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Reproductive Flashcards

1
Q

CNS development

A

SONIC HEDGEHOG GENE

Mutation results in holoprosencephaly

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2
Q

Gene produced at apical ectodermal ridge

Organization along dorsal-ventral axis

A

WNT-7 GENE

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3
Q

Gene produced at apical ectodermal ridge

Stimulates underlying mesoderm (lengthening)

A

FGF GENE

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4
Q

Gene for segmental craniocaudal organization

Codes for transcription factors

A

HOMEOBOX GENES

Mutation results in appendages in wrong locations

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5
Q

Timing of hCG production and implantation of blastocyst

note: hcG levels peak at around 10 weeks . Are produced by a developing blastocyst and later the placental syncytiotrophoblast

A

WEEK 1

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6
Q

Timing of bilaminar disc - epiblast and hypoblast

A

WEEK 2

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7
Q

Timing of granulation and trilaminar disc:

Epiblast forms primitive streak (endoderm, mesoderm, ectoderm)
Midline mesoderm becomes notochord
Overlying ectoderm becomes neural plate

A

WEEK 3

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8
Q

Neuroectoderm forms neural tube
Organogenesis begins

Note - Very susceptible to teratogens (before all-or-none)

A

WEEK 3-8

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9
Q 
Timing of...
Heart begins to beat
TVUS detects heart
Fetal movement begins
Genitalia become M/F
A

4 weeks
6 weeks
8 weeks
10 weeks

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10
Q

Derivatives of surface ectoderm

A 
Adenohypophysis (Rathke pouch)
Epidermis
Salivary, sweat, and mammary glands
Anal canal below pectinate line
Oral cavity epithelium
Olfactory epithelium
Auditory sensory organs
Lens
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11
Q

Derivatives of neuroectoderm

A 
Brain
Spinal cord
Neurohypophysis
Pineal gland
Retina
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12
Q

Derivatives of neural crest

A 
PNS
Pia/Arachnoid
Cranial nerves
Skull bones
Odontoblasts
Melanocytes
Chromaffin cells (adrenal medulla)
Parafollicular (C) cells
Aorticopulmonary septum
Endocardial cushions
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13
Q

Derivatives of mesoderm

A 
Dermis
Muscle, bone, and connective tissue
CV structures, lymphatics, and blood
Serous linings
Spleen
Kidneys
Ureters
Adrenal cortex
Upper vagina
Testes and Ovaries
Notochord (nucleus pulposus)

Note - Defects result in VACTERL (vertebral, anal, cardiac, TE fistula, renal, limb) defects

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14
Q

Derivatives of endoderm

A 
Gut tube epithelium
Lungs
Thyroid
Thymus and Parathyroid
Eustachian tube
Stomach
Liver
Gallbladder
Pancreas
Bladder and Urethra
Lower vagina
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15
Q

Difference between agenesis and aplasia

A

Agenesis - Absent primordial tissue

Aplasia - Primordial tissue present

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16
Q

Difference between deformation and malformation

A

Deformation - Extrinsic disruption after embryonic period

Malformation - Intrinsic disruption during embryonic period (weeks 3-8)

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17
Q

Teratogenic effect of alkylating agents

A

Absence of digits

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18
Q

Teratogenic effect of Methimazole

A

Aplasia cutis congenita

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19
Q

Teratogenic effect of Tetracyclines

A

Discolored teeth

Inhibited bone growth

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20
Q

Teratogenic effect of Thalidomide

A

Limb defects

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21
Q

Teratogenic effect of Warfarin

A

Bone deformities
Fetal hemorrhage
Ophthalmologic abnormalities

Note - Use Heparin instead

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22
Q

Teratogenic effect of cocaine, smoking

Note - Mechanism is vasoconstriction

A

Low birth weight
Preterm birth
IUGR
Placental abruption

Note - Smoking also increases risk of SIDS

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23
Q

Teratogenic effects of maternal diabetes

A

Macrosomia
Caudal regression syndrome
Congenital heart defects
Neural tube defects

Note - Caudal regression syndrome presents with flaccid paralysis, limb contractures, anal atresia, and syringomyelia

