Reproductive 8% Flashcards
Dysfunctional uterine bleeding
Excessive uterine bleeding with no demonstrable organic cause:
Polymenorrhea (cycles with intervals of 21 days or fewer),
menorrhagia (abnormally heavy or prolonged bleeding) and/or
metrorrhagia (uterine bleeding at irregular intervals)
Dysfunctional uterine bleeding diagnosis; treatment
Diagnosis of exclusion;
treat with oral contraceptives and NSAIDs
Endometrial cancer
Postmenopausal vaginal bleeding;
most common GYN malignancy - usually adenocarcinoma.
Endometrial cancer diagnosis
Endometrial biopsy - vaginal bleeding in post menopausal women is CA until proven otherwise.
Endometrial cancer treatment
Hysterectomy bilateral salpingo-oophorectomy +/- radiation.
Endometriosis
A disease in which the kind of tissue that normally grows inside the uterus grows outside the uterus. It can grow on the ovaries, fallopian tubes, bowels, or bladder. Rarely, it grows in other parts of the body. A benign disease related to the menstrual cycle, usually cyclical
Endometriosis findings
Uterus is fixed and retroflexed. Tender nodularity of cul de sac and uterine ligaments.
Endometriosis diagnosis; treatment
Laparoscopy: Chocolate cysts observed. Definitive study.
Treatment: Resect endometriosis, oral contraceptive therapy.
Endometriosis associated with the 3 D’s:
Dyspareunia (painful intercourse),
dyschezia (difficulty in defecating),
dysmenorrhea
Leiomyoma
Also known as fibroids, is a benign smooth muscle tumor that very rarely becomes cancer (0.1%).
Leiomyoma presentation
Black women, family history.
Abnormal uterine bleeding; polymenorrhea, menorrhagia, intermenstrual bleeding and/or metrorrhagia along with urinary symptoms (eg, urinary frequency or urgency).
Uterine mass.
Leiomyoma diagnosis; treatment
Ultrasound: Intramural fibroids are most common. Definitive treatment: myomectomy or hysterectomy.
Prolapse presentation
Caucasian women, after labor/delivery, chronic cough. Vaginal fullness, abdominal pain worse late in day, after prolonged standing. Relieved by lying down.
Prolapse, uterus
Prolapse of the uterus into the vaginal canal - graded by uterine descent: 0°- No descent. 1° - descent between normal and ischial spine. 2°- between ischial spines and hymen. 3°- within hymen. 4° - through hymen.
Prolapse, bladder
Prolapse of the bladder into the front wall of the vagina (cystocele) - leads to a “reservoir effect” where the bladder is not completely emptied when the urine is passed.
Prolapse, rectum
Prolapse of the rectum into the back wall of the vagina (rectocele) - complain of a sensation of bulging in the vagina when they strain to open their bowels.
Ovarian Cysts
Pain, menstrual delay, hemorrhagic shock from cyst rupture. Follicular cysts are most common.
Ovarian Cysts diagnosis; treatment
Ultrasound.
Observe - Most resolve within 6-8 weeks (2 menstrual cycles). Persistent cysts, large cysts (>6 cm) or complex cysts can be removed.
PolyCystic Ovary Syndrome (PCOS)
Obesity, hirsutism, acne, amenorrhea or oligomenorrhea, menarche occurs at expected age. Strongly associated with obesity, acanthosis nigricans, insulin resistance and hyperinsulinemia.
PolyCystic Ovary Syndrome (PCOS) diagnosis; treatment
Ultrasound: String of pearls. Labs: LH:FSH > 2.0, increased androgens, increased testosterone.
Treat with oral contraceptives, metformin.
Ovarian Neoplasms
Patient in mid-50’s with abdominal fullness, bloating, fatigue, weight loss and ascites.
Ovarian Neoplasms diagnosis; treatment
Tumor marker: CA 125, second most common gynecological cancer (first is endometrial).
Asymptomatic premenopausal patients with simple ovarian cysts < 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives.
