Reproductive System Flashcards
Female Tanner Staging: Stage 1
- Breast: Papilla elevation only
- Pubic hair: None
Female Tanner Staging: Stage 2
- Breast: breast buds palpable, areola enlarge
- Pubic hair: Small amount (long, downy hair on the labia)
Female Tanner Staging: Stage 3
- Breast: Elevation of areola contour, areola continues to enlarge
- Pubic hair: Hair becomes more coarse and curly with lateral extension
Female Tanner Staging: Stage 4
Breast: secondary mound of areola
Pubic hair: Adult-like, extends across pubis
Female Tanner Staging: Stage 5
Breast: Adult breast contour
Pubic Hair: Extends to thighs
What is the most common etiology of dysfunctional uterine bleeding (DUB)?
Chronic anovulation (90%)
Workup of DUB (2)
- Hormone levels, transvaginal US
- Endometrial biopsy done if endometrial strip >4mm on transvaginal US or in women >35 years old to r/o endometrial hyperplasia or carcinoma
DUB treatment: acute severe bleeding
- High dose estrogens, high dose OCPs with reduction in dose as bleeding improve.
- D&C if IV estrogen fails
DUB treatment: anovulatory cause (3)
- OCPs
- Progesterone: used if estrogen is CI
- GnRH agonists: Leuprolide causes temporary amenorrhea
DUB treatment: ovulatory cause (3)
- OCPs
- Progesterone: orally or IUD
- GnRH agonists (leuprolide)
DUB treatment: Surgical options (2)
- Hysterectomy (definitive treatment)
- Endometrial ablation
Primary dysmenorrhea
Not due to pelvic pathology. Due to increased prostaglandins. Pain usually 1-2 years after onset of menarche in teenagers
Secondary dysmenorrhea
Due to pelvic pathology (ex: endometriosis, adenomyosis, leiomyomas, adhesions, PID). MC seen as women age
Dysmenorrhea: Management (3)
- NSAIDs. Supportive: local heat, vitamin E 2 days prior and 3 days into menses
- OCPs/Depo-provera/vaginal ring
- Laparascoopy: If medications fails (endometriosis MC in younger patients, adenomyosis in increasing age)
What is premenstrual syndrome?
Cluster of physical, behavioral, mood changes with cyclical occurrence during luteal phase of menstrual cycle and at least 7 days symptom free during the follicular phase
What is premenstrual dysphoric disorder (PMDD)?
Severe PMS with functional impairment
Premenstrual syndrome: Management (5)
- SSRIs
- OCPs: Drosperinone-containing OCP for PMDD
- GnRH
- Refractory breast pain: Danazol, bromocriptine
- Bloating: Spironolactone, calcium carbonate, low salt diet
Amenorrhea work-up
Pregnancy test, prolactin, FSH, LH, TSH
What is primary amenorrhea?
Failurue of onset of menarche by age 13 years (in the absence of secondary sex characteristics) or age 15 years (with secondary sex characteristics)
Amenorrhea: If the uterus and breasts are present, what may it signify?
Outflow obstruction: Transverse vaginal septum, imperforate hymen
Amenorrhea: If the uterus is absent but the breasts are present, what may this signify? (2)
- Mullerian Agenesis (46 XX)
- Androgen insensitivity (46 XY)
Amenorrhea: If the uterus is present, but the breasts are absent, what may this signify? (2)
- Elevated: Increased FSH, Increased LH = ovarian causes
- Premature ovarian failure (46 XX)
- Gonadal dysgensis (ex: Turner 45XO)
- Normal/Low: Decreased FSH, Decreased LH
- Hypothalamus-pituitary failure
- Puberty delay (ex: athletes, illness, anorexia)
Amenorrhea: If the uterus and breasts are absent, what may this signify?
Rare. Usually caused by a defect in testosterone synthesis. Presents like a phenotypic immature girl with primary amenorrhea (will often have intrabdominal testes)
What is secondary amenorrhea?
Absence of menses for 3 months in a patient with previously normal menstruation (or 9 months in a patient who was previously oligomenorrheic)
Secondary amenorrhea: hypothalamus dysfunction etiologies (5)
- Hypothalamus disorder
- Anorexia (or weight loss 10% below IBW)
- Exercise
- Stress nutritional deficiencies
- Systemic disease (ex: Celiac)
Secondary amenorrhea: Hypothalamus dysfunction diagnosis
Normal/low FSH and LH; low estradiol, normal prolactin
Secondary amenorrhea: hypothalamus dysfunction treatment
Stimulate gonadotropin secretion: clomiphene, menotropin (pergonal)
Secondary amenorrhea: Pituitary dysfunction diagnosis
Decreased FSH, LH, Increased prolactin. MRI of pituitary sella
Secondary amenorrhea: pituitary dysfunction treatment
Transsphenoidal surgery (tumor removal)
Secondary amenorrhea: ovarian disorder clinical manifestations
sx of estrogen deficiency (similar to menopause): hot flashes, sleep & mood disturbances, vaginal dryness, dyspareunia, dry/thin skin
Secondary amenorrhea: lab levels for ovarian abnormalities
- Increased FSH
- Increased LH
- Decreased estradiol
Secondary amenorrhea: lab values for pituitary or hypothalamus causes
- Normal/Decreased FSH, LH
With the progesterone challenge test, if there is withdrawal bleeding, what does this signify?
Ovarian (patient is anovulatory or oligoovulatory) and there is enough estrogen present
With the progesterone challenge test, if there is no withdrawal bleeding, what does this signify?
- hypoestrogenic ex. HP failure OR
- Uterine (ex: Asherman’s or uterine outflow tract [imperforate hymen])
What is Asherman’s syndrome?
Acquired endometrial scarring usually secondary to postpartum hemorrhage, s/p D&C or endometrial infection
Secondary amenorrhea: Uterine disorder diagnosis (2)
- Pelvic US: absence of normal uterine stripe.
- Hysteroscopy: to diagnose and treat
Secondary amenorrhea: uterine disorder treatment
Estrogen treatment: to stimulate endometrial regeneration of denuded area
What is adenomyosis?
Islands of endometrial tissue within myometrium
Adenomyosis: clinical manifestations (2)
- Menorrhagia (progressively worsens)
- Dysmenorrhea, +/- infertility
Adenomyosis: Physical examination
Tender symmetrically (uniformly) enlarged “boggy uterus”*, “globular” enlargement
Adenomyosis: Diagnosis (2)
- Diagnosis of exclusion of secondary amenorrhea. MRI
- Post-TAH examination of uterus: definitive dx
Adenomyosis: Treatment (2)
- Total abdominal hysterectomy (TAH): only effective therapy
- Conservative tx: to preserve fertility, analgesics, low dose OCPs
What is a leiomyoma?
Benign uterus smooth muscle tumor. MC benign gynecological lesion
Different types of leiomyomas
Intramural, submucosal, subserosal, parasitic
Which population is at the highest risk of having leiomyomas?
African-Americans
Leiomyoma: diagnosis
Pelvic US: shadowing. Also used to observe for growth
For the majority of patients, what the treatment of leiomyomas?
Observation
Medical management of leiomyomas (2)
- Progestins (ex: medroxyprogesterone)
- Leuprolide: Most effective medical tx
Surgical management of leiomyomas (3)
- Myomectomy: used especially to preserve fertility
- Endometrial ablation, artery embolization. May affect fertility
- Hysterectomy: Definitive tx***. MC cause for hysterectomy
MC organisms in endometritis (4)
GABHS, S. aureus, anaerobes, polymicrobial (vaginal flora)
With endometritis, in patients who have given birth via C-section, what is the antibiotic treatment that is given to prevent endometritis?
1st generation cephalosporin x 1 dose during c-section (cefazolin)
Endometritis: Diagnosis
Clinical: pts with fever, abdominal pain, and uterine tenderness esp. with C-section or postabortal
Endometritis: Management (2)
- Infection with C-section: Clindamycin + Gentamicin
- Infection with vaginal delivery or chorioamnionitis: Ampicillin + Gentamicin
MC sites of endometriosis
Ovaries*, posterior cul-de-sac, broad & uterosacral ligaments, rectosigmoid colon, bladder & distal ureter
Endometriosis: Risk factors (3)
- Nulliparity
- Family history
- Early menarche
Classic triad of endometriosis (3)
- Cyclic premenstrual pelvic pain +/- low back pain
- Dysmenorrhea
- Dysparenunia; dyschezia (painful defecation). Pre-post menstrual spotting
What is the most common cause of infertility in women?
Endometriosis
Endometriosis: Diagnosis (2)
- Laparoscopy with biopsy: definitive diagnosis*
- Endometrioma (endometriosis involving the ovaries large enough to be considered a tumor, usually filled with old blood appearing chocolate colored [chocolate cyst])
Endometriosis: Medical management (4)
- Premenstrual pain: Combined OCPs + NSAIDs
- Progesterone tx
- Leuprolide (GnRH analog)
- Danazol (testosterone)
Endometriosis: Surgical management (2)
- Conservative laparoscopy with ablation (used if fertility is desired)
- TAH-BSO (if no desire to conceive)
Endometrial hyperplasia: clinical manifestations
Menorrhagia, metrorrhagia, postmenopausal bleeding, +/- vaginal discharge
Endometrial hyperplasia: Diagnosis (2)
- Transvaginal US (TVUS): >4 mm* (screening test)
- Endometrial biopsy: definitive diagnosis**
When is an endometrial biopsy used with endometrial hyperplasia? (
- Women >35 years old
- Increased endometrial strip seen on TVUS
- Unopposed estrogen tx
- Tamoxifen
- Atypical glandular cells on Pap smear or persistent bleeding despite endometrial stripe <4mm
Endometrial hyperplasia without atypia: Treatment (2)
- Progestin tx (PO or IUD-Mirena)
- Repeat endometrial biopsy in 3-6 months
Endometrial hyperplasia with atypia: Treatment (2)
- Hysterectomy
- Progestin tx if not surgical candidate or pt wishes to preserve fertility
What is the MC gynecological CA in the US?
Endometrial cancer
Endometrial Cancer: With the endometrial biopsy, what is the most common subtype of endometrial cancer?
Adenocarcinoma (>80%)
Endometrial cancer: Treatment (2)
- Stage I: Hysterectomy +/- psot op radiation treatment
- Stage II: TAH-BSO + lymph node excision + post-op radiation treatment
What is the most effective treatment for menopausal symptoms?
Estrogen only
Risks of estrogen only HRT (2)
- Thromboembolism
- Increased risk of endometrial cancer (often used in patients with no uterus)
What coud vaginal bleeding + abdominal pain + amenorrhea signify?
Threatened abortion (MC), ectopic, nonviable pregnancy
Pelvic organ prolapse: Grades
Grade I: descent into upper 2/3 of vagina
Grade II: cervix approaches introitus
Grade III: Outside introitus
Grade IV: entire uterus outside the vagina - complete prolapse
Pelvic organ prolapse: Prophylactic treatment
kegel exercises, weight control
Pelvic organ prolapse: nonsurgical treatment (2)
- Pessaries
- Estrogen treatment
Pelvic organ prolapse: surgical treatment (2)
- Hysterectomy
- Uterosacral or sacrospinus ligament fixation
Pharmacologic treatment for stress incontinence
- Alpha agonists: Midodrine, pseudoephedrine
- Estrogen: Cream or estradiol-impregnated vaginal ring
Pharmacologic treatment for urge incontinence (3)
- Anticholinergics (1st line meds): Tolterodine, propantheline, oxybutynin
- TCAs: Imipramine
- Mirabegron: Beta-3 agonist
Pharmacologic treatment for overflow incontinence (2)
- Cholinergics: bethanacol
- Alpha-1 blockers: Tamsulosin (for BPH)
Functional ovarian cysts: Treatment (2)
- Supportive: Most cysts <6-8 cm are functional and usually spontaneously resolve. Rest. NSAIDs, repeat pelvic US in 6 weeks.
- OCPs
Functional ovarian cysts: complications (2)
- Ovarian torsion
- Bleeding
What is the second most common type of gynecological cancer that also has the highest mortality of all gyn cancers?
Ovarian cancer
Ovarian cancer: Risk factors (5)
- +FH
- increased number of ovulatory cycles (infertility, nulliparity, >50 yo)
- BRCA1 & BRCA2
- Peutz Jehgers
- Turner’s syndrome
Ovarian cancer: PE (3)
- Abdominal or ovarian mass, ascites*
- Sister Mary Joseph’s node: METS to umbilical lymph nodes
- Constipation
Ovarian cancer: Diagnosis (2)
- Biopsy: 90% are epithelial tumors (seen esp. postmenopausal). Germ cell tumors in pts <30 years
- Transvaginal US useful screening in high risk patietns. Mammography to look for primary in breast
Ovarian cancer: Management (3)
- Early stage: TAH-BSO + selective lymphadenectomy
- Surgery: Serum Ca-125 levels are used to monitor treatment progress*
- Chemotherapy: Paclitaxel + Cisplastin or carboplatin
What is the MC type of benign ovarian neoplasm?
Dermoid cystic teratomas
Benign ovarian neoplasms: treatment
Surgery
PCOS: Labs
Increased testosterone, increased DHEA-S (Intermediate of testosterone); Increased LH: FSH ratio 3:1
Anti-adrogenic agents for hirustism in PCOS
Spironolactone*, leuoprolide, finasteride
Pap smear results: Negative for intraepithelial lesion or malignancy (no neoplasia)- No HPV management (4)
Follow routine PAP screening
- Every 2 years starting age 21 until 29 y
- Every 3 years ≥30y (if h/o 3 negative cytologies previously)
- Yearly if HIV, in-uteruo DES exposure, increased risk factors
- D/C age 65-70 y (if last 3 PAP’s were normal)
Pap smear results: Negative for intraepithelial lesion or malignancy (no neoplasia): Greater than 25 yo and HPV management (2)
Two options:
- cytology and HPV testing in 12 months OR
- Genotype for HPV 16, 18
ASC-US: Management if greater than 25 (2)
Two possible options
- Do HPV testing*: HPV negative –> repeat PAP and HPV cotesting in 3 years; HPV positive –>colposcopy with biopsy
- Repeat PAP in 1 y. If negative, resume PAP screening. Colposcopy if positive
ASC-US or LSIL Management if 21-24yo
Repeat PAP in one year or HPV testing
ASC-US Management if <21 yo
Repeat PAP in one year
ASC-H Management
Colposcopy allows for visualization of cervix using magnification after applying dilute acetic acid for accentuation of lesions
LSIL (inlcudes CIN I): Management for 25-29yo
Colposcopy with biopsy
LSIL (includes CIN I): Management for ≥ 30yo (2)
- HPV negative –> repeat cytology in 1 year
- HPV positive –> colposcopy with biopsy
HSIL (Includes CIN II, CIN III, and carcinoma in situ) Management
Colposcopy in all ages
Pap smear: Glandular cell abnormalities management (2)
- Colposcopy for all glandular cells abnormalities
- Glandular abnormalities may be indicative of endometrial hyperplasia
LSIL (CIN I) : Managment (3)
- Observation: 75% resolve by immune system within one year. May be an option if <20 y
- Excision: LEEP procedure or cold knife cervical conization
- +/- Ablation
HSIL (CIN 2, CIN 3, and carcinoma-in-situ) Management (2)
- Excision: LEEP, cold knife cervical conization
- Ablation: Cryocautery, laser cautery, electrocautery
2 types of cervical carcinomas
Squamous (90%) and adenocarcinoma (10%)
Clear cell carcinoma linked to DES
Cervical carcinoma: Stage 0 (carcinoma in situ) treatment (3)
- Exicision (LEEP, cold knife cervical conization); preferred
- Ablation tx (cryotherapy or laser)
- TAH-BSO
Cervical carcinoma: Stage Ia1 (microinvasion)
Surgery: Conization, TAH-BSO, XRT
Cervical carcinoma: Other Stage I, IIA
TAH-BSO; XRT + chemo tx (cisplatin)
Cervical carcinoma: Stage IIb-IVa (locally advanced) management
XRT + Chemo (Cisplatin +/- 5FU)
Cervical carcinoma: Stage IVb or recurrent (distant METS)
Palliative XRT, chemo (surgery is not likely to be curative)
What is cervical insufficiency (incompetent cervix)?
Premature cervical dilation especially in 2nd trimester
Cervical insufficiency: PE
Painless dilation and effacement of cervix
Cervical insufficiency: Management (2)
- Bed rest, weekly injection of 17 α-hydroxyprogesterone (increases progesterone)
- Cerclage (suturing of cervical os)
What is the most common subtype of vulvar cancer?
90% squamous
Vulvar cancer: clinical manifestations (2)
- Pruritus MC presentation (70%), vaginal itching, irritation
- Asymptomatic (20%). Post-coital bleeding, vaginal discharge
Vulvar cancer: diagnosis
Red/white ulcerative, crusted lesions. Biopsy
Vulvar CA: Treatment (4)
Surgical excision, XRT, chemo (ex: 5-FU), laser treatment
Vulvovaginal atrophy: management (3)
- Vaginal estrogens
- Ospemifene: SERM (estrogen agonist in vagina; antagonist in breast, uterus)
- Vaginal moisturizers (won’t help with atrophy)
What is the MC cause of vaginitis?
Bacterial vaginosis
MC organisms for bacterial vaginosis
Gardnerella vaginalis, anaerobes
Bacterial vaginosis: Vaginal discharge
Thin, homogenous, watery grey-white “fish rotten” smell
Bacterial vaginosis: urinary pH
>5
Bacterial vaginosis: Microscopic (2)
- Clue cells*
- Few WBCs, few lactobacilli
Bacterial vaginosis: Management (2)
- Metronidazole (Flagyl) x 7 days
- Clindamycin
Trichomoniasis: vaginal discharge (3)
- Copious malodorous discharge
- Frothy yellow green discharge*
- Strawberry cervix* (cervical petechiae)
Trichomoniasis: pH
>5
Trichomoniasis: Microscopic (2)
- Mobile protozoa (wet mount)
- WBCs
Trichomoniasis: Management (2)
- Metronidazole (Flagyl): Oral preferred
- Tinidazole
Trichomoniasis: Prevention (2)
- Spermicidal agents
- MUST TREAT PARTNER
Candida vulvovaginitis: vaginal discharge
Thick curd-like/cottage cheese discharge
Candida vulvovaginitis: urinary pH
Normal
Candida vulvovaginitis: Microscopic
Hyphae, yeast on KOH prep
Candida vulvovaginitis: Management (2)
- Fluconazole
- Intravaginal antifungals: Clotrimazole, nystatin, butoconazole, miconazole
Cytolytic vaginitis: Pathophysiology
Overgrowth of lactobacilli
Cytolytic vaginitis: vaginal discharge
Nonodorous discharge white to opaque
Cytolytic vaginitis: Urinary pH
Normal
Cytolytic vaginitis: Management (2)
- Discontinue tampon usage (to decrease vaginal acidity)
- Sodium bicarbonate (sitz bath or douche)
What is the MC cause of cervicitis?
Chlamydia
Chlamydia: Diagnosis (2)
- LCR test most spp/sensitive
- Cultures, DNA probe
Chlamydia: Treatment (2)
- Azithromycin OR doxycycline
- Treat for gonorrhea
Chlamydia: second line treatment (2)
- Erythromycin, ofloxacin, levofloxacin
- Cultures, DNA probe
Chlamydia: Prevention
Avoid sexual intercourse 7d after treatment
Chlamydia: Complications
PID, infertility, ectopic pregnancy, premature labor
Gonorrhea: Diagnosis
Culture, DNA
Gonorrhea: Management (3)
- Ceftriaxone IM
- Cefixime
- Treat for chlamydia
Gonorrhea: Complications (2)
- PID, infertility, ectopic pregnancy
- Reactive arthritis
Chancroid: Clinical manifestations (3)
- Genital ulcer: soft, shallow, painful*
- +small vesicles or papules
- PAINFUL inguinal LAD
Chancroid: Management (4)
- Azithromycin
- Ceftriaxone IM
- Erythromycin
- Ciprofloxacin
PID: Outpatient treatment
Doxycycline + ceftriaxone (cover gonorrhea & Chlamydia) OR clindamycin + gentamicin
PID: Inpatient treatment
Doxycycline + 2nd generation cephalosporin (ex: Cefoxitin or Cefotetan)
Toxic shock syndrome: Diagnosis
CBC, cultures, clinical. Isolation of organism is NOT required
Toxic shock syndrome: Management (3)
- Hospital admission, supportive measures
- Anti-staphylococcus abx x 1-2 weeks: Clindamycin + Oxacillin or Nafcillin
- If MRSA: Clindamycin + Vancomycin (or Linezolid)
Management of cystitis in pregnancy
- amoxicillin*, augmentin, cephalexin, macrobid, cefpoxidime, fosfomycin
- Sulfisoxazole
SERM (tamoxifen) is an agonist in what systems?
Bone, endometrium, liver, and coagulation system
Ectopic pregnancy: Physical examination
Cervical motion tenderness, adnexal mass
Indications for methotrexate in ectopic pregnancy
Hemodynamically stable patients, early gestation <4 cm, beta-HCG <5,000
Shoulder dystocia: nonmanipulative treatment
McRoberts maneuver
Shoulder dystocia: manipulative treatment
Woods “Corkscrew” maneuver; C section
What is a hydatidiform mole?
Neoplasm due to abnormal placental development with trophoblastic tissue proliferation arising from gestational tissue (not maternal) origing
What is a complete molar pregnancy?
Egg with no DNA fertilized by 1 or 2 sperm. 46XX all paternal chromosomes. Associated with a higher risk of malignant potential (choriocarcinoma development)
Gestational Trophoblastic Disease (Molar pregnancy): Clinical manifestations (4)
- Painless vaginal bleeding
- Uterine size/date discrepancies
- Hyperemesis gravidarum
- Choriocarcinoma
With choriocarcinoma, where is the most common METS location?
Lungs
Gestational Trophoblastic Disease (Molar Pregnancy): Diagnosis (2)
- Beta-HCG: Markedly elevated (>100,000)
- Ultrasound: “Snowstorm” or “cluster of grapes” appearance
Gestational Trophoblastic Disease (Molar Pregnancy): Treatment (2)
- Uterine suction curettage ASAP
- METS: chemotherapy (ex: Methotrexate*) destroys trophoblastic tissue
When is gestational DM usually diagnosed?
24-28 weeks of gestation
Gestational DM: Pathophysiology
Caused by placental release of human placental lactogen (HPL), which antagonizes insulin
Gestational DM: Diagnosis (3)
- Screening: 50g oral glucose challenge test (nonfasting) @ 24-28 weeks gestation. If >140mg/dL in one hour –> proceed to 3 hour oral GTT
- 3 hour 100g oral GT: Gold standard*
- Glucosuria
When is a 3 hour oral GTT considered to be positive?
1 hour >180
2 hour >155
3 hour >140
Gestational DM: Treatment (3)
- Insulin: Tx of choice! (does not cross the placenta)
- Glyburide: higher risk of eclampsia
- Early delivery @ 38 weeks
With gestational DM, what is the fasting glucose goal?
<95
Gestational DM: Insulin requirements (2)
- NPH/regular insulin: 2/3 in the AM and 1/3 in the PM
- 0.8 IU/kg 1st trimester; 1.0 IU/kg in 2nd trimester; 1.2 IU/kg in 3rd trimester
RH alloimmunization: Clinical manifestations
- If subsequent newborn is Rh positive: hemolytic anemia, jaundice, kernicterus, hepatosplenomegaly
- Fetal hydrops, congestive heart failure in the newborn
What is fetal hydrops?
Fluid accumulation in 2 spaces: Pericardial effusion, ascites, pleural effusion, SQ edema
When is RhoGAM given in the mother?
At 28 weeks gestation and also within 72 hours of delivery of the Rh positive fetus
Treatment of erythroblastosis fetalis in the newborn (in Rh alloimmunization)
Moderate to severe anemia treated with Ag negative RBCs through ultrasound-guided umbilical vein transfusion
Premature rupture of membranes (PROM): Risk factors (4)
- STDs
- Smoking
- Prior pre-term delivery
- Multiple gestations
PROM: Diagnosis (3)
- Nitrazine test: amniotic fluid pH>7.1
- Fern test: amniontic fluid: fern pattern
- Sterile speculum exam: look for infection
PROM: Management (2)
- Await for spontaneous labor or induction of labor (with oxytocin or prostaglandin gel)
- Monitor for infection (infection MC complication of PROM)
If the cervical dilation is ≥3 cm and the effacement is 80%, what is the diagnosis?
Premature labor (PTL)
If the cervical dilation is 2-3 cm and the effacement is <80%, what is the diagnosis?
Premature labor likely
If the cervical dilation is ≤2 cm and the effacement is <80%, what is the diagnosis?
PTL unlikely
Premature labor: diagnosis (3)
- Tocolytics: Given for 48 hours to delay delivery so steroids can take full effect on the fetus
- Antenatal corticosteroids
- Antibiotics: GBS prophylaxis if needed (penicillin G)
Tocolytics given in premature labor (4)
- Beta2 agonist: Terbutaline, ritodrine
- Magnesium sulfate
- Nifedipine: not given concurrently with Mg
- Indomethacin
S/E of terbutaline
pulmonary edema
1st-line anti-emetics given in hyperemesis gravidarum
Pyridoxine (vitamin B6) +/- doxylamine
Threatened abortion: Definition (2)
- Pregnancy may be viable (progress) or abortion may follow
- MC cause of 1st trimester bleeding
Threatened abortion: Products of conception
No POC expelled from the uterus
Threatened abortion: Cervical os
Closed
Threatened abortion: Clinical manifestation (3)
- Bloody vaginal discharge (Spotting–>profuse)
- +/- contraction of uterus
- Uterus size compatible with dates
Threatened abortion: management (3)
- Supportive
- Serial beta-HCG to see if doubling
- No sex or douching
Inevitable abortion: definition
Pregnancy not salvageable
Inevitable abortion: Products of conception
No POC expelled
Inevitable abortion: Cervical os (2)
- Progressive cervix dilation (>3 cm, effaced)
- +/- Rupture of membranes
Inevitable abortion: Clinical manifestation (3)
- Moderate bleeding >7 days
- Moderate-severe uterus cramping
- Uterus size compatitble with dates
Inevitable abortion: Management (2)
- D&E 2nd trimester, suction curettage in 1st
- RhoGAM if indicated
Incomplete abortion: Definition
Pregnancy not salvageable
Incomplete abortion: Products of Conception
Some POC expelled, some retained
Incomplete abortion: Cervical os
Dilated
Incomplete abortion: Clinical manifestation (3)
- Heavy bleeding
- Mod-severe cramping
- Retained tissue. Boggy uterus
Incomplete abortion: Management (3)
- D&C in 1st, D&E after 1st
- Pitocin
- RhoGAM if indicated
Complete abortion: Definition
Pregnancy not salvageable
Complete abortion: Products of conception
All POC expelled from uterus
Complete abortion: Cervical os
Usually closed
Complete abortion: Clinical manifestation (2)
- Pain, cramps, and bleeding usually subsides
- Pre-pregnancy size of uterus
Complete abortion: Management
RhoGAM if indicated
Missed abortion: Definition
Embryo not viable but retained in uterus
Missed abortion: Products of conception
No POC expelled
Missed abortion: Cervical os
Closed
Missed abortion: Clinical manifestation (2)
- Loss of pregnancy sx
- +/- brown discharge
Missed abortion: Management (2)
- D&C if 1st trimester, D&E OR
- Misoprostol
Septic abortion: Definition
Retained POC becomes infected –>infection of uterus and organs
Septic abortion: Products of conception
Some POC retained
Septic abortion: Cervical os (2)
- Closed
- Cervical motion tenderness
Septic abortion: Clinical manifestation (3)
- Foul, brownish discharge, fevers, chills
- Uterine tenderness
- Spotting –> heavy bleed
Septic abortion: Management (3)
- D&E to remove POC +
- Broad spectrum abx
- +/- Hysterectomy if refractory
Placenta Previa: Definition
Abnormal placental implantation on or close to cervical os
Placenta Previa: Clinical manifestations (2)
- 3rd trimester bleeding - sudden onset of PAINLESS bleeding (bright red)
- No abdominal pain; uterine soft and nontender
Placenta Previa: Fetal heart rate
Normal
Placenta Previa: Diagnosis
Pelvic US
Placenta Previa: Management (3)
- Hospitalization
- Stabilize fetus (tocolytics, amniocentesis)
- Delivery when stable
When is a C-section done in placental previa?
If it is complete
Placenta Previa: Risk factors
Multiparity, increasing age
Abruptio placenta: Definition
Premature separation of placenta from the uterine wall
Abruptio placenta: Clinical manifestations (3)
- 3rd trimester bleeding - continuous and often dark red
- Severe abdominal pain* (painful uterine contractions), rigid uterus*
- +/- back, abdominal pain, shock sx
Abruptio placenta: Fetal HR
Fetal bradycardia (fetal distress!!)
Abruptio placenta: Diagnosis (2)
- Pelvic US
- Do not perform a pelvic exam
Abruptio placenta: Management (2)
- Hospitalization
- Immediate delivery: may lead to DIC
Abruptio placenta: Risk factors (6)
- Maternal HTN MC cause
- Smoking, etoh, cocaine
- Folate deficiency
- High parity
- Increased age
- chorioamnitis
Vasa previa: Definition
Fetal vessels traverse the fetal membranes over the cervical os
Vasa previa: Clinical manifestations
Rupture of membranes ⇒ PAINLESS vaginal bleed
Vasa previa: Fetal HR
Fetal bradycardia (fetal distress!!)
Vasa previa: Diagnosis
Pelvic US
Vasa previa: Management
Immediate C-section
Preeclampsia: Definition
HTN + Proteinuria* +/- edema after 20 weeks gestation
Preeclampsia: Diagnosis (mild)
- BP ≥ 140/90 on 2 separate occasions @ least 6 hours apart
- Proteinuria ≥300mg/24 hr (or >1+ on dipstick)
Preeclampsia: Diagnosis: Severe
- BP ≥160/110
- Proteinuria: ≥5g/24h (or >3+ on dipstick)
- Oliguira (<500 ml/24h)
- Thrombocytopenia, +/-DIC
- HELLP syndrome
Preeclampsia: Management (Mild)
- Delivery is the only cure (performed at 34-36 weeks)
- Steroids to mature lungs 26-30w
- Supportive: daily weights, BP and dipstick weekly, bed rest
Preeclampsia: Management (severe)
- Delivery is the only cure (Performed at 34-36 weeks)
- Hospitalization: low salt, Mg sulfate
- BP meds: started if BP ≥180/110
BP meds used in pregnancy
Hydralazine*, labetalol, nifedipine
Eclampsia: Definition
Seizures or coma* in patients who meet preeclampsia criteria
Eclampsia: Clinical manifestations (2)
- Abrupt tonic clonic seizures**
- +/- HA, visual changes, cardiorespiratory arrest
Eclampsia: Diagnosis (2)
- Same as preeclampsia + seizures
- Hyperreflexia
Eclampsia: Management (4)
- ABCDs 1st
- Mg sulfate: for seizures (Lorazepam 2nd line)
- Delivery of fetus: once pt is stabilized
- BP meds: Hydralazine*, labetalol
What is DOC for chronic HTN in pregnancy?
Methyldopa
Ladin’s sign
Uterus softening after 6 weeks
Hegar’s sign
Uterine isthmus softening after 6-8 weeks gestation
Piscacek’s sign
Palpable lateral bulge or softening of uterus cornus 7-8 weeks gestation
Goodell’s sign
Cervix softening 4-5 weeks gestation
Chadwick’s sign
Cervix and vulva bluish color 8-12 weeks
When is fetal heart tones first heard and what is the normal rate?
10-12 weeks. Normal is 120-160 bpm
When does a pelvic US detect a fetus?
5-6 weeks
When is quickening (fetal movement) first noticed?
16-20 weeks
When is triple screening (alpha-fetoprotein, beta-HCG, estradiol) first measured?
15-20 weeks
Down syndrome: Alpha-fetoprotein, beta-HCG, and estradiol levels
- Alpha-fetoprotein: Low
- Beta-HCG: High
- Estradiol: Low
Open neural tube defects (ex: spina bifida): Alpha-fetoprotein, beta-HCG, and estradiol levels
- Alpha-fetoprotein: High
- Beta-HCG: N/A
- Estradiol: N/A
Trisomy 18: Alpha-fetoprotein, beta-HCG, and estradiol levels
- Alpha-fetoprotein: Low
- Beta-HCG: Low
- Estradiol: Low
When is GBS screening done?
35-37 weeks
APGAR score: Appearance (skin color changes)
0=Blue all over
1=Acrocyanosis (body pink but blue extremities)
2= Pink baby (no cyanosis)
APGAR score: Pulse
0=0
1=<100
2=≥100
APGAR score: Grimace
0=No response to stimulation
1=Grimaces feebly
2=Cry or pull away
APGAR score: Activity
0=None
1=Some flexion
2=Flexes arm and legs resist extension
APGAR score: Respiration
0=Absent
1=Weak, irregular
2=Strong cry
Post-partum hemorrhage: etiologies (2)
- Uterine atony: MC cause
- Others: uterine rupture, congestion, bleeding d/o, DIC
Post-partum hemorrhage: Risk factors (3)
- rapid or prolonged labor
- Overdistended uterus
- C-section
Post-partum hemorrhage: Management (2)
- Uterotonic agents: Oxytocin IV, misoprostol
- Bimanual massage. Treat the underlying cause.
Fibrocystic breast disorder: Clinical manifestations (2)
- Usually multiple, mobile, well demarcated areas in breast tissue. Often tender*, bilateral. Often no axillary involvement nor nipple discharge.
- Breast cysts may increase or decrease in size with menstrual hormonal changes
Fibrocystic breast disorder: Diagnosis (3)
- US
- Biopsy shows straw-colored fluid (no blood)
- +/- Seen on mammogram
Fibrocystic breast disorder: Management
Most spontaneously resolve. Can do FNA of fluid if symptomatic
Fibroadenoma of the breast: Clinical manifestations (3)
- Smooth, well-circumscribed, mobile rubbery lump with no axillary involvement or nipple discharge
- Gradually grows over time and does not usually wax and wane with menstruation*
- May enlarge in pregnancy
Fibroadenoma of the breast: Management
Most small tumors resorb with time. +/- excision (not usually done)
Breast CA: Types (3)
- Ductal carcinoma
- Lobular carcinoma
- Medullary, mucinoid, tubular, papillary, metastatic, mammary Paget’s disease
Breast CA: Ductal carcinoma (2)
- Infiltrative ductal carcinoma MC (75%). Associated with lymphatic METS especially axillary
- Ductal carcinoma in situ (DCIS). Does not penetrate the basement membrane.
Breast CA: Lobular carcinoma (2)
- Infiltrative lobular carcinoma
- Lobular carcinoma in situ (may not progress but associated with risk of invasive BRCA in either breast)
Breast CA: Clinical manifestations (2)
- Breast mass that is usually painless, hard, fixed (non-mobile) lump*
- Unilateral nipple discharge (may be bloody)
Which medication is useful for breast CA tumors that are ER (estrogen receptor) positive?
Anti-estrogen (Tamoxifen)
Which medication is useful for postmenopausal ER positive breast CA patients?
Aromatase inhibitors (ex: Letrozole, Anastrozole, Exemestane)
Which medication is useful for HER2 positivity in breast CA patients?
Monoclonal Ab treatment (Trastuzumab [Herceptin], Lapatinib)
Which medications can be used in postmenopausal women or women >35 years old with a high risk of breast CA?
Tamoxifen or Raloxifene (SERM). Treatment is usually for 5 years. Tamoxifen is preferred. Aromatase inhibitors are an alternative.