OB/GYN 2
Terms
undefined, object
copy deck
- Refer for Mammography at age
- 35/40
- MOST COMMON BREAST PROBLEMS
-
breast pain (mastalgia), nipple discharge,
palpable mass - breast pain (mastalgia), nipple discharge, palpable mass
- BREAST PAIN
- ______pain is usually bilateral & poorly localized; usually resolves spontaneously
- Cyclic
-
________ pain is usually a sharp, burning localized pain
May be secondary to an underlying fibroadenoma or cyst - Non cyclic
-
Nipple discharge
_________--spontaneous, bloody, often associated with a mass-usually unilateral & confined to one duct. Most common cause is intraductal papilloma.
_________—discharge only with compression, multiple duct involvement -
Pathologic
Physiologic - T/F : All spontaneous or unilateral nipple discharge should be referred for surgical exam
- TRUE
- In premenopausal women normal glandular tissue is __________
- nodular
- Differential diagnosis of a dominant breast mass:
- macrocyst, fibroadenoma, fibrocystic changes, fat necrosis, & cancer
- second most common type of cancer in women worldwide. A causal link exists with HPV.
- CERVICAL CANCER
- Pap Smear is recommended at least every ________years age _________
-
3 years
20-65 -
_____________ covers the cervix
___________is beyond this junction into the os -
Squamous epithelium
Columnar epithelium - _____________(transformation zone) is where the pap is taken
- Squamocolumnar junction
-
_____________________
Specimen Type
Specimen Adequacy
General Categorization
Automated Review
Ancillary Testing
Interpretation/Result
Educational Notes & Suggestions - Bethesda Reporting System
-
HPV VACCINE
~ ___________
Protects against types _______(cause most genital warts)
Protects against types ______ (causes 70% of cervical dysplasia) -
GuardAsil (Merck)
6, 11
16,18 -
Management of the Abnormal Pap Smear
__________—repeat in a timely fashion
__________—repeat annually or every 3 years
___________—repeat in a timely fashion
___________—treat &/or discuss with patient
___________—r -
UNSATISFACTORY
NEGATIVE
NO ENDOCERVICAL CELLS
ORGANISMS PRESENT
ASC-US (atypical squamous cells of undetermined significance -
Management of Abnormal Pap Smears (cont)
___________—repeat in 4-6months or refer
____________, ________, __________—refer
Other Malignant Neoplasms (an abnormal formation of tissue that serves no useful function & grows at the exp -
Low-grade squamous intraepithelial lesion) LGSIL
HG (High grade) SIL
Squamous Cell Carcinoma
Glandular Atypia - Pap smears that suggest invasive disease require further evaluation by:
- colposcopy, biopsy, endocervical curettage, cryotherapy laser vaporization, loop excision, cone biopsy, hysterectomy
-
age (75% menopausal-late 60s)
obesity (especially upper body type)
PCOD
Unopposed exogenous estrogen
Diabetes
Personal or family history of ovarian or breast cancer
Nulliparity
Late Menopause (after age 52) -
Uterine Cancer
Risk Factors - Directly related to the amount of estrogen stimulation & endometrial hyperplasia
- UTERINE CANCER
- Postmenopausal bleeding is ____________until proven otherwise
- endometrial cancer
- any nonmenstrual or intermenstrual bleeding
- METRORRHAGIA
-
Diagnostic Evaluation for Endometrial Cancer
Endometrial Biopsy
__________(allows for more extensive sampling)
___________(endometrial thickness <6mm, usually not associated with cancer)
___________(useful in staging)
Pap Smea -
D&C
Transvaginal Uterine Sonography
Hysteroscopy with directed biopsy
Type 1 - ________STAGING IS USED FOR ENDOMETRIAL CANCER
- FIGO
-
Risk factors-unopposed estrogen stimulation (anovulatory cycles, infertility, infertility drugs, nulliparity, low parity, exposure to toxins/carcinogens (dietary fat, perineal talc use, asbestos exposure)
Heredity (breast, ovarian, Lynch II Syndrome - OVARIAN CANCER
-
Ovarian Cancer (cont)
Etiology-unknown
Classification based on type-
a) _____________(>90%; increases with age)
b) _____________ (most common in children/young adults)
c) _______________(rare-usually occur in pos -
epithelial cell tumors
germ cell tumors
sex cord-stromal tumors -
Abdominal bloating
Dyspepsia
Frequent urination
Pelvic pressure or pain
Constipation
Pelvic mass
Abdominal distention
Pleural effusion
Ascites
Adenopathy
Cachexia - CLINICAL PRESENTATION OF OVARIAN CANCER
-
OVARIAN CANCER STAGES:
I
II
III
IV -
Stage I: Ovarian cancer that is confined to one or both ovaries.
Stage II: Ovarian cancer that has spread to pelvic organs (e.g., uterus, fallopian tubes), but has not spread to abdominal organs.
Stage III: Ovarian cancer that has spread to abdominal organs (e.g., abdominal lymph nodes, liver, bowel).
Stage IV: Ovarian cancer that has spread outside to distant sites (e.g., lung, brain, lymph nodes in the neck). - T/F: IF OVARIAN CANCER METASTASIZES, THE CLASSIFICATION NEEDS TO CHANGE ACCORDINGLY
- FALSE-Once ovarian cancer is assigned a stage, the classification does not change, even if the cancer recurs or metastasizes to other sites within the body.
- Ovarian cancer staging usually is described in terms of the _______ system (staging scheme developed by the International Federation of Gynecology and Obstetrics) and the ______system (classification system developed by the American Joint Committee on Ca
-
FIGO
TNM -
TX FOR OVARIAN CANCER:
EARLY STAGE:
ADVANCED STAGE: -
Early Stage: Surgery--Five year survival rate >90%
Advanced Stage: Chemotherapy, autologous bone marrow transplantation, hormonal therapy Five year survival rate 30-40% - the bleeding manifestations of anovulatory cycles
- DYSFUNCTIONAL UTERINE BLEEDING
- a thickened endometrium causes by perimenopause, puberty, PCOS, obesity, unopposed estrogen replacement therapy
- CAUSES OF DUB
- estrogen low relative to progesterone; results in a thinned endometrium (low estrogen pills < 30 mcg, POP, Depo-Provera, Norplant, Mirena IUS)
- PATTERNS OF DUB
- orthostatic BP changes, > heart rate, pallor, large amount of blood in vaginal vault, uterus may be enlarged due to retained clots
- ACUTE DUB
- stable heart rate & BP, body habitus (obesity, stigmata of PCOS), pale or normal skin color, small amount or no blood in vaginal vault, uterus WNL
- CHRONIC DUB
- scanty or infrequent menstrual flow
- Oligomenorrhea
-
_________________
Any pregnancy in which 2 or more embryos exist simultaneously
Higher perinatal morbidity and mortality than singleton gestations
_______________
Cleavage of one fertilized egg at various stages
___________
-
Multifetal Pregnancy
Monozygotic twins
Dizygotic -
This is a twin placenta. Note the two umbilical cords.
