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
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
26
ovarian cysts - nonfunctional, most common, management
do not arise from normal fx endometrioma: unilateral, blood-filled (hemorrhagic) - called chocolate cysts manage: surgical incision
27
PCOS (poly cystic ovary syndrome) - classic triad, how pts present
1. anovulation 2. polycystic ovaries 3. androgen excess normal menses followed by episodes of amenorrhea that become progressively longer #1 cause of androgen excess and hirsutism - most patients present due to hirsutism or infertility - also have obesity, acne, insulin resistance - bilateral ovaries affected
28
hirsutism
male pattern hair on females | - common sign of PCOS
29
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
30
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
31
ovarian neoplasm - benign vs. malignant
benign: smooth, regular surface, unilateral, small, simple malignant: nodular, irregular, fixed, bilateral, large, complex
32
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
33
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
34
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
35
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
36
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: 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
37
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
38
grading cervical lesions - cytology vs. histology results
cytology: from PAP - ASC, LSIL, HSIL, Cancer histology: from biopsy during colposcopy - CIN I, 2, 3
39
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)
40
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!)
41
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)
42
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
43
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
44
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!!
45
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
46
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
47
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
48
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
49
types of cancers caused by prolonged, unopposed estrogen
endometrial ovarian breast Not: cervical caused by HPV!!
50
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
51
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
52
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
53
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)
54
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
55
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
56
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
57
menopause -alternative tx
Hot flashes: - DepoProvera - IM - SSRI - Yoga, acupuncture - Soy, black cohost Osteoporosis: - Ca++ w/ vit. D Vaginal dryness - topical estrogen
58
vaginitis - 3 main types
Candida (yeast) Bacterial vaginosis (BV) Trichomonas
59
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)
60
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)
61
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)
62
metronidazole (Flagyl) warning
MUST avoid ETOH (severe N/V) and sun exposure
63
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
64
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
65
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
66
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
67
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
68
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
69
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
70
condoms - what two things can it prevent
only contraception method that prevents pregnancy and STI!!
71
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
72
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
73
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
74
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
75
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
76
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
77
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
78
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
79
IUC - complications
uterine perforation salpingitis ectopic pregnancy prolonged or irregular bleeding
80
sterilization - avoid pregnancy
tubal sterilization (female) - most common vasectomy (male )
81
emergency contraception
Plan B levonorgestrel (progesterone) - 1st dose within 72 hrs after unprotected sex - 2nd dose 12 hrs later Efficacy: >95%
82
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
83
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
84
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
85
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
86
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
87
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 ```
88
Chadwick's sign
bluish discoloration of vagina and cervix due to estrogen and progesterone during pregnency
89
skin changes during pregnancy
melasma/cholasma: dark patches on face linea nigra: line on abdomen
90
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
91
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
92
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)
93
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
94
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
95
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
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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
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signs of placental separation
fresh show of blood - BRB cord lengthening fundus rises uterus firm and globular (contracts down)
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dystocia
difficult birth: inadequate pelvis, position of baby, inadequate contractions / dilation
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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
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labor induction - medications and "surgical"
prostaglandins (cervidil): - given vaginally - "ripens" cervix oxytocin (Pitocin)" - causes uterine contractions - given IV amniotomy: breaking membranes
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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fetal fibronectin testing
cervical swab used to predict risk of delivery w/in 2 weeks
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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
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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
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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
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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
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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
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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
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gestational diabetes - screening
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
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gestational diabetes - tx
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)
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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)
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chronic HTN - tx in pregnancy
monthly U/S: check of IUGR serial BP and urine protein medication: - METHYLDOPA
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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
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preeclampsia - predisposing factors
``` NULLIPARITY (most common) extremes of age: <20, >35 multiple gestation DM chronic HTN ```
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preeclampsia - complications and prevention
``` progression to eclampsia renal failure pulmonary edema HELLP syndrome DIC ``` prevent: 1gm calcium during pregnency
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HELLP syndrome
complication of pre-eclampsia Hemolysis Elevated Liver enzymes Low Platelets
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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
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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
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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
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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
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post partum hemorrhage - causes
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
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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