Postmenopausal women with simple cysts < 3 cm in diameter may also be followed, provided the serum CA 125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy. If the cyst is > 3 cm or the CA 125 is elevated, further evaluation is necessary.
Cervical cancer exam
Friable, bleeding cervical lesion.
Cervical cancer etiology
Squamous cell carcinoma. Most caused by HPV (High risk types, 16 and 18).
Cervicitis etiology
Usually occurs due to sexually-transmitted diseases, such as chlamydia or gonorrhea, herpes, HPV, trichomonas
Cervicitis exam
Cervical motion tenderness
Cervicitis treatment
Azithromycin for Chlamydia + Ceftriaxone for gonorrhea
Cervical Dysplasia
HPV especially types 16, 18. Associated with cigarette smoking. Transformational zone most commonly affected.
Cervical Dysplasia vaccine; diagnosis; treatment
Gardasil vaccine at age 11-12 it can be administered starting at 9 years of age.
Pap smear every 3 years starting at age 21 (regardless of sexual activity). Every 5 years if pap smear and HPV are negative starting at age 30.
ASC-US or LSIL, CIN-1: Reflex HPV, if positive and at least 25 years old – colposcopy, if negative or under 25 years old – retest in 1 year.
HSIL, CIN-2, CIN-3, CIS: Colposcopy. Outside cervix – LEEP or cryotherapy
Incompetent Cervix
History of cone biopsy, DES [Diethylstilbestrol (DES), also known formerly as stilboestrol, is a synthetic nonsteroidal estrogen] exposure.
Causes 2nd trimester abortion.
Cervical cerclage. Placed at 14-16 weeks and removed at 36 weeks to allow for delivery
Cystocele (bladder hernia)
Prolapse of the bladder into the front wall of the vagina - leads to a “reservoir effect” where the bladder is not completely emptied when the urine is passed.
Vaginal cancer
Abnormal vaginal bleeding.
Squamous cell carcinoma caused by HPV.
Vulvar Cancer
Vaginal pruritis is most common presentation.
Squamous cell and melanoma > pruritic black lesions. Paget’s > pruritic red lesions.
Vaginal Prolapse
Feeling of vaginal or pelvic pressure, heaviness, bulging, bowel or bladder symptoms. Common after hysterectomy.
Baden-Walker grades of female genital prolapse – uses the hymen as crossing point
Grade 1 – descent above the hymen, Grade 2 – descent to the hymen, Grade 3 – descent beyond the hymen, Grade 4 – total prolapse
Rectocele
Prolapse of the rectum into the back wall of the vagina - complain of a sensation of bulging in the vagina when they strain to open their bowels
Vaginitis, Trichomonas
Frothy yellow, green, gray vaginal discharge and strawberry cervix.
Wet mount: Flagellated protozoa. pH: Basic.
Treatment: Metronidazole
Vaginitis, Bacterial vaginosis
Organism: Haemophilus, aka Gardnerella.
Signs: Fishy odor, thin gray discharge.
Wet mount: Clue cells. pH: Basic 4.5
Treatment: Metronidazole.
Vaginitis, Candida
Thick white vaginal discharge. Associated with recent antibiotic use, diabetes mellitus, steroid use.
KOH prep: Pseudohyphae. pH: Normal 4.
Treatment: Fluconazole
Amenorrhea, primary
No menses by age 16.
Turner’s syndrome – XO karyotype, webbed neck, broad chest.
Androgen insensitivity – breast development only. Imperforate hymen – observed on speculum exam. Mullerian agenesis – secondary sex characteristics, no uterus
Amenorrhea, secondary
Previously had menses, amenorrhea for 6 months.
Most often pregnancy. Also caused by weight changes, hypothyroid, prolactinoma.
Dysmenorrhea
Pain with menses or precede menses by 1 to 3 days. Pain tends to peak 24 h after onset of menses and subsides after 2 to 3 days.