⬢There is no membrane dividing the two umbilical cords which is indicative of a monoamniotic placenta.
⬢Note the entanglement of the umbilical cords. - Monochorionic-Monoamniotic Twin Placenta
-
Maternal Complications
Exaggerated maternal physiologic response to pregnancy
_____increase in blood volume
Hypertension
___________-uterine stretch theory
Increased Fe and Folic Acid requirements
May predispose to anemia -
500ml
Premature Labor
great vessels, ureters -
Hydramnios
Malpresentation
Placenta Previa
Placental Abruption
Premature rupture of membranes
Umbilical cord prolapse
IUGR
Congenital anomalies
Increased perinatal morbidity/mortality
TTTS - Fetal Complications
-
ANTEPARTUM HEMORRHAGE
-UK ETIOLOGY
-PLACENTAL:
-CERVICAL:
-VAGINAL:
-UTERINE:
-BOWEL OR BLADDER BLEEDING: -
**Placental
Previa
Abruption
Vasa Previa
**Cervical
Carcinoma
Erosion
Polyp
**Vaginal
Varicose veins
Lacerations
**Uterine
Fibromyomata
**Bowel or bladder bleeding -
ANTEPARTUM HEMORRHAGE
Sterile speculum exam to rule out ________
Digital cervical exam after ruling out ___________
Labs
CBC-compare to previous
_______________
Most Important
Also check for placental abruption/clots -
vaginal or cervical cause
placental previa
Ultrasound exam for placental location -
<37 WEEKS
>37 WEEKS -
Expectant Management if <37 weeks
Delivery usually if >37 weeks - 3 most common causes of maternal death
-
Hemorrhage
Infection
Hypertensive Disease -
Failure of the uterus to contract after placental separation called _________
-Cause of 75 to 80% postpartum hemorrhages
-Leads to excessive placental site bleeding
Management
IV infusion of dilute _______
If bleeding continues,_ -
uterine atony
oxytocin
Ergonovine maleate
Methylergonovine -
Occurs during delivery
2nd most common cause of pp hemorrhage - Genital tract trauma
-
Uterine Inversion
“Turning inside out†of uterus in _______ of labor
Retained Placental Tissue
Placenta usually separates near “__________†with uterine contractions after delivery of fetus -
3rd stage
Nitabuch’s Layer -
_____________
Rare syndrome of unknown etiology
Hemolytic anemia, fluctuating neurological signs, renal dysfunction, fever
Usually fatal
Rare, 80% mortality
Fulminating consumption coagulopathy
Intense bronchospasm
-
Thrombotic Thrombocytopenia
Amniotic Fluid Embolus
ITP
VWD -
Fetal Head
-Vaginal delivery necessitates accommodation of the fetal head by the bony pelvis of the mother
-_________the least compressible part of baby
-_________at birth are thin, weakly ossified, easily compressible
-Interconnected -
Fetal head
Cranial bones
molding -
Sutures
Membrane occupied spaces between cranial bones
_________
Between the parietal bones
_________
Separates occipital bone from parietal bones
_________
Separates parietal and frontal bones
_________
Betw -
Sagittal Suture
Lambdoid Suture
Coronal Suture
Frontal Suture -
___________Membrane filled spaces located at the point where sutures intersect
_________________
Larger, diamond shaped, 2x3 cm
Located at intersection of sagittal, frontal, and coronal sutures
Closes/ossifies at 18 months
Allow -
fontanelles
anterior
posterior -
Maternal Pelvis: 4 Shapes
___________
Classic female
50% of women
Most easily accommodates fetal head-most spacious
_________
Classic male
30% of women
Limited space at all levels
_________
Anthropoid ape -
Gynecoid
Android
Anthropoid
Platypelloid -
Pelvic Inlet
Plane of Greatest Diameter
Anterior-posterior and Transverse
Plane of Least Diameter
Mid plane
Pelvic Outlet - 4 pelvic planes
- Progressive cervical effacement and/or dilatation from regular uterine contractions
- labor
-
Primagravida-2 or more weeks before labor
Multigravida-occurs in early labor
Noticed as flattening of upper abdomen, increased prominence of lower abdomen
Bladder compression and increased frequency of urination - lightening
-
Preparatory Events Before Labor: False Labor
____________________
Irregular, usually painless uterine contractions
During last 4-8 weeks
In last month, more frequent, q 10-20min
Unpredictable, sporatic, rhythmic, mild
NOT a - Braxton Hicks Contractions
-
Preparatory Events Before Labor:_________________
Cervix firm and rubbery prior to labor
Cervical softening prior to delivery due to increased H2O and collagen lysis
Effacement: Thinning of cervix
Occurs as cervix taken up into the lo - Cervical Effacement
-
From onset of true labor to complete dilatation of cervix
From complete dilatation of cervix to birth
From birth of baby to delivery of placenta
From delivery of placenta to approximately 6 hours after -
4 stages of labor:
1st
2nd
3rd
4th -
Second Stage of Labor
Urge to bear down
Duration 30 minutes to 3 hours
__________: Visualization of head at vulva
Station
Progress of presenting part through birth canal
Cephalic presentation
Head shape changes
___ -
Crowning
Molding
Cephalopelvic Disproportion (CPD)
Caput -
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion - Mechanisms of Labor
-
Perineal Lacerations
With or without episiotomy
1st degree laceration
Involves :
2nd degree laceration
Involves :
3rd degree laceration
Involves :
4th degree laceration
Involves : -
vaginal mucosa/skin
submucosal layer of vagina or perineum
anal sphincter
rectal mucosa -
Period following delivery of baby and placenta to 6 weeks pp
red, 1st few days following delivery
paler, 3-4 days after delivery
yellow, white, 10 days after delivery -
Puerperium
lochia rubra
lochia serosa
lochia alba -
Regional Anesthesia
Local infiltration for episiotomy
_________-active labor
Spinal-immediately before delivery
________-perineal anesthesia, before delivery
_________
Anesthetize nerves of uterus, T10-L1
Inject lateral -
Epidural
Caudal
Paracervical
Pudendal -
_______________
Narcotics
Demerol (meperidine)
Stadol (butorphanol)
Sedatives/Tranquilizers
Phenergan (promethazine)
____________
Nitrous oxide
Penthrane
Ethrane -
Systemic Medications
Inhalation analgesia - to use vacuum extractor, fetus MUST be ___________ presentation
- VERTEX
- ________ is more informative than Apgar Score
- cord pH sampling
-
the baby’s “lifeline.â€
Shiny Schultz vs Dirty Duncan presentation
Often sent to pathology after delivery for examination and testing - Placenta
-
Eccentric insertion of umbilical cord
Inserts usually at edge like “badminton†racquet
No clinical significance: - Battledore Placenta
-
Blood vessels course unprotected for long distances through the membranes to insert into the margins of the placenta
Blood vessels may pass over cervical os or other position where they may be compressed by fetus or ruptured with rupture of membrane - Velamentous Insertion
-
Large central circular depression on fetal surface of placenta surrounded by an elevated ridge
Amnion and chorion fold back on themselves, forming a double layer of fetal membranes
Increased incidence of early Ab and bleeding in late pregnancy - Circumvallate Placenta
-
Implantation of part or all of the placenta in the lower uterine segment
Associated with increased perinatal and maternal mortality - Placenta Previa
