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clin med > women's health > Flashcards

women's health Flashcards

1
Q

when should pap smears begin and end? and how frequent?

A

age 21 until 65
every 3 years: 21-29
every 5 years with HPV cotesting from ages 30-65

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2
Q

who is gardasil recommended for?

A

females age 9-26. intramuscular injections @ 0,2 and 6 months

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3
Q

when should clinical breast exam and mammogram begin?

A

breast exam: annually starting at age 19

mammogram: annually starting at age 45 - earlier if family history of young onset, BRCA positive

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4
Q

BRCA mutation increases your breast and ovarian cancer risk by how much?

A

BC: 50-80& compared to lifetime risk in gen population of 12%
OC: 40-50% (BRCA1), 10-20% (BRCA2) compared to lifetime risk in general population of 1.4%

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5
Q

what is HNPCC (lynch syndrome)

A

autosomal dominant
mutation involved mismatch repair genes

COLORECTAL CANCER RISK: 50-70% (compared to 2% risk in general population)
ENDOMETRIAL CANCER risk: 30-60% (compared to 2-3% in general population)

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6
Q

inflammation + infection of the vagina

A

vaginitis

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7
Q

physiological changes for vaginitis

A

vaginal pH

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8
Q

symptoms of vaginitis

A 
pain
discharge
pruritus
dysuria
change in discharge (color and or consistency)
odor
labial edema
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9
Q

white, thick, curd-like discharge, adherent to vaginal walls and/or cervix with associated pruritus, dyspareunia, erythema, and edema is what?

A

vaginitis

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10
Q

what are risk factors for vaginitis?

A 
pregnancy
diabetes (may be first sign of DM)
long-term use of broad-spectrum antibiotics
use of corticosteroid meds
heat, moisture, occlusive fabrics
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11
Q

diagnostic for vaginitis

A

candida albicans
we mount with spores and hyphae
ph 4.0-4.5

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12
Q

how do you treat vaginitis?

A

ask if they prefer intravaginal agents or oral agents

intravaginal - clotrimazole, miconazole, terconasole
-creams, suppositories, and tablets
7 day regimen is recommended

oral: fluconazole (diflucan) 150 mg PO x 1 dose
if complicated, repeat dose in 72 hours

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13
Q

for vaginitis is therapy recommended for male partners?

A

no

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14
Q

what is the most common vaginitus

A

bacterial vaginosis

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15
Q

signs and symptoms of bacterial vaginosis

A

may be asymptomatic
grayish malodorous discharge
may worsen after vaginal intercourse and after completion of menses

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16
Q

diagnosis of bacterial vaginosis

A

gardnerella vaginalis
positive amine of “whiff” test - addition of KOH releases amines causing a “fishy” odor
wet mount wiht clue cells
pH > 4.5

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17
Q

treatment of bacterial vaginosis

A 
metronidazole (flagyl) 500 mg PO BID x 7 days
metronizaole gel (metrogel) 0.75% PV qhs x f days - used twice weekly for 6 months can reduce recurrences

if allergic to flagyl, then clindamycin 300mg PO BID x 7 days

therapy not recommended for male partners

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18
Q

patients can be asymptomatic or present with frothy gray or yellow-green vaginal discharge (copious), pruritus, cervical petechiae (“strawberry cervix”)

A

trichomoniasis

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19
Q

diagnosis of trichomoniasis

A

women: trichomonas vaginalis
wet mount with motile lagellated anerobic protozoa (always double check) - motile trichomonads
vaginal pH > 4.5
pap smear has limited sensitivity and low specificity
DNA probe
rapid test

men: most reliable is PCR/ culture of urine or urethral swab

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20
Q

treatment of trichomoniasis

A

metronidazole (flagyl) 2g PO x 1 dose

tinidazole 2g PO x 1 dose

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21
Q

does a partner have to be treated for trichomoniasis?

A

yes!!

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22
Q

where is the highest incidence of chlamydia?

A
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23
Q

complications of chlamydia

A

PID
ectopic pregnancy
infertility
neonatal transmission: conjuctivitis, pneumonitis

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24
Q

presents with watery to purulent discharge, cervical friability, urethritis, cervicitis may be asymptomatic

A

chlamydia

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25
Q

what is the incubation period for clamydia trachomatis?

A

1-5 weeks

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26
Q

how do you diagnose chlamydia?

A

NAAT (nucleic adcid amplification) –> women its a vaginal swab, men its urine

DNA probe with endocervical swab
urine PCR

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27
Q

when is a TOC (test of cure) recommended for chlamydia?

A

only in pregnancy - tests for reinfection in 3 months

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28
Q

treatment of chlamydia

A

KNOWN EXPOSURE- TREAT EMPIRICALLY

azithromycin 1 g orally in a single dose (observed) or doxycycline 100 mg orally twice a day for 7 days

**partner must be treated!!

proctitis/epidydimitis: doxy 100 mg po BID x 7 days plus ceftriaxone 250 mg IM x 1

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29
Q

presents with dysuria, purulent vaginal discharge, pharyngitis, and possible disseminated disease

A

gonorrhea

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30
Q

diagnosis of gonorrhea

A

neisseria gonorrhoeae - incubation period of 2-8 days
DNA probe with endocervical swab
urine PCR (less sensitive)
culture other sites (pharynx, rectum)

all sexually active males with symptoms: urine testing
all sexually active females with symptoms : vaginal or endocervical swab
-treat before culture

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31
Q

treatment of chlamydia

A

ceftriaxone (recephin) 250 mg IM x 1 dose
AND
azithromycin 1 g PO x 1 dose

(shot)

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32
Q

does the partner have to be treated for chlamydia?

A

YES

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33
Q

inflammation of the uterus, fallopian tubes, and/or ovaries (salpingitis, endometritis)

A

PID

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34
Q

causes of PID

A

STIs (c trachomatis, n gonorrhoeae)
enteric gram negative organisms
ascending infections (G. vaginalis, H. influenzae, S. agalactiae)

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35
Q

risk factors for PID

A 
multiple sex partners
age 15-24 years old
non-caucasian race
contraceptive practices (OCPs, condoms decrease risk)
history of STIs
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36
Q

diagnosis of PID

A

uterine tenderness
cervical motion tenderness (chandelier sign)
adnexal tenderness

temp >101
abnormal cervical or vaginal mucopurulent discharge
WBC > 10,000
ESR >15
tubo-ovarian complex
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37
Q

when should you hospitalize someone for PID?

A 
if surgical emergencies can't be ruled out (appendicitis, peritonitis)
tubo-ovarian abscess
non-compliant
can't tolerate PO regimen
failed outpatient treatment
pregnant
fever >102
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38
Q

treatment of PID

A

parenteral antibiotics
cefoxitin 2g IV q 6 hrs X 24 hours after signs of improvmenent

AND

doxycycline 100 mg BID x 14 days

AND

metronidazole 500 mg BID x 14 days (if BV positive or TOA)–> not in janet’s

can also get same regimen outpatient but cefoxitin is IM

transition to oral abx once clinically improved . complete 14 day course

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39
Q

diagnosis of syphilis

A 
genital ulcer - painless
treponemal pallidum (incubation period of 9-90 days)
darkfield examination
non-treponemal serologic testing (RPR)
treponemal serologic testing
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40
Q

stages os syphilis

A

primary: painless chancre - well demarcated hard ulcer with raised, rolled borders. resolves in 1-5 weeks
secondary: 6-12 weeks post-exposure. maculopaular rash involving palms and soles, lymphadenopathy, mucosal pathes in mouth/genitals, condyloma lata

tertiary: late syphilis
5-20 years later, solitary gumma, cardiovascular syphilis, neurosyphilis

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41
Q

tx of syphilis

A 
early latent (less than 1 year):
benzathine penicillin G 2.4 million units IM x 1 dose

pregnancy:
primary: penicillin G 2.4 million units IM x 1 dose
secondary/tertiary: penicillin G 2.4 million units IM x 3, repeat in 1 week

tertiary, late latent
penicillin G 2.4 million units IM weekly for 3 weeks

**PARTNER MUST BE TREATED*

if they have PCN allergy, need to be desentitized

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42
Q

high risk HPV types

A

16, 18 - cause 70% of all cervical cancers; can also cause vulvar, vaginal, anal, oropharyngeal and penile cancer

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43
Q

what percent of sexually active adults will acquire HPV in their lifetime?

