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PANCE > Reproductive System (Male and Female) (7%) > Flashcards

Reproductive System (Male and Female) (7%) Flashcards

1
Q

breast abscess

A
  • occurs especially during nursing (MC s. aureus)
  • presentation: redness, tenderness, induration
  • dx: incision and bx if severe or indurated - r/o inflammatory carcinoma
  • tx: bactrim, clinda, doxy
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2
Q

breast fibroadenoma

A
  • more common in AA and young (15-35)
  • presentation: round, firm (soft, rubbery), painless, freely movable, discrete, mobile
    • hormonal relationship: cyclical size
  • signs: nontender, unilateral, mobile density, smooth firm mass
  • dx: if <30 - US +/- FNA
    • if >30 - mammogram
    • Excisional bx (if <25), if BRCA + mom
  • tx: decrease caffeine
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3
Q

fibrocystic breast dz

A
  • MC benign breast condition (MC 30-50yo)
  • Presentation: asx or painful, bilateral, size fluctuation during menstrual cycle
    • MULTIPLE LESIONS distinguishes fibrocystic changes from carcinoma
    • breast pain, dipple discharge, lumpy and bumpy prior to menses
  • signs: tender, bilateral, mobile density, thick gray-green nipple d/c, worse with caffeine intake
  • dx: US +/- bx, FNA (diagnostic and tx)
  • tx: support bra, decrease caffeine, danazol
  • increased risk breast CA when atypia is present
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4
Q

mastitis

A
  • MC in postpartum (2-4th week, S. aureus)
  • Presentation: lactating women, FEVER, chills, flu-like, acute, responds to abx
  • signs: decreased milk, redness, tenderness, firm mass, breast pain, unlilateral, heat
  • dx: culture of purulent material or milk (not routine)
  • tx: dicloxacillin (PCN allergy - erythromycin)
    • cold compress, NSAIDs and tylenol, continue to breast feed and express milk
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5
Q

Abortion

A
  • a pregnancy that ends spontaneously before the fetus has reached a viable gestational age (before 20 wks gestation or <500g)
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6
Q

spontaneous abortion dx and tx

A
  • dx: quant B-hCG, CBC, blood type, ab screen US
  • tx:
    • >13wk: medical abortion (mifepristone - antiprogesterone) (misoprostol - prostaglandin)
    • D&C - first trimester
    • D&E - second trimester
    • Surgery required if ineffective or excessive blood loss
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7
Q

Complete abortion

A
  • known pregnancy with passage of all products of conception before 20wk gestation
  • passage of all products, no symptoms of preg, test (-)
  • consider ectopic
  • sxs: vaginal bleeding, cervical os closed, uterus firm, well contracted, small for dates, no CMT or adnexal tenderness
  • dx: US, empty uterus
  • tx: does NOT require evacuation of uterus, still needs monitoring
    • curettage nearly 100% successful in completing early preg losses
  • Health maintenance: vaginal rest to decrease risk of infxn
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8
Q

missed abortion

A
  • retention of nonviable preg for prolonged period (2+ menstrual cycles)
  • pt presents w/ smaller gest size by exam than by dates and no FHT
  • sxs: missed menses (persistent amen.), + preg test or inappropriately rising hCG levels, no bleeding, loss of earlier sxs of preg (nausea, breast tenderness)
    • no cramping, 2-3wk lag, cervical os CLOSED, uterus small for dates, no CMT or adnexal tenderness
  • dx: UCG, hCG, CBC, type and screen, fibrinogen weekly for coag, US - fetal demise, no cardiac activity, macerated
  • tx: Resuscitation, observation, serial exams, medical, surgical, or expectant management
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9
Q

threatened abortion

A
  • consider ectopic in ddx, vag bleeding before 20th wk w/o loss of fluid or tissue (normal preg with bleeding)
  • sxs: bleeding, cramping, cervical os closed, uterus sized for date, softer than normal, no CMT or adnexal tenderness
  • dx: + UPT, CBC, type and screen
  • tx: no intervention if no abnormality, 50% proceed to SAB, increased risk PTB and LBW
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10
Q

inevitable abortion

A
  • during first 20wks w/ bleeding, cramping, dilated cervix or gush of fluid WITHOUT passage of POC
  • dx: uCG, hCG, CBC, type and screen, transvag US, US shows IUP, slow cadiac activity, abnormal yolk sac, abnormal gestational sac
  • tx: resuscitation, observation, serial exams, send home to run natural course or may elect for surgical or medical managment
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11
Q

incomplete abortion

A
  • involves passage of products of conception, POC can be at the open os with partial expulsion, intermittent pain and continued bleeding
  • sxs: heavy bleeding (passage of POC), painful cramping (cervical dilation), cervical os open, POCs seen, uterus soft, tender, not well contracted, small for date
  • tx: UCG, hCG, CBC, type and screen, US - retained POCs, clot
  • dx: surgery but can be expectant management (surg not necessary for all women and is invasive), persistent, heavy bleeding with significant pain requires D and C
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12
Q

Induced abortion

A
  • medical or surgical termination of an intact pregnancy before the time of viability
  • mifepristone and methotrexate: increase uterine contractility by reversing the progesterone-induced inhibition of contraction
  • misoprostol: stimulates the myometrium directly
  • medical abortion up to 49d gestation
  • surgical abortion greater than 49d
  • tx:
    • first trimester: suction curettage
    • second trimester: mifepristone (RU 486) = antiprogestin
      • PLUS: methotrexate (antimetabolite), misoprostol (prostaglandin)
      • OR: suction or extraction forceps
    • last line: D&E (dilation and evacuation)
  • complications: uterine perforation, cervical laceration, hemorrhage, incomplete removal, infxn
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13
Q

septic abortion

A
  • Infected abortion, whether complete or incomplete
  • More common with illegal abortions under unsterile conditions by persons who have little or no knowledge of medicine or anatomy
  • sxs: bleeding, sanguinopurulent drainage (strawberry milkshake) +/- passage of POCs, fever, chills, abd pain, amenorrhea
    • tachycardia, tachypnea, fever, dilated os, uterus soft
  • dx: UCG, hCG, CBC, type and screen, blood and endometrial cx, US - retained POCs, clot, foreign body
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14
Q

Ectopic pregnancy etiology, RF, and sxs

A
  • MC site = ampulla
  • RF: An ECTOPIC
    • An: AMA
    • E: exposure to DES in utero
    • C: cigarette
    • T: tubal ligation
    • O: ovulation induction
    • P: prior PID/ectopic
    • I: infertility
    • C: contraceptive IUD
  • sxs: abd pain, bleeding
    • ominous findings: vertigo/syncope, shoulder pain worse with insp.
    • generalized unilateral tenderness, os closed, adnexal tenderness, CMT, uterus smaller than dates
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15
Q

ectopic pregnancy dx, tx

A
  • dx: UPT +, serum BhCG x3 q48h (inappropriately rising)
    • gestational sac on TVUS: 4-5wk after LMP
  • tx: methotrexate IM 50mg (check baseline kidney and liver fn)
    • need to follow up day 4 and 7, then weekly until neg for hCG
    • contraindications: breastfeeding, immunodef, liver dz, blood dyscrasias, pulm dz, PUD, renal dz
    • exploratory laparotomy or laparoscopy if ruptured ectopic
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16
Q

gestational trophoblastic dz

A
  • RF: asian, 2+ miscarriages
  • dx: FIGO criteria:
    • plateau of 4 hCGs over 3+ wks
    • rise of 3 weekly consecutive hCGs over 2+ wk (by at least 10%)
    • persistently elevated hCG >6mo after D&C
    • histologic dx of choriocarcinoma
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17
Q

Molar Pregnancy etiology, RF, and sxs

A
  • excessively edematous immature placentas, including: complete hydatidiform mole, partial hydatidiform mole, and malignant invasive mole
  • RF: hx previous mole, age extremes, vit A and carotene def, long term OCP use, presents during 11-25wk gest.
  • sxs: hx of 1-2mo amenorrhea, 50% vag bleeding (spotting to profuse hemorrhage), N/V significant
  • signs: large uterus for dates
  • complications: anemia, preeclampsia, hyperemesis, hyperthyroidism (tachycardia)
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18
Q

Partial mole

A
  • Partial mole: may contain fetal parts, placenta, triploid karyotype resulting from fert of egg by dispermy, marked villi welling, lower hCG levels, affects older patients, longer gestations, dx as missed or incomplete abortions
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19
Q

Complete mole

A
  • Complete mole: does not contain fetal or placental parts, diploid from fert of empty egg by single sperm or two sperm, trophoblastic prolif with hydrpic degen, larger uteri, pre-eclampsia, post-molar GTD
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20
Q

molar pregnancy dx and tx

A
  • dx: CBC, SCr, AST, type and screen, PT/PTT, BhCG, TVUS shows snowstorm, elevated free T4 and decreased TSH
  • tx: CXR (lungs MC site of mets), suction dilatation and curettage or hysterectomy with ovarian preservation, repeat BhCG 48h after and repeat q1-2wk until hCG unde
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21
Q

