**Repro Blueprints A USMLE 2
Terms
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copy deck
-
Definition:
child at fertilization to 8 weeks - Embryo
-
Definition:
child at 8 weeks to delivery - Fetus
-
Definition:
Softening and cyanosis of the cervix at or after 4 weeks - Goodell's sign
-
Definition:
softening of the uterus (after 6 weeks) - Ladin's sign
-
Definition:
first trimester - fertilization to 12 weeks
-
Definition:
second trimester - 12 weeks to 24 weeks
-
Definition:
third trimester - 24 weeks to delivery
-
Definition:
child delivery less then 24 weeks - Priviable
-
Definition:
Quickening - Patient's initial presentation of fetal movement
- what are the changes in CO, HR, SV, TPR and BP during pregnancy?
-
Inc CO, HR, SV
Dec TPR,
Dec BP (returns to nml >24 weeks) - (4) Respiratory changes during pregnancy
-
Inc Tidal volume,
Inc PaO2 and PAO2,
Dec lung capacity,
Mild Respiratory Alkalosis - (3) GI changes during pregnancy
-
Inc vomiting,
Dec motility (constipation),
Prolonged gastric emptying (GERD) - (4) Renal changes during pregnancy
-
Inc kidney size,
Inc GFR (by 50%) leading to...
Dec BUN and Creatinine by 25%,
Inc Renin, Aldosterone and Na absorption
(balanced by Inc GFR) - (4) Blood changes during pregnancy
-
Inc plasma volume (50%),
Inc RBC (20%),
both percents lead to Dec Hct,
possibly causing Iron deficiency anemia,
Inc Fibrinogen and factors VII - X leading to...
Inc Thromboembolism -
what hormones are maintained by the placenta in pregnancy?
(4) -
Estrogen,
hCG,
hPL,
Progesterone (after initial maintenance from corpus luteum) -
what causes increased Thyroid Binding Globulin?
how does this affect T3 and T4? -
Inc estrogen
T3 and T4 inc binding to TBG leading to low serum levels of free T3 and T4 -
what is the cause of gestational diabetes?
how? -
hPL
it is an insulin antagoinist
(inc diabetic effect and leading to inc insulin and protein synthesis) -
what is the adequate amount of nutrition needed in pregnancy?
breast feeding? -
Pregnancy: 300 kcal/day
Breast feeding: 500 kcal/day - how often should prenatal visits be?
-
every 4 weeks until week 28
week 28 - 36: every 2 weeks,
36 to term: every week -
when is genetic screening done?
what are the (3) main tests? -
during second trimester
(usu 15 - 20 weeks)
MSAFP,
b-hCG,
Estriol -
which germ cell ovarian tumor has a different treatment method then the others?
what is the Tx? -
Dysgerminoma
Tx:
Radiation -
what is tested in pregnancy b/t 27 and 29 weeks?
(3) -
Glucose Loading Test (for gestational diabetes),
Hematocrit (for iron levels),
Glucose Tolerance Test if GLT is positive -
how is the Glucose Loading Test performed?
(2) -
give 50g oral glucose and check in one hour
if > 140 mg/dL, then do GTT -
How is a Glucose Tolerance Test performed?
What are the blood glucose values for fasting, one, two and three hour intervals? -
Fasting glucose:
give 100 g oral glucose and test at 1, 2 and 3 hours
Gestational Diabetes =
Fasting glucose > 105 mg/dL
or
any two values over 180, 155 or 140 respectively - what can dehydration lead to later in pregnancy?
- Braxton-Hicks contractions
-
what causes edema of lower extremities, feet and ankles, and hemorrhoids in pregnancy?
Tx? -
Compression of IVC and pelvic veins
Tx:
elevating feet -
what is the best test for fetal lung maturity?
normal levels? -
Lecithin/Sphingomyelin ratio
nml > 2 - describe a positive Non-Stress Test
- 2 increases in FHR in 20 min that are >15 beats above nml and for >15 seconds
- describe a positive Oxytocin Challenge Test
- 3 contractions in 10 minutes
- (5)* categories of the Biophysical Profiles
-
Test the Baby MAN!:
Fetal Tone,
Fetal Breathing,
Fetal Movement,
Amniotic Fluid volume,
NST
(zero or 2 points each; nml is 8 - 10) -
Definition:
multiple gestation w/ at least one IUP and at least one ectopic - Heterotrophic Pregnancy
- at what b-hCG levels should you detect an IUP on vaginal US?
-
IUP should be seen on US w/ b-hCG of
1500 – 2000 mIU/mL - at what b-hCG levels should you detect a fetal heartbeat w/ trans-abdominal US?