A

over 80% - a diagnosis of HPV in one sex partner is not indicative of sexual infidelity in the other partner

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44
Q

physical exam for HPV

A

flat, papular, pedunculated growths

commonly found around the introitus

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45
Q

how do you diagnose HPV?

A

biopsy - atypical, indurated, pigmented, ulcerated. immunocompromised, refractory to therapy

HPV DNA tests

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46
Q

treatment of genital warts

A

imiquimod 5% cream (aldara) - immune enhancer that stimulates interferon and cytokine production
patient-applied
apply 3x per week at bedtime for up to 16 weeks
wash the tx area with soap and water 6-10 hours after the application

trichloroacetic acid (TCA) - destroys warts by chemical coagulation of proteins. apply weekly in office setting. low viscosity therefore can spread rapidly and damage adjacent tissues

cryotherapy with liquid nitrogen - destroys warts by thermal-induced cytolysis. repeat appications every 102 weeks

CO2 laser vaporization

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47
Q

prevention of HPV

A

gardasil (males and females age 9-26) - even if you have HPV, should get it

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48
Q

when is HSV recurrence most common?

A

during first year of infection

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49
Q

can HSV be transferred from someone who does NOT have a visible sore?

A

yes - can also transfer to another part of the body.

more likely for an infected male to transmit to female partner than vice versa

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50
Q

how do you diagnose HSV?

A

PCR testing (more rapid results than culture)

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51
Q

treatment of HSV

A

PRIMARY:
acyclovir 400 mg TID x 7-10 days
acyclovir 200 mg 5 times daily x 7-10 days

RECURRENT:
acyclovir 400 mg TID x 5 days, 800 mg BID x 5 days, or 800 mg TID x 2 days

initiate therapy within 1 day of lesion onset or during the prodrome that precedes outbreaks. topical therapy offers minimal clinical benefit

SUPPRESSION:
acyclovir 400 mg BID
famiciclovir 250 mg BID
reduces frequency of recurrences by 70-80%

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52
Q

what is the risk of transmission among women who acquire genital herpes near the time of delivery?

A

30-50%

1% among women with h/o recurrent HSV at term or who acquire genital HSV during the first trimester

suppression from 26 weeks gestation through delivery
C-section if active lesion present at delivery

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53
Q

painful, soft, ulcer with nectrotic edges and inguinal lymphadenopathy

A

chancroid- diagnosis by H. ducreyi, gram stain shows “school of fish” pattern. very rare (6 cases in 2014)

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54
Q

treatment of chancroid

A

azithromycin 1 g x 1 dose

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55
Q

tender inguinal and/or femoral lymphadenopathy, unilateral, self-limited genital ulcer of papule, anal pain, tenesmus, proctocolitis with mucoid and/or hemorrhagic discharge. caused by chlamydia, increasing in the MSM population

A

lymphogranuloma venereum (LGV) - diagnosis is C. trachomatis. clinical diagnosis of exclusion

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56
Q

treatment of LGV

A

doxycycline 100 mg bid x 21 days

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57
Q

rare in US, painless ulcers, slowly progressive lesions without regional adenopathy, highly vascular (beefy red appearance) , anogenital infection

A

granuloma inguinale- difficult to culture , punch biopsy with Wright’s stain exhibits donovan bodies

tx: doxycycline 100 mg BID x 3 weeks

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58
Q

what is the definition of infertility?

A

inability to conceive after 12 months or more of unprotected intercourse ( 6 months if AMA) –> 85% of couples will conceive within the first 12 cycles of trying

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59
Q

who should have fertility testing?

A

anyone unable to conceive if trying for at least one year

couples with a female partner 35 years old or older who have been unable to conceive after 6 months

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60
Q

what are you looking for in the history for a fertility evaluation?

A

chronic disease (thyroid, uncontrolled diabetes, lupus, painful menses? endometriosis?)
family hx of infertility, miscarriage
STDs- risk of tubal disease
surgical hx: abdominal surgery - risk of tubal disease
menstrual cycle history -regular vs. irregular
PMH of partner

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61
Q

what do you look for with the pelvic US for a fertility evaluation?

A

fibroids
ovarial cysts/endometriosis
antral follicle count
saline sonohystrogram

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62
Q

what test looks at the tubes and uterine cavity?

A

hysterosalpingogram

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63
Q

labs for a fertility evaluation

A

cycle day 3 labs - FSH, estradiol
TSH
prolactin
luteal phase progesterone

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64
Q

evaluation of FSH for a fertility evaluation

A

cycle day 3
FSH 10 decreased ovarian reserve - refer
must be done with estradiol (estradiol

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65
Q

evaluation of AMH for a fertility evaluation

A

antimullerian hormone: protein produced by granulosa cells in the ovary and controls the formation of primary follicles

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66
Q

this test is a direct reflection of follicle/egg status and is not influenced by estradiol/other hormones. it is also consistent through menstrual cycle

A

AMH (antimullerian hormone)

3-3.5 25 y/o
2-2.5 35 y/o
1.0 40 y/o

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67
Q

normal sperm parameters

A 
volume 2.0-5.0 mL
count > 20 x 10^6/mL
motility > 50%
morphology > 14%
-stain approximately 200 sperm
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68
Q

fertility tx for PCP

A

optimize natural fertility
ovulation predictor kits
timed intercourse
provide reassurance to anxious couples

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69
Q

what is the most fertile day?

A

day before ovulation (egg viable for 12-24 hours, sperm 72)

in general, start intercourse around CD10 and have IC every other day for a week

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70
Q

treatment for infertility that is an anti-estrogen that increases endogenous FSH levels

A

clomid - clomiphene
50 mg tablets, one tab by mouth CD3-7
try for 3 cycles then refer

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71
Q

who is clomid best for?

A

patients who are not ovulating - helps recruit an egg for ovulation. may help select the ‘best’ egg to ovulate in a cycle and support a “strong” follicle with better progesterone support

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72
Q

fertility treatment done by specialists

A

ovulation induction: clomid, femara, gonadotropins, ultrasound monitoring

intrauterine insemination: male factor, cervical factor, timing

donor sperm IUI
in vitro fertilization (tubal disease, endometriosis, severe male factor, unexplained infertility)
donor egg IVF
surrogacy

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73
Q

difference between primary and secondary amenorrhea

A

primary: absence of menses @ age 15 years in the presence of normal growth and secondary sexual characteristics or 13 years, if no menses have occurred and there is an absence of secondary sexual characteristics
- congenital abnormalities
- sex chromosome disorders
- H-P-O axis problem

secondary: absence of menstruation for 3-6 months in a women who previously menstruated normally
- pituitary or hypothalamic disorders (insufficiency, failure or tumors)
- ovarian disorders (dysfunction, neoplasm, PCOS)
- endocrine disorders (cushings, addisons, thyroid, diabetes)
- nutritional
- chronic disease

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74
Q

outermost cavity of the female reproductive system and forms the lower part of the birth canal

A

vagina - 8-12 cm in length

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75
Q

area of skin between the vagina and anus

A

perineum

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76
Q

when does the menstrual cycle start?