Gestational DM

A
  • carbohydrate intolerance only present during pregnancy, lifetime risk of developing it is 50% (vs 5% in gen pop), 50% risk if insulin needed, recurrence common
  • maternal complications: preeclampsia, hyperacceleration of diabetic complicaitons, traumatic birth including shoulder dystocia
  • fetal complications: macrosomia, prematurity, fetal demise, delayed fetal lung maturity
  • sxs: usually asx
  • RF: hx previous LGA infant, obesity, >25yo, glucosuria, Fhx DM, AA, asian, hispanic, american indian
  • dx: screening recommendations
    • obtain random glucose on all preg women in first prenatal visit, then conduct repeat at 24-28wk
    • HgbA1C not recommended as screening method in gest DM
    • nonfasting 50g glucose challenge, check serum level 1 hr later. If >130, perform 3hr gtt
    • 3hr gtt: 100g fasting glucose, levels taken at 1, 2, and 3hrs. if two or more values meet or exceed cutoff values, pt dx w/ GDM
      • fasting: 95
      • 1hr: 180
      • 2hr: 155
      • 3hr: 140
  • tx: diet and exercise, check blood glucose after fasting and after each meal
    • pts with fasting glucose >105 or 2hr postprandial >120 may need insulin
    • if pt well controlled and no macrosomia, labor induced at 40wks. If glucose poorly controlled or macrosomia, induction at 38wks
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22
Q

incompetent cervix dx and tx

A
  • dx: sonogram (decreased cervical length <30mm), fetal fibronectin (fFN) testing +, CBC, amnio, evaluate for placental abruption
  • tx: cerclage placement: reinforces weak cervix
    • used if hx of cervical insuff with cerclage placement, hx of spontaneous PTB and short cervical length <25mm prior to 24wk
  • contraindications to cerclage: bleeding, uterine contractions, ruptured membrane
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23
Q

placential abruption

A
  • separation of placenta from implantation site before delivery of baby
  • RF: preeclampsia, chronic HTN, smoking, cocaine, thrombophilia, prior abruption, AMA, multiparity, multifetal gestation, prior uterine surgery, polyhydraminos, fibroid, PPROM
  • sxs: painful vaginal bleeding, uterine tenderness, frequent contractions
  • signs: uterine tenderness (“woody”), fetal distress, shock, dilated cervix
  • dx: clinical dx - US, CBC, coags, fibrinogen, type and screen BUN/Cr, tocodynamometry (FHR monitoring), urine output
  • tx: immediate delivery due to high risk of fetal death
    • preterm/no distress (34-37): induce labor
    • term/no distress: vaginal delivery
    • fetal distress: emergent CS regarless of age
    • fetal demise: vaginal delivery, induction, D&E if 2nd trim.
    • complications: life-threatening PPH and increased need for emergent hysterectomy
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24
Q

Placenta previa

A
  • placenta implants over internal cervical os
  • most common abnormality of placental implantation
  • RF: AMPS (AMA, multiparity, multiple gestation, prior previa, c-section, D&C, smoking)
  • sxs: painless vaginal bleeding, nontender uterus, breech/transverse lie common
  • consequences: PPH, required C-section, placenta accreta, increta, or percreta, abruption, and growth restriction
  • dx: if dx in first or second trim., repeat US, DO NOT PERFORM DIGITAL EXAM
    • ​on TVUS, placenta is low
    • CBC, coags, type and screen
    • fetal HR monitoring
    • tx: hospitalization for evaluation, if 37+ wks - delivery, if <36wks - expectant management (asx or preterm = close observation and steroids; mature fetus+/- contractions = base on fetal testing, document lung maturity, schedule 36-38wk)
  • delivery regardless of gest age if: severe fetal status, life threatening hemorrhage, bleeding after 34wk
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25
Q

Gestational HTN

A
  • diagnosed >20wk, NO PROTEINURIA
  • RF: extremes of age, nulliparity, chronic HTN, underlying vasc. dz, multifetal gest., AA, gest age <34wk, mean SBP >135, high serum uric acid
  • sxs: BP >140/90, no proteinuria or end organ damage, normotensive by 12wk postpartum
  • dx: goal is to distinguish from preeclampsia
    • 24h urine (ro proteinuria), eval for: HA, visual changes, RUQ/epigastric pain, vag bleeding, dec fetal mvmts
    • CBC w/diff, LFTs, SCr, BPP
  • tx: BP <160/110 = bed rest, no HTN tx, no seizure prophylax.
    • BP >160/110 = antiHTN drugs and seizure prophylax.
    • no weight lifting, week/biweek visits, serial US q3-4wks
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26
Q

Preeclampsia/eclampsia

A
  • sxs occur after 20wks gestation; most often occurs near term but can be up to 6 weeks postpartum
  • preeclampsia: HTN, edema, proteinuria (edemal no longer necessary for diagnosis)
  • HELLP: presence of severe preeclampsia with addition of Hemolysis, Elevated Liver enzymes, and Low Platelets
  • Eclampsia is severe preeclampsia with the addition of seizures
  • MC RF for preeclampsia is nulliparity. Other factors include extremes of age, multiple gest., DM, preexisting renal dz, chronic HTN
  • Complications of preeclampsia: HELLP syndorme, abruptio placentae, renal failure, cerebral hemorrhage, pulm edema, disseminated intravascular coagulation
  • sxs: edema of face and hands, sudden weight gain, HA, visual disturbances, N/V, RUQ pain, decreased urine output, HTN, proteinuria, hyperreflexia
  • mild preeclampsia: >140/90
  • severe preeclampsia: >160/110
  • Dx: urine protein, 24hr urine protein, CBC, fibrinogen, PT/PT, chem panel (incl liver enzymes, Cr, uric acid leves)
  • tx: delivery is ultimate tx for HTN of pregmild preeclampsia: if reliable, can be outpt. delivery through induction is indicated after 37wk
    • mag sulfate to dec risk of sz (continued until 24hr postpartum)
    • urine output monitored , hydralazine or labetalol for HTN can be given, betamethasone given before 34wk gest. to enhance fetal lung maturity
    • severe preeclampsia or eclampsia is indication for prompt delivery regardless of gest age
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27
Q

Rh incompatibility

A
  • when mom is Rh neg and fetus is Rh pos
  • Rh immunoglobulin (RhoGam) administered at 28-29wks to all Rh neg moms. If baby found to be Rh pos after delivery, mother receives RhoGam again to protect for future preg.
  • RhoGam should be administered at any event in which mom and fetal blood can mix (ectopic, SAM or TAB, CVS, amnio, trauma)
  • If Ab develops in mom against baby, future baby risks severe anemia and death (fetal hydrops)
  • dx: routine prenatal blood work, in sensitized preg, combo of coombs test, amnio, and US used to follow fetus for distriss or fetal hydrops
  • tx: routine RhoGam admin. at 28wks and w/in 72hr of delivering Rh pos infant
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28
Q

Chlamydia

A
  • Most common bacterial STD
  • RF: lack of condom use, lower socioeconomic status, living in an urban area, having multiple sex partners
    • most common in F 15-19, then 20-24
    • independent risk factor for cervical cancer
  • Sxs:
    • men: dysuria, purulent urethral discharge, itching, scrotal pain and swelling, fever
    • women: puruelnt urethral discharge, intermenstrual or post-coital bleeding, dysuria
      • mucopurulent discharge from cervical os, friable cervix
  • Dx: NAAT, wet mount (leukorrhea >10 WBC), culture, enzyme immunoassay, PCR
  • Tx: azithro x1 or doxy
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29
Q

Gonorrhea etiology and sxs

A
  • transmitted sexually or neonatally
  • 30% coinfected with chlamydia
  • Sxs: asymptomatic in women, symptomatic in men
    • Cervicitis or urethritis (purulent discharge, dysuria, intermenstrual bleeding)
    • Disseminated: fever, arthralgias, tenosynovitis, septic arthritis, endocarditis, meningitis, skin rash (distal extremities)
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30
Q

Gonorrhea dx and tx

A
  • dx: NAAT, gram stain (leukocytes, gram neg intracell. diplococci), cultures (men from urethra, women from endocervix)
  • tx: tx empirically because cultures take 1-2d
    • Ceftriaxone x1, add Azithromycin or doxy to cover chlamydia
    • if disseminated, hospitalize and IV or IM ceftriaxone
  • Complications of dz: PID, infertility, epididymitis, prostatitis, salpingitis, tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome
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31
Q

Breech Presentation

A
  • 3-4% all preg.
  • RF: fibroids, oligo/polyhydramnios, uterine anomalies, pelvic tumors obstructing canal, abnl placentation, advanced multiparity, contracted maternal pelvis
  • sxs: clinical suspicion (on palpation or pelvic exam)
  • signs: leopold maneuvers to confirm breech, pelvic exam - breech = soft, irregular; cephalic = round, firm, smooth
  • dx: US, continuous electronic monitoring of baby
  • tx: monitor closely for spontaneous version
    • external cephalic version
      • indications: singleton breech, nonvertex second twin, woman in 36+ wk gest.
      • contra: engagement of presenting part, marked oligohydram, placenta previa, uterine anomalies, nuchal cord, multiple gest., PROM, previous uterine surg, IUGR
      • complications: placental abruption, uterine rupture, ROM with cord prolapse, amniotic fluid embolism, PTL, fetal distress, fetomaternal hemorrhage, fetal demise
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32
Q

shoulder dystocia

A
  • inability to deliver shoulders after head has delivered
  • RF: fetal macrosomia, GDM, hx shoulder dystocia in prior birth, prolonged 2nd stage labor, instrumental delivery
  • sxs: any indications of macrosomia - gentle downward pressure on head fails to deliver anterior shoulder form behind pubic symphysis. Avoid continuing pressure to head to deliver as this is ineffective and can damage brachial plexus
    • attempt maneuvers
    • complications: erb palsy, postpartum hemorrhage and lacerations
  • tx: hyperfexion of maternal hips (mcroberts maneuver), offer cesarean in future deliveries
  • prevention: address hx of shoulder dystocia macrosomia by estimated fetal weight, DM, prolonged 2nd stage, instrumental delivery
  • previous hx of dystocia places women at an increased risk dystocia in future preg
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33
Q