- Fetal heartbeat should be seen w/ b-hCG > 5000 mIU/mL
- Tx for Ruptured Ectopic
-
Exploratory Lap
(and maintain fluid levels) -
what hormone best resembles b-hCG?
how? -
LH
they also have similar beta units
(in addition to similar alpha) -
what is the criteria to use Methotrexate for an ectopic?
(2) -
ectopic must be < 3.5 cm,
w/o heartbeat - what is the progesterone level in a nonviable intra- or extra-uterine pregnency?
- < 5 ng/mL
- what is the progesterone level in 98% of intrauterine pregnancies?
- > 25 ng/mL
- what does G5P2124 indicate?
- Twins
-
Definition:
Spontaneous abortion time - pregnancy ending < 20 weeks
-
Type of Abortion:
any IU bleeding < 20 weeks w/o dilation or expulsion of POC - Threatened abortion
-
Type of Abortion:
death of embryo of fetus < 20 weeks w/ complete retention of POC (usu leads to complete SAB) - Missed abortion
-
Type of Abortion:
no expulsion of POC, but bleeding and dilation of cervix such that viability is unlikely - Inevitable abortion
- (2) ways an incomplete abortion can be taken to completion in first trimester
-
D&C
Prostaglandins (Misoprotol) -
causes of abortion in second trimester
(4) -
Congenital abnormalities
cervical / uterine abnormalities,
trauma,
systemic Dz or infection - (3) ways an incomplete abortion can be taken to completion in second trimester
-
D&E,
Prostaglandins (Misoprostol),
Oxytocin at high doses -
Definition:
Painless dilation leading to infection, Preterm Premature Rupture of Membranes (PPROM) or PTL - Incomplete cervix
-
what should be done if patient is in first trimester and has a history of incomplete cervix?
when? -
Cerclage
12 - 14 weeks - (3) tests to verify if patient has ruptured membranes
-
Pool - collection of fluid in vagina
Nitrazine - turns blue (alkaline)
Ferning -
Definition:
Rupture of membranes > 1 hour before onset of labor -
Premature Rupture of Membranes
(PROM) - (5) parts of a Bishop score
-
Dilation,
Effacement,
Station,
Cervical consistency,
Cervical position -
Bishop score points zero - 3 for:
Dilation -
zero: Closed
1 point: 1 - 2
2 points: 3 - 4
3 points: > 5 -
Bishop score points zero - 3 for:
Effacement -
zero: 0 - 30%
1 point: 40 - 50%
2 points: 60 - 70%
3 points: > 80% -
Bishop score points zero - 3 for:
Station -
zero: -3
1 point: -2
2 points: -1 to zero
3 points: +1 - +3 -
Bishop score points zero - 3 for:
Cervical consistency -
zero: Firm
1 point: Medium
2 points: Soft
3 points: (none) -
Bishop score points zero - 3 for:
Cervical position -
zero: Posterior
1 point: Mid
2 points: Anterior
3 points: (none) -
Definition:
Lengthening (thinning) of the cervix - Effacement
-
Definition:
relationship of fetal occiput to maternal pelvis - Fetal Position
- (4) ways to Induce labor
-
Pitocin,
Prostaglandins (Cervadil or Misoprostol),
Mechanical dilation of cervix,
Rupture of membranes (Amniotomy) - MC 4 steps to Augment and monitor labor progress
-
water broke?
if not -> Amniotomy
change?
if not -> IUPC
change?
if not -> Pitocin
change?
if not -> C-section -
what does an IUPC measure with respect to contractions?
(2) -
1. Time of contraction
2. Strength of contractions - Name the (6)* movements of labor in order and what each means
-
Engagement - biparietal diameter (largest) part of head enters pelvis,
Flexion - smallest diameter of head enters,
Descent - head completely into pelvis,
Internal rotation - from OT to OA or OP,
Extension - vertex passes beyond pubic synthesis; crowning occurs
External rotation - after delivery of the head as the head rotates to face forward - (3) P's of the Active Phase that may cause problems in delivery
-
Power
(strength of contractions),
Passenger
(size and position of infant),
Pelvis
(shape) - (5) steps of Tx in patient w/ Non-reassuring fetal status
-
1. Give mother oxygen mask
2. turn her to Left side to decrease IVC compression
3. D/C Pitocin
4. if due to Hypertonus (long contraction) or Tachysystole (>5 contractions in 10 min), give Terbutaline to relax uterus
5. If 1 – 4 does not work, C-section patient -
Dx:
Painless vaginal bleeding in the third trimester
Tx for perterm patient (<36 weeks)?
