Reproductive Flashcards
1st sign of puberty in males
increase in testicular size
1st sign of puberty in females
thelarche (onset of breast development)
Child orients to voice by…
4 months
Child orients to name and gestures by…
9 months
Rapprochement
Moving away from mom and coming back. By 2 years.
Language at 3 years
3-word sentences + 1,000 words + speech 75% intelligible
Counts to 10 by…
5 years
Prints letters by..
5 years
Oxytocin function
1) stimulates labor
2) uterine contractions
3) milk let-down
4) controls uterine hemorrhage
rectocele
Tear in the rectovaginal septum. Occurs in childbirth or hysterectomy.
Surfactant production begins…
Week 26, but mature levels not achieved until around week 35.
surfactant components
Complex mix of lecithings, the most important of which is dipalmitoylphosphatidylcholine.
What inhibits lactation before birth?
Progesterone (this is why retained placental tissue will inhibit lactation) AND estrogen. Both stimulate prolactin production, but block the action of prolactin on the breast.
If a woman can’t lactate after childbirth think…
Sheehan’s
What stimulates uterine contractions?
1) oxytocin, but only in third trimester and after cervix is dilated.
2) PGI2 stimulates uterine contractions prior.
Cystocele
Fibrous wall between bladder and vagina is torn by childbirth, allowing the bladder to herniate into the vagina. This causes a bulge of the anterior vaginal wall.
Rectocele
Tear in the rectovaginal septum. Rectal tissue bulges through tear and into vagina as hernia. Usually during childbirth or hysterectomy.
Autonomic innervation of the male sexual response
• /point and shoot erection, parasympathetic, ejaculation, sympathetic. Midget chef travelling out of his dick/emission (sperm moving from testes into prostatic urethra) = SNS, hypogastric. Beating off into a big bowl of pudding/ejaculation (sperm moving from prostatic urethra to outside) = visceral and somatic nerves, pudendal.
Location: Travis Krogman’s basement
When and why does body temperature increase occur?
Basal body temperature significantly increases shortly after ovulation, due to metabolic effects of progesterone produced by the corpus luteum. Progesterone acts at thermal regulatory center of hypothalamus. Basal body temperature remains high during the luteal phase of the menstrual cycle but falls precipitously a few days before the onset of menstruation.
Hysterosalpingogram + analyzing results.
1) injecting contrast medium into the uterus.
2) If the fallopian tubes are open, the contrast medium will fill the tubes and spill out into the abdominal cavity. Thus contrast in the abdominal cavity is normal. If they’re blocked, then contrast medium will not spill out.
What determines development of Wolffian ducts?
Testosterone
How does LH increase testosterone synthesis?
Stimulating cholesterol desmolase.
What secretes GnRH?
Arcuate nuclei of hypothalamus.
Negative feedback of FSH secretion?
Inhibin
testosterone precursor
androstenedione
LH inhibition
- testosterone inhibits LH secretion by inhibiting release of GnRH
AND inhibiting release of LH
Growth of prostate regulated by…
DHT
Variation in FSH and LH levels over life span (male and female)
Childhood – FSH greater than LH.
Puberty and reproductive years – LH greater than FSH
Senescence – FSH greater than LH.
Estrogen biosynthesis
Cholesterol –> pregnenolone –> androgens in theca cells. Androgens diffuses to granulose cells, where it is aromatized to estrogen.
Estrogen action in phase of menstrual cycle
1) follicular
2) midcycle
3) luteal
1) negative feedback on anterior pituitary
2) positive feedback on anterior pituitary
3) negative feedback on anterior pituitary
Estrogen and prolactin
Estrogen stimulates prolactin secretion but then blocks its action on the breast.
uterine threshold to contractile stimuli during pregnancy
Estrogen lowers the uterine threshold to contractile stimuli during pregnancy; progesterone raises the uterine threshold to contractile stimuli during pregnancy. Near term the estrogen/progesterone ratio increases, which makes the uterus more sensitive to contractile stimuli.
Follicular phase
1) primordial follicle develops to the graafian stage.
2) LH and FSH receptros are up-gregulated in theca and granulosa cells
3) Estradiol levels increase and cause proliferation of the uterus
4) FSH and LH are suppressed by effect of estradiol
5) progesterone is low.
ovulation in relationship to menses
always 2 weeks prior to menses, regardless of cycle length
estrogen levels in follicular and luteal phase
rise just prior to ovulation, then drop, then rise again during luteal phase.
cervical mucus during ovulation
Increases in quantity, becoming less viscous and more penetrable by sperm.
Luteal phase changes
1) corpus luteum develops
2) vasculatory and secretory activity of endometrium increases
3) rise in basal body temp
corpus luteum secretes…
estrogen + progesterone
Why does menses occur?
Abrupt withdrawal of estradiol and progesterone.
placenta secretes…
hCG
Pregnancy hormones
steadily rising estrogen + progesterone
progesterone synthesis during pregnancy
corpus luteum in 1st trimester, placenta in second and third
major placental estrogen
estriol
How is lactation maintained?
Suckling, which stimulates both oxytocin and prolactin secretion.
Why is ovulation suppressed during pregnancy?
Because prolactin
A) inhibits hypothalamic GnRH secretion
B) Inhibits the action of GnRH on the anterior pituitary and consequently inhibits LH and FSH secretion.
C) antagonizes the actions of LH and FSH on the ovaries.
Steroid hormones
glucocorticoids (cortisol) + estrogen/testosterone/progesterone + vitamin D + thyroid hormone + retinoic acid
Which step in hormone biosynthesis if inhibited blocks the production of all androgenic compounds but does not block the production of glucocorticoids?
17-hydroxypregnenolone –> dehydroepiandrosterone
Which step in steroid hormone synthesis is stimulated by ACTH?
cholesterol –> pregnenolone. This is the step catalyzed by cholesterol desmolase.
What is the source of estrogen during the second and third trimesters?
Maternal ovaries and the fetal adrenal gland. During the second and third trimesters, the fetal adrenal gland synthesis dehydroepiandosteroen-sulfate (DHEA-S) which is hydroxylated in the fetal liver and then transferred to the placenta, where it is aromatized to estrogen.
What is the source of estrogen during the first trimester?
corpus luteum
What stimulates oxytocin secretion?
dilation of the cervix.
PTU mechanism
Inhibits oxidation of iodide.
PTH renal receptors
Located on basolateral membranes, not luminal.
Site of action of PTH calcium reabsorption
Distal tubule
Insulin receptor
4 subunits + tyrosine kinase activity
Why do AIS patients lack a uterus and cervix?
Anti-mullerian hormone secretion
spermatozoa
motile sperm; mature sperm
spermatid
precursor to spermatozoa
When does spermatogenesis begin?
puberty
chromatid
one copy of a newly copied chromosome which is still joined to the other by a centromere.
spermatid: 1) ploidy 2) number of chromosomes
1N, 1C
spermatogonium: 1) ploidy 2) number of chromosomes
2N,2C
secondary spermatocyte: 1) ploidy 2) number of chromosomes
1N,2C
Primary spermatocyte: 1) ploidy 2) number of chromosomes
2N, 4C
primary spermatocyte DNA copy number
4C
spermiogenesis
final stage of spermatogenesis; maturation of spermatids into mature, motile spermatozoa.
Spermiation
Removal of unnecessary cytoplasm and organelles.
Where do sperm acquire motility?
