womens healh Flashcards
1
Q
when to start an infertility work up?
A
after 1 year
2
Q
when to start an infertility workup before 1 year
A
age >35, previous infertility, previous infection/disease/surgery, DES exposure
3
Q
definition of infertility
A
No pregnancy after 1 year of frequent unprotected intercourse
4
Q
important points of hx in females in infertility workup
A
HPI intercourse schedule PMH previous pregnancies, menstrual cycle, puberty, STIS, endocrine disorders meds SH exercise, stress, sleep FH DES, spontaneous abortions ROS hair growth, breast discharge
5
Q
what should a health vaginal canal look like?
A
• Presence of pink, moist, rugated vaginal mucosa as evidence of good estrogen
6
Q
some male conditions related with infertility
A
• Hypospadias infertility from surgeries for this • Cryptorchidism • Varicocele • Hydrocele ED hypogonadism
7
Q
tests to rule out other causes of infertility
A
STI screen ==> R/O disease/infection UPT==> R/O pregnancy TSH==> Assess thyroid function Prolactin ==> Assess pituitary function \+/- LH &FSH==>Assess ovary and feedback loop
8
Q
what are tests rec’d for checking ovulatation?
A
OPK, sergum progresterone, progesterone challenge
9
Q
if progesterone challenge doesn’t work, what next?
A
check LH
10
Q
if LH low…? if LH high?
A
if low, check FSH
if high check pituitary
11
Q
if LH normal, if FSH high, low estrogen?
A
primary ovarian failure
12
Q
if LH normal, and FSH normal..?
A
Hypothalamic-pituitary vs. outflow disorder
13
Q
what percent of infertility is unexplained?
A
10-15%
14
Q
• Inflammation or infection of the vaginal canal
A
vaginitis
15
Q
usual etiology of candidate vaginitiis
A
• Candida albicans
16
Q
types of HPV with warts
A
6 and 11
17
Q
types of HPV with cervical dysplasia
A
types 16 and 18
18
Q
methods that proves ovulation
A
regular cycles, OPKs,
19
Q
pros of OCPs
A
Effective contraception
Decrease in pregnancy-related deaths
Non-contraceptive Benefits
Better cycle control
Decrease in iron deficiency anemia
Maintenance or improvement in bone density
Protection from ovarian and endometrial CA
20
Q
cons of OCPs
A
No protection against STDs Adverse effects risk of thromboembolism and stroke May elevate BP Estrogenic and progestin side effects Drug interactions Daily pill taking Cost > $30/month
21
Q
effects of too much estrogen
A
Nausea Breast tenderness Increased BP Melasma Headache
22
Q
contraindications to ocp
A
Absolute Contraindications Hx of thromboembolic disease Hx of stroke or CAD Hx of breast cancer Hx of estrogen-dependent neoplasm Undiagnosed abnormal uterine bleeding Pregnancy (known or suspected) Heavy smokers ( ≥ 15 cigarettes/day) over the age of 35 Hx hepatic tumors Active liver disease Migraine HA with focal neurologic symptoms Postpartum (during 1st 21 days as well as days 21-42 in women with additional TE risk factors)
23
Q
RELATIVE CI
A
Smoking 50 years
Elective major surgery requiring immobilization (planned in the next 4 weeks)
24
Q
too little estrogen
A
Early or mid-cycle breakthrough bleeding
Increased spotting
Hypomenorrhea
25
too much progesterone
Breast tenderness
Headache
Fatigue
Mood changes
26
too little progesteron
late breakthrough bleeding
27
too much androgen
```
Increased appetite
Weight gain
Acne, Oily skin
Hirsutism
LDL, HDL
```
28
abx that can decrease dose of OCP
griseofulvin, penicillins, or
| tetracyclines
29
pt ed on OCPs during abx use
An alternate or
additional form of birth control may be advisable
during concomitant use & for 7 days after
30
take extra dose if miss one or vomit?
yes, if vomit within one hour after taking dose
31
OCPs FDA approved for acne
Ortho-TriCyclen, Estrostep, Yaz
32
who should be considered for extended cycle oCP?