A

with the removal of the endometirum and release of FSH by the anterior pituitary

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77
Q

what occurs during the ovarial cycle?

A

development of ovarian follicle
production of hormones
release of ovum during ovulation

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78
Q

what occurs during the uterine cycle?

A

removal of endometrium from prior uterine cycle

preparation for implantation of embryo under the influence of ovarian hormones

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79
Q

what occurs during the follicular phase?

A
  1. rise of FSH during first days of the cycle, several ovarian follicles are stimulated
  2. follicles compete with each other for dominance
  3. dominate follicle is formed
  4. as they mature, the follicles secrete increasing amounts of estrogen, which thickens the new functional layer of the endometrium in the uterus
  5. estrogen also stimulates crypts in the cervix to produce fertile cervical mucus

at the end of this phase, ovulation occurs

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80
Q

what occurs during ovulation

A

during the follicular phase, estrogen suppresses production of luteinizing hormone (LH) from the pituitary gland

once estrogen levels reach a threshold stimulate production of LH

the release of LH matures the ovum and weakens the wall of the follicle in the ovary

after being released from the ovary, the ovum is swept into the fallopian tube

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81
Q

solid body formed in an ovary after the ovum has been released into the fallopian tube and produces significant amounts of progesterone

A

corpus luteum- falling levels of progesterone trigger menstruation and the beginning of the next cycle

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82
Q

what marks the beginning of ovulation?

A

LH surge

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83
Q

average age of menarche

A

12.5 - begins approximately 2-3 years after initiation of puberty

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84
Q

when does a period become regular?

A

approximately after 2-2.5 years

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85
Q

prolonged/excessive bleeding occurring at regular intervals. often c/o large clots

A

menorrhagia

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86
Q

irregular intervals, frequent bleeding, non-excessive amounts

A

metrorrhagia - often associated with dysfunctional uterine bleeding

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87
Q

prolonged, excessive bleeding at irregular intervals

A

menometrorrhagia

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88
Q

regular bleeding

A

polymennorrhea (oligomenorrhea is regular bleeding > 35 day intervals)

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89
Q

amenorrhea

A

absence of uterine bleeding for at least 6 months or 3 cycles

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90
Q

how is premenstrual dysphoric disorder different from PMS?

A

more severe, cause both mood symptoms and functional impairment

psychological diagnosis DMS category

tx: SSRIs: fluoxitine, birtch control

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91
Q

difference between primary and secondary dysmennorhea

A

primary: no pathologic causes, hormonally due to rise in prostaglandins

secondary: due to an organic cause
-reproductive organs: endometriosis, ovarian cysts, PID, post-op adhesions
GI: constipation, IBS, IBD
urinary: infection

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92
Q

causes of abnormal uterine bleeding

A

pregnancy
myomas: subserosal, intramural, submucosal
infection
systemic diseases (thyroid, liver, coagulation disorders)
pelvic neoplasm
PCOS

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93
Q

growth of extra-uterine endometrial tissue

A

endometriosis - endometrial tissue can be found on any intra-abdominal structures

pathogenesis: unknown

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94
Q

symptoms of endometriosos

A

dysmennorhea : onset 2-7 days prior to menses, diminishes as menstrual flow decreases

infertility*** (3-4 times greater incidence in infertile women)

dyspareunia

heavy and/or irregular uterine bleeding

rectal pain

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95
Q

gold standard for diagnosis of endometriosis

A

laparoscopy or laprotomy evaluation with tissue biopsies to confirm extra-uterine endometrial tissue

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96
Q

management of endometriosis

A

analgesics (naproxen 250 mg or 500 mg every 6-8)

OCP

danazol: suppresses menstruation

GnRH analogs: suppresses ovulation, therefore an increase in menopausal vasomotor symptoms is seen

GOAL: inhibit ovulation thus lowering hormone levels and preventing stimulation of implants and potentially shrinking their size

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97
Q

what accounts for 75% of primary amenorrhea?

A

turner’s syndrome

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98
Q

how do you manage amenorrhea?

A

keep in mind that it’s a symptom, so therapy is directed at the underlying cause, therefor proper evaluation and diagnosis is always required

weight loss (10% of body weight)

hormonal therapy

if endocrine problem treat underlying problem

menstrual regularity is important to maintain

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99
Q

what do women with PCOS exhibit?

A

a steady state of estrogen, androgen and LH as opposed to fluctuating levels seen in ovulating women

effects about 6% of premenopausal women

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100
Q

symptoms of PCOS

A

hirsuitism
obesity
virilization: acne, deepening of voice, alopecia
amenorrhea

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101
Q

what will a transvaginal US reveal for PCOS?

A

“string of pearls” on ovary

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102
Q

traditional evaluation of PCOS

A

total and free testosterone

DHEAS

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103
Q

how do you diagnose PCOS?

A 
diagnosis of exclusion
rotterdam criteria (2/3)
-oligo  or anovulation
-clinical or biochemical signs of hyperandrogenism
-polycystic ovaries
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104
Q

management of PCOS

A

weight reduction (7% reduction in body weight)
birth control (reduces hyperandrogenic effects and allows for normal menstrual cycles)
medroxyprogestone 10 mg/d x first 10 days of the month
ovulation induction
insulin sensitizing therapy

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105
Q

definition of menopause

A

cessation of spontaneous menstrual bleeding for 1 year- results from loss of ovarian function which leads to a decrease in estrogen and progesterone hormones

average age is 51.5 years- premature menopause is defined as cessation of periods before age 40

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106
Q

what hormones rise in menopause?

A

LH and FSH

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107
Q

hormone replacement therapy for menopause

A

combined therapy: estrogen + progesterone - prevents endometrial hyperplasia, therefore no additional risk for uterine cancer

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108
Q

removal of the uterus and cervix

A

total hysterectomy

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109
Q

removing uterus without cervix

A

supracervical hysterectomy

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110
Q

removing both tubes and ovaries

A

bilateral salpinto-ooporectomy

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111
Q

removing uterus, cervix, parametrium, and upper portion of the vagina

A

radial hysterectomy - doesn’t include lymph nodes

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112
Q

patient positioning for pelvic exam

A

adults: lithotomy
pediatrics: frog leg

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113
Q

degrees of uterine prolapse

A

1st: cervix still well within vagina
2nd: cervix at the introitus
3rd: cervix and vagina outside introitus

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114
Q

strawberry cervix (punctate lesions, erythematous in appearance) is a sign for what?

A

trichomonal infections

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115
Q

what is chadwick’s sign?

A

bluish discoloration of the cervix or vaginal walls present 6-8 weeks gestation

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116
Q

what is hegar’s sign?

A

softening of the cervical isthmus usually in the 2nd and 3rd trimester

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117
Q

what is the chandelier’s sign?

A

pain with palpation of the cervix–> PID

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118
Q

what are DNA probes used for?

A

screening for chlyamydia and gonorrhea

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119
Q

what are wet mount or cultures used for?

A

to screen for yeast, BV, and trich

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120
Q

most common position of the uterus

A

anteverted (bent forward)

can also be:
Retroverted – bent backwards (~20%)
Anteflexed – top of the uterus folded forward
Retroflexed – top of the uterus folded backwards

121
Q

where should you measure the uterus size?