Epididymis
Testosterone negative feedback point
inhibits GnRH
estrogen secreting cells of uterus
theca cells
other name for suspensory ligament
infundibulopelvic ligament
androstenedione site of synthesis
adrenal glands + gonads
Tanner staging
- Code: Tanner rower kid from Dartmouth: /**tanner stage is assigned independently to genitalia, pubic hair, and breast (e.g., a person can have Tanner stage 2 genitalia, Tanner stage 3 pubic hair). Tiny Tanner kid with hat on running around in hallway/1 = childhood (prepubertal). Closer left corner + hen nesting on his head + naked with blonde pubs + bra on/2 = pubic hair appears (pubarche) + breast buds form (thelarche). Far left corner + holding a hambone + dark thick pubic hair + dick hanging down to floor + huge double D’s/3 = pubic hair darkens and becomes curly + penis size/length increases + breasts enlarge. Far right corner + Tanner with long blond hair + super wide chode + nipples protruding from his chest + dark skin around his dick + /4 = penis width increases + darker scrotal skin + development of glans + raised areolae. Closer corner + hailing on tanner + dressed in suit + areolae sticks are gone/5 = adult + areolae are no longer raised.
- Location: Rowing room
Fertilization occurs on ___ day of ovulation
Day 1, otherwise degenerates.
menopause labs
High FSH
klinefelter’s labs
High FSH, LH, and estrogen. Low T and inhibin.
androstenedione
converted to either testosterone or estrogen.
What converts androstenedione to testosterone?
17beta-hydroxysteroid dehydrogenase
hypogonadotropic hypogonadism
Kallman syndrome
HTN and proteinuria that develops in 8th week pregnancy
Molar pregnancy (preeclampsia only develops after 20th week)
Placenta accreta pathophys
Defective decidual layer leads to placenta attachment to myometrium
HIstology findings in ectopics
- decidualized endometrium only
- no chorionic villi or embryo
HPV tumorigenesis
E6 (HPV 16) inhibits p53; E7 (HPV 18) inhibits RB
Renal failure secondary to HPV infection pathophysiology
Cervical cancer»_space; lateral invasion to block ureters
Most common cause of endometritis
Retained products of conception
Endometrial hyperplasia conditions
1) PCOS
2) hormone replacement therapy
3) granulosa cell tumor
Most common gyn malignancy
Endometrial cancer
Most deadly gyn malignancy
ovarian cancer
Anovulation causes
1) prolactinoma
2) Cushing’s
3) Thyroid disorders
4) adrenal insufficiency
5) HPO axis abnormalities
6) obesity
7) eating disorder
impotence
failure to sustain an erection during intercourse. analogous to amenorrhea.
PCOS pathophys?
increased estrogen production in fatty tissue suppresses FSH production GnRH increases in response and thus LH rises testosterone production increases in theca cells as a consequence elevated testosterone results in development of male sex characteristics.
Why are OCPs given in PCOS?
treat hirsutism and acne by suppressing pituitary LH secretion and subsequently decreasing ovarian androgen production
Treatment of choice for infertility in PCOS
weight loss
Drug to induce ovulation in PCOS/profertility
clomiphene
breast cancer RF’s
She’s topless in the middle of a nativity scene + obese + black + tons of gerbil cycles stacked up behind her/risk factors = increased estrogen exposure + increased total number of menstrual cycles + older age at 1st live birth + obesity (increased estrogen exposure as adipose tissue converts androstenedione to estrone) + BRCA1 and BRCA2 gene mutations + African American ethnicity (increased risk for triple negative breast cancer).
multiparity is protective in what cancer?
endometrial
Most common cause of prostatitis
chronic abacterial prostatitis
Frequent low volume urine…
detrusor overactivity
PSA function
proteolytic enzyme that increases sperm motility and maintains semen in liquid state. Liquefies semen and allows sperm to swim freely.
Gonadal hormone affected less by cryptorchidism
Testosterone (leydig cells can survive, esp. with unilateral cryptorchidism)
Cryptorchidism RF for..
germ cell tumors
germ cell tumors
1) seminoma
2) Yolk sac
3) chorio
4) teratoma
5) embryonal carcinoma
vast majority of testicular cancer in men is…
germ cell tumor
90% of gonadal tumors in women are…
NON-germ cell tumors
spermatocele
dilated epididymal duct OR rate testis presenting as scrotal swelling (can be transilluminated)
Phimosis
Foreskin cannot be fully retracted. Usually due to small orifice of prepuce.
Balanoposthitis
Infection of glans and prepuce in uncircumscribed males due to smegma.
Molecules responsible for testicular descent
1) MIF (Transabdominal phase)
2) hCG/androgens (inguinoscrotal phase-spontaneous descent after birth)
Sex steroid affects on blood lipids
Testosterone increases LDL, decreases HDL.
Estrogen increases HDL, decreases LDL.
Treatment for hereditary angioedema
Danazol.
antidepressant to use for complicated depression with cardiac concerns
MAOIs
Spironolactone
1) MOA
20 mechanism
o Coded character: Spyro the dinosaur: he picks up desmond tutu covered in tacks and kills him + is attacking mike covered in tacks with thong/inhibits steroid BINDING, 17alpha-hydroxylase, 17,20 desmolase. Spyro has a bra on + is putting a baseball bat up his vagina/toxicity = gynecomastia + amenorrhea.
o Location: YHS auditorium, walkway between front and back seating areas
treatment for hirsutism
Ketonocazole/spironolactone
SERM that is an estrogen antagonist at uterus
Raloxifen
Exemestane
Aromatase inhibitor, like anastrazole
progesterone role in OCPs
Decrease proliferation of endometrium (less suitable for implantation) + thickening of cervical mucus + preventing shedding
CRH affects in pregnancy
1) stimulates laber
2) induces fetal cortisol secretion
Tamsulosin affects on peripheral vasculature
Selective for alpha1A,D receptors (found on prostate) vs. vascular alpha1B receptors. So it is a good drug for BPH.
PCOS clinical picture can be induced by which drug?
Danazol (androgen agonism leads to reduced LH secretion)
Other name for cardinal ligament
transcervical ligament
Ligament that is a derivative of the gubernaculum
Round ligament
squamous epithelia in vagina type
NONKERATINIZED stratified squamous
What neurotransmitter is antierectile?
NE
What regulates emission?
sympathetic NS
What nervous system controls ejaculation?
somatic and visceral
Source of energy for sperm
fructose
What is the acrosome in sperm derived from?
golgi apparatus
spermiogenesis
spermatid –> spermatozoa
what happens during spermiogenesis?
Extrusion of cytoplasm + gaining of acrosome and flagellum.
What 2 diseases are increased in offspring of older men?
Achondroplasia + Marfans
What do sertoli cells secrete?
1) inhibin
2) MIF
3) androgen-binding protein
leydig cell endocrine mechanism
paracrine
when does spermatogenesis begin?
puberty
How long does spermatogenesis take?
2 months
Site of spermiogenesis
epidydimis
Which hormone is responsible for early penile growth? late penile growth?
1) DHT
2) testosterone
testosterone and hematologic effect
Increases hematocrit
potency in decreasing order of estrogens
estradiol, estrone, estriol
estrogen form associated with fetal well-being
estriol
Holoprosencephaly
forebrain (prosencephalon) fails to develop into two hemispheres.
Sonic hedgehog
o Code: he’s riding a Polaris snowmobile/produced at base of limbs in zone of polarizing activity. Huge arrow sticking out of the wall above him from anterior to posterior/involved in patterning along anterior-posterior axis. Blue statue of brain with stem attached to his right (CNS code)/involved in CNS development. Cyclops for a head/mutation can cause holoprosencephaly.
Wnt-7
o Code: Whitney with a hook arm/Wnt-7. Sitting on top of a big ridge in the ground + club extremities/produced at apical ectodermal ridge (thickened ectoderm at distal end of each developing limb). She has big fish dorsal fins on/necessary for proper organization along dorsal-ventral axis.
