Repro

1726 Pathogenesis of male pattern adnorgenetic ahair loss:

Clinical: shorted hair follicle growth, follicular miniaturization Inheritance= polygenic Androgens are central in pathogensisis - individuals with androgeninsensitivty are unaffected - strongly influenced by DHT produced by 5 -alpha reductase soinhibitors of this can help (finasteride) Vs. alopecia areata - autoimmune hair loss - rapid onset patchy or diffuse hair loss - trx: glucocorticoids

Pathogenesis of preeclampsia?

Abnormal placenta vasculatre Placental hypxia and ischemia -> release of antiangiogenic factors into maternal circulation -> release from hypoxic placenta causes endothelial injury -> damage increases its permeability -> prteinuria + dysregulation of vascular tone -> increased BP -> end organ damagee to brain, liver

342 Woman G1Po comes to initial gyn visit, does not yet feel the fetus move. Estimated GA is 16 weeks. Hx of irregular menses. Nephew needed surgery just after birth. 2nd trimester maternal quad screening shows decreased AFP. Which is likely cause? a. dating error b. fetal abdominal wall defct c. fetal growth restriction d. fetal heart defect e. hydatidiform mole

Dating error AFP is produced by fetal liver, GI tract, and yolk sac, and levels increase with GA - GA is prob incorrect in this pt due to hx of irregular menses - do US to determine GA Incrased AFP indicates: 1. NT defects 2. ventral wall defects 3. multiple gestation Decreased ADP indicats: - aneuploidy d. heart defects not associated c. tobacco causes growth restirction e. mole - increased hcG

1957 Woman with heavy painful menstrual bleeding for 3 months. Had a bilateral tubal ligation 3 yeaers ago. Has 4 kids. Normal BMI. Uterus is uniformly enalrged. Biopsy shows secretory endometrium. LMP was 4 weeks ago and her normal cycle is 30 days. Which is the most likely cause of this patient's symptoms? a. endometrial tissue in myometrium b. greater in creased in endometrial glands comapred to stroma c. hyperplastic growth of tissue from endometrial surface

Adenomyosis Clinical: 1. heavy bleeding due to increased endometrial surface 2. dysmenorrhea 3. uniformly enlarged uterus from hormonal stimulation of endometrial glands in myometrium Endometrial biopsy shows normal secretory phase of cycle for her since she is 4 weeks from LMP (21 days) Dx: microscopic exam or hysterecotmy specimen E. Endometrial hyperplasia (grands > stroma) presents with irregular bleeding but it is usually not painful F. endometrial polyp - cause AUB but do not cause uterine enlargement

What structures to the superficial inguinal nodes drain?

All cutaneous structures inferior to the umbilicus - including external genitalia and anus up to the pectinate line, scrotum Located under the inguinal ligament

1560 In female ovary, estradiol produced by what?

Androgens - released by theca interna Converted to estradiol by granulosa cells Theca externa = CT support

12262 A woman who did not know she was pregnancy delivers a baby with Potter sequence. She took amny different meds for poorly controlled HTN over the past year. Which is the likely cause of the abnormality? a. alpha 2 adrenergic agonism b. beta adrenergic R blockade c. cellular damage from free radicals d. impaired metabolism of Ag1 e. impaired oxygen delivery f. imparied PGE production

Impaired metabolism of Ag 1 Ag2 is required for normal renal development -> use of ACE inhibitors or ARBs prevented conversion of Ag1 or action of Ag2 at AT1 receptor -> renal maldevelopment -> oligohydroamnios -> Potter sequence -> pulm hypoplasia, flat face, limb deformities a. methyl dopa and labetalol can be used in pregnancy - labeetalol can cause bradycardia, hypoglcmie and hypotension but no congenital malformations c. free radical damage increasescancer risk e. tobacco imapries O2 delivery -> IUGR and preterm deliery f. NSAIDs cause premature closure of PDA - not used for HTN

What can cause hematoma in pudendal nerve block?

Inadvertent injection into internal pudendal or inferior gluteal a.

What is the estimated fetal nuchal translucency, preg associated plasma protein and hcG in a Down syndrome fetus?

Increased nuchal translucency, decreased PAPP and increased hcG + increased inhbiin A AFP is increased in everything but aneuploidies PAPP decreased in all aneuploidies

12298 A woman with Turner's syndrome wants to know if she can coneive. How can she? a. bromocriptine b. clomiphene c. pulsatile GnRH d. hcG e. IVF

IVF Turner syndrome you have ovarian failure - with estrogen and progesterion supplment, women develop a thick endometrial lining that is substantial to support pregnancy - need to implant an ovum and then provide hormonal therapy to maintain the zygote a. bromocriptine - used for hyperprolactinemia b. clomiphene can be used for feritliity in women with ovulatory failure who are normogonadotropic, normoprolactinemic and euthyroid c. pulsatile GnRH used in women who are hypogonadotrophic hypogonadal anovulation - pit and ovarian function must be intact for this to work d hCG can trigger ovulation when follicles are mature

Woman post C section has burning pain and paresthesias, what nerve is injured?