A

from pubic symphysis to the uterine fundus

12 weeks – fundus rises above the pelvic brim
20 weeks – at the umbilicus
40 weeks – at the zyphoid process

122
Q

what is included in the cervical cancer screening?

A

cervical cytology and oncogenic subtypes of human papillomavirus

Follow-up of abnormalities in screening tests with colposcopy and cervical biopsy may result in a diagnosis of

123
Q

cervical anatomy

A 
The ectocervix (surface of the cervix that is visualized on vaginal speculum examination) is covered in flat, squamous epithelial cells
-CIN refers to squamous abnormalities

The endocervix, including the cervical canal, is covered with tall, columnar or glandular epithelial cells
Glandular cervical neoplasia includes adenocarcinoma in situ and adenocarcinoma

As the squamocolumnar junction (SCJ) migrates over time, this creates the transformation zone

124
Q

what is the transformation zone in the cervix?

A

represents the region of active cell division and therefore is the region most likely to develop abnormal growth –> where you need to sample with a pap smear

125
Q

what type of HPV is thought to induce precancerous and cancerous lesions

A

persistent

126
Q

most common high risk oncogenic or cancer-associated types

A

**16, 18

31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 82

Low-risk = non-oncogenic types
Common types: 6, 11, 40, 42, 43, 44, 54, 61, 72, 81

127
Q

where should a pap smear be done?

A

squamocolumnar junction/transition zone (where most changes begin)–> Cytologic evaluation

Primary purpose is to identify changes on the cervix related to cervical cancer

128
Q

cervical cancer screening differences:

A

Diagnostic Testing = Cytology Only
Reflex Testing = HR-HPV added on if cytology result ASCUS ( atypical cells of undetermined significance) or above
Co-Testing = Cytology and HR-HPV
HPV Typing = Specifically looking for strains 16 and 18

Future Trends: Primary HPV Testing

129
Q

who should be screened for HPV?

A

21-29: every 3 years with cytology. (Reflex testing every 3 years)

30-65: screening with a combination of cytology and HPV testing (“co-testing”) every 5 years

over 65: negative prior screening ad no history within the last 20 years should not be screened

After a benign hysterectomy Don’t do it

HPV vaccinated: Recommended screening practices should not change on the basis of HPV vaccination status.

These guidelines do not address special, high-risk populations who may need more intensive or alternative screening, including:
History of high grade cervical dysplasia
History of invasive cervical cancer
Exposed in utero to diethylstilbestrol (DES)
Immune-compromised (HIV, s/p transplant, lupus, etc)

130
Q

terminology for cytologic and histologic pap smear findings

A

cytologic: described with the
term “squamous
intraepithelial lesion (SIL)”

histologic: described with the term “cervical intraepithelial neoplasia (CIN)”

131
Q

3 degrees of CIN severity

A

CIN 1 = low-grade lesion
refers to mildly atypical cellular changes in the lower third of the epithelium.

CIN 2 = considered a high-grade lesion
refers to moderately atypical cellular changes confined to the basal two-thirds of the epithelium (formerly called moderate dysplasia) with preservation of epithelial maturation. There is considerable variability in this category.

CIN 3 = high-grade lesion
refers to severely atypical cellular changes encompassing greater than two-thirds of the epithelial thickness and includes full-thickness lesions

132
Q

direct microscopic visualization of the cervix

A

colposcopy- Entire cervix should be visualized including the transformation zone (squamocolumnar junction)

Abnormal areas can be biopsied to allow for diagnosis of cervical dysplasia
Endocervical curettage (ECC)
frequently performed as well

133
Q

what can be used during a colposcopy that causes abnormal areas to turn white?

A

acetic acid

Lugol’s iodine will stain normal vaginal tissue stains brown due to its high glycogen content, while abnormal tissues will not stain, and thus appears pale compared to the surrounding notmal tissue (called non-staining areas)

134
Q

what is LEEP?

A

loop electrosurgical excision procedure

can be done in office or OR
diagnostic and therapeutic
cauterizes margins –> less bleeding, but pathologist unable to determine if margins positive or negative

135
Q

what is CKC?

A

cold knife conization
always done in OR
pathologist able to give more detail about status of surgical margins
higher risk complications

136
Q

what is the newest HPV vaccine?

A

gardasil 9- newly approved vaccine against HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58. Gardasil 9 adds protection against five additional HPV types (31, 33, 45, 52 and 58) which cause approximately 20% of cervical cancers and were not covered by previously FDA-approved vaccines. Approved for use in both males and females.

137
Q

what is the latency period between HPV exposure and cervical cancer development?

A

10-15 years

138
Q

benign pelvic masses

A 
functional ovarian cyst - most common in premenopausal women
Pregnancy Related 
Leiomyomas (pedunculated fibroid)
TOA
Endometrioma
Hydrosalpinx
139
Q

what are the different physiologic cysts?

A

follicular cyst: Due to failure of follicle to rupture during normal ovulation
Smooth, thin walled, unilocular, round
Usually

140
Q

risk factors for physiologic cysts and tx

A

Tobacco use
Progesterone-only contraception
Bilateral tubal ligation
Tamoxifen use

tx: Watchful waiting
Serial sonography
Surgery needed only if concern that brisk bleeding from a ruptured cyst may cause anemia or hemodynamic instability

141
Q

what is a tubo-ovarian abscess

A

Usually due to PID
Occ related to endometriosis, pyelonephritis, malignancy
Associated w/ anaerobes or actinomyces
Present w/abdominal pain, +/- fever and leukocytosis
Rupture: peritonitis, fevers, chills, sepsis
Tx: antibiotics, drainage

142
Q

“chocolate cyst” due to growth of ectopic endometrial tissue. Present w/ cyclic pelvic pain, dysmenorrhea, dyspareunia
Complex/ heterogenous
on US

A

endometrioma

143
Q

this follows PID, fimbria are smooth and clubbed. Secretions collect within and distend the tube
On US, multiple hypoechoic mural nodules with incomplete septae

A

hydrosalpinx

144
Q

Benign neoplasm of smooth muscle origin. Usually originate from uterus, but can be in the broad ligament
Present in 25% of reproductive aged women
When degenerating, can appear as complex adnexal masses
Can cause elevation in CA-125
Dx – US, MRI

A 
leiomyomas 
Treatment:
Symptom Treatment: OCP’s, IUD’s, Iron – “anemia”, & NSAIDS
Lupron -  “Menopause” side effects
Uterine Artery Embolization
Surgery: Myomectomy vs. Hysterectomy
145
Q

different ovarian tumors

A 
Germ Cell Tumors
Arise from primordial germ cells
Sex Cord Stromal  Tumors 
Develop from the dividing cell population that would normally give rise to cells surrounding the oocytes, including the cells that produce ovarian hormones (the nongerm cell and nonepithelial components of the gonads) 
Epithelial Tumors 
Arise from epithelial cells
146
Q

the most common benign ovarian GCT in women of reproductive age . Many asymptomatic
Can present w/pelvic pain from enlargement or torsion
10-15% are bilateral
Malignant transformation: 1-3%

A

teratoma (looks like hairball in the cyst)

147
Q

this is diagnosed by US with a “tip of the iceberg” sign, fat-fluid levels, hair, and robitansky protuberance

A

teratoma

148
Q

what are cystadenomas?

A

benign neoplasms

Serous
Most common benign neoplasm 
Thin walled, uni- or multi-locular
20-25% bilateral 
5 cm to >20 cm
Mucinous
Less common
Multiloculated, much larger
Less frequently bilateral
149
Q

what is endometriomas associated with (symptom-wise)?

A

dysmennorrhea or dyspareunia (pain with sex)

150
Q

Physiologic cysts may be associated with what?

A

dull, achy pain that is localized to the size of the mass

151
Q

what is suggestive of tuboovarian abscess?

A

fever + vaginal discharge

152
Q

fallopian tube cancer is associated with what?

A

Serosanguinous vaginal discharge without fever

153
Q

what is the most appropriate initial study for a pelvic mass workup?

A

pelvic US
Both transabdominal and transvaginal should be obtained
Best evaluation of the adnexa (parts adjoining an organ)

154
Q

if yo are at all concerned about a cancer, what test should you order at a minimum?

A

CXR (chest CT frequently not approved by insurance without bx proven cancer)

155
Q

this is a tumor marker for epithelial ovarian cancer (but also elevated in many other settings)

A

CA125-glcyoprotein produced by ovary, peritoneal, and pleural linings

but also for other gynceologic malignancies and benign conditions, so use in conjunction with clinical picture

156
Q

elevation in which tumor markers should prompt a GI workup?

A

CAE or CA19-9

157
Q

tumor marker for breast cancer

A

CA15-5

158
Q

what are most cases of ovarian torsion associated with?

A

adnexal mass

159
Q

when is surgery indicated for a pelvic mass?

A

malignancy is suspected(allows for definitive histologic dx)

Risk associated w/mass (torsion, infection, etc)

Mass is symptomatic

160
Q

when should you refer a woman with a pelvic mass?

A

premenopausal:
very elevated CA 125, ascites, evidence of abdominal or distant metastases

postmenopausal:
elevated CA125 level
ascites
nodular or fixed pelvic mass
evidence of abdominal or distant mets
161
Q

what contraceptive method has the best and least effectiveness towards unintended pregnancy?

A

best: levonorgestrel IUD, female sterilization, copper-T IUD, injectible
worst: no method, spermicide, diaphragm

162
Q

difference in contraceptive effectiveness

A

most effective: prevents pregnancy >99% of the time
IUD/IUS implants, sterilization

very effective: prevents ~91-99% (pills, injectables, patch, ring)

moderately effective: ~81-90: condom, sponge, diaphragm

163
Q

ethinyl estradiol & progestin is an example of what form of contraception?

A

combined contraceptive pills

*(20ug, 35ug, 50ug) )

164
Q

MOA of ethinyl estradiol & progestin

A

progestin suppresses ovulation by preventing LH surge, thickens cervical mucus, slows tubal motility, and thins the endometrium

ehinyl estradiol augments efficacy-inhibits FSH and improves cycle control by stabilizing the endometrium

165
Q

is there an increase in risk of ischemic or hemohemorrhagic stroke is associated with use of OCs containing

A

NO

Breast cancer patients and immediate post-partum patients, migraines with aura (increase risk of stroke), 35 and older and smoking : don’t use BC
Obsesity is not a contraindication to BC

166
Q

what are contraindications to estrogen use?

A

smoking AND age > 35

HTN, vascular disease, artherosclerosis (prior MI or CVA), vascular disease, cardiomyopathy

history of PE/DVT

Known thrombogenic mutations, lupus with antiphospholipid antibodies

Major surgery with prolonged immobilization

Breast cancer, hepatoma, hormonally sensitive tumors

Postpartum

167
Q

MOA of vaginal ring

A

Flexible ring with ethinyl estradiol & etognogestrel

suppresses ovulation

168
Q

MOA of progestin only pills (mini pills)-Micronor (Norethindrone)

A

Suppresses Ovulation
Thickens cervical mucus
Thins endometrium
Slows tubal motility

daily use, no hormone free week

169
Q

what is the injectible contraceptive and how long does it last?

150mg IM depot medoxyprogestrone acetate
104 mg SC depot medoxyprogsterone acetate

A

depo-provera, 13 weeks

DepoSubQ

170
Q

disadvantages of injectable contraceptive?

A

Many patients (up to 70%) stop using by 1 year
Irregular spotting first 6-12 months
Weight gain (average 5.4 lbs in 1st year)
Temporary bone loss/thinning (reversible)
Slow return fertility upon stopping

171
Q

what is the duration for nexplanon (implant)?

A

3 years

Single implant 4cm long
Etonogestrel

Downside that some women can have some irregular bleeding. Doesn’t increase, just makes it more sporadic. Don’t get an actual period, more just a couple days of spotting

172
Q

MOA of nexplanon (implant)

A

systemic progestin suppression LH/FSH thickened cervical mucous, thin endometrium. doesn’t’ contain estrogen

173
Q

what is paragard and its MOA and its duration?

A

copper IUD- non-hormonal IUD

Mechanism of Action
Spermicidal
Prevents fertilization

10 years

174
Q

what else can paragard be used for?

A

emergency contraception for up to 5 days

175
Q

what is mirena, dkyla, liletta?

A

hormonal IUD

176
Q

MOA and duration of hormonal IUD

A

Mechanism of Action
Thickens cervical mucus
Impairs tubal and sperm motility
Thins endometrium

duration: 5 years

177
Q

contraindications for IUDs

A

Infection:
Pelvic inflammatory disease (within 3 mos)
Purulent cervicitis or pelvic infection (delay insertion until treatment is complete)
Post-abortal sepsis (within 3 mos)
Known pelvic tuberculosis
Wilson’s disease (Copper IUD)
Distorted uterine cavity (any congenital or acquired abnormality interfering with IUD insertion, including uterine fibroids)
Unexplained vaginal bleeding
Pregnancy!
Current malignant gestational trophoblastic disease, untreated or endometrial cancer
Breast cancer, other hormone sensitive cancers (LNG-IUD)

178
Q

when can hormonal emergency contraception be given?

A

up to 72-120 hours after unprotected sex

179
Q

what are the different emergency contraception?

A

Plan B – (use up to 72 hours after unprotected sex)- high dose progesterone- prevents LH surge. not that effective

Ella (ulipristal) -(use up to 120 hours after unprotected sex) - more effective but need scrip

Copper IUD (up to 5 days after ovulation)

180
Q

what are indications for emergency contraception?

A 
Intercourse within past 120 hours without contraceptive protection (independent of time in the menstrual cycle) although the longer the delay of initiating treatment, the lower the efficacy. 
Contraceptive mishap
Barrier method dislodgment/breakage
Expulsion of IUD
Missed oral contraceptive pills
Error in practicing coitus interruptus
Sexual assault
Exposure to teratogens (e.g., cytotoxic drugs)
181
Q

the majority of women having abortions are what?

A

in their 20s, poor, non-hispanic white, never-married, not cohabitating, protestant

182
Q

methods of abortion in first trimester

A

medication abortion (up to 10 weeks)

  • Mifepristone/Misoprostol
  • Mifepristone in the office and then go home with misoprostol which terminates pregnancy
Two medications
Abortifacients:
Antiprogestin: Mifepristone 200 mg
Expulsion Agents:
Prostaglandin analogue: Misoprostol 800 mcg

Different from FDA approved regimen!
Mifepristone 600 mg and Misoprostol 400 mcg

Dilation & Curettage

  • Manual vacuum aspiration (MVA)
  • Electrical vacuum aspiration
183
Q

methods of abortion in second trimester

A

Second Trimester
Dilation & Evacuation (12-13+ wks up to viability)
Induction Abortion

184
Q

what is MVA?

A

Vacuum aspiration abortion, most generally through ~11 weeks LMP among U.S. providers
Evacuation of incomplete SAB’s or other pregnancy loss
Completion of incomplete or failed medical abortion
Suction component of D&E at 14-18 weeks LMP
Removal of amniotic fluid or as security curettage in D&E and induction abortion

185
Q

second most reported STI in the US, usually has a higher incidence in men

A

neisseria gonorrhea- relationship with HIV - presences of NG infection facilitates transmission and acquisition of HIV

186
Q

4 stages of infection of gonorrhea

A

attachment
local penetration
local invasion
local inflammatory response with or w/out systemic dissemination (typically infections of urogenital but can become systemic)

187
Q

clinical presentation of uncomplicated vs complicated gonorrhea infection

A

uncomplicated: most are asymptomatic, can present with cervicitis/urethritis in females (generally infects the columnar epithelial cells of the cervix) or urethritis/epidydimitis in males

complicated: tenosynovitis (can affect multiple tendons), dermatitis, polyarthralgias (fever, chills, malaise at onset), purulent arthritis, often preceded by urogenital infection
- should sample joint fluid if have inflammatory arthritis

188
Q

treatment of uncomplicated gonorrhea

A

ceftriaxone 250 mg IM x 1

azithromycin 1 g po x 1 (to cover for C. trachomatis)

189
Q

what is not recommended for treating GC?

A

quinolones - because they have so much resistance

190
Q

most commonly reported bacterial infection in the US

A

chlamydia trachomatis (more common in women)

191
Q

complications in trichomonas in men

A

prostate CA if not treated, epididymitis, infertility

192
Q

how should you treat trichomonas in pregnant women?

A

SYMPTOMATIC pregnant women should be treated AFTER THE FIRST TRIMESTER to reduce risk of preterm birth
ASYMPTOMATIC pregnant women - don’t treat

193
Q

which HSV can cause genital infection?

A

both but most recurrent genital herpes is cased by HSV 2

194
Q

clinical features of primary infection of HSV

A

painful genital ulcers, fever, HA, tender local LAD, local pain and itching , dysuria . acute urinary retention can occur in severe infection and should be differentiated from urinary hesitation

195
Q

diagnosis of HSV

A

viral culture of vesicle contents
cell culture and/or PCR swab for denuded lesions
tzanck smear - less sensitive and specific, only helpful if +, doesn’t differentiate between types

HSV serology has limited value because positive serology can mean present or past infection

196
Q

treatment of primary HSV infection

A

oral antivals - acyclovir, famcyclovir, valacyclovir for 7-10 days

197
Q

what is the treatment for recurrent HSV?

A

shorter, episodic course antiviral dosing taken at first prodrome and at least within 48 hours of first lesion appearance

HSV suppressive therapy for very frequent attacks or multiple sexual partners

198
Q

which HPV types account for most cervical CA

A

16 and 18

type 6 and 7 often cause benign genital warts

199
Q

what is the test to diagnose HPV in males?

A

no FDA approved test

200
Q

what occurs in primary syphilis

A

painless chancre (shanker) at inoculation site 3-6 weeks after non tender regional LAD occurs. resolves 4-6 weeks without scarring

201
Q

what is secondary syphilis?

A

untreated patients enter a bactermic stage approximately 6 weeks after primary chancre heals. the bacteria multiply and spread via blood throughout the body

rash - macular lesions, symmetrically distributed- palms, soles, mucous membranes (also on palms and soles –> rocky mountain fever, endocarditis)

any organ system can be infected

202
Q

what is tertiary syphilis?

A

develops over 6-40 years
slow inflammatory damage to small blood vessels and neurons
1. gummatous syphilis - granulomatous lesions become nectrotic and fibrotic - skin and bone
2. cardiovascular syphilis - aneurysm in ascending aorta or aortic arch due to chronic inflammation
3. neurosyphilis - asymptomatic, subacute meningitis, meningovascular syphilis, Tabes dorsalis, general paresis. CSF should be tested

203
Q

screening for syphilis

A

utilizes a non-treponemal test -RPR and vDRL. based upon reactivity of patients blood with syphilis to a cardiolipin-chilerstol-lecithin Ag –> syphilis causes cellular damage and release of cardiolipin and lecithin, the body produces antibodies against these antigens. less sensitive and specific for primary disease

confirm: utilize a treponemal test - FTA-ABS, TP-PA, MHA-TP
- this will detect the antibody to the spirochete itself. confirmatory

204
Q

how do you treat neurosyphilis?

A

benzathine PCN G 18-24 million units per day, administered as 3 to 4 million units IV every four hours x 10-14 days-> doesn’t make it go awawy, but symptoms may improve

IF PCN allergy, desensitize

205
Q

highest risk factor for PID

A

females with multiple sex partners, age less than 25, sti exposure, previous sti/pid

206
Q

most common causes of PID

A

N. gonorrhoeae and C trachomatis

rare during pregnancy after 12 weeks due to mucous plut

207
Q

perihepatitis due to ascending infection that causes inflammation of hepatic capsule. presents with RUQ pain radiating to the shoulder (similar to gallbladder), but they have normal liver labs. LAPARASCOPY- PATCHY PURULENT AND FIBRINOUS EXUDATE (“VIOLIN STRING” ADHESIONS)

A

fitz hugh-curtis syndrome

208
Q

what weeks is the first trimester?

A

1-14

Start trimester on the date of the LMP

209
Q

what weeks is the second trimester?

A

14-28

210
Q

what weeks is the third trimester?

A

28-40

211
Q

when is a fetus viable?

A

23-24 weeks gestation

212
Q

preterm verse term

A

preterm: prior to 37 weeks gestation

213
Q

labs to diagnose pregnancy

A

urine BhCG- doubles every 72 hours in pregnancy

A level of > 1500 with no sonographic evidence of a fetus is highly indicative of ectopic pregnancy

214
Q

how do you determine the fundal height during pregnancy?

A

Palpate the uterine fundus with bimanual exam up to 12 weeks.
Palpate uterine fundus with abdominal exam after 16 weeks. (MacDonald Maneuver)

215
Q

how much weight should a normal weight woman gain during pregnancy?

A

25-35 pounds

Gains by Trimester

	- 2 to 5 pounds total for 1st trimester.
	- ~0.5 lbs per week for the first 28 weeks.
	- ~1.0 lb every week after 28 weeks

72% of weight gain is due to physiologic changes (~9lbs)
- fetus, placenta, amniotic fluid, uterus, maternal blood volume, breasts, edema

216
Q

what supplements should pregnant women be taking?

A

Prenatal Vitamins

Iron: Supplement 30 mg FeSO4 daily

Folic Acid: 400 mcg daily

- Seizure disorder
- Previous NTD
217
Q

what dietary avoidances are in pregnancy?

A

Soft cheeses: Listeria (crosses placenta can lead to bacteremia.)

- Raw meats/fish: toxoplasmosis & salmonella
- Deli Meats: Listeria
- Fish: mercury levels can impact brain development
218
Q

what are the ToRCH infections?

A

Toxoplasmosis (cat feces, no changing litter boxes)
Rubella
CMV
Herpes Simplex

219
Q

what is the prenatal evaluation schedule?

A

Visits every 4 weeks until ~ 28 weeks

Visits every 2 weeks until ~ 36 weeks

Visits every week from ~ 36 weeks until delivery.

220
Q

initial pregnancy labs

A 
Urinalysis: w/culture & sensitivity
	-identify infection
	-proteinuria: sign of pre-eclampsia
	-glucosuria: sign of gestational diabetes
CBC (H/H)
Type & Screen
	-Rh type: determine maternal/fetal incompatibilities
Pap follow established pap guidelines
HIV, Hep B (surface Ag), Syphilis (RPR)Rubella titer, gonorrhea, Chlamydia  
Carrier screening (optional)
Hemoglobin electrophoreisis/sct
CF 
Eastern European Jewish decent
221
Q

what pain med should you NOT use during pregnancy?

A

motrin -affects development of fetal heart

222
Q

what is PICA in pregnancy a sign of?

A

craving for non-food items, often ice. - anemia

223
Q

what lab should be repeated at every pregnancy visit?

A

UA
Repeat H/H ~28 weeks
If positive GC/Chlamydia, repeat 3rd trimester

224
Q

when does genetic testing begin in pregnancy?

A

trisomy 21 (quad screen) - 10 weeks
Free fetal DNA
Screens for T21,T18, T13 and sex chromosome aneuploidy

amnioentesis - 16 weeks

225
Q

treatment of UTI during pregnancy

A

Nitrofurantoin 100 mg BID x 3-7 days

- Cephalexin 500 mg BID x 3-7 days
- Ampicillin 500 mg BID x 3-7 days

Contraindicated Antibiotics

- Fluoroquinolones: teratogenic to fetal cartilage
- Sulfas: neonatal hyperbilirubinemia
- Trimethoprim: folic acid antagonist
226
Q

treatment for Rh incompatibility

A

Rhogam at 28 weeks and within 72hours postpartum

227
Q

fetal circulation

A

1 vein- carries oxygenated blood originating from the placenta to the fetus’s portal system.

  • blood enters the ductus venous shunt (liver)
  • then enters into right heart
    • foramen ovale: allows blood to enter left heart; closes with baby’s first breath following delivery
  • left heart delivers blood to rest of fetal body

*opposite of what you would think
2 arteries - Removes waste from fetal circulation

228
Q

normal fetal heart rate

A

110-160

229
Q

what is quickening?

A

when mother can first detect fetal movement

- occurs ~18 weeks

- described as a fluttering in the abdomen

Kick Count

- conduct daily at approximately 28 weeks
- tallying 10 movements within the course of 2 hours
230
Q

maneuvers for palpating fetal lie- Determine presenting part at every visit after 36 weeks.

A

Leopold’s Maneuvers

231
Q

stages of labor

A

Stage 1
-begins with cervical effacement & dilation.
-ends with complete dilation.
-Latent phase: contrations may occur at regular intervals
-Active phase: begins with 4 cm dilation.
Stage 2
-from complete dilation
-average duration: primigravida ~50 minutes, multigravida ~20 minutes
Stage 3
-From birth of the neonate to placental delivery. (usually within 60 minutes)
Stage 4
-The first hour immediately post-partum

232
Q

Relationship to presenting fetal part to ischial spines

A

Station –3: at pelvic inlet, “floating”
Station 0: level of the ischial spine, “engaged”.
Station +3: level of the perineum (usually baby is crowing)

233
Q

ways to induce labor

A

Cervical ripening

	- mechanical
	- synthetic prostaglandin
		 - Cervidil

Induction methods
Oxytocin
amniotomy

(Indications- maternal medical conditions (many )
diabetes
-fetal conditions (many)
IUGR

234
Q

***perineal tear degrees

A

First Degree
- only mucosa or skin injury
Second Degree (most common)
-first degree tears plus disruption of the superficial fascia & the transverse perineal muscle.
Third Degree:
-first & second degree tears plus the external anal sphincter
Fourth Degree:
-all of the above plus laceration extending into the rectal mucosa.

235
Q

Incision intended to decrease the extent of perineal tears.

A

episiotomy - NOT recommended

236
Q

indications for a c section

A 
breech or transverse lie
	multiples (not all)
	Macrosomia
	Fetal Distress	
	placenta previa or abruption
237
Q

C-Section Complications

A 
Blood loss
Infections
Higher incidence of PE
Damage to maternal organs
Anesthesia risks
Subsequent surgeries
238
Q

important things to watch for during post-partum care

A

Infection
Excessive blood loss
-CBC, lightheadedness, tachycardia, hypotension
Hypertension
Episiotomy/lacerations/surgical incisions
Mood

239
Q

when does the post-partum visit occur

A

6-8 weeks

240
Q

spontaneous abortion

A

pregnancy loss at less than 20 weeks gestation

Pregnancy loss is most common in the first trimester – 80% occur by 12 weeks gestation

241
Q

bleeding & cramping, no cervical dilatation, pregnancy still viable.

A

threatened abortion

242
Q

cervical dilation, bleeding but no passage of products of conception yet occurred.

A

inevitable abortions

243
Q

fetus & placenta are expelled. Pain absent, bleeding/spotting may persist.

A

complete abortion

244
Q

cervical dilation, retained products of conception, usually the placenta. Cramping & persistent bleeding, which is often excessive.

A

incomplete abortion

245
Q

Pregnancy which ceases to develop but no products of conception have been expelled. No bleeding, no pain, cervix remains firm and closed

A

missed abortion

246
Q

3 or more consecutive spontaneous abortions.

A

recurrent abortion

247
Q

workup for suspected misscarriage

A

BhCG: Baseline, then repeat in 48-72 hours to determine trend.
in a normal pregnancy levels should double every 72 hours
Ultrasound:
look for products of conception
fetal pole
fetal heartbeat.
PE

248
Q

management for incomplete, inevitable, or missed abortion

A

dilation and curettage

249
Q

Gestational Trophoblastic Disease- abnormal fertilization of a pregnancy, non-viable at any point

A

molar pregnancy

No pregnancy for minimum of 1 year: patients need to be on contraception.

250
Q

complete molar pregnancies are at an increased risk for development of what?

A

choriocarcinoma

251
Q

higher than normal BhCG levels are indicative of what?

A

molar pregnancy

also Protrusion or expulsion of grape-like vesicles from cervical os or vagina
-trophoblasts; edematous villi
With or without vaginal bleeding

252
Q

when should you have a high suspicion for ectopic pregnancy?

A

any pregnant patient with new onset, severe pain

253
Q

causes of ectopic pregnancy

A

Any condition that interferes with migration of fertilized ovum to the uterus

PID-scarring of the uterus & fallopian tubes secondary to sexually transmitted infections

IUD in place

pregnancy after tubal ligation

254
Q

Sudden, severe lower quadrant pain that typically remains unilateral

A

ectopic pregnancy

Pain may radiate to shoulder (but rarely will present with this)
due to phrenic nerve irritation
Back pain
Irregular vaginal bleeding or spotting
Pelvic exam may be normal
Abdominal exam positive for pain
if several days have gone by since onset you may see distention due to bleeding into the peritoneum
palpable mass may be found
255
Q

when does an ectopic usually occur?

A

usually around 6 weeks but can happen as late as 12

256
Q

workup for ectopic

A

BhCG (beta HCG)- may be lower than IUP of same gestational age. serial hCG may be slower to rise, or plateau

CBC
anemia may be present
leukocytosis may be seen

Ultrasound-to evaluate for signs of intrauterine pregnancy (IUP)
abdominal U/S with no IUP & hCG level of >6500 or transvaginal U/S with no IUP & hCG level >2000-3000 diagnostic of ectopic.

257
Q

management of ectopic

A

Stable Patients…
Medical therapy – Methotrexate 50 mg/m2
Surgical therapy – Laparoscopic salpingostomy (opening the tube but it’s not removed) or salpingectomy (taking out whole tube)

Unstable Patients…
Emergent surgical therapy- most people get salpingectomy

Provide RhoGam for Rh negative patients.

258
Q

false labor. uterine contractions that occur at irregular intervals and consists of mild cramping and contraction of uterine wall

A

braxton hicks contractions

Management: Conservative
adequate water intake
lay down/change position
deep breathing

259
Q

Systolic BP ≥ 140 or Diastolic BP ≥ 90 taken twice at least 6 hours apart.

A

gestational hypertension

Diagnosed at >20 weeks gestation

260
Q

Occurs after 20 weeks gestation and up to 6 weeks post-partum.
Hypertension
Proteinuria or
Thrombocytopenia, Renal insufficiency, Impaired liver function, Pulmonary edema, Cerebral or visual symptoms

A

preeclampsia

> +1 is positive, consider 24 hour urine collection (> 300 mg is positive) gold standard

Risk Factors
previous history or family history of GHTN
African American race
CHTN
AMA (advanced material age), but also a risk factor if you’re very young, so “extremes of materal age”
diabetes
multiple gestations
obesity
261
Q

Preeclampsia with severe features

A 
Systolic BP > 160 or diastolic >110
HELLP Syndrome: 
Hemolysis, 
Elevated Liver transaminases
Low Platelets: thrombocytopenia
262
Q

management of severe preeclampsia

A

34-37: deliver immediately

Preeclampsia with severe features at EGA

263
Q

what is eclampsia

A

50% of seizures develop prior to labor

Maternal & fetal risks
higher risk of placental abruption
higher risk of DIC

264
Q

how do you treat eclampsia?

A

Turn patient to side to prevent aspiration

Immediately IV bolus
Magnesium sulfate 6 g IV (loading dose)
Diazepam 5-10 mg over 4 minutes or until seizure ceases.

Post-seizure
Continuous IV infusion of magnesium sulfate at 2 g/hr
measure urine output
measure for signs of magnesium toxicity
loss of DTR’s, decreased RR
calcium gluconate for reversal
265
Q

when should you screen for gestational diabetes?

A

Perform 24-28 weeks gestation (or at initial prenatal visit in high risk women)

266
Q

interpretation of GTT

A

fasting > 95
1 hour >180
2 hrs > 155
3 hrs > 140

positive if elevated in any 2 of the 3 hour tests.
if one abnormal, close monitoring and possible retesting

267
Q

Complications of GDM

A 
Fetal macrosomia – with associated delivery complications
Intrauterine fetal demise
Premature birth
Neonatal hypoglycemia 
may lead to neonatal death
268
Q

Fetal Heart rate tracing abnormalities

A

loss of variability
repetitive severe variable decelerations or late decelerations.
prolonged decelerations.

potential causes: umbilical cord compression (variable decelerations), uteroplacental insufficiency (late decelerations)

269
Q

too little amniotic fluid

A

oligiohydraminos

AFI

270
Q

too much amniotic fluid

A

polyhydraminos

AFI > 19

271
Q

Implantation of the placenta in the lower uterine segment covering the internal cervical os

A

placenta previa
marginal
partial
total

More common in multiparous women & women with prior c-section.

272
Q

IUGR

A

intrauterine growth restriction

273
Q

signs and symptoms of placenta previa

A

Painless bleeding as early as 20 weeks
Intrauterine growth restriction (IUGR)

Diagnosis is made on ultrasound.
18-24 weeks, repeat U/S in 3rd trimester
if previa is

274
Q

33 week G6P7 (all C-section)
delivered presents with severe
abdominal pain and bleeding. What is
the likely diagnosis?

A

placenta abruptio

Bleeding
Pain
Uterine Contractions
Up to 30% of mild abruptions have no pain
The fetus can tolerate up to 40% separation without long term effects
Once approach 50% abruption typically outcome is fetal demise.

275
Q

management of placenta abruption

A

Hospitalization
Continuous maternal & fetal monitoring
Delivery-vaginal delivery not contraindicated if maternal/fetal stability present. 50% deliver vaginally.
Blood products: high risk for hemorrhage
RhoGam for Rh negative mothers

276
Q

most common cancer of female reproductive system? most lethal cancer of female reproductive system?

A

common: endometrial ( uterine)
lethal: ovarian

277
Q

cancer arising from epithelial tissue

A

carcinoma

278
Q

cancer arising from connective tissue (bones, tendons, cartilage, muscle, and fat)

A

sarcoma

279
Q

cancer arising from plasma cells of bone marrow

A

myeloma

280
Q

what is present in 99.7% of cervical cancer?

A

HPV

Normal Immune System - takes 15 to 20 years for cervical cancer to develop
Weakened Immune System (such an untreated HIV infection) – can take only 5 to 10 years for cervical cancer to develop
All new cervical cancers pts should be tested for HIV, if positive this is an AIDs defining illness

281
Q

most common histology of cervical cancer?

A

squamous cell carcinoma

282
Q

what is the first line chemo therapy for almost all gyn cancers?

A

carboplatin/taxol

283
Q

vulvar cancer most often affects what?

A

labia majora- Often present with a prurtitic or painful lesion

284
Q

post menopausal bleeding is what until proven otherwise?

A

endometrial cancer-

Also, any change in bleeding habits after age 35 needs to be worked up

285
Q

Treatment of hyperplasia:

A

Do not desire future fertility  Total Hysterectomy +/- BSO (no LND); This is Definitive treatment
Desire to retain fertility Treat with progestins and monitor with serial EMBs (Provera, Megace, Mirena IUD)

286
Q

biggest risk for endometrial cancer

A

unopposed estrogen

followed by age, obesity

287
Q

This is a genetic mutation, which is
autosomal dominant and causes
endometrial cancer and increased risk of colon cancer

A

lynch syndrome

288
Q

umbilical nodule associated with malignancy

A

sister mary joseph nodule

289
Q

what is the frequent breast lesion, Most common in women 30-50, Asymptomatic or painful breast mass
?

A

fibrocystic breast disease

not pathologic

290
Q

what is mastalgia

A

breast pain
Mild mastalgia is a normal physiologic cyclical change during late luteal phase
Result from variation in plasma concentration of gonadotrophic and ovarian hormones

291
Q

what is the workup of a breast mass?

A

triple test

Physical exam
-Clinical impression

Imaging
-Mammogram and/or Ultrasound (Approx.10% of cancers are mammographically occult. Age cutoff for mammogram: >30 years old)

Biopsy (required for any solid mass)

  • FNA, Core needle biopsy vs. surgical
  • Concordance
292
Q

what is the preferred method for initial diagnosis of a breast mass?

A

core needle biopsy

293
Q

painless, well circumscribed, freely mobile tumors

Rounded, lobulated or discoid shape

A

fibroadenoma

10% will regress spontaneously
Most tend to stop growing at 2-3 cm
Rapid growth during
Pregnancy
Hormone Replacement Therapy
May involute in postmenopausal women
294
Q

t or f: fibroadenoma is considered to have malignant potential

A

false

However, because they contain an epithelial tissue, neoplasia can occur

295
Q

Most common mass during pregnancy and postpartum

A

lactating adenoma - distinct mobile mass

296
Q

Most common cause of spontaneous serous or serosanguinous drainage.Most common cause of nipple discharge

A

intraductal papilloma - not a premalignant lesion

benign tumor growing from lining of duct

297
Q

abnormal mammogram

A 
Microcalcifications (clustered, stellate, pleomorphic)
Spiculated mass
Tissue distortion
Asymmetric density
New or evolving findings
Prompts a biopsy or short term follow-up
298
Q

most common breast cancer

A

infiltrating ductal

299
Q

only painful breast cancer

A

inflammatory breast cancer

clin med (12 decks)

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