Location: far left corner
FGF gene
o Code: Frank from Dartmouth/FGF. he’s on a ridge just like Whitney’s/produced at apical ectodermal ridge. He has super long limbs/stimulates mitosis of underlying mesoderm, providing for lengthening of limbs.
o Location: far right corner
Homeobox (Hox) genes
o Code: Ryder Hockman: huge arrow hanging down from ceiling/involved in segmental organization of embryo in a craniocaudal direction. /code for transcription factors. He has legs for arms and arms for legs/Hox mutations appendages in wrong locations.
Location: bouldering wall to right of entryway
Morula by…
day 4
blastocyst by…
Day 5
Implantation
Days 6-10
Week 1 of fetal development
o Code: Shark with top hat in entryway/week 1. Blastocyst stuck to left wall + placenta hanging from ceiling/hCG secretion begins around the time of implantation of blastocyst.
Week 2 of fetal development
o Code: Shark with ice cream sandwhich around his waist + in hen’s nest in front of entryway/bilaminar disc (epiblast, hypoblast). 2 weeks = 2 layers.
week 3 of fetal development
o Code: 3 layered disc around his waist + holding a hambone/trilaminar disc. /3 weeks = 3 layers. Chef next to him/gastrulation (cells of epiblast migrate through primitive streak to become the endoderm, mesoderm, and notochord). Fish skewered into a cord on the right + cave man streaked with poop to the right of it + giant neuron synapsing onto a plate + miso soup covered in skin on shelf above/primitive streak + notochord + mesoderm and its organization + neural plate begin to form. /primitive streak is a groove in the midline of the caudal half of the epiblast layer of the two layer embryo. /during gastrulation in the third week, cells of the epiblast migrate through the primitive streak to become the endoderm, mesoderm, and notochord.
o Location: Behind front desk.
gastrulation
cells of the epiblast migrate through the primitive streak to become the endoderm, mesoderm, and notochord.
When do fetal movements start?
Week 8. Gait at week 8.
Craniopharyngioma
o Code: Henry Nichols: Jesus standing on desk/rare, slow-growing, benign. He’s sitting on top of a saddle (suprasellar code)/typically located in the suprasellar region. /cystic with solid areas. He’s seating at the desk with his head covered in brown and yellow cysts + room flooded with yellow, viscuous fluid with yellow eggs floating in it and steak/cysts usually filled with a brownish-yellow, viscuous fluid resembling machine oil due to presence of protein and cholesterol crystals. Calcium balls hanging from the ceiling/calcification of cysts is highly characteristic. Massive almond dug into the right wall with Daniel Radcliffe/harry potter sitting on top/derived from remnants of Rathke’s pouch/anterior pituitary. Nests filled with wet carrots lining left wall + palisading fences surrounding carrots + Indians in the middle/on light microscopy, cysts are lined by cords/nests of stratified squamous epithelium with peripheral palisading and internal areas of lamellar “wet” keratin. Eyes on the side of his head/bitemporal hemianopsia. He has huge teeth/similar to tooth-like tissue because of origin from remnants of Rathke’s ouch.
o Location: Nate’s office
VACTERL syndrome
/half of neonates with tracheoesophageal fistula (TEF) have associated congenital malformations. /vertebral + anal + cardiac + tracheoesophageal fistula + renal + limb abnormalities.
Surface ectoderm derivatives
♣ Surface ectoderm
♣ Code: Will standing in front of bar: Daniel Radcliffe riding an almond on right/Rathke’s pouch (anterior pituitary). Eye hanging from bar and looking through lens + bar lined with corn/lens + cornea. His ears are cut off/inner ear sensory organs. Nose is bright red/olfactory epithelium. /nasal & oral epithelial linings. Roof covered in skin/epidermis. Skin is sweating + Will is salivating intensely + boobs squirting milk on roof/salivary, sweat & mammary glands. /surface ectoderm. Super long hair + really long nails + massive ears + bright white teeth/hair + nails + inner ear + external ear + enamel of teeth. Chipmunk face/parotid gland. 2 gay dudes banging on Will’s right/anal canal below pectinate line.
♣ Location: rooftop in front of bar
neural tube derivatives
♣ Code: huge tube with CNS statue in middle/neural tube. statue of a spinal cord + brain/brain & spinal cord. Almond on the right/posterior pituitary. Christmas tree to the right of it/pineal gland. Projector with white screen to the left of statue/retina. Optic fiber cables hanging all around top of neural tube/optic nerve. Floor covered with stars/astrocytes. Floaty tubes wrapped around neural tube/oligodendrocytes.
♣ Location: Rooftop right corner, closer to city
neural crest derivatives
♣ Code: wave crashing onto left side/neural crest. Gang of thugs to his left + gang tied around post and crying face on top of post/autonomic, sensory, and celiac ganglia + postganglionic sympathetic neurons. Dr. Schwann cleaning Will’s teeth/schwann cells. Apple pie on top of his head + spider on top eating the pie/pia and arachnoid mater. Red cushions all around him + aorticopulmonary septum spiraling up towards the sky behind the skull/aorticopulmonary septum & endocardial cushions. Arc d’triumph overhead made of bones and shark fins/branchial arches (bones and cartilage). Big statue of a skull behind Dr. Swan/skull bones. Massive mole on top of his head/melanocytes. Giraffe with head of medulla to the right of Dr. Schwann/adrenal medulla. Thighs attached to parachutes descending from the sky/thyroid parafollicular C cells. Dr. Schwann blasting dentin into the patients mouth/odontoblasts (dentin forming cell). Cartilaginous bone stuck into the patients trach/tracheal cartilage. 2 penguins at the foot of the bed/chromaffin cells. Fat opera singer on right (larynx code) with shark fin on her head/laryngeal cartilage.
Mesoderm derivatives
o Code: Sam Purcell: super jacked/Muscles (skeletal, cardiac & smooth). /connective tissue, bone & cartilage. Whole room lined with peritoneum and he’s inside of it/serosa linings (eg peritoneum). Floor covered in blood + heart hanging above him/cardiovascular system + blood + lymphatic system. Big filter in left far corner/spleen. Big giraffe behind him + 2 kidneys hanging on either side with ureters hanging down to the floor + he has huge swollen nuts/internal genitalia + kidney + ureters. /adrenal cortex.
endoderm derivatives
o Code: Sam Purcell: hippo at bar + huge stack of pancreas next to bar/GI tract + liver + pancreas. He has wings on/lungs. Mime at bar/thymus. Parachute on his back/parathyroids. Huge jacked thighs/thyroid follicular cells. Big ear attached to the middle of his head/middle ear. Bladder extrophy + pissing onto the floor/bladder + urethra.
o Location: bar on first floor
aplasia
absent organ despite presence of primordial tissue.
Hypoplasia
incomplete organ development; primordial tissue present
Disruption
Secondary breakdown of previously normal tissue or structure (eg, amniotic band syndrome).
Deformation
Extrinsic disruption; occurs after embryonic period.
Malfformat
Intrinsic disruption; occurs during embryonic period (weeks 3-8).
Sequence
Abnormalities resulting from a single primary embryologic event (eg. oligohydramnios –> Potter sequence).
ACE inhibitor teratogenic effect
Renal damage
antiepileptic teratogenic effects
NTDs + cardiac defects + cleft palate + skeletal abnormalities (eg, phalanx/nail hyoplasia, facial dysmorphism)
antiepileptics associated with teratogenic effects
valproate + carbamazepine + phenytoin + phenobarbital
Diethylstilbestrol teratogenic effects
Vaginal clear cell adenocarcinoma + congenital Mullerian anomalies
What drugs are folate antagonists?