-
Placenta Previa
Tends to be associated with:
Fetal anomalies
Twin Gestation
History of _________
Advanced __________
Previous C/S
Grand multiparity due to change in size and contour of uterine cavity
________ cause -
multiple uterine curretages
maternal age
Bleeding -
Painless bright red vaginal bleeding in 3rd trimester-sometimes earlier
Uterus non tender and non irritable
AVOID digital cervical exam until U/S - Placenta Previa Symptoms
-
_____________________
Correct apparent or potential shock
IV, Type and Match, H & H
Prior to term, prolongation of pregnancy desired-expectant mgt
If term, abdominal delivery, C/S
Assess for placenta accreta-common
Rh is - Placenta Previa Management
-
Placenta ____________
Placenta attaches too deep in uterine wall but does not penetrate uterine muscle
Chorionic villi in contact with myometrium
Placenta __________
Penetrates uterine muscle
Chorionic villi invade myometrium
-
Accreta
Increta
Percreta -
______________
Partial or complete detachment of placenta from normal site of implantation on uterine wall
Complete or marginal
Increased perinatal and maternal morbidity
Classification of the degree of separation based upon percentag - Placental Abruption
-
Placental Abruption Etiology
Uncertain and speculative
Trauma-MVA
Most spontaneous and nontraumatic
_____tension
_______ umbilical cord
Uterine anomaly or tumor
Drugs-________ -
Hyper
Short
cocaine -
Abruption:
As it evolves, blood coagulates and dissects or separates the placenta from the uterus
Blood infiltrates myometrium-_____________
________ abruption painful, no vaginal blood
________abruption, painless, +vaginal bleeding -
Couvelaire uterus
Central
Marginal -
Abruption Symptoms
________ Bleeding
_________Pain
Symptoms proportionate to degree of separation
Total blood loss may not be apparent-______________
Tachycardia, shock, hypertonic uterus, _________fundal height
Non reassuri -
Vaginal
Uterine
retroplacental clot
increases -
Abruption Management
Variable and depends on :
Priorities are _________ and safe and timely delivery
Assess FHT and UC patterns continuously
In absence of fetal distress-vaginal delivery -
gestational age, fetal distress, cervical dilatation, hemodynamic status
replacement of lost blood -
________
Occurs with velamentous insertion of the cord (vessels separate while still in the membranes.)
Presence of fetal blood vessels overlying cervical os
Bleeding from vasa previa from the fetus-exsanguination with very little blood lo - Vasa Previa
- Refers to the process of physical changes by which a child’s body becomes an adult body, capable of reproduction
- puberty
- __________ overlaps puberty. It refers to psychosocial & cultural characteristics of development as well as the physical changes of puberty.
- Adolescence
-
Breast Development
________ – (Tanner stage 2) First sign is usually a firm, tender lump under the center of the areola of one or both breasts (average __ years)
Swelling of the breast tissue extends beyond the edges of the __________ ( -
Thelarche
11
areolae
secondary mound forming
Contour -
Pubic Hair
__________ – initially usually visible along the labia (Tanner stage 2)
________are to numerous to count & appear on the _______(Tanner stage 3)
___________ densely filled with hair (Tanner stage 4)
-
Pubarche
Hairs / Mons
Pubic Triangle
thighs & abdominal -
Mucosal surface of the vagina changes in response to increasing levels of _________, becoming thicker & a duller pink in contrast to the brighter red of the prepubertal vaginal mucosa
_____________ – whitish secretions which are a normal -
estrogen
Physiologic leukorrhea
ultrasound -
Menstruation & Fertility
________is the first menstrual bleeding
Average age in the U.S. is ______years (usually 2 tears after thelarche)
Menses usually irregular & nonovulatory in the beginning
Within __years, most cycles are -
Menarche
12.7
2 -
In response to rising levels of estrogen, the lower half of the pelvis _______
_________increases to a greater % than with males (esp. breasts, hips, thighs). This produces the typical female shape. -
widens
Fat tissue -
Sequence of hair appearance:
Arm & leg hair increases over the next __years -
Axillary hair, perianal hair, upper lip hair, preauricular hair, & periareolar
10 -
The estrogen-induced height growth spurt begins with ________
________grow first
Peak velocity ___ in/yr midway between thelarche & menarche
In the 2 years following menarche, growth slows to about 2 inches & involves t -
thelarche
Legs & feet
3-4 inches per year
spine -
Rising levels of ________can change the fatty acid composition of perspiration, resulting in an adult body odor
__________changes precede thelarche & menarche by 1 or more years
Androgens also increase the secretion of oil (sebum) from the -
androgens
Body odor
acne -
_______________ occurs in a PG Rh-negative patient carrying a Rh-positive fetus
Immune system of mom (Rh-) stimulated to produce IgG antibodies to Rh antigen
___________ then cross placenta and destroy fetal RBC’s -
Rh isoimmunization
Antibodies -
___ exposures to Rh antigen required to produce antibodies and sensitization
Antibody response called _______________ -
2
Rh sensitization -
Most sensitization occurs at _________
With succeeding pregnancies, Anti Rh antibodies in mom’s system can cross placenta and destroy fetal RBC (________) -
delivery
hemolysis -
____________ test (maternal serum):
Detects fetal RBC’s in maternal circulation
Percutaneous Umbilical Blood Sampling (PUBS):
_________ to check for amount of bilirubin
Perform if fetomaternal hemorhage suspected -
Kleinhauer Betke
Amniocentesis -
__________ Test
Checks for antibodies attached to RBC
Performed on baby’s blood of Rh negative mom
Determines whether the mom has formed harmful antibodies and transferred them through the placenta to the fetus
____________ Te -
Direct Coombs
Indirect Coombs -
_______ 300mcg (anti Rh gamma globulin) given IM to Rh negative mother
At ___ weeks
Again within ___ hours of delivery
Remember: Rh incompatibility develops only when mother is Rh negative and infant is Rh postive -
RhoGam
28
72 -
Pre Eclampsia - Pregnancy Induced Hypertension (PIH)
Triad of symptoms
_______ - 140/90 or
Increase of 30 systolic/15 diastolic mmHg
_______
__________
Seen at opposite ends of spectrum of
Maternal age—yo -
Hypertension
Edema
Proteinuria -
HELLP Syndrome-
Form of severe pre eclampsia - Hemolysis, Elevated Liver Enzymes, Low Platelets
- Addition of grand mal seizures to pre eclampsia
- eclampsia
-
Pre Eclampsia Management
Goal: _____________
Outpatient management if pressures stable and NO proteinuria
Bed rest in _________
position
Increases uteroplacental perfusion
Avoids vena cava syndrome
Inpatient -
Prevent Eclampsia
left lateral
36 -
Antihypertensive Therapy:
IV __________
Oral Aldomet, Atenolol, Labetolol
Anticonvulsant Therapy:
_________ (Epsom Salt) IV or IM
______ (diazaepam) half life of 72 hours-Neonatal effects -
Hydralazine
Magnesium Sulfate (MgSO4)