Fetal Distress

A
  • generally believed that reduced baseline heart rate variability is single most reliable sign of fetal compromise
  • sinusoidal: Fetal anemia from Rh-alloimmunization, fetal intracranial hemorrhage, severe asphyxia, fetomaternal hemorrhage, twin-twin tranfusion syndrome, or vasa previa
  • early decelerations: normal head compression during uterine contractions (active labor) - in most cases, onset, nadir of decel, and recovery are coincident with beginning, peak, and end of contraction respectively
  • late decels: uteroplacental insufficiency - decel occurs after the peak of contraction
  • variable decels: umbilical cord compression -> fetal anoxia -> death - abrupt decrease in FHR; decrease in FHR is >/=15 bpm, lasting >/=15s, and <2min in duration
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34
Q

Prolapsed umbilical cord

A
  • descent of umbilical cord into lower uterine segment where it may lie adjacent to presenting part (occult) or below presenting part (overt)
  • complications: variable fetal heart rate decels during uterine contractions with prompt return of HR as contraction end
  • Occult prolapse: cannot be palpated during pelvic exam
    • tx: immediate pelvic exam, place patient in lateral sims or trendelenburg - if FHT return to norm, continue labor. Deliver O2 to mom and monitor FHR continuously. Rapid c-sec if compression cont.
  • Overt prolapse: associated with ROM and displacement of umbilical cord into vagina
    • RF: premi, abnl pres, occiput posterior, pelvic tumors, multiparity, placenta previa, cephalopelvic disproportion
    • MC LIE = TRANSVERSE LIE (20%)
    • US at onset of labor to determine lie and cord position. Cont fetal monitoring
    • tx: pelvic exam, place patient in knee-chest pos., and apply continuous upward pressure against presenting part to lift and maintain fetus away from prolapsed cord
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35
Q

PROM etiology, RF, sxs

A
  • RF: genital tract infxn (BV), smoking, prior PPROM, shortened cervical length, amnio
  • rupture of membranes before onset of labor
  • important cause of PTL, prolapsed cord, placental abruption, and intrauterine infxn
  • NIH recommends use of steroids in PROM pts before 32wks in absence of amniotic infxn
  • sxs: term >37wk, sudden gush of fluid or continued leakage
    • avoid digital exam
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36
Q

PROM dx and tx

A
  • dx: hallmark findings are ferning, nitrazine testing (amnio fluid - paper turns blue = alkaline), pooling, CBC and UA, phosphatidyl glycerol (indicates pulm maturity), AFI w/ US
  • tx: if chorioamnionitis present, active delivery indicated regardless of gest age
    • if no infxn and term, manage expectantly or actively
    • if no infxn and preterm, similar delivery to PTL
    • abx and hydration prolongs latency period by 5-7d - IV ampicillin and IV erythromycin
    • tocolysis: prolongs interval to delivery to gain time for steroids to be administered (only 48h - longer increases risk of infxn)
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37
Q

PPROM

A
  • occurs before 37wks
  • major risk involved is chorioamnionitis and endometritis
    • chorio: cause = myco/ureoplasma, sxs = uterine tenderness, tachycardia (maternal and fetal), foul smelling purulent amniotic fluid, maternal leukocytosis, tx = ampicillin + gentamycin
  • tx: if no sign of maternal or fetal iunfxn or distress, expectant management preferred - pt admitted to hospital and put on bedrest
    • if under 34wks, steroids administered
    • NST and BPP performed daily to assess fetal well-being
    • amnio checks lung maturity
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38
Q

Preterm labor/delivery

A
  • delivery of viable infant before 37 wks gest.
  • MCC neonatal deaths not from congenital malformations
  • LBW infants born prematurely often have significant developmental delays, cerebral palsy, and lung dz
  • RF: smoking, cocain use, uterine malformations, cervical incompetence, infxn, and low prepreg weight
  • preterm labor defined as regular uterine contractions (>4-6/hr) between 20-36wks gest. and in the presence of one or more of the following:
    • cervical dilation of 2cm or greater at presentation
    • cervical dilation of 1cm or greater on serial exam
    • cervical effacement of greater than 80%
  • dx: US - normal length of cervix = 4cm
  • tx: bed rest, abx, hydration, steroids, tocolytics (mag sulfate, CCB)
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39
Q

barrier methods of contraception

A
  • condoms, diaphragms, cervical caps
  • protection against STIs: decreased risk HIV, gonorrhea, nongonococcal urethritis, herpes
  • natural membrane condoms less effective than latex
  • rare reports of toxic shock syndrome with diaphragm and contraceptive sponge
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40
Q

sterilization

A
  • reduces risk of ovarian cancer
  • most commonly used method
  • hysterectomy, BSO, tubal ligation, vasectomy
  • NOT reversible
  • 1.85% risk pregnanyc, 30% risk of ectopic pregnancy
  • SE include functional ovarian cysts,
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41
Q

Intrauterine Devices

A
  • Advantages: high level of efficacy, no increased rate of pelvic infxn and infertility
    • Skyla: good for 3y
    • Mirena: good for 5y, good for women with menorrhagia
    • ParaGuard: good for 10y
  • Disadvantages: not for use in women at high risk for bacterial STI in last 3-6mo
    • may not be effective in women with uterine leiomyomas because they alter the size or shape of the uterine cavity
  • Side effects:
    • ParaGuard - increased menstrual blood flow, dysmenorrhea
    • Mirena: more frequent spotting up to 6mo after placement or amenorrhea (30% by 2y, 60% by 12y)
    • expulsion duirng first year (likely in first month), 5%
    • uterine perforation (0.1%)
    • not associated iwht increased risk pelvic infxn for low-risk pts
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42
Q

implanon

A
  • advantages: up to 3y
  • disadvantages: not for use in women who cannot tolerate unpredictable and irregular bleeding
  • SE: causes irregular bleeding that doesn’t normalize over time
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43
Q

OCPs

A
  • Advantages: increased bone density, reduced menstrual blood loss (and anemia), low risk ectopic, improved dysmenorrhea from endometriosis, improved acne, decreased risk ovarian and endometrial CA and various benign breast dzs, prevention of atherogenesis, decreased activity of RA and incidence and severity of acute salpingitis
  • disadvantages: user dependent, increased risk thromboembolism, contraindicated with hypercoagulable state (smoking >35, hx VTE), contraindicated in ER/PR pos breast CA
  • SE: breakthrough bleeding, amenorrhea, mastalgia, weight gain, increased risk CV event
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44
Q

LARCs

A
  • long acting reversible contraceptives
  • prevent pregnancy through primarily spermicidal effect caused by sterile inflammatory rxn
  • if woman develops infxn with IUD in place, dont remove device, treat as STI
  • if TOA forms, start IV abx and remove device immediately
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45
Q

Copper containing (ParaGuard) MOA, Indications, Contraindications

A
  • MOA: local inflammaatory response induced in uterus leads to lysosomal activation
  • Indications: 10y
  • Contraindications: pregnancy or suspicion of pregnancy, abnl uterus (i.e. fibroids), acute PID, postpartum endometritis or postabortal endometritis, known or suspected uterine or cervical CA, genital bleeding (unknown), mucopurulent cervicitis, Wilson dz
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46
Q

Progestin releasing IUD (mirena - levonorgestrel releasing intrauterine system)

A
  • MOA: progestin renders endometrium atrophic, stimulates cervical mucus thickening (blocks sperm penetration into uterus), decreases tubal motility (prevents ovum/sperm union), may inhibit ovulation
  • indications: good for 5y
  • Contraindications: preg, uterine anomaly, PID, postpartum endometritis or infected abortion in past 3 mos, uterine or cervical neoplasia/abnormal pap, genital bleeding (unknown orig), untreated cervicitis or vaginitis, acute liver dz or liver tumor, susceptibility to pelvic infxn, breast cancer, prior ectopic
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47
Q

Implanon

A
  • single rod, etonogestrel
  • MOA: progestin continuously suppresses ovulation, increases cervical mucus viscosity, causes endometrial atrophy
  • Indications: up to 3y
  • Contraindications: preg, thrombosis or VTE, hepatic tumors, liver dz, undx abnormal genital bleeding, breast CA
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48
Q

