Obstetrics/Gynecology Flashcards
1
Q
Definition of primary amenorrhea
A
- absence of spontaneous menstruation by 16yo WITH secondary sex characteristics or 14yo WITHOUT secondary sex characteristics
- 4 main categories based on karyotype
- Turner syndrome (Gonadal agenesis) - 45 XO
- Hypothalamic-pituitary insufficiency - 46 XX
- Androgen insensitivity - 46 XY
- Imperforate hymen - 46 XX
2
Q
Definition of secondary amenorrhea
A
- woman who has previously menstruated
- absence of menses for 3 months if previous cycles nl
- absence of menses for 6 months if previous cycles irreg
- Cause
- THE MCC 2ary amenorrhea = PREGNANCY
- Drug use, stress, significant weight change, or excessive exercise
- PCOS, CNS tumor, hyperPRL, Sheehan syndrome (causes postpartum hypopit - pituitary gland is damaged, caused by excess blood loss (hemorrhage) or extremely low blood pressure during or after labor)
- previously normal menstrual cycles and normal E, think stress or outflow obstruction (Asherman syndrome - scar tissue forms in the uterus, rare but can be a complication of multiple D&Cs)
- If galactorrhea present, prolactinemia is MCC
3
Q
Amenorrhea
A
- Primary or secondary
- women with no menstruation in presence of E stimulation of endometrium have increased risk of endometrial cancer
4
Q
Diagnostic studies for amenorrhea
A
- First line: B-hCG, TSH, PRL
- Second line: FSH, E, LH, T
- If bleeding occurs after progesterone challenge, anovulatory cycles are the cause
5
Q
Characteristics of dysfuncitonal uterine bleeding (DUB or AUB)
A
- Presents as abnormal bleeding with a generally unremarkable PE
- Abnormal uterine bleeding in non-pregnant women
- different from normal cycle in terms of regularity, flow, duration, and volume
- normally occurs right after menarche or during perimenopause
- Causes = PALM-COIEN (polyp, adenomyosis, leiomyoma, malignancy - coag, ovulatory dysFN, endometrial, iatrogenic, not otherwise classified)
- Menorrhagia = heavy or prolonged bleeding
- Metrorrhagia = irregular bleeding between menses
- PE includes speculum, evaluate for bleeding from other sources
6
Q
Diagnostic studies for DUB
A
- B-hCG, CBC, iron, PT, PTT, documentation of ovulation, thyroid, serum P, LFTs, PRL, serum FSH
- Pap, US, hysterosalpingography, hysteroscopy, and/or D&C
- endometrial bx should be done on all women over 35yo w/ obesity, HTN, or DM and on all postmenopausal pts
7
Q
management of DUB (AUB)
A
- depends on severity of bleeding - may include observation, iron therapy, and volume replacement
- progestin trial - if bleeding stops, anovulatory cylces are confirmed
- OCPs:
- older women w/o risk factors
- OCPs should NOT be used in women over 35 who smoke, have HTN, DM, or hx of vascular dz, breast CA, liver dz, or focal HA
- D&C can be dx and curative
- refractory cases may require endometrial ablation or vaginal hysterectomy
8
Q
Dysmenorrhea general characteristics
A
- PRIMARY: painful menstruation caused by increased prostaglandin and leukotriene levels - painful uterine cramping, N/V/D
- Onset: usually w/in 2yrs menarche, peak incidence = late teens/early 20s
- THERE IS NO PATHOLOGIC ABNORMALITY
- SECONDARY: painful menstruation caused by identifiable condition (usually uterus or pelvis - endometriosis, adenomyosis, fibroids, PID, IUD)
- usually affects older women (>25yo)
9
Q
clinical features of dysmenorrhea
A
- Primary: sxs are central lower abdomen or pelvis radiating to back or thighs, beginning before or at onset of menses, lasting 1-3 days
- PE, labs, radiologic tests = nl
- Secondary: similar sxs as above but may also include bloating, heavy menstrual bleeding, and dyspareunia
- less related to first day of flow
10