(3)
Tx for term patient? -
Placenta previa
Tx for Preterm:
1. Monitor in hospital
2. Transfusion PRN
3. Tocolytic to prolong until 36 weeks
Tx for Term:
C-section -
Dx:
Vaginal bleeding, painful contractions, firm and tender uterus
Tx? -
Placental Abruption
Tx - Delivery
(by C-section if mother or baby is unstable) -
Dx:
sudden onset of intense abdominal pain assoc w/ pregnancy
Tx? -
Uterine rupture
Tx - immediate laparotomy -
Dx:
Vaginal bleeding and sinusoidal FHR pattern
MCC?
Tx? -
Fetal Vessel Rupture
MCC - Velamentous cord insertion
Tx - emergency C-section -
Dx:
contractions and changes in cervix at < 37 weeks gestation - Preterm Labor
-
The only Tocolytic approved by the FDA
MOA? -
Ritrodrine
MOA: Beta-agonist - Tocolytic that acts as a calcium antagonist
- Magnesium sulfate
- what is the test to determine if patient is near a Magnesium sulfate toxicity?
- check DTRs continuously...they are depressed less then the toxic level of 10 mg/dL
- what Calcium channel blocker is used as a Tocolytic?
- Nifedipine
- what NSAID is used as a Tocolytic?
- Indomethacin
- MC concern w/ PROM?
- Chorioamnionitis
-
when is it common to see maternal hypotension?
what can it cause in child?
what is Tx for maternal hypotension? -
After epidural
causes - Fetal bradycardia
Tx - IV hydration and Ephedrine - Tx for fetal bradycardia lasting for longer then 4 - 5 minutes?
- C-section
-
Monozygotic Twins:
separation before the differentiation of trophoblasts - Dichorionic-Diamnionic
-
Monozygotic Twins:
separation after trophoblast differentiation and before amnion formation - Monochorionic-Diamnionic
- what type of twins can develop Twin-to-Twin Transfusion Syndrome?
-
Mono-Di
(one big baby and one small) -
Twin type:
division of fertilized ovum - Monozygotic
-
Twin type:
fertilization of two ova by two sperm - Dizygotic
-
Monozygotic Twins:
separation after amnion formation -
Monochorionic-Monoamnionic
(highest mortality rate) -
Dx:
pregnant woman with HTN, edema, proteinuria - Preeclampsia
- (3) risk factors for onset of Preeclampsia
-
Nulliparity,
Multiple gestation,
Chronic HTN - Tx for Preeclampsia near term and preterm
-
Near term:
Delivery
Preterm (and Eclampsia Tx):
Mag sulfate - against seizures
Hydralazine - HTN - with Eclampsia, what percentage of patients have seizures before labor, during labor and after labor?
-
Before: 25%
During: 50%
After: 25% -
what anti-hypertensives are given to mothers with chronic HTN during birth?
(2) -
Nifedipine
Labetolol -
what tests should be performed if patient has chronic HTN w/ pregnancy?
(2)
why? -
Baseline ECG,
24-hr urine collection
helps differentiate superimposed preeclampsia - How common is gestational diabetes?
- approx 15% of pregnancies
- (3) fetal complications of Gestational Diabetes
-
Macrosomia,
Shoulder dystocia,
neonatal Hypoglycemia - when is a C-section indicated in gestational diabetes?
- if fetal weight > 4500g
-
How is the DM-1 patient managed during pregnancy?
Delivery? -
Pregnancy - insulin pump
Delivery - insulin drip -
What gestational age of onset would you stop considering using a tocolytic agent?
A steroid agent?
What is done after that? -
Tocolytic: >34 weeks
Steroid: >36 weeks
then: Expectant management - how are lower UTIs treated versus pyelonephritis in pregnancy?
-
Lower UTI - oral Abx
Pyelonephritis - IV Abx - (2) complications of pyelonephritis during pregnancy for mother
-
Septic shock
ARDS - what can Bacterial Vaginosis cause during pregnancy?
- Preterm delivery
-
Leading cause of Neonatal sepsis
Tx? -
Group B strep
Tx:
Ampicillin -
Dx:
maternal fever, uterine tenderness, high WBC, fetal tachycardia
Tx? (2) -
Chorioamnionitis
Tx:
Delivery,
IV Abx -
Dx:
nausea and vomiting in pregnancy to the extent where the patient cannot maintain adequate hydration and nutrition
(3) Tx? -
Hyperemesis Gravidarum
Tx:
IV hydration,
Electrolyte repletion,
Antiemetics -
Management of women w/ Epilepsy during pregnancy
(3) -
check antiepileptic drug levels monthly,
Level 2 Ultrasound at 19 - 20 weeks,
supplement w/ Vitamin K from 37 weeks to delivery -
what do women w/ mild renal dz have a risk of getting during pregnancy?
