ovarian cysts
in postmenopausal women–> consider malignancy
bening: common in reproductive age
- many resolve on own
most common type is functional ( follicular test),
- resolve in 60 days
dx: sonogram
management: observation 30-60 days
- follicular or theca lutein- surgical evaluation is present
nonfunctional: endometraiona ( chocolate cyst)– surgery
PCOS
1 cause of androgen excess ad hirsutism
- bilat cysts
- presentation: hirsutism, infertility
- women with regular periods in young years and in 20s periods are very
sonogram/labs: string of pearls, oyster ovaries
elevated androgen, high FSH, LH, lipid abnormality , insulin resistant
tx: OCPs, DepoProvers, weight loss
if wants pregnancy:climid with metformin
ovarian cysts- neoplastic masses
bening neoplastic process
- serous cyst adenoma- -uniloular, most common
- bening cystic teratoma- mobile on long pedicles ( have teeth and hair)
mangement: surgery
ovarian cancer
2nd gyn malignancy
- mean age 69
RF: BRCA 1 gene, fix, nulliparity, late menopause, caucuasian/ asian, diet high in sat fat
screenin: biannual pelvic exam
- sonogram not done for routine screening
tumor types: epilethial
s/s: early - most asymptomatic
later: abd distenction, pain, early satiety, urinary frequency, change in bowel habits
exam: fixed, bilat nodualr pelvic mass, abd distenion, ascities, sister mary joseph’s nodule in the umbilicus
dx: sonogram, biopsy
tumor markers: CA 125 and CEA
tx: TAH/ SBO
chemo -IV or IP
-rad tx
Pap smear screening
who gets tested:
women under 21 should be tested regardless of sexual initiation
- 21-29- every 3 years
30-65- Pap and HPV every 5 years or Pap one every 3 years
over 65–> previous normal Paps- no testing
h/o pre-cancer- Paps 20 years after that dx
check for statement of adequacy: most have endocervical cells,
if adequate:
negative, atypical squamous cells, low grade spumous, or high grade , or cancer
management:
ASCUS- repeat 4-6 months, if second is same do colposcopy
ASC-H, LSIL, HSIL-colposccopy/ bx/ HPV testing
treat histology not pap results
CIN1- repeat in 6- 12 months
HPV DNA testing
CIN1 or C1N3- cryotherapy
cold knife conization, or LEEP
cervical cancer
3rd most common
RF: early sex, too man sex partner, HPV, smoking
16, 18, 31, 33
squamous cell
s/sx: post-coital bleeding
exam: cervix if friable
dx: pap and bx
tx TAH
Stage 3/ 4 chemo and rad tx
cytocele/ retocele/ uterine prolapse
common after menopause
- cystocele- prolapse of bladder into ant wall of vagina
- retocel- herniation of rectum into post wall
uterine prolapse- prolapse vaginal canal
sx: vaginal fullness or pressure, feeling of incomplete voiding/ defecation
tx: topical estrogen therapy ( cystocele)
- pessary
- kegel exercises
- surgcial repair
mastitis
- occurs inf breastfeeding women
- caused by nipple trauma
- s. aureus
sx: unlit, erytheamt, tenderness
- fever/ child
tx: dicloxacilin, cefalexin, erythro
- continue breast feeding on affected side
breast abscess
farther along mastitis
- localized mass
- f/c
management: I and D
IV abx- vancomycin
stop breastfeeding
pump and dump
fibrocystic breast
- sxs: painful cystic billet breast pain, size of cyst fluctuate during menstrual cycle
exam; bilat cysts that vary in size
sonogram- fluid filled cysts
tx: conservation, reduce caffeine, increase vitamin e, tamoxifen, or bromocritpin
fibroadenoma
- AA, 20 years of puberty
- painless and unlit
- mobile
s/s: painless uniat lump
dx: sonogram- smooth, uniform, solid, FNA ( no fluid)
-watched,
large- surgery
breast cancer
most common cause in women, 2nd MC cause of cancer
RF: BRCA 1 and 2
- prolonged use of unopposed estrogen
- early menarche, late menopause, late first pregnancy, nulliparty, over 40
- high fat diet
- obesity
- hyperplasia with fibrocystic breast
mammogram screening: If average risk: start at 40 40-40--> every 1-2 years > 50-- every year
Genetic RF: 25-35
not accurate
consider MRI
tumor types 80% infiltrating ductal
- painless, stony hard unlit mass
- infiltrating lobular- 10%
- inflammatory- 2%
- Paget’s dz- 1% ( rash on her breast and tried anti-fungal cream)
sx: painless mass in URQ, nipple d/x, erosion.