Q
diagnostic studies for dysmenorrhea
A
- dx of primary dysmenorrhea based on hx, use of menstrual diary, PE
- specific tests for secondary dysmenorrhea - hysteroscopy, D&C, laparoscopy
- all allow both dx and tx
11
Q
management of dysmenorrhea
A
- Primary:
- start NSAIDs right before expected menses, continue 2-3 days
- OCPs, vit B (B1, thiamine; B6, pyridoxine), magnesium, acupuncture, heat, regular exercise
- Secondary:
- underlying conditions should be treated
- sx treatment may be sufficient
12
Q
Pelvic Inflammatory disease etiology and sxs
A
- etiology: infxn ascends from cervix to involve endometrium and/or fallopian tubes
- MCC = gonorrhea, chlamydia, genital mycoplasmas
- RF: endocervical infxn, BV, hx of PID, vaginal douching, IUD insertion, D&C or C-section
- signs and sxs:
- mucopurulent malodorous vaginal discharge
- abd pain
- abnl vaginal bleeding
- bilateral lower abdominal and pelvic pain
- N/V
- urethritis, proctitis
- Fever
- yellow endocervical discharge, easily induced bleeding
- uterine or adnexal tenderness and swelling, CMT
- rebound/guarding
13
Q
Pelvic inflammatory disease dx and tx
A
- Dx: ESR elevated, leukocytosis, B-hCG, NAATs, gram stain
- US: enlarged fallopian tubes with fluid in cul-de-sac
- laparoscopy - last line, rule out appy, ectopic, tumor
- endometrial bx
- outpt: ceftriaxone IM and doxy PO x14d
- +/- flagyl BID x 14d
- inpt: hosp if: dx uncertain, pregnant, abscess suspected, severely ill or N/V preclude outpt management, HIV pos
- Doxy + IV cefotetan or cefoxitin x 48h, then PO doxy BID x14d
- clindamycin + gentamicin qh x48h, then PO doxy BID x14d
14
Q
bacterial vaginosis
A
- MCC vaginitis
- RF: new partner, smoking, IUD, douching, pregnancy
- signs, sxs: mostly asx
- increased vag d/c
- dysuria, frequency, dyspareunia
- noticeable fishy discharge after menses or intercourse, no itching
- thin ivory/gray d/c
- dx: amsel criteria (3 of 4)
- thin, gray, homogenous d/c
- positive whiff
- clue cells
- elevated pH >4.5 (basic)
- tx: metronidazole BID x7d
- Or vaginal metronidazole
15
Q
atrophic vaginitis
A
- postmenopausal women, thinning of vag epithelium
- signs, sxs: dyspareunia, thin vag d/c, vag pruritis, burning, soreness
- atrophic vulvar changes (smooth, shiny, pale, dry, thin), scattered vag petechia, thin clear or brown d/c (leukorrhea)
- UTI, urge incontinence may be associated
- Dx: clinical dx
- vaginal cytology (greater % of parabasal cells)
- vaginal pH: 5-7
- tx: H2O soluble lubes, topical vaginal estrogens, oral estrogens
16
Q
candidiasis
A
- 2nd MCC vaginitis
- RF: high dose OCP, diaphragm use, DM, abx, pregnant, immune suppression, tight clothes
- signs, sxs: vulvar or vag itching, burning, external dysuria, dyspareunia, odorless thick cottage cheese curd-like d/c
- erythema of vulva, excoriations from scratching
- dx: wet mount - budding yeast
- gram stain - pseudohyphae
- vaginal culture (+) for yeast
- pH <4.7 (acidic)
- tx: fluconazole 150 PO once
- tx uncircumcised partners
- short-course topical azole
- recurrent: weekly topical /PO
- resistant: boric acid TID x7d
17
Q
breast abscess
A
- occurs especially during nursing (MC s. aureus)
- presentation: redness, tenderness, induration
- dx: incision and bx if severe or indurated - r/o inflammatory carcinoma
- tx: bactrim, clinda, doxy
18
Q
mastitis
A
- MC in postpartum (2-4th week, S. aureus)
- Presentation: lactating women, FEVER, chills, flu-like, acute, responds to abx
- signs: decreased milk, redness, tenderness, firm mass, breast pain, unlilateral, heat
- dx: culture of purulent material or milk (not routine)
- tx: dicloxacillin (PCN allergy - erythromycin)
- cold compress, NSAIDs and tylenol, continue to breast feed and express milk