1) trimethoprim
2) methotrexate
3) antiepileptics
methimazoel teratogenic effects
aplasia cutis congenita
tetracyclines teratogenic effects
discolored teeth + inhibited bone growth
term for limb defects with thalidomide
phocomelia, micromelia
Warfarin teratogenic effects
Bone deformities + fetal hemorrhage + abortion + ophthalmologic abnormalities
substance associated with sudden infant death syndrome
smoking
maternal diabetes teratogenic effects
caudal regression syndrome (anal atresia to sirenomelia) + congenital heart defects + NTDs + macrosomia
methylmercury teratogenic effects
neurotoxic
facial characteristics of fetal alcohol syndrome
Smooth philtrum + thin vermillion border (upper lip) + small palpebral fissures + small eye opening
Most severe presentation of fetal alcohol syndrome
Heart-lung fistulas + holoprosencephaly
dizygotic twin mechanism
2 eggs separately fertilized by 2 different sperm
urogenital sinus develops into..
prostate gland + bulbourethral glands (of cowper) in men. Greater vestibular glands (of bartholin) and urethral and paraurethral glands (of skene) in women.
Twinning
- Code: Marion and Johnny: left corner: both in separate eggs (chorion code) covered in hair hanging from ceiling/if cleavage is between 0-4 days dichorionic/diamnionic. /di/di can be either monozygotic or dizygotic twins. Dizygotic twins always have their own amnion and own placenta. Right corner: Cunkelman brothers are in same egg hanging from ceiling covered in ivy + but both in separate amnions/if cleavage is between 4-8 days monochorionic/diamniotic. One enlarged brother and one smaller brother at the feet/monochorionic placentas are monozygotic (identical twins) + are at highest risk of twin-twin transfusion syndrome (TTTS). Tin cans covering floor + Cunkelman brothers are 69ing in the same egg/cleavage between 8-12 days = monochorionic/monoamniotic. Right closer corner: Cunkelman brothers are stuck together + mouths full of dimes/after 13 days = monochorionic/monoamniotic conjoined twins. /Most dangerous type (umbilical cords can get twisted and cut off blood supply). /twin pregnancies increase risk of miscarriage + also causes hyperemesis (hyperemesis is caused by elevated betaHCG) + increased risk of aneuploidy.
- Location: AD basement
cytotrophoblast
Inner layer of chorionic villi
syncytiotrophoblast
Outer layer of chorionic villi; synthesizes and secretes hormones, eg, hCG (syncytiotrophoblast synthesizes hormones)
fetal components of placenta
cytotrophoblast + syncytiotrophoblast
How does syncytiotrophoblast evade immune attack from mom?
Lacks MHC-1 expression
Where does maternal blood exist in placenta?
Lacunae.
Umbilical arteries connect…
Fetal internal iliac arteries to placenta.
Fetal umbilical vein connections…
Drains into IVC via liver or via ductus venosus.
Wharton’s jelly
Gelatinous substance within the umbilical cord.
umbilical arteries and vein origin
allantois
When is allantois formed?
3rd week
Urachus formation
Yolk sac forms the allantois, which extends into the urogenital sinus. Allantois becomes the urachus.
What is the urachus?
Duct between fetal bladder and umbilicus.
Patent urachus + presentation
Total failure of urachus to obliterate. Urine discharge from umbilicus.
Urachal cyst
partial failure of urachus to obliterate; fluid-filled cavity lined with uroepithelium, between umbilicus and bladder.
Urachal cyst sequela
Infection + adenocarcinoma
vesicourachal diverticulum
Slight failure of urachus to obliterate –> outpouching of bladder.
Function of vitelline duct
Connects yolk sac to midgut lumen.
When does vitelline duct usually obliterate?
7th week
Vitelline fistula etiology
Vitelline duct fails to close, leading to meconium discharge from umbilicus.
Meckel deverticulum etiology
Partial closure of vitelline duct, with patent portion attached to ileum.
What does maxillary artery branch from?
External carotid
Derivatives of 1st aortic arch?
Maxillary artery
Derivatives of 2nd aortic arch?
stapedial artery + hyoid artery
Derivatives of 3rd aortic arch?
Common carotid + proximal part of internal carotid
Derivatives of 4th aortic arch?
On left, aortic arch; on right, proximal part of right subclavian artery
Derivatives of 6th aortic arch?
Proximal part of pulmonary arteries and (ON LEFT ONLY) ductus arteriosus
Path of recurrent laryngeal nerve
Right recurrent loops around right subclavian artery; left recurrent lops around aortic arch distal to ductus arteriosus.
branchial arch derivatives
Clefts (aka GROOVES) = ectoderm
Arches = mesoderm (mmuscles, arteries) + neural crest (bones, cartilage)
Pouches = endoderm
External auditory meatus origin
1st branchial cleft
What do 2nd through 4th branchial clefts give rise to?
Temporary cervical sinuses, which are obliterated by proliferation of 2nd arch mesenchyme.
Branchial cleft cyst etiology
congenital epithelial cyst that arises on the ***lateral part of the neck due to failure of obliteration of the second branchial cleft (or failure of fusion of the second and third branchial arches) in embryonic development.
Pierre robin presentation
Micrognathia + glossoptosis + cleft palate + airway obstruction
1st arch nerve derivatives
V2 + V3
1st arch muscle derivatives
Muscles of mastication + mylohyoid + anterior belly of digastric + tensor tympani + tensor veli palatini
Muscles of mastication
Temporalis + masseter + lateral and medial pterygoids
1st arch cartilage derivatives
1) Maxillary process –> maxilla + zygoMatic bone
2) Mandibular process –> Meckel cartilage + mandible
3) Malleus and incus
4) sphenoMandibular ligament
2nd arch cartilage derivatives
(S’s) Stapes + Styloid process + lesser horn of hyoid + stylohyoid ligament
2nd arch muscle derivatives
Muscles of facial expression – Stapedius, Stylohyoid, platySma, posterior belly of digastric
3rd arch cartilage derivative
Greater horn of hyoid
3rd arch muscle derivative
Stylopharyngeus
3rd arch nerve derivative
CN IX
Caveat about arch 5
Makes no major developmental contributions
4th-6th arch cartilage derivative
Arytenoids + cricoid, corniculate + cuneiform + thyroid (ACCCT)
4th arch muscle derivatives
Most pharyngeal constrictors + cricothyroid + levator veli palatini
6th arch muscle derivatives
All intrinsic muscles of larynx except cricothyroid
What forms posterior 1/3 of tongue?
Arches 3 + 4
4th arch cranial nerve
CN X (superior laryngeal branch)
6th arch cranial nerve
CN X (recurrent laryngeal branch)
1st branchial pouch derivatives + caveat
1) middle ear cavity + eustachian tube + mastoid air cells.
2) endoderm-lined structures of ear.
2nd branchial pouch derivatives
Epithelial lining of palatine tonsil.
3rd branchial pouch derivatives
Dorsal wings –> inferior parathyroids.
Ventral wings –> thymus
3rd branchial pouch caveat
3rd-pouch structures end up below 4th pouch structures.
4th pouch derivatives
Dorsal wings –> superior parathyroids.
Ventral wings
–> ultimobranchial body
–> parafollicular (C) cells of thyroid.
Cleft lip etiology
Failure of fusion of maxillary + medial nasal processes (formation of primary palate)
cleft plate etiology
1) failure of fusion of 2 lateral palatine shelves
OR
2) Failure of fusion of lateral palatine shelves with nasal septum
AND/OR
3) failure of fusion of lateral palatine shelves with median palatine shelf
Female genital development
Mesonephric duct degenerates and paramesonephric duct develops.
What determines testes development?
TDF from SRY gene
MIF suppresses…
development of paramesonephric ducts.
What stimulates development of mesonephric duct?
Androgens from Leydig cells (Men have Mesonephric ducts)
mesoneprhic AKA…
Wolffian duct
What does paramesonephric (Mullerian) duct give rise to?
Fallopian tubes, uterus, upper portion of vagina.
What is the lower portion of the vagina derived from?