Valium -
Pregnancy associated with increased tissue resistance to insulin
Glucose screen for gestational diabetes _______ weeks -
Diabetes of Pregnancy
24-28 -
“White’s Classification of Diabetes in Pregnancyâ€
Class __ -Gestational DM, glucose intolerance developing during pregnancy, fasting blood glucose normal
Class ___ or __ -also abnormal fasting blood glucose
Approxim -
A
A/B or B -
Polyhydramnios
Pre Eclampsia
Ketoacidosis and Diabetic Coma
Vascular End Organ Deterioration - Cardiac, Renal, Ophthalmic, Peripheral Vascular
Neurologic - Peripheral neuropathy, GI disturbance - GDM Maternal Complications
-
Congenital anomalies result from hyperglycemia during first 4-8 weeks of pregnancy
Macrosomia with traumatic delivery
Delayed organ maturity - amniocentesis for fetal lung maturity
Congenital Anomalies - CV, Neural tube defects (spina bifi - GDM Fetal Complications
-
Small for gestational age, birth weight below 10th percentile for given gestational age
Discrepancy between Uterine Size and Gestational Age, Size<Dates - Intrauterine Growth Restriction (IUGR)
-
etiology of IUGR:
_______-Poor nutrition, Tobacco, Drugs, Alcohol
________-Pre Eclampsia, HTN, Chronic Renal Disease,
_____-Intrauterine infections, congenital anomalies -
Maternal
Placental
Fetal -
IUGR Management:
Diagnosed by ________ exam
Modify any associated factors:
Nutrition, tobacco, alcohol
Non Stress Tests, Contraction Stress Tests
Delivery - ultrasound
-
Calf area, swelling and tenderness of involved extremity
On exam, erythema, tenderness, warmth, palpable cord over involved superficial veins
NOT life threatening and does NOT lead to PE
Pain meds, elevation, local application of heat - Superficial Thrombophlebitis
-
1 in 2000 ante partum, and 1 in 700 postpartum
Pain with dorsiflexion of foot-Homan’s Sign
Acute swelling and pain
Doppler ultrasound, anticoagulant therapy
Heparin-high molecular weight, does not cross placenta
Warfarin-low mo - Deep Venous Thrombosis (DVT)
-
1 in 2500 in pregnancy
DVT the instigating factor - Pulmonary Embolism (PE)
-
Increased GFR of PG causes increased excretion of iodine and reduced plasma iodine levels
Increased incidence of prematurity, IUGR, and higher neonatal morbidity and mortality, fetal anomalies, PTL
Cause: ______ Disease-usually remi -
Thyroid Disease
Graves -
Major complication/risk
Precipitating factors include infection, labor, C/S, or noncomplicance with meds - Thyroid Storm
-
Occurs 3-6 months after delivery
Hyperthyroid state of 1-3 months followed by hypothyroidism
Sometimes misdiagnosed as depression - Recurrent Postpartum Thyroiditis
-
May adversely affect neuropsychological development of child
Check TSH level prenatally - Maternal hypothyroidism
-
Occur more frequently in PG due to a combination of hormonal and mechanical factors
Decreased ureteral tone and motility combined with compression of ureters at pelvic brim resulting in dilatation of upper ureter, renal pelvis, and bladder - UTI
-
___________ most frequent medical complication of UTIs necessitating hospitalization
Fever, chills and shaking, CVA or flank tenderness
Pyuria and bacteriuria
Treatment with antimicrobial agents
Ampicillin, cephalexin, nitrofura - Pyelonephritis
-
Cultured from vaginal canal in 5 -25% of pregnant women
If has + history, IV antibiotics in labor - Group B Strep (GBS)
-
Symptoms
Maternal:
Postpartum endometriosis in mother
Associated with premature rupture of membranes
Neonatal:
Early onset neonatal sepsis-within first day of life - Group B Strep (GBS) infection
- TORCH
-
Toxoplasmosis - no litter box cleaning
Other (Syphillis)
Rubella
CMV
HSV - abdominal delivery -
Seizure Meds - ________
Fetal hydantoin syndrome in 10% of exposed babies
30% may have isolated craniofacial anomalies, limb reduction deficits, mental retardation, CV anomalies - Dilantin
-
Seizure Meds - __________
Drug of choice in PG, risk low
True teratogenicity difficult to assess because usually taken in combination with other drugs - Phenobarbital
-
Seizure Meds - avoid _________
Congenital malformations in utero similar to dilantin
_________ deficiency a result of anticonvulsant therapy -
Depakote (Valproic acid)
Folic acid -
Cholestasis and pruritis without other major liver dysfunction
Tendency to recur with each pregnancy, hereditary deficiency aggravated by high estrogen levels of pregnancy
Associated with oral contraceptives
Benign course with no maternal - Intrahepatic/Idiopathic Cholestasis of Pregnancy
-
Main Sx of Cholestasis - __________, usually in 3rd trimester
_________ may be observed in late PG -
Itching
Jaundice -
Treatment
__________ binds to bile acids in gut
Supplement fat soluble vitamins (6)
Itching disappears within hours of delivery -
Cholestyraine
A, D, E, K -
Chronic hypertension with superimposed pre eclampsia
D/C _____ -Associated with fetal anomalies - ACE-I’s
-
Severe ________ associated with high spontaneous Ab rate, increased incidence of IUGR, and IUFD
Monitor closely during PG to assure adequate maternal and fetal assessment
Avoidance of dehydration, aggressive treatment of respiratory -
asthma
80 -
Monthly up to 32 weeks
Every 2 weeks until 36 weeks
Weekly after 36 weeks until delivery - Prenatal Care Visits
-
Commonly Performed Labs:
_____________ between 24 and 28 weeks when insulin requirements are maximal
Serum __________at 16 to 20 weeks to predict open neural tube defect
Folic Acid and Avoid Hot Tubs
_________ fetal -
Blood Glucose/OGTT
Alpha fetoprotein (AFP)
Ultrasound
TB -
Other tests:
Cervical cultures for ____ and ____
Toxoplasmosis antibody test
HBsAg Titer
Sickle Cell Preparation or Hemoglobin Electrophoresis in all previously unscreened ____________ women
RhoGam a -
GC and GBS
African American
negative -
Gestational Age Assessment, Assure S=D
Fundal Height Measurement
From symphysis pubis to top of fundus
From __ weeks to term is equivalent to gestational age
S>D may indicate ____________
S<D may indicate _______
-
22
multiple gestation
IUGR -
Abdominal Exam At 28 weeks to identify:
__________-relationship of parts of fetus to each other
Normally complete flexion, fetus folded with convex back, arms crossed
If deflexed consider brow presentation, extended head
_ -
Attitude
Lie -
Abdominal Exam cont’d:
_________- Portion of fetus that descends through birth canal
When lie longitudinal, presenting part either cephalic (head) or breech
When lie is transverse, presenting part is shoulder usually
___ -
Presenting Part
Position
Leopold Maneuvers -
Special Concerns:
_________ - Important in maintaining health and feeling of well being
Amount maintained at pre pregnant level
_______ - Frequent rest periods
Avoid exposure to teratogens
_______ - Not harmful during -
Exercise
Work
Travel
Immunizations
Sexual Intercourse
Bathing -
_________ Test:
Observe fetal heart rate in response to mom’s perception of fetal movement
Normal fetus responds to fetal movement with an acceleration in FHR of ____ beats or more per minute for at least 15 seconds.