(2 pregnancy problems) -
Preeclampsia,
IUGR - Leading cause of maternal death
- Pulmonary emboli
- Tx for pregnancy-related DVT and PE
- Heparin
-
Management for Hyperthyroidism in pregnant woman
(3) -
Thyroid-stimulating immunoglobulins (TSI) should be screened.
if elevated, screen for fetal goiter and IUGR
continue w/ PTU medication - Management for Hypothyroidism in pregnant woman
-
Synthroid
(Increased Synthroid requirements during preg for somone already on meds) -
(3) common problems that can occur in the pregnant SLE patient.
what (3) meds can be used in these patients as prophylaxis? -
Risk for:
Pregnancy loss,
IUGR,
Preeclampsia
Meds:
Low-dose aspirin,
Heparin,
Corticosteroids - how are Lupus flares and Preeclampsia differentiated in pregnancy?
- Complement levels
- SLE and Sjogren mothers with anti-Ro and Anti-La antibodies have risk of developing what fetal problem?
- Fetus w/ Congenital Heart Block
-
Dx:
infant is delivered and has growth restriction, CNS problems, cardiac defects and abnormal facies -
Alcohol abuse during pregnancy
(FAS) -
Pregnancy Risk:
Caffeine > 150 mg/day - Spontaneous abortions
-
Pregnancy Risk:
Cigarette smoking
(4) -
Growth restriction,
Abruptions,
Preterm delivery,
Fetal death -
Pregnancy Risk:
Cocaine
(2) -
Placental Abruption,
CNS defects in children - what is best for the pregnant woman on Heroin during pregnancy?
- Quitting outright will endanger fetus--need to be enrolled in a methadone clinic, then quit after delivery
- (2) central issues in the immediate postpartum period for the patient
-
Pain management,
Wound care - when do diaphragms and cervical caps need to be refitted postpartum?
- 6 weeks
-
what are the (3) hormonal contraceptives of choice postaprtum?
Why? -
Depo-provera,
Norplant,
Progesterone-only minipill
b/c they are less likely to decrease milk production in breast-feeding patients -
What are the causes of postpartum hemorrhage?
(6)* -
Coagulation Defect;
Atony;
Rupture;
Placenta (POC) retained;
Implantation site bleed;
Trauma -
what are the steps in managing a postpartum hemorrhage?
(4 steps) -
1. R/O cervical/vaginal lacerations
2. if still bleeding:
give Uterotonic agents (Oxytocin)
3. if still bleeding:
D&C
4. if still bleeding:
Laparotomy w/ bilateral O'Leary sutures to tie off uterine arteries -
Dx:
fever, high WBC, uterine tenderness 5 - 10 days post C-section
Tx?
(2) -
Endomyometritis
Tx:
D&C
broad-spectrum Abx until afibrile for 48 hrs - what is the underlying cause of labial fusion?
- excess Androgens
-
MC form of enzymatic deficiency assoc w/ ambiguous genitalia
what is deficient? -
Congenital Adrenal hyperplasia
(21-hydroxylase deficiency) -
Dx:
hyperandrogenism, salt wasting, hypotension, hyperkalemia, hypoglycemia, ambiguous genitalia -
Congenital Adrenal Hyperplasia
(21-hydroxylase deficiency) -
what main lab is elevated in Congenital Adrenal Hyperplasia?
what is Tx? -
17-alpha-hydroxyprogesterone
Tx: Cortisol
(and a mineralcorticoid if pt is salt-wasting) -
what is the name of the fertilized oocyte 2 - 4 days after fertilization?
what is it called in the next stage? -
Blastomere / Morula
next:
Blastocyst -
Dx:
patient at puberty w/ primary amenorrhea and cyclic pelvic pain, lower abdominal girth - Imperforate hymen
-
Definition:
build-up of blood behind the hymen in person with imperforate hymen
Tx? -
Hematocolpos
Tx: surgery - (2) causes of Vaginal Agenesis
-
Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH)
Androgen Insensitivity -
Dx:
normal female karyotype w/ ovaries and secondary sexual characteristics, but congenital absence or hypoplasia of vagina, cervix, uterus and fallopian tubes - Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH)
- what is the Tx for Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH)?