Urogenital sinus
What is the male remnant of the Mullerian duct?
Appendix testis
Disease name for mullerian agenesis
Mayer-Rokitansky-Kuster-Hauser syndrome
Mayer-Rokitansky-Kuster-Hauser syndrome presentation
Primary amenorrhea (due to a lack of uterine development) in females with fully developd secondary sexual characteristics (***functional ovaries).
What is the remnant of the mesonephric duct in females?
Gartner duct
What does the mesonephric (Wolffian) duct give rise to in men?
SEED – Seminal vesicles, Epididymis, Ejaculatory duct, Ductus deferens.
What would happen if you lacked sertoli cells or MIF?
Develop both male and female internal genitalia and male external genitalia.
Bicornuate uterues etiology
Incomplete fusion of Mullerian ducts
Uterus didelphys
complete failure of fusion –> double uterus + double vagina + double cervix. *pregnancy possible.
genital tubercle gives rise to in men…
glans penis + corpus cavernosum and spongiosum
urogenital sinus gives rise to in men…
Bulbourethral glands (of Cowper) + prostate gland
urogenital folds gives rise to in men…
Ventral shaft of penis (penile urethra)
Labioscrotal swelling gives rise to in men…
scrotum
genital tubercle gives rise to in women…
glans clitoris + vestibular bulbs
urogenital sinus gives rise to in women…
Greater vestibular glands (of Bartholin) + Urethral and paraurethral glands (of Skene)
Urogenital folds give rise to in women…
Labia minora
Labioscrotal swelling gives rise to in women…
Labia majora
which spadias is more common?
hypospadias
hypospadias associations
inguinal hernia + cryptorchidism
hypospadias etiology
Failure of urethral folds to fuse
epispadias etiology
Faulty positioning of genital tubercle
epispadias associations
Exstrophy of the bladder
male remnant of gubernaculum
Anchors testes within scrotum.
female remnant of gubernaculum
Ovarian ligament + round ligament of uterus
Remnant of process vaginalis in men
Forms tunica vaginals
Female remnant of process vaginalis
obliterated
glans penis drainage
deep inguinal nodes
External iliac drainage
Body of uterus + cervix + superior bladder
What is at risk of injury during ligation of uterine vessels in hysterectomy?
Ureter
What does round ligament connect?
Uterine fundus to labia majora
Round ligament course
Travels through round inguinal canal; above the artery of Sampson.
Broad ligament connects
uterus, fallopian tubes, and ovaries to pelvic side wall
broad ligament contains…
ovaries, fallopian tubes, round ligaments of uterus
3 components of broad ligament
Mesosalpinx + mesometrium + mesovarium
Most common area for cervical cancer?
Squamocolumnar junction
glands in uterus in proliferative phase vs. secretory phase
Long tubular glands in proliferative phase; coiled glands in secretory phase.
Bulbourethral gland (Cowper) location in men
Sits below the prostate
What covers seminiferous tubules?
Tunica albuginea
area damaged with posterior urethra damage
membranous urethra
area damaged with anterior urethra damage
bulbar + penile urethra
anterior urethra damage sequela
Can cause urine to leak beneath deep fascia of Buck. If fascia is torn, urine escapes into superficial perineal space.
How do PDE-5 inhibitors work?
Inhibit cGMP breakdown.
Opposite mechanism as NO and erection
NE –> increased Ca concentration –> smooth muscle contraction –> vasoconstriction –> no boner.
What lines the seminiferious tubule?
Spermatogonium
What regulates spermatogenesis?
Sertoli cells
Aromatase in men?
Expressed in sertoli cells, which convert testosterone and androstenedione to estrogens.
What is the problem with varicocele?
Increases body temperature. Since sertoli cells are temp sensitive, this decreases sperm production + decreases inhibin B.
*testosterone production not affected by temperature.
spermatogonium pathway
spermatogonium –> spermatocyte –> spermatids –> spermatozoan.
What regulates female fat distribution?
estrogen
Estrogen regulatory actions
1) **upregulates estrogen + LH + progesterone receptors.
2) Feedback inhibition of FSH and LH
estrogen changes in pregnancy
50-fold increase in estradiol and estrone.
1000-fold increase in estriol
Desmolase function
cholesterol –> androgens
What stimulates desmolase?
LH
What positively stimulates aromatase?
FSH
What indicates ovulation?
Increased progesterone
Where is progesterone synthesized in men?
adrenal cortex + testes
Location of progesterone synthesis in women?
Corpus luteum + placenta + adrenal cortex
other impt functions of progesterone
1) uterine smooth muscle relaxation (preventing contractions)
2) decreased estrogen receptor expression
C =
of chromatids
secondary oocyte: N,C
1N, 2C
ovum: N,C
1N, 1C
oogonium: N,C
2N, 2C
primary oocyte
2N, 4C
Ovulation mechanism
Increased estrogen leads to increased GnRH receptor expression on anterior pituitary. Estrogen surge stimulates LH release –> ovulation
Mittelschmerz associations + caveat
Peritoneal irritation (eg, follicular swelling/rupture, fallopian tube contraction). *appendicitis.
When is follicular growth the fastest?
2nd week of follicular phase
oligomenorrhea
Greater than 35 day cycle
Polymenorrhea
Less than 21 day cycle
Metrorrhagia
Frequent or irregular menstruation
Menorrhagia defined as
Greater than 80 mL blood loss or greater than 7 days of mensss
menometrorrhagia
Heavy + irregular menstruation
When is it possible to get pregnant?
There are only 6 days during any cycle, regardless of length, when a woman can get pregnant – the five days leading up to ovulation and the 24 hours after ovulation. This is because sperm can live for up to 5 days in a woman’s body, and the ovum lives for only 12-24 hours.
Ductus venous
Shunts blood from umbilical vein directly into the IVC, bypassing the liver
Neuroectoderm
Includes both neural crest + neural tube
What secretes hCG in the placenta?
syncytiotrophoblasts
How do you calculate gestational age?
From date of last menstrual period.
How do you calculate embryonic age?
Calculated from date of conception (gestational age MINUS 2 weeks). (Woman had her period, roughly 2 weeks later ovulated and got pregnant, so you need to subtract the window period).
physiologic adaptations in pregnancy
1) Increased cardiac output (increased preload, decreased after load).
2) Increased HR
3) Increased placental and renal perfusion
4) Anemia (increased plasma, increased RBCs, leading to decreased viscosity)
5) hypercoagulable (in order to decrease blood loss at delivery)
6) Hyperventilation (in order to eliminate fetal CO2)
When dose hCG peak?
8-10 weeks. This is the period of time in which hCG maintains the corpus luteum (and thus progesterone synthesis)
When does corpus lute degenerate?
After 8-10 weeks. Placenta is capable of synthesizing its own estriol and progesterone by then.
Why can states of increased hCG cause hyperthyroidism?
Shared subunit of hCG and TSH.
What does pregnancy test detect?
Beta subunit of hCG (has to because this is the unique subunit).
Causes of increased hCG
1) Down syndrome
2) multiple gestations
3) hydatidorm moles
4) choriocarcinoma
Causes of decreased hCG
1) ectopics
2) Edwards
3) Patau
Apgar evaluated at
1 minute and 5 minutes
Grimace scoring on apgar
2 = cries and pulls away 1 = grimaces or weak cry 0 = no response
Respiration scoring on apgar
1) strong cry
2) slow, irregular, shallow gasps
3) no breathing
Low birth weight definition
Less than 2500 g
Low birth weight associations
increased risk of SIDS + increased risk of overall mortality.
Problems associated with low birth weight
1) impaired thermoregulation
2) immune disfunction
3) hypoglycemia
4) polycythemia
5) impaired neurocognitive/emotional development
Complications of low birth weight
1) infections
2) NRDS
3) necrotizing enterocolitis
4) intraventricular hemorrhage
5) persistent fetal circulation
What does breast milk contain?
