women's health Flashcards
(299 cards)
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
2
Q
who is gardasil recommended for?
A
females age 9-26. intramuscular injections @ 0,2 and 6 months
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
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%
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)
6
Q
inflammation + infection of the vagina
A
vaginitis
7
Q
physiological changes for vaginitis
A
vaginal pH
8
Q
symptoms of vaginitis
A
pain discharge pruritus dysuria change in discharge (color and or consistency) odor labial edema
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
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
11
Q
diagnostic for vaginitis
A
candida albicans
we mount with spores and hyphae
ph 4.0-4.5
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
13
Q
for vaginitis is therapy recommended for male partners?
A
no
14
Q
what is the most common vaginitus
A
bacterial vaginosis
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
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
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
18
Q
patients can be asymptomatic or present with frothy gray or yellow-green vaginal discharge (copious), pruritus, cervical petechiae (“strawberry cervix”)
A
trichomoniasis
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
20
Q
treatment of trichomoniasis
A
metronidazole (flagyl) 2g PO x 1 dose
tinidazole 2g PO x 1 dose
21
Q
does a partner have to be treated for trichomoniasis?
A
yes!!
22
Q
where is the highest incidence of chlamydia?
A
23
Q
complications of chlamydia
A
PID
ectopic pregnancy
infertility
neonatal transmission: conjuctivitis, pneumonitis
24
Q
presents with watery to purulent discharge, cervical friability, urethritis, cervicitis may be asymptomatic
A
chlamydia
25
what is the incubation period for clamydia trachomatis?
1-5 weeks
26
how do you diagnose chlamydia?
NAAT (nucleic adcid amplification) --> women its a vaginal swab, men its urine
DNA probe with endocervical swab
urine PCR
27
when is a TOC (test of cure) recommended for chlamydia?
only in pregnancy - tests for reinfection in 3 months
28
treatment of chlamydia
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
29
presents with dysuria, purulent vaginal discharge, pharyngitis, and possible disseminated disease
gonorrhea
30
diagnosis of gonorrhea
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
31
treatment of chlamydia
ceftriaxone (recephin) 250 mg IM x 1 dose
AND
azithromycin 1 g PO x 1 dose
(shot)
32
does the partner have to be treated for chlamydia?
YES
33
inflammation of the uterus, fallopian tubes, and/or ovaries (salpingitis, endometritis)
PID
34
causes of PID
STIs (c trachomatis, n gonorrhoeae)
enteric gram negative organisms
ascending infections (G. vaginalis, H. influenzae, S. agalactiae)
35
risk factors for PID
```
multiple sex partners
age 15-24 years old
non-caucasian race
contraceptive practices (OCPs, condoms decrease risk)
history of STIs
```
36
diagnosis of PID
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
```
37
when should you hospitalize someone for PID?
```
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
```
38
treatment of PID
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
39
diagnosis of syphilis
```
genital ulcer - painless
treponemal pallidum (incubation period of 9-90 days)
darkfield examination
non-treponemal serologic testing (RPR)
treponemal serologic testing
```
40
stages os syphilis
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
41
tx of syphilis
```
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
42
high risk HPV types
16, 18 - cause 70% of all cervical cancers; can also cause vulvar, vaginal, anal, oropharyngeal and penile cancer
43
what percent of sexually active adults will acquire HPV in their lifetime?
over 80% - a diagnosis of HPV in one sex partner is not indicative of sexual infidelity in the other partner
44
physical exam for HPV
flat, papular, pedunculated growths
| commonly found around the introitus
45
how do you diagnose HPV?
biopsy - atypical, indurated, pigmented, ulcerated. immunocompromised, refractory to therapy
HPV DNA tests
46
treatment of genital warts
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
47
prevention of HPV
gardasil (males and females age 9-26) - even if you have HPV, should get it
48
when is HSV recurrence most common?
during first year of infection
49
can HSV be transferred from someone who does NOT have a visible sore?
yes - can also transfer to another part of the body.
| more likely for an infected male to transmit to female partner than vice versa
50
how do you diagnose HSV?