-
Create vagina:
w/ dilators
or
McIndoe procedure
(surgically creating vagina w/ skin grafts) -
Dx:
woman w/ scant pubic hair and small breasts w/ vaginal agenesis or absence and absence of uterus
cause? -
Androgen Insensitivity
cause:
nonfunctioning androgen receptors
(normal levels of Testosterone) -
Dx:
symmetric white, thinned skin on labia, perineum and perianal region. Shrinkage and agglutination of labia w/ occasional pruritis or dysparunia
Tx? -
Lichen Sclerosis
Tx:
Topical steroids (Clobetasol) -
Dx:
localized thickening of the vuvlar skin from edema w/ chronic pruritis, possible raised white lesion on labia majora or clitoris - Squamous cell hyperplasia
-
Dx:
multiple shiny, flat, purple papules usu on the inner aspects of the labia minora, vagina and vestibule. Often erosive and causing pruritis and mild inflammation - Lichen Planus
-
Dx:
Thickened white epithelium, slight scaling, usually unilateral and circumscribed on vulva, w/ pruritis
(2) Tx? -
Lichen Simplex Chronicus
Tx:
Ultraviolet light
Topical steroids -
Dx:
Red, moist and sometimes scaly lesions on vulva, which may also be found on scalp, axilla, groin and trunk - Vulvar Psoriasis
-
Dx:
palpable red granular spots and patches in the upper third of the vagina on the anterior wall - Vaginal Adenosis
- how are vulvar lesions Dx?
- Biopsied
- MC benign tumor on the vulva
- Epidermal Inclusion cysts
-
Definition:
Dz that causes occlusion of the sweat glands on mons pubis and labia majora, causing cyst formations
Tx? -
Fox-Fordyce Dz
Tx: I&D - how do you differentiate an epidermal cyst from a sebaceous cyst?
-
Epidermal - solitary cyst
Sebaceous - collection of cysts - where are the Skene glands located?
- Paraurethral
- where are the Bartholian glands located?
- Bilaterally at 4 and 8 o'clock on labia majora
- what is first step in Tx if a Bartholian cyst first appears in woman over 40yo?
- Biopsy to R/O Bartholian gland carcinoma
-
Tx of a Bartholian Abscess
what is Tx for recurrent Bartholian Abscesses? -
Tx:
I&D w/ placement of Word catheter
Recurrent:
Marsupialization -
Definition:
Cervical dilated retention cysts - Nabothian cysts
-
Definition:
Cervical cysts that lie deep in the stroma and are from remnants of Wolffian ducts - Mesonephric cysts
- even though cervical polyps are not premalignant, why are they removed?
- to avoid masking bleeding from other sources and to avoid misidentification for an endometrial polyp
-
MC Uterine formation anomaly
cause? -
Septate uterus
cause:
Problems w/ fusion of Paramesonepheric ducts -
what are anomalies of the uterus assoc with (non-gyn medical)?
(2) -
Urinary tract anomalies
Inguinal hernias -
Dx:
amenorrhea or dysmenorrhea, dyspareunia, cyclic pelvic pain, infertility or recurrent pregnancy loss or premature labor -
Uterine anatomic anomalies
(Septate uterus) -
Dx:
small uterine cavity, second-trimester pregnancy loss, malpresentation and possible premature labor - Bicornuate uterus
- Tx of Septate and Bicornuate uteri
- Surgical removal of septum
-
Definition:
Benign, estrogen-sensitive smooth muscle tumors of the uterus
found in what percentage of reproductive-age women? -
Fibroids
(Uterine Leiomyomas)
in 20 - 30% of reproductive-age women -
Incidence of Fibroids in Black women
(3) causes to increase risk of developing fibroids -
3 - 9 x higher in Black
Risks:
Non-smoking,
Obese,
PeriMenopausal - what distinguishes a Fibroid from adenomyosis?
- Fibroid has a Pseudocapsule
- Top (2) MC Sx in patient w/ Fibroids
-
Asymptomatic (50 - 65%)
(MC otherwise is Prolonged bleeding) -
Drug Tx for Fibroids
(3)
MOA of these drugs collectively -
Provera,
Danzol,
GnRH agonists (Lupron)
MOA - shrink fibroids by reducing circulating Estrogen -
If drugs dont work, what is the name of the surgical Tx for Fibroids?
Only Difinitive Tx? -
Myomectomy
(removal of one or more Fibroid surgically)
Only Difinitive Tx:
Hysterectomy - what causes Endometrial Hyperplasia?
- continuous endogenous or exogenous Estrogen in absence of Progesterone
-
In endometrial hyperplasia, what proliferates in endometrium?