IgA + macrophages + lymphocytes
What does breast milk reduce risk of?
Risk of asthma + allergies + DM + obesity.
what does breastfeeding reduce maternal risk for?
breast + ovarian cancer.
Menopause diagnosis
amenorrhea for 12 months.
why do women have decreased estrogen production with menopause?
Decline in follicles.
average age of menopause
51
Source of estrogens after menopause and complication
Peripheral conversion of androgens. Increased androgens can lead to hirsutism.
Hormonal changes of menopause
decreased estrogen + very increased FSH + increased LH + increased GnRH
premature ovarian failure
Signs of menopause before age 40
HAVOCS
Hot flashes + Atrophy of vagina + Osteoporosis + CAD + Sleep disturbances
Source of androstenedione
ADrenal
What is responsible for closing of epiphyseal plates in boys?
Estrogen converted from testosterone.
estrogen synthesis in males
by CYP 450 aromatase primarily in adipose tissue + testis
spermatogonium function
Undergo mitosis, continually replenishing supply of sperm
stage 1 tanner in girls
Flat-appearing chest with raised nipple + no sexual hair
Term for stage III breasts in girls
“breast mound”
Term for stage II breasts in girls
“breast bud”
glans development in tanner staging
Stage IV
Stage IV in girls breast term
“Mound on mound”
Caveat about pubic hair in Stage IV
*spares thighs
Caveat about pubic hair in Stage V
Covers medial thigh
Penis and testes growth in Stage V?
Enlarge to adult size
Cause of increased FSH in klinefelters?
Decreased inhibit B due to dysgenesis of seminiferous tubules.
Cause of increased estrogen in klinefelters?
decreased testosterone –> increased LH –> increased estrogen synthesis
Most common cause of primary amenorrhea?
Turner’s
How could you get a Turner patient pregnant?
IVF + exogenous estradiol and progesterone
Other cause of Turner’s?
Mitotic error leading to mosaicism
Double Y presentation
Normal fertility + severe acne + learning disability + ASD
Ovotesticular disorder of sex development
More common in girls.
Both ovarian and testicular tissue present (ovotestis); ambiguous genitalia.
Previously called true hermaphroditism.
AIS hormones
Increased LH + increased testosterone
46, XX DSD
Disorderment of Sexual Development. Ovaries present, but external genitalia virilized or ambiguous. Due to excessive and inappropriate exposure to androgenic steroids during early gestation (eg, CAH or exogenous androgens during pregnancy).
46, XY DSD
Testes present, but external genitalia female or ambiguous. Eg, AIS.
Placental aromatase deficiency presentation?
1) Can’t synthesize estrogens from androgens, so XX virilization with increased testosterone and androstenedione.
Scenario: maternal virilization during pregnancy.
Placental aromatase deficiency. Fetal androgens aren’t aromatized and can cross the placenta.
AIS labs
Increased testosterone + Increased estrogen + increased LH
5alpha-reductase inheritance
Inability to convert testosterone to DHT.
5alpha-reductase presentation
Ambiguous genitalia until puberty, when increased testosterone causes masculinization + increased growth of external genitalia.
5alpha-reductase labs
Normal testosterone/estrogen + normal or increased LH
Hydatidorm mole histo
Cystic swelling of villi + proliferation of chorionic epithelium (only trophoblast)
Preeclampsia before 20 weeks?
hydatidiform moles
partial mole etiology
2 sperm + 1 egg
hCG in complete mole vs. partial
Very high hCG in complete + only minor elevation in partial
Imaging buzzwords for complete mole
“Honeycombed”
“clusters of grapes”
“Snowstorm”
Risk of gestational trophoblastic neoplasia with complete mole
15-20%
Risk of gestational trophoblastic neoplasia with partial mole
less than 5%
Risk of choriocarcinoma wit complete mole
2%
Choriocarcinoma histology
1) Malignancy of trophoblastic tissue (cytotrophoblasts + syncytiotrophoblasts).
2) NO chorionic villi present.
3) Increased frequency of multiple/bialteral theca-lutein cysts.
Caveat about abrupt placenta
Can be concealed or apparent. Abrupt, painful bleeding.
RF’s for placenta accreta
1) prior C-section
2) inflammation
3) placenta previa
Most common type of placenta accreta
placenta accreta
placenta accrete pathophys
placenta attaches to myometrium without penetrating it.
placenta increta pathophys
Placenta penetrates into myometrium
placenta percreta pathophys
Placenta penetrates through myometrium and into uterine serosa (invades entire uterine wall).
placenta percreta sequela
can result in placental attachment to rectum or bladder.
placenta accreta pathophys
Often detected on US prior to delivery. No separation of placenta after delivery leading to postpartum bleeding (can cause Sheehan’s)
placenta previa RF’s
1) multiparty
2) prior C-section
vasa previa
Fetal vessels run over, or in close proximity to cervical os.
vasa previa sequela
1) vessels can rupture
2) exsanguination
3) fetal death
vasa previa triad
Membrane rupture + painless vaginal bleeding + fetal bradycardia
fetal bradycardia
HR less than 110 beats/min
vasa previa management
Emergency C-section
vasa previa associations
Velamentous umbilical cord insertion
Velamentous umbilical cord insertion
Cord inserts in chorioamniotic membrane rather than placenta. Fetal vessels travels to placenta unprotected by Wharton jelly.
Causes of postpartum hemorrhaging
4 T’s:
1) Tone (uterine atony)
2) Trauma
3) thrombin (coagulopathy)
4) tissue (retained products of conception)
Most common cause of postpartum hemorrhaging?
Uterine atony
Ectopic RF’s
1) prior ectopic pregnancy
2) history of infertility
3) salpingitis (PID)
4) ruptured appendix
5) prior tubal surgery
Polyhydramnios other causes
1) fetal anemia
2) multiple gestations
oligohydramnios associations
1) placental insufficiency
2) bilateral renal genesis
3) posterior urethral valves
Gestational HTN
BP greater than 140/90 after 20th week of gestation. No pre-existing HTN. No proteinuria or end-organ damage
Gestational HTN treatment
Hydrazine, alpha-methyldopa, labetalol, nifedipine. Deliver at 37-39 weeks.
Causes of maternal death with eclampsia.
1) stroke
2) intracranial hemorrhage
3) ARDS
HELLP syndrome
- Hemolysis, Elevated Liver enzymes, Low platelets.
- Manifestation of severe eclampsia.
Gyn tumor epidemiology Incidence
endometrial, ovarian, cervical
Gyn tumor epidemiology mortality
ovarian, endometrial, cervical
Sarcoma botyroides is a..
variant of embryonal rhabdomyosarcoma
Sarcoma botyroides
vaginal tumor affecting girls under 4. Spindle shaped cells. design positive. Presents with clear, grape-like polypoid mass emerging from vagina.
Carcinoma in situ classification.
CIN 1, CIN 2, CIN 3 (severe dysplasia –> DCIS)
Classic presentation of DCIS
Postcoital vaginal bleeding
Number 1 risk factor for cervical DCIS
multiple sexual partners
Cervical cancer diagnosis
colposcopy + biopsy
Other name for PCOS
Stein-Leventhal syndrome
First aid explanation for PCOS pathophys
Hyperinsulinemia and/or insulin resistance alters hormonal feedback response –> Increased LH/FSH –> increased testosterone from theca internal cells –> decreased rate of follicular maturation –> enraptured follicles (cysts) + an ovulation.
Most common ovarian mass in young women?
Follicular cyst
What is a follicular cyst?
Distended and enraptured graafian follicle.