PCR testing (more rapid results than culture)
51
treatment of HSV
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%
52
what is the risk of transmission among women who acquire genital herpes near the time of delivery?
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
53
painful, soft, ulcer with nectrotic edges and inguinal lymphadenopathy
chancroid- diagnosis by H. ducreyi, gram stain shows "school of fish" pattern. very rare (6 cases in 2014)
54
treatment of chancroid
azithromycin 1 g x 1 dose
55
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
lymphogranuloma venereum (LGV) - diagnosis is C. trachomatis. clinical diagnosis of exclusion
56
treatment of LGV
doxycycline 100 mg bid x 21 days
57
rare in US, painless ulcers, slowly progressive lesions without regional adenopathy, highly vascular (beefy red appearance) , anogenital infection
granuloma inguinale- difficult to culture , punch biopsy with Wright's stain exhibits donovan bodies
tx: doxycycline 100 mg BID x 3 weeks
58
what is the definition of infertility?
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
59
who should have fertility testing?
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
60
what are you looking for in the history for a fertility evaluation?
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
61
what do you look for with the pelvic US for a fertility evaluation?
fibroids
ovarial cysts/endometriosis
antral follicle count
saline sonohystrogram
62
what test looks at the tubes and uterine cavity?
hysterosalpingogram
63
labs for a fertility evaluation
cycle day 3 labs - FSH, estradiol
TSH
prolactin
luteal phase progesterone
64
evaluation of FSH for a fertility evaluation
cycle day 3
FSH 10 decreased ovarian reserve - refer
must be done with estradiol (estradiol
65
evaluation of AMH for a fertility evaluation
antimullerian hormone: protein produced by granulosa cells in the ovary and controls the formation of primary follicles
66
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
AMH (antimullerian hormone)
3-3.5 25 y/o
2-2.5 35 y/o
1.0 40 y/o
67
normal sperm parameters
```
volume 2.0-5.0 mL
count > 20 x 10^6/mL
motility > 50%
morphology > 14%
-stain approximately 200 sperm
```
68
fertility tx for PCP
optimize natural fertility
ovulation predictor kits
timed intercourse
provide reassurance to anxious couples
69
what is the most fertile day?
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
70
treatment for infertility that is an anti-estrogen that increases endogenous FSH levels
clomid - clomiphene
50 mg tablets, one tab by mouth CD3-7
try for 3 cycles then refer
71
who is clomid best for?
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
72
fertility treatment done by specialists
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
73
difference between primary and secondary amenorrhea
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
74
outermost cavity of the female reproductive system and forms the lower part of the birth canal
vagina - 8-12 cm in length
75
area of skin between the vagina and anus
perineum
76
when does the menstrual cycle start?
with the removal of the endometirum and release of FSH by the anterior pituitary
77
what occurs during the ovarial cycle?
development of ovarian follicle
production of hormones
release of ovum during ovulation
78
what occurs during the uterine cycle?
removal of endometrium from prior uterine cycle
| preparation for implantation of embryo under the influence of ovarian hormones
79
what occurs during the follicular phase?
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
80
what occurs during ovulation
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
81
solid body formed in an ovary after the ovum has been released into the fallopian tube and produces significant amounts of progesterone
corpus luteum- falling levels of progesterone trigger menstruation and the beginning of the next cycle
82
what marks the beginning of ovulation?
LH surge
83
average age of menarche
12.5 - begins approximately 2-3 years after initiation of puberty
84
when does a period become regular?
approximately after 2-2.5 years
85
prolonged/excessive bleeding occurring at regular intervals. often c/o large clots
menorrhagia
86
irregular intervals, frequent bleeding, non-excessive amounts
metrorrhagia - often associated with dysfunctional uterine bleeding
87
prolonged, excessive bleeding at irregular intervals
menometrorrhagia
88
regular bleeding
polymennorrhea (oligomenorrhea is regular bleeding > 35 day intervals)
89
amenorrhea
absence of uterine bleeding for at least 6 months or 3 cycles
90
how is premenstrual dysphoric disorder different from PMS?