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24
Q

Teratogenic effect of methylmercury - found in fish

A

Neurotoxicity

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25
Teratogenic effect of X-rays
Microcephaly | Intellectual disability
26
Mechanism of fetal alcohol syndrome
Failure of cell migration Note - Most severe form can present with heart-lung fistulas and holoprosencephaly
27
``` Timing of cleavage for twins with... Dichorionic diamniotic Monochorionic diamniotic Monochorionic monoamniotic Conjoined ```
Before Morula (0-4 days) Before Blastocyst (4-8 days) Before embryonic disc (8-12 days) > 13 days
28
Function of fetal placental component... Cytotrophoblasts Syncytiotrophoblasts
Inner layer - Produces cells Outer layer - Produces hormones (e.g. b-hCG) Note - Fetal component of placenta lacks MHCI to prevent attack by maternal immune system
29
Structure of maternal component of placenta
Decidua basalis contains maternal blood from endometrial vessels in lacunae around chorionic villi
30
Embryologic origin of umbilical arteries and umbilical vein
Allantois - Surrounding fluid is Wharton jelly Note - Single artery associated with congenital and chromosomal abnormalities
31
Origin and function of urachus - 3rd week
Connects fetal bladder to umbilicus - derived from urogenital sinus (allantois)
32
Origin and function of vitelline duct (omphalomesenteric duct) - 7th week
Connects yolk sac to midgut lumen Note - Failure to close forms vitelline fistula leading to meconium discharge from umbilicus
33
Location of looping of recurrent laryngeals
Right recurrent - Around right subclavian | Left recurrent - Distal to ductus arteriosus
34
Embryologic origin of branchial clefts, arches, and pouches
Cleft - Ectoderm Arch - Mesoderm (muscle, arteries) and Neural crest (cartilage) Pouch - Endoderm
35
1st branchial arch cartilage, muscle, and nerve Note - Used for mastication
Cartilage: Maxillary and Mandibular processes Malleus and Incus ``` Muscle: Muscles of mastication (masseter, temporalis, pterygoid) Mylohyoid Anterior belly of Digastric Tensor tympani Tensor veli palatini ``` Nerve: CN V2 and V3
36
2nd branchial arch cartilage, muscle, and nerve Note - Used for facial expression
``` Cartilage: Styloid Stylohyoid ligament Lesser horn of hyoid Stapes ``` ``` Muscle: Muscles of facial expression Stylohyoid Platysma Posterior belly of Digastric Stapedius ``` Nerve: CN VII Note - Auditory volume modulation by Stapedius (CN VII)
37
3rd branchial arch cartilage, muscle, and nerve Note - Used for swallowing
Cartilage: Greater horn of hyoid Muscle: Stylopharyngeus Nerve: CN IX
38
4th-6th branchial arch, cartilage, muscle, and nerve Note - Used for swallowing and speaking
``` Cartilage: Arytenoid Cricoid Corniculate Cuneiform Thyroid ``` Muscle: Levator veli palatini Pharyngeal constrictors Intrinsic laryngeal muscles Nerve: 4th - CN X superior laryngeal branch (swallow) 6th - CN X recurrent laryngeal branch (speak)
39
Micrognathia Glossoptosis Cleft palate Airway obstruction
PIERRE ROBIN SEQUENCE
40
Mandibular hypoplasia | Facial abnormalities
TREACHER COLLINS SYNDROME Neural crest dysfunction
41
Branchial pouch derivatives
1st - Middle ear, Eustachian tube, Mastoid air cells 2nd - Palatine tonsils 3rd - Inferior parathyroid, Thymus 4th - Superior parathyroid, Ultimobranchial body (parafollicular C cells)
42
Failure of the left or right maxillary process to fuse with the intermaxillary segment Intermaxillary segment formed by fusion of medial nasal prominence - Failure to fuse is associated with severe midline defect
CLEFT LIP Note - Cleft palate is failure of the secondary palate to fuse together, or to fuse with the primary palate
43
Mechanism of female genital development
Mesonephric duct degenerates Paramesonephric (Mullerian) duct develops Forms fallopian tubes, uterus, and upper vagina In males remnant forms appendix testis Note - Lower portion of vagina from urogenital sinus
44
``` Primary amenorrhea (hypoplastic uterus) Fully developed secondary characteristics (ovaries) ``` Note - Increased risk of unilateral renal agenesis
MULLERIAN AGENESIS (MAYER-ROKITANSKY-KUSTER-HAUSER SYNDROME)
45
Mechanism of male genital development
SRY on Y chromosome produces TDF Testes develop Sertoli cells secrete MiF Leydig cells secrete Testosterone Testosterone develops mesonephric (Wolffian) ducts Forms seminal vesicles, Epididymis, Ejaculatory duct, Ductus deferens (not Prostate) In females remnant forms Gartner's duct Note - External genitalia/Prostate (Genital tubercle, Urogenital sinus) require DHT (5a-reductase)
46
Development of both male and female internal genitalia, and male external genitalia
No Sertoli cells or lack of MiF
47
Double uterus, vagina, and cervix
Complete failure of Mullerian duct fusion Note - Partial failure results in Bicornuate uterus
48
``` Male and female derivatives of... Genital tubercle Urogenital sinus Urogenital folds Labioscrotal swelling ```
Glans penis/Corpus or Glans clitoris/Vestibular bulbs Bulbourethral glands/Prostate or Bartholin/Skene glands Penile urethra or Labia minora Scortum or Labia Note - Bartholin glands are Greater vestibular glands, and Skene's glands are urethral/paraurethral glands
49
Mechanism of hypospadia Note - Associated with inguinal hernias and cryptorchidism
Failure of urethral folds to fuse -can cause increased UTI and sterility
50
Mechanism of epispadias Note - Associated with bladder exstrophy
Faulty positioning of genital tubercle
51
Male and female derivatives of... Gubernaculum - fibrous tissue Processus vaginalis - invaginated peritoneum
Anchors testis to scrotum or ovarian/round ligaments | Tunica vaingalis or obliterated
52