PMS, HA, anemia, endometriosis
33
pt ed of OCPs
Directions for Use
Adherenc, star,,,,,t missed pills
Other Topics
Identify backup method (provide a few condoms)
OCs will not protect against STDs
Discuss the transient nature of most OC side effects in new users, especially spotting and
bleeding
Discuss noncontraceptive benefits of OCs
Five possible warnings of serious trouble
34
spotting on OCPs could be a sign of what?
nonadherence
35
how soon should you take oral EC agents?
within 72 hours
36
OTC emergency contraception
plan b one step for all ages, my way and next choice for >17
37
T or F: EC can disrupt a fertilize egg after implantation
F
38
what is yuzpe method for emergency contraceptoin
take multiple doses of normal OCP +antiemetic
39
based on ACOG guidelines, EC should be offered after how many hours?
120
40
pros and cons of patch
pros: easy, high adherence, cons: breast tenderness, increased risk of clots
41
pros and cons of vaginal ring
pros: convenient, effective, reversible cons: FB sensation, coital problems, expulsion, irritation/infection
42
mechanism of patch, ring, depo shot birth control pill
anovulatory
43
pros/cons of depo
pros: bleeding absent, non daily, affordable, immediately effective cons: office visit every 90 days, decreased bone density, weight gain, fatigue
44
pros and cons of subnormal implant
pros: can leave in for 3 years
cons: may be felt under skin
45
pros and cons of iUd
pros: effective, easy, no hormones
cons: r/o PID, req office visit for insertion/removal
46
when is IUD insertion done?
• Usually done during menses- open os, not pg
47
IUD insertion procedure
clean cervix, get uterine depth, insert with tube, trim tail
48
how long are iUDs good for?
3-10 years
49
* Mechanical barrier between cervix and vaginal canal
| * Circular ring fitted for each individual
diaphragm
50
how often does male contribute to infertility?
20% of the time
51
pmS sx suggest ovulation T or F
T
52
best drug to induce ovulation (increases FSH and LH by tricking body into thinking low estrogen)
clomiphene citrate (clomid or serophene)
53
what is primary sx of vaginitis?
change or increase in discharge
54
thick white discharge, intense pruritis of vagina and vulva and no odor makes you think of what?
candidiasis
55
tests for all with discharge
pH, wet prep (could combine with koh)
56
vaginal hygiene patient education
wipe front to back, wear cotton underwear, avoid baths or foreign bodies (esp during vaginitis), avoid douching and perfumed stuff
57
normal vaginal flora
staph, strep, lactobacillus
58
etiology of bacterial vaginosis
gardnerella vaginalis, mobiluncus spp., mycoplasma spp., bacteroides
59
RFs of bacterial vaginosis
multiple partners, douching, vaginal irritants, smoking
60
non irritating, thin/gray-white/yellow discharge with foul odor makes you think of?
bacterial vaginosis
61
what are the 4 damsel criteria for bacterial vaginosis? must have 3.
abnormal discharge (color with foul odor), abnormal or high pH, positive whiff test, clue cells on wet prep
62
profuse frothy discharge + odor and pruritus makes you think of? +/- petechia on cervix
trichomonas
63
pH over 4 indicates? 4.5? 5?
4: candidiais
4.5 BV
5 trichomonas
64
T or F: viral shedding is possible with hPV even if not warts visible
t
65
tx of HPV warts
difficult, cryotherapy, electrocautery/currettage, laser, surgery, chemical
66
risk factors for spontaneous abortions
* Known: Age (AMA- advanced maternal age, > 35 years), Previous SAb, Smoking, BMI 25kg/m2
* Potential: Alcohol (>3 drinks/weeks), NSAIDS, Caffeine (100F
67
MC cause of spontaneous abortion
abnormal chromosomes
68
Vaginal bleeding through a closed cervical os
threatened abortion
69
T or F: threatened abortion means the fetus will not survive
F
70
signs of a threatened abortion
* Vaginal bleeding
* Pelvic pain/cramping
* Cervical os: Open or closed- should stay closed during pregnancy
* Products of conception: Passed or retained-
71
• A spontaneous abortion in which the entire contents of the uterus are expelled
complete abortion
72
common time of complete abortions
73
signs and sx of septic abortion
```
signs of infection
•Fever, chills
• Tachycardia
• Vaginal discharge- usually purulent
• Peritonitis- diffuse abdominal pain
• Septicemia
signs of abortion
• Vaginal bleeding
• Pelvic tenderness
• Cervical os open- how infection got in
• Uterus tender and boggy
```
74
how do you evaluate history of a spontaneous abortion?