OCP MOA, indications, contraindications, adverse effects

A
  • MOA: suppression of hypothalamic GnRH, prevention of FSH and LH secretion, prevent menorrhagia, progestins inhibit ovulation
  • Indications: 3wks each month
  • Contraindications: preg, HTN, smoker >35yo, DM, thrombogenic cardiac valvulopathies, cerebrovascular or coronary artery dz, migraines, thrombophlebitis, hx VTE, undx abnl bleeding, breast CA, cholestatic jaundice of preg, hepatic adenomas or CA or liver dz, endometrial CA
  • Adverse effects: breakthrough bleeding, amenorrhea, breast tenderness, weight gain, increased risk CV dz
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49
Q

Progestin-only pill

A
  • aka minipills
  • MOA: progestins inhibit ovulation
  • Indications: good for women at increased risk of CVD (HTN), hx of thrombosis, migraines, smoker >35yo, lactating women, reduced risk ovarian and endometrial CA
  • Contraindications: unexplained uterine bleeding, breast CA, hepatic neoplasms or liver dz, pregnant
  • Adverse effects: increased incidence irreg bleeding, higher preg rate
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50
Q

depo-provera

A
  • MOA: inhibits ovulation and prevents sperm implantation
  • Indications: IM injection q3mos, given 5d after menses onset, does NOT suppress lactation, good for women for whom estrogen-containing contraceptive is contraindicated (migraine, sickle cell, fibroids), decreased risk of ovarian and endomet. CA
  • Contraindications: unexplained uterine bleeding, breast CA, liver dz, preg, hx of VTE
  • Adverse Effects: irreg bleeding, weight gain, breast tenderness, increased risk cervical CA, delay in return of fertility (12-18mo), shouldnt be used longer than 2y (d/t decreased bone mineral density)
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51
Q

postcoital contraception

A
  • Copper IUD insertion (up to 5d after, 99-100% efficacy)
  • oral antiprogestins or mifepristone (within 72hrs or up to 120hrs after, 98-99% efficacy)
  • Levonorgestrel (delays or prevents ovulation, within 72hrs, 60-94% efficacy)
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52
Q

obesity and contraception

A
  • IUD may be MORE EFFECTIVE than oral or transdermal
  • methods that include estrogen are considered less effective for obese women
    • therefore, IUD, DMPA, and progestin-only pills are most effective
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53
Q

Multiple Gestation

A
  • Etiology: routine US screeing, then again at 18-20wks
  • Sxs: earlier and more severe pressure in pelvis, nausea, backache, varicosities, constipation, hemorrhoids, abd distention, and difficulty breathing
    • uterus larger than expected (>4cm for dates), excessive maternal weight gain, polyhydramnios
  • Dx: MSAFP elevated, US (outline or ballottement of more than 1 fetus, multiplicity of small parts, fetal heart tones (recording of different fetal rates simultaneously, varying by 8 bpm), Hgb/Hct and RBC reduced compared to blood volume, tidal volume increased
  • Tx: increase iron and Ca supplement, high protein, more weight gain, tocolytics to suppress PTL and extend gestation 48h so effects of steroids realixed, admit first sign of labor or PTL
  • Complications: morbid course of pregnancy, maternal anemia, UTI, preeclampsia, eclampsia, hemorrhage, uterine atony, higher rates of GDM and hypoglycemia, operative intervention more likely
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54
Q

Postpartum hemorrhage etiology, RF, and sxs

A
  • RF: prolonged thrid stage of labor, multiple delivery, episiotomy, fetal macrosomia, prior hx of PPH
  • MCC excessive blood loss in pregnancy
  • sxs: pt returns to hospital a few days after delivery
    • brisk vaginal bleeding (>500mL)
  • signs: enlarged uterus or vaginal mass (inverted uterus), uterine bleeding with good tone and normal size, hemorrhagic shock
  • complications: uterine perf, orthostatic HoTN, anemia, fatigue
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55
Q

Postpartum hemorrhage dx and tx

A
  • dx: CBC, coag studies (PT, PTT, platelts), BUN, SCr, type and screen
  • tx: insert fingers of one hand into vagina and compress uterus against abdominal wall
    • IV oxytocin (pitocin) 10-40units in 1L saline for atony
    • Misoprostol
    • emergent OB/GYN consult
    • D&C
56
Q

infertility RF

A
  • Female RF:
    • Ovary: PCOS, hx radiation, hypogonadotrop8ic hypogonadism, ovarian failure
    • Tube: hx PID, pelvic surgery, personal or family hx endometriosis
    • Uterus: asherman syndrome, structural abnl, hx of D&C, recurrent miscarriage, IUD
    • Cervix: abnormal PAP, cervical infxn
  • Male RF:
    • illness with fever in last 70-90d, viral orchitis, chemo, urogenital surgery, torsion, recent hot tub use, lube use, anabolic steroids, chronic ETOH/smoking/marijuana
57
Q

infertility sxs, dx, tx

A
  • sxs: inability to conceive after 1 yr trying
  • dx: US, EMB, pap, postcoital test, cervical cultures, ovarian reserve test (>35yo, unexplained, smoker), ovulation testing, BBT, midluteal progesterone, hysterosalpingogram, chromopertubation (GOLD STANDARD), hysterosonogram and pelvic US, semen analysis
  • tx: Clomid, IVF
  • Tubal infertility: 12% after 1 ep of PID, 25% after 2 eps, 50% after 3 eps
58
Q

general characteristics of menopause

A
  • definition: menopause is the last menses, and perimenopause (usually lasting 3-5 yrs) is the time surrounding menopause.
  • Dx made: 1 yr of no periods after age 40 with no pathologic cause
    • FSH elevated (21-100), estradiol low (<20)
    • progesterone levels nl
  • mean age = 51.5 yrs
  • smoking is associated with early menopause
  • premautre menopause (spontanous premature ovarian failure) is cessation of menses before age 40 years
  • ovaries continue to produce testosterone and androstenedione; estrone is the predominant postmenopausal circulating estrogen
59
Q

clinical features of menopause

A
  • vasomotor sxs (hot flashes) vary in intensity - usually resolve in 2-3 yrs (3-6 wks with E tx)
  • urogenital atrophy can cause poor vaginal lubrication, dyspareunia, dysuria, urge incontinence, pelvic relaxation, atrophic cystitis, easy bleeding
  • accelerated bone loss may cause osteoporosis
  • E related cardiovascular protection declines
  • changes in sleep cycle
  • skin thins, becomes less elastic, facial hair increases, hair loss increases and nails become brittle
  • confusion, memory loss, lethargy, depression, loss of sex interest
60
Q

diagnostic studies for menopause

A
  • FSH of greater than 30 is diagnostic of menopause
61
Q

management of menopause

A
  • treated on the basis of individual risk factors and sxs
  • lifestyle modifications may help sxs, reg exercise can decrease menopausal sxs
  • women with INTACT uterus should NOT use E alone (increased risk of endometrial CA)
  • combined hormone replacement tx indicated for short-term tx of hot flashes
    • can increase risk of CV dz, breast CA, and cognitive changes
  • contraindications to hormone tx include undiagnosed vaginal bleeding, acute vascular thrombosis, liver dz, hx of endometrial or breast CA
  • Ca and vit D supplementation, bisphosphonates, SERMs, calcitonin all used for osteoporosis
  • topical E can improve urogenital sxs
  • SSRI and SNRIs (caution with use with tamoxifen)
  • soy, black cohosh, and ginseng may also help alleviate
62
Q

Definition of primary amenorrhea

A
  • absence of spontaneous menstruation by 16yo WITH secondary sex characteristics or 14yo WITHOUT secondary sex characteristics
  • 4 main categories based on karyotype
    • Turner syndrome (Gonadal agenesis) - 45 XO
    • Hypothalamic-pituitary insufficiency - 46 XX
    • Androgen insensitivity - 46 XY
    • Imperforate hymen - 46 XX
63
Q

Definition of secondary amenorrhea

A
  • woman who has previously menstruated
  • absence of menses for 3 months if previous cycles nl
  • absence of menses for 6 months if previous cycles irreg
  • Cause
    • THE MCC 2ary amenorrhea = PREGNANCY
    • Drug use, stress, significant weight change, or excessive exercise
    • PCOS, CNS tumor, hyperPRL, Sheehan syndrome (causes postpartum hypopit - pituitary gland is damaged, caused by excess blood loss (hemorrhage) or extremely low blood pressure during or after labor)
    • previously normal menstrual cycles and normal E, think stress or outflow obstruction (Asherman syndrome - scar tissue forms in the uterus, rare but can be a complication of multiple D&Cs)
    • If galactorrhea present, prolactinemia is MCC
64
Q

Amenorrhea

A
  • Primary or secondary
  • women with no menstruation in presence of E stimulation of endometrium have increased risk of endometrial cancer
65
Q

Turner Syndrome: karyotype, PE, Labs, management

A
  • Karyotype: 45 XO
  • PE: short webbed neck, no breast development
  • Labs: High FSH
  • Management: cyclic estrogen and progestins
66
Q

Hypothalamic-pituitary insufficiency: karyotype, PE, Labs, management

A
  • Karyotype: 46 XX
  • PE: no breast development
  • Labs: Low FSH, Low LH
  • Managment: Cyclic estrogen and progestins
67
Q

Androgen insensitivity: karyotype, PE, Labs, management

A
  • karyotype: 46XY
  • PE: Normal breast development
  • Labs: High testosterone
  • Management: Remove testes; start estrogen
68
Q