Lymphatic drainage of... Ovaries, Testes Uterus, Cervix, Superior bladder Prostate, Penis, Cervix, Proximal vagina, Inferior bladder Vulva, Scrotum, Distal anus, Distal vagina Glans penis
``` Para-aortic (where testicular artery arises) External iliac Internal iliac Superficial inguinal Deep inguinal ```
53
Structures with in... Infundibulopelvic (suspensory) ligament Cardinal ligament (cervix) Round ligament (fundus to labia majora)
Ovarian vessels/ovarian nerve plexus (ovarian torsion) Uterine vessels Sampson's artery
54
Epithelial histology of fallopian tube and ovary
Fallopian - Simple columnar with cilia Ovary - Simple cuboidal Note - No cilia in uterus
55
Path of sperm during ejaculation
``` Seminiferous tubules Rete testis Efferent ductules Epididymis Vas deferens Ejaculatory duct Urethra Penis ``` Note - Seminal vesicle joins ejaculatory duct in prostate, and Cowper's (bulbourethral) joins after prostate
56
Difference between presentation of posterior (membranous) and anterior (penile) urethral injury
Posterior - Pelvic fracture causing urine to leak into retropubic space between pubis and bladder Anterior - Perineal straddle injury causing urine to leak beneath Buck's fascia or through it into perineal space (scrotum, in front of pubis)
57
Innervation of erection, emission, and ejaculation
Erection - Pelvic nerve (parasympathetic) Emission - Hypogastric (sympathetic) Ejactulation - Pudendal (somatic)
58
Functions and regulation of Sertoli cells - line inside of seminiferous tubules [ADD PIC FOR GNRH]
With FSH... Regulate spermatogenesis Support and nourish spermatozoa Tight junctions form blood-testis barrier Secrete androgen binding protein (maintain local levels) Secrete Inhibin B to feedback inhibit FSH Secrete MiF Convert testosterone and androstenedione to estrogen Note - Increased temperature decreases spermatogenesis (and inhibin production)
59
Function and regulation of Leydig cells - interstitium between seminiferous tubules
With LH... Secretes testosterone Note - Temperature independent
60
Relative potency of estrogens (greatest to least)
17b-Estradiol (ovary) Estrone (adipose) Estriol (placenta) Note - Estradiol/Estrone increase 50x in pregnancy, while Estriol (fetal well being) increases 1000x
61
Metabolic effects of estrogen
Stimulates PRL Stimulates SHBG Stimulates HDL Inhibits LDL Note - Also inhibits Osteoclasts
62
Mechanism of estrogen production in granulosa cells
Pulsatile GnRH LH activates Desmolase Convert Cholesterol to Androgen Androgen moves from Theca interna to Granulosa Aromatase (under FSH) converts Androgen to Estrogen Note - Ovary can also produce Androstenedione (P-450) which can be converted to Estrone
63
Timing of oogenesis
``` Primary oocyte arrested in prophase I until ovulation Secondary oocyte (haploid) arrested in metaphase II until fertilization If fertilization does not occur within 1 day the oocyte degenerates ```
64
Mechanism of ovulation and menstruation Note - Luteal phase is always 14 days after ovulation [ADD MENSTRUATION PIC}
Follicular phase: Developing follicle stimulates GnRH release Estrogen leads to proliferation of endometrium (tubular glands) Estrogen switches to positive feedback of LH and FSH LH surge Rupture of follicle and ovulation ``` Luteal phase: Corpus luteum (theca-lutein) begins producing Progesterone (major) and Estrogen (minor) - Progesterone maintains endometrium (coiled glands) ``` Menstruation: Corpus luteum regresses and endometrium sheds Note - Increased temperature after ovulation is due to increase in Progesterone
65
Appendicitis-like pain associated with follicular swelling/rupture, or fallopian tube contraction
MITTELSCHMERZ
66
Definition of oligomenorrhea and polymenorrhea
Oligo - > 35 day cycle | Poly - < 21 day cycle
67
Menorrhagia (heavy) and Metrorrhagia (frequent, irregular)
Menometrorrhagia
68
Most frequent site of fertilization
Ampulla of fallopian tube
69
Placental hormone secretion during pregnancy [add pregnancy]
b-hCG rises until 14 days then drops 17-OH progesterone rises in first trimester then declines hPL rises throughout pregnancy in proportion ot fetal mass CRH rises sharply around week 28 Note - b-hCG detected in serum at 1 week and on pregnancy tests at 2 weeks Note - Decreased Estriol levels indicate placental abnormalities/FGR
70
Gestational age vs Embryonic age
Gestational - Last menstrual period | Embryonic - Gestational - 2
71
``` Physiological adaptations during pregnancy... CO Preload (BV) Afterload (SVR) HR RR Plasma volume RBC Viscosity Coagulability ```
``` Increased Increased Decreased Increased Increased Markedly increased Increased Decreased Increased ``` Note - Increase in plasma volume is greater than increased in RBC leading to anemia
72
Function of b-hCG
Secreted by syncytiotrophoblasts to maintain corpus luteum and progesterone production - eventually placenta is able to make its own progesterone and estrogen and b-hCG decreases
73
Effects of Progesterone during pregnancy note: hCG maintains the corpus luteum during the first trimester of pregnancy. A deficiency of hCG allows progesterone to drop and increasing the risk of miscarriage
``` Decreased myometrial excitability Production of thick cervical mucus Inhibition of FSH, LH Decreased Estrogen receptor expression Fall after delivery disinhibits Prolactin ``` Note - Estrogen induces Prolactin
74
``` APGAR 2, 1, 0 point criteria... Appearance Pulse Grimace Activity Respiration ``` Note - < 7 requires evaluation
``` Pink, Extremities blue, Pale or blue >100, <100, No pulse Cries/pulls away, Grimaces/weak cry, No response Active, Flexion, None Strong cry, Slow irregular, No breathing ```
75
``` Hormonal changes during menopause... Estrogen FSH LH GnRH ``` Note - Occurs earlier in smokers
Decreased Markedly increased Increased Increased Note - Estrogen source becomes peripheral conversion of androgens, and increased androgen leads to hirsutism