Dysmenorrhea, primary
Begins early after menarche, not associated with pelvic pathology, associated with prostaglandins, treatment with NSAIDs and oral contraceptive pills
Dysmenorrhea, secondary
New onset in an older women, associated with a secondary pathologic (structural) cause - adenomyosis, endometriosis, fibroid, PID, IUD, treat underlying cause.
Premenstrual syndrome (PMS)
Caused by an imbalance of estrogen and progesterone along with excess prostaglandin production.
Symptoms during luteal phase (1-2 weeks before menses) - Bloating, irritability. PMDD - causes marked disruption in functioning.
Symptoms resolve at the onset of menses.
Menopause
Menopause is a clincal diagnosis and is defined by cessation of menses for at least 12 months.
Average age is 51.5.
Menopause diagnosis; treatment
Definitive diagnosis: FSH > 30 mIU/mL
Women who have a uterus should be given a progestin in addition to estrogen because unopposed estrogen increases risk of endometrial cancer.
Menopause, contraindications for HRT
↑ triglycerides, undiagnosed vaginal bleeding, endometrial cancer, history of breast CA or estrogen sensitive cancers, CVD history, DVT or PE history
Breast abscess
Often is a complication of mastitis - symptoms are the same with the addition of localized mass and systemic signs of infection.
Breast abscess etiology; treatment
Staphylococcus aureus is the most common cause. Incision and drainage + antibiotics (nafcillin/oxacillin IV or cefazolin PLUS metronidazole)
Breast Cancer
Most common malignancy in women. Risk factors (increased exposure to estrogen): Menarche before age 12, old age of first full term pregnancy, no pregnancies, menopause after age 52.
Breast Cancer screening
Self breast exam, monthly beginning at age 20, immediately after menstruation or on days 5-7 of the menstrual cycle.
Clinical breast exam: every 3 years in women age 20-39 y/o then annually after age 40.
Mammogram every 2 years from age 50-74. Every 2 years beginning at age 40 if increased risk factors – 10 years prior to the age the 1’st degree relative was diagnosed.
Fibroadenoma
Young adult female with painless, firm solitary (rubbery feeling) well defined mobile breast mass. No changes with menstrual cycle.
Fibrocystic disease
Multiple bilateral breast masses that increase in size and pain before menses, usually resolves with the start of the menstrual cycle.
Aspiration of cysts: straw colored fluid with no blood.
Gynecomastia
Physiologic gynecomastia: affects pubescent boys. Watch and wait, typically resolved in 1 year
Gynecomastia etiology
Drugs: particularly spironolactone, anabolic steroids, and antiandrogens.
Klinefelter’s syndrome- XXY karyotype, tall, thin, long limbs. Hypogonadism. Treatment: Danazol
Galactorrhea
Bilateral milky breast secretions that occur in a non-lactating patient.
Rule out prolactin-secreting pituitary adenoma: TSH, CT or MRI.
Treat with dopamine agonist - bromocriptine.
Mastitis
Occurs in breastfeeding mothers.
Organism: S. aureus,
Treat with Dicloxacillin, warm compresses. Continue to breastfeed.
Pelvic inflammatory Disease exam
Chandelier sign (cervical motion tenderness).
Pelvic inflammatory Disease etiology
Causative agents include Gonorrhea and Chlamydia.
Pelvic inflammatory Disease complications
Infertility, ectopic pregnancy, tubo-ovarian abscess (adnexal mass).
Contraceptive Methods, barrier methods
Failure rates are as high as 40%, offer STI protection, safe for patients with contraindications to hormones.
Male condoms: 20% failure rate, offers STI protection.
Female condoms: 21% failure rate, offers STI protection.
Diaphragm: 15% failure rate, must remain in place 6-24 hours after intercourse, requires pelvic exam and fitting.
Contraceptive Methods, spermicides
Nonoxynol-9.
Destroys sperm - often used with other forms of BCP such as condoms.
27% failure rate.
Slight increased risk for HIV.
Contraceptive Methods, OCP’s
9% failure rate, 0.3% failure rate when used correctly.
Improves dysmenorrhea and controls menstrual cycle.