Diagnostic studies for amenorrhea

A
  • First line: B-hCG, TSH, PRL
  • Second line: FSH, E, LH, T
  • If bleeding occurs after progesterone challenge, anovulatory cycles are the cause
69
Q

Characteristics of dysfuncitonal uterine bleeding (DUB or AUB)

A
  • Presents as abnormal bleeding with a generally unremarkable PE
  • Abnormal uterine bleeding in non-pregnant women
    • different from normal cycle in terms of regularity, flow, duration, and volume
  • normally occurs right after menarche or during perimenopause
  • Causes = PALM-COIEN (polyp, adenomyosis, leiomyoma, malignancy - coag, ovulatory dysFN, endometrial, iatrogenic, not otherwise classified)
  • Menorrhagia = heavy or prolonged bleeding
  • Metrorrhagia = irregular bleeding between menses
  • PE includes speculum, evaluate for bleeding from other sources
70
Q

Diagnostic studies for DUB

A
  • B-hCG, CBC, iron, PT, PTT, documentation of ovulation, thyroid, serum P, LFTs, PRL, serum FSH
  • Pap, US, hysterosalpingography, hysteroscopy, and/or D&C
  • endometrial bx should be done on all women over 35yo w/ obesity, HTN, or DM and on all postmenopausal pts
71
Q

management of DUB (AUB)

A
  • depends on severity of bleeding - may include observation, iron therapy, and volume replacement
  • progestin trial - if bleeding stops, anovulatory cylces are confirmed
  • OCPs:
    • older women w/o risk factors
    • OCPs should NOT be used in women over 35 who smoke, have HTN, DM, or hx of vascular dz, breast CA, liver dz, or focal HA
  • D&C can be dx and curative
  • refractory cases may require endometrial ablation or vaginal hysterectomy
72
Q

Dysmenorrhea general characteristics

A
  • PRIMARY: painful menstruation caused by increased prostaglandin and leukotriene levels - painful uterine cramping, N/V/D
    • Onset: usually w/in 2yrs menarche, peak incidence = late teens/early 20s
    • THERE IS NO PATHOLOGIC ABNORMALITY
  • SECONDARY: painful menstruation caused by identifiable condition (usually uterus or pelvis - endometriosis, adenomyosis, fibroids, PID, IUD)
    • usually affects older women (>25yo)
73
Q

clinical features of dysmenorrhea

A
  • Primary: sxs are central lower abdomen or pelvis radiating to back or thighs, beginning before or at onset of menses, lasting 1-3 days
    • PE, labs, radiologic tests = nl
  • Secondary: similar sxs as above but may also include bloating, heavy menstrual bleeding, and dyspareunia
    • less related to first day of flow
74
Q

diagnostic studies for dysmenorrhea

A
  • dx of primary dysmenorrhea based on hx, use of menstrual diary, PE
  • specific tests for secondary dysmenorrhea - hysteroscopy, D&C, laparoscopy
    • all allow both dx and tx
75
Q

management of dysmenorrhea

A
  • Primary:
    • start NSAIDs right before expected menses, continue 2-3 days
    • OCPs, vit B (B1, thiamine; B6, pyridoxine), magnesium, acupuncture, heat, regular exercise
  • Secondary:
    • underlying conditions should be treated
    • sx treatment may be sufficient
76
Q

premenstrual dysphoric disorder

A
  • severe PMS with functional impairment
  • PMS and PMDD are highly associated with unipolar depressive disorder and anxiety disorders, such as obsessive-compulsive disorder, panic disorder, and generalized anxiety disorder
  • type of depression that occurs during the luteal phase of the menstrual cycle
  • Criteria: 5+ sxs were present most of the cycle and during the last week of luteal phase
  • Treatment:
    • 1st line = SSRI
    • 2nd line - OCP, xanax, GnRH agonists
77
Q

PMS risk factors

A
  • FHx of PMS, vitamin B6, calcium, or magnesium deficiency
78
Q

clinical sxs of PMS

A
  • HA
  • Breast tenderness
  • Pelvic pain
  • bloating
  • premenstrual tension
  • more severe: irritability, dysphoria, mood lability
  • Abdominal discomfort, clumsiness, lack of energy, sleep changes, mood swings
  • Behavioral: social withdrawal, altered daily activities, marked change in appetite, increased crying, changes in sexual desire
79
Q

treatment of PMS

A
  • Step 1 (mild sxs): limit caffeine, alcohol, tobacco, chocolate
    • eat small frequent meals high in complex carbs
    • decrease sodium intake
    • supplements (calcium, magnesium, etc.)
    • NSAIDs
    • Bromocriptine for mastalgia
    • spironolactone for cyclic edema
    • stress management: CBT, aerobic exercise
  • Step 2 (moderate sxs): SSRIs (14d prior to the onset of menstruation and continue through the end of cycle)
    • anxiolytics: alprazolam, buspirone
  • Step 3 (severe sxs): hormonal ovulation suppression
    • OCPs
    • GnRH agonist: lupron
    • Danazol for mastalgia
    • definitive surgical tx: bilateral oophorectomy
80
Q

endometrial cancer general characteristics

A
  • MC gyn cancer and 4th MC malig in women in US
  • postmen make up 75% pts
  • Adenocarcinomas make up 75% cancer cell types
  • RF: obesity, nulliparity, infertility, late menopause, DM, unopposed E, HTN, gallbladder dz, chronic tamoxifen use, not related to sexual hx
  • white women more likely to develop than black women
  • OCPs have protective effect
  • SMOKING IS CONSIDERED PROTECTIVE
81
Q

Clinical features, dx, and management of endometrial cancer

A
  • features: cardinal sx = postmen bleeding (90% pts)
    • obesity, HTN, DM may be present
  • Dx: US, pap, endometrial bx
    • endocervical curettage is definitive choice, endometrial bx has accuracy of 90-95%
  • management: total hysterectomy with bilateral salpingo-oophorectomy
    • radiotx may be indicated, chemo at advanced stages
    • recurrence txd with high dose progestins or antiestrogens
82
Q

PCOS characteristics and clinical features

A
  • MCC androgen excess and hirsutism
  • bilaterally enlarged polycystic ovaries, amenorrhea or oligomenorrhea, and infertility
  • normal puberty and adolescence followed by progressively longer eps of amenorrhea
  • genetic predisposition is somewhat implicated
  • increased risk for endometrial hyperplasia and carcinoma d/t unopposed E
  • Features: 1/2 pts are hirsute, truncal obesity, acne, menstrual irreg, impaired glucose tolerance in 30% pts
83
Q

PCOS dx and tx

A
  • dx: US - “string of pearls” within ovaries
    • lab test - elevated androgen, increased LH/FSH ratio, lipid abnormalities, insulin resistance
  • tx: weight reduction improves hirsutism, lipid and glucose parameters, and fertility
    • androgen-lowering agents (including OCP)
    • infert treated with clomiphene citrate (clomid)
    • lipid abnlities and insulin resistance managed medically
      • metformin increases ovulation and pregnancy rates
84
Q

ovarian CA characteristics and clinical features

A
  • high risk women = older (>/= 69), nulliparous, white, + fhx ovarian or endometrial CA
  • long-term OCP may be protective - ovulation suppression
  • 10% genetic predisposition, 90% sporadic
  • 80% of ovarian CA is epithelial in origin
  • Features: dx often delayed d/t no specific sxs
    • late dz presents w/ ascites, abdominal distention, early satiety, change in bowel habits, fixed mass
    • sister mary joseph nodule = met at the umbilicus
85
Q

ovarian CA dx, tx, and protective factors

A
  • Dx: BRCA1 associated w/ 5% cases, CA-125 used to follow tx, especially in postmen women
    • inhibin A and B
    • transvag or abd US useful in distinguishing benign from malignant
    • histologic exam via bx = dx
  • tx: surgery plus chemo and radiation
    • chemo = IV carboplatin and paclitaxel
  • protective factors: OCP, tubal ligation, BSO (bilat salpingo-oophorectomy), breastfeeding, chronic anovulation, ANYTHING that reduces number of ovulations
86
Q

cervical carcinoma Etiology, RF, sxs, dx, tx

A
  • bimodal distribution (35-39; 60-64)
  • RF: HPV exposure, early coitarche, multiple sex partners, immunosuppression, SMOKING, low SE status, lack of reg pap smears
  • sxs: postcoital bleeding, vaginal bleeding and d/c, dyspareunia
  • dx: abnormal cytology, HPV (+), gross lesion
  • tx:
    • stage 1: conservative, simple, or radical hysterectomy
    • stage 2 +: chemo +/- radiation
87
Q

cervical dysplasia

A
  • MCC: HPV 16 and 18 (18 MC with adenocarcinoma)
  • Most HPV infxns regress in 2 yrs
  • HPV not enough to cause cancer itself - requires cofacts (smoking, hormones, OCP (>5y), dietary, immunosuppression (lupus), HIV)
  • RF: old, AA, low ES, low edu, increased # sex partners, SMOKING, multiparous,, hx of STD
  • Indications for conization (LEEP or cold knife):
    • unsatisfactory colpo
    • +endocerv curettage
    • Pap smear indicating adenocarcinoma in situ
    • bx that cannot rule out invasive CA
    • Discrepancy between pap smear and bx result
88
Q

