Obstetrics/Gynecology Flashcards
Breast Mass Path: Pt: Dx: Tx:
Path:
Fibrocystic breast disease MC benign lesion in breast-> fluctuating estrogen levels during menstrual cycles
Pt:
Rope-like or cobblestoning texture in bilateral breasts w/ cyclical pain associated w/ mensuration
30-50 y/o
Dx:
U/S: dense, prominent fibroglandular tissue w/ cysts but no discernible mass
Tx: Therapeutic aspiration Avoidance of trauma to breasts Wearing a supportive bra Oil of evening primrose Diet modifications: -Caffeine restriction -Low-fat diet -Decrease alcohol consumption
Breast cancer
Path:
Dx:
Tx:
Path: MC: invasive ductal carcinoma
Dx:
Mammography + core biopsy (stereotactic biopsy)
Soft tissue mass or density and clustered microcalcifications
Spiculated soft tissue mass
MC location: upper outer quadrant
Biomarker: cancer antigen 27.29
Tx:
Estrogen receptor (ER) and progesterone receptor (PR)- cell proliferation controlled by estrogen (inhibited by tamoxifen)
-Endocrine therapy: Tamoxifen, letrozole
-Chemotherapy for high-risk characteristics:
High-grade tumors, Large size (>2cm), Pathologically involved lymph nodes
ER-negative and PR-negative
Unlikely to respond to endocrine therapy
Cytotoxic chemotherapy
HER2 (human epidermal growth factor 2) +
Trastuzumab, targets HER2 receptors
PAP Smear: Negative
Neg HPV-> q3y
> 25 y/o +HPV-> repeat annually
PAP Smear: ASC-US
atypical squamous cells of undermined significance <30: repeat in 1 yr >30: HPV +: colposcopy HPV -: repeat in 3 yrs
PAP Smear: LSIL
Low grade squamous intraepithelial lesion
Colposcopy
PAP Smear: ASC-H
Atypical squamous cells cannot exclude HSIL- high grade squamous intraepithelial
Colposcopy
PAP Smear: HSIL
High grade squamous intraepithelial lesions
Colposcopy or loop excision
PAP Smear: AGC
Atypical glandular cells of undetermined significance
Colposcopy
>35: endometrial bx
OCPs
MOA
Contraindications:
MOA:
Progestin: Suppression of LH-> inhibits ovulation, Thickening of cervical mucus, Altered fallopian tube peristalsis
Estrogen: Suppressed FSH-> prevents development of dominant follicle, Potentiates progestin effects, Primarily cycle control
Contraindications: Epilepsy Breastfeeding High risk for VTE Morbid obesity severe vascular HA (migraine) DM Severe HTN
Progestin
Indications
MOA
Indication: breast feeding, cannot take estrogen
MOA: thickening of cervical mucus
Cystocele Path: Pt: Dx: Tx:
Path: Posterior bladder herniating into the anterior vagina
Pt: Incontinence
Dx: Speculum exam-> anterior bulge in vagina
Tx:
Pelvic floor muscle training
Vaginal pessary
Colporrhaphy: surgical repair of defect in vaginal wall
Dysfunctional uterine bleeding
Path:
Dx:
Tx:
Path:
Chronic anovulation (90%):
disruption of hypothalamus-pituitary axis (teens, perimenopausal)
Unopposed estrogen: inc endometrial overgrowth
Ovulatory (10%)
Dx: DOE
hormone levels, TV U/S,
endometrial bx: endometrial stripe >4mm on U/S, women >35yrs
Tx:
Acute severe bleeding:. High-dose IV estrogen or high dose OCPs. Reduce dose as bleeding improves, D&C may be used if IV estrogen fails
Anovulatory (90%)
OCPs 1st line, Progesterone (medroxyprogesterone): if estrogen is contraindicated, GnRH agonists (leuprolide): causes temporary amenorrhea (if given in continuous fashion)
Ovulatory (10%)
OCPs: regulate cycles, thins endometrial lining
Progesterone: orally or IUD (mirena reduced bleeding in 79-94%)
GnRH agonists: Leuprolide w/ add-back progesterone (to reduce the S/E of leuprolide)
Surgery: hysterectomy, endometrial ablation
Dysmenorrhea
Path:
Tx:
Painful menstruation that affects normal activities
Path:
Primary: not due to pelvic pathology
Inc prostaglandins -> painful uterine muscle wall activity.