Iliohypogastric - innervates suprapubic skin

658 Man with BPH starts taking a med which releives symptoms but also causes increased hair growth. What is MOA of med? a. decreased Leydig cell stimulation by LH b. Decreased Leydig cell androgen synthesis c. decreased peripheral androgen aromatization d. decreased peripheral androgen 5-alpha-reduction e. impaired androgen receptor interaction f. impaired 2nd messenger action

Decreased peripheral androgen 5-alpha reduction Finasteride: decreased DHT production - DHT has > affinity for testosterone R and mediates testosterone effects including development of male external genitals and prostate enlargement. - Finasteride counteracts effects and used for BPH - Decreased production of testosterone decreases androgenetic alopecia due to less androgen receptor stimulation a. decreaedLeydig cell stimulation by LH = leuprolide, goserelin B. Decreased leydig cell androgen syntehsis - ketoconzasole C. decreaed peripheral androgen aromatization - Anastrzole - used for ER positive breast cancer e. impaired androgen receptor interaction - flutamide, cyproterone, spironolactone - used to treat metastatic prostate cancer but not BPH due to anti androgen side effects

419 A child has hydrocele. This embryo defect can give rise to which other condition?

Indirect inguinal hernia Hydrocele and indirect inguinal hernia due to persistent processus vaginalis - small opening allows fluid leakage from peritoneal cavity -> hydrocele - large opening allows intestine to herniate through the patient processus vaginalis -> indirect inguinal hernia

14818 65 yo man wit BPH has gynecomastia. Obstructive urinary symptoms were nt relieved by tamsulosin so he has new medication 8 months ago and then developed gyncecomastia. Breast findings due to which effect? a. block of androgen R b. decreased testicular production of testosterone c. displacement of estrogen from SHBG d/ increased peripheral conversion of testosterone to estrone e. increased prolactin production

Increased peripheral conversion of testosterone to estrone Gynecomastia is caused by increaed estogen/androgen ration - pt most likely given 5-alphareductase inhibitor (finasteride, dutaseride) which blocks conversion of testosterone to DHT -> excess testosterone is conerted to estrogens by aromatose -> gynecomastia - develops slowly A cimetidine, spironolactone and antiandrogens (flutamide, biclutamide) block binding of androgen to R c. ketoconazole decreaes testicular production and leuprolid, goserlin supress LH and testicular testerone production d. spironolactne, ketoconazole and other meds can displace estrogen from plasma binding proteins and raise free estrogen levels

8325 A 3 wweek old baby has a palpable bulge in his beck. Feeds well and normal growth. Favors loking to the R and cries when head turned to the L. Firm mass on L side of neck that does not move when he swallows. What condition was most likely present prenatally? a. folate deficiency b. intrauterine malposition c. defective fetal collagen synthesis d. maternal alcohol use e. URI in mom

Intrauterine malposition Baby has congenital torticollis - cause: birth trauma (breech delivery) or malposition of the head in utero (macrosomia, olighydraminos) -> results in SCM injury and fibrosis - may also have additional MSK abomlaies: hip dysplasia, metatarsus adductus (adduction of the forefoot) and clubfoot - clinical: 1. head tilted toward affected side iwth chin pointed away from the contracture 2. soft tissue mass palpable in inferior 1/3 of affected SCM 3 plagiocephaly and facial asymmetry seen in severe cases

1055 17 yo boy with Klinefelter's syndrome has bilateral breast enlargement and glandular tissue is palpated under both nipple areolar complexes. Lab eval shows what? a. increased FSH f. increased prolactin

Klinefelter's characteristics: 1. atrophied, hyalinized seminiferious tubules -> low inhibin 2. damaged Leydig cells -> low testosterone 3. lack of feedback inhibition by testosteorne -> increased LH and FSH -> increased estrogen levels 4. tall stature due to increased long bone growth (low testosteorne does not stimulate epiphyseal growth plate from closing)

1987 How is lactation supressed in pregnant?

Lactogenesis begins during 2nd trimeter but lactation is supressed by high progesterone inhibiting the binding of proloactin to receptors on breast alveolar cells - post delivery -> progesterone drops -> prolactin binds receptors -> lactatin Progesteorne and prolactin both supresses FSH adn LH release from anterior pit

1688 In which phase are female gametes arrested in prior to fertilization?

Metaphase of Meiosis 2 1. Before birth: mitosis of oogonia -> primary oocyte 2. childhood to puberty: oocytes undergo meiosis 1 arrested in prophase 3. puberty: primary oocytes finish meiosis 1 4. at ovulation: secondary oocytes begin meiosis 2 and arrest in metaphae 5. once fertilized -> complete meiosis 2 Normally fertilized embryo is diploid due to contribution from ovum and sperm

1902 Newborn has impairment in sertoli cell function. HPG axis otherwise not affected. Serum hormone levels are taken. Which pattern of blood hormone levels is likely to be seen? - testosterone, inhibin, FSH, LH

Normal testosterone, decreased inhibin, increased FSH, normal LH No production of inhibin due to sertoli cell dysfucntion -> icnreased FSH Tesoterone and LH (Leydig cells) unaffected

Loss of medial thigh sensation and ability to adduct the thigh, which nerve is injured?

