian tumor analysis
A system to classify ovarian cysts according to echography
RMI or risk of malignancy index for ovarian cancer includes
age
ecography (IOTA)
Ca125
ovarian cancer therapy
surgery
carboplatin and toxolo with CHEMOtx that is always done after surgery
PARP inhibitor for maintenance
At what stage of meiotic divsion do oocytes stop before ovulation
Prima prophase
(after ovulation it stops in second metaphase until fecondazione)
what day is considered the start of pregnancy
the first day of the last menstruation
the umbilical cord contains
2 umbilical arteries and one vein, with Wharton gelatin
T/F hcg is first high in the blood, then in the urine
T
hCG is a glycoprotein
T
where is DHEAS produced
surrene fetale
Bartolin glands is for?
is a gland (not visible, not palpable) at the vulvar lesion. Responisible for lubrification during sex.
Can be obstructed (cyst, abscess, carcinoma of Bartolin - adeno K)
TX: drenaggio
Veginal dryness is often due to a deficiency of what hormone?
estrogen (often in menopause)
uterine cervix parts (seen on colposcopy plus biopsy)
endo cervix: Has cyclindaral monostratitfed with glands
Junction squamous columnar - most sensitive to HPV
exocervix: squamous cells, not keratinised
validity of a colposcopy is based on 3 hours
adequacy (no period, no leukorrhea)
visibility (must see the squamocolumnar junction)
describe the zone of transformation
The uterus, the fallopian tubes and the upper third of the vagina all originate from the
Muller duct
(note that the ovaries have another origin)
the external iliac artery supplies?
thigh
internal iliac a divides into anterior (visceral) and posterior, which further divide into
anterior (visceral): Vescicale superior, vesciale inferior, vaginale. Obturator, ombelicale, uterine artery
gluteal superior and inferior arteries origins
gluteal inferior comes from inferior branch of internal iliac
gluteal superior comes form posterior branch of the internal iliac
define infertility
inability to get pregnant after 1 year of unprotected sex
IUI means?
insemination intrauterine - take seminal fluid, concentrate it, put it in the opening of the cervix.
Is first line option.
FIVIT stands for
fecondazione in vitro
implant blastocyst in the uterine
IC SI stands for?
intra cytoplasmatic sperm injection
contraception methods
natural: mucus, body temp
Barrier: condom, IUD
Hormonal: the pill (combined, or only progesterone)
combined contraceptive options
(a) the pill
(b) the anello cervicale
(c) cerotto (transdermic)
Index of pearl is
the number of unplanned pregnancies DIVIDED BY the number of cicli di esposizione
- the efficiency of contraception is inversely proportional to the pearl index
Most efficient to least methods of contraception
1- steralisation
2- E+P pill, anello vaginale, cerotto
3- IUD, minipill (P), implant
4- condoms
5- mucus, temp, cycle monitor
6- interrupted orgasm
contraindications to E+P contraception
pregnancy
liver disease
Malattia vascolare
K ormonodipendente
IPA
Fumo
emicrania con aura
DM con vasculopatia
trombofilia nota
RELATIVE CI:
emicrania
depression
DM
IPA cronica
dislipidemia
what tumors are associated with oral contraceptive use?
hepatic adenoma
Absolute contraindications for IUD implantation
the mechanism of IUD is to induce local inflammation
- past PID, ectopic pregnancy, or pain/hypermenorrhea
Emergency contraception steps
Levonorgestin (within 72 hours of sex)
ilipristal acetate (within 120 hours of sex)
mifepristone: induce abortion (PGI activator)
what drug is smeared in IUD?
levonorgesten
T/F expiration volumes are reduced in pregnance
T
T/F hCG causes nausea?
T
(note moles produce more hCG than normal pregnancy)
Increase the cardiac gittata, si riducono le resistenze vascolari, aumenta il volume ematico
T
Ecografia of the first trimester shows you
(at the 11-13 +6 wks)
camera gestazionale intrauterina
numero e vitalita degli embrioni
BCF (HR)
CRL (cranio-caudal lenght)
malformativa grave
annessiali/uterina patologica
Ecographia of the 2nd trimester shows you
(done 19-21 +6 weeks)
Done to exclude severe malformations
Ecografia of the 3rd trimester
(done 32-34 weeks) - aka flussiometry
- not compulsory, only in pts with risk of slow growth
- check presentation, placenta, crescita fetale, liquido amniotico
screening of fetal malformation
ecografia
dosage of alfa-fetoprotein
test combinato del primo trimestre includes
valutazoine biochemica: PaPP-A, free B-hCG
Ecografia: nuchal transparency
Mother’s age
(if risk > 1/250 then do invasive imaging)
villocentesis is more risky than amniocentesis
Yes (1%)
ecografia signs for downs syndrome
golf ball in the heart
no nasal bone
elevated nuchal transparency
is the DNA fetal test diagnostic?
No
lets you see trisomy 21, 13, 18
Can be done before villocentesis (from 11 wks onwards, or amniocentesis from 14 weeks onwards)
tests to check for fetal wellbeing are
CTG cardiotocography basal (non stress test)
test di contrazione (di Pose)
pH fetale intraparto
Pulsiossimetria fetale intraparto
CTG tests
for 20 mins
fetal heartbeat (110-160bpm)
contraction of the uterine
What is variablity on a CTG
the difference, during a minute, between two peaks which must be at least 5.
>= 5 is normal
<5 bpm for >=40 mins is non rassicurante
<5 for >=90 minutes is anormale!
what are accelerations on a CTG
the increase of FCF >=15 bpm for >= 15 seconds - are a good sign, Must be at least 2 accelerations in 20 mins
the three types of deceleration in CTG
(1) Type 1 (precoci): the peak of deceleration coincides with the peak of the contraction. is a vagal reflex of the fetus
(2) type 2 : (tardive) the peak of deceleration is after the peak of contraction
(3) Type 3 (variable) for cord compressions
when can you order a induction of labor based on ECG
if you have an alteration of parameters or repeated decelerations on CTG
in a woman with regular cycles, main cause of bleeding in between cycles are
fibromatosis and polyps
Mola means
malattia trofoblastica gestazionale
T/F mola vescicolare in 80% of cases cures spontaneously
T
Mola idatiforme occurs because of
Mola idatiforme (has risk of giving malattia trofoblastica persistente MTP or metastatica)
forms due to a genetic defect at moment of fertilisation
complete vs incomplete mole
complete: empty ova meets sperm cell
incomplete: one ova meets two sperm
diagnosis of mole
bHCG>100 mila
Eco: fiocchi di neve o grappolo d’uva, citi ovarivhe, no sacco gestazionale
biochemica: fegato, rene, tiroide
RX torax: edema polmonare
TX for mole
hysterectomia
raschiamento (<40 y/o)
RX torace
avoid pregnancy in the next year
When is placenta previa diagnosed?
from the beginning of the routine ecographia.
Is a placenta implanted near the inferior uterus opening
Placenta forms from the 5th week and 5th month of pregnancy onwards
classification of placenta previa
centrale: if it covers the orifizio uterino interno (complete or incomplete)
marginale: found within 3 cm from the border of the orifice uterine interno
laterale: found more than 3 cm from the uterine border
RF for placenta previa
mother >35
pluriparti
previous cesarean
curettage of the uterus
presentation of placenta previa
bright red blood bleeding
no pain
no ipertono uterino
no fetal suffering (variable)
TX of placenta previa
if <34 weeks: light bleeding (wait+corticosteroids). Severe bleeding (cesarean)
If >34 weeks : light bleeding (if central/marginal PP then schedule cesarean, if lateral then natural birth).
Severe bleeding: cesarean
distacco di placenta bleeds
dark coagulated blood, pain, fetal suffering (bradycardia)
what is puerperale emorrhagia?
the first cause of death in obstetrics
>500 ml of blood
What is the most common cause of post partum hemarrhage within the first 24 hours
after the first 24 hours: residual remains of the placenta in the uterus (need raschiamento)
Atonia uterina
(other common causes are: 4 T’S: tono, trauma, trombina, tessuto placentale)
what are he main causes of atonia uterina?
stressed myometrium: over expansion of myometrium, etc
TX of atonia uterina
massage
oxytocin
legatura dei vasi uterini (or balloon)
hysterctomy
what drugs induce contraction of uterine
oxytocin
ergometrina (cant use in pre-eclampsia cases)
sulprostone
tocolytics (aka atosiban: are RELAXORS!!)
define preterm labor
contractions (>6/hour for at least 2 hours) with modicatins of the uterine cervice (raccrociamento (is <2 cm on eco) and dilation)
diagnose braxston hicks
> 6 contractions/hours for 2 hours with pain, and lasting more than 30s
NO CERCIX CHANGES
TX of threats of preterm labor
<24 weeks: wait/high risk of abortion
>34 weeks: deliver
between 24 and 34 weeks: do echo, check cervix lenght (if <2cm - ricovera pz for incoming birth). Do fibronectin test (if + wait, if -ve wait.)
- corticosteroids for baby lungs (betamethaosne 12mg every 24 hours in 2 somministrazioni) (dexamethasone 6mg ogni 12 ore in 4 somministrazioni)
- Mg for baby brain
- antibiotics if needed
- tocolytics: to slow contractions - atosiban, ritodrina, nifedipine, indomethacin
T/F when there is an opening of the membranes, tocolytics are NOT ALLOWED
T
define premature rupture of membranes
rupture before the start of the travaglio (labor), indipendant of the epoca of gestasion
TORCH infections in pregnancy
toxoplasmosis
others
rosolia (most dangerous)
CMV
HSV
greg triad of fetal danni that manifest with a maternal infection of rubeola
sordita sensoriale
problemi oculari
problemi cardiaci
fetal manifestations when mother contracts toxoplasmosis
tetrad of sabin
hydrocephalus
corloretinite
intracranial calcifications
mental retardation
CMV fetal manifestations if materal infection occurs
microcephalus
hydrocephalus
periventricular calcifications
the hodge plains are
Hodge’s system of parallel pelvic planes is conventionally used to determine the fetal head height. Hodge’s system subdivides the region from the pelvic inlet to the tip of the coccyx into three equidistant parallel planes
how to define dystocia of the shoulder
more than 60 seconds of difference between the expulsion of the fetal head and fetal shoulders
mcrobets manuver
This is commonly the first maneuver performed along with suprapubic pressure. The patient’s thigh is hyper-flexed towards the abdomen. This will straighten the maternal sacrum on the lumbar spine.
can you use heparin in pregnancy?
yes, bc it doesnt pass the placental barrier
also insulin
Vaccines that can’t be used in pregnancy are: morbillo, rosolia, poliomelitite, parotidite, varicella, febbre gialla
two types of anesthesia for labor
epidural: before labor, many doses
spinal: is deeper, in the subarachnoid space. One single dose, during labor
inducing labor how
prostaglandin vaginal: misoprostolo
oxytocin
amniorexi
Fail of induction: when you cant induce labor even after 12 hours of oxytocin administration and ruptured membranes
sniff test lets you diagnose?
vaginosi batteria - fish smell (gardenerella)
TX with metronidazole
trichomonas infections of cervix appears as
cervicite a fragola
PID therapy
cerftriaxone 500mg single dose IM
doxycyclinexos for 14 days
metronidazole per ox 14 days
Anna discovers she is pregnant, goes to her gynecologist for the first screening visit, she is obese and has a fasting blood sugar level of around 120mg/dl. The next step that the patient will have to follow is
Perform an OGTT at 16-18 weeks. Being a high-risk patient, she will have to carry out a glucose load of 75 g at 16-18 weeks of gestation
Ritodrine, a b2 agonist. Is used in preterm labor bc it is a
tocolytic
Abundant, liquid leucorrhoea is a typical symptom of
bacterial vaginosis
The typical vaginal discharge is a white, milky, non-viscous discharge, which is adherent to the vaginal wall and has a fishy odour. The pH of the discharge is >4.5.
Metronidazole 400mg 2/die for a week
Which is the predominant class of immunoglobulins in colostrum?
igA
Taking vitamin A derivatives during pregnancy can lead to neural tube defects and skeletal abnormalities.
T
vulvar lesions in this way: “large rounded cells, without cell bridges”. Among the clinical information you can read: red, itchy lesions. What do you suspect?
The clinic and histological characteristics allow us to diagnose vulvar Paget’s disease. Precisely those large cells without cell bridges are called Paget cells. Treatment is simple vulvectomy.
Laparoscopy shows, on the left, an indistinct fallopian tube embedded in a 5 cm circumscribed, brownish-red mass involving the adnexal region. Which of the following infectious agents is most likely associated with these signs?
Sexually transmitted diseases are the most common cause of inflammation of the fallopian tubes.
Chlamydia trachomatis
The sniff test is able to identify:
gardenella vaginalis
