Women's health starred slides

Question 2

1) Define gravidity
2) Define parity

Answer 2

1) # of pregnancies, current and past, regardless of outcome (multiple gestation only counts once)
2) # of times a woman has given birth to an infant ≥20 weeks of gestation regardless of outcome
multiple gestation only counts once (except for living children)

Question 3

How do you document OB history?

Answer 3

GTPAL (ex, G2P1001): gravidity, term, preterm, abortion/(miscarriage), living

Question 4

1) Define term
2) Define preterm
3) Define abortion
4) Define living

Answer 4

1) Number of times a woman has given birth to an infant ≥37 weeks gestation
2) Number of times a woman has given birth to an infant between 20-36 6/7 weeks gestation
3) Number of losses before 20 weeks
4) Number of living children

Question 5

1) Define gravida
2) Define primigravida and multigravida
3) Define nulligravida

Answer 5

1) Is or has been pregnant
2) Is in or has had one pregnancy; has been pregnant more than once
3) Has never been pregnant

Question 6

1) Define primipara
2) Define multipara
3) Define nullipara

Answer 6

1) Has only birthed one child or is pregnant for the 1st time
2) Has given birth 2+ times
3) Has never given birth or had pregnancy go past gestational abortion age

Question 7

What does GTPAL stand for?

Answer 7

G = total pregnancies
T = # born ≥37 weeks (= term)
P = preterm
A = miscarriages/abortions
L = living children

Question 8

1) Define “breast self-examination”
2) Is it generally currently recommended for average-risk women? Why or why not?

Answer 8

1) Self-inspection in a systematic way on a regular, repetitive basis (e.g., monthly) for detection of breast cancer.
2) No longer recommended for average-risk women, lack of evidence for benefits (beyond mammography) and potential harm from false-positives.

Question 9

Pt education on “Breast Self-Awareness” is recommended; what does this include?

Answer 9

1) Being aware of normal appearance and feel of one’s breasts
2) Be educated on signs/symptoms of breast cancer and notify health care provider if any changes (pain, mass, new nipple discharge, redness).

Question 10

1) True or false: Breast cancers are not frequently self-detected
2) True or false: Breast cancer is the most common female malignancy

Answer 10

1) False; they are frequently self-detected
2) True

Question 11

When should clinical breast exams (CBE) be recommended to each of the two age groups?

Answer 11

1) 25-39 yo: may be offered every 1-3 yrs based on shared decision-making*
2) ≥40 yo: may be offered annually based on shared decision-making*
*Uncertainty if CBE offers additional benefits beyond screening mammography, and there is possibility of false positives/harm.

Question 12

When should mammography be recommended to each of the two age groups?

Answer 12

1) 40-75 years old: screen every 1-2 yrs
2) Older than 75 years: shared decision-making process about whether to continue screening (dependent on health/life expectancy)

Question 13

1) What should you do first in a breast exam?
2) Is asymmetry of breasts common?
3) What should you further evaluate for?
4) What should you describe about any masses?
5) What is normal for large breasts?

Answer 13

1) Visual inspection first; have pt lean forward for large and/or pendulous breasts
2) Yes, some asymmetry is common
3) Marked differences or recent changes
4) Size, shape, consistency, position, & mobility
5) Normal firm transverse inframammary ridge with large breasts

Question 14

1) When should you palpate the breast?
2) In what 2 positions should you inspect?
3) In what positions should you palpate? How should you palpate?

Answer 14

1) After visual inspection
2) With pt seated with arms at sides, then with pt supine and ipsilateral arm above head*
Palpation with pt supine, ipsilateral arm above head; use pads of fingers for palpation (not tips/no nails)

Question 15

1) What should you thoroughly palpate during a breast exam?
2) What technique is best validated?
3) What should you squeeze?

Answer 15

1) Rectangular area extending from clavicle to inframammary fold and from midsternal line to posterior axillary line and well into axilla (tail of breast)
2) Vertical strip
3) Not nipple, but rather tissue surrounding

Question 16

What are 8 symptoms concerning for malignancy?

Answer 16

1) Rapid change in the appearance of one breast
2) Thickness, heaviness or visible enlargement of one breast
3) Discoloration, giving the breast a red, purple, pink or bruised appearance
4) Unusual warmth of the affected breast
5) Dimpling or ridges on the skin of the affected breast, similar to an orange peel
6) Itching
7) Enlarged lymph nodes under the arm, above the collarbone or below the collarbone
8) Flattening or nipple inversion

Question 17

1) What does redness of the breast suggest?
2) What is it often due to?
3) In women who have not recently nursed a baby it is worrisome for what?