```
• LMP (last menstrual period): Confirm pregnancy, Dating
• Signs of spontaneous abortion
• Signs of sepsis
• Consider Differential Diagnosis
− Physiologic – due to implantation
− Ectopic pregnancy
− Cervical, vaginal or uterine pathology
```
75
definition of recurrent pregnancy loss
• 3 or more losses before 20 weeks (0.4-1% of pregnancies)
76
what Must you rule out in any woman of reproductive age with abdominal/pelvic pain or irregular bleeding
ectopic pregnancy
77
where are most ectopic pregnancies?
fallopian tubes
78
what are risk factors for ectopic pregnancies?
1. Pelvic infections: Douching, multiple partners
2. Previous ectopic pregnancy
3. Age >35
4. In vitro, infertility treatments
5. History of abdominal or pelvic surgeries
6. IUD in place
7. Exposures to DES
79
signs of ectopic pregnancy
severe abdominal pain, abornaml uterine bleeding, amenorrhea, pregnancy sx, dizziness, signs of sepsis..
80
how to make dx of HSV
serology or PCR best b/c can detect asx or clinical
81
must take PO antivirals for herpes within how many hors of onset?
24-72
82
tx for chlamydia and gonorrhea
AZT po 1 gm x1 or doxy 100 mg x 7 days (or ceftriaxone 250 mg IM + AT po 1 gm x1 for gonorrhea)
83
MC sx of chlamydai and gonorrhea
discharge from cervix (mucopurulent in chlamydia or watery and profuse milky/mucopurulent with gonorrhea), fever, pelvic pain
84
signs of primary s yphilis
pain hard indurated ulcer
85
complications of PID
tubal occlusion, infertility, ectopic pregnancy risk
86
sx of PID
low abdominal pain MC, dyspareunia, vaginal discharge +/- odor, N/V, F/C, dysuria, irregular bleeding
87
what sign is pathopneugmonic for PID?
cervical motion tenderness
88
gene related to ovarian malignancies
CA-125
89
cancers associated with CA-125
ovarian, endometrial, breast, colon
90
important points to discuss with pt and partner before conception
Risks of maternal health/development
Genetic testing options (cystic fibrosis, hereditary)
Family history
91
what are 3 main mechanisms that cause sx of pregnancy?
1. Hormonal changes
2. Maternal structural changes
3. Unknown
92
gi changes in pg
reflux, hemorrhoids, constipation, decreased gallbladder function, N/V
93
pulm changes in pregnancy
increased o2 demands, increased rest drive, can hyperventilate, sob
94
CV changes
increased CO, could compress vena cava when laying, roll on side
95
optical weight gain in pg for normal BMI and rate
25-35 lbs, about 3-5
96
gravida
of pg
97
para
of completed pregnanites
98
what does the 4 parts of para stand for?
term, preterm, abortion induced or missed, living
99
important parts of initial visit hisotry
* Personal and demographic information
* Past OB history: Miscarriages, deliveries, OB complications- preterm labor, mode of delivery, birth weight
* Personal and family medical history- HTN, DM, pre-eclampsia, Preterm labor/delivery
* Past surgical history
* Genetic history
* Menstrual and gynecological history
* Current pregnancy history
* Psychosocial information- Single mom, partner info, supportive SO/family, drug use, homeless
100
chadwicks sign
increased vasculature of the cervix in first trimester, causes blue coloring, normal
101
parts of physical for pg initial visit
* Baseline BP, weight- Over/under weight
* Complete physical
* Focus on CV, Respiratory, pelvic, neurology
* Pelvic Exam
102
safe abx in pg
* Amoxicillin
* Ampicillin
* Clindamycin
* Erythromycin
* Penicillin
* Cephalosporins
103
avoid these abx in p if
* Tetracyclines
* Nitrofurantoin (not best in 1st trimester and term) though people use it a lot
* Sulfonamides
* Fluoroquinolones
104
at what age is fetus most susceptible to drugs and disease?
days 17-56
105
when is is important to start counting fetal kick counts and gestational diabetes glucose tolerance test?