Two such accel -
Non Stress
15
20 -
Ultrasound:
Amniotic fluid -
___________ suggests fetal compromise and umbilical cord compression
Fetal Breathing and Fetal Movements -
Chest wall movement
___ breathing movements in 10 minutes or __ body movements in 10 -
Oligohydramnios
30
3 -
Biophysical Profile:
fetal breathing movements
gross body movements
fetal tone
reactive non stress test
qualitative amniotic fluid volume
Score 2 or 0 on each criteria
____ Normal
____ Equivocal
____ Abn -
8-10
6
<6 -
____________ test:
Assesses uteroplacental function
Dilute solution of IV _______ OR
Nipple Stimulation
Elicit __ contractions in 10 minutes
FHR response to contractions observed
Positive CST -
Non r -
Contraction Stress
oxytocin
3 -
Withdraw amniotic fluid, around 15-20 weeks
Examine fluid for evidence of Rh sensitization, Down’s syndrome, other chromosomal abnormalities
Maternal Serum Alpha-Fetoprotein (AFP)
Elevated in women carrying fetus with _____________ -
Amniocentesis
open neural tube defect
US -
Ultrasonography - ID structural defects
__________ Abnormalities: Anencephaly, hydrocephaly, neural tube defect,
_____________ Abnormalities: Omphalocele, gastroschisis
______ Abnormalities: agenesis
________ Dysplasias
C -
Cranio spinal
Gastrointestinal
Renal
Skeletal
Heart -
____________ Sampling -
Transabdominal or Transcervical-Ultrasound Guided
_______ weeks, earlier than amnio
Needle through abdomen or cervix into placenta
Chromosomal studies
Risk of spontaneous Ab, fetal injury, Rh immuni -
chorionic villi
10-12 -
Age-women over ___ at increased risk
Down’s syndrome, other chromosomal abnormalities
Autosomal Recessive Disorders - __ recessive genes must be present
Tay Sachs, SSA, Thalassemia, Cystic Fibrosis
Autosomal Dominant Dis -
34
2
50%
Sex -
Any agent or factor that can cause abnormalities of form or function in an exposed fetus
Dose & Timing - Most vulnerable period between ___ weeks, organogenesis
Drugs and Chemical Agents - alcohol (FAS), Thalidomide, Vitamin A in high -
Teratogens
3-8 -
Sperm produced in the seminiferous tubules of the testes in a process called ____________
Seminiferous tubules contain many germinal epithelial cells called ____________
Type A Spermatagonia-Type B Spermatagonia-Primary Spermatocyte -
spermatogenesis
spermatogonia
74 -
After sperm are in the epididymis for 18 hours to 10 days, the develop capability of _________
Most sperm stored in the _________. Can remain there for several months depending on sexual activity -
motility
vas deferens -
____________ is the physiologic change sperm must undergo in the female reproductive tract prior to fertilization.
________ lies over sperm head as a kind of “chemical drill bit†designed to enable the sperm to burrow its way to the oocyt -
Capacitation
Acrosome - _________ - union of sperm and ovum, fertilization restores the diploid number of chromosomes and determines sex
- zygote
-
Fertilized ovum reaches endometrial cavity about __ days after ovulation, undergoes further development for 2 to 3 days before implanting. Implantation usually occurs on ___ day following
ovulation
Before implantation the zygote grows to -
3
7th
morula -
Shortly after implantation, a cavity develops in the mass of cells and the embryo begins to develop - _________ Stage
___________ then proliferates rapidly forming placenta and various membranes of pregnancy -
Blastocyst
Trophoblast -
Placenta: Transfer of substances occurs by
___________ (passive, random movement, concentration gradient)
_______________ (passive, concentration gradient, proteins act as carriers)
____________ (requires energy)
As placenta ag -
Simple diffusion
Facilitated diffusion
Active transport -
Mean PO2 in maternal blood ___ mmHg
Mean PO2 in fetal blood ___ mmHg
PCO2 of fetal blood ___ mmHg higher than maternal -
50
30
2-3 -
________ - facilitated diffusion, carrier molecules in trophoblast cell membrane
_________ diffuse more slowly than glucose, so
glucose preferentially used by fetus
Ketone Bodies, Potassium, Sodium, Chloride Ions diffuse from -
Glucose
Fatty Acids -
Most important function: causes corpus luteum to secrete estrogen and progesterone to maintain pregnancy
After about 7 weeks, placenta secretes enough E and P - Human Chorionic Gonadotropin Beta hCG
-
Increases to about 30 times normal by end of pregnancy
Largest quantity-________(usually small amount in nongravid female)
Cause enlargement of the ________
Cause enlargement of the breasts and growth of the breast ductal structure
Ca -
estrogens
estriol
uterus
pelvic ligaments -
Essential for pregnancy
Causes uterine endometrium to proliferate, creating environment conducive to implantation. Also provides nutrients to developing morula and blastocyst
Decreases contractility of the gravis uterus-prevents uterine contrac -
Progesterone
spontaneous Ab -
Secreted around 5th week of pregnancy
Increased progressively through pregnancy in direct proportion to weight of ________
Promotes _________ development
Causes deposition of protein tissue similar to growth hormone
Actions on glucos -
Human Placental Lactogen(hPL)
placenta
breast
insulin -
Moderately increased throughout pregnancy
Possibly mobilize maternal amino acids for fetal tissue synthesis - Glucocorticoids
-
Specifically causes uterine contractions
Uterus more responsive near term
Increased quantities near onset of labor