dx: 90% seen on exam u/s mammogram FNA open bx
surgery: 1 cm
hormone therapy-HR positive( tamoxifen and AI)
Zometa to dec fx
menopause
mean age 51
-low estrogen
changes: cessation of sense, hot flashes, dec vaginal lubrication, depression, mood swings
late changes: CAD
- everything dries up and falls down
FHS> 30 diagnostic
tx: HRT-contervial
used for hot flashes and dryness
CI: liver dz, thrombosis, CA of breast or endometrial
alternative tx:
hot flashes- depo vera, SSRI, yoga, acupuncture
osteopsosi: calc with vitamin d
vaginal dryness
vaginitis
candida: RF: HIV, DM, abx s/sx: thick white 10% KOH pseudonyme tx: diflucan po or single dose or azole cream
bacterial vaginosis
-smells bad, d/c worse after menses, scant/ sticky, clue cells,
flagyl 500 mg bid X 7 days
-think about cost
trichomonas - sexual awtiviy, copious d/c, green/ yellow frothy ( strawberry cervix), protozoa, flagyl 2 g po X 1 dose
flagyl- avoid ETOH and sun
chlamydia
most common of STI
RF: sex
gonorrhea
- vaginal itching or penile itching
- cervical motion tenderness
- dissementiated infection
- cause of septic arthritis ( wrist, elbows, knee, ankles)
- macular papular leions on hands and feet
tx: zithromax X 1 dose
or ceftrixome
tx partners
HPV
most common STI in women
- subtype 6 and 11 are being
16, 18, 31, 33- cause cervical cancer
-cauliflower -like warts on external genitalia, anus, cervical
dx: HPV DNA testing, clinical on PAP
tx: small lesions
-podophyllin, imiquimod
large lesions: cryotherapy or surgery
prevention gardais vaccine
girls and boys 9-26
16, 18,
pelvic inflame dz
- bacteria starts in uterus and works its way up bilat
pathogens: chlamydia- dos common, gonorrhea,
RF: age 20, prior PID, prior douche
sx: bilat pelvic pain, back pain down the legs
exam: mucopurlent cervical d/c
- cervical motion tenderness
dx: cervcial cx
- elevatd WBC
- sonogram
d/d: ectopic, appendicitis, pyelonephritis
tx: inpatient- pelvic access, fever above 102, pregnancy, unreliable pt
outpatient: ceftriazone IM single dose +doxcycyline po X 14 days
contraception
NPF- tracking a women menstrual cycle,
avoid sex 48 hours before and after this time
- check Basal body temp and monitor cervical mucous
failure rate: 25%
barrier methods “
condoms- protects gains STI, diaphragm ( bladder irritation), cervical cap
, spermicides
advantage: low SE profile, low cost
hormonal method
estrogen and progesterone - 3 weeks and 1 week off ( get periods
monphasic- dose is stay
-advantage- in monogamous relationship
OrthoEva- path changed once a week X 3 weeks
failure rate 1%
Nuva Ring-
leave in for 3 weeks and then come out for menses
- estrogen suppress FSH so follicle won’t mature
- no ovulation
- mucous is thicker
benefits: dec endometrial can, ovarian cyst, dysmneoorhea, fiber breast
CI: pregnancy, H/o: dat, breast/ endometrial cancer, melanoma, abn liver function tests
progesterone only
- taken daily
- take same time every day
- good breastfeeding
- women > 40
Depo Provea- IM every 3 months - return of ovulation up to 18 months ( good for teenagers) SE: weight gain, mood changes, only use for 2 years calcium loss
SQ Rods: left 3-5 years
cannot take oral
ovulation start promptly after removal
SE: scarring
- MOA: ovulation interrupted
CI: breast ca and liver tumors
IUD
replace every 5-10 years -wire in winning of future -multi-parous women - smokers > 35 y/o CI: pregnancy, uterine bleeding, acute gyn infection,
complications: uterine perforation,
sterilization
tubal is most common
vasectomy is reliable
infertility
not able to conceive w/in 12 months of unprotected sex
primary- no prior pregnancy
secondary- after previous pregnancy
causes: an-ovulation- most common
- tubal dz
- male factor
- unexplained
an ovulation
- PCOS, high prolactin, hypothalamic-pit dysfunction, hypothyroidism
dx: menstrual diary, literal phase day 21
management: bromocriptine to dx hyperpolactinemia, climid to stimulate ovulation, metformin to increase ovulation and pregnancy
infertility- tubal dz
-cause: scarring/ adhesions
PID, endometriosis, h/x rupture appendix
dx: hysterosalpinogram
lapro
management: surgery/ lysis of adhesions
infertility-male factors
abnormal semen analysis
cause: increase scrotal temp, smoking, excessive ETOH, varicocele
dx: semen analysis
tx: tx etiology
-IUI
doner insemination
General approach to infertility
- phase 1-
- detailed h/o and type of coitus, ovulation tracking, semen analysis, TSH, prolatic, LH