28 weeks
106
at what point do you give rhogam?
28 weks
107
which gestational age?
• Appearance of a tadpole
• Measured in crown-rump length by ultrasound because legs are not well developed yet
• Cardiac motion can be detected by US
• Fetus is most susceptible to drugs, disease and other factors that interfere with normal growth between days 17-56- prenatal vitamins, stop drug/alcohol/smoking
6 wks
108
```
which gestational age?
● Presents for initial prenatal H&P (see previous slides)
Common symptoms:
● Nausea and Vomiting
● Heartburn
● Constipation
● Urinary Frequency
● Fatigue
● Backache
```
8-10 wks
109
which gestational age?
• The embryo has multiplied to more than 250 cells by day 6.
• Specialization of cells:
• Outer layer- Nervous System, Skin and Hair
• Inner layer- Respiratory and Digestive Systems
• Middle layer- Skeleton, Muscles, Circulatory System, Kidneys, and Sex Organs
• Home pregnancy tests are now positive- Some are sensitive up to 6 days after a missed period
• Serum pregnancy test is most accurate
4 weeks gestation
110
which gestational age?
• Pt generally feeling better in 2nd trimester, feel stronger flutters/fetal movement
• Fundus at umbilicus
• Fetal Anatomy Screen (FAS) US completed for anomalies
• Weight – 140 gm (5 oz) size of a banana
• Nervous system starts to function
• Fetus can hear
• Sex genitalia fully developed
• Patient should be able to feel fetal movement- second time mother might feel as soon as 13 weeks
• Lips developing—can see clef palate?
20 weeks
111
which gestational age?• Development of bones and muscles
• External parts: face and ears
• Most organs developed and functioning
16 weeks
112
which gestational age?
• Crown rump length (CRL) 38mm (1.5 in)
• Weight – 14 grams (1/2 oz)
• Organs now present- Maturation occurs in 2nd and 3rd trimesters
• Most critical development has occurred
• Rates of miscarriage drops after this week.
• By end of week placenta has taken over
• Mom typically feels better at this point
12 weeks
113
which gestational age?
• Weight – ½ kg (1 lb)
• Fetus responds to sounds by movement or increase in heart rate
• Bone marrow begins to make blood cells
• Lower airways develop (begins producing surfactant)
• Fat stores begin
• If fetus not moving can provoke to get movements
• Fundal height is 24 cm
• Begin assessing for preterm labor (PTL) sx
• Can start to obtain testing for PTL
• Can give betamethasone for lung development prn
• Can give terbutaline prn PTL contractions
• Pt should be feeling fetus by now
24 weeks
114
which gestational age?
• Weight – 2.5--3 kg ( 6.5 lbs)
• Brain developing rapidly
• Lungs nearly developed
• Vertex position (97%)
• Early term labor, considered full term at 37 weeks
• Group B strep culture obtained
• Cervical exams begin
• Assessing dilation, effacement, station, consistency
• If fetus not vertex, may undergo external cephalic version (ECV)
• Weekly appts begin
36 weeks
115
which gestational age?
• Weight – 1.8 kg (4 lbs)
• Layer of fat forming
• Fetus will gain more than half its weight between now and delivery
• Pregnancy sx may return
• Blood volume has increased 40-50% since beginning of pg
• Continuing assess PTL risks
• Pt may begin feeling Braxton-Hicks contractions, known as tightening and releasing discomfort without pain (practice ctx, not changes cervix)
• Begin assessment of fetal position (Leopold's Maneuvers)
32 weeks
116
which gestational age?