(2) - Glandular and Stromal elements of endometrium
-
Risk factors for getting Endometrial Hyperplasia
(9) -
CLONED PHD:
Chronic Anovulation,
Late Menopause (> age 55),
Obesity,
Nulliparity,
Estrogen-producing tumors (granulosa-theca cell tumor),
Diabetes,
PCOS,
Hypertension,
Drugs - Tamoxifen -
Dx:
long periods of Oligomenorrhea or amenorrhea followed by irregular or excessive uterine bleeding - Endometrial Hyperplasia
-
main Dx evaluation used to Dx Endometrial Hyperplasia
what is second choice? -
Endometrial Bx
(or D&C...second choice) -
Risk of malignant transformation from Endometrial Hyperplasia in:
1. Simple Hyperplasia
2. Complex Hyperplasia
3. Atypical Simple Hyperplasia
4. Atypical Complex Hyperplasia -
Simple = 1%
Complex = 3%
Atypical Simple = 8%
Atypical Complex = 29% -
what is the initial Tx for all types of endometrial hyperplasia in child-bearing patient?
Non-child bearing patient? -
Child bearing:
Progestin therapy for 3 months
(followed by resampling of Endometrium)
Non-child bearing:
Hysterectomy -
MC functional Ovarian cyst; usu unilateral
what can they lead to?
Tx? -
Follicular cyst
leads to:
Ovarian torsion
Tx:
resolve spontaneously - MCC of infertility in USA
- PID
-
Dx:
patient w/ abdominal pain, adnexal tenderness and cervical motion tenderness, possible ESR, Inc WBC, fever, or purulent cervical discharge - PID
- how is the tuboovarian abscess rupture treated in PID?
- Removal of infected tube
- Antibiotic Tx for outpatient versus inpatient w/ PID
-
Outpatient:
Ceftriaxone + Doxycycline
Inpatient:
Clindamycin + Gentamycin - Bug that causes PID in pt w/ intrauterine device
- Actinomyces Israelii
-
Dx:
nodularities on Broad ligament and a retroverted uterus w/ abdominal pain
Tx? -
Endometriosis
Tx:
birth control pills - MCC of infertility in menstruating woman over age of 30 w/o PID?
- Endometriosis
- How is chlamydia Tx in pregnant patient?
- Erythromycin
-
Dx:
ovarian cyst that can cause a missed period or dull lower quadrant pain; can rupture to cause acute abdominal pain and intraabdominal hemorrhage
Tx? -
Corpus Luteum cyst
Tx:
resolve spontaneously
(or oral contraceptives if recurrent) -
Dx:
large, bilateral ovarian cysts filled w/ clear, straw-colored fluid;
high b-hCG - Theca-Lutein cyst
- First step in management for a cystic adnexal mass in premenarchal and postmenopausal patients
-
Exploratory Lap
(due to high risk on cancer in those age groups) -
what percent of ovarian masses in women of reproductive age are functional cysts?
non-functional neoplasms? -
functional cysts = 75%
non-functional neoplasms = 25% - First Dx evaluation for Ovarian cysts
- Pelvic Ultrasound...wait 6 - 8 weeks then repeat
-
in reproductive-aged woman who has an ovarian cyst seen on ultrasound, what management steps are taken if the cyst size is:
1. < 6 cm
2. 6 - 8 cm
3. > 8 cm -
1. observe for 6 - 8 weeks ->
start on oral contraceptives ->
repeat US
2. if Unilocular = repeat steps above;
if multilocular or solid on US =
Exploratory Laparoscopy
3. Exploratory Laparoscopy for cystectomy - if ovarian cysts do not resolve with oral contraceptives in 60 - 90 days, what is next step?
- Cystectomy via Laparoscopy
-
Definition:
Endometriosis in the ovary - Endometrioma
-
Risk factors for endometriosis
(2) -
First-degree relatives
(mothers AND Sisters)
autoimmune disorders - how is endometriosis detected on rectovaginal exam?
- Uterosacral nodularity
-
Instead of using oral contraceptives for endometriosis, what else can be used?
(2)
what do they do? -
GnRH agonists in steady state
(Leuprolide)
or
Danazol
(inhibits gonadal steroid synthesis)
they supress FSH and LH - what are the drawbacks to Danazol therapy for Endometriosis?
-
Androgen-related anabolic side effects:
Acne, Oily skin, weight gain, deep voice, Hirsutism - AE of GnRH agonists
-
Estrogen deficiency
Menopausal symptoms:
hot flashes, loss of bone density, HA, vaginal atrophy and dryness - what intraabdominal problem can endometriosis lead to?