Answer 17

1) Infection or inflammation
2) Mastitis in postpartum patient.
3) Inflammatory breast cancer (IBC)

Question 18

1) What is dimpling often a sign of?
2) In what positions should you assess it?

Answer 18

1) A tumor beneath.
2) With pt supine, sitting, and standing

Question 19

1) Is it suspicious if there’s asymmetry of the breast?
2) What is nipple retraction a sign of if new?

Answer 19

1) Yes
2) A tumor beneath. Carefully palpate around and under the nipple

Question 20

List 5 abnormal nipple findings

Answer 20

1) Discoloration or ulceration
2) Clear or milky discharge (galactorrhea)
3) Nipple discharge may be sent for culture & sensitivity and cytopathology
4) Bloody discharge (usually unilateral)
5) Pus/purulent discharge

Question 21

1) What is galactorrhea and what may it be due to? Bilateral or unilateral usually?
2) Is bloody discharge of the nipple usually bilateral or unilateral? What is it associated with?
3) What does pus usually indicate?

Answer 21

1) Clear or milky discharge may be due to stimulation (normal) or elevated prolactin levels (abnormal).
-Bilateral (usually)
2) Usually unilateral, associated w. inflammation (usually intraductal papilloma).
-Evaluation to rule out malignancy is required.
3) Infection but may be due to underlying tumor.

Question 22

1) Is nipple discharge usually cancer? Explain.
2) What can be a sign of ductal ectasia or fibrocystic changes?

Answer 22

1) Usually benign but may be an early sign of endocrine dysfunction or cancer
2) Non-bloody, bilateral discharge with nipple stimulation (“nonspontaneous”)
*spontaneous = occurring without nipple stimulation

Question 23

1) When is milky discharge of the nipple common? What else is it associated with?
2) What is bloody unilateral nipple discharge concerning for?
What does it usually require?

Answer 23

1) During childbearing; hyperprolactinemia or hypothyroidism, OCPs, tricyclic antidepressants
2) Invasive ductal carcinoma, intraductal papilloma, or intraductal carcinoma (e.g., be concerned for cancer)
-Ductography and ductal excision

Question 24

1) If you clearly identify a discrete mass, consider it to be _________ until proven otherwise.
2) In general, determination of final diagnosis requires a what?

Answer 24

1) malignant
2) Biopsy

Question 25

1) Should a dominant breast mass that does not have a corresponding abnormality on Mammogram still be considered malignant until proven otherwise? 2) Mammograms miss up to ____% of cancers

Answer 25

1) Yes 2) 30%

Question 26

True or false: While uncommon, breast cancer can occur in men

Answer 26

True (Thus, discrete masses should be appropriately evaluated).

Question 27

1) Breast cancer can occur in young women (20s and 30s) so what should be appropriately evaluated? 2) What is more difficult about evaluating young patients for breast cancer?

Answer 27

1) Thus worrisome masses in this population should be appropriately evaluated. 2) Mammograms more likely to be false-negative

Question 28

1) True or false: you should pay very careful attention to any mass that the patient brings to your attention. 2) True or false: Women who are very self-aware can often detect subtle/early changes concerning for malignancy that an examiner may have difficulty identifying.

Answer 28

1) True 2) True

Question 29

1) Define mastalgia 2) What percent of women does it affect during lifetime?

Answer 29

1) Breast pain 2) 70% of women

Question 30

1) What is the most common type of mastalgia? What is it associated with? Bilateral or unilateral? 2) What is noncyclical mastalgia not associated with? What is it associated with? 3) What is extramammary (non-breast, pain referred from other locations) mastalgia associated with?

Answer 30

1) Bilateral and benign, begins during luteal phase, resolves with menses 2) Menstrual cycle; assoc with duct ectasia, mastitis, large breast size, meds, pregnancy, etc. 3) Chest wall trauma, rib fxs, shingles (varicella-zoster virus), heart, gallbladder, etc.

Question 31

1) What is required to determine the cause of mastalgia? 2) What should be done if there's concerning findings? Why? Give examples

Answer 31

1) Careful physical exam to determine cause. 2) Imaging to rule out malignancy/serious pathology (unilateral, noncyclical, localized pain, breast mass, skin changes, etc.)

Question 32

1) Define fibrocystic breast changes 2) How common is it? 3) What are the symptoms?