Follicular cyst associations
hyperestrogenism + endometrial hyperplasia
Theca-lutein cyst associations
choriocarcinoma + hydatidiform moles
What causes theca-lutein cysts?
gonadotropin stimulation
Majority malignant ovarian neoplasms are…
epithelial
Most common malignant tumor
serous cystuadenocarcinoma.
Other RFs for ovarian neoplasms
1) infertility
2) endometriosis
3) PCOS
4) BRCA mutations
5) Lynch syndrome
Protective factors for ovarian neoplasms
1) previous pregnancy
2) history of breastfeeding
3) OCPs
4) tubal ligation
Ovarian neoplasm presentation
adnexal mass + abdominal dissension + bowel obstruction + pleural effusion.
serous cyst adenoma histology
Lined with fallopian tube-like epithelium
Complex mass on ultrasound…
endometrioma
What is endometriosis?
ectopic endometrial tissue
what is an endometrioma?
endometriosis within ovary with cyst formation. This is endometriosis in the ovary.
What is a chocolate cyst?
endometrioma filled with dark, reddish-brown blood (in the ovary).
other name for mature cystic teratoma?
Dermoid cyst
Most common ovarian tumor in females 10-30 yo?
Mature cystic teratoma
struma ovarii
monodermal mature cystic teratoma presenting as hyperthyroidism
Presentation of mature cystic teratoma
Pain secondary to ovarian enlargement or torsion
Brenner tumor presentation
Looks like bladder. Solid tumor that is pale yellow-tan and appears encapsulated. “Coffee bean” nuclei.
fibromas
bundles of spindle-shaped fibroblasts
Miegs syndrome triad
ovarian fibroma + ascites + hydrothorax.
“pulling” sensation in groin…
Miens syndrome
theca + presentation
Basically a benign granulose cell tumor, may produce estrogen. Abnormal uterine bleeding in a postmenopausal woman.
Most common malignant stroll tumor…
Granulose cell tumor
Granulose cell tumor presentation in pre-adolescents
sexual precocity
Pseudomyxoma peritonei
Intraperitoneal accumulation of mutinous material from ovarian or appendiceal tumor.
Pseudomyxoma peritonei association
mutinous cystadenocarcinoma
Dysgerminoma histology + markers
1) sheets of uniform “fried egg” cells.
2) hCG + LDH
Tumor in sacrococcygeal area in young children…
Yolk sac tumor
What is an endometrial polyp?
well-circumscribed collection of endometrial tissue within uterine wall. May contain smooth muscle cells. Can extend into endometrial cavity.
Endometrial polyp presentation
Asymptomatic or painless abnormal uterine bleeding.
adenomyosis etiology
hyperplasia of basal layer of endometrium
Uterus presentation in adenomyosis
Uniformly enlarged, soft, globular uterus.
Most common tumor in females
Leiomyomas (uterine fibroids)
Which is a greater RF for endometrial carcinoma: nuclear type or complex architecture?
nuclear atypia
Most common gynecologic malignancy
Endometrial carcinoma
Peak incidence of endometrial carcinoma?
55-65 years old
endometritis causes
1) Retained products of conception
2) miscarriage
3) abortion
4) foreign body (IUD)
endometritis etiology
retained material in the uterus promotes infection by bacterial flora from vagina or intestinal tract.
endometritis treatment
gentamicin with clindamycin +/- ampicillin
Most common sites of endometriosis
Ovary (often bilateral) + pelvis + peritoneum.
Endometriosis etiology
1) retrograde flow
OR
2) metaplastic transformation of multipotent cells
OR
3) transportation of endometrial tissue via lymphatic system
dyschezia
pain with defecation
dyschezia in a woman think..
endometriosis
Uterus presentation in endometriosis
Normal-sized
Cyclic pelvic pain in a woman think…
endometriosis
endometriosis treatment options
1) NSAIDs
2) OCPs
3) progestins
4) GnRH agonists
5) danazol
6) laparoscopy
Breast conditions in the stroma
1) Fibroadenoma
2) phyllodes tumor
Terminal duct/lobular unit breast conditions
1) fibrocystic change
2) DCIS and LCIS
3) ductal carcinoma
4) lobular carcinoma
Lactiferous sinus and major duct breast conditions
1) intraductal papilloma
2) abscess/mastitis
3) Paget’s disease
Most common benign breast disease in women under 35
fibroadenoma
Most common benign breast condition in women over 35
fibrocystic changes
Fibrocystic changes presentation
Woman over 35 with premenstrual breast pain or lumps; often bilateral and multifocal.
Most common cause of nipple discharge (serous or bloody)?
Intraductal papilloma
mammography finding fat necrosis
calcified oil cyst
When is gynecomastia physiologic?
Newborn, pubertal, and elderly males.
Most common site of malignant breast tumors
Terminal duct lobular unit
DCIS characteristics
1) Fills ductal lumen
2) Arises from ductal atypica
Mammography finding in DCIS
Microcalcifications
Paget cells
intraepithelial adenocarcinoma cells
Most common of all breast cancers
invasive ductal carcinoma
medullary carcinoma prognosis
Good
Inflammatory breast cancer prognosis
Poor (50% survival at 5 years)
Etiology of peyronie’s
Abnormal curvature of penis due to fibrous plaque within tunica albuginea.
Penile fracture
Rupture of corpora cavernous due to forced bending.
priapism definition
erection lasting longer than 4 hours
priapism treatment options
1) corporal aspiration
2) intracavernosal phenylephrine
3) surgical decompression
bilateral vs unilateral lab findings in cryptorchidism
Testosterone is down in bilateral, normal in unilateral
Cryptorchidism commonly seen in…
Premies
“bag of worms” on palpation
varicocele
Varicocele – transiluminate or no?
does NOT transilluminate.
varicocele treatment options
1) varicocelectomy
2) embolization
Most common locations of extragonadal germ cell tumors in adults
Retroperitoneum + mediastinum + pineal + suprasellar regions.
Most common cause of scrotal swelling in infants
congenital hydrocele
hematocele
bloody hydrocele
acquired hydrocele
scrotal fluid collection usually secondary to infection, trauma, or tumor.
paratesticular fluctuant nodule…
spermatocele. Paratesticular = intrascrotal mass without testicular origin
Things that don’t transilluminate
1) varicocele
2) tumor
choriocarcinoma histology
Disordered syncytiotrophoblastic and cytotrophoblastic elements
choriocarcinoma mets
hematogenous mets to lungs + brain
potential presentation of choriocarcinoma
gynecomastia + hyperthyroidism pictures (due to shared alpha subunit
embryonal macroscopic description
hemorrhagic mass with necrosis
labs in embryonal carcinoma
1) Increased hCG + normal AFP when pure.
1) both increased when mixed.
Lydia cell tumor presentation
Gynecomastia in men, precocious puberty in boys
androblastoma
sertoli cell
caveat about testicular lymphoma
Arises from metastatic lymphoma to testes.
prostate in BPH description
smooth, elastic, firm nodular enlargement
Which lobes are involved in bPH
lateral and middle lobes (explains why urethra is compressed)
Other drug for BPH
tadalafil
tadalafil and caveat
PDE-5 inhibitor (sildenafil, vardenafil, tadalafil) but doesn’t drop BP.
prostatitis prostate description
warm, tender, enlarged prostate.
Lobe most commonly involved in prostatic adenocarcinoma
Posterior lobe (peripheral zone)
other prostate cancer tumor
prostatic acid phosphatase (PAP) + ALP with osteoblastic bone mets.
infertility treatment
Leuprolide
What are the synthetic estrogens?
1) ethinyl estradiol
2) DES
3) mestranol
Treatment for men with androgen-dependent prostate cancer?
estrogen
estrogen contraindications?