- Adhesion formation -> bowel obstructions
- what is the drug management of Endometriosis in the woman wanting to conceive?
-
None
Only Tx in these patients is Conservative surgical therapy by removal of lesions laparoscopically -
what percent of women with Adenomyosis also have Endometriosis?
Fibroids? -
Endometriosis - 15%
Fibroids - 50% - Incidence of Adenomyosis?
- 15% of women in late 30s - early 40s
-
Dx:
pelvic exam reveals a diffusely enlarged globular uterus and secondary dysmenorrhea - Adenomyosis
-
What is the first Dx test for Adenomyosis?
What is the only definitive Dx test?
What is the Tx? -
Ultrasound
(if suggestive, then MRI to distingiush b/t it and Fibroids)
Definitive means of Dx and Tx:
Hysterectomy -
Tx for Adenomyosis
(3 meds or one procedure) -
NSAIDs and analgesics,
Oral Contraceptives,
Progestins
Definitive Tx:
Hysterectomy -
Dx:
fever, rash and desquamataion of palms and soles of feet, hypotension -
Toxic Shock Syndrome
(s.aureus) - how is HIV screened and confirmed?
-
screened w/ ELISA
confirmed w/ Western blot -
Dx:
Cottage cheese-like discharge, pruritis, burning, dysuria, vulvar edema
what is Dx test and result?
Tx? -
Candida Albicans
Test:
branching hyphae and spores on KOH prep
Tx:
Topical OTC Azole cream -
Dx:
diffuse, malodorous, gray-green, frothy discharge from vagina
what is Dx test and result?
Tx? -
Trichomonas Vaginalis
Test:
Bugs swimming under microscope; Wet prep
Tx:
Metronidazole (Flagyl) 2g orally in single dose -
Dx:
vaginal discharge that is thin, yellow and has a "fishy" amine odor
what is Dx test and results?
Tx? -
Bacterial Vaginosis
(Gardnerella)
Test:
Clue cells on Wet prep,
Whiff test exaggerates the odor w/ KOH
Tx:
Metronidazole (Flagl) 500mg orally BID for 7 days -
Dx:
Painless cancre
what is the Hystological Dx test and results?
Tx? -
Syphilis (stage 1)
Test:
Spirochetes on Dark-field Microscopy
Tx:
Penicillin -
Dx:
maculopapular rash extending to the palms and soles and/or moist papules on the skin or mucous membranes - Syphilis (stage 2)
-
Dx test for HSV
Tx? -
Tzanck smear
Tx:
Acyclovir -
Dx:
painful, demarcated, non-indurated ulcer located anywhere in the anogenital region; painful inguinal lymphadenopathy -
Chancroid
(Haemophilus Ducreyi) -
Dx:
STD that causes LGV
(2) possible Tx? -
Chlamydia
(MC STD)
Tx:
Doxycycline 100mg orally BID for 7 days,
1-time dose of Azithromycin -
Dx:
mucopurulent cervicitis; gram-negative bug
Tx? -
N. Gonorrhea
Tx:
Ceftriaxone 250mg IM -
Dx:
small, 1 - 5mm domed papule w/ umbilicated center, can occur all over body
what is Dx test and results?
Tx? -
Molluscum contaginosum
Tests:
waxy material and intracytoplasmic inclusions on Wright stain or Giemsa stain
Tx:
Cryotherapy -
Dx:
Pruritis, iritated skin, vesicles and burrows confined to pubic area
Tx? -
P. Pubis (Pediculosis)
["Crabs"]
Tx:
Lindane (Kwell) shampoo to pubic hair - what is the protrusion of the vaginal vault secondary to the loss of support structures post hysterectomy?
- Vaginal Vault Prolapse
-
Initial Tx for pelvic relaxation or Stress Incontinence?
If that doesn't work, what is the Tx? -
Kegel exercises
if not:
Vaginal Pessaries
(and/or Estrogen replacement) -
Dx:
Urine loss w/ exertion or straining (coughing, exercise, etc)
cause? -
Stress incontinence
cause:
Pelvic relaxation and displacement of the Urethrovesical junction -
Dx:
urine leakage due to involuntary and uninhibited bladder contractions
cause? -
Urge Incontinence
cause:
Detrusor instability -
Dx:
continuous urine leakage
cause? -
Total Incontinence
cause:
Urinary fistulas from birth trauma or pelvic surgery / radiation -
Dx:
incomplete voiding, urinary retention and overdistention of the bladder
cause? -
Overflow Incontinence
cause:
poor or absent Bladder Contractions due to meds or neurological dysfunction - what are (2) easy office Dx evaluations for incontinence?
