Reproductive Flashcards
What stimulates release of the ovum from the follicule on day 14 of the menstrual cycle?
Luteinizing hormone (LH)
What is the most common type of endometrial cancer?
Adenocarcinoma
What is a common risk factor for endometrial cancer? How does it present? How is it dx?
RF: unopposed estrogen stimulation (Oral contraceptives can have a protective effect)
S/S: Innappropriate uterine bleeding, including prolonged heavy periods or spotting. Normal pelvic exam
Dx: Pap smear and endometrial bx (should be done for any postmenopausal bleeding)
Pelvic US to r/o fibroids, polyps, and endometrial hyperplasia
what are the most common sites for Endometriosis?
Pelvis and ovaries
What is the definitive diagnose for Endometriosis? What would you see on microscopically on a tissue sample?
Direct visualization with Laparoscopy is required to make the diagnosis (Chocolate cysts, Powder burns, Raspberry lesions)
Tissue sample: Endometrial glands, stroma, and heomsiderin-laden macrophages
What are RF for uterine prolapse?
RF: Increased intrabdominal pressure (Obesity, coughing, heavy lifting)
How do you diagnose Leiomyoma?
AKA Fibroids
Pelvic US reveals hypoechogenic areas among normal myometrial material
Pelvic exam reveals irregular, nontender masses
What are the symptoms of Uterine prolapse? how is it tx?
Vaginal fullness, lower abdominal ache, low back pain
Sxs worse after prolonged standing or late in the day
Most also have cystocele, rectocele, or enterocele
Tx: Kegal exercises for prevention, Surgery, wt reduction
How do you treat Ovarian Cysts?
- Premenarchal with cysts >2cm: Ex lap
- Reproductive
- cysts<6 cm: observe x 6 weeks
- Cysts >8 cm: Ex lap
- Postmenopausal with palpable cyst: Ex lap
What tx can be given to women with Polycystic ovarian disease desiring fertility?
Clomiphen Citrate
Symptoms/signs of ovarian Cancer; Test of choice?
- Initially asymptomatic
- Ascites, vague GI sxs
- PE: Adnexa is tender with fixed pelvic mass
- fixed, solid bilateral nodules
TOC: Pelvic US
What HPV types are strongly linked to cervical cancer? What is the most common cancer cell type?
HPV 16, 18, and 31
Most common cell type is Squamous cell carcinoma
What Cervical cancer cell type is linked to exposure in utero of diethylstillbestrol (DES)?
Clear Cell carcinoma (A type of Adenocarcinoma)
What are the different ratings for cervical intraepithelial neoplasms (CIN)?
CIN-1 mild dysplasia
CIN-2 Moderate dysplasia
CIN-3 is severe dysplasia
CIS-Carcinoma-in-situ
What is the most classic symptom of Cervical carcinoma?
Postcoital bleeding
After abnormalities in PAP smear and other signs, what is the most appropriate technique for histologic evaluation?
Colposcopy with biopsy
Follow up testing after Pap smear shows ASC-US?
- ASC-US (Atypical squamous cells of undetermined significance)
- 20 years or younger: Rpt PAP in 12 months
- 21 and older: HPV test, or RPT PAP in 6 mo. and 12 mo. or colposcopy
- postmenopausal: HPV test, RPT pap in 6 mo., and 12 mo. or colposcopy
- Preg: HPV test or colposcopy (WITHOUT ENDOCERVICAL SAMPLING!) or delay testing until delivery
Follow up testing after abnormal PAP results showing LSIL
Low grade squamous intraepithelial lesion (includes HPV and mild dysplasia)
- <20 y/o: rpt pap in 12 mo.
- 21 <: Colposcopy
- Postmenopausal: HPV test, Rpt pap in 6 mo. and 12 mo. or colposcopy
Follow up testing for abnormal PAP smear results showing HSIL
High grade intraepithelial lesion (includes moderate and severe dysplasia)
- <20 years: Colposcopy
- 21 years through postmenopausal: Colposcopy or LEEP
- Pg: Colposcopy (WITHOUT ENDOCERVICAL SAMPLING!!)
Follow up testing for abnormal PAP smear results showing ASC-H
Atypical squamous cells-cannot rule out high grade)
- For everyone: Colposcopy
- If pregnant: colposcopy WITHOUT ENDOCERVICAL SAMPLING!
Follow up testing for abnormal PAp smear showing ACG
Atypical Glandular cells
- All subcatagories (except atypical endometrial cells): Colposcopy with endocervical sampling and HPV testing and endometrial sampling (if older than 35)
- Atypical endometrial cells: Endometrial and endocervical sampling followed by colposcopy and HPV testing
- If pregnant: Colposcopy and HPV testing (WITHOUT ENDOCERVICAL OR ENDOMETRIAL SAMPLING)
Tx for Gonorrhea and Chlamydia
Gonorrhea: Ceftriaxone IM
Chlamydia
- Azithromycin x 1 or doxycycline x 7days
- erythromycin in pregnancy
HOw do you treat an incompetent cervix?