Phase 2:
- hystersalpinogram
- lapro
- IVF if no cause
fetus/ infant nomenclature
abortion: 42 weeks
twins counts as 1 pregnancy
presumption manifestations of prengnay
amenorrhea n/v quickening ( fetal movement) nulliparas 18-20 weeks multipara: 14-16 weeks
urinary frequency, nocturia, infection
signs; chadwicks signs- bluish discoloration of vagina and cervix
skin change: melasma/ chloasma ( dark patches on face)
-linea nigra
probable manifestation
- positive pregnancy test
- hagar’ sign -softenging b/w fundus and cervica
uterine growth-
12 weeks-symphisi pubis
20 weeks - at umbilicus
after 20 weeks- 1 cm
positive manifestations
fetal heart tones
-u/s examination of fetus
labs:
cholesterol increase > 200
BUN/ cr decrease
prenatal labs
abc, blood type, vdrly, hep b, rubella,
every visit- check maternal weight, BP, fundal height, fetal size , urine dipstick for protein,glucose, ketones
screening tests
1st visit- dating sonogram -discuss screening tests
10-13 weeks-nuchal translucency
15-18 weeks- alpha-fetal protein/ quadruple screen
18-22 weeks- anatomical sonogram
24-28 weeks: glucose challenge test
28 weeks- Rhogam if woman is RH negative
32 weeks- repeat abc, VDRL, chlamydia, gonorrhea, Grp B strep
trisomy 21
1st trimester- PAPP-A- low
free beta hCG- high
2nd trimester-
AFP -low
inhibin A
nuchal translucency screenin test
10- 13 weeks
10-13 weeks- CVS, not risky
15-20 - amniocentesis
weight gain/ nutrition
20-35 pounds
- intake 300 kc/per day
- avoid ETOH, smoking, drugs, unpasteurized foot, deli meat, farm salmon
stages of labor
stage 1- onset of labor to full dilated ( 10 cm )
second stage: fully dilated to birth of infant
3rd stage; - delivery of infant to delivery of placenta
causes of slowed labor
pelvic floors- inadequate pelvis, failure to descent, contraction factors ( tx picot )
aides:
episiotomy- incision to widen vulvar orifice
forceps
vacuum- suction cup on stop of baby’s head
- do first before C-seciton
induction of labor:
considered when prolgoned pregnancy
- DM, pre-eclmapia
CI: cephalospelic dispropriotn, placenta previa, uterine scar, traverse lie
inducing labor
meds: early- prostaglandin gel, given vaginally to ripen the service
some dilation and effacement- Piton - causes uterine contraction, given IV
antepartum testing
NST- non-stress test
- reactive test
- 2 acceleration in 20 minutes, up 15 beast from baseline- positive test is GOOD
Contraction stress test:
given pitocin and watch monitor
-if late decellerations- BAD
vibroacoustin stiumuatlion:
auditory source to wake up the baby
-
biophysical profile- watch sonogram for 20 minutes
- check breathing, gross body movements, fetal tone, amniotic fluid index
monitor during labor
120-160 normal fetal HR
- if consistent decceleration- could be fetal distress
external fetal monitor
internal fetal monitor- dilated and ruptured
if non-reassuring FHR
- stop piton, scalp PH
induced abortion
medical ( up to 7-9 weeks)
suction curetage
spontaneous abortion
-pregnancy ends befor 20 weeks gestation
more than 80% of abortions
RF: parity, increase with material/ paternal age
60% -caused by chromosomal abn
endocrine, infection, ETOH, caffeine
clarifications of spontaneous abortion
all except for missed have vaginal bleeding
threatned- women w/ vaginal bleeding and pregnant,
inevitable- POC have not passed
incomplete vaginal bleeding, partial pass of POC
habitual abortion 2-3 ore more abortions
check genetic, endocrine labs
incompetent cervix
-cervical weakness causing passive, painless cervical dilation
results in 1st or 2nd trimester abortion or pre-term labor
management:
cerclage- cervical suture in 1st trimester to provide support to weak cervix
ectopic pregnancy
-embryo is somewhere besides uterine cavity
most common in tube
cause: salpingitis ( PID)
sxs: pain, vaginal bleeding, amenorrhea
( women with positive pregnancy test now having slight vaginal bleeding with pain)
unruptured- more pain
ruptured- pain better, hypotension, tachycardia
lab: B-HCG or serum positive
sonogram: absence of IU gestational sac
tx: methotrexate
- serum b-hcg
stable, compliant
has to comply
surgical: salpingostomy,
gestational trophoblastic dz
hydatiform mole- grape like vesicle on sonogram, no egg/ fetus
presentaiotn: positive pregnancy test, vag bleeding, pre-ecamplisa , hyperemesis
studies: b-hcg titer higher than gestation age
sonogram: sack of grapes on snows town pattern