19
Q
intrauterine pregnancy signs/sxs, dx, tx
A
- signs/sxs: breast enlargement/engorgement and colostrum, vaginal cyanosis, cervical softening (7wks), enlargement and softening of corpus (>8wk), abdominal enlargement (16wk), palpable uterine fundus above pubic symphysis (12-15wk), FHT (10-12wk)
- the following are NOT diagnostic: amenorrhea, N/V, breast tenderness, urinary frequency/urgency, “quickening”, weight gain
- dx: UPT, B-hCG double q48h, peak at 50-70d, fall in 2-3 timesters, progesterone remains stable during first trimester (best indicator of viable preg >25ng/mL)
- tx: prenatal vits or folic acid (0.4-0.8mg unless prior kid with NTD then 4mg 1 mo prior to conception)
20
Q
endometriosis etiology, RF, and sxs
A
- hx of PID/STD, laparoscopy for chronic pelvic pain or dysmenorrhea, infertility
- present in 30% infertile women
- MC in 25-35yo white women, estrogen dependent inflammatory dz
- MC locations: ovaries, anterior and posterior cul-de-sac, post broad ligaments, uterosacral lig, uterus, fallopian tubes, sigmoid colon, appendix, round lig
- RF: nulliparity, prolonged E exposure (early menarche), exposure to DES in utero, lower BMI, high consumption trans unsaturated fat, outflow tract obstructions
- Sxs: cyclical pelvic pain, dysmenorrhea (pain 1-2d before menses, persists throughout), dyspareunia, dyschezia, hematochezia, dysuria, hematuria
- fixed uterus, retroflexed, nonmobile, palpable adnexal mass
- complications: infertility
21
Q
endometriosis dx, tx
A
- Dx:
- transvag US: hypoechoic, vascular, or solid mass (irreg margins, spiculated - MOST ENDOMETRIAL TISSUE CANNOT BE SEEN ON US)
- DEFINITIVE: exploratory laparoscopy and bx (“blue-black powder burn lesions” raised flame-like patches)
- serum CA125 can be elevated
- Tx:
- mild-moderate (no reg absence from school/work, no US evidence): NSAIDs, OCPs, Depo, Mirena
- Severe (reg absence from school/work, failed tx, recurrence): GnRH agonist (leuprolide) with OCPs
- Laparoscopy
- DEFINITIVE tx: hysterectomy + bilateral salpingo-oophorectomy
22
Q
Ovarian cyst
A
- Etiology/RF: ectopic endometrial tissue within ovary - bleeds and results in hematoma
- Sxs: asx or pelvic pain, menstrual irreg., urinary frequency, constipation, pelvic “heaviness”, syrup-like chocolate colored material)
- Dx: US (first line), preg test, CBC, CA-125
- Tx:
- small, asx: OCP, repeat US in 6-8wk
- Large, sx: cystectomy (first line), follow w/ long term OCP
- oophorectomy (definitive) - recurrent cysts, no more childbearing, postmen.
- Complications: hemoperitoneum (with rupture)
23
Q
Spontaneous Abortion etiology, RF, and sxs
A
- most occur in first 12wks (80%)
- fetal RF: chromosomal abnl (MC: trisomy, monosomy X), congenital anomalies
- Maternal RF: Advanced age, previous SAB, smoking, infxn, uterine anomalies, maternal dz, gravidity, fever, prolonged ovulation to implantation interval, high or low BMI, celiac dz
- Sxs: vaginal bleeding, pain, type of abortion determined by passage of POC and whether cervix is dilated or not
24
Q
spontaneous abortion dx and tx
A
- dx: quant B-hCG, CBC, blood type, ab screen US
- tx:
- >13wk: medical abortion (mifepristone - antiprogesterone) (misoprostol - prostaglandin)
- D&C - first trimester
- D&E - second trimester
- Surgery required if ineffective or excessive blood loss
25
Ectopic pregnancy etiology, RF, and sxs
* MC site = ampulla
* RF: An ECTOPIC
* An: AMA
* E: exposure to DES in utero
* C: cigarette
* T: tubal ligation
* O: ovulation induction
* P: prior PID/ectopic
* I: infertility
* C: contraceptive IUD
* sxs: abd pain, bleeding
* ominous findings: vertigo/syncope, shoulder pain worse with insp.