76
Menopause before age 40
PREMATURE OVARIAN FAILURE (PRIMARY OVARIAN INSUFFICIENCY)
77
Relative potency of Androgens (greatest to least)
DHT > Testosterone > Androstenedione (adrenals) Note- most circulating testosterone is bound to albumin and sex-hormone binding globulin. Note - DHT responsible for prostate growth, balding, and sebaceous gland activity
78
Responsible for closing of epiphyseal plates
Conversion of Testosterone to Estrogen - in males occurs by Cytochrome P-450 aromatase in adipose tissue and testis
79
Mechanism of steroid induced infertility
Inhibition of HPG axis Decreased intratesticular testosterone Decreased testicular size Azoospermia Note - Also increases LDL and decreases HDL
80
Mechanism of spermatogenesis [ADD PIC OF SPERMATOGENESIS]
- Spermatogonia in seminiferous tubules in close association with basal lamina - cross blood-testis border - Complete replication to form primary spermatocyte - Meiosis I forms secondary spermatocytes (haploid) - Meiosis II forms spermatid - Spermiogenesis (loss of cytoplasm, gains acrosomal cap) - Fully mature spermatozoon
81
Tanner Stage II
Pubarche Testicular enlargement Thelarche
82
Tanner Stage III
Coarsening of pubic hair Penis size and length Breast enlarges, mound forms
83
Tanner Stage IV
Coarse hair across pubis sparing thigh Penis width/glans Breast enlarges, raised areola, mound on mound
84
``` Primary hypogonadism/small penis Hypergonadotropic hypogonadism Tall with long extremities Female hair distribution Testicular atrophy/small firm testes Gynecomastia ``` Presence of Barr body
KLINEFELTER 47 XXY Dysgenesis of seminiferous tubules leads to... Decreased inhibin B Increased FSH Abnormal Leydig cell function... Decreased testosterone Increases LH and Estrogen
85
``` Streak ovaries Short stature Shield chest Bicuspid aortic valve Coarctation Webbed neck Cystic hygroma Lymphedema Horseshoe kidney hypothyroidism ``` No Barr body
TURNER SYNDROME 45 XO Decreased estrogen Increased FSH, LH Note - Mosaicism may result in 45 XO, 46 XX Note - Pregnancy may be possible with exogenous estrogen
86
Both ovarian and testicular tissue present | Ambiguous genitalia
OVOTESTICULAR DISORDER OF DEVELOPMENT (TRUE HERMAPHRODITISM) 46 XX > 46 XY
87
``` Testosterone and LH in... Defective androgen receptor Testosterone secreting tumor or exogenous source Primary hypogonadism Hypogonadotropic hypogonadism ```
Increased, Increased Increased, decreased Decreased, Increased Decreased, decreased
88
Ovaries present External genitalia ambiguous or virilized Increased Testosterone Increased Androstenedione
46 XX DSD (PLACENTAL AROMATASE DEFICIENCY) Excessive exposure to androgens during gestation
89
Female external genitalia Testes present (labia majora) - usually in the abdominal or inguinal area Rudimentary vagina Uterus and fallopian tubes absent Increased Testosterone Increased Estrogen Increased LH
46 XY DSD (ANDROGEN INSENSITIVITY) androgen receptor defect
90
Low sperm count or amenorrhea Anosmia Decreased GnRH Decreased FSH Decreased LH Decreased Testosterone
KALLMANN SYNDROME Hypogonadotropic hypogonadism - Defective migration of GnRH cells and formation of olfactory bulb
91
Vaginal bleeding Uterine enlargement more than expected Pelvic pressure ``` b-hCG sequelae: Early preeclampsia (< 20 wks) Theca-lutein cysts Hyperemesis gravidarum Hyperthyroidism ```
HYDATIDIFORM MOLE (COMPLETE) Cystic swelling of chorionic villi and proliferation of trophoblasts - May develop into Choriocarcinoma Note - Partial moles are less symptomatic and present like miscarriages
92
``` Difference between complete and partial mole... Karyotype Components Uterine size hCG Imaging Risk of neoplasia ```
``` Complete: 46XX; p-57- Paternal DNA replicates in empty egg Increased Markedly increased Snowstorm Yes ``` ``` Partial: 69XXX, 69XXY, 69XYY; p-57+ Two sperm fertilize a normal egg Normal Increased Fetal parts Rare ``` Note - Occasionally complete moles may also result from two sperm entering an empty egg (46XY)
93
``` Abnormal or elevated b-hCG Shortness of breath Hemoptysis Hyperthyroidism Hematogenous spread to lungs ``` Increased frequency of bilateral theca-lutein cysts
CHORIOCARCINOMA Malignancy of cytotrophoblasts and syncytiotrophoblasts - No villi present Note - May occur during or after pregnancy in mom or baby
94
Risk factors for placental abruption - painful third trimester bleeding
``` Trauma Smoking Hypertension Preeclampsia Cocaine ```
95
Risk factors for placenta accreta/increta/percreta - postpartum bleeding Note - Accreta is on myometrium, Increta is in myometrium, and Percreta is through myometrium into uterine serosa
Prior c-section Inflammation Placenta previa
96
Risk factors for placenta previa - painless third trimester bleeding
Prior c-section | Multiparity
97
Membrane rupture Painless vaginal bleeding Fetal bradycardia (< 110)
VASA PREVIA Cord inserts into chorioamniotic membrane rather than the placenta (velamentous insertion) - fetal vessels travel to placenta unprotected by Wharton's jelly
98
Risk factors for... Amenorrhea Lower than expected b-hCG Sudden lower abdominal pain
ECTOPIC PREGNANCY results from delayed transit of the blastocyst into the uterine cavity Prior ectopic pregnancy Infertility or PID Prior tubal surgery Ruptured appendix note: chlamydia commonly causes PID and ultimately scarring of the fallopian tubes via a type IV HSN rxn
99
Causes of poly- and oligohydramnios
``` Polyhydramnios: GI atresias Maternal diabetes Fetal anemia Multiple gestations ``` Oligohydramnios: Placental insufficiency Urogenital malformations
100
Treatment of gestational (> 20 wks) hypertension - no end organ damage or preexisting HTN ("Hypertensive Moms Love Nifedipine") Note - Before 20 wks indicates chronic HTN