Combined estrogen and progesterone - not used in women > 35 years of age that are smokers, patients with history of blood clots, breast cancer or migraines with aura.
35 and younger who smoke OK
Contraceptive Methods, Progestin-only mini pill
9% failure rate, 0.3% failure rate when used correctly.
Safe in lactation - can be used in breastfeeding woman.
No estrogenic side effects (headache, nausea, HTN).
Contraceptive Methods, Transdermal patch
The contraceptive efficacy of the transdermal patch is comparable to that of combined OCP’s.
The failure rate is 0.3 percent with perfect use and 9 % with typical use.
Contraceptive Methods, NuvaRing
Flexible plastic vaginal ring.
7% failure rate.
Applied every week for 3 weeks then 1 week off.
Contraceptive Methods, IUD
Most effective form of birth control. Reversible.
Copper IUD (Paragard) - 0.8% failure rate, women who cannot have hormones that want children later in life (replaced every 10 years).
Progestin-only IUD (Mirena)- 0.2% failure rate, replaced every 3-5 years.
Contraceptive Methods, Depo-Provera
Long-acting progesterone injection.
5% failure rate; lasts 3 months.
Contraceptive Methods, Implanon
Long-acting progesterone implanted in the upper arm;
0.05% failure rate; lasts 3 years
Contraceptive Methods, Emergency contraception
Up to 25% failure rate
Levonorgestrel emergency contraceptive (Plan B One-Step, etc) within 3 days of unprotected sex or prescribe Ella (ulipristal) within 5 days.
Recommend backup for 7 days after levonorgestrel…and for 14 days or until the next period after Ella, whichever comes first.
Contraceptive Methods, Sterilization
Tubal ligation - 0.5% failure rate, permanent.
Essure - chemicals or coils to scar fallopian tubes - 0.5% failure rate, can be done in office.
Vasectomy - 0.15% failure rate - vas deferens from each testicle is clamped, cut, or otherwise sealed. This prevents sperm from mixing with the semen that is ejaculated from the penis.
Infertility
Failure to conceive after 1 year of unprotected intercourse.
First step: Test male sperm.
Anovulation is the most common cause - amenorrhea and abnormal periods.
65% female, 20-40% male, 15% unknown.
Treatment for anovulatory women: Clomiphene citrate.
Normal labor/delivery, cervical examination
Dilation – up to 10 cm.
Effacement (softening) – up to 100%.
Station (position of the baby the head) – 0 is at ischial spine.
Stages of labor
Stage 1: Onset contractions to full dilation (primi- 6-20 hours ) (multi- 2-14 hours).
Stage 2: Full dilation to baby delivery (primi- 30 mins-3 hours) (multi- 5-6 minutes).
Stage 3: After baby delivery to expulsion of placenta (0-30 mins).
Placenta should have 2 arteries and 1 vein.
APGAR score
Activity (2=active movement), Pulse (2= >100 BPM), Grimace (2= pulls away, sneeze), Appearance (2=pink), Respiration (2=crying).
Score from 1-10 with > 7 normal, 4-6 fairly low, 3 and under critically low. A score of 4 necessitates resuscitation.
Test is done at 1 and 5 minutes after birth
Prenatal diagnosis/care, G_ P_ or G_ P _ _ _ _
G is the number of pregnancies.
P is the number of deliveries.
Or P is full-term deliveries, premature deliveries, abortions, living children.
Prenatal diagnosis/care,
Nagel’s rule for due date:
Chadwick’s sign:
Hegar’s sign:
LMP + 7 days - 3 months.
Blue cervix.
Cervical softening.
Prenatal diagnosis/care, Advanced maternal age
Age 35 - offer testing for genetic abnormalities.
Prenatal diagnosis/care, Total weight gain range
25–35 lb, except in obese women, for whom weight gain should be <15 lb.
Prenatal diagnosis/care, Folic acid supplementation
0.4–0.8 mg prior to conception; 4 mg for secondary prevention.