cervical cytology results and recommended next steps

A
  1. ASCUS (atypical squamous cells of undetermined significance)
    1. repeat cytology at 6-12 mo
      1. if both negative, return to routine screening
      2. if either +, colposcopy
  2. AGC (atypical glandular cells of undetermined significance)
    1. colposcopy with bx of lesions
  3. LSIL (low-grade intraepithelial lesions)
    1. colposcopy with bx of lesions
  4. HSIL (high-grade intraepithelial lesions)
    1. colposcopy with bx of lesions
89
Q

vaginal neoplasia etiology, RF, and sxs

A
  • etiology: 80-90% are mets from cervix, uterus, rectum, bladder
  • MC: squamous cell carcinoma, upper 1/3 of vagina, posterior to cervix
  • RF: same as cervical CA
  • sxs: asymptomatic (found after hysterectomy)
    • vaginal bleeding (postcoital or postmenopausal)
    • watery, blood, malodorous discharge
    • vaginal mass
    • urinary sxs: urgency, frequency, dysuria, hematuria
    • GI sxs: constipation, melena
90
Q

vaginal neoplasia dx and tx

A
  • dx: lugols soln (turn’s abnormal areas black)
    • punch bx: MC SCC
    • colposcopy
  • tx: radiation and surgery
    • laser ablation
    • WLE
91
Q

vulvar neoplasia etiology, RF, sxs, dx, tx

A
  • 4th MC, mean age = 65
  • RF: age, HPV (16), hx of CIN or other genital malignancy, SMOKING, immunosuppression (HIV, SLE, chronic steroids), vulvar dystrophy (lichen sclerosis)
  • sx: hx of lichen sclerosus (vulvar itching, visible vulvar lesions)
    • less common: bleeding, pain, ulceration, dysuria, enlarged groin nodes
  • dx: Bx, vulvoscopy (acetowhite lesions)
  • tx: radical vulvectomy and groin node dissection
    • if high risk - chemo
92
Q

Breast cancer RF

A
  • age, sex, first degree relative, BRCA1 or 2
  • associated factors: nulliparity, ealry menarche, late menopause, post men ERT or radiation exposure, advanced maternal age at first term birth
  • ALL invasive lobular and 2/3 ductal carcinomas are HER2 pos (estrogen-receptor)
93
Q

Breast CA presentation

A
  • single, nontender, firm, immobile mass
  • 45% upper outer quadrant, 25% under nipple and areola
  • signs: early, no palpable masses
    • rare: nipple d/c, retraction, dimpling, breast enlargement, shrinkage, skin thickening or peau d’orange, eczematous changes, breast pain, fixed mass, axillary node enlargement, ulcerations, arm edema, palpable supraclavicular nodes
94
Q

Breast CA dx

A
  • any solid dominant breast mass on exam evaluated with FNA or excisional bx
  • genetic testing for pts with strong family hx
  • axillary lymph node staging with sentinel lymph node bx
95
Q

breast CA tx

A
  • tamoxifen: for estrogen receptor pos dz and postmen women
  • adjuvant chemo and hormonal manipulaiton
  • lumpectomy with sentinel node bx preferred for early stage
  • breast cancer associated with higher risk of endometrial cancer and vice-versa
  • axillary lymph node status is the most important prognostic factor for invasive carcinoma in the absence of distant metastasis
96
Q

Paget dz of the breast

A
  • uncommon, ductal carcinoma, presents as eczematous lesions of the nipple
  • presentation: eczematoid eruption and ulceration of nipple and areola, pain, itching, burning
    • bloody d/c or nipple retraction
  • signs: scale, crust, itching, palpable mass (50%)
  • dx: full-thickness bx
  • tx: local excision, breast conservation with whole breast radiation (if negative margins)
    • most are high grade and show HER2 overexpression
97
Q

cystocele etiology, RF, and sxs

A
  • anterior vaginal prolapse of the posterior bladder wall into the vagina, emerging from the introitus
  • pelvic floor injury during childbirth
  • RF: genetics, prior prolapse surgery, connective tissue dz, pregnancy, vaginal delivery, parity, advanced age, obesity, menopause, DM, race
  • sxs: vaginal bulge or fullness, pressure, heaviness, worse with valsalva
    • concurrent urinary incontinence
    • incomplete emptying (retention, straining to void (obstruction)
  • examine in lithotomy position and standing
  • pt must push up bladder in order to void
98
Q

cystocele dx and tx

A
  • Dx: POP-Q (pelvic organ prolapse quantification), US or MRI, Q-tip test, voiding cystourethrogram, cystometrogram
  • tx: pessary, anterior vaginal colporrhaphy, tension-free vaginal tape procedure
  • prophylaxis: kegel exercises (strengthen levator ani and perianal mm.), estrogen tx after menopause
99
Q

uterine prolapse etiology, RF, sxs

A
  • etiology: loss of normal ligamentous support (cervix protrudes from introitus), risk increases postmen.
  • RF: older, multigravid, any condition that increases intra-abdominal pressure (obesity, chronic cough, constipation, repetative lifting)
  • sxs: vaginal fullness or mass (worse after long standing, late in the day)
    • lower abdominal aching, low back pain, urinary incontinence, “sitting on a ball”
    • soft, reducible mass on pelvic exam (examine in both lithotomy and standing)
  • complications: chronic decubitus ulceration of vaginal epithelium in procidentia
100
Q

uterine prolapse dx and tx

A
  • dx: POP-Q (pelvic organ prolapse quantification), Q-tip test, cystourethroscopy, cystometrogram, anoscopy, colonoscopy, anal manometry, or transanal US
  • tx: conservative management (weight reduction, smoking cessation, kegels), vaginal pessary (best for older, postmenopausal women), vaginal hysterectomy with sacrospinous ligament suspension (for severe prolapse), colpocleisis (vagina is surgically obliterated)
  • Most accompanied by cystocele, rectocele, or enterocele
101
Q

rectocele etiology, RF, sxs

A
  • etiology: prolapse of posterior vaginal wall and rectum
  • RF: pelvic floor injury during childbirth
  • sxs: prolonged, excessive use of laxatives or frequent enemas (constipation)
    • introital bulging, concurrent fecal incontinence, constipation, low back pain, dyspareunia
    • left decubitus position for detection
  • complications: hemorrhoids
102
Q

rectocele dx, tx

A
  • dx: POP-Q (pelvic organ prolapse quantification), anal manometry, transanal US, MRI, colonoscopy, defocography, EMG
  • tx: nonsurgical (use of meds: laxatives, EST), posterior colporrhaphy (repair of posterior fascial defects), colpocleisis (closure) or colpectomy (removal) of the vagina if not sexually active
103
Q

ovarian torsion

A
  • associated with ovarian cysts or neoplasm (torsion of normal ovaries is common in children)
  • sxs: sudden onset of unilateral lower quadrant pain, nausea, TTP
  • dx: WBC normal, B-hCG negative, US (ovarian mass, free fluid in the pelvis), +/- doppler US to check blood flow to ovaries
  • tx: rapid surgical exploration
104
Q

endometriosis etiology, RF, and sxs

A
  • hx of PID/STD, laparoscopy for chronic pelvic pain or dysmenorrhea, infertility
  • present in 30% infertile women
  • MC in 25-35yo white women, estrogen dependent inflammatory dz
  • MC locations: ovaries, anterior and posterior cul-de-sac, post broad ligaments, uterosacral lig, uterus, fallopian tubes, sigmoid colon, appendix, round lig
  • RF: nulliparity, prolonged E exposure (early menarche), exposure to DES in utero, lower BMI, high consumption trans unsaturated fat, outflow tract obstructions
  • Sxs: cyclical pelvic pain, dysmenorrhea (pain 1-2d before menses, persists throughout), dyspareunia, dyschezia, hematochezia, dysuria, hematuria
    • fixed uterus, retroflexed, nonmobile, palpable adnexal mass
  • complications: infertility
105
Q

endometriosis dx, tx

A
  • Dx:
    • transvag US: hypoechoic, vascular, or solid mass (irreg margins, spiculated - MOST ENDOMETRIAL TISSUE CANNOT BE SEEN ON US)
    • DEFINITIVE: exploratory laparoscopy and bx (“blue-black powder burn lesions” raised flame-like patches)
    • serum CA125 can be elevated
  • Tx:
    • mild-moderate (no reg absence from school/work, no US evidence): NSAIDs, OCPs, Depo, Mirena
    • Severe (reg absence from school/work, failed tx, recurrence): GnRH agonist (leuprolide) with OCPs
      • Laparoscopy
    • DEFINITIVE tx: hysterectomy + bilateral salpingo-oophorectomy
106
Q

Ovarian cyst

A
  • Etiology/RF: ectopic endometrial tissue within ovary - bleeds and results in hematoma
  • Sxs: asx or pelvic pain, menstrual irreg., urinary frequency, constipation, pelvic “heaviness”, syrup-like chocolate colored material)
  • Dx: US (first line), preg test, CBC, CA-125
  • Tx:
    • small, asx: OCP, repeat US in 6-8wk
    • Large, sx: cystectomy (first line), follow w/ long term OCP
      • oophorectomy (definitive) - recurrent cysts, no more childbearing, postmen.
  • Complications: hemoperitoneum (with rupture)
107
Q