Hydralazine a-Methyldopa Labetalol Nifedipine
101
Mechanism of preeclampsia - gestational HTN with proteinuria or end-organ damage -HTN after 20 wks in previously normotensive women. if there is absence of proteinuria then it is just gestational HTN
Secondary to placental ischemia and hypoperfusion due to impaired remodeling of maternal spiral arteries Abnormal placentation results in placental hypoxia - Placenta releases antiangiogenic factors which damage endothelium in mother definitive treatment is termination of pregnancy via delivery
102
Treatment of Eclampsia - preeclampsia with seizures leading to stroke, ICH, or ARDS
IV Mg/antihypertensives and immediate delivery
103
Hemolysis Transaminitis Thrombocytopenia Schistocytes on smear
HELLP SYNDROME subset of severe preeclampsia Can lead to hepatic subcapsular hematomas which rupture and cause hypotension - requires immediate delivery
104
Incidence and mortality of gynecologic cancers (greatest to least)
Incidence - Endometrial > Ovarian > Cervical | Mortality - Ovarian > Endometrial > Cervical
105
Toddler with... Clear, grape-like mass from vagina Spindle-shaped cells Desmin+
SARCOMA BOTRYOIDES (EMBRYONAL RHABDOMYOSARCOMA VARIANT)
106
Mechanism behind HPV 16/18 induced cervical cancer Note - Most important risk factor is multiple sexual partners [ADD PIC OF KOILO change}
Integration into host genome E6 gene product degrades p53 E7 gene product binds RB releasing E2F
107
Metabolic disorders resulting in anovulation
``` Obesity or anorexia Hyperprolactinemia Thyroid disorders Cushing syndrome Adrenal insufficiency ```
108
Mechanism of PCOS (Stein-Leventhal syndrome) note: one or both ovaries are often significantly ENLARGED note: treatment with spironolactone which blocks mineralocorticoid receptors, making it a potassium sparing diuretic. Spironolactone also has antiandrogen effects that can be used clinically to treat hirsutism in women
Hyperinsulinemia or insulin resistance alters hypothalamic hormonal feedback response Increased LH/FSH increases androgens from theca interna Decreased rate of follicular maturation leads to unruptured follicles (cysts) and anovulation Note - Increased risk of endometrial cancer due to unopposed estrogen from anovulatory cycles
109
Associations of follicular and theca-lutein cells
Follicular - Hyperestrogenism, Endometrial hyperplasia Theca-lutein - Choriocarcinoma, Hydatidiform moles
110
Used to monitor response of epithelial ovarian neoplasms to therapy
CA-125 i.e. cystadenocarcinomas which are derived from the surface epithelium of the ovaries
111
Bilateral benign neoplasm lined with fallopian tube-like epithelium forming papillary fronds - May see Psammoma bodies - CA-125 marker +
SEROUS CYSTADENOMA Most common ovarian neoplasm
112
Multiloculated large benign neoplasm lined by mucus-secreting epithelium
MUCINOUS CYSTADENOMA
113
Benign ovarian mass with thyroid follicles - may present with hyperthyroidism Note - Often presents in women of childbearing age
MATURE CYSTIC TERATOMA (DERMOID CYST) Immature teratoma often presents in older women and contains neuroectoderm - very malignant/aggressive Note - May be malignant in adult males (not children or women)
114
Grossly pale yellow-tan and encapsulated | Coffee bean nuclei on H/E stain
BRENNER TUMOR Benign
115
``` Ovarian fibromas Ascites Hydrothorax Pulling sensation in groin Low back pain ```
MEIGS SYNDROME
116
Postmenopausal bleeding Precocious puberty Breast tenderness Increased inhibin [ADD EXNER PIC] Large, unilateral, yellow mass Cuboidal cells in Rosettes (Call-Exner bodies) Pink eosinophilic material surrounding coffee-bean nuclei
GRANULOSA CELL TUMOR Associated with increased estrogen exposure (e.g. anovulation, nulliparity) - Decreased risk with pregnancies, breastfeeding, and birth control Note - Yellow color due to lipid content in theca cells Note- contrast to Sertoli-Leydig cell tumors that secrete male hormones
117
Bilateral malignant ovarian neoplasm with Psammoma bodies Note - Most common malignant ovarian neoplasm
SEROUS CYSTADENOCARCINOMA
118
Intraperitoneal accumulation of mucinous material
PSEUDOMYXOMA PERITONEI From ovarian mucinous cystadenocarcinoma or appendiceal tumor
119
Teenage girl with sheets of "fried egg" cells Elevated hCG Elevated LDH
DYSGERMINOMA Note - Not embryonic (teratoma) or extra-embryonic (yolk-sac, choriocarcinoma) tumor
120
Toddler with... Ovarian, testicular, or sacrococcygeal mass Grossly yellow, friable (hemorrhagic) solid mass Schiller-Duval bodies (endodermal sinuses that resemble primitive glomeruli) Elevated AFP (AFP in schiller-duval bodies) ADD PIC FOR SCHILLERDUVAL note: AFP indicates yolk cell differentiation
YOLK SAC (ENDODERMAL SINUS) TUMOR or INFANTILE EMBRYONAL CARCINOMA - most common testicular cancer in young children - primitive cells, endodermal sinuses, cytoplasmic granules that stain immunologically for alpha-fetoprotein
121
Mucin-secreting signet cell adenocarcinoma usually b/l ovaries [add krukenberg pic]
KRUKENBERG TUMOR Metastasis from GI tract (usually stomach)
122
Dysmenorrhea Menorrhagia Globular, soft uterus nonfocal thickening of the myometrium
ADENOMYOSIS Hyperplasia of basal layer of endometrium (glandular) into uterine myometrium (endometrial glands in the myometrium of the uterus) Pain is caused by the glands breaking down and bleeding within the confines of the myometrium Note - Uniformly enlarged uterus compared to fibroids (smooth muscle proliferation)
123
Whorled pattern of smooth muscle bundles with well-demarcated borders presents as heavy menstrual bleeding biochemical vasoactive growth factors cause venous ectasia (dilation). large venules overwhelm normal hemostatic mechanisms (platelet aggregation, fibrin etc) show immunoreactivity for smooth muscle acting