Answer 32

1) Benign changes in breast epithelium producing a nodular, sensitive breast 2) Common; ½ of all women experience 3) Lumpiness, swelling, pain/tenderness; nodular, rope-like densities

Question 33

What are the essentials of fibrocystic breast change diagnosis? What is the most common age?

Answer 33

1) Painful, often multiple, usually bilateral mobile masses in the breast. 2) Rapid fluctuation in size of masses is common. *Frequently worsens just before menses (increase in pain and size of cysts). 3) Affected by hormone levels -Most common age is 30–50 years (premenopausal); occurrence is rare in postmenopausal women.

Question 34

1) How are fibrocystic breast changes diagnosed 2) How are they treated?

Answer 34

1) Diagnosed with CBE and sx history; mammogram, ultrasound may be used. Aspirate palpable cysts 2) Observation (Decrease caffeine intake), vitamin E supplementation

Question 35

1) Define mastitis 2) What are the symptoms?

Answer 35

1) Inflammation of breast tissue that may be accompanied by infection (e.g., bacteria): 2) Erythema, warmth, swelling, tenderness/pain; fatigue, malaise, fever

Question 36

1) When does mastitis generally occur? What is it particularly associated with? 2) How is lactational mastitis treated?

Answer 36

1) I lactating or recently lactating women; incomplete emptying of the breast (engorgement) or plugged duct(s) 2) NSAIDs, cold compresses, ongoing breastfeeding and/or hand expression to help empty breast, antibiotics if associated infection

Question 37

3 most common breast masses are what?

Answer 37

Fibroadenoma (benign tumor), cysts, and breast cancer

Question 38

1) With fibroadenoma (benign tumor) what is the typical age? 2) How many are there usually? 3) Shape and size? 4) Consistency? 5) Delineation? 6) Mobility? 7) Tenderness? 8) Retraction signs?

Answer 38

1) 15-25 years, usually puberty and young adulthood, but up to 55 2) Usually single, may be multiple 3) Round, disc like, or lobular; typically small (1-2cm) 4) Usually firm (but may be soft) 5) Well delineated 6) Very mobile 7) Usually nontender 8) Absent

Question 39

1) In cysts of the breast, what is the typical age? 2) How many are there usually? 3) Shape? 4) Consistency? 5) Delineation? 6) Mobility? 7) Tenderness? 8) Retraction signs?

Answer 39

1) 30-50 yrs, regress after menopause 2) Single or multiple 3) Round 4) Soft to firm, usually elastic 5) Well delineated 6) Mobile 7) Often tender 8) Absent

Question 40

1) In breast cancer, what is the typical age? 2) How many are there usually? 3) Shape? 4) Consistency? 5) Delineation? 6) Mobility? 7) Tenderness? 8) Retraction signs?

Answer 40

1) 30-90, most common >50 2) Usually single, although may coexist w other nodules 3) Irregular or stellate 4) Firm or hard 5) Not clearly delineated 6) May be fixed to skin or underlying tissues 7) Usually nontender 8) May be present

Question 41

1) What age is a pelvic exam recommended in? 2) Describe how to perform a pelvic exam

Answer 41

1) ACOG recommends annual pelvic exam in women 21 yrs & older 2) -Empty bladder to ensure comfort & assist your exam -“Clean catch” urine specimen from mid-stream if needed (A full bladder will push the uterus and cervix higher in the pelvis and make the exam more difficult and uncomfortable.) -Muscle relaxation needed -Explain every part of exam before performing (“Talk before you touch”) -Avoid being abrupt or stern -Rehearse what you will say and how you will say it.

Question 42

What should you evaluate about the cervix?

Answer 42

1) Nulliparous vs multiparous 2) Normal vaginal discharge? 3) Ectropion (when inside of cervical canal everts), retention (Nabothian) cysts, small polyps (benign) 4) Inflammation, masses, dysplasia (further eval)

Question 43

List the 5 early Sx of Adnexal Neoplasm. Specify which is most common

Answer 43

1) Abdominal bloating or distention- most common 2) Abdominal or pelvic pain 3) Decreased energy or lethargy 4) Early satiety 5) Urinary urgency

Question 44

What should you physically examine for Adnexal Neoplasm?

Answer 44

1) Assess for any signs of infection or cancer 2) The breast examination is especially important because the ovary is a common site of metastatic breast carcinoma (abdomen, too) 3) Bimanual exam assessing each side and comparing sides -keep in mind age-parameters for ovarian size

Question 45

Give the vague symptomatology of ovarian cancer

Answer 45

Abdominal bloating or distention Abdominal or pelvic pain Decreased energy Early satiety Urinary urgency Abnormal menstrual cycles Unexplained back pain that worsens over time Non-specific gastrointestinal symptoms

Question 46

1) What are functional ovarian cysts? 2) What type of cyst occurs when an ovarian follicle fails to rupture during follicular maturation and ovulation does not occur?