Leiomyoma (fibroid) etiology, RF, sxs

A
  • etiology: E and P sensitive - grow during preg, shrink after men.
    • MC solid pelvic tumor, MC in AA females - benign, smooth muscle cell tumor of myometrium
  • RF: Black, early menarche, ETOH intake, + family hx
  • Protective factors: increased parity, long acting progestin only (depo), SMOKING
  • sxs: MOSTLY ASX
    • menorrhagia, pelvic pain/pressure, bulk related sxs (voiding diff. - constipation, urinary urgency, frequency), dyspareunia, dysmenorrhea, infertility
    • abdominal distention, enlarged, mobile uterus with irregular contour
  • complications: increased risk miscarriage
108
Q

Leiomyoma dx and tx

A
  • dx: pelvic US - distinguishes fibroids from adnexal masses (first line, diagnostic)
    • hysteroscopy - less accurate than US
    • MRI - size and location (for surgical planning)
    • hysterosalpingogram - defines contour of endomet. cavity
    • EMB - if >40yo to r/o endometrial CA
  • tx: observation and reassurance if asx, small, postmen
    • bimanual q6mo
    • OCPs, POPs (first line)
    • GnRH agonists (most effective but cause bone loss)
    • myomectomy (contra in preg.) - used in AUB, bulk related sxs, infert, recurrent miscarriage
    • hysterectomy (definitive tx)
109
Q

Spouse or partner neglect/violence

A
  • F>M as victims
  • RF: young (<35), pregnant, single, divorced, ETOH or drug abuse in vitim or partner, smoking, low SES
  • Signs/sxs: injury explanation doesn’t fit with exam, frequent ED visits, HA, abd pain, fatigue
    • vague during hx, minimal eye contact, abuser in room answers all questions or refuses to leave, injuries to central area, bruising in various stages of healing
  • Dx: HITS (hurt, insult, threaten, screamed at), WAST (women abuse screening tool), PVS (partner violence screen), AAS (abuse assessment screen), WEB (women’s experience with battering)
  • Tx: speak with pt alone, document all hx and findings, screen women of childbearing age and refer to intervention services
110
Q

sexual assault in adults

A
  • sxs: sleep disturbance, decreased appetite, somatic sxs, depression, suicidality, anxiety, decreased self-esteem, sexual dysfunction, fragility of sense of masculinity and confusion about sexual orientation
  • tx: evaluate and collect evidence up to 24h after assault, report to authorities, FU 1-2 wk
111
Q

sexual assault in children

A
  • sxs: nonspecific, rectal or genital bleeding, STIs not acquired prenatally, sexually explicit acting out, signs of penetration, inappropriate knowledge of sexual activity, developmentally inappropriate play, swelling or blue discoloration of the anus
  • dx: forensic evidence collection, screen for STIs, evaluate for pregnancy
  • tx: evaluate and collect evidence up to 24h after assault, report to CPS, followup 1-2wk
112
Q

Pelvic Inflammatory disease etiology and sxs

A
  • etiology: infxn ascends from cervix to involve endometrium and/or fallopian tubes
    • MCC = gonorrhea, chlamydia, genital mycoplasmas
    • RF: endocervical infxn, BV, hx of PID, vaginal douching, IUD insertion, D&C or C-section
  • signs and sxs:
    • mucopurulent malodorous vaginal discharge
    • abd pain
    • abnl vaginal bleeding
    • bilateral lower abdominal and pelvic pain
    • N/V
    • urethritis, proctitis
    • Fever
    • yellow endocervical discharge, easily induced bleeding
    • uterine or adnexal tenderness and swelling, CMT
    • rebound/guarding
113
Q

Pelvic inflammatory disease dx and tx

A
  • Dx: ESR elevated, leukocytosis, B-hCG, NAATs, gram stain
    • US: enlarged fallopian tubes with fluid in cul-de-sac
    • laparoscopy - last line, rule out appy, ectopic, tumor
    • endometrial bx
  • outpt: ceftriaxone IM and doxy PO x14d
    • +/- flagyl BID x 14d
  • inpt: hosp if: dx uncertain, pregnant, abscess suspected, severely ill or N/V preclude outpt management, HIV pos
    • Doxy + IV cefotetan or cefoxitin x 48h, then PO doxy BID x14d
    • clindamycin + gentamicin qh x48h, then PO doxy BID x14d
114
Q

trichomoniasis

A
  • signs, sxs: increased d/c and odor, dysuria, frequency, dyspareunia, itching, irritation
    • thin yellow-green to gray, adherent frothy discharge in vagina
    • malodorous, musty (amine)
    • hyperemic mucosa, friable cervix, strawberry cervix (petechiae)
  • dx: wet mount, ph 5-6.5 (basic)
  • tx: 2 g metronidazole PO x1, no ETOH 48h, TREAT PARTNER
115
Q

bacterial vaginosis

A
  • MCC vaginitis
  • RF: new partner, smoking, IUD, douching, pregnancy
  • signs, sxs: mostly asx
    • increased vag d/c
    • dysuria, frequency, dyspareunia
    • noticeable fishy discharge after menses or intercourse, no itching
    • thin ivory/gray d/c
  • dx: amsel criteria (3 of 4)
    • thin, gray, homogenous d/c
    • positive whiff
    • clue cells
    • elevated pH >4.5 (basic)
  • tx: metronidazole BID x7d
    • Or vaginal metronidazole
116
Q

atrophic vaginitis

A
  • postmenopausal women, thinning of vag epithelium
  • signs, sxs: dyspareunia, thin vag d/c, vag pruritis, burning, soreness
    • atrophic vulvar changes (smooth, shiny, pale, dry, thin), scattered vag petechia, thin clear or brown d/c (leukorrhea)
    • UTI, urge incontinence may be associated
  • Dx: clinical dx
    • vaginal cytology (greater % of parabasal cells)
    • vaginal pH: 5-7
  • tx: H2O soluble lubes, topical vaginal estrogens, oral estrogens
117
Q

candidiasis

A
  • 2nd MCC vaginitis
  • RF: high dose OCP, diaphragm use, DM, abx, pregnant, immune suppression, tight clothes
  • signs, sxs: vulvar or vag itching, burning, external dysuria, dyspareunia, odorless thick cottage cheese curd-like d/c
    • erythema of vulva, excoriations from scratching
  • dx: wet mount - budding yeast
    • gram stain - pseudohyphae
    • vaginal culture (+) for yeast
    • pH <4.7 (acidic)
  • tx: fluconazole 150 PO once
    • tx uncircumcised partners
    • short-course topical azole
    • recurrent: weekly topical /PO
    • resistant: boric acid TID x7d
118
Q

APGAR score

A
119
Q

First stage of labor

A
  • Latent Phase: begins when mom feels reg contractions, ends with 3-5cm dilation
  • Active Phase: begins with CERVICAL dilation of 3-5cm
    • at 9cm - very active/fast - monitor and augment with oxytocin
    • ends with complete dilation (10cm)
      • Protraction - not changing at rate we expect (nulliparous = <2cm/h dilation or <1cm/h descent) (multiparous = <1.5cm/h dilation or <2cm/h descent)
      • arrest of dilation = no cervical change over 2h
      • arrest of descent = no fetal descent over 1h
  • Management: Oxytocin unless large baby, monitor fetus q2-4h
120
Q

Second Stage of labor

A
  • interval between full cervical dilation and delivery of the infant
  • measured by descent, flexion, and rotation of presenting part
  • median duration = 30min - 3hr, highly variable (epidural = 1 additional hr)
  • begin pushing (dorsal lithotomy)
121
Q

Fourth stage of labor

A
  • postpartum hemorrhage most likely to occur
  • check maternal BP and pulse immediately after delivery and q15m during this time
122
Q

Mechanism of delivery

A
  • in the vertex position, includes engagement, flexion, descent, internal rotation, extension, external rotation, and expulsion
  • engagement: head enters superior strait in occiput transverse position
  • flexion: good flexion noted in most cases, aids engagement and descent
  • descent: depends on pelvic architecture and cephalopelvic relationships. descent is usually slowly progressive
  • internal rotation: during descent, head rotates so that sagittal suture occupies the anteroposterior diameter of the pelvis
  • extension: follows distention of perineum by vertex, head stems beneath symphysis, extension is complete with delivery of the head
    • crowning: when largest diameter of fetal head is encircled by vulvar ring
  • external rotation: after delivery, head rotates to position it originally occupied at engagement. Next, shoulders rotate anteroposteriorly for delivery. Then, head swings back to its position at birth
123
Q

changes and monitoring during

A
  • 6-12 gestational weeks: Uterine size and growth determined by pelvic examination, fetal heart tones 10-12 wks, UA, randome glucose, CBC, tests for: syphylis, rubella, varicella immunity, blood group, Rh, anti-Rho, HBsAg, HIV
    • GC and Chlamydia test and pap, test for sickle cell in black women
    • fetal aneuploidy testing for all women before 20wks
    • high risk for aneuploidy: noninvasive testing with cell-free fetal DNA from moms blood (screens for trisomy 13, 18, 21)
    • CVS can be performed 11-13wk
  • 12 wks: uterus palpable above pubic symphysis, fetus begins to move
  • 14 wks: GENDER
  • 16 wks: eye mvmnts, quad screen and amnio
  • 20 wks: midpnt of preg
  • 24 wks: lungs almost fully developed, US exam, pt instructed about signs/sxs PROM
  • 28 wks: GLUCOSE TOLERANCE TEST, CBC, syphilis and HIV, fetal position, kick counts
  • 36 wks: repeat syphilis and HIV tests, culture for gonorrhea/Chlamydia
  • 35-37 wks: prenatal culture - screen for GBS
  • 41 wks: cervical exam for prob of successful induction of labor, induction undertaken if cervix favorable
124
Q