Secondary: due to pelvic pathology
endometriosis, adenomyosis, leiomyomas, adhesions, PID
Tx:
NSAIDs
Ovulation suppression
Laparoscopy
Intrauterine pregnancy
Dx:
Yolk sac within a gestational sac
intrauterine fetal pole
Intrauterine fetal heart activity
TVUS >38 days after LMP or beta-hCG >1500
Abdominal US >45 days after LMP or beta-hCG >4000
Menopause
Dx:
Tx:
Dx: Inc FSH/LH dec estrogen
Tx:
hot flashes: estrogen, progesterone, clonidine, SSRIs
Vaginal atrophy: estrogen
Osteoporosis prevention: calcium + vit D, weight bearing exercise, bisphosphonates, calcitonin
RTC:
Estrogen only:
pros: most effective tx sx, no inc risk of breast cancer
cons: inc risk endometrial cancer, VTE, liver disease
E + P:
pros: sx relief, dec heart and stroke risk, dec osteoporosis, dec dementia, protective against endometrial cancer
cons: VTE, slight increase risk of breast cancer
Pelvic inflammatory disease Path: Pt: Dx: Tx:
Path:
MC Chlamydia trachomatis
Hx of unprotected sex w/ multiple partners
Pt:
Cervical motion tenderness -> “chandelier sign”
Dyspareunia
Dx: Abdominal tenderness + cervical motion tenderness + adnexal tenderness plus at least one of the following: \+gram stain Temperature >38 WBC >10k Pus culdocentesis or laparoscopy
Tx:
Out pt:
Ceftriaxone 250mg IM x1 dose + doxycycline 100mg BID x14d +/- metronidazole
In pt:
IV doxycycline + 2nd gen cephalosporin (cefoxitin, cefotetan) OR
Clindamycin + gentamicin
Rectocele Path: Pt: Dx: Tx:
Path:
Distal sigmoid colon (rectum) herniated into the posterior distal vagina
Pt:
Constipation
Hx of childbirth, trauma, previous surgeries
Dx: Speculum exam-> posterior bulge in posterior vaginal wall
Tx:
Colporrhaphy: surgical repair of defect in vaginal wall
Manage constipation-> high fiber diet
Pessary device
Threatened abortion Path: Pt: Dx: Tx:
Path:
Pregnancy may be viable or abortion may follow
MC cause of 1st trimester bleeding
Pt: Bloody vaginal discharge Spotting -> profuse \+/- contractions Uterus size compatible w/ dates
Dx:
Products of conception: No POC expelled from uterus
Cervical OS: Closed
Tx:
Supportive: rest @ home, return to ER if sx persist or passage of POC
Serial B-HCG to see if doubling
RhoGAM if indicated
Vaginitis Path: Pt: Dx: Tx:
Path: Trichomonas vaginalis
Pt:Malodorous frothy, green/yellow vaginal discharge
Strawberry cervix
Dx: Wet mount Labs: pH>5 Flagellated motile, pear shaped
Tx: PO metronidazole 2g x1 dose or tinidazole
Bacterial Vaginitis
Path: Gardnerella vaginalis
Pt:Malodorous vaginal secretions
Dx: 3/4 Amsel criteria thin, gray/white discharge pH>4.5 clue cells KOH to smear -> fishy odor, “whiff test”
Tx: Metronidazole (ok while pregnant)
Inevitable abortion Path: Pt: Dx: Tx:
Path: Pregnancy not salvageable
Pt:
Moderate bleeding >7d
Mod-severe uterus cramping
Uterus size compatible w/ dates
Dx: Products of conception: No POC expelled Cervical OS: Progressive cervix dilation: >3cm, effaced \+/- rupture of membranes
Tx:
2nd trimester: Dilation and Evacuation (D&E)
1st trimester: suction curettage
RhoGAM if indicated
Incomplete abortion Path: Pt: Dx: Tx:
Path: Pregnancy not salvageable
Pt: Heavy bleeding Mod-severe cramping Retained tissue Boggy uterus
Dx:
Products of conception: some POC expelled, some still retained
Cervical OS: Dilated
Tx: May be allowed to finished D&E after 1st trimester D&C in 1st trimester Pitocin RhoGAM if indicated
Complete abortion Path: Pt: Dx: Tx:
Path: Complete passage of all products
Pt:
Pain, cramps and bleeding usually subsides
Pre-pregnancy size of uterus
Dx:
Products of conception: All POC expelled from uterus
Cervical OS: usually closed
Tx:
RhoGAM if indicated
Missed abortion Path: Pt: Dx: Tx:
Path: Fetal demise but still retained in uterus
Pt:
Loss of pregnancy sx
Brown discharge
Dx:
Products of conception: no POC expelled
Cervical OS: closed
Tx:
D&E 2nd trimester
D&C 1st trimester
Misoprostol
Septic abortion Path: Pt: Dx: Tx:
Path: The retained POC becomes infected -> infection of uterus and organs
Pt:
Foul brownish discharge, fever, chills
Uterine tenderness
Spotting -> heavy bleed
Dx:
Products of conception: Some POC retained
Cervical OS: Closed, CMT
Tx:
D&E to remove POC + broad spectrum abx
+/- hysterectomy if refractory