Uterine stretching causes increased release - Oxytocin (Posterior Pituitary)
-
Biologically active lipids
Not true hormones, not synthesized in one gland and transported via circulating blood to a target organ. Synthesized at or near site of action
Synthesized in the endometrium and myometrium
Cause contraction of th - Prostaglandins
-
___________ stimulates absorption of sodium and secretion of potassium, maintaining Na K balance and protects against hypovolemia
PG women retain fluid
________ rises in pregnancy due to high E and P
Aldosterone secretion declines in toxem -
Aldosterone
Renin -
___________ glands enlarge during PG
Cause calcium absorption from maternal bones, maintains normal calcium concentration in maternal serum as fetus removes calcium for bone ossification - Parathyroid
-
Thyroid gland enlarges about 50% during PG
Increased production of _________
_________ - Higher amniotic fluid concentrations in laboring than non laboring women
Possible association with onset of parturition
________ - Se -
thyroxine
Leukotrienes
Relaxin -
Absence of adequate amniotic fluid during mid pregnancy associated with _____________ at birth—often incompatible with life
Abnormalities of amniotic fluid result of changes in fetal renal function, swallowing, lung fluid production or trans - pulmonary hypoplasia
-
___________ - Decreased volume of amniotic fluid
Caused by conditions that prevent or reduce amniotic fluid production, most commonly related to abnormalities in fetal ________
May produce fetal ________ as a result of umbilical cord comp -
Oligohydramnios
kidneys
hypoxia
meconium -
____________ - Excessive amount of amniotic fluid, usually over 2 liters, usually accumulates slowly
Increased risk of premature labor due to hyperdistension of the uterus
Maternal respiratory discomfort
Umbilical cord prolapse
Fetal -
Polyhydramnios
anencephaly
diabetic PG
ultrasound -
_____________ Contractions become progressively stronger toward the end of pregnancy, then become excessively strong in labor
____________ is the process by which the baby is born -
Braxton Hicks
Parturition -
The fetus is connected by the __________ to the placenta
Umbilical _______ carries oxygenated blood from the placenta to fetus
________ does the work of exchanging CO2 and O2, so fetal lungs are not used for breathing, and blood is -
umbilical cord
vein
Placenta
arteries -
With 1st breath at birth, ________ open & fetal circulation changes
Sphincter in ____________ constricts so that all blood entering the liver passes through the hepatic sinusoids
___________(normal connection between aorta and p -
alveoli
ductus venosus
Ductus arteriosus -
3 Fetal Shunts:
___________ - Shunts blood from PA to aorta
___________ - Shunts blood from umbilical vein and liver to IVC
___________ - Shunts highly O2 blood from RA to LA -
Ductus arteriosus
Ductus venosus
Foramen ovale -
Adult Structures:
Ductus arteriosus - ___________
Ductus venosus - ___________
Foramen ovale - ___________
Umbilical vein - ___________ -
Ligamentum arteriosum
Ligamentum venosum
Fossa Ovalis
Ligamentum teres -
Maternal Physiological Adjustments in Pregnancy: Gastrointestinal Changes
Stomach and intestines displaced
Delayed gastric emptying
Appetite increased with cravings—_____, Ptyalism
Vascular swelling of gums
_________ due -
Pica
Hemorrhoids
Gastric Reflux
Constipation
pruritis gravidarum -
Maternal Physiological Adjustments in Pregnancy: Hematological
________ volume increases beginning at 6th week in PG, intravascular
RBC increases beginning at 12th week
Disproportionate increase in plasma volume over RBC volume—hem -
Plasma
Physiologic Anemia of PG
decreased -
Maternal Physiological Adjustments in Pregnancy: hypercoagulable state
Fibrinogen __________
Factors VII, VIII, IX, and X increase
Prothrombin, Factor V and XII are _________
Bleeding time does not change
Platelet & WBC count -
increases
unchanged
increase -
Maternal Physiological Adjustments in Pregnancy: Cardiac (CO=SVxHR)
CO begins to increase by 5th week
Fx of increased ____ and decreased systemic ______________ -
HR
vascular resistance -
Maternal Physiological Adjustments in Pregnancy: Pulmonary
________
Increased chest diameter, subcostal angle changes
Increased diaphragmatic excursion and diaphragm elevation
Heart displaced _____ and ______
Hyperventilat -
Dyspnea
left and upward -
Maternal Physiological Adjustments in Pregnancy: Renal
GFR increases
Creatinine Clearance increases
Plasma osmolality decreases
Increased sensitivity to renin and angiotensin
Renal glycosuria common
Proteinuria
M - hydronephrosis of PG
-
Maternal Physiological Adjustments in Pregnancy: Endocrine
Carbohydrate Metabolism
Overall effect is that PG is diabetogenic
First half: tendency to __________
Second half: tendency to __________
Progressive insulin r -
hypoglycemia
hyperglycemia
hPL -
Maternal Physiological Adjustments in Pregnancy: Genital Tract
Increased vascularity and hyperemia of vagina, perineum, vulva
Increased secretions
Characteristic violet color of vagina-_________sign - Chadwick’s
-
Maternal Physiological Adjustments in Pregnancy: Skin Changes
_________ or melasma gravidarum — Mask of PGMore common in darked skin people, more pronounced in summer, fades after delivery, can occur in nonPG on OCP’s
_______ - -
Chloasma
Striae
Linea nigra -
Fetus not growing in the usual place-uterine cavity.