Induction and Augmentation of labor

A
  • induction: process of initiating labor by artificial means
  • Bishop method: pelvic scoring
  • common indications for induction:
    • maternal: preeclampsia, DM, heart dz
    • fetal: prolonged preg, Rh incompatibility, chorioamnionitis, PROM, placental insuff., suspected IUGR, fetal abnl
  • augmentation: artificial stimulation of labor that has begun naturally
125
Q

maternal physiology during pregnancy: things that increase

A
  • Increase: blood volume, iron utilization, leukocytosis (last trim.), thrombocytosis (clotting factors), plasma volume (increased red cell mass), estrogen production (by placenta) - RAAS, increased aldo, increased Na reabs. and H2O retent., PRL, progesterone (dec. GI mot.)
    • CO, SV, HR, venous pressure in lower extrem, renal blood flow,
    • TV, insp capacity, minute vent.
    • Gastrin
    • hyperpig (linea nigra, melasma), spider angiomas, palmar erythema, cutis marmorata, hemorrhoids, thickening of hair
126
Q

maternal physiology during pregnancy: things that decrease

A
  • systemic arterial pressure (nadir 24-28wks), periph vascular resistance, blood viscosity, exp reserve and residual volume, esophageal peristalsis, emptying of gallbladder
127
Q

other physiologic changes during pregnancy

A
  • respiratory alkalosis: compensated with metabolic acidosis
  • chadwick sign: vaginal mucosa appears dark bluish red and congested
  • hegar sign: 6-8 wks of menstrual age, firm cervix contrasts with softer fundus and compressible interposed softened isthmus
  • increased pigmentation, abdominal striae
  • syncytiotrophoblast produces hCG that increases exponentially during first trimester following implantation (doubling time of hCG = 1.4 - 2 days)
    • hCG reaches peak levels 60-70d and then decreases - plateau reached at 16wks
  • intradecidual sign: anechoic center surrounded by single echogenic rim
  • double decidual sign: two concentric echogenic rings surrounded by gestational sac
    • visualization of yolk sac
    • CRL is predictive of gest. age until 12wks
  • quickening: 18-20wks
128
Q

Third stage of labor

A
  • period between delivery of the infant and delivery of the placenta
  • do not exert excess traction on umbilical cord (may cause uterine inversion) - can cause maternal mortality
  • retained placenta: does not deliver >30 min after delivery, still bleeding
  • Placenta accreta - placenta growts through the uterus d/t absence of decidua
    • RF = prior C-section, hx retained placenta, preterm delivery, age 35+, parity >5, labor induction (extended)
  • place sterile gloved hand into uterine cavity and manually remove placenta from uterus within 30min, DO NOT SEDATE
129
Q

intrauterine pregnancy signs/sxs, dx, tx

A
  • signs/sxs: breast enlargement/engorgement and colostrum, vaginal cyanosis, cervical softening (7wks), enlargement and softening of corpus (>8wk), abdominal enlargement (16wk), palpable uterine fundus above pubic symphysis (12-15wk), FHT (10-12wk)
    • the following are NOT diagnostic: amenorrhea, N/V, breast tenderness, urinary frequency/urgency, “quickening”, weight gain
  • dx: UPT, B-hCG double q48h, peak at 50-70d, fall in 2-3 timesters, progesterone remains stable during first trimester (best indicator of viable preg >25ng/mL)
  • tx: prenatal vits or folic acid (0.4-0.8mg unless prior kid with NTD then 4mg 1 mo prior to conception)
130
Q

hyperemesis gravidarum

A
  • unexplained intractable N/V/retching beginning in first trimester, peaks during 8-12wk
  • MC in young mothers and pts w/ hx of motion sickness, migraines, N/V associated with OCPs
  • signs/sxs: severe intractable N/V during preg, weight loss >5%, starts during 3-5wk
    • dehydration, ptyalism
    • complications: wernicke encephalopathy, ATN, central pontine myelinolysis, Mallory-Weiss tear, pneumomediastinum, splenic avulsion
  • dx: hypokalemia, alkalosis, UA: ketonuria, TFTs: elevated T3, elevated LFTs, bili, amylase, lipase
  • tx: supportive (hydration, vit supp, acupuncture, hypnotherapy, avoid triggers, herbal teas, vitB, ginger), >50% resolve by 16wk, 80% by 20wk
131
Q

murmur of pregnancy

A
  • MC reason for cardio assessment during preg, correlated with increasd blood volume across aortic and pulmonic valves
  • signs/sxs: most occur at 10-12wks gest., CP, palps, SOB, fatigue
    • MC: soft mid-systolic ejection murmur with greatest intensity at LSB, increased second heart sound split with insp, distended neck veins, S3 gallop and 3rd heart sound normal after midpreg.
  • dx: EKG and echo
  • tx: most resolve spontaneously by 1wk postpartum
  • diastolic murmurs are NOT NORMAL in pregnancy
132
Q

Endometritis

A
  • MC occurs after c-section or when membranes are ruptured >24hr before delivery
  • MC present 2-3d postpartum. Fever higher than 38.3 (101) and uterine tenderness are suspicious for endometritis. Adnexal tenderness, peritoneal irritation, and decreased bowel sounds may occur
  • Dx: WBC count commonly more than 20,000, causative bacteria vary widely but anaerobic strep MC, UA
  • tx: abx administered until afebrile for 24hrs (glinda plus gent = 1st line; ampicillin added if no response in 24-48h; metronidazole added if sepsis present)
    • single dose of abx at time of cord clamping reduces incidence of endometritis
133
Q

Puerperium

A
  • defined as 6-wk period after delivery
  • Immediately after deliver, the uterus is at the level of umbilicus
    • after 2d uterus involutes, 5-7d firm and no longer tender, after 2wk descends into pelvic cavity, by 6wk back to antenatal size
  • lochia (bleeding) is sloughing off of decidual tissue - can last 4-5wk postpartum
    • lochia rubra: beginning, blood, shreds of tissue (serious, reddish/browh, lasts 3-4d)
    • lochia serosa: mucopurulent, pale, malodorous
    • lochia alba: thick, mucoid, yellowish white (2nd-3rdwk)
  • in non breastfeeding women, menses resumes 6-8wk postpartum; breastfeeding women typically anovulatory and may remain amenorrheic for duration of lactation
  • 1st PP visit should be 6wk after delivery
    • on pelvic exam, perineum well healed and uterus back to pregravid size
    • lactating mothers occasionally have atrophic vaginitis
    • get Hgb and Hct, fasting glucose, EPDS (edinburgh postnatal depression scale - >/= 10 receives further assessment/tx)
    • emphasize contraception, vit supplements for nursing moms
    • atrophic vag tx w/ E
134
Q

Perineal Laceration/Episiotomy Care

A
  • Episiotomy: incision of perineum (midline or mediolateral) - ACOG recommends restricted use, increased risk 3rd and 4th degree lacs and fecal incontinence, increased postop pain and slower healing
    • indicated for shoulder dystocia, breech, forceps, vacuum
    • routine episiotomy associated with increased maternal blood loss, increased risk disruption of anal sphincter (3rd degree lac) and rectal mucosa (4th degree lac), and delay in pts resumption of sexual activity
  • tx: immediately after delivery, cold compresses applied to perineum. Perineal area gently cleansed with plain soap at least once or twice per day and after voiding or defecation
    • repair of lacs using absorbable sutures (2-0 or 3-0)
    • cold or iced sitz baths for additional pain relief
135
Q

Perineal laceration degrees

A
  • 1st: involves fourchette, perineal skin, vaginal mucous membrane
  • 2nd (MC): fascia and muscles of perineal body
  • 3rd: extends to external anal sphincter
  • 4th: extends to rectal mucosa and includes internal anal sphincter
    • RF: midline episiotomy, mid/low forceps, nulliparity, second stage arrest of labor (pushing too long), persistent occiput posterior position, local anesthesia, Asian race
136
Q

Postpartum hemorrhage etiology, RF, and sxs

A
  • RF: prolonged thrid stage of labor, multiple delivery, episiotomy, fetal macrosomia, prior hx of PPH
  • MCC excessive blood loss in pregnancy
  • sxs: pt returns to hospital a few days after delivery
    • brisk vaginal bleeding (>500mL)
  • signs: enlarged uterus or vaginal mass (inverted uterus), uterine bleeding with good tone and normal size, hemorrhagic shock
  • complications: uterine perf, orthostatic HoTN, anemia, fatigue
137
Q

Postpartum hemorrhage dx and tx

A
  • dx: CBC, coag studies (PT, PTT, platelts), BUN, SCr, type and screen
  • tx: insert fingers of one hand into vagina and compress uterus against abdominal wall
    • IV oxytocin (pitocin) 10-40units in 1L saline for atony
    • Misoprostol
    • emergent OB/GYN consult
    • D&C

PANCE (2 decks)

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