• Weight – 1 kg ( 2 lbs 4 oz)
• Brain wave patterns appear like full-term newborn
• Lungs continue developing--Viability rates increased
• Start measuring fetal movements (fetal kick counts) daily
• Screen for gestational diabetes (GDM) with 1hr glucose tolerance test. Confirm with 3hr
• If RH negative, recheck antibody screen and give Rhogam 300mcg injection
• Recheck hemoglobin
• Give Tdap at >27 weeks
• Begin follow ups every 2 weeks
28 weeks
117
what is leopold maneuver?
feeling for what position baby is in
118
method to determine IUGR
doppler velocimetry
119
typical signs of ectopic pregnancy
abdominal pain and vaginal bleeding
120
risks for placenta previa
* Prior C/S or hx of uterine curettage
* ? Damage to myometrium or endometrium
* Cocaine
* Advanced maternal age
* Tobacco
* Increasing parity
* Hx previous previa- Recurrence rate is 6-12x in subsequent pregnancies
121
what does a painless bleed in 2nd/3rd trimester indicate?
placenta previa
122
2nd/3rd trimester painful bleeding indicates?
placental abruption
123
risk factors for placental abruption
Risk Factors
• Hypertensive disorders- Pre-eclampsia
• Maternal trauma- MVA, assaults, falls, nosocomial infections
• Substance abuse- Tobacco (90% increased risk), Cocaine, Alcohol do a tox screen
• Rupture of Membranes (ROM)
− Prolonged (>24 hours)
− Over distention of the uterus with acute decompression from loss of amniotic fluid
− PROM/PPROM
• Retroplacental fibromyoma or uterine anomaly- placenta implanted on uterine fibroids, septum
• Previous abruption
• Multiparity, multiple gestations
• Previous C-section
• Thrombophilia
• Short umbilical cord
• Maternal age (extremes of age): 35 yrs
124
clinical presentation of placental abruptoin
* Vaginal bleeding- Concealed, could present just with cramping/pelvic pain but no bleeding
* US to assess placental location- Not all US detect abruptions, often a clinical diagnosis
* Painful contractions
* Uterus tender to palpation- tetanic (hard uterus)
125
MC medical disorder in pregnancy
HTN
126
dx of preecamplsia
• Proteinuria > 0.3 g protein in a 24-hour urine specimen
• In the absence of proteinuria, increased BP accompanied by
1. Symptoms of headache (different from normal HA), blurred vision, abdominal pain
2. Abnormal laboratory tests: Low platelet counts, abnormal liver enzymes
127
• Gestational BP elevation after 20 weeks of gestation in a woman with previously normal BP
preecmpalsia-eclampsia
128
leading cause of iUGR in pg
chronic HTN
129
drugs to give to treat acute HTN in pregnancy
hydralaizine (arterial vasodilator), beta blocker (only labetalol), nifedipine (calcium antagonist), sodium nitropruside,
130
greatest risk for post part HTN
antenatal preeclamspsia
131
elampsia
preeclampsia + seizures
132
```
what do each of these mean?
White Scheme- DM Classification KNOW!
A1
A2
B
C
D
F
R
H
T
```
White Scheme- DM Classification KNOW!