1) ER positive breast cancer
2) history of DVTs
SERMs
1) clomiphene
2) tamoxifen
3) raloxifene
Clomiphene SE’s
1) hot flashes
2) ovarian enlargement
3) multiple simultaneous pregnancies
4) visual disturbances
tamoxifen properties
Antagonist at breast; agonist at bone, uterus.
Treatment for ER/PR positive cancer?
Tamoxifen
Raloxifine properties
Antagonist at breast + antagonist at uterus + agonist at bone.
name some progestins
1) levonorgestrel
2) medroxyprogesterone
3) etonogestrel
4) norethindrone
5) megestrol
treatment for abnormal uterine bleeding?
progestins
Progestin challenge
Test used to evaluate a pt experiencing amenorrhea. If patient has sufficient estradiol, they will experience withdrawal bleeding after progestin is finished (this indicates she has estrogen which causing the lining of the uterus to build up which will cause bleeding), indicating the patient’s amenorrhea is due to an ovulation. If no bleeding occurs after withdrawal, amenorrhea due to either a) low serum estradiol b) HPO dysfunction C) some others.
*Presence of withdrawal bleeding excludes anatomic defects and chronic anovulation without estrogen.
Asherman syndrome
adhesions or fibrosis of endometrium
ulipristal
antiprogestin
ulipristal use
emergency contraception
combined contraception mechanism
Estrogens and progestins inhibit LH/FSH and thus prevent estrogen surge and thus prevent LH surge and ovulation
combined contraception contraindications
1) smokers older than 35
2) cardiovascular disease
3) migraines (especially with aura)
4) breast cancer
Most effective emergency contraceptive?
copper IUD
ritodrine
like terbutaline, beta2 agonist used to relax the uterus and decrease contraction frequency.
danazol MOA
partial agonist at androgen receptors
tamsulosin MOA
inhibits smooth muscle contraction
Other use for PDE-5 inhibitors
pulmonary HTN
term for blue-tined vision (PDE-5 inhibitors)
cyanopia
dyspepsia
indigestion
dyspepsia associated with
PDE-5 inhibitors
anemia of pregnancy mechanism
Your body makes more blood in pregnancy but keeps the same amount of RBC’s (eg increased plasma relative to RBCs)
Why does uterine atony cause bleeding?
Normally contraction of the uterus causes compression of blood vessels, inhibiting hemorrhaging during delivery
Anovulatory cycle etiology
normal bleeding is due to a decline in estrogen, with anovulatory cycles, there is no progesterone and bleeding is caused by unopposed estrogen (inability of estrogen to support a growing endometrium.
anovulatory cycle definition
absence of ovulation and a luteal phase.
Stress incontinence treatment
pelvic floor muscle strengthening (kegel) exercises + weight loss + pessaries (device inserted into the vagina to provide structural support).
When does rooting disappear by?
2-3 months
When does palmar grasp disappear by?
3 months
Galant reflex
stroking along one side of the spine while newborn is in ventral suspension (face down) causes lateral flexion of lower body toward stimulated side.
Chadwick’s sign + timing
- Code: he has a vagina and it’s blue/bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. He’s pregnant + hash block to his right + ivy all around him/can be observed as early as 6 to 8 weeks after conception and its presence is an early sign of pregnancy.
- Location: Chad Lorenz from Yarmouth, far end of tennis court, right corner
Pica association
iron-deficiency anemia
rectal prolapse associations
associated with pregnancy + constipation + severe diarrhea + cystic fibrosis. Worm cartoon with a huge whip on left table/whipworm.
Imperforate anus
- Code: Nick fom NYA: green ball of gue hanging from ceiling overhead/manifests with inability to pass meconium. Green gue coming out of his dick/meconium may discharge from urethra or vagina if a fistula is present. Walls made of spades + huge yellow bag sticking out of ceiling from above + dead giraffe on floor in front of white board/commonly associated with urinary tract malformations (eg. Renal agenesis + hypospadias + epispadias + bladder extrophy).
- Location: upstairs in NYA
Primary amenorrhea in a patient with fully developed secondary sexual characteristics suggests..
Defect in genital tract like imperforate hymen or mullein duct anomaly.
imperforate hymen presentation
cyclic abdominal or pelvic pain + a hematocolpos that can manifest as a vaginal bulge and/or mass palpated anterior to the rectum + back pain + difficulties with defecation and urination.
Familial testotoxicosis
1) pathophys
2) treatment
Ron Jeremy. /mutation of LH receptor causes it to be constitutively activated. /autonomous leydig cell activity. /presentation = testes enlarged but not to the extent expected for degree of virilization. /autosomal dominance with only male penetrance. /treatment = androgen blocker OR ketoconazole.
Noonan syndrome
male version of Turner’s
Neonatal abstinence syndrome (NAS)
o Code: bunch of people shooting up around the room/withdrawal from transplacental opiates due to maternal drug use. Super jacked baby (hypertonia code) + shitting on the ground + sweating profusely + black eyes (mydriasis code)/presentation = tachypnea + hypertonia + hyper-excitability + increased startle reflex + irritability + diarrhea + vomiting + ANS (sweating, sneezing, mydriasis). Jack from Dartmouth is cradling the baby/treatment = methadone or morphine. /stem may suggest it by mentioning hep C infection.
o Location: TV room
Why is maternal diabetes an RF for NRDS?
Insulin inhibits surfactant production
Cardiac complication of maternal diabetes
Transposition of the great arteries
Caudal regression syndrome
o Code: /associated with poorly controlled maternal diabetes. He has jellow legs + is pissing all over himself + has a tail + legs are fused together + on a stretcher + heart man in right corner + Joe holding stretcher up/presentation = sacral agenesis causing lower extremity flaccid paralysis + dorsiflexed contractures of the feet + urinary incontinence + anal atresia to sirenomelia + congenital heart defects + NTDs.
o Location: Harry Plumer’s dad’s house
o Sirenomalia = legs are fused together like a mermaid’s table
Bartholin’s gland cyst
Barbara Neistadt: /relatively common. /presentation = tender, flocculent swelling below the skin of the posterolateral part of the labium majora. /obstruction of bartholin’s gland, typically a sequel to a previous infection. /cysts lined by either transitional epithelium or metaplastic squamous epithelium.
vestibular adenitis
- Code: Genevieve Adams: She’s inside of a vestibule + it’s lined with inflammation statues smoking blunts/chronic inflammation of the lesser vestibular glands. /vestibular glands lie just outside the hymenal ring. Ulcers covering her inside vagina + axe in her vagina/presentation = small + exquisitely painful ulcerations of the vestibular mucosa. /greater vestibular glands are Bartholin’s glands, minor are vestibular glands.
- Location: Table outside café in Ed2
Lichen sclerosus
1) presentation
2) histology
- Code: Anna Schreiber: /chronic inflammatory condition producing white plaques usually on or near genitals. She’s itching her vagina intensely ++ getting banged out and screaming in pain by her boyfriend/presentation = dyspareunia + dysuria + pruritis. Table lined with inflammation statues/histo = inflammatory infiltrate at dermal-epidermal junction + thinned epidermis. Squamous indian sitting on her right/RF for squamous cell carcinoma.
- Location: table outside of Ethai’s
presentation of ovarian cancers in young girls
precocious puberty
Peritoneal carcinomatosis
Omentum looks really f’d from transcoelomic spread of cancers in the abdominal cavity (ovarian carcinoma most common source but colon cancer can produce a similar picture).
Peritoneal effusion
1) Increased ammonia (produced by bacterial proliferation in the damaged intestine) without an increase in creatinine.
2) gram stain of peritoneal fluid will demonstrate presence of enteric flora.
Cloudy urine after sex…
retrograde ejaculation
Very little seminal fluid released from urethra
retrograde ejaculation
retrograde ejaculation associated with
complication of TURP due to damage of internal urethral sphincter.
Precocious puberty definition
Before age of 8 in girls, 9 in boys.