more severe, cause both mood symptoms and functional impairment
psychological diagnosis DMS category
tx: SSRIs: fluoxitine, birtch control
91
difference between primary and secondary dysmennorhea
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
92
causes of abnormal uterine bleeding
pregnancy
myomas: subserosal, intramural, submucosal
infection
systemic diseases (thyroid, liver, coagulation disorders)
pelvic neoplasm
PCOS
93
growth of extra-uterine endometrial tissue
endometriosis - endometrial tissue can be found on any intra-abdominal structures
pathogenesis: unknown
94
symptoms of endometriosos
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
95
gold standard for diagnosis of endometriosis
laparoscopy or laprotomy evaluation with tissue biopsies to confirm extra-uterine endometrial tissue
96
management of endometriosis
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
97
what accounts for 75% of primary amenorrhea?
turner's syndrome
98
how do you manage amenorrhea?
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
99
what do women with PCOS exhibit?
a steady state of estrogen, androgen and LH as opposed to fluctuating levels seen in ovulating women
effects about 6% of premenopausal women
100
symptoms of PCOS
hirsuitism
obesity
virilization: acne, deepening of voice, alopecia
amenorrhea
101
what will a transvaginal US reveal for PCOS?
"string of pearls" on ovary
102
traditional evaluation of PCOS
total and free testosterone
| DHEAS
103
how do you diagnose PCOS?
```
diagnosis of exclusion
rotterdam criteria (2/3)
-oligo or anovulation
-clinical or biochemical signs of hyperandrogenism
-polycystic ovaries
```
104
management of PCOS
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
105
definition of menopause
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
106
what hormones rise in menopause?
LH and FSH
107
hormone replacement therapy for menopause
combined therapy: estrogen + progesterone - prevents endometrial hyperplasia, therefore no additional risk for uterine cancer
108
removal of the uterus and cervix
total hysterectomy
109
removing uterus without cervix
supracervical hysterectomy
110
removing both tubes and ovaries
bilateral salpinto-ooporectomy
111
removing uterus, cervix, parametrium, and upper portion of the vagina
radial hysterectomy - doesn't include lymph nodes
112
patient positioning for pelvic exam
adults: lithotomy
pediatrics: frog leg
113
degrees of uterine prolapse
1st: cervix still well within vagina
2nd: cervix at the introitus
3rd: cervix and vagina outside introitus
114
strawberry cervix (punctate lesions, erythematous in appearance) is a sign for what?
trichomonal infections
115
what is chadwick's sign?
bluish discoloration of the cervix or vaginal walls present 6-8 weeks gestation
116
what is hegar's sign?
softening of the cervical isthmus usually in the 2nd and 3rd trimester
117
what is the chandelier's sign?
pain with palpation of the cervix--> PID
118
what are DNA probes used for?
screening for chlyamydia and gonorrhea
119
what are wet mount or cultures used for?
to screen for yeast, BV, and trich
120
most common position of the uterus
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
where should you measure the uterus size?
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
what is included in the cervical cancer screening?
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
cervical anatomy
```
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
what is the transformation zone in the cervix?
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
what type of HPV is thought to induce precancerous and cancerous lesions
persistent
126
most common high risk oncogenic or cancer-associated types
**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
where should a pap smear be done?
squamocolumnar junction/transition zone (where most changes begin)--> Cytologic evaluation
Primary purpose is to identify changes on the cervix related to cervical cancer
128
cervical cancer screening differences:
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
who should be screened for HPV?
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
terminology for cytologic and histologic pap smear findings
cytologic: described with the
term "squamous
intraepithelial lesion (SIL)"
histologic: described with the term "cervical intraepithelial neoplasia (CIN)"
131
3 degrees of CIN severity
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
direct microscopic visualization of the cervix
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
what can be used during a colposcopy that causes abnormal areas to turn white?
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
what is LEEP?
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
what is CKC?
cold knife conization
always done in OR
pathologist able to give more detail about status of surgical margins
higher risk complications
136
what is the newest HPV vaccine?
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
what is the latency period between HPV exposure and cervical cancer development?