Cervical cerclage between 16-18 weeks of pregnancy
Remove sutures at 36 weeks
What is a cystocele? What are the sxs? How is it diagnosed? Tx?
Protrusion of the bladder into the vagina due to an anterior wall defect
Sxs: Pelvic pressure and stress incontinence (most common) and straining to urinate
Diagnosed by physical exam: bulging in the anterior portion of the vagina
Tx: surgery
What is the most common Vulva/vaginal cancer cell type? How does it diagnosed?
Squamous cell carcinoma
Dx: Acetic acid or staining with toluidine blue
vaginal bx by colposcopy
How do you diagnose Secondary Amenorrhea?
Absence of menses for 6 months or longer (or 3 missed menstrual cycles)
- Pregnancy test
- TSH and prolactin levels (to evaluate for hypothyroid and hyperprolactinemia
- Progesterone challenge test: to determine presence or absence of estrogen
If Over age 40, would want to r/o ovarian failure as well (LH, FSH, estradiol)
What test is diagnostic for menopause/
FSH > 30
WHat is the most common type of breast cancer?
Ductal carcinoma (80-85%)
HOw do you screen for breast cancer? How do you establish diagnosis?
SCreening: mammography; US if under 30 y/o bc dense breast tissue
Dx: Fine-needle biopsy
What is the most common tumor in women under 25 years old?
Fibroadenoma
How do you treat Gynecomastia?
Clomiphene: an antiestrogen, approx 50% of pts achiece partial reduction in breast size
Tamoxiflen: effective for recent-onset and tender gynecomastia
Reduction mamoplasty–For patients with macromastia (Breast size >5 cm); or where medical therapy failed
causes of galactorrhea and treatment
Usually results from too much prolactin
Causes:
- Pituitary Adenoma (hyperprolactinemia)
- Medications: H2 blocker (Cimetidine), Anti-psychotic (Risperdone), Spironolactone
- hypothyroidism
- CKD
- 50% no known cause
Tx: Bromocriptine-DOC
How do you treat Mastitis in the nursng mother?
Empty breasts frequently through continued nursing or pumping
Start antibiotics if symptoms are not improving within 12-24 hours or if the woman is ill
Dicloxacillin 500 mg PO QID x 10-14 days
If inpatient: IV nafcillin 2 grams q4 hours
How does Pelvic inflammatory dz present and how is it diagnosed?
Sxs: lower abdominal pain and pelvic pain
PE: cervical motion tenderness (Chandelier’s sign); purulent cervical discharge
Adnexal mass if tubo-ovarian abscess is present
dx:
- Definitive diagnosis made by laparoscopy
- Transvaginal US (?)
- Gram stain and culture
Treatment of PID
Broad spectrum cephalosporins: Cefoxitin, Cefotetan, and doxy
If allergic to cephalosporins: Clindamycine plus gentamycin
What drug promotes ovulation and when do you take it?
Clomiphene citrate–days 3, 4, 5 of the cycle
What is the bishop score? What do you use it for?
Used to determine if a cervix is favorable
Favorable >8
Used to decide if labor should be inducted in a nonlaboring patient. Success related to bishop score. Scores less than 5->not ready for induction
prepare patient for induction by prostaglandings to ripen the cervix
What do you use to induce labor?
IV pitocin: stimulates contractions
describe the first stage of labor
Stage one begins with regular uterine contractions and ends with complete cervical dilation at 10 cm
6-20 hours for nulliparous and 2-14 hours for multiparous
Divided into two stages: Latent and active
- Latent stage: cervical effacement and early dilation
- Active phase: occurs when dilation has reached 4 cm or greater
Describe the second stage of labor:
begins with complete cervical dilation and ends with delivery of the fetus
30 minutes to 3 hours nulliparous
5 min to 1 hour for multiparous
Describe the third stage of labor
Time period between the delivery of the fetus and the delivery of the placenta and fetal membranes
Describe the 4th stage of labor
After delivery of the placenta, in which mother’s stability is monitored and lacerations and hemorrhages are treated (1-6 hours)
When can an internal fetal monitor be used?
Cervix must be dilated to 2 cm and membranes ruptured
In fetal HR monitoring, What are accelerations?
An increase of 15 bpm x 15 seconds above the normal baseline
Fetal HR monitoring: what are Early decelerations?
begin and end at the same time as teh contraction
Often present as a woman approaches the second stage of labor
What are variable decelerations?
Benign if mild and infrequent; Rapid drop in fetal heart rate
Occur with cord compression
What are LATE decelerations
Always worrisome!!