LEIOMYOMA (FIBROID) uterine smooth muscle (myometrial) cells submucosal/intracavitary fibroids have been associated with anemia [ADD LEIOMYOMA PIC]
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Risk factors for endometrial hyperplasia/carcinoma
``` HRT without Progestin Nulliparity Late menopause PCOS Obesity Diabetes Granulosa cell tumor Lynch syndrome ```
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Treatment of endometritis - inflammatory infiltrate
Ampicillin + Gentamicin + Clindamycin
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Young woman with... Small, well-defined, mobile mass Increased size with estrogen Slit ducts
FIBROADENOMA Benign mass of breast stroma
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Premenopausal woman with... Fluid-filled duct dilation, blue dome Papillary apocrine change and metaplasia Stromal fibrosis
FIBROCYSTIC CHANGE Benign disease of terminal duct/lobular unit Note - Increased acini or calcification with stromal fibrosis is sclerosing adenosis which slightly increases risk of cancer. It is characterized by fibrosis that distorts the glands and lobules into a whorled pattern and proliferation of small ducts
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Bloody or serous nipple discharge | Proliferating papillary cells with fibrovascular core
INTRADUCTAL PAPILLOMA Benign tumor of lactiferous sinus - slight increased chance of cancer THe presence of myoepithelial cells is key to the diagnosis of intraductal papilloma [ADD PIC of MYOEPITHELIAL CELL]
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Pre or menopausal woman with... Large mass of connective tissue Leaf-like lobulation
PHYLLODES TUMOR Benign tumor of stroma - may become malignant
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Calcified oil cyst on mammogram Necrotic fat and giant cells on biopsy Lipid laden (foamy) macrophages Hemosiderin
FAT NECROSIS
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Drugs causing gynecomastia | "Some Hormones Create Knockers"
Spironolactone Hormones Cimetidine Ketoconazole
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Filled ductal lumen with neoplastic cells Nearby engorged blood vessels Microcalcifications on mammography
DUCTAL CARCINOMA IN SITU Note - If central necrosis of ductal proliferation then comedocarcinoma
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Intraepithelial adenocarcinoma Lesions that are scaly, vesicular, or oozing start in nipple and spread to areola +cytokeratin stain (epithelial cells) and mucin
PAGET DISEASE underlying ductal adenocarcinoma (If mass then invasive and if no mass then in situ) mucin containing cells (paget cells)
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Small, glandular nests/cords of duct-like cells surrounded by desmoplastic stromal response Stellate infiltration on mammography
INVASIVE DUCTAL CARCINOMA
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Orderly row of cells ("Indian file") in breast mass | Decreased E-cadherin expression
INVASIVE LOBULAR CARCINOMA
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Fleshy breast mass with lymphocytic infiltrate sheet of tumor surrounded by abundant lymphoplasmacytic reaction
MEDULLARY CARCINOMA Good prognosis
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Structure of the penis
Deep fascia contains... Corpus spongiosum around urethra Tunica albuginea Deep dorsal vein, dorsal artery, and dorsal nerve Tunica albuginea contains... Corpus cavernosum around deep artery Note - Fibrous plaque in tunica albuginea causes Peyronie's disease
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SCC of penis presenting with... Leukoplakia on shaft Erythroplakia on glans Reddish papules Note - Associated with HPV
``` Bowen disease (solitary white plaque) Erythroplasia of Queyrat (single or multiple shiny red plaques) Bowenoid papulosis (multiple red brown papules) ```
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``` Levels in cryptorchidism Inhibin B FSH LH Testosterone ```
Decreased Increased Increased Normal or Decreased if bilateral - Leydig temperature independent
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Scrotal mass increasing with standing | Does not transilluminate
VARICOCELE aorta and superior mesenteric artery compress the left renal vein. The increased pressure in the left renal vein causes retrograde blood flow to testes and dilation of the pampiniform plexus --> "nutcracker effect" also left gonadal vein is longer and more perpendicular
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Transilluminating swelling
HYDROCELE The processus vaginalis is an evagination of the parietal peritoneum that descends through the inguinal canal Incomplete obliteration of processus vaginalis results in spermatic cord hydrocele
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Paratesticular fluctuant nodule
SPERMATOCELE Cyst in epididymis or rete testis
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``` Teenage boy with... Painless testicular enlargement "Fried egg" cells Increased ALP PLAP + (placental alkaline phosphatase) Nests or lobules of malignant cells surrounded by lymphocytic infiltrate ```
SEMINOMA Radiosensitive - excellent prognosis [ADD seminoma pic]
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Malignant hemorrhagic mass with necrosis Painful Glandular/papillary morphology Elevated hCG
EMBRYONAL CARCINOMA
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Most common locations of extragonadal germ cell tumors
Retroperitoneum Mediastinum Pineal Suprasellar In infants and young children - sacrococcygeal teratomas