-
Standing stress test
Cotton swab test - what class of meds are used to help Tx Stress Incontinence?
- Alpha Adrenergic agents
- what class of meds are used to Tx Urge Incontinence?
-
Anticholinergics
(help w/ detrusor stability) - how is Total Incontinence treated?
- Surgical repair of the fistula
- what drug class increases bladder contractility?
- cholinergics
- what drug class lowers urethral resistance?
- alpha-adrenergic agents
-
what is the Tx for Overflow Incontinence?
(1 procedure or 2 possible meds) -
Self catheterization
or Meds:
Cholinergics,
Alpha-adrenergic agents - what is the order of the (5) stages of Puberty in females?
-
All Girls Think Puberty's Messy:
Adrenarche (Androgen production),
Gonadarche (GnRH production),
Thelarche (Breast production),
Pubarche (pubic hair),
Menarche - what is stage 4 of Thelarche?
-
Areolar mound
(in stage 5, mound disappears again) - what is the first phenotypic sign of puberty?
-
Thelarche
(breast production) - when does menarche occur in relation to thelarche?
- about 2.5 years after the development of breast buds
-
what (2) phases of the menstrual cycle describe the ovary?
the endometrium? -
Ovary:
Follicular phase,
Luteal phase
Endometrium:
Proliferative phase,
Secretory phase - when does the placenta begin to develop its own estrogen and progesterone?
- at 8 - 10 weeks gestation
-
Definition:
the termination of the reproductive phase in a woman's life -
Climacteric
(menopause, the final menstruation, marks the cornerstone event of the climacteric) - what during menopause leads to the hot flashes, mood changes, insomnia and depression?
- fall in Estrogen production
- what is the average age of menopause?
- 48 - 52
- what occurs with respect to the CV system during menopause?
- Affects lipid profiles, leading to atherosclerosis and increased risk of CAD
-
Dx:
severe pain w/ menses that cannot be attributed to an organic cause, is usually dx before 20 yo - Primary Dysmenorrhea
-
what is believed to be the reason of Primary Dysmenorrhea?
Tx? (3) -
Increased levels of Prostaglandins
Tx:
NSAIDs,
OCPs,
and/or
TENS
(Transcutaneous Electrical Nerve Stimulation) -
Dx:
HA, weight gain, bloating, breast tenderness, mood fluctuation, anxiety, irritability in the second half of the menstrual cycle -
Premenstrual Syndrome
(PMS) -
what is the Dx criteria for PMS?
(2) -
symptoms of PMS in the second half of the menstrual cycle with at least 7-day symptom-free interval during the first half;
symptoms must occur in two consecutive cycles -
Dx:
regularly timed menses, but an unusually heavy or prolonged flow - Menorrhagia
-
How many days is the flow suppose to last in the normal menstrual cycle?
how much blood loss? -
days: 3 - 5
blood loss: 30 - 50mL -
Definition:
idiopathic heavy and/or irregular bleeding that cannot be attributed to another cause -
Dysfunctional Uterine Bleeding
(DUB) -
Dx:
regularly timed menses but unusually light amount of flow - Hypomenorrhea
-
Dx:
bleeding that occurs b/t regular menstrual periods - Metrorrhagia
-
Dx:
excessive (greater then 80mL) or prolonged bleeding at irregular intervals - Menometrorrhagia
-
Dx:
irregular periods greater then 35 days - Oligomenorrhea
-
Dx:
frequent periods that occur less then 21 days apart - Polymenorrhea
- (3) of the MCC of Oligomenorrhea
-
PCOS,
Chronic Anovulation,
Pregnancy -
when is DUB most common?
(in General and list 4 times) -
when she is "Anovulatory":
Adolescence,
Perimenopause,
Lactation,
Pregnancy -
When does pathologic Anovulation related to hormones occur?
(3) -
Hypothyroidism,
Hyperprolactinemia,
Hyperandrogenism - if a woman > 35 yo has abnormal uterine bleeding, what is the next step?
- Endometrial Bx to r/o cancer
-
Drug Tx for DUB (Anovulatory vs. Ovulatory)?
Tx for Acute Hemorrhage / Heavy bleed from uterus? -
Anovulatory DUB:
Progestins to stimulate withdrawal bleeding
Ovulatory DUB:
NSAIDs
Acute hemorrhage/heavy bleed:
IV Estrogens to stop bleeding - what is the metabolic goal of pregnancy?
- Increase availability of Glucose for the fetus, while mother utilizes lipids
- MCC of postmenopausal bleeding
- Endometrial and/or Vaginal Atrophy