10-15 years
138
benign pelvic masses
```
functional ovarian cyst - most common in premenopausal women
Pregnancy Related
Leiomyomas (pedunculated fibroid)
TOA
Endometrioma
Hydrosalpinx
```
139
what are the different physiologic cysts?
follicular cyst: Due to failure of follicle to rupture during normal ovulation
Smooth, thin walled, unilocular, round
Usually
140
risk factors for physiologic cysts and tx
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
what is a tubo-ovarian abscess
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
"chocolate cyst" due to growth of ectopic endometrial tissue. Present w/ cyclic pelvic pain, dysmenorrhea, dyspareunia
Complex/ heterogenous
on US
endometrioma
143
this follows PID, fimbria are smooth and clubbed. Secretions collect within and distend the tube
On US, multiple hypoechoic mural nodules with incomplete septae
hydrosalpinx
144
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
```
leiomyomas
Treatment:
Symptom Treatment: OCP’s, IUD’s, Iron – “anemia”, & NSAIDS
Lupron - “Menopause” side effects
Uterine Artery Embolization
Surgery: Myomectomy vs. Hysterectomy
```
145
different ovarian tumors
```
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
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%
teratoma (looks like hairball in the cyst)
147
this is diagnosed by US with a "tip of the iceberg" sign, fat-fluid levels, hair, and robitansky protuberance
teratoma
148
what are cystadenomas?
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
what is endometriomas associated with (symptom-wise)?
dysmennorrhea or dyspareunia (pain with sex)
150
Physiologic cysts may be associated with what?
dull, achy pain that is localized to the size of the mass
151
what is suggestive of tuboovarian abscess?
fever + vaginal discharge
152
fallopian tube cancer is associated with what?
Serosanguinous vaginal discharge without fever
153
what is the most appropriate initial study for a pelvic mass workup?
pelvic US
Both transabdominal and transvaginal should be obtained
Best evaluation of the adnexa (parts adjoining an organ)
154
if yo are at all concerned about a cancer, what test should you order at a minimum?
CXR (chest CT frequently not approved by insurance without bx proven cancer)
155
this is a tumor marker for epithelial ovarian cancer (but also elevated in many other settings)
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
elevation in which tumor markers should prompt a GI workup?
CAE or CA19-9
157
tumor marker for breast cancer
CA15-5
158
what are most cases of ovarian torsion associated with?
adnexal mass
159
when is surgery indicated for a pelvic mass?
malignancy is suspected(allows for definitive histologic dx)
Risk associated w/mass (torsion, infection, etc)
Mass is symptomatic
160
when should you refer a woman with a pelvic mass?
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
what contraceptive method has the best and least effectiveness towards unintended pregnancy?
best: levonorgestrel IUD, female sterilization, copper-T IUD, injectible
worst: no method, spermicide, diaphragm
162
difference in contraceptive effectiveness
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
ethinyl estradiol & progestin is an example of what form of contraception?
combined contraceptive pills
*(20ug, 35ug, 50ug) )
164
MOA of ethinyl estradiol & progestin
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
is there an increase in risk of ischemic or hemohemorrhagic stroke is associated with use of OCs containing
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
what are contraindications to estrogen use?
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
MOA of vaginal ring
Flexible ring with ethinyl estradiol & etognogestrel
suppresses ovulation
168
MOA of progestin only pills (mini pills)-Micronor (Norethindrone)
Suppresses Ovulation
Thickens cervical mucus
Thins endometrium
Slows tubal motility
daily use, no hormone free week
169
what is the injectible contraceptive and how long does it last?
150mg IM depot medoxyprogestrone acetate
104 mg SC depot medoxyprogsterone acetate
depo-provera, 13 weeks
DepoSubQ
170
disadvantages of injectable contraceptive?
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
what is the duration for nexplanon (implant)?
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
MOA of nexplanon (implant)
systemic progestin suppression LH/FSH thickened cervical mucous, thin endometrium. doesn't' contain estrogen
173
what is paragard and its MOA and its duration?
copper IUD- non-hormonal IUD
Mechanism of Action
Spermicidal
Prevents fertilization
10 years
174
what else can paragard be used for?
emergency contraception for up to 5 days
175
what is mirena, dkyla, liletta?
hormonal IUD
176
MOA and duration of hormonal IUD
Mechanism of Action
Thickens cervical mucus
Impairs tubal and sperm motility
Thins endometrium
duration: 5 years
177
contraindications for IUDs
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
when can hormonal emergency contraception be given?
up to 72-120 hours after unprotected sex
179
what are the different emergency contraception?
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
what are indications for emergency contraception?
```
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
the majority of women having abortions are what?
in their 20s, poor, non-hispanic white, never-married, not cohabitating, protestant
182
methods of abortion in first trimester
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
methods of abortion in second trimester
Second Trimester
Dilation & Evacuation (12-13+ wks up to viability)
Induction Abortion
184
what is MVA?
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
second most reported STI in the US, usually has a higher incidence in men
neisseria gonorrhea- relationship with HIV - presences of NG infection facilitates transmission and acquisition of HIV
186
4 stages of infection of gonorrhea
attachment
local penetration
local invasion
local inflammatory response with or w/out systemic dissemination (typically infections of urogenital but can become systemic)
187
clinical presentation of uncomplicated vs complicated gonorrhea infection
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
treatment of uncomplicated gonorrhea
ceftriaxone 250 mg IM x 1
| azithromycin 1 g po x 1 (to cover for C. trachomatis)
189
what is not recommended for treating GC?
quinolones - because they have so much resistance
190
most commonly reported bacterial infection in the US
chlamydia trachomatis (more common in women)
191
complications in trichomonas in men
prostate CA if not treated, epididymitis, infertility
192
how should you treat trichomonas in pregnant women?
SYMPTOMATIC pregnant women should be treated AFTER THE FIRST TRIMESTER to reduce risk of preterm birth
ASYMPTOMATIC pregnant women - don't treat
193
which HSV can cause genital infection?
both but most recurrent genital herpes is cased by HSV 2
194
clinical features of primary infection of HSV
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
diagnosis of HSV
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
treatment of primary HSV infection
oral antivals - acyclovir, famcyclovir, valacyclovir for 7-10 days
197
what is the treatment for recurrent HSV?
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
which HPV types account for most cervical CA
16 and 18
type 6 and 7 often cause benign genital warts
199
what is the test to diagnose HPV in males?
no FDA approved test
200
what occurs in primary syphilis
painless chancre (shanker) at inoculation site 3-6 weeks after non tender regional LAD occurs. resolves 4-6 weeks without scarring
201
what is secondary syphilis?
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
what is tertiary syphilis?
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
screening for syphilis
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
how do you treat neurosyphilis?
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
highest risk factor for PID
females with multiple sex partners, age less than 25, sti exposure, previous sti/pid
206
most common causes of PID
N. gonorrhoeae and C trachomatis
rare during pregnancy after 12 weeks due to mucous plut
207
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)
fitz hugh-curtis syndrome
208
what weeks is the first trimester?
1-14
Start trimester on the date of the LMP
209
what weeks is the second trimester?
14-28
210
what weeks is the third trimester?
28-40
211
when is a fetus viable?
23-24 weeks gestation
212
preterm verse term
preterm: prior to 37 weeks gestation
213
labs to diagnose pregnancy
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
how do you determine the fundal height during pregnancy?
Palpate the uterine fundus with bimanual exam up to 12 weeks.
Palpate uterine fundus with abdominal exam after 16 weeks. (MacDonald Maneuver)
215
how much weight should a normal weight woman gain during pregnancy?
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
what supplements should pregnant women be taking?
Prenatal Vitamins
Iron: Supplement 30 mg FeSO4 daily
Folic Acid: 400 mcg daily
- Seizure disorder
- Previous NTD
217
what dietary avoidances are in pregnancy?
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
what are the ToRCH infections?
Toxoplasmosis (cat feces, no changing litter boxes)
Rubella
CMV
Herpes Simplex
219
what is the prenatal evaluation schedule?
Visits every 4 weeks until ~ 28 weeks
Visits every 2 weeks until ~ 36 weeks
Visits every week from ~ 36 weeks until delivery.
220
initial pregnancy labs
```
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
what pain med should you NOT use during pregnancy?
motrin -affects development of fetal heart
222
what is PICA in pregnancy a sign of?
craving for non-food items, often ice. - anemia
223
what lab should be repeated at every pregnancy visit?
UA
Repeat H/H ~28 weeks
If positive GC/Chlamydia, repeat 3rd trimester
224
when does genetic testing begin in pregnancy?
trisomy 21 (quad screen) - 10 weeks
Free fetal DNA
Screens for T21,T18, T13 and sex chromosome aneuploidy
amnioentesis - 16 weeks
225
treatment of UTI during pregnancy
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
treatment for Rh incompatibility
Rhogam at 28 weeks and within 72hours postpartum
227
fetal circulation
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
normal fetal heart rate
110-160
229
what is quickening?
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
maneuvers for palpating fetal lie- Determine presenting part at every visit after 36 weeks.
Leopold’s Maneuvers
231
stages of labor
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
Relationship to presenting fetal part to ischial spines
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
ways to induce labor
Cervical ripening
- mechanical
- synthetic prostaglandin
- Cervidil
Induction methods
Oxytocin
amniotomy
(Indications- maternal medical conditions (many )
diabetes
-fetal conditions (many)
IUGR
234
***perineal tear degrees
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
Incision intended to decrease the extent of perineal tears.
episiotomy - NOT recommended
236
indications for a c section
```
breech or transverse lie
multiples (not all)
Macrosomia
Fetal Distress
placenta previa or abruption
```
237
C-Section Complications
```
Blood loss
Infections
Higher incidence of PE
Damage to maternal organs
Anesthesia risks
Subsequent surgeries
```
238
important things to watch for during post-partum care
Infection
Excessive blood loss
-CBC, lightheadedness, tachycardia, hypotension
Hypertension
Episiotomy/lacerations/surgical incisions
Mood
239
when does the post-partum visit occur
6-8 weeks
240
spontaneous abortion
pregnancy loss at less than 20 weeks gestation
Pregnancy loss is most common in the first trimester – 80% occur by 12 weeks gestation
241
bleeding & cramping, no cervical dilatation, pregnancy still viable.
threatened abortion
242
cervical dilation, bleeding but no passage of products of conception yet occurred.
inevitable abortions
243
fetus & placenta are expelled. Pain absent, bleeding/spotting may persist.
complete abortion
244
cervical dilation, retained products of conception, usually the placenta. Cramping & persistent bleeding, which is often excessive.
incomplete abortion
245
Pregnancy which ceases to develop but no products of conception have been expelled. No bleeding, no pain, cervix remains firm and closed
missed abortion
246
3 or more consecutive spontaneous abortions.
recurrent abortion
247
workup for suspected misscarriage
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
management for incomplete, inevitable, or missed abortion
dilation and curettage
249
Gestational Trophoblastic Disease- abnormal fertilization of a pregnancy, non-viable at any point
molar pregnancy
No pregnancy for minimum of 1 year: patients need to be on contraception.
250
complete molar pregnancies are at an increased risk for development of what?
choriocarcinoma
251
higher than normal BhCG levels are indicative of what?
molar pregnancy
also Protrusion or expulsion of grape-like vesicles from cervical os or vagina
-trophoblasts; edematous villi
With or without vaginal bleeding
252
when should you have a high suspicion for ectopic pregnancy?
any pregnant patient with new onset, severe pain
253
causes of ectopic pregnancy
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
Sudden, severe lower quadrant pain that typically remains unilateral
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
when does an ectopic usually occur?
usually around 6 weeks but can happen as late as 12
256
workup for ectopic
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
management of ectopic
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
false labor. uterine contractions that occur at irregular intervals and consists of mild cramping and contraction of uterine wall
braxton hicks contractions
Management: Conservative
adequate water intake
lay down/change position
deep breathing
259
Systolic BP ≥ 140 or Diastolic BP ≥ 90 taken twice at least 6 hours apart.
gestational hypertension
Diagnosed at >20 weeks gestation
260
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
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
Preeclampsia with severe features
```
Systolic BP > 160 or diastolic >110
HELLP Syndrome:
Hemolysis,
Elevated Liver transaminases
Low Platelets: thrombocytopenia
```
262
management of severe preeclampsia
34-37: deliver immediately
Preeclampsia with severe features at EGA
263
what is eclampsia
50% of seizures develop prior to labor
Maternal & fetal risks
higher risk of placental abruption
higher risk of DIC
264
how do you treat eclampsia?
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
when should you screen for gestational diabetes?
Perform 24-28 weeks gestation (or at initial prenatal visit in high risk women)
266
interpretation of GTT
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
Complications of GDM
```
Fetal macrosomia – with associated delivery complications
Intrauterine fetal demise
Premature birth
Neonatal hypoglycemia
may lead to neonatal death
```
268
Fetal Heart rate tracing abnormalities
loss of variability
repetitive severe variable decelerations or late decelerations.
prolonged decelerations.
potential causes: umbilical cord compression (variable decelerations), uteroplacental insufficiency (late decelerations)
269
too little amniotic fluid
oligiohydraminos
| AFI
270
too much amniotic fluid
polyhydraminos
| AFI > 19
271
Implantation of the placenta in the lower uterine segment covering the internal cervical os
placenta previa
marginal
partial
total
More common in multiparous women & women with prior c-section.
272
IUGR
intrauterine growth restriction
273
signs and symptoms of placenta previa
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
33 week G6P7 (all C-section)
delivered presents with severe
abdominal pain and bleeding. What is
the likely diagnosis?
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
management of placenta abruption
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
most common cancer of female reproductive system? most lethal cancer of female reproductive system?
common: endometrial ( uterine)
lethal: ovarian
277
cancer arising from epithelial tissue
carcinoma
278
cancer arising from connective tissue (bones, tendons, cartilage, muscle, and fat)
sarcoma
279
cancer arising from plasma cells of bone marrow
myeloma
280
what is present in 99.7% of cervical cancer?
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
most common histology of cervical cancer?
squamous cell carcinoma
282
what is the first line chemo therapy for almost all gyn cancers?
carboplatin/taxol
283
vulvar cancer most often affects what?
labia majora- Often present with a prurtitic or painful lesion
284
post menopausal bleeding is what until proven otherwise?
endometrial cancer-
| Also, any change in bleeding habits after age 35 needs to be worked up
285
Treatment of hyperplasia:
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
biggest risk for endometrial cancer
unopposed estrogen
followed by age, obesity
287
This is a genetic mutation, which is
autosomal dominant and causes
endometrial cancer and increased risk of colon cancer
lynch syndrome
288
umbilical nodule associated with malignancy
sister mary joseph nodule
289
what is the frequent breast lesion, Most common in women 30-50, Asymptomatic or painful breast mass
?
fibrocystic breast disease
| not pathologic
290
what is mastalgia
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
what is the workup of a breast mass?
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
what is the preferred method for initial diagnosis of a breast mass?
core needle biopsy
293
painless, well circumscribed, freely mobile tumors
| Rounded, lobulated or discoid shape
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
t or f: fibroadenoma is considered to have malignant potential
false
| However, because they contain an epithelial tissue, neoplasia can occur
295
Most common mass during pregnancy and postpartum
lactating adenoma - distinct mobile mass
296
Most common cause of spontaneous serous or serosanguinous drainage.Most common cause of nipple discharge
intraductal papilloma - not a premalignant lesion
| benign tumor growing from lining of duct
297
abnormal mammogram
```
Microcalcifications (clustered, stellate, pleomorphic)
Spiculated mass
Tissue distortion
Asymmetric density
New or evolving findings
Prompts a biopsy or short term follow-up
```
298
most common breast cancer
infiltrating ductal
299
only painful breast cancer
inflammatory breast cancer