Answer 46

1) Not neoplasms, but anatomic variations that arise due to normal ovarian function 2) Follicular cyst

Question 47

1) When does a follicular cyst become medically significant? 2) How are they diagnosed?

Answer 47

1) If large enough to cause pain or persists beyond one menstrual interval 2) Pelvic ultrasound (adjunct to PEx)

Question 48

1) How do most follicular cysts resolve? 2) What if the presumed functional cyst persists?

Answer 48

1) Most spontaneously resolve within 6 weeks 2) Another type of cyst or neoplasm should be suspected and further evaluated

Question 49

1) Placental growth is a cardiovascular change during pregnancy that involves what? 2) What two things does the body increase to compensate for these changes? 3) When does the placenta stop growing?

Answer 49

1) New vessels are added, increased blood flow to placenta 2) HR and cardiac output 3) At ~week 26

Question 50

What does more fluid being present during pregnancy lead to? (2 things)

Answer 50

1) Daytime pedal edema 2) Nocturia/frequent nighttime urination (bc of daytime edema)

Question 51

Why does nocturia/frequent nighttime urination occur in pregnancy?

Answer 51

Excess blood volume that was in her legs all day finally returns to more central circulation and acts like a fluid bolus

Question 52

1) Define physiologic hypotension 2) IVC compression can happen in pregnancy; what are the symptoms and what process in the body causes each? 3) How can IVC compression be relieved?

Answer 52

1) Normal dip in the BP during pregnancy 2) Less venous return > cardiac output is decreased > blood pressure falls > dizziness, presyncope > syncope 3) If she’s on her back or right side, move to left lateral decubitus

Question 53

1) What urinary change is common in pregnancy besides nocturia? 2) What are pregnant people at higher risk of?

Answer 53

1) Mild glucosuria 2) UTI

Question 54

Why are pregnant ppl at a higher risk of UTI?

Answer 54

Dilation of urinary tract (secondary to increased blood volume) = greater risk of ascending infection

Question 55

1) Define gestational diabetes 2) What factors put people at risk for this?

Answer 55

1) Elevated blood glucose that starts after 20 weeks gestation 2) Obesity, being Hispanic or Southeast Asian

Question 56

How is gestational diabetes diagnosed?

Answer 56

All women are screened weeks 24-28 with oral glucose tolerance test (OGTT)

Question 57

List 3 potential GI pregnancy side effects

Answer 57

1) Constipation 2) GERD 3) Gallbladder disease

Question 58

What 2 things should you counsel a pregnant pt with constipation on?

Answer 58

1) Dietary fiber 2) Stool softener vs. motility agent

Question 59

1) What causes GERD in pregnant people? 2) How is it treated? (2 things)

Answer 59

1) LES relaxation plus compression of stomach by gravid uterus = reflux 2) -Lifestyle changes: Avoid caffeine, spicy food, nicotine, mint, large meals, fatty meals -TUMS (calcium carbonate) acceptable in pregnancy

Question 60

What can accompany gallbladder disease in pregnancy? (3 things)

Answer 60

1) Formation of new stones 2) Worsening of stones 3) Cholecystitis

Question 61

What causes breast enlargement in pregnancy? What are the 3 steps?

Answer 61

-Mammary glands 1) Proliferate in 1st trimester 2) Glands differentiate in 2nd trimester 3) Glands produce milk in 3rd trimester

Question 62

When is 1st trimester? 2nd? 3rd?

Answer 62

1st trimester: conception to 12 weeks 2nd trimester: 13-27 weeks 3rd trimester: 28-40 weeks

Question 63

What are 5 potential skin changes that can occur w pregnancy? Describe each

Answer 63

1) Hyperpigmentation: “mask of pregnancy” also called “melasma” -Etiology unknown 2) Linea nigra: Darkening of skin over linea alba 3) Palmar erythema 4) Spider angiomata: telangiectasia

Question 64

1) What should be the causes of weight gain in pregnancy? 2) How much weight gain is normal in each pt of pregnancy?

Answer 64

1) Amniotic fluid, placenta, fetus, maternal adipose stores 2) 1 lb/month first trimester 1lb/week thereafter

Question 65

1) How does being underweight affect pregnancy weight gain recommendations? 2) What abt being overweight?