A1 - GDM not requiring insulin- majority of pregnancies
A2 - GDM requiring insulin
B - Onset > age 20 years or duration 20 years
F - Nephropathy
R - Proliferative retinopathy or vitreous hemorrhage
H - atherosclerotic heart disease clinically evident
T - Renal transplant
133
indications for c/s in diabetics
EFW >4500g or DM with prolonged second stage or arrest of descent with EFW >4000g
134
etiologies of post part hemorrhage
atony, retained placental fragments, coagulopathy, lacerations of vagina or cervix, uterine rupture or inversion
135
T or F: you should not breastfeed if you re hIV + even if undetectable viral loads
T, excpe tin 3rd world (r/o malnutrition greater than HIV transmission)
136
CI to vacuum extractor
• Fetal prematurity (
137
indications for C/S
* Failure to dilate
* Failure to descend
* Malpresentation ~11%
* Non-reassuring FHR ~10%
* Previous uterine scar ~30%
* Maternal request • Abnormal placentation-
* Placenta previa, vasa previa, placenta accreta
* Maternal infection- HSV or HIV
* Multiple gestation • Fetal bleeding diathesis
* Mechanical obstruction to vaginal birth previous obstruction with labor
* Large leiomyoma or condyloma acuminata, severely displaced pelvic fracture, macrosomia, fetal anomalies such as severe hydrocephalus
138
% of breast cancer that is hereditary
5-10%
139
RFs for breast cancer
12.8% by age 90
• Menarche before age 12 higher # of cycles in life=higher risk
• First live birth after age 30
• Nulliparity
• Menopause after age 55
• Atypical hyperplasia or LCIS dx by breast biopsy
• Postmenopausal obesity
• HRT
• Alcohol use (>2 drinks/day)
• Previous therapeutic radiation to chest or upper body
• Family history of breast cancer
140
T or F: you are at an increased risk of prostate, pancreatic and colon, uterine and melanoma with + BRCA
T
141
when to suspect a hereditary cancer
in >2 close relatives, dx
142
red flags for hereditary cancer
* Breast cancer before 50
* Ovarian cancer at any age b/c 25% chance hereditary
* Male breast cancer at any age- 13% of positive BRCA
* Multiple primary cancers
* Ashkenazi Jewish ancestry
* Relatives of a BRCA mutation carrier
* Triple negative breast cancers (ER-/PR-/Her2-)
143
2 genetic testing methods
sequencing (determine code) and MLPA or Q-PCR to find whole deletions or duplications
144
T or F: you can reach detection rate in 100%
F
145
if genetic test done 5 years ago, no need to get it again
false, tests and fm hx can change
146
T or F: Family history is the most effective screening tool for assessing cancer risk
T
147
causes of uterine displacement
* Childbirth
* Heavy physical labor
* Connective tissue labor- Marfans-absence of strong support
* Family tendency
* Age plus gravity
148
tx of uterine prolapse
nothing, pessary or surgery (hysterectomy)
149
sx of cystocele
* Pressure
* Feeling something bulging “feels like egg in vagina when I’m showering”
* Urinary incontinence, retention
* Frequent UTIs
150
non surgical options for cystocele
pessaries, kegels, double voiding, surgery
151
history clues to rectocele
* Pressure
* Feeling something bulging
* Stool incontinence- incomplete emptying, odor
* “when I am running little balls of poop come out” or “can’t seem to wipe away all the stool”
152
causes of vaginal fistulas
* Childbirth injuries: lacerations, necrosis
* Previous surgery- urologic procedures
* Crohn’s disease- most common cause of rectovaginal fistulae
153
FSH > what indicates post menopause?
>30
154
GU problems in menopause
atrophy of estrogen dependent tissues: atrophic vaginitis/dryness, itching, burning, more susceptible to UTIs, endometrial atrophy and spotting, cystocele, etc dysuria and frequency
155
menoapuse
• 12 months of amenorrhea immediately following last menstrual period- clinical diagnosis
156
when to consider premature ovarian failure
* 1% of women who undergo menopause 30 IU/L
| * Causes infertility and perimenopausal/menopausal symptoms
157
lifestyle modifications for hot flashes
keep cool, exercise, medication, relaxation, stress reduction, avoid spicy food, caffeine, alcohol, and nicotine
158
most common fx sites in osteoporosis?
Vertebrae, hip, and distal radius
159
diff btwn primary and secondary osteoporosis
secondary d/t other dz
160
diff between type I and II primary osteoporisis
type I d/t increased osteoclastic bone resorption, type II d/t decreased osteoblastic activity
161
conditions involved in secondary osteoporosis
* Malignancies
* Corticosteroid use
* GI disorders- poor absorption
* Endocrine disorders- thyroid problems • Disuse from prolonged immobilization- MS
* Medications such as heparin or AEDs
* Alcohol use
162
osteopenia
bone density below normal, if catch here can prevent osteoporosis
163
RFs for osteoporosis
```
• Alcoholism
• Smoking
• Small, thin body build
• Weight 25 • Sedentary lifestyle
• Low calcium and vitamin D
• Corticosteroid use
• Prolonged immobilization
and age, causion or asian, female gender, family hx
```
164
dowager's thump
thoracic kyphosis
165
screening rec'd for bone screen
postmenopausal >65, postmenopausal
166
interpretation of T score -1 to -2.5 SD
osteopenia