Obturator

Man has erectile dysfunction due to spinal cord injury at L2. Sildenafil is likely to help by acting at which labeled area?

Sildenafil increases blood flow to the penis by dilating the corpus cavernosum (increased NO via inhibition of PDE5 --> cGMP --> smooth muscle relaxation). It doesn't actually affect the blood vessels supplying the corpus cavernosum, A = Maybe the superficial dorsal vein B = Areolar tissue C = Urethra (surrounded by corpus spongiosum) D = Corpus cavernosum (correct answer)

12225 A pt with Turner Syndrome has 40% cells with XO and 60% cells with XX. What is the cause? a. germline mosaicism b. somatic mosaicism

Somatic mosaicism - affects the cells forming in the body -> manifests in affected individuals Vs. germline - affect cells that give rise to gametes -> allows affected genes to pass to offspring -> chance of affected depends on prop. of gametes that carry mutation -> affected parent does not develop clinical manifestations -> not detecable on karyotype

2066 14 month boy has failure to thrive and developmental delay. He can barely lift his head and can't sit unsupoorted. No bablling or forming words. Poor growth. Lab shows low hemoglobin, MCV 114, low RC and normal allmonia. Urine shows large amounts of orotic acid crystals. Supplementaiton with which substance would benefit the patient? a. ascorbic acid b. folic acid c. guanine d. iron e. pyridoxne f. uridine

Uridine Pt has hereditary orotic aciduria - inheritance: AR - disorder of de novo pyrmidine synthesis - clinical: physical and metnal retardation, megaloblastic anemia, elevated urinary orotic acid levels - path; defect in uridine 5' moniphosphate UMP synthease -> catalyzes conversion of orotic acid to UMP -> excretino of large amounts of orotic acid in the urine -> trx: uridine supplementation DDx: ornithine transcarbamylase also produces orotic acid urea but has hyperammonia due to impared urea synthesis (FA 60) + no megaloblastic anemia FA 389

In sites other than epiphyseal growth plate, the effect of estrogen is:

anabolic - estrogen increases osteoblast bone deposition and decreases osteoclastic bone resorption

How does exogenous hcG promote gynecomastia in men?

Binds to testicle and produces estradiol

WHich of the following is the first sign of objective puberty? a.breast bud b. axillary hair c. pubic hair d. menses e. height

Breast bud -> pubarche -> growth spurt -> menses

HIPAA requires specific pt's consent regardless of identification

But basic info can be shared such as if pt is stable or not if it is in the pt's best interest - if the pt is incapacitated

Anterior or lateral thigh numbess post delivery, what nerve is injured?

lateral femoral cutaneous - meralgia paresthetics

use of medroxyprogesterone

reduces incidence of endometrial hyperplasia and endometrial carcinoma in postmenopausal women on estrogen replacement therapy

11657 Man with prostate cancertreated with GnRH agonist develops gynecomastia. Which med could have prevented this? a. biclutamide b. danazol c. finasteride e. tamoxifen

tamoxifen Tamoxifen is an estrogen inhibitor at breast tissue and agonist at emdometrial tissue Biclutamide, finasteride would decrease testosterone/DHT effects and exacerbate gynecomastia Danazol (synthetic steroid) has androgenic and antiestrogenic effects - which can improve gynecomastia but also lead to rapid growth of prostate cancer and would not be appopriate for this pt

578 What is the mechanism of protective factors against ovarian cancer? What is the tumor marker?

Protective factors: oral contraceptives, multipaity, breast feeding Due to less repair at ovarian surface due to reduced lifetime ovarian frequency Infertility and infertility related conditions are risk factors due to repeated ovulation + hormonal therapy -> excess estrogen Tumor marker = CA 125

Abrupt onset erectile dysfunctin vs slower progression

Psychogenic vs. organic causes (vascular insuficency, medicatin related - thiaides, sympathetic blockers)

1831 The hysterosalpingogram shown in the image can result in which 2 repro tract anomalies? How do you differentiae?

1. bicornuate uterus - failure of lateral paramesopnephric ducts to fuse (partial) (vs. complete lack of fusion results in uterine didelphys) - on MRI: abnormal contour of the fundus 2. longitudinