uWISE Flashcards
CO increase in pregnancy
30-50%, w/50% of that occurring by week 8
mechanism of increased CO in pregnancy
increased stroke volume (first half), increased maternal heart rate (second)
what shunts blood in late pregancy when IVC may be occluded
paravertebral collaterals
CO and MAP in labor
40% increased CO, MAP increased by 10mmHg
normal hyperdynamic PE findings in late pregnancy
increased 2nd heart sound split w/inspiration, distended neck veins, low-grade systolic ejection murmur
total body oxygen consumption increase in preg
20%: 50% to uterus, 30% heart and kidneys, 18% respiratory muscles, rest to mammary tissue
ABG in pregancy
normally show respiratory alkalosis
plasma increase in single gestation
50% (blood volume increases 35% by term
iron needed in preg
60mg qD. (recommended supplement is 27mg) actively transported to fetus, so fetal hemoglobin is normal even if mother is Fe deficienct
clotting factor increase in preg
I, VII, VIII, IX, and X by 50%, rest normal
VTE risk increase in preg
5.5x
WBC in labor
may increase up to 30
trace glucose on dipstick in preg
normal! but proteinuria is concerning
renin and angiotensin increase in preg
renin activity increases 10x, angiotensin by 5x
creatinine and BUN in preg
decrease!
GI changes in preg
lower esophageal sphincter tone (GERD), decreased GI motility, impaired gallbladder contractility: gallstones, cholestatis of bile salts
estrogen on the liver in preg
increases synthesis of fibrinogen, ceruloplasmin, and binding proteins for corticosteroids, sex steroids, thyroid hormone and vit. D
ptyalism
sensation of excess saliva caused by decreased swallowing 2/2 nausea
LFTs in preg
alk phos doubles, cholesterol increases, albumin increases but appears dilutionally lowered
thyroid in early pregnancy
hCG stimulates transient rise in free T4, estrogen increases TBG, leading to lasting elevation of total T3 and T4
carb metabolism in preg
human placental lactogen (hPL) leads to decreased tissue response to insulin, hyperglycemia after meals, and hypoglycemia while fasting
hyperpigmentation of pregancy cause
elevated estrogen and melanocyte-stimulating hormone, cross-react with similarly structured hCG
skin changes in preg
vascular spiders, striae gravidarum, hyperpigmentation, linea nigra, chloasma (mask of pregnancy), eccrine sweating and sebum increase leading to acne
colostrum
thick yellow fluid expressed from breasts in late preg
placenta produces
estrogen, progesterone, hCG, hPL
why HgbF has higer oxygen affinity and saturation than HgbA
more avid 2,30DPG binding
primary source of amniotic fluid by mid second trimester
fetal urine
why neonatal vitamin K is given
fetal livers don’t do much; K prevents hemmorhagic disorders
when does fetus make own T3/T4
24-28 weeks
sex differentiation happens when
testes in week 6 (testosterone and mullerian inhibitory factor), ovaries in week 7 (no hormones, wolffian ducts regress)
passive immunity comes from
maternal IgG
Iron deficiency v. dilutional anemia
Fe deficiency comes w/microcytic anemia
contributes to pulmonary edema in pregnancy
decreased plasma osmolality
other causes of pulmonary edema in preg
tocolytic use, fluid overload, preeclampsia
if PVR exceeds SVR in the setting of VSD
left to right shunting, cyanosis
can cause hydronephrosis in late preg, usually R
right ovarian vein complex dilation
implanted egg w/o DNA, chorionic villi dilate with fluid (grape like), hyperplasia of tropoblastic tissue
molar pregancy, results in spontaneous abortion. check lungs for metastatic disease
wt gain in preg, BMI under 18.5
28-40lb
wt gain in preg, BMI normal
25-35lb
wt gain in preg, BMI over 25, under 30
15-25lb
wt gain in preg, BMI over 30
11-20lb
most common cause of PPH
uterine atony (more than 500cc if vag, 1000 if C)
Sheehan syndrome
AP necrosis from PPH, causing lost of gonadotropin, ACTH and TSH. Tx estrogen, progesterone, thyroid and adrenal hormones
greatest risk for puerperal infection
protracted labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic statu
risk of endometritis in vag v C
3% of vaginal, 5-10x higher in C
most common cause of post-partum fever
endometritis (uterine fundal tenderness on PE)
bacteria in PP endometritis
polymicrobial resulting in a mix of aerobes and anaerobes in the genital tract. The most causative agents are Staphylococcus aureus and Streptococcus
PP blues, duration and prevalence
less than two weeks, 40-85%
most telling sign of PP depression
no love for family, indifferent toward infant
breastfeeding duration rec
six months
breast feeding benefits
decreased ovarian cancer, maybe breast cancer, and provides IgA to baby
vaccinations in pre-preg
rubella, varicella, pertussis and hep B. (don’t give attentuated vaccines, like rubella, to pregnant pt)
always test pregnant woman for
HIV
screening by background: african
sickle hemoglobinopathies
screening by background: Mediterranean, SE asian, african
alpha, beta thalassemia
screening by background: ashkenazi, french canadian, cajun
tay-sachs
screening by background: ashkenazi
tay-sachs, faconi anemia, neimann-pick, bloom, gauchier, canavan disease, familial dysautonomia, CF
recommended folic acid
0.4 mg, unless prior NTD pregancy or meds affecting folate, then 4mg)\
bluish vagina
chadwick sign
softening cervix
hegar sign
quickening happens when
16-18 weeks, sometimes as late as 20
standard urine hCG labs detect pregnancy
4 weeks after LMP
serum pregancy tests detect
unique b-subunit of hCG, so don’t count LH, and detect pregnancy sooner
mean doubling time for hCG in normal pregancy
1.5-2 days
doppler detects fetal HR at
12 weeks. fetoscopes at 18-20 weeks
fundal height in cm represents gestational age
when exits pelvis until 36 weeks
Naegele rule
add 7 days to LMP, then subtract three months
normal pregnancy
40 plus or minus two weeks
ultrasound can detect pregnancy
3-4 weeks (transvag) or 5-6weeks from lmp
b-hCG 1,500
should see gestational sac, if not consider ectopic
b-hCG over 4000
should see embryo and fetal heartbeat
antenatal appointment schedule
every 4 weeks for 28 weeks, every two until 36, and weekly after
gestational hypertension
140/90 (either) after 20 weeks w/o proteinuria
normal monthly weight gain
3-4 pounds
normal fetal HR
110-160 bpm
percent of fetuses in cephalic (head-down) position at term
95%
contraindications to external cephalic version
multifetal gestation, fetal compromise, uterine abnormalities, problems of placentation
optimal first ultrasound
18-20w
placenta accreta
chorionic villi attach to myometrium
placenta increta
chorionic villi invade into myometrium
placenta percreta
chorionic villi invade through myometrium and serosa, and sometimes into adjacent organs
first trimester screening (10-13w)
PAPP-A, b-hCG, u/s assessment of nuchal transparency
second trimester screening (15-20w)
triple (MSAFP, estriol, and inhibin), or quadruple (hCG) screening
third trimester screening (24-28w)
glucose challenge (then GTT if abnormal), group b strep at 35w, H/H, antibodie screening repeat in Rh- or HIV pt
big fetus ddx
incorrect age, multiples, macrosomia, hydatidiform mole, polyhydramnios
small fetus ddx
incorrect age, hydatidiform mole, FGR, oligohydramnios, or fetal demise
indications for fetal testing; prexisting
anti-phospholipid, cyanotic heart dz, SLE, renal dz, DM on insulin, HTN
indications for fetal testing: fetal
HTN of preg, decreased movement, oligo/polyhydramnios, growth restriction, postterm, isoimmunization, previous unexplained fetal demise, multiples, monochorionic diaminotic multiple gestation
reactive Nonstress test
2+ accelerations (15 beats above baseline for 15seconds) in 20 minutes. bad is no accelerations in 40minutes
decelerations in contraction stress test
postitive, equivocal, or unsatifcatory, depending on pattern, frequency and strength (high rate of false positives)
biophysical profile components
NST, fetal breathing movements, fetal movement, fetal tone, amniotic fluid at least 2cm
important phospholipids in the surfactant complex
lecithin/sphingomylen (L/S ration), phosphatidylglycerol (marks complete lung maturation at 35w)
RDS signs
grunting, chest retractions, nasal flaring, hypoxia leading to acidosis or death
recovery after delivery
4-6 weeks
exercise while preg
30minutes moderate daily
hot tubs, saunas, supine exercise
no
mineral supplementation while preg
just iron, 27 mg
avoid sex in preg if
placenta previa, premature rupture of membranes, hx or current preterm labor
air travel restrictions in preg
up to 36 weeks, unless poor DM, HTN, or sickle cell (should stay near providers or travel with records), and move every 1-2 hours
birth defect prevalence
2-3%, 5% results of enviromental chemicals or drugs, 15 pharmaceuticals
recommended limit on radiation exposure in preg
5 rad (CT ab/spine has max dx rad at 3.5)
fish restriction
methyl mercury. under 12oz (two servings0 per week, only 6oz albacore tuna
FAS triad
growth restriction, facial abnormalities (short palpebral fissures, low ears, mid-face hypoplasia, smooth philtrum, thin upper lip), CNS dysfunction (microcephaly, intellectual disability, behavior disorders)
tx for constipation of pregancy
docusate, psyllium hydrophlic mucilloid, lubricants
Women with poorly controlled diabetes immediately prior to conception and during organogenesis have a four- to eight-fold risk of having a fetus with a
structural anomaly, most likely CNS or cardiac
highest detection rate for trisomy 21
Sequential screen: (first trimester NT and PAPP-A + second trimester quad screen, 93% Detection Rate)
HPV strains in vaccine
(6,11) 16, 18
nonspecfic tests for syphilis
VDRL, RPR (nontreponemal)
strawberry cervix
trichomoniasis. frothy yellow-green discharge as well. tx:metronidazole, tinidazole
herpes culture sens/spec
highly specific, not sensitive (10-20% false negative rate)
How/where HPV causes cancer
carcinogenesis in the transformation zone of the cervix, where the process of squamous metaplasia replaces columnar with squamous epithelium
ACOG breast cancer screening
annually after 40
screening: first degree relative with colon cancer before 60
begin screening with colonoscopy at age 40, or 10 years before the youngest relative diagnosis, and repeat every five years
DEXA screening
age 65, or sooner with risk: early menopause, glucocorticoid therapy, sedentary lifestyle, alcohol consumption, hyperthyroidism, hyperparathyroidism, anticonvulsant therapy, vitamin D deficiency, family history of early or severe osteoporosis, or chronic liver or renal disease
cause of compensated respiratory alkalosis in pregnancy
increased minute ventilation
causes of acute pilmonary edema in pregnancy
tocolytic use, cardiac disease, fluid overload and preeclampsia
ureter prone to compression by uterus and ovarian veins
right. left is cushioned by sigmoid colon
why total T3 and T4 increase in pregnancy
Thyroid binding globulin (TBG) is increased due to increased circulating estrogens with a concomitant increase in the total thyroxine.
Poorly controlled DM prior to pregnancy most often leads to
cardiac anomolies
Can CVS dx neural tube defects?
No. just dna abnormalities
fragile X prevalence
1 in 3,600 males and 1 in 4,000 to 6,000 female
first trimester ultrasound gives dating within
3-5 days. second: within 1 week third: within 3 weeks
quad screening false positive rate
5%
GTT cutoffs
fasting under 95, one hour under 180, two hour under 155, three hour under 140.
seen with preexisting DM but not gDM
IUGR
When is ibuprofen dangerous in pregnancy?
can close ductus arteriosis after week 32
tx umbilical cord prolapse
attempt to push head back and immeadiate c/s
wide spaced nipples and lymphadema in neonate
turner’s syndrome
Mother w/DM1, moderate glucose control, neonate with
small, hypoglycemic
TTTS effects on donor and recipient
recepient: volume overload, polyhydramnios, polycythemia, hydrops. Donor: IUGR, oligo
neonate, mother with gDM
hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress
in HIV+ mom, start neonate AZT
immeadiately at birth
neonate CPR position
sniffing position (tilting the neonate’s head back and lifting the chin (not flex, as in adult)
APGAR components
HR, RR, reflex, activity, color (2 each)
breastfeeding is associated with decreased
ovarian cancer
burning pain in breasts, shiny nipples with peeling periphery
candidiasis
signs that baby is getting sufficient milk
3-4 stools in 24 hours, six wet diapers in 24 hours, weight gain and sounds of swallowing
percent of spontaneous abortions w/chromosomal anomalies
50-60% (most often autosomal trisomy)
when to place cerclage
hx of cervical incompenence, second trimester (14weeks)
testing for multiple early pregnancy losses
Testing for lupus anticoagulant, diabetes mellitus and thyroid disease are commonly performed. Maternal and paternal karyotypes should also be obtained
ACE inhibitors in pregnancy
beyond the first trimester of pregnancy has been associated with oligohydramnios, fetal growth retardation and neonatal renal failure, hypotension, pulmonary hypoplasia, joint contractures and death
treat thyroid storm in pregnancy
thioamides (i.e. PTU), propranolol, sodium iodide and dexamethasone (NOT radioactive iodine)
tx kidney stones in preg
aggressive hydration, double-J stent if needed
tx lupus in preg
corticosteroids, hydroxychloroquine for skin symptoms
tx breast cancer in preg
no radiotherapy (chemo okay?)
antidepressant bad in preg
paxil (paroxetine). increased risk of fetal cardiac malformations and persistent pulmonary hypertension
test for appendicitis in preg
graded compression ultrasound (remember, appendix could be anywhere!)
pre-eclampsia!
systolic blood pressure of 160 mm Hg or higher, or diastolic blood pressure of 110 (2x, 4h apart) thrombocytopenia, LFTs x2, severe persistent right upper quadrant or epigastric pain unresponsive to medication, renal insufficiency, pulmonary edema or new-onset of cerebral or visual disturbances.
Mg in preeclampsia
if BP over 160/110
mg toxicity causes
respiratory depression
thromobcytopenia over 100,000
contraindication to expectant management of severe preeclampsia remote from term.
indicate immeadiate delivery in preeclampsia
high BP on max 2 meds, non-reassuring fetal surveillance, LFTs x2, eclampsia, persistent CNS symptoms and oliguria
risk of isoimmunization w/o rhogam
2% antepartum, 7% after full term delivery, and 7% with subsequent pregnancy
best test for the noninvasive diagnosis of fetal anemia
MCA peak systolic velocity
how much rhogam at 28weeks
300mcg, which neutralizes 30cc of fetal blood
determine dose of rhogam to give to mother after exposure
kleinhauer-betke test
indicates the severity of materal Rh hemolytic disease
bilirubin
tx severe fetal Rh disease
fetal transfusion, maternal plasmaphoresis is second line
days and twins
di/di split within three days, mono/di 4-8, mono/mono 8-12, conjoined after 13
risk of multiples with ArT
5-6%
twinning is not related to
paternal family hx
intellectual disabilities from x-rays
8-15 weeks
ultrasound criteria for missed abortion
CRL over 7 with no fetal heart beat
induce labor with closed cervix
cytotec (miso) prior to pitocin (no foley if cervix isn’t open)
associated with breech
Prematurity, multiple gestation, genetic disorders, polyhydramnios, hydrocephaly, anencephaly, placenta previa, uterine anomalies and uterine fibroids
AROM when?
arrest in active phase (more than 4cm)
success rates in VBAC
70-80% after one c/s, 70% after two
before digital exam in third trimester bleeding
pelvic ultrasound. determine placenta placement before further exam!
steroids cutoff
under 34 weeks
low anterior placenta and prior c/s means risk for
placenta accreta
most preterm labor is
idiopathic
most cervical incompetence is dx’d
early second trimester
tocolytics contraindicated in DM
terbutaline (never use for more than 48h), ritodrine
tocolytics contraindicated in myasthenia gravis
magnesium sulfate
indomathcin contraindicated as tocolytic when
after 33 weeks (d. arteriosis closure) also associated with oligohydramnios
magnesium toco mec
competing with calcium entry into cells.
ritodrine, terbutaline, and salbutamol toco mec
Beta-adrenergic agents work by increasing cAMP in the cell, thereby decreasing free calcium.
nifedipine toco mec
Calcium channel blockers prevent calcium entry into muscle cells by inhibiting calcium transport
indomethacin toco mec
Prostaglandin synthetase inhibitors, such as Indomethacin, work by decreasing prostaglandin (PG) production by blocking conversion of free arachidonic acid to PG.
associated w/nifedipine use
Fetal hypoxia and decreased uteroplacental blood
betamathasone effects on neonate
increased lung maturity, decreased RDS, decreased ICH, decreased necrotizing enterocolitis(no increase in infections)
fetal fibronectin NPV in symptomatic women
99% 99 out of every 100 patients with a single negative test result will not deliver in the next 14 days
first test for PROM
vaginal fluid nitralazine or ferning
risks for PPROM
mostly infection, also 2x inrease from smoking, prior pprom. Shortened cervix
time from ROM to delivery
At term, 90% will spontaneously go into labor within 24 hours of PROM. At 28 weeks to 34 weeks, 50% will go into labor within 24 hours and 80% within 48 hours
prolongs latency in PROM by 5-7 days
antibiotics (steroids prolong less)
Neonatal survival when rupture occurs between 20 and 23 weeks
25%
amniocentesis signs of infection
glucose under 20, increased interleukin 6 (leukocytes aren’t very helpful)
tx fetal hypoperfusion
change in maternal position to left lateral position, supplemental O2, treatment of maternal hypotension, discontinue oxytocin, consider intrauterine resuscitation with tocolytics and intravenous fluids, fetal acid-base assessment with fetal scalp capillary blood gas or pH measurement
smooth muscle constrictor, contraindicated in PPH in pt w/HTN
methylergovine
smooth muscle constrictor, contraindicated in PPH in pt w/asthma
prostaglandin F-2 alpha (hemabate, always delivered IM)
associated with retained placentas
prior Cesarean delivery, uterine leiomyomas, prior uterine curettage and succenturiate lobe of placenta (NOT Placental abruptions, labor augmentation, degree of parity and circumvallate placenta)
tx endomyometritis
ampicillin (or other gram + coverage), gentatmicin (or other gram negatives)
most common agents acute cystitis
. coli (75%), P. mirabilis (8%), K. pneumoniae (20%), S. faecalis (
first tx of infected wound
open drainage, then abx if indicated
tx septic thrombophlebitis
add anticoagulant to antibiotics
most common source of fever first day postpartum
lungs! get cxr before starting abx
FDA catergory C
Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well controlled studies in humans
most common SSRI side effect
insomnia
fluoxetine in preg
abnormal muscle movements (EPS) and withdrawal symptoms: agitation, abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and difficulty feeding
peaks higher at ovulation
LH
follicular phase
pre-ovulatio, selected tertiary follicle
luteal phase
post ovulation, corpus luteum becomes albicans and degrades
associated with post-term pregnancies
placental sulfatase deficiency, fetal adrenal hypoplasia, anencephaly, inaccurate or unknown dates and extrauterine pregnancy
risks of postterm pregnancy
macrosomia, oligohydramnios, meconium aspiration, uteroplacental insufficiency and dysmaturity
favorable cervix after 42 wks
induce!
withered, meconium stained, long-nailed, fragile and have an associated small placenta
dysmaturity, 10% of babies born after 43 weeks
low birth weight, overlapping fingers, micronathia, and cardiac defects
trisomy 18
extremem DM causes IUGR by
uteroplacental insufficiency (vascular disease)
increased S/D ratio on umbical doppler
reflects increased vascular resistance. It is a common finding in IUGR fetuses.
head-sparing growth asymetry
uteroplacental insufficincy (as in HTN)
infective causes of IUGR
will be symmetric. rubella, CMV, syphilis, varicella, protozoan toxoplasmosis. No bacteria are known to cause IUGR.
morbities of IUGR
oligo, fetal demise, perinatal demise, meconium aspiration, polycythemia
adult complications of fetal IUGR
cardiovascular disease, chronic hypertension, chronic obstructive lung disease and diabetes
most reliable first trimester dating
ultrasound crown rump
when do fibriods indicate c/s
when in lower uterine sgement
requirements for forceps
complete cervical dilation, head engagement, vertex presentation, clinical assessment of fetal size and maternal pelvis, known position of the fetal head, adequate maternal pain control and rupture of membranes
vaccuums v. forceps
decreased lacs, increased cephalohematoma, jaudice, lateral rectus paralysis (resolves sponaneously)
BTL failure rate
1%
CVS v. amnio
CVS is earlier (12 v. 15), more rare limb abnormalities, more alloimmunization, more repeat attempts, higher procedure loss rate
Depot irregular bleeding should resolve by
2-3 months. (amenorrhea in 50%)
window for emergency contraception
72-130 hr
contraception that decreases ovarian and endometrial cancer
combined OCPs
slightly reduced the risk of ovarian cancer
BTL
strongest predictor of regret of BTL
age (40% under age 25)
patch fails more in pts
over 198 lbs
associated with early recurrent pregnancy loss
antiphosopholidid antibody. work-up: anticardiolipin, beta-2 glycoprotein antibody, PTT, russel viper venom test.
tx: antiphospholipid antibody in pregnancy
aspirin and heparin
medical abortion v. surgical
more blood loss
manual vacuum aspiration cut-off
less than eight weeks
asherman’s syndrome
adhesions/fibrosis associated with d/c (up to 32% after 3 d/cs)
squamous cell carcinoma from lichen sclerosis?
less than 5%
inflammatory mucocutaneous lesions with relapsing obliterating rashes and lesions in skin, hair, nails, oral and vulvar mucosa
lichen planus, tx topical superpotent corticosteroids
severe vulvar pruritis, worse at night, thick rugose labia
lichen simplex chronicus. tx topical steroids and antihistamines
mucopurulent cervicitis tx
may be gonorrhea or chamydia–tx both
post-exposure prophylaxis for hep B
within 7 days of blood exposure, 14 days of sexual. give HBIG and start vaccination series (known exposure)
incubation period for hep B
6 weeks to 6 months
outpatient PID treatment
ceftriaxone, cefoxitin, or other third-generation cephalosporin (such as ceftizoxime or cefotaxime) PLUS doxycycline WITH or WITHOUT metronidazole
inpatient PID treatment
Cefotetan or cefoxitin PLUS doxycycline or clindamycin PLUS gentamicin
tubal infertility rates in PID
tubal infertility has been reported as 12% after one episode of PID, 25% after 2 episodes and 50% after three episodes
cause of overflow incontinence
underactive detrusor (neuro, MS, DM) or obstruction (postop, severe prolapse)
cause of urge incontinence
detrusor instability
best surgical option for genuine stress incontinence
retropubic urethoplexy (needle suspensions and anterior repairs have lower rates of success)
tx “drain pipe urethra”, intrinsic sphincteric deficiency
urethral bulking is first line, then tight sling. artificial sphinter as last resort
anticholinergics for parasympathetic detrusor instability (urge incontinence)
oxybutynin.
complex mass in postmeno woman
exploratory surgery!
first line endometriosis management
combined OCPs
pelvic “fullness” or “heaviness,” which may extend to the vulvar area and legs. Associated symptoms include vaginal discharge, backache and urinary frequency
pelvic congestion syndrome
provides cutaneous sensation to the groin and the skin overlying the pubis
iliohypogastric nerve (T12 L1)
provides cutaneous sensation to the groin, symphysis, labium and upper inner thigh
ilioinguinal nerve (T12 L1)
May increase pain of fibrocystic breast changes
caffeine
nipple itch is usually
chemical irritation! (rarely, paget’s)
abx for breastfeeding mastitis
dicloxacillin (or penicillin type, for s. aureus. can give erythro if allergic)
sequence of sexual maturation
breast budding, then adrenarche (hair growth), a growth spurt and then menarche. In a minority of cases, pubarche (pubic hair growth) can occur before thelarche (breast/areolar development).
body weight for menses
at least 85 lbs
olfactory tract hypoplasia and the arcuate nucleus does not secrete GnRH
Kallman syndrome (no smell, no secondary sex characteristics) tx: pulsatile GnRH
premature menses before breast and pubic hair development
McCune Albirght syndrome
tx precocious puberty
GnRH agonist
normal age of menarche
9-17
check in patients with mullerian agenisis
renal utrasound! 25-35% have renal ageneisi
secondary amenorrhea resulting from intrauterine scarring/synechiae.
asherman’s syndrome
causes of hypothalamic-pituitary amenorrhea
functional (weight loss, obesity, excessive exercise), drugs (marijuana and tranquilizers), neoplasia (pituitary adenomas), psychogenic (chronic anxiety and anorexia nervosa). Get LH/FSH
dyspareunia in premature ovarian failure
due to vaginal dryness from decreased estrogen
initial laboratory assessment for a patient with amenorrhea and no other symptoms or findings on physical exam
Prolactin! Prolactinoma is most common pituitary tumor causing amenorrhea
Asian e/short duration hirsutism and the significantly elevated DHEAS
adrenal tumor
looks lik PCOS w/normal serum testosterone
check 17-hydroxyprogesterone for 21-hydroxylase deficiency
terminal hair growth, depression, striae
cushings! check dexa suppression test
post pregnancy hair loss
high estrogen in preg causes synchrony, leading to increased shedding 1-5 months postpartum
unilateral tumor in pt 20-40; hirsutism and virilization.
sertoli-leydig cell tumors
estrogen secreting tumors
granulosa cell, thecomas
ancanthosis nigricans, temporal balding, clitoral enlargement and deepening of the voice
hyperthecosis (severe PCOS)
second line (after OCPs) for idiopathic hirsutism
spironalactone
leuprolide
GnRH agonist. Precocious puberty, fibroids, enodmetriosis, breast and prostate cancer, pedophilia
progestin mechanism for AUB
inhibit further endometrial growth, converting the proliferative to secretory endometrium.
polyp observation cutoff
bigger than 1.5cm
tx for submucosal fibroid
hysteroscopic myomectomy (can’t access with laproscopy)
dysmenorrhea failing OCPs and depot
ex lap
Hyperplastic overgrowth of endometrial glands/stroma
polyps
Endometrial glands/stroma and hemosiderin-laden macrophages
endometriosis
adenomyosis and GnRH agonists
pain recurs after therapy
physical examination in patients with primary dysmenorrhea
normal!
should be performed on all women over age 40 with irregular bleeding to rule out endometrial carcinoma
endometrial biopsy
good endometrial strip postmeno
less than 4 cm
premature ovarian failure occurs
before age 35
postenopausal calcium requirement
1200 mg qd
repeat DEXA how often
q2y
HRT and cholesterol
HDL levels increase and LDL levels decrease (good!)
osteopenia DEXA T-score
-1 to -2.5. review risk factors, encourage increased vit. D and Ca intake
menopausal symptoms in postmeno hysterectomy
decreased circulating androgens
conception over time in healthy couples
After one month, 20% of couples will conceive; after three months, 50%; after six months, 75%; and after 12 months, 90% will conceive
infertility after salpingitis
15%
characterized by normal FSH and low estrogen levels
exercise-induced hypothalamic amenorrhea. tx is less exercise, then exogenous gonadotropins (LH, FSH)
test for decreased ovarian reserve
clomiphene challended. give days 5-9, the check FSH on day 3 & 10. Elevated FSH means diminished reserve
male role in infertility
35%
PMDD timing
last week of luteal phase, resolve with follicular phase
vitamin deficiency associated with PMS
A, E, B6 (also Ca, Mg, and positive family hx)
SSRIs for PMS
daily, or for ten days of luteal phase
molar pregnancy risk factors
Asian, under 20 or over 40, 2 or more miscarriages, low beta-carotene and folic acid consumption.
recurrent risk in molar pregnancy
1-2% (20 fold!), 10% after two
enlarged uterus and vaginal bleeding, a Beta-hCG value >1,000,000 mIU/mL
mole!
partial mole
Karyotype 69XXY (or other triploid), fetus present, lower risk of developing post-molar GTD
complete mole
diploid resulting from fertilization of “empty egg” by single sperm (46XX, 90%) or by two sperm (X & Y = 46XY 6-10%
partial v complete mole presentation
partials have marked villi swelling, lower bHCG, older pts, longer gestations. completes are larger uteri, PEC, more GTD
new pregnancy after mole
6 mos after negative HCG
GTD risk in complete moles
20% (5 in partials)
tissue diagnosis needed for choriocarcinoma?
No! bHCG is sufficient
only vulvar carcinomas treated with excisional biopsy (all others radical vulvectomy and groin node dissection)
microinvasive squamous cell carcinoma of the vulva only made after pathology evaluation of a small (
90% of vulvar cancers
squamous cell carcinoma. (over 65, smoking, not pigmented)
pigmented vulvar lesion
melanoma or high-grade vulvar intraepithelial neoplasia
erythematous with lacy white mottleing of the surface
Paget’s
VIN 3 tx
local superficial excision (precancerous!)
condyloma tx
TCA (thrichloroacetic acid), Aldara,
cervical dysplasia tx
cryotherapy
VIN 2 tx
lasers if multifocal, or vulvevtomy
in situ carcinoma associated with breast cancer
paget’s disease of the vulva
ASGUS under 30
repeat pap in one year if HPV positive, three years if negative
white plaque on cervix
leukoplacia! biopsy asap
most concerning on colposcopy
disorderly vessels most of all, then punctations and mosiacism.
dx lesion in endocervical canal
conization of lesion can’t be visualized (ECC has high flase negatives)
HSIL with normal biopsy
LEEP or conization, then cotesting at 12 and 24 months
CIN grading
extent of involvement of the epithelial layer. CIN does not extend below the basement membrane. Carcinoma in situ (CIS) involves the basement membrane. In cancer, the cells invade beyond the basement membrane. In microinvasive cancer, they invade less than 3 mm
indicated in positive ECC
cervical conizations
most common symptom of fibroids
menorrhagia
fibroid size reduction in GnRH treatment
estradiol level and with body weight, resumes growth potential if treatment is stopped
untreated CAH on endometrial biopsy
30% will have endometrial cancer
weight and endometrial cancer
10x increase if more than 50 lbs overweight
abnormal bleeding in postmenopausal woman, enlared endometrial stripe, rare atypia on biopsy
d/c for further eval
screening in patients on tamoxifen
none, just annual exams
risk factors for ovarian cancer
nulliparity, family history, early menarche and late menopause, white race, increasing age and residence in North America and Northern Europe. Not smoking
BRCA contribution to cancer
5 to 10 percent of breast cancers and 10 to 15 percent of ovarian cancers in white American women
The most useful radiologic tool for evaluating the entire peritoneal cavity and the retroperitoneum
CT (PET scan is not useful in diagnozing ovarian malignancy
The five-year survival of patients with epithelial ovarian cancer is directly correlated with
tumor stage
tx advanced ovarian cancer
debulking, post-op chemo with taxane and platinum adjunct
response rate is 60-80%, five-year surivival in stage III ans IV is 30%
most common tumor in women of all ages
dermoid tumor (median 30y, 80% in reproductive age)