Answer 65

1) Gain more; build up adipose stores 2) Gain less: adipose stores are adequate, and weight gain should be due to fluid, placenta, fetus

Question 66

1) What assesses (grossly) the growth of the fetus? 2) What is this measurement equal to?

Answer 66

1) Fundal height measurement 2) Fundal height (in cm) ≈ gestation age (in weeks) between 16-36 weeks gestation

Question 67

A larger than expected fundal height measurement is concerning for what 4 things?

Answer 67

1) Molar pregnancy 2) Large for gestational age baby/Gestational diabetes 3) Polyhydramnios 4) Multiples

Question 68

A smaller than expected fundal height measurement is concerning for what 3 things?

Answer 68

1) Small for gestational age baby or IUGR 2) Fetal Death 3) Oligohydramnios

Question 69

1) What is the goal for kick counts/ # of movements? 2) Fetal movement decreases in response to fetal _______________. 3) If mom perceives decreased fetal movement, what should be instituted?

Answer 69

1) > 10 movements/2 hrs 2) hypoxemia 3) Further testing

Question 70

1) Auscultation of heart tones can usually be done by fetoscope by the _____th week and with doppler by the _____th week (though typically not done until ______th week). 2) After how many can weeks fetal heart rate be assessed with external fetal monitor? 3) What 2 fetal HR questions should you ask yourself?

Answer 70

1) 12th; 8th; 10th 2) Sixteen (16) 3) -Is the heart rate within normal range? (110-160 bpm) -Do you hear/see any abnormalities?

Question 71

When should a pregnant woman go to the hospital? (4 reasons) *important*

Answer 71

1) Contractions occur approximately every 5 minutes for at least 1 hour 2) A sudden gush of fluid or a constant leakage of vaginal fluid (suggesting rupture of membranes [ROM]) 3) Any significant vaginal bleeding 4) Significant decrease in fetal movement

Question 72

At 20 weeks, fundus should be where?

Answer 72

At the umbilicus (20 cm fundal height) *important*

Question 73

1) What is the most common cause of perinatal morbidity and mortality? 2) What is this defined as?

Answer 73

1) Preterm birth 2) Birth before 37 completed weeks of gestation

Question 74

What are the two types of preterm birth?

Answer 74

Spontaneous vs medically indicated (induced)

Question 75

List 4 maternal complications (medical or obstetric) that may cause PTL

Answer 75

1) Activation of maternal/fetal HPA axis due to stress 2) Inflammation/infection (see next slide) 3) Hemorrhage (e.g., placental abruption) 4) Pathologic uterine distention (polyhydramnios, etc.) -Preterm labor may be secondary to these pathogenic processes

Question 76

What are 7 S/Sx of preterm labor?

Answer 76

1) Menstrual-like cramps 2) Low, dull backache 3) Abdominal pressure 4) Pelvic pressure 5) Abdominal cramping (with or without diarrhea) 6) Increase or change in vaginal discharge (mucous, watery, light bloody discharge) 7) Uterine contractions, often painless

Question 77

1) Define post-term pregnancy 2) What two groups is it most common in? 3) What is the most common cause of it?

Answer 77

1) Pregnancy that has gone beyond 42 completed weeks 2) Primiparous (first birth/pregnancy), and hx of post-term delivery 3) Incorrect estimation of gestational age

Question 78

1) Who is a post-term pregnancy an increased risk to? What type of assessments must start if post-term? 2) Due to increased morbidity, most practices will not let pregnancy go beyond ___ wks

Answer 78

1) Incr. risk to baby; fetal assessment (kick counts, non-stress tests, ultrasound evaluation of amniotic fluid) 2) 42 wks

Question 79

List 5 conditions assoc. with post-term pregnancy

Answer 79

1) Macrosomia 2) Shoulder dystocia 3) Meconium aspiration syndrome (MAS) 4) Dysmaturity syndrome 5) Oligohydramnios

Question 80

1) Define macrosomia 2) Define shoulder dystocia 3) What can MAS cause?

Answer 80

1) Weigh of >4,500 g (~9.9 lbs) 2) Impaction of the anterior fetal shoulder behind the symphysis pubis during vaginal delivery causing a brachial plexus injury (emergency) 3) Severe respiratory distress/death

Question 81

1) Define dysmaturity syndrome 2) Define oligohydramnios. When is this an indication for delivery?

Answer 81

1) Infants with characteristics resembling chronic growth restriction 2) Decreased amniotic fluid; if >36 weeks