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PANCE Review > Reproductive System > Flashcards

Reproductive System Flashcards

1
Q

menstrual cycle - basics and phases

A

length: 21-38 days

menstrual phase: day 1-7
- FSH begins to rise

proliferative/follicular phase: day 7-14

  • estrogen (stimulated by FSH) causes proliferation of endometrium and follicular growth
  • estrogen triggers LH surge causing ovulation (day 14)

secretory/progestational/luteal phase: day 14-28

  • high levels of progesterone
  • progesterone converts thickened endometrium to vascularized tissue (preps to host fertilized egg)
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2
Q

menorrhagia / heavy menstrual bleeding or prolonged bleeding - causes

A

Von Willebrand’s dz
molar pregnancy
malignant endometrial CA
perimenopause

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3
Q

metrorrhagia / irregular bleeding - causes

A

bleeding b/t cycles

polyps
cervical CA
OC pills

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4
Q

menometrorrhagia / heavy + irregular bleeding

A

molar pregnancy
malignant endometrial CA
premenopause

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5
Q

dysfunctional uterine bleeding (aka abnormal uterine bleeding) - causes (reproductive age v. post-menopausal)

A

bleeding due to an anovulatory cause

Reproductive age:

  • pregnancy (and preg complications)
  • anovulation/hormone abnormalities
  • systemic (PCOS, pituitary, thyroid)

Post-menopausal (think structural vs. non-structural):

  • medications (HRT)
  • trauma (vaginal atrophy), polyps
  • malignancy
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6
Q

abnormal uterine bleeding - approach

A
  1. take a good hx
  2. bleeding history
  3. PE: growths, masses, trauma
  4. Labs: preg test (#1), CBC, TSH, TSH/LH
  5. Imaging: U/S
  6. endometrial biopsy: over 35 w/ obesity, HTN, DM or anyone after menopause
  7. progestin trial
    - if bleeding stops, think ovulatory problem!
    - investigate pituitary and order prolactin and TSH
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7
Q

abnormal uterine bleeding - management

A

Goals:

  • must control bleeding
  • consider if women wants to maintain fertility or not (depends on age)

treatment:

  • hormonal (OCP - progesterone only) - if not trying to get pregnant
  • surgery: D&C (can also consider endometrial ablation or hysterectomy if no desire for future fertility)
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8
Q

amenorrhea - primary and secondary definition

A

primary:

  • no menses by 14 yr and absence of 2ndary sex characteristics
  • no menses by 16 yr w/ presense of 2ndary sex characteristics

secondary:

  • no menses for 3 mo (previously normal cycle)
  • no menses for 6 mo (previous irregular cycle)
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9
Q

primary amenorrhea - causes

A

Turner’s Syndrome: no ovaries but pituitary pumps out FSH so see high FSH
- manage w/ OCP (estrogen and progestin)

hypothalamic-pituitary insufficiency: see low FSH and LH
- manage w/ OCP (estrogen and progestin)

Androgen insensitivity: see high testosterone (XY genetically)
- remove testes, start estrogen

Imperforate hymen: dx on PE
- surgically open

Anorexia
- tx eating d/o

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10
Q

secondary amenorrhea - causes

A

PREGNANCY (most common cause

androgen excess disordered: PCOS

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11
Q

secondary amenorrhea - dx

A

hx and PE: pelvic exam signs of androgen excess

Labs:

  • pregnancy test
  • TSH and prolactin
  • FSH/LH only if TSH and protecting normal

Progestin challenge: Provera 10mg orally for 5 days

  • bleed 2-7 days later
  • if bleeding: ovulatory issue
  • if no bleeding: structural issue
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12
Q

secondary amenorrhea - tx

A

NOT desiring pregnancy:
- OCP

Desire pregnant: tx varies by cause

  • elevated prolactin - dopamine agonist
  • surgery
  • fertility specialist
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13
Q

primary dysmenorrhea - sxs, cause, PE results, tx

A

sxs: abd pain and cramps, N/V/D, H/A
- most common w/in 2 yrs of menarche

cause: NO PATHOLOGIC CAUSE
- inc. prostaglandins
- inc. leukotriene levels

PE results
- normal

tx:

  • NSAIDS - 1st line
  • Cox-2 inhibitor (less GI side-effects)
  • OCP
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14
Q

secondary dysmenorrhea - definition/population, sxs, causes, dx, tx

A

excessive menstrual pain during mid-reproductive yrs
- USUALLY PATHOLOGIC

sxs: pelvic pain related to menstrual cycle
- infertility
- dyspareunia (painful sex)

causes:

  • endometriosis
  • pelvic adhesions / fibroids (prior surgery)
  • polyps

dx:

  • pelvic U/S
  • laproscopy

tx: depends on cause

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15
Q

premenstrual syndrome (PMS) - definition, dx, tx

A

physical and emotional sxs that occur during 2nd half of menstrual cycle
- caused by low serotonin levels

dx: clinical (benign PE)
- only occurs during 2nd half of cycle
- accompanied by bloating, H/A, aches, irritability

tx:

  • lifestyle modifications: exercise, small, frequent meals
  • SSRI for emotional; NSAIDS for aches
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16
Q

endometriosis - definition

A

endometrial tissue outside uterine cavity

  • occurs in women of reproductive age
  • no matter where it is, it will “plump up” during proliferative phase
  • most common on ovary
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17
Q

endometriosis - classic triad and most common sxs

A

dysmenorrhea: low sacral backache premenstrually that resolves w/ menstruation

dyspareunia

infertility

most common sx: pelvic pain

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18
Q

endometriosis - PE, dx, tx

A

PE:
- retroverted uterus w/ uterosacral ligament nodularity (CLASSIC FINDING)

dx: clinical
- laparoscopy is definitive (cannot se on U/S)

tx:

  • observation (1st line)
  • medicine (all for women not trying to get pregnant): NSAIDS or OCP, continuous progesterone, danazol-testosterone (bad SE: deep voice)
  • surgical (for women who want to get pregnant)
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19
Q

pelvic pain - ddx

A

endometriosis: diffuse

ectopic pregnancy: one-sided

acute appendicitis: RLQ

PID: will also have fever, chills

adhesions: hx of prior surgery or infection

IBS: would also have GI sxs

ovarian cyst

psychologic d/o

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20
Q

uterine leiomyoma (fibroids) - definition, population, most common type

A

most common benign uterine tumor

  • women in 40’s with many babies
  • AA women 5x more likely

Types:
- submucous location within the uterine cavity (cause abnormal bleeding)

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21
Q

uterine leiomyoma (fibroids) - sxs, exam, tx

A

sxs: abnormal menstrual bleeding, pain, pressure, infertility
exam: enlarged uterus, firm, nontender, asymmetric
dx: U/S is best

tx:

  • conservative (most do not require tx)
  • GnRH agonists help to shrink fibroids
  • endometrial ablation (if not planning on future pregnancy)
  • surgery: severe sxs and want to keep fertility
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22
Q

endometrial cancer - risk factors, what is protective

A

MOST common Gyn Cancer
- caused by prolonged estrogen exposure

Risks:

  1. Prolonged estrogen exposure
    - nulliparity (no babies)
    - early menarche/late menopause
    - chronic unopposed estrogen
    - tamoxifen (breast cancer tx)
  2. DM, HTN, obesity
  3. cancer of breast, colon, ovaries

protective: OCP

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23
Q

endometrial cancer -tumor type, sxs, exam, dx, tx

A

tumor type: adenocarcinoma (75%)

sxs: post-menopausal bleeding
exam: normal

dx: endometrial biopsy
- curettage is definitive
- stages I-IV

tx:
- total abd hysterectomy and bilateral salpingo-oophorectomy (remove ovary and tubes)
- radiation post-operative (stage I and II)
- radiation, progestins, chemo (stage III and IV)

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24
Q

ovarian cysts - population, characteristics

A

common in reproductive years

  • due to excess estrogen and progesterone
  • most benign and resolve spontaneously

Note: considered malignant in post-menopausal women until proven otherwise

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25
Q

ovarian cysts - most common type, dx, tx

A

most common type: functional (arise from normal function)
- follicular: unilateral, small, resolve on own

dx: U/S (mobile, simple, fluid filled)

tx:
- observe for 30-60 days
- surgical eval if not changing

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26
Q

ovarian cysts - nonfunctional, most common, management

A

do not arise from normal fx

endometrioma: unilateral, blood-filled (hemorrhagic)
- called chocolate cysts

manage: surgical incision

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27
Q

PCOS (poly cystic ovary syndrome) - classic triad, how pts present

A

1 cause of androgen excess and hirsutism

  1. anovulation
  2. polycystic ovaries
  3. androgen excess

normal menses followed by episodes of amenorrhea that become progressively longer

  • most patients present due to hirsutism or infertility
  • also have obesity, acne, insulin resistance
  • bilateral ovaries affected
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28
Q

hirsutism

A

male pattern hair on females

- common sign of PCOS

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29
Q

PCOS (poly cystic ovary syndrome) - dx, tx

A

Dx:

  • image: U/S (see “oyster ovaries” or “string of pearls”
  • labs: inc. androgens, lipid abnormalities, insulin resist

tx:

  • OCP, Depo -Provera, wt loss (if not trying to get pregnant)
  • Clomid: if trying to get pregnant
  • Metformin: w/ Clomid if trying to get pregnant
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30
Q

ovarian neoplasm that grows hair and teeth

A

cystic teratoma

  • benign, dermoid cyst
  • most common germ cell tumor
  • most common ovarian neoplasm in women <30

tx: surgical excision

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31
Q

ovarian neoplasm - benign vs. malignant

A

benign: smooth, regular surface, unilateral, small, simple
malignant: nodular, irregular, fixed, bilateral, large, complex

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32
Q

ovarian cancer - population, risk factors, screening

A

2nd most common GYN cancer
- mean age is 69 y/o

risks: BRCA1 gene, FH, inc. lifetime ovulations (nulliparity, early monarchy/late menopause
screen: bimanual exam

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33
Q

ovarian cancer - most common tumor type, sxs, PE

A

epithelial tumor

sxs:

  • early: asymptomatic
  • later: abd distention, early satiety, urinary frequency, change in bowel habits

exam:
- fixed, bilateral pelvic masses
- abd distention/ascites
- sister Mary Joseph’s nodule: MET implant in umbilicus

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34
Q

ovarian cancer - dx, tumor markers, tx

A

dx:

  • U/S suggests
  • biopsy definitive

tumor markers:
- CA-125, CEA

tx:

  • total abd hysterectomy and bilateral salpingo-oophorectomy (remove ovary and tubes)
  • radiation and chemo
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35
Q

PAP smear screening - definition, recommendations

A

used to diagnose cervical lesions

women < 21: none
21-29: q 3 yrs
30-65: Pap _ HPV q 5 yrs or Pap alone q 3 yrs
> 65:
- previously normal Paps = no testing
- hx of pre-cancer: Paps for 20 yrs post-dx

Note: even if vaccinated (HPV) - follow same PAP schedule

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36
Q

PAP results (Bethesda System) - what are you measuring and possible results

A

sample must have endo-cervical cells

Negative for intraepithelial lesion or malignancy

Squamous Epithelial cell abnormalities:

  1. atypical squamous cells (either of uncertain significance (ASCUS) or cannot exclude high-grade lesion (ASC-H))
  2. low-grade squamous intraepithelial lesions (LSIL)
    - transient HPV infection
  3. high-grade squamous intraepithelial lesions (HSIL)
    - HPV viral persistence and invasive potential
  4. cancer
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37
Q

PAP - management of results

A

ASCUS:

  • repeat PAP in 4-6 mo
  • if repeat is same or worse = colposcopy (visual examination of cervix)

ASC-H, LSIL, HSIL:
- colposcopy, biopsy, HPV testing

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38
Q

grading cervical lesions - cytology vs. histology results

A

cytology: from PAP
- ASC, LSIL, HSIL, Cancer

histology: from biopsy during colposcopy
- CIN I, 2, 3

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39
Q

abnormal PAP - management (depends on biopsy results - histology)

A

CIN1:

  • repeat PAP +/- colposcopy
  • HPV DNA testing

CIN2 or CIN3:

  • need to remove lesion
  • cryotherapy and cold-knife conization (for women who do not want to maintain fertility)
  • LEEP: loop electrosurgical excision procedure (for women want to maintain feritlity)
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40
Q

cervical cancer - cause and risk factors

A

3rd most common GYN cancer
- 99% caused by HPV (types 16, 18, 31, 33)

Risks:

  • early sex, multiple partners
  • smoking
  • immunosuppression
  • HPV (get vaccine!)
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41
Q

cervical cancer - tumor type, sxs, PE, dx, tx

A

tumor type: squamous cell (90%)

sxs:
- asymptomatic
- post-coital bleeding

PE: friable, bleeding cervical lesion

dx: PAP and biopsy (stage I-IV)

tx:

  • hysterectomy
  • radiation and chemo (stages III and IV)
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42
Q

cystocele, rectocele, uterine prolapse - population, definition

A

common after menopause
- everything falls down

cystocele: prolapse of bladder into anterior wall of vagina
rectocele: herniation of rectum into posterior wall of vagina

uterine prolapse: prolapse down vaginal canal

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43
Q

cystocele, rectocele, uterine prolapse - sxs, tx

A

sxs:
- vaginal fullness, pressure, incomplete voiding or defecation

tx:

  • topical estrogen (cystocele)
  • pessary: cork (if not good surgical candidate)
  • Kegal exercises
  • surgical repair
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44
Q

mastitis - sxs and tx

A

infection that occurs in breastfeeding women
- caused by nipple trauma (S. aureus)

sxs:
- unilateral erythema, edema, tenderness (one quadrant of breast)
- fever and chills

tx:

  • dicloxacillin (most common), cefalexin, or erythromycin
  • CONTINUE breast feeding

Note: must tx to avoid breast abscess!!

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45
Q

breast abscess - sxs and tx

A

progression from mastitis

sxs: same as mastitis w/ addition of:
- localized mass
- systemic signs of infection

tx:

  • I&D
  • IV ABX: Nafcillin/oxacillin IV or cefazolin PLUS metronidazole

STOP breastfeeding on affected side
- most pts hospitalized

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46
Q

fibrocystic breast disease - sxs, PE, dx, tx

A

common, benign condition of breast
- women in reproductive age (20-50)

sxs: cyclic (premenstrual), bilateral breast pain
- size of cysts fluctuate during menstrual cycle

PE: bilateral cysts that vary in size

dx: U/S

tx:

  • reduce caffeine, inc. PO vit E
  • OCP
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47
Q

breast fibroadenoma

A

most common benign breast tumor

  • in young women
  • PAINLESS
  • solid, mobile
  • unilateral lumpo

PE: mobile, firm, smooth, rubbery lump

dx: U/S and fine needle aspiration to confirm no fluid

tx:
- observe small masses
- surgically remove large masses

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48
Q

breast cancer

A

MOST COMMON cancer in women; 2nd MC cause of cancer death

risks:

  • BRAC1 and 2
  • prolonged unopposed estrogen (early menarche, late menopause, over 40, etc.)
  • hyperplasia w/ fibrocystic dz
  • high fat diet
  • obesity
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49
Q

types of cancers caused by prolonged, unopposed estrogen

A

endometrial
ovarian
breast

Not: cervical caused by HPV!!

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50
Q

mammogram screening

A

average risk:

  • begin at 40 y/o
  • 40-49: q 1-2 yrs
  • > 50 - every year

genetic risk factors:

  • start b/t 25-35
  • consider MRI
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51
Q

breast cancer - 4 types

A

infiltrating ductal: most common (80%)

  • painless, stony, hard, unilateral mass
  • begins as ductal carcinoma in situ (DCIS)
infiltrating lobular (10%): 
 - often bilateral

inflammatory (2%):
- peau d’orange

Paget’s disease (1%): - pruritic, scaly rash on nipples

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52
Q

breast cancer - sxs, dx

A

sxs:

  • painless mass (upper, outer quadrant)
  • nipple d/c
  • itching of nipple
  • skin dimpling or pulling in of nipple

dx:
- exam, U/S (solid vs. cystic), mammogram (screen for non-palpable mass), fine needle aspiration (blood = malignancy)
- open biopsy: definitive

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53
Q

breast cancer - management

A

surgery: lumpectomy v. mastectomy

radiation and chemo

hormone therapy: for estrogen and progesterone positive receptor tumors

  • Tamoxifen
  • aromatase inhibitor (1st line if METS)
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54
Q

menopause - age, definition, sxs

A

mean age = 51 y/o

all sxs are associated with estrogen deficiency

Immediate sxs:

  • cessation of menses
  • hot flashes
  • dec. vaginal lubrication
  • depression/mood swings

Late changes:

  • osteoporosis
  • CVD
55
Q

menopause - signs and labs

A

signs:

  • everything shrinks and dries up
  • dec. size of uterus, ovaries, breasts

cystocele, rectocele, and uterine prolapse occur

labs: FSH > 30mlU/mL is diagnostic
- FSH keeps pumping out telling ovaries to work but they are shut down

56
Q

menopause - tx with HRT (benefits, drawbacks, and contraindications)

A

hormone replacement therapy

  • mainly for hot flashes, vaginal dryness
  • benefits: promotes good lipid profile
  • drawbacks: inc. risk for CHD, breast cancer, stroke, pulmonary embolism

contraindications:

  • liver dz
  • thrombosis
  • CA of endometrium or breast
57
Q

menopause -alternative tx

A

Hot flashes:

  • DepoProvera - IM
  • SSRI
  • Yoga, acupuncture
  • Soy, black cohost

Osteoporosis:
- Ca++ w/ vit. D

Vaginal dryness
- topical estrogen

58
Q

vaginitis - 3 main types

A

Candida (yeast)

Bacterial vaginosis (BV)

Trichomonas

59
Q

candida - risk factors, sxs, d/c, micro findings, tx

A

risk: immunocompromised (HIV, DM), ABX
sxs: itchy, red, odorless

d/c: “cottage cheese”

micro: pseudohyphe in KOH prep

tx:

  • PO fluconazole (single dose)
  • “azole” creams (3-7d)
60
Q

bacterial vaginosis (BV) - sxs, d/c, micro findings, tx

A

sxs: malodorous d/c

d/c: fishy grey, scant, thin, sticky

micro: clue cells

tx:
- metronidazole PO (multiple doses)

61
Q

trichomonas - risk factors, sxs, d/c, micro findings, tx

A

risks: sexual activity

sxs: copious, malodorous d/c
- “strawberry cervix”

d/c: green/yellow, “frothy”

micro: motile flagellated protozoa

tx:
- metronidazole PO (single dose)

62
Q

metronidazole (Flagyl) warning

A

MUST avoid ETOH (severe N/V) and sun exposure

63
Q

chlamydia - definition, risk factors, sxs, labs, tx

A

most common bacterial STI in women

risks:

  • sex <20 y/o
  • multiple partners

sxs:

  • asymptomatic
  • mucopurulent cervical d/c
  • cervical motion tenderness

labs:
- nucleic acid amplification test (NAAT)

tx:

  • azithromycin (single dose)
  • doxycycline (BID x 7d); use AMOX in pregnancy

Note: must also tx sexual partners

64
Q

gonorrhea -definition, risk factors, sxs, labs, tx

A

STI; often co-infection w/ chlamydia

sxs:

  • asymptomatic
  • vaginal itching and burning, dysuria
  • purulent cervical d/c
  • cervical motion tenderness

labs:
- nucleic acid amplification test (NAAT)

tx: treat for both gonorrhea and chlamydia
- cefixime PO (single dose)
- ceftriaxone IM (single dose)

Note: must also tx sexual partners

65
Q

gonorrhea - disseminated

A

can be disseminated
- #1 cause of septic arthritis in young, sexually active adults

sxs:

  • GU sxs of gonorrhea (itch, burn, purulent d/c)
  • if disseminated: lesions on hand/feet, tenosynovitis, endocarditis, meningitis
66
Q

human papillomavirus (HPV) - definition, sxs, dx, tx

A

most common VIRAL STI in women

  • subtypes 6 and 11: genital warts
  • subtypes 16, 18, 31, 33: cervical and penile cancer

sxs: cauliflower-like warts on external genitalia, anus, cervix, or perineum

dx:

  • HPV DNA testing
  • direct visualization (PAP)

tx:

  • small lesions: burn off
  • large lesions: cryosurgery, laser ablation, surgical excision
67
Q

HPV prevention

A

Gardasil vaccine

  • recommended for girls and boys 9-26
  • protects against HPV 6, 11, 16, 18
  • 3 doses: 1st, 2nd 2 mo later, 3rd 6 mo later
68
Q

pelvic inflammatory disease (PID) - definition, pathogens, risks, sxs, PE findings

A

pathogens (bacteria) travel up vaginal canal and into tubes / ovaries / pelvis

pathogens:

  • chlamydia (most common)
  • gonorrhea
  • E. coli

risks: young, multiple partners, douching

sxs: DIFFUSE, bilateral abd and pelvic pain (gradual or sudden onset)
- back pain
- fever (+/-)

PE:

  • mucopurulent cervical d/c
  • cervical motion tenderness; bilateral adnexal tenderness
  • rebound tenderness on abd exam
69
Q

pelvic inflammatory disease (PID) - dx, tx

A

Dx:

  • cervical cultures
  • elevated WBC, ESR, C-reactive protein
  • WBC on wet prep

Tx:
Outpatient:
- Ceftriaxone IM (single dose) PLUS doxycycline PO (x 14 d)

Inpatient (if access, high fever, pregnant, OP tx failure):
- IV ABX

70
Q

condoms - what two things can it prevent

A

only contraception method that prevents pregnancy and STI!!

71
Q

hormonal methods of contraception (combined estrogen and progestin) - 3 types

A

Oral Contraceptive Pills (OCP)

  • combo pills most common
  • 3 weeks on, 1 week off

Patch (orthoEvra)

  • change 1/week
  • failure higher if >200lbs

Vaginal Ring (NuvaRing)

  • lasts for 3 weeks
  • good for women who have not had vaginal delivery in past
72
Q

hormonal methods of contraception (combined estrogen and progestin) -mechanism of action

A

estrogen suppresses FSH so no follicle/ovulation

progesterone suppresses LH surge, so no ovulation

Thicker cervical mucus - hostile to sperm

Endometrial atrophy - unfavorable to implantation

73
Q

estrogen-containing hormonal methods - benefits, contraindications

A

Benefits:

  • Dec. risk of endometrial and ovarian cancer, ovarian cysts, endometriosis, dysmenorrhea, fibrocystic breasts
  • Regulates menses

Absolute Contraindication:

  • pregnancy
  • hx of thromboembolism, CVA, CHD, breast or endometrial cancer, melanoma, abnormal LFTs

Relative Contraindications:
- DM, chronic HTN, hyperlipidemia, smoker over 35 yrs

74
Q

hormonal methods of contraception (progestin only pills) - use, indications for use

A

progestin-only pills (called “mini pills”)

  • take every day (no week off)
  • high incidence of break-through bleeding

indications:

  • breast feeding
  • overe 40
  • women who cannot take estrogen
75
Q

hormonal methods of contraception (progestin only shot) - use, side effects, warnings

A

IM injection (Depo-Provera)

  • IM shot q 3 months
  • side effects: break-through bleeding, weight gain, mood changes

Warnings:

  • return of ovulation can take up to 18 months!
  • Black Box: calcium loss, bone weakness –> ONLY use for 2 yrs or less
76
Q

hormonal methods of contraception (progestin only implant)

A

subcutaneous rod inserted under upper arm skin (Jadelle, Implanon)

side effects:

  • break-through bleeding
  • scaring at insertion site

Note: ovulation returns promptly after removal

77
Q

hormonal methods of contraception (progestin only) - mechanism of action and contraindications

A

mature follicle is formed but not released

  • suppresses LH surge
  • NO effect on FSH (that is estrogen driven)

contraindications:

  • breast carcinoma
  • liver tumors
78
Q

IUD - population, two types, mechanism of action

A

best for women who have had kids (multiparous)
- Levonorgestrel (Mirena) (5 yrs); dec. cramping and bleeding

  • Copper-banded (ParaGuard) (10yrs); may inc. cramping and bleeding

mechanism of action:

  • alters endometrial environment
  • ovum transport altered - changes tubal ciliary action
79
Q

IUC - complications

A

uterine perforation
salpingitis
ectopic pregnancy
prolonged or irregular bleeding

80
Q

sterilization - avoid pregnancy

A

tubal sterilization (female) - most common

vasectomy (male )

81
Q

emergency contraception

A

Plan B levonorgestrel (progesterone)

  • 1st dose within 72 hrs after unprotected sex
  • 2nd dose 12 hrs later

Efficacy: >95%

82
Q

infertility - definition, primary vs. secondary, causes

A

inability to conceive w/in 12 months of unprotected sex

primary: absence of previous pregnancy
secondary: after previous pregnancy

causes:

  • anovulation (most common)
  • tubal dz
  • male factor
  • unexplained
83
Q

infertility from anovulation - causes, dx

A

polycystic ovaries
high prolactin levels
hypothalamic-pituitary dysfunction
hypothyroidism

dx:

  • menstrual diary
  • luteal-phase (day 21) progesterone level < 3ng/ml
  • no mid-cycle basal body temp elevation
84
Q

infertility from tubal dz - causes, dx

A

causes:

  • scarring/adhesions
  • hx of surgery, PID, endometriosis, ruptured appendix

dx:

  • hysterosalpingogram: shoot dye up tubes to see if blocked
  • laparoscopy

tx:
- surgery or lysis of adhesions

85
Q

infertility from male factors - causes, dx

A

abnormal semen analysis resulting from:

  • inc. scrotal temp
  • smoking
  • ETOH ingestion
  • epididymitis
  • varicocele

dx: semen analysis

tx:

  • tx etiology if identified
  • intrauterine insemination
  • sperm injection
  • donor insemination
86
Q

infertility - general approach

A

Phase I (inexpensive / non-invasive)

  • detailed hx, type of intercourse
  • ovulation tracking
  • semen analysis
  • TSH, prolacting, LH
  • FSH in women > 35 (high in menopause)

Phase II (expensive/invasive)

  • hysterosalpingogram
  • laparoscopy
  • IVF if no cause found
87
Q

Pregnancy - trimesters, weeks for “term”, GPTPAL

A

Trimesters:

1st: 1-12 weeks
2nd: weeks 13-27
3rd: weeks 28-40

Term: 37-42 weeks

G: # of pregnancies
P: # of vaginal births
T: # of full-term pregnancies
P: # of preterm pregnancies
A: # of abortions b/f 20 weeks
L: total # of living children
88
Q

Chadwick’s sign

A

bluish discoloration of vagina and cervix due to estrogen and progesterone during pregnency

89
Q

skin changes during pregnancy

A

melasma/cholasma: dark patches on face

linea nigra: line on abdomen

90
Q

uterine growth during pregnancy

A

12 wks: at symphysis pubis

20 wks: at umbilicus

after 20 wks: 1 cm for every week gestation
- way to monitor fetal growth

91
Q

normal labs in pregnancy

A

normal to have high cholesterol - do not need to treat
- f/u 6 wks after birth

renal: normal to have dec. in BUN, Cr, uric acid
- if high/normal, can be signs of pre-E

92
Q

Pre Natal Labs

A

Blood type (Rh factor, antibodies to blood group antigens)
Glucose tolerance test
Hep B, syphylis, HIV, rubella, GC/CT
Group B strep (can be part of women’s normal vaginal flora)

93
Q

pregnancy - screening tests and timing

A

first visit (7-9 wks): dating sonogram; discuss optional screening tests

10-13 wks: nuchal translucency
15-18 wks: alpha-fetoprotein / quad screen
18-22 wks: anatomical U/S
24-28 wks: glucose tolerance test
28 wks: Rhogam (if mom is Rh-)
32 wks: repeat CBC, VDRL/PRP (syphylis), chlamydia, gonorrhea, GBS

94
Q

pregnancy - screening blood tests (quad screen) - what is measured and levels for chromosomal abnormalities

A

Quad screen:

  • AFP
  • estriol
  • beta HCG
  • inhibin A

Note:

  • PAPP-A: low in preg; elevated in trisomy 21
  • nuchal translucency (seen on U/S) - back of neck measured

Trisomy 21 (Down’s): AFP and Estriol down; PAPP-A, inhibin A, BHCG, nuchal translucency up

Trisomy 18 (Edward’s): AFP, Estriol, BHCG and Inhibit A down; nuchal translucency up

Neural tube defect: AFP up, rest normal

95
Q

pregnancy - optional diagnostic tests

A

chorionic villus sampling (CVS): 10-13 wks

amniocentesis: 15-20 wks

Not: these give you a definitive answer based on baby’s DNA

96
Q

stages of labor

A

stage 1: onset of labor to full dilation (10cm)

stage 2: full dilation to birth

stage 3: delivery of infant to delivery of placenta

97
Q

signs of placental separation

A

fresh show of blood - BRB
cord lengthening
fundus rises
uterus firm and globular (contracts down)

98
Q

dystocia

A

difficult birth: inadequate pelvis, position of baby, inadequate contractions / dilation

99
Q

labor induction - common indications and absolute contraindications

A

Indications:

  • prolonged pregnancy (>42 wks)
  • DM
  • Pre-eclampsia
  • Suspected intrauterine growth retardation

Contraindications:

  • cephalopelvic disproportion
  • placenta previa
  • uterine scar from previous C-section
  • transverse lie
100
Q

labor induction - medications and “surgical”

A

prostaglandins (cervidil):

  • given vaginally
  • “ripens” cervix

oxytocin (Pitocin)”

  • causes uterine contractions
  • given IV

amniotomy: breaking membranes

101
Q

antepartum fetal monitoring (close to or during labor)

A

non stress test:

  • most common
  • monitor fetus HR from outside
  • postive test: 2 accelerations in 20 minutes
  • positive test is a GOOD THING

contraction stress test (CST):

  • observe baby’s HR in response to contractions
  • positive test: decelerations with each contraction
  • positive test is a BAD things
102
Q

induced abortion - medications and surgical options

A

mifepristone and misoprostol:

  • medication
  • up to 1st 7-9 wks LMP

suction curettage

  • surgical procedure
  • safest and most effective method for 12 wks or less
  • local anesthesia for cervix
surgical curettage (D&amp;C): aspiration
 - surgical abortion up to 16 wks LMP

dilation and evacuation (D&E):
- up to 18 wks

Past 18 wks
- induce labor

103
Q

spontaneous abortion (e.g. miscarriage) - definition and risks

A

Any pregnancy that ends before 20 wks gestation

  • most occur in 1st 12 wks
  • most due to chromosomal abnormalites

Risks:

  • parity (more births)
  • Inc. maternal and paternal age
  • conception w/in 3 mo of term birth
104
Q

spontaneous abortion - classifications

A

threatened:

  • vag bleed: yes
  • cervix open: no
  • POC passed: no

inevitable:
- vag bleed: yes
- cervix open: yes
- POC passed: no

incomplete:

  • vag bleed: yes
  • cervix open: yes
  • POC passed: partial

complete:

  • vag bleed: yes
  • cervix open: yes
  • POC passed: yes

missed: fetal demise on U/S
- vag bleed: no
- cervix open: no
- POC passed: no

105
Q

normal B-hCG levels during pregnancy

A

urine (home preg test): positive 10-14 days after ovulation

serum: positive 8-9 days after ovulation

levels should DOUBLE every 48 hrs during 1st trimester if normal, intrauterine pregnancy

106
Q

ectopic pregnancy - definition, cause, sxs

A

implantation of blastocyst anywhere outside uterine cavity
- most common in tube

cause:
- hx of salpingitis (results in scarring and blocking of tube)

sxs (unruptured):

  • amenorrhea (pos preg test)
  • unilateral pain
  • vaginal bleeding
  • adnexal mass

sxs (ruptured):

  • above sxs
  • hypotension
  • tachycardia
  • abd guarding
107
Q

ectopic pregnancy - dx

A

labs:
- B-hCG positive in urine or serum but NOT doubling appropriately (q 48 hrs)

imaging:
- U/S shows absence of intrauterine gestational sac

presumptive dx:
- B-hCG titer > 1500 w/ no intrauterine gestational sac

108
Q

ectopic pregnancy - tx

A

MUST end pregnancy - dangerous for mom

Medical:

  • methotrexate (folic acid inhibitor)
  • Criteria for use: serum B-hCG < 5,000, ectopic <3.5cm, no pulmonary, renal or hepatic dz, stable and compliant patient

Surgery:
- salpingostomy: if unruptured (open tube and remove ectopic preg) - best to preserve fertility

  • salpingectomy: if ruptured and tube destroyed (complete removal)
109
Q

gestational trophoblastic disease

A

neoplasms from an abnormal proliferation of the placenta or trophoblast (cells that make placenta)

benign: hydatidiform mole (molar preg)
- more likely to ask about on PANCE

malignant: choriocarcinoma

110
Q

hydatidaform mole (aka molar pregnancy) - characteristics of complete

A

Positive pregnancy test with…

grape-like vesicles  or "snow storm" (on U/S)
empty egg
paternal X's only
fetus ABSENT
20% progress to malignancy

Studies:
- b-hCG is higher than it should be

111
Q

hydatidaform mole (aka molar pregnancy) - hx, PE, studies, tx

A

Hx/PE:

  • vaginal bleeding
  • pre-eclampsia-like sx b/f 20 wks
  • severe hyperemesis
  • new onset hyperthyroidism
  • uterus larger than gestational age
  • no fetal heart tones

Studies:

  • B-hCG: excessively high
  • U/S: sack of grapes or snowstorm pattern

tx:
- D&C, serial b-HCG, OC’s for 1 yr

112
Q

preterm labor - definition, triad, risk factors

A

labor occurring b/t 20 weeks and 37 weeks

Triad:

  • gestation < 37 wks
  • uterine contractions (at least 3 in 20 min)
  • dilation and effacement

Risks:
- GBS, PROM (premature), short cervix (<4cm), previous preterm birth, cocaine, nicotine

113
Q

fetal fibronectin testing

A

cervical swab used to predict risk of delivery w/in 2 weeks

114
Q

preterm labor - management

A

observation:

  • 30-60 min
  • hydration

ABX: tx for possible infection

Glucocorticoids (betamethasone)

  • enhance fetal lung maturity (if < 34 wks)
  • inc. levels of surfactant

Tocolytics (Tocolysis Mg Sulfate): dec. contractions/slow labor

  • inhibits myometrial contractility mediated by Ca++
  • SE: nausea, fatigue, dec. reflexes, resp distress)
  • antidote: calcium gluconate
115
Q

premature rupture of membranes (PROM) - definition, risks, dx, tx

A

rupture of membranes b/f labor begins
- most common dx leading to NICU admit

Risks:

  • infection (GBS, STI)
  • smoking
  • cervical incompetence

Dx:

  • nitrazine paper
  • ferning test: on slide
  • speculum exam (sterile)

Tx:

  • before 34 wks: bed rest and attempt to prolong to 35 wks
  • at least 35 wks: induce
116
Q

maternal Rh Isoimmunization (incompatibility)- definition, risk

A

mom produces antibodies against foreign red blood cell antigens in maternal circulation
- most common antigen is D

risk is present only if mom is Rh- and dad is Rh + and baby is Rh+
- risk is larger for subsequent pregnancies since mixing occurs at birth

117
Q

Rh incompatibility - tx

A

RhoGAM

  • binds and hemolyzes any D-positive RBC in maternal circulation so mom does not mount her own antibody response
  • given at 28 wks
  • also given at other high risk times (potential for fetal and mom’s blood to mix): after delivery of Rh+ infant, ectopic preg, amnio, D&C, trauma
118
Q

multiple gestation - sxs and office visit frequency

A

all sxs of pregnancy are usually more severe

prenatal office visits more often

additional risks to mom (spontaneous abortion, premature labor) and fetus

119
Q

gestational diabetes - definition, population at higher risk, material risks, fetal risks

A

CHO intolerance of variable severity only present during pregnancy

Risks:

  • obesity
  • > 25 y/o
  • ethnicity: AA, Asian, Hispanic, Indian

Maternal risks:

  • pre-eclampsia
  • traumatic birth

Fetal risks:

  • macrosomia
  • delayed fetal lung maturity
120
Q

gestational diabetes - screening

A

b/t 24-28 weeks:

  1. glucose challenge test (GCT):
    - non fasting 50 g glucose load
    - check glucose after 1 hr
    - > 140 mg/dl, move to GGT
  2. glucose tolerance test (GTT):
    - 100 g oral glucose load after overnight fast
    - check plasma glucose at fasting, after 1 hr, 2 hr, and 3 hr
    - 2 or more abnormal values - gestational diabetes
121
Q

gestational diabetes - tx

A
  1. diet and exercise
  2. check glucose (finger stick) 4 times daily
    - fasting
    - 2 hr post meal
  3. insulin: if not controlled by diet

Also:

  • weekly check-ups and NST (non-stress test) at 32-34 wks
  • induce labor at 40 wks (if good control) and 38 wks (if bad control or signs of macrosomia)
122
Q

HTN in pregnancy - first step

A

determine is this is a chronic issue from before pregnancy, if brought on due to pregnancy, and if any end organ damage (pre-E)

123
Q

chronic HTN - tx in pregnancy

A

monthly U/S: check of IUGR

serial BP and urine protein

medication:
- METHYLDOPA

124
Q

pre-eclampsia and eclampsia - definitions and timing

A

pre-E:

  • classic triad of HTN, proteinuria, and edema
  • mild: BP>140/90, proteinuria, no other sxs
  • severe: above + sxs (h/A, visual disturbance, RUQ pain)

Eclampsia:
- all of the above + seizures

Note: can occur anytime after 20 wks station, but common near term
- no inc. risk of HTN later in life

125
Q

preeclampsia - predisposing factors

A 
NULLIPARITY (most common)
extremes of age: <20, >35
multiple gestation
DM
chronic HTN
126
Q

preeclampsia - complications and prevention

A 
progression to eclampsia
renal failure
pulmonary edema
HELLP syndrome
DIC

prevent: 1gm calcium during pregnency

127
Q

HELLP syndrome

A

complication of pre-eclampsia

Hemolysis
Elevated Liver enzymes
Low Platelets

128
Q

preeclampsia - management (mild v. severe)

A

cure = delivery of fetus

mild:

  • <37wks: bed rest, testing, betamethasone (if < 34 wks)
  • > 37 wks: induce delivery

severe:

  • hospitalize
  • <34 wks: monitor in ICU, betamethasome for fetal lung development
  • > 34 wks: deliver vaginally or c-section and watch for HELLP
  • meds: Magnesium sulfate (MgSo4) for seizure prophylaxis
129
Q

placental abruption - definition and risks

A

separation of placenta from sit of uterine implantation before delivery of fetus

  • most common cause of 3rd trimester bleeding
  • most common obstetric cause of DIC
  • more serious if blood is confined within uterine cavity (and does not come out of cervix)

Risks:
- HTN, smoking, cocaine, trauma

130
Q

placental abruption - sxs, dx, tx, complications

A

vaginal bleeding
abdominal and back PAIN
fetal distress

dx: clinical
tx: emergent c-section

complications:

  • fetal demise
  • maternal hemorrhage
  • maternal DIC and death
131
Q

placenta previa - definition, sxs,

A

placenta is implanted over os (partial or complete)
- common cause of 3rd trimester bleeding

sxs:

  • PAINLESS vaginal bleeding
  • cramping, contractions

DO NOT DO VAGINAL EXAM!!
- must first do U/S to confirm no placenta previa

tx:
- ALWAYS deliver by C-section

132
Q

post partum hemorrhage - causes

A
  1. uterine atony (loss of tone)
    - most common
    - risks: short or long labor, infected uterus
    - PE: soft, “boggy” uterus
    - Tx: uterine massage, oxytocin
  2. genital laceration
    - uncontrolled vaginal delivery
    - PE: visual laceration
    - Tx: suture
  3. retained placenta:
    - non-contracted uterus
    - PE: missing cotyledon on placenta
    - Tx: manual exploration
133
Q

endometritis - definition, sxs, dx, tx

A

infection of endometrium of uterus
- most common after c-section, prolonged ROM

sxs:

  • post partum fever
  • uterine tenderness
  • presents 2-3 days post-partum

dx:
- high WBC, U/A, shows bacteria

tx:
- clindamycin plus gentamicin

PANCE Review (16 decks)

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