Fetal heart rate drops during the second half of the contraction; Denote uteroplacental insufficiency
If this happens, stop oxytocin, change maternal position, administer oxygen
What is a perfect apgar score? What would that entail?
Perfect apgar score: 10
Active movement, Pules >100 bpm, Sneezes/coughs/pulls away, Pink all over, Respiration good (with crying)
How do you calculate expected date of confinement using Nagele’s rule?
Subtract 3 months, add seven days, and add 1 year
When can you hear fetal heart tones?
At 10 to 12 weeks by doppler
Normal is 120-160
When should you start feeling fetal movements?
18 to 20 weeks
What labs show an increase risk of trisomy 21?
Low pregnancy-associated plasma protein A (PAPP-A) and abnormally high free Beta-hCG
When do you scren for gestational diabetes?
24-28 weeks
When do you do a vag-rectal culture for Group B strep?
35-37 weeks
Describe the types of abortion
- Defn: Termination of pregnancy before 20 weeks gestation
- Incomplete abortions:
- Expulsion of some but not all of the products of conception
- Vaginal bleeding, open cervix
• Inevitable abortion:
- Dilation of the cervix without expulsion of the products of conception Vaginal bleeding; no products of conception have been released but there is no way to maintain pg—Pg will not continue
• Threatened abortion
o Intrauterine bleeding prior to 20 weeks with a closed cervix
o Cervix closed; could be a normal pregnancy
• Missed abortion
o Fetal demise without symptoms; No products of conception have passed
o No bleeding, closed cervix
May need D&C for incomplete or missed abortion
What is the most common cause of third trimester bleeding?
Abruptio placentae
What is abruptio placentae and when does it commonly occur? classic sx? dx? tx?
The premature separation of a normally implanted placenta after the 20th week of gestation but before birth
Most occur after 30 weeks
Sxs: **Painful (severe) **Vaginal bleeding, abnormal FHR, uterine hypertonus
Associated with h/o cocaine use, abdominal trauma, maternal HTN, multiple gestation, and polyhydraminos
Dx: US NOT diagnostic; Need to monitor fetus and fetal stress testing
Tx: delivery
What is placenta previa? what is c/i? How is it diagnoseD?
When the placenta partially or completely covers the cervical os
Sxs: Painless 3rd trimester vaginal bleeding (No abdominal discomfort, normal FHR, no significant maternal hx)
DO NOT PERFORM DIGITAL EXAMINATION
diagnosed before 20 weeks gestation by US
How do you treat placenta previa?
Tx: Large Bore IV, watchful waiting if patient is stable (may resolve on its own)
C-section is preferred method of delivery
Define Preterm labor
Delivery of a viable infant before 37 weeks gestation
Regular uterine contractions (>4 to 6/hr) between 20 and 36 weeks of gestation and one or more of the following:
- Cervical dilation of 2 cm or > at presentation
- Cervical dilation of 1 cm or > on serial examinations
- Cervical effacement of >80%
Name drugs used in Preterm labor to prevent or stop
-
Magnesium sulfate–inhibits myometrial contractility
- Give calcium gluconate if mg toxicity
- beta mimetic adrenergic agents: relax smooth muscle to decrease uterine contractions–>reduce incidence of delivery within 24 and 48 hours of administration.
- CCB: inhibit smooth muscle contractility
If history of Preterm delivery:
- 17 alpha hydroxyprogesterone-weekly injections from 16-36 weeks
Give steroids to mom for fetal lung maturity
When does Endometritis occur? What organism is commonly involved? What is first line tx?
Commonly occurs after C section or when membranes are ruptured >24 hours before delivery
- Presents 2-3 days postpartum with high fever and uterine tenderness
COmmon organism: Anaerobic streptococci
First-line Tx: Clindamycin plus gentamycin
- Add ampicillin if no response in 24-48 hours
- Metronidazole if septic
How is ectopic pregnancy diagnosed?
If serum hCG is lower than expected (serum hCG normally doubles every 48 hours)
Transvaginal US–diagnostic in 90%, reveals adnexal mass
If no mass seen, but still strongly suspected, follow patient with serial beta-hcg levels
How do you treat an ectopic pregnancy?
Methotrexate-if early diagnosis
- Criteria: serum hcg
Laparoscopy
How do you diagnose gestational diabetes?
Screen at 24-28 weeks:
- 1 hour non fasting glucose challenge
- If >130 at 1 hour-administer a 3 hour glucose tolerance
- After overnight fast–>check glucose level
- Administer 100 gm glucose load and then check at 1,2,and 3 hours
- If 2 or more abnormal values—>Diagnosis
Complete vs. partial hydatidaform moles
Gestational trophoblastic disease–>A group of diseasea arising from Placenta
Complete: Most common; Empty egg, “grapelike vesicles” or “snowstorm pattern” on US-20% progress to malignancy
Partial: Fetus is present, but nonviable, less than 5% progress to malignancy
How do you diagnose a molar pregnancy? clinical presentation?
s/s: abnormal vag bleeding, uterine size > dates, hyperemesis gravidarum (due to very high hCG levels), preeclampsia sxs befoer 20 weeks gestation
Dx: hCG level >100,000 mU/mL
Tx: Chemo/surgery
What is the defn of gestational HTN? how is it monitored/treated?