pre-term labor
20-36 weeks
triad- preterm pregnancy, uterine contractions ( 3 in 20 minutes), dilation/ effacement
RF: infection, Group B strep, cocaine, heavy cig smoking
sx: contraction, vag bleeding
labs: fetal fibronectiven testing
positive
negative lower risk
cervical length - if 2 cm at 20 weeks
if both abn 50/50 go into labor
management:
observe for 30-60 minutes and hydrate her
then abx to tx subclinical infection
bethamethsaone to help w/ fetal lungs
tocolytics- increase labor
premature rupture of membranes
- most common dx leading to NICU admission
Risks: vaginal/ cervical infection -cervical incompetence - multiple pregnancy - cig smoking
sxs: gush of fluid from vagina
- every time she cough or strains–> feels a squirt
signs: sterile speculum exam, pooling, nitrazine paper, ferning test, visual leakage
treatment:
34 weeks for lung mature- bethamethsone
> 35 weeks - induce
under 34- immature lungs - keep baby in mom, check NST, CBC, bed rest until she is 35 weeks then deliver
maternal RH isoimmuniation
mom produces ab again foreign red blood cells antigen in maternal circulation
- risk is present only if mom is RH negative and dad id RH + and baby is RH +
tx: Rhogam
- 28 weeks protective
-
multiple gestation
- more severe s/sx of pregnancy
- high risk
complications: spontaneous abortion - pre-eclampsia -increas of death for fetus, -cord prolapse - incr risk for placenta separation
gestational diabetes
DM during pregnancy
RF: AA, hispanic, indian
correlation with pre-eclampsia, traumatic birth
fetal risK : macrosomia, prematurity, still birth,
delayed fetal lung maturity
24-28 week- GCT
- non fasting 50 g glucose load
- check maternal glucose after 1 hour
- if > 140 mg/ dl move to GTT
GTT- fasting testing
take blood and then given 100 gm oral glucose at 1, 2, and 3 hours
- 2 abn values
fasting: 95
don’t use h A1c during DM
A1: diet controlled
A2: insulin
tx: diet and exercise
finger stick X qid
keep BS
HTN in pregnant
chronic HTN-
HTN before 20 weeks before gestation
140/ 90- 179/109
- no end organ damage
check monthly sonogram- to make sure baby growing
-stat weekly NST and biophysical profile
serial BP and urine protein
medication 150/100
methoadopa
preeclampsia/ eclampsia
- proteinuria, edema, HTN
eclampsia- above pause seizures
after 20 weeks and moslty near term
- can occur up to 2 weeks post part
No incr risk for HTHn later in life
** most common risk factor is nulliparity
multiple gestation
DM
chronic HTN
complications: ecclmpia
, renal failure, HELP, DIC
prevention: 1 gm calcium daily
mild and severe classification
mild tx: BP high,
proteinuria, and no other sx –>
tx: deliver baby
before 37 weeks–: bed rest and check BP and urine dips
- if not reliable–> admit them and deliver at 37 weeks
severe: BP higher 160-180/ 100, ++ proteinuria, and have sxs ( HA, blurred vision, RUQ pain, elevated creatinine)
tx: hospitalize , ICU given betamethasome over 34 weeks --> induced not stable--> immediate C-section mag sulfate- to dec seizures hydralazien and labetolol
placental abruption
placenta becomes detached from side of uterine
most common cause of 3rd trimester bleeding
RF: HTH, cocaine, cig smoking, trauma
external form: blood drains through the cervix
- more common, less serious
concealed- hemorrhage is confined
- less common, more serious
sx: abd pain ( searing)
fetal distress
labs/test: clinical, sonogram, H/H, PT/PTT
tx:
if large and fetal distress- emergency C-seciton
if small- watchful waiting
complications: fetal demise, maternal hemorrhage, maternal DIC and death
placenta previa
placenta over the cervical os
- may be partial or complete
RF: advanced mat age, multiple gestation, previous previa, scarred endometrium
sx: painless, bright red bleeding
may have contractions
( no prenatal care, easily seen on sonogram)
signs: sonogram , no vaginal exam
tx: if little spotting- bed rest
if full gush of blood- delivered C-section
complications: embolism, prematurity, hypoxia
post part hemorrhage
uterine atony
- uterus continues to contact after baby born
RF: later is short or long or infection
findings: soft uterus
tx: piton and uterine manage
Genital laceration
- suture it
Retained placenta-
see on the placenta missing or go in do manual exploration
endometritis
infection in the endometrium
ruptured membrane > 24 hours
2-3 days post part
fever , uterine tenderness
labs: elevated WBC
UA
tx: clindamycin and gentamicin