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``` Golden brown mass Reinke crystals - Eosinophilic cytoplasmic inclusion Produce androgens or estrogen Gynecomastia in men Precocious puberty in boys ```
LEYDIG CELL TUMOR Note - Sertoli-Leydig equivalent in women presents with masculinization
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Hyperplasia of lateral and middle prostate lobes
BPH Smooth, elastic, firm nodular enlargement - not premalignant but may increase PSA
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Warm, tender, enlarged prostate | Low back pain
PROSTATITIS Suspect acute bacterial prostatitis in a patient with exquisitely tender prostate gland Acutely mostly e. coli Chronically may be bacterial or abacterial
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Treatment of... Hyperplasia of posterior prostate lobe Elevated total PSA Decreased free PSA
PROSTATIC ADENOCARCINOMA Androgen receptor inhibitors - Flutamide, Bicalutamide GnRH agonists - Leuprolide Note - May also consider Estradiol/Mestranol
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Antiprogestins used for pregnancy termination and emergency contraception
Mifepristone - Termination Ulipristal - Contraception Note - Most effective emergency contraception is copper IUD Note- in a patient with IUD infection think Actinomyces israelii
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Ductal epithelial hyperplasia with stromal fibrosis - No acinar cells
GYNECOMASTIA -most common breast mass in men under 25 yo Caused by... Increased Estrogen (Tumors, Obesity, Cirrhosis, Hyperthyroidism, Androgen use) Decreased Androgen (Hypogonadism, Hyperprolactinemia, Renal failure) Drugs
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Mechanism of hyperandrogenism in PCOS
LH predominance leads to increased androgen production by Theca cells Androgens are converted in the periphery to Estrogen also increasing the risk of endometrial hyperplasia Note - Infertility treated with Clomiphene (estrogen receptor modulator) which decreases negative feedback of elevated Estrogen on the hypothalamus
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Ovarian mass producing thyroid hormone
Struma ovarii - Teratomas are the most common germ cell tumor of the ovary (originate from 3 germ layers) but struma ovarii is only one tissue type - Monodermal mature teratoma - Abundant mature thyroid tissue not under TSH control - Hyperthyroidism
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Most common etiologies (2) of septic abortion
S. aureus | E. coli
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Function of HPL
Increases maternal insulin resistance Increased blood glucose, proteolysis, lipolysis Glucose/Amino Acids shunted to fetus Ketones provide energy for mother Note - Also leads to compensatory increase in maternal insulin secretion which if inadequate leads to gestational diabetes
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Cause of DIC in postpartum hemorrhage
Released Tissue Factor (Thromboplastin) Note - Rule out amniotic fluid embolism (cardiogenic shock)
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``` Endometrial glands and stroma outside the uterus Most commonly affects ovaries Chocolate cyst (old blood and surrounded by thick fibrotic wall and surface adhesions) ```
Endometriosis
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What supplementation is not needed during pregnancy toxicity can cause: spontaneous abortions fetal defects like microcephaly, cardiac, early epiphyseal closure, growth retardation
vitamin A provitamin A from plant sources does not cause toxicity as it is metabolized into the active vitamin A in a highly regulated process preformed vitamin causes toxicity due to efficient absorption and storage TERATOGEN in first trimester when prganogenesis is occurring.
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First line medication in pregnancy for nausea and vomiting
B6 pyridoxine
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``` Polymicrobial infection after cesarean delivery Malodorous locia (vaginal discharge etc) after delivery uterine tenderness leukocytosis ``` risk factors: - prolonged labor or rupture of membranes - cesarean delivery
postpartum endometritis fever, leukocytosis, uterine tenderness, foul smelling vaginal discharge
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-Initiates transition from the proliferative phase of the endometrial cycle to the secretory phase ADD PROGESTERONE PIC
Progesterone - proliferative phase is characterized by endometrial thickening and differentiation - secretory phase is characterized by a thick endometrium with long, coiled glands that are lined by a columnar epithelium with prominent cytoplasmic vacuoles adjacent to the gland lumen
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Mutations in the human epidermal growth factor 2 (HER-2) are a common cause of breast cancer. What is its gene products
Receptor tyrosine kinase results in activation of Ras which induces activity of MAPKKK members like Raf. Raf continues phosphorylation cascade in the cell and induces cellular growth and proliferation note: intrinsic tyrosine kinase activity or RTKs are the primary receptors for growth factors
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Spontaneous abortions are due to? note: spread from circulation into the placenta causes an acute necrotizing villitis/chorionitis with presence of microabscesses (can be surrounded by histocytic proliferation)
LISTERIOSIS Listeria monocytogenes from unpasteurized dairy foods and deli meats
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What is the most common cause of pelvic inflammatory disease and how do you stain it