Implantation of the zygote outside the uterus or in an abnormal location within the uterus
Almost all (98%) of ectopic pregnancies occur in the ___________ tubes….â€______________†-
Ectopic Pregnancy
fallopian
Tubal Pregnancy -
Narrow fallopian tubes not designed to accommodate a growing embryo
Thin walls of the tube stretch to the point of rupture
Risk increases for women with a previous ectopic pregnancy, tubal scarring
Fallopian tube damage, surgery, en -
smoking
hemorrhage -
Combined intrauterine and extrauterine pregnancy (____________) may occur rarely
In the U. S. underdiagnosed or undetected __________is currently the most common cause of maternal death in the _______ trimester -
heterotropic
ectopic pregnancy
first -
Symptoms
_______ usually the first sign, usually adnexal or lower quadrant
May be in pelvis, abdomen or can extend up to the shoulders due to blood from a ruptured ectopic pregnancy building up under the __________
Described as sharp and s -
Pain
diaphragm -
Pelvic Inflammatory Disease
Abortion: Threatened or Incomplete
Ovarian Pathology: Torsion or Cyst
Acute Appendicitis - DDx Ectopic Pregnancy
-
Diagnosis:
________ to locate pain, tenderness or a growing mass in the abdomen
CBC may show anemia and __________
ABO and RH
Lab testing for _______
Usually doubles every 2 days during normal pregnancy. Rate slower in ectopic pr -
Pelvic exam
leukocytosis
Beta hCG
ULTRASOUND -
Occurs in 60%
Blood leaks from the tubal ampulla over a period of days
Blood accumulates in peritoneum
Slight vaginal spotting reported
Palpable pelvic mass
Abdominal distention and mild paralytic ileus often present - Chronic Ectopic Pregnancy
-
Common Sites of Ectopic Pregnancy:
___________ - Mid portion of the fallopian tube
_______ - Fallopian tube area closer to the uterus
________ - Distal end of tube, away from uterus
_______ - Within uterine muscle, “hornâ€
Per -
Ampullary
Isthmic
Fimbrial
Cornual -
Treatment:
Salpingectomy
Resection
Hysterectomy
Single dose IM ___________ - methotrexate
-
Natural termination of pregnancy prior to 20 weeks gestation or fetal weight less than 350gms
Assessment
Intrauterine pregnancy at less than 20 weeks
Low or falling B hCG levels
Bleeding, midline cramping, pain
Open cervic - Spontaneous Abortion
-
Present with cervical dilatation >2cm and minimal symptoms
When cervix dilated 4cm or more, active labor or rupture of membranes occurs
Associated with cervical conization or surgery, cervical injury, DES exposure, and abnormalities of the c - Incompetent Cervix
- Bleeding with or without cramping, pregnancy continues, cervix not dilated
- Threatened Ab
- Cervix dilated, membranes may be dilated, bleeding and cramping, no passage of products of conception---but inevitable
- Inevitable Ab
- Complete expulsion of fetus and placenta, pain ceases, spotting may persist
- Complete Ab
- Partial expulsion of POC, usually placenta remains in uterus, mild cramping, bleeding persists
- Incomplete Ab
- Pregnancy has ceased to develop, but no expulsion of conceptus, brown vaginal discharge, no free bleeding, minimal to no pain
- Missed Ab
-
Laboratory Findings:
Low or falling ____ levels
____ if bleeding
ABO and Rh
Rhogam (Rho(D) immune globulin if Rh –
__________ to pathology, possible genetic analysis -
hCG
CBC
Products of conception -
Ultrasound Findings:
Gestational sac at _____ weeks from LMP
Fetal pole at __ weeks
Fetal cardiac activity at ___ weeks
Serial observations required to evaluate changes in size of embryo
Small sac without a fetal pole diagnostic -
5-6
6
6-7 -
Ectopic pregnancy
Menses
Hydatidiform mole - DDX of Spontaneous Ab
-
Treatment Threatened Ab:
_______ 24-48 hours with gradual resumption of activities
Abstinence from coitus and douching
________ treatment contraindicated
_________ only if signs of infection -
Bedrest
Hormonal
Antibiotics -
Treatment Missed or Inevitable Ab:
___________ regarding inevitable fate of PG
Planning for elective termination, IV oxytocin, D&C
Cervical laminaria or prostaglandin vaginal suppository - Counseling
-
Surgical Treatment Incomplete Ab:
Removal of ____ remaining in uterus to stop bleeding and prevent infection
__________ and para cervical block
_________ exploration with forceps, curretage or uterine aspiration -
POC
Analgesics
Uterine -
Surgical Tx Cerclage and Restriction of Activities:
Treatment for ______________
Suture to close cervix using McDonald or Shirodkar method
Used with caution with advanced cervical dilatation or prolapsed membranes into vagina
________ -
incompetent cervix
Ruptured membranes and infection -
Loss of 3 or more previable (<500 gm) pregnancies in succession
Occurs in 0.4 to 0.8% of PG - Recurrent Ab
-
Aimed at detection of maternal or paternal defects contributing to Ab
General and GYN exams essential
PCOS (Stein Leventhal) should be ruled out
Glucose, thyroid functions
Anticardiolipin Ab, Leiden Factor V
Baby ASA
Chromos - Preconception Therapy
-
Early prenatal care with frequent visits
Complete bedrest ONLY for bleeding or pain
Hormonal therapy contraindicated
Excellent prognosis if cause of Ab can be determined - Post Conception Therapy
-
Breast cancer is the most common cancer in American women
____ of women with breast cancer have an inherited risk for cancer due to genes passed on from their parents
one in nine will develop breast cancer - 10%
-
Being Female
Advancing Age
Strong Family Hx
Reproductive Hx
Having a Previous Breast Tumor
Finding of premalignant changes in your breast tissue
Never having children
Having your first child after age 30
- Risks for developing breast cancer
-
__________ can detect changes in breast tissue that may be associated with cancers and premalignant changes
the best means to find early curable cancers - cancers too small to be detected by touch
Additional imaging tests - ________ -
Mammograms
ultrasound -
The _________ diagnosis is the most important information in planning treatment
A biopsy of the abnormal tissue is ___________ to make the diagnosis of breast cancer
Most mammogram abnormalities are not cancer; most are due to _____ -
tissue
required
benign -
Breast Ca Tx:
Surgery to remove all the tumor
________________ surgery - most patients
Removal of the full breast - __________- may be required for some patients -
Breast preserving
mastectomy -
Breast Ca Tx:
ADJUVANT THERAPY: Medical therapy to decrease the chance of tumor recurrence - to improve the chances for cure
___________- many different therapies
___________- tamoxifen, aromatase inhibitors -
Chemotherapy
Hormonal therapy -
Breast Ca Tx:
___________- to prevent tumor recurrence in the remaining breast tissue; required for breast preserving therapy - RADIATION THERAPY
-
Tamoxifen benefited women with:
the breast cancer gene
age greater than ___ years
premalignant changes in previous biopsies
SE:
small increase in risk for ________ cancer
_________ -
55
uterine
blood clots - Mammography is Recommended annually after age ___ with a baseline at age ___
-
40
35 -
Physical Exam
Diagnostic Mammogram
Ultrasound
Fine needle aspiration cytology
Core biopsy either free handed stereotactic or ultrasound guided
Open biopsy with or without needle localization - Evaluation of a Breast Mass
-
Nodule
Stellate Mass
Architectural Distortion
Calcification - cancer forms
-
Ductal Carcinoma In Situ (DCIS)
Lobular Carcinoma In Situ (LCIS)
Invasive Ductal Carcinoma (IDC)
Invasive Lobular Carcinoma (ILC) - types of cancer
-
________ Findings: Single, nontender, firm to hard mass with ill defined margins, mammographic abnormalities, and no palpable mass
_____ Findings: Skin or nipple retractions, axillary lymphadenopathy, breast enlargement, redness, edema, pain, -
Early
Late -
__________ disease, when accompanied by proliferative or atypical changes is associated with increased risk
Concomitant administration of estrogen and ___________ markedly increases incidence when compared with estrogen alone -
Fibrocystic
progesterone -
SERM - Selective Estrogen Receptor Modulator
Approved for pre menopausal use to prevent breast cancer - Tamoxifen
-
_________ (Evista) approved for osteoporosis also shows promise in preventing breast cancer
__________ inhibitors (Arimidex, Femara)also show promise -
Raloxifene
Aromatase -
Infiltrating ductal carcinoma
Nipple erosion or ulceration usually
Not common, about 1% of all breast cancers - Paget's Carcinoma
-
Most malignant form of breast cancer
Less than 3% of all cases
Overlying skin erythematous, edematous, warm
Often mistaken for infection - Inflammtory Carcinoma
-
Rare
Average age 60
Prognosis, even in Stage 1 is worse in men than women
Men have estrogen too - Male Breast Carcinoma
-
Variations of Normal Puberty
________ – gradual – hormonal/physical/purpose
_______– affected by genetic & environmental factors (nutritional status, social circumstances & exogenous hormones)
__________differences (nutrition -
Onset
Age
Racial/ethnic
Genetic -
Puberty as a Neurohormonal Process
The brain’s hypothalmus begins to release pulses of _____
Cells in the anterior pituitary respond by secreting________ into the circulation
The ovaries/testes respond to the rising amounts of LH & F -
GnRH
LH & FSH
estradiol & testosterone -
The conclusion of puberty is ________________
___________(potential fertility) precedes completion of growth in girls by 1-2 years & 3-4 years in boys -
reproductive maturity
Nubility -
Menopause
__________– usually become irregular, occasional menorrhagia, flow diminishes, then stops. No bleeding for one year, menopause has occurred.