HTN present AFTER 20 weeks gestation but no other sxs
Tx: 1. monthly US, serial BP and urine protein, weekly NST during 3rd trimester
- Methyldopa for severe cases
What is the classic triad for preeclampsia?
What is HELLP syndrome?
What is Eclampsia?
- Preeclampsia: HTN, Edema, Proteinuria
- Edema no longer needed for dx
- sxs must occur after 20 weeks and up to 6 weeks postpartum
- Eclampsia: severe preeeclamsia with seizures
- HELLP: severe preeclampsia PLUS hemolysis, elevated liver enzymes, and low platelets
What is the first line for inpt tx to decrease chance of seizures in pts with preeclampsia? What other meds are used in preeclampsia?
IV MgSO4; continue for 24 hours after delivery to prevent seizures
other Tx:
Hydralazine or labetalol
Betamethasone if fetus is
When is Rho-gam given?
- 300 mg given to all RH negative mothers at 28 weeks gestation
- Within 72 hours of delivery if Rh positive infant
- anytime blood mixing may occur
Which type of ovarian cyst is associated with ovulation? Pregnancy? Molar pg?
Follicular: associated with ovulation
Corpus Luteum: associated with pregnancy, may rupture and bleed->“Chocolate syrup cyst”
Thecal: often bilateral, results from excess hCG secretion in molar pregnancy
What is methotrexate?
Folic acid antagonist–kills embryo
What are the top 4 causes for vaginal bleeding in the adolescent?
- Anovulation
- pregnancy
- exogenous hormone use
- coagulopathy
What is the most common gynecologic cancer in the US?
Endometrial Cancer
What can be used to control the heavy bleeding associated with fibroid tumors?
Intermittent progestin supplementation (depot methodroxyprogesterone acetate 150 mg IM every 28 days)
What is the medical treatment used to treat myomas in symptomatic patients?
2 to 3 month course of leuprolide acetate (Lupron Depot), a Gn-RH analog
These produce a continous release of Gn-RH on the pituitary, resulting in decrease release of pituitary gonadotropins (and therefore decreased production of estrogen from the ovaries)–>The myomas growth is stimulated by estrogen
What is the best way to diagnose nonpalpable breast lesions seen on the mammogram?
With nonpalpable lesions, core needle or excisional bx is preferred over FNA biopsy
What is a rectocele? What is the primary sx of a rectocele?
Due to defect in the posterior vaginal wall
Sxs: difficulty defecating, feeling of pressure or as if somethign is protruding from the vagina
WHat tx can be used for a vaginal yeast infxn in a pregnant woman?
Miconazole cream
What are the qualifications for accelarations in a NORMAL Fetal stress test?
Two or more accelerations in 20 minutes
What is responsible for 50% of postpartum hemorrhages? (bleeding after the baby is delivered)
Uterine Atony
How is anemia defined in the pregnant patient?
Hgb below 10 g/dL (esp. in the 2nd trimester)
In the first trimester and at term most healthy pg women have hgb of 11 g/dL or greater
(nonpregnant pt -less than 12 g/dL)
Define the 3 trimesters
1st trimester: 0 to 12 weeks
2nd trimester: 13 to 27 weeks
Third trimester: 28 to 40 weeks
What studies establish the diagnosis of ovarian failure?
- Serum FSH level
- Serum LH level
- serum estradiol
When should Serum testosterone and DHEAS levels be ordered?
In secondary dysmenorrhea if the pt shows symptoms of androgen excess (acne, hirsutism, male pattern baldness, clitoromegaly) or HTN
What is the primary effect of OCPs?
Suppression of FSH and LH
What can be done for a pt on OCPs who has break through bleeding during the third week of the cycle?
Change a pill with a higher progestin component.
When breakthrough bleeding occurs during the third week of the cycle, its due to a lack of progestin.
How is gardasil administered?
3 doses: o months, 2 months, 6 months
When can a woman stop getting annual PAP smears? mammograms?
- 70 y/o with 3 consecutive normal PAP smears and no h/o pre-invasive lesions
OR
- any age if undergone a hysterectomy and no h/o invasive dz
Mammograms may be stopped at 70 y/o also.
How do you treat Trichomoniasis? bacterial vaginosis?
Trich–>Metronidazole single 1 gram dose PO
BV–>Metronidazole 500 mg