Chlamydia trachomatis (D-K) because it is an intracellular organism, it can only be visualized inside epithelial cells with iodine, giemsa, or fluorescent antibody strains Lives inside epithelial cells and is an ATP scavenger and cannot synthesize its own ATP
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genotypic male with feminized genitalia and a normal male internal reproductive tract virilization at puberty due to increased testosterone levels can be due to finasteride exposure in utero (contraindicated)
5a-reductase deficiency needed to make dihydrotestosterone which allows for differentiation of external genitalia note: Wolffian duct becoming internal reproductive organs requires testosterone
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common causes of: 1) first trimester pregnancy loss 2) second and third trimester loss 3) third trimester loss
1) chromosomal abnormalities 2) chorioamnionitis due to ascending bacterial infections 3) abruptio placentae and placenta previa
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Male tumor types
ADD TUMOR PIC
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Uterine bleeding that occurs at irregular (intermenstrual) intervals is referred to as dysfunctional uterine bleeding
Usually due to anovulatory cycles endometrium undergoes unopposed estrogenic stimulation results in disorganized proliferative endometrium Dx with the progestin challenge test which triggers menstruation
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Mullerian inhibiting substance or anti-Mullerian hormone is produced by
Sertoli cells in an XY fetus it suppresses the differentiation of the paramesonephric(Mullerian) ducts an thereby prevents the formation of female internal reproductive organs
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[ADD PIC OF SEPTATEUTERUS]
complete or partial septate uterus - presence of a membrane that divides the uterine cavity - can cause a habitual abortion due to defective placental implantation
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- gray white to yellow - cordlike structures resembling seminiferous tubules [ADD TUMOR2}
SERTOLI CELL TUMOR
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Enter the inguinal canal by tearing through the posterior wall of the canal formed by the transversalis fascia. Passes through inguinal triangle Note: All inguinal hernia pass through the superficial inguinal ring while only indirect inguinal hernias pass through the deep inguinal ring
DIRECT HERNIA
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Prostaglandin medication used to induce labor
dinoprostone PGE2 induces cervical softening and effacement
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Cryptorchidism has an increased risk of
both the undescended testicle and the normal testicle are at increased risk of testicular cancer
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How does excessive exercise delay puberty? Female athelete triad of intense exercise and dieting + amenorrhea + osteoporosis due to decreased estrogen
It suppresses hypothalamic secretion of GnRH results in hypothalamic amenorrhea low gonadotropins and estrogen
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Effect of growth hormone on insulin
reduce insulin sensitivity during pregnancy the placenta produces a GH variant called placental growth hormone. Causes gestational diabetes and hyperglycemia in the mother
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[add picture of inflammatory breast cancer]
Inflammatory breast cancer - marked swelling - erythema - warmth to skin - tumor invasion into dermal lymphatics - blockage causes lymphedema and "peau d'orange" - commonly mistaken for acute mastitis
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role of syncytiotrophoblasts and cytotrophoblasts in placental development
syncytiotrophoblasts invade the myometrium and develop an endothelial phenotype. Maternal spiral arteries are remodeled by invading fetal cytotrophoblasts to create a wide high capacitance low resistance vessel which facilitates delivery of oxygen and nutrients to the placental site note: in pre eclampsia the invasion of cytotrophoblasts is incomplete and shallow. The spiral arteries fail to be invaded and remain small caliber vessels causing placental hypoperfusion
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Produces short germinating hyphae on germ tube test (inoculation of a sample into animal serum) or at body temp
candida albicans note: risk factors include diabetes mellitus, systemic antibiotics, increased estrogen levels, decreased immunity
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Estrogens role in menstrual cycle
Estrogen levels are low at the beginning and rise slowly during the follicular phase Estrogen suppresses FSH and LH through negative feedback inhibition Estrogen reaches threshold and helf for atleast 2 days Causes positive feedback and a surge in FSH and LH Causes ovulation
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Most common inutero infection in the united states - petechial rash "blueberry muffin" baby - hepatosplenomegaly - periventricular brain calcification - jaundice - inflammation of the retina - sensorineural deafness - intracranial calcifications - microcephaly - heterophile negative mononucleosis
Congenital CMV infection tx with ganciclovir
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Congenital torch infections
ADD TORCH
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Osteolytic lesions and osteoblastic lesions in metastasis to bone
breast metastasis can produce both osteolytic and osteoblastic lesions lung, renal, and thyroid cancer generate osteolytic lesions

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