Prenatal diagnosis/care, office visit schedule
Monthly visits to a healthcare professional for weeks 4–28 of pregnancy
Visits twice monthly from 28 to 36 weeks
Weekly after week 36 (delivery at week 38–40)
Prenatal diagnosis/care, First trimester (weeks 1-12)
Fetal heart tones: 10-12 weeks. Screening: PAPP-A; Free beta HCG; Ultrasound: nuchal translucency (10-13 weeks); >3.5 mm – trisomy or neural tube defect. CVS (10-13 weeks).
Prenatal diagnosis/care, Second trimester (weeks 13-27)
Fetal movement: Nullipara: 18-20 weeks, Multipara: 14-16 weeks.
Uterine growth: At umbilicus @ 20 weeks; weeks gestation should equal fundal height in cm.
Screening:
Maternal AFP (increased = neural tube defects, decreased = trisomy);
Inhibin A;
Unconjugated estriol.
Ultrasound (18-20 weeks) - anatomy scan, gender reveal.
Amniocentesis (15-18 weeks).
Prenatal diagnosis/care, Third trimester (weeks 28- birth)
Full term is 37 weeks. Plan for induction after 40 weeks.
Vaccines: Tdap (28 weeks); Rhogam (28 weeks) – for Rh-negative mothers only.
Screening:
Gestational diabetes [(24-28 weeks): 50g non fasting 1-hour test followed by 3-hour GTT if > 130 mg/dl on 1-hour];
Rh antibodies for Rh-negative mothers (28 weeks); Vaginal-rectal culture for Group B strep (35 weeks) - If positive, treat with IV penicillin during delivery; Nonstress test: 20-minute monitoring - should see two accelerations (15 BPM above baseline, for 15 seconds), and no decelerations;
Biophysical profile: NST, amniotic fluid level, fetal movements, fetal tone, fetal breathing.
Abortion, threatened
Vaginal bleeding, closed cervical os.
Abortion, inevitable
Vaginal bleeding, open cervical os, no passage of tissue.
Abortion, incomplete
Vaginal bleeding and tissue passage from open cervical os.
Abortion, complete
Complete passage of fetal tissue.
Abruptio placentae
Painful vaginal bleeding in the third trimester.
Abruptio placentae, treatment
Delivery of the fetus and placenta is definitive treatment; blood type, cross-match and coag studies as well as placement of large bore IV line;
Cesarean section most often is the preferred route for delivery.
Cesarean section
C-sections constitute about 32% of deliveries in the United States.
Most common reasons for cesarean are a previous cesarean, dystocia or failure to progress, breech presentation and fetal distress.
Dystocia
Abnormal labor progression;
Macrosomia (big baby), small pelvis, poor contractions.
Shoulder Dystocia
Failure of the shoulders to deliver spontaneously after delivery of the fetal head.
Turtle Sign - retraction of the delivered head against the maternal perineum.
McRoberts maneuver and Woods “Corkscrew”
Ectopic pregnancy; diagnosis
Most often in ampulla.
Serial quantitative Beta HCG; HCG is > 1,500, but no fetus in utero. Normal pregnancy HCG increases by 66% every 48 hours.
Transvaginal ultrasound: Ring of fire sign (hypervascular lesion with peripheral vascularity on Doppler).
Fetal distress, Non-stress testing
GOOD - Reactive NST > 2 accelerations in 20 minutes, with increased fetal heart rate 15 bpm lasting > 15 seconds, indicates fetal well being.
BAD - Nonreactive NST - No fetal heart rate accelerations or < 15 bpm lasting < 15 seconds, get contraction stress test.
Fetal distress, Contraction stress test
Measures fetal response to stress at times of uterus contraction.
GOOD - Negative CST - No late decelerations in the presence of 2 contractions in 10 minutes, indicates fetal well being, repeat CST as needed.
BAD - Positive CST - Repetitive late decelerations in the presence of 2 contractions in 10 minutes, worrisome especially if nonreactive NST, prompt delivery.
Gestational diabetes, Glucose tolerance test
Between 24 and 28 weeks of gestation - 50 g (1 hour) glucose challenge test (non-fasting). Positive if blood glucose is > 130 mg/dL.
