Reproductive System Flashcards
menstrual cycle - basics and phases
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)
menorrhagia / heavy menstrual bleeding or prolonged bleeding - causes
Von Willebrand’s dz
molar pregnancy
malignant endometrial CA
perimenopause
metrorrhagia / irregular bleeding - causes
bleeding b/t cycles
polyps
cervical CA
OC pills
menometrorrhagia / heavy + irregular bleeding
molar pregnancy
malignant endometrial CA
premenopause
dysfunctional uterine bleeding (aka abnormal uterine bleeding) - causes (reproductive age v. post-menopausal)
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
abnormal uterine bleeding - approach
- take a good hx
- bleeding history
- PE: growths, masses, trauma
- Labs: preg test (#1), CBC, TSH, TSH/LH
- Imaging: U/S
- endometrial biopsy: over 35 w/ obesity, HTN, DM or anyone after menopause
- progestin trial
- if bleeding stops, think ovulatory problem!
- investigate pituitary and order prolactin and TSH
abnormal uterine bleeding - management
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)
amenorrhea - primary and secondary definition
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)
primary amenorrhea - causes
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
secondary amenorrhea - causes
PREGNANCY (most common cause
androgen excess disordered: PCOS
secondary amenorrhea - dx
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
secondary amenorrhea - tx
NOT desiring pregnancy:
- OCP
Desire pregnant: tx varies by cause
- elevated prolactin - dopamine agonist
- surgery
- fertility specialist
primary dysmenorrhea - sxs, cause, PE results, tx
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
secondary dysmenorrhea - definition/population, sxs, causes, dx, tx
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
premenstrual syndrome (PMS) - definition, dx, tx
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
endometriosis - definition
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
endometriosis - classic triad and most common sxs
dysmenorrhea: low sacral backache premenstrually that resolves w/ menstruation
dyspareunia
infertility
most common sx: pelvic pain
endometriosis - PE, dx, tx
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)
pelvic pain - ddx
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
uterine leiomyoma (fibroids) - definition, population, most common type
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)
uterine leiomyoma (fibroids) - sxs, exam, tx
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
endometrial cancer - risk factors, what is protective
MOST common Gyn Cancer
- caused by prolonged estrogen exposure
Risks:
- Prolonged estrogen exposure
- nulliparity (no babies)
- early menarche/late menopause
- chronic unopposed estrogen
- tamoxifen (breast cancer tx) - DM, HTN, obesity
- cancer of breast, colon, ovaries
protective: OCP
endometrial cancer -tumor type, sxs, exam, dx, tx
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)
ovarian cysts - population, characteristics
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
ovarian cysts - most common type, dx, tx
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
ovarian cysts - nonfunctional, most common, management
do not arise from normal fx
endometrioma: unilateral, blood-filled (hemorrhagic)
- called chocolate cysts
manage: surgical incision
PCOS (poly cystic ovary syndrome) - classic triad, how pts present
1 cause of androgen excess and hirsutism
- anovulation
- polycystic ovaries
- 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
hirsutism
male pattern hair on females
- common sign of PCOS
PCOS (poly cystic ovary syndrome) - dx, tx
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
ovarian neoplasm that grows hair and teeth
cystic teratoma
- benign, dermoid cyst
- most common germ cell tumor
- most common ovarian neoplasm in women <30
tx: surgical excision
ovarian neoplasm - benign vs. malignant
benign: smooth, regular surface, unilateral, small, simple
malignant: nodular, irregular, fixed, bilateral, large, complex
ovarian cancer - population, risk factors, screening
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
ovarian cancer - most common tumor type, sxs, PE
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
ovarian cancer - dx, tumor markers, tx
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
PAP smear screening - definition, recommendations
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
PAP results (Bethesda System) - what are you measuring and possible results
sample must have endo-cervical cells
Negative for intraepithelial lesion or malignancy
Squamous Epithelial cell abnormalities:
- atypical squamous cells (either of uncertain significance (ASCUS) or cannot exclude high-grade lesion (ASC-H))
- low-grade squamous intraepithelial lesions (LSIL)
- transient HPV infection - high-grade squamous intraepithelial lesions (HSIL)
- HPV viral persistence and invasive potential - cancer
PAP - management of results
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
grading cervical lesions - cytology vs. histology results
cytology: from PAP
- ASC, LSIL, HSIL, Cancer
histology: from biopsy during colposcopy
- CIN I, 2, 3
abnormal PAP - management (depends on biopsy results - histology)
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)
cervical cancer - cause and risk factors
3rd most common GYN cancer
- 99% caused by HPV (types 16, 18, 31, 33)
Risks:
- early sex, multiple partners
- smoking
- immunosuppression
- HPV (get vaccine!)
cervical cancer - tumor type, sxs, PE, dx, tx
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)
cystocele, rectocele, uterine prolapse - population, definition
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
cystocele, rectocele, uterine prolapse - sxs, tx
sxs:
- vaginal fullness, pressure, incomplete voiding or defecation
tx:
- topical estrogen (cystocele)
- pessary: cork (if not good surgical candidate)
- Kegal exercises
- surgical repair
mastitis - sxs and tx
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!!
breast abscess - sxs and tx
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
fibrocystic breast disease - sxs, PE, dx, tx
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
breast fibroadenoma
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
breast cancer
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
types of cancers caused by prolonged, unopposed estrogen
endometrial
ovarian
breast
Not: cervical caused by HPV!!
mammogram screening
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
breast cancer - 4 types
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
breast cancer - sxs, dx
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
breast cancer - management
surgery: lumpectomy v. mastectomy
radiation and chemo
hormone therapy: for estrogen and progesterone positive receptor tumors
- Tamoxifen
- aromatase inhibitor (1st line if METS)
menopause - age, definition, sxs
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
menopause - signs and labs
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
menopause - tx with HRT (benefits, drawbacks, and contraindications)
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
menopause -alternative tx
Hot flashes:
- DepoProvera - IM
- SSRI
- Yoga, acupuncture
- Soy, black cohost
Osteoporosis:
- Ca++ w/ vit. D
Vaginal dryness
- topical estrogen
vaginitis - 3 main types
Candida (yeast)
Bacterial vaginosis (BV)
Trichomonas
candida - risk factors, sxs, d/c, micro findings, tx
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)
bacterial vaginosis (BV) - sxs, d/c, micro findings, tx
sxs: malodorous d/c
d/c: fishy grey, scant, thin, sticky
micro: clue cells
tx:
- metronidazole PO (multiple doses)
trichomonas - risk factors, sxs, d/c, micro findings, tx
risks: sexual activity
sxs: copious, malodorous d/c
- “strawberry cervix”
d/c: green/yellow, “frothy”
micro: motile flagellated protozoa
tx:
- metronidazole PO (single dose)
metronidazole (Flagyl) warning
MUST avoid ETOH (severe N/V) and sun exposure
chlamydia - definition, risk factors, sxs, labs, tx
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
gonorrhea -definition, risk factors, sxs, labs, tx
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
gonorrhea - disseminated
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
human papillomavirus (HPV) - definition, sxs, dx, tx
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
HPV prevention
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
pelvic inflammatory disease (PID) - definition, pathogens, risks, sxs, PE findings
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
pelvic inflammatory disease (PID) - dx, tx
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
condoms - what two things can it prevent
only contraception method that prevents pregnancy and STI!!
hormonal methods of contraception (combined estrogen and progestin) - 3 types
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
hormonal methods of contraception (combined estrogen and progestin) -mechanism of action
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
estrogen-containing hormonal methods - benefits, contraindications
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
hormonal methods of contraception (progestin only pills) - use, indications for use
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
hormonal methods of contraception (progestin only shot) - use, side effects, warnings
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
hormonal methods of contraception (progestin only implant)
subcutaneous rod inserted under upper arm skin (Jadelle, Implanon)
side effects:
- break-through bleeding
- scaring at insertion site
Note: ovulation returns promptly after removal
hormonal methods of contraception (progestin only) - mechanism of action and contraindications
mature follicle is formed but not released
- suppresses LH surge
- NO effect on FSH (that is estrogen driven)
contraindications:
- breast carcinoma
- liver tumors
IUD - population, two types, mechanism of action
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
IUC - complications
uterine perforation
salpingitis
ectopic pregnancy
prolonged or irregular bleeding
sterilization - avoid pregnancy
tubal sterilization (female) - most common
vasectomy (male )
emergency contraception
Plan B levonorgestrel (progesterone)
- 1st dose within 72 hrs after unprotected sex
- 2nd dose 12 hrs later
Efficacy: >95%
infertility - definition, primary vs. secondary, causes
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
infertility from anovulation - causes, dx
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
infertility from tubal dz - causes, dx
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
infertility from male factors - causes, dx
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
infertility - general approach
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
Pregnancy - trimesters, weeks for “term”, GPTPAL
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
Chadwick’s sign
bluish discoloration of vagina and cervix due to estrogen and progesterone during pregnency
skin changes during pregnancy
melasma/cholasma: dark patches on face
linea nigra: line on abdomen
uterine growth during pregnancy
12 wks: at symphysis pubis
20 wks: at umbilicus
after 20 wks: 1 cm for every week gestation
- way to monitor fetal growth
normal labs in pregnancy
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
Pre Natal Labs
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)
pregnancy - screening tests and timing
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
pregnancy - screening blood tests (quad screen) - what is measured and levels for chromosomal abnormalities
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
pregnancy - optional diagnostic tests
chorionic villus sampling (CVS): 10-13 wks
amniocentesis: 15-20 wks
Not: these give you a definitive answer based on baby’s DNA
stages of labor
stage 1: onset of labor to full dilation (10cm)
stage 2: full dilation to birth
stage 3: delivery of infant to delivery of placenta
signs of placental separation
fresh show of blood - BRB
cord lengthening
fundus rises
uterus firm and globular (contracts down)
dystocia
difficult birth: inadequate pelvis, position of baby, inadequate contractions / dilation
labor induction - common indications and absolute contraindications
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
labor induction - medications and “surgical”
prostaglandins (cervidil):
- given vaginally
- “ripens” cervix
oxytocin (Pitocin)”
- causes uterine contractions
- given IV
amniotomy: breaking membranes
antepartum fetal monitoring (close to or during labor)
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
induced abortion - medications and surgical options
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&C): aspiration - surgical abortion up to 16 wks LMP
dilation and evacuation (D&E):
- up to 18 wks
Past 18 wks
- induce labor
spontaneous abortion (e.g. miscarriage) - definition and risks
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
spontaneous abortion - classifications
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
normal B-hCG levels during pregnancy
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
ectopic pregnancy - definition, cause, sxs
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
ectopic pregnancy - dx
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
ectopic pregnancy - tx
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)
gestational trophoblastic disease
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
hydatidaform mole (aka molar pregnancy) - characteristics of complete
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
hydatidaform mole (aka molar pregnancy) - hx, PE, studies, tx
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
preterm labor - definition, triad, risk factors
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
fetal fibronectin testing
cervical swab used to predict risk of delivery w/in 2 weeks
preterm labor - management
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
premature rupture of membranes (PROM) - definition, risks, dx, tx
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
maternal Rh Isoimmunization (incompatibility)- definition, risk
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
Rh incompatibility - tx
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
multiple gestation - sxs and office visit frequency
all sxs of pregnancy are usually more severe
prenatal office visits more often
additional risks to mom (spontaneous abortion, premature labor) and fetus
gestational diabetes - definition, population at higher risk, material risks, fetal risks
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
gestational diabetes - screening
b/t 24-28 weeks:
- glucose challenge test (GCT):
- non fasting 50 g glucose load
- check glucose after 1 hr
- > 140 mg/dl, move to GGT - 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
gestational diabetes - tx
- diet and exercise
- check glucose (finger stick) 4 times daily
- fasting
- 2 hr post meal - 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)
HTN in pregnancy - first step
determine is this is a chronic issue from before pregnancy, if brought on due to pregnancy, and if any end organ damage (pre-E)
chronic HTN - tx in pregnancy
monthly U/S: check of IUGR
serial BP and urine protein
medication:
- METHYLDOPA
pre-eclampsia and eclampsia - definitions and timing
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
preeclampsia - predisposing factors
NULLIPARITY (most common) extremes of age: <20, >35 multiple gestation DM chronic HTN
preeclampsia - complications and prevention
progression to eclampsia renal failure pulmonary edema HELLP syndrome DIC
prevent: 1gm calcium during pregnency
HELLP syndrome
complication of pre-eclampsia
Hemolysis
Elevated Liver enzymes
Low Platelets
preeclampsia - management (mild v. severe)
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
placental abruption - definition and risks
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
placental abruption - sxs, dx, tx, complications
vaginal bleeding
abdominal and back PAIN
fetal distress
dx: clinical
tx: emergent c-section
complications:
- fetal demise
- maternal hemorrhage
- maternal DIC and death
placenta previa - definition, sxs,
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
post partum hemorrhage - causes
- uterine atony (loss of tone)
- most common
- risks: short or long labor, infected uterus
- PE: soft, “boggy” uterus
- Tx: uterine massage, oxytocin - genital laceration
- uncontrolled vaginal delivery
- PE: visual laceration
- Tx: suture - retained placenta:
- non-contracted uterus
- PE: missing cotyledon on placenta
- Tx: manual exploration
endometritis - definition, sxs, dx, tx
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