* generalized unilateral tenderness, os closed, adnexal tenderness, CMT, uterus smaller than dates
26
ectopic pregnancy dx, tx
* dx: UPT +, serum BhCG x3 q48h (inappropriately rising)
* gestational sac on TVUS: 4-5wk after LMP
* tx: methotrexate IM 50mg (check baseline kidney and liver fn)
* need to follow up day 4 and 7, then weekly until neg for hCG
* contraindications: breastfeeding, immunodef, liver dz, blood dyscrasias, pulm dz, PUD, renal dz
* **exploratory laparotomy or laparoscopy if ruptured ectopic**
27
placential abruption etiology, RF, and sxs
* separation of placenta from implantation site before delivery of baby
* RF: preeclampsia, chronic HTN, smoking, cocaine, thrombophilia, prior abruption, AMA, multiparity, multifetal gestation, prior uterine surgery, polyhydraminos, fibroid, PPROM
* sxs: painful vaginal bleeding, uterine tenderness, frequent contractions
* signs: uterine tenderness ("woody"), fetal distress, shock, dilated cervix
28
placential abruption dx and tx
* dx: clinical dx - US, CBC, coags, fibrinogen, type and screen BUN/Cr, tocodynamometry (FHR monitoring), urine output
* tx: immediate delivery due to high risk of fetal death
* preterm/no distress (34-37): induce labor
* term/no distress: vaginal delivery
* fetal distress: emergent CS regarless of age
* fetal demise: vaginal delivery, induction, D&E if 2nd trim.
* complications: life-threatening PPH and increased need for emergent hysterectomy
29
Placenta previa etiology, RF, and sxs
* placenta implants over internal cervical os
* most common abnormality of placental implantation
* RF: AMPS (AMA, multiparity, multiple gestation, prior previa, c-section, D&C, smoking)
* sxs: painless vaginal bleeding, nontender uterus, breech/transverse lie common
* consequences: PPH, required C-section, placenta accreta, increta, or percreta, abruption, and growth restriction
30
placenta previa dx and tx
* dx: if dx in first or second trim., repeat US
* on TVUS, placenta is low\
* CBC, coags, type and screen
* fetal HR monitoring
* **DO NOT PERFORM DIGITAL EXAM**
* tx: hospitalization for evaluation, if 37+ wks - delivery, if \<36wks - expectant management (asx or preterm = close observation and steroids; mature fetus+/- contractions = base on fetal testing, document lung maturity, schedule 36-38wk)
* delivery regardless of gest age if: severe fetal status, life threatening hemorrhage, bleeding after 34wk
31
Fetal Distress
* generally believed that reduced baseline heart rate variability is single most reliable sign of fetal compromise
* sinusoidal: Fetal anemia from Rh-alloimmunization, fetal intracranial hemorrhage, severe asphyxia, fetomaternal hemorrhage, twin-twin tranfusion syndrome, or vasa previa
* early decelerations: normal head compression during uterine contractions (active labor) - in most cases, onset, nadir of decel, and recovery are coincident with beginning, peak, and end of contraction respectively
* late decels: uteroplacental insufficiency - decel occurs after the peak of contraction
* variable decels: umbilical cord compression -\> fetal anoxia -\> death - abrupt decrease in FHR; decrease in FHR is \>/=15 bpm, lasting \>/=15s, and \<2min in duration
32
PROM etiology, RF, sxs
* RF: genital tract infxn (BV), smoking, prior PPROM, shortened cervical length, amnio
* rupture of membranes before onset of labor
* important cause of PTL, prolapsed cord, placental abruption, and intrauterine infxn
* NIH recommends use of steroids in PROM pts before 32wks in absence of amniotic infxn
* sxs: term \>37wk, sudden gush of fluid or continued leakage
* **avoid digital exam**
33
PROM dx and tx
* dx: hallmark findings are **ferning, nitrazine testing** (amnio fluid - paper turns blue = alkaline)**, pooling**, CBC and UA, phosphatidyl glycerol (indicates pulm maturity), AFI w/ US
* tx: if chorioamnionitis present, active delivery indicated regardless of gest age
* if no infxn and term, manage expectantly or actively
* if no infxn and preterm, similar delivery to PTL
* abx and hydration prolongs latency period by 5-7d - IV ampicillin and IV erythromycin
* tocolysis: prolongs interval to delivery to gain time for steroids to be administered (only 48h - longer increases risk of infxn)
34
Chlamydia etiology and sxs
* Most common bacterial STD
* RF: lack of condom use, lower socioeconomic status, living in an urban area, having multiple sex partners
* most common in F 15-19, then 20-24
* independent risk factor for cervical cancer
* Sxs:
* men: dysuria, purulent urethral discharge, itching, scrotal pain and swelling, fever
* women: puruelnt urethral discharge, intermenstrual or post-coital bleeding, dysuria
* mucopurulent discharge from cervical os, friable cervix
35
chlamydia diagnostics and tx
* Tx: NAAT, wet mount (leukorrhea \>10 WBC), culture, enzyme immunoassay, PCR
36
Gonorrhea etiology and sxs
* transmitted sexually or neonatally
* 30% coinfected with chlamydia
* Sxs: asymptomatic in women, symptomatic in men
* Cervicitis or urethritis (purulent discharge, dysuria, intermenstrual bleeding)
* Disseminated: fever, arthralgias, tenosynovitis, septic arthritis, endocarditis, meningitis, skin rash (distal extremities)
37
Gonorrhea dx and tx
* dx: NAAT, gram stain (leukocytes, gram neg intracell. diplococci), cultures (men from urethra, women from endocervix)
* tx: tx empirically because cultures take 1-2d
* Ceftriaxone x1, add Azithromycin or doxy to cover chlamydia
* if disseminated, hospitalize and IV or IM ceftriaxone
* Complications of dz: PID, infertility, epididymitis, prostatitis, salpingitis, tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome
38
lymphogranuloma venereum
* MCC: chlamydia trachomatis - primary infxn of lymphatics and lymph nodes
* Sx: hx of proctitis with or without anal lesions
* first stage = painless genital ulcer 3-12d after infxn
* second stage = unilateral lymphadenitis or lymphangitis with tender inguinal or femoral LAD
* Enlarged bubos, which are painful
* Tender lymphadenopathy at the femoral and inguinal lymph nodes, separated by a groove made by poupart ligament ("sign of the groove")
* dx: serologic testing for syphilis - RPR/VDRL
* Tx: drainage of buboes, doxy 100mg BID x 21d
39
chancroid
* etiology: haemophilus ducreyi (G-)
* sxs: PAINFUL chancre
* PAINFUL lymphadenopathy - leads to bubo formation
* dysuria and dyspareunia in Fs
* multiple painful punched out ulcer with undermined borders
* dx: serologic testing for syphilis - RPR/VDRL
* culture and gram stain of fluctuant lymph node or ulcer for H ducreyi
* Tx: 1 g azithromycin
* fluctuant inguinal lymph nodes should be incised and drained
40
HPV
* etiology: MC - condylomata acuminatum
* Low-risk types: 6, 11
* anogenital warts - most common viral STD in US
* Causes nearly 100% of cervical cancers - most significant RF for cervical CA
* sxs and signs: most asymptomatic
* flesh-colored papillary exophytic lesions on genitalia
* dx: RPR/VDRL - r/o syphilis
* HIV, HPV viral typing not recommended daily
* Shave or punch bx confirms - hyperplastic prickle cells, koilocytotic or vacuolated squamous epithelial cells in clumps on pap (cervical warts)
* tx: most resolve spontaneously
* podophyllin or trichloroacetic acid
* surgery (cryotherapy, excision, electrocautery, intralesional interferon
* guarasil
* 6, 11 = warts
* 16, 18 = cervical CA
* condoms reduce transmission of warts
41
trichomoniasis
* signs, sxs: increased d/c and odor, dysuria, frequency, dyspareunia, itching, irritation
* thin yellow-green to gray, adherent frothy discharge in vagina
* malodorous, musty (amine)
* hyperemic mucosa, friable cervix, strawberry cervix (petechiae)
* dx: wet mount, ph 5-6.5 (basic)
* tx: 2 g metronidazole PO x1, no ETOH 48h, TREAT PARTNER