If ≥ 130 mg/dl after 1 hour then get a 3 hour 100 g glucose tolerance test (GOLD STANDARD)
Results are positive if: One hour > 180, Two hour > 155, Three hour > 140.
Gestational diabetes, complication; treatment
Most common complication: macrosomia.
Insulin is considered first line therapy, glyburide, dietary management.
Gestational trophoblastic disease signs; symptoms
Beta HCG higher than expected, size-date discrepancy, hyperemesis.
Gestational trophoblastic disease, Mole Types
Complete mole - no fetal parts “Grape-like” mass or “snowstorm” on transvaginal ultrasound.
Incomplete mole - fetal parts.
Choriocarcinoma - cancer of gestational contents.
Hypertension in pregnancy, goal, Rx, contraindicated Rx
Treatment goal: < 140/90.
Treat with Methyldopa, Hydralazine, metoprolol.
Contraindicated: ACE inhibitors, ARBs, diuretics, calcium channel blockers.
Preeclampsia
Classic triad: HTN, + Proteinuria and edema after 20 weeks GA.
Eclampsia
HTN, + Proteinuria + seizures or coma.
Treatment: magnesium and delivery.
HELLP syndrome
A manifestation of preeclampsia with hemolysis, elevated liver enzymes, and low platelets.
Multiple gestation
One in 80 births; 3% chance of twins; monitor for complications.
Elevated beta-HCG.
Two or more fetuses observed on ultrasound.
Monozygotic: identical; Dizygotic: fraternal.
Placenta previa
Painless vaginal bleeding *bright red in 3rd trimester (versus painful, dark red vaginal bleeding in placenta abruptio) usually no abdominal pain.
Placenta previa precautions
No pelvic/cervical digital exam, no intercourse, no vigorous exercise.
Postpartum hemorrhage
Blood loss: > 500 mL of blood within the first 24 hours after vaginal delivery or 1,000 ml with cesarean.
Postpartum hemorrhage, Uterine atony
A boggy and enlarged uterus - 90% of postpartum hemorrhages.
Treatment: Uterotonic agents (contracts the uterus down): Oxytocin IV, Misoprostol, bimanual uterine massage, last resort hysterectomy.
Postpartum hemorrhage, Genital Track Trauma
Precipitous labor, operative vaginal delivery (forceps, vacuum extraction).
Treatment: Laceration greater than 2 cm are repaired surgically.
Postpartum hemorrhage, Retained Placental Tissue
Occurs when separation of the placenta from uterine wall or expulsion of the placenta is incomplete.
Treatment: Surgery.
Postpartum hemorrhage, Coagulation Disorders
DIC associated with severe preeclampsia, amniotic fluid embolism, placental abruption.
Premature rupture of membranes (PROM)
Clinical definition: rupture of membranes at ≥ 37 weeks gestation prior to the start of uterine contractions.
Preterm premature rupture of membranes (PPROM) describes PROM < 37 weeks gestation.
Premature rupture of membranes (PROM), diagnosis
Need to confirm that this is truly amniotic fluid.
Speculum - fluid pooling in posterior fornix.
Nitrazine test - blue (due to elevated pH) determine if this is amniotic fluid - PH > 7.1 means it is positive.
Microscope examination: ferning - take a specimen of the fluid put it on a slide and let it air dry will see “fern pattern” crystallization of the amniotic fluid (crystallization of estrogen and amniotic fluid).
Premature rupture of membranes (PROM), treatment
Depends on gestational age:
> 34 weeks – induce labor;
32-34 weeks collect fluid and check for lung maturity – then induce;
< 32 weeks stop contractions and start 2 doses of steroid injection then deliver the baby – give antibiotics.
RH incompatibility
Rh negative mother, Rh positive fetus.
1st pregnancy is always unaffected.
Give Rhogam at 28 weeks, within 72 hours of delivery and during any uterine bleeding throughout pregnancy.
Given if Rh negative mother and father Rh positive or unknown. Risk of hydrops fetalis