_________– feelings of intense heat over face & trunk, with flushing of the skin & -
Cessation of Menstruation
Hot flushes -
__________– decreased estrogen secretion, thinning of the vaginal mucosa & decreased vaginal lubrication. Can lead to dyspareunia. Pelvic exam reveals pale, smooth vaginal mucosa & a small cervix & uterus. **Tx:**___________
____ -
Treatment of Menopause (cont)
Vaginal atrophy – hormone therapy, including estrogen vaginal cream, or estradiol vaginal ring
Osteoporosis – 800mg Calcium/day from food sources & 1000mg of elemental calcium as a supplement at menopause (taken with meals to > absorption). Daily weight bearing exercise. Most at risk: Asian & Caucasian women with thin frames, family history & smokers. - __________treated with oral conjugated estrogens, estradiol, estrone sulfate, transdermal estradiol. Add a progestin to prevent endometrial hyperplasia or cancer if the woman has an intact uterus. Use for the shortest time possible. Other useful meds-SSR
- Vasomotor symptoms
-
Surgical Menopause
____________results in severe vasomotor symptoms, rapid onset of dyspareunia, & osteoporosis unless treated. Conjugated estrogens (or equivalent) of 1.25mg/day taped to .625 after age 45-50. - Oophorectomy
-
___________
Cause: the protozoan T. vaginalis
Symptoms: Men-often none, occ. NGU
Symptoms: Women-a diffuse frothy, malodorous, yellow-green vaginal discharge with vulvar irritation, cervical petechiae or no s/s
Diagnosis: , positive w - Trichomonas
-
Trich Treatment
Considered an STD
Must treat partner(s)
________2gm po
________2gm po
________500mg po BID X 7 days
No alcohol while on these meds -
Metronidazole
Tinidazole
Metronidazole -
___________
Cause: C. trachomatis ( WBCs on smear)
Symptoms: men-clear urethral discharge, dysuria
Symptoms: women-clear cervical discharge, or no discharge, dysuria, mild CMT
Diagnosis: culture, GenProbe, urine tests - Chlamydia
-
CT Treatment
_________-1gm po in a single dose
__________100mg po BID X 7 days
Compliance is a common issue
Importance to dual treat contacts and to treat empirically/epidemiologically
Bulk of cases in those between ages of _____ -
Azithromycin
Doxycycline
16-24 -
____________
Cause: gram-negative intracellular diplococci (on smear), N. gonorrhoeae
Symptoms: men-mucopurulent uretheral discharge
Symptoms: women-mucopurulent cervical discharge
Diagnosis: smear, culture, empirically/epi - Gonorrhea
-
GC Treatment
__________125mg IM X1
__________500mg po in a single dose
Dual treat if no confirmatory tests available
Dual treat partners, unless have test results
Also important to educate on cause/prevention & ancillary test -
Ceftriaxone (Rocephin)
Ciprofloxacin -
____________
Over diagnosed/ Difficult to diagnose/ exclusionary-clinical findings
Cervical motion tenderness on exam (_____________)
It is a spectrum of inflammatory disorders of the upper female genital tract
Causes: GC, CT, H. infl -
Pelvic Inflammatory Disease
Chandelier sign -
PID Treatment
If severe: hospitalize & treat with IV _________/________ plus po or IV ______
Oral treatment: _________250 mg & ______100mg po BID X 14 days; may add __________500 mg po BID X 14 days
Recheck in 3 days, if no better, -
Cefotetan/Cefoxitin
Doxy
Ceftriaxone (Rocephin)
Doxy
Metronidazole -
COAC Treatment
_________10-25% in tincture of benzoine-apply to each wart-wash off in 1-4 hours. May repeat weekly.
_____________80% apply to each wart. May repeat weekly.
_____________ May repeat every 1-2 weeks.
___________5% (Aldar -
1.Podophylin
2.Trichloroacetic Acid [TCA]
3.Cryotherapy (liquid nitrogen or cryoprobe)
4.Imiquimod -
___________
Cause: T. pallidum
Symptoms: Primary infection-________; secondary-skin rash, mucocutaneous lesions (palmar/plantar rash), & lymphadenopathy; latent-no s/s found only on serologic testing; tertiary-cardiac, auditory, gummatous l -
Syphilis
chancre
"Snuffles" -
__________
Caused by Hemophilus ducreyi
More prevalent in developing countries
Symptoms-women-none; men-single painful ulcer with ragged serpipinous border. Classically occurs with ________________, many rupture. Usually found near the cor -
Chancroid
painful inguinal lymphadenopathy
bubo - Treatment: Azithromycin 1 gm po or ceftriaxone 250mg IM or Cipro 500mg BID X 3 days. Aspirate lymph nodes DO NOT I&D. Treat sex partners. Test for HIV & syphilis, & GC/CT
- tx for chancroid
- syphilis tx
-
Benzathine penicillin G 2.4 million units IM in a single dose
if PCN allergic Doxy 100mg po bid X 28 days **CI in pregnant pts** - __________Cause: polymicrobial clinical syndrome resulting from replacement of the normal H2O2-producing Lactobacillus species in the vagina with high concentrations of anaerobic bacteria (Prevotella, Mobiluncus), G. vaginalis, & Mycoplasma hominis.
-
Bacterial Vaginitis
vaginitis -
BV
Symptoms: homogenous thin, white vaginal discharge; fishy odor (more noticeable after intercourse)
Diagnosis: vaginal exam, presence on ________cells on microscopic exam, pH _____ & positive whiff test (10% KOH). Presence on pap is not d -
clue
>4.5 -
BV Treatment
Partner treatment not necessary
__________500mg po BID X 7 days
Metro Gel applicator full in vagina QD X 5 days
_________2% cream applicator full in vagina HS X 7 days
______________insert one HS X 3 days -
Metronidazole
Clindamycin
Clindamycin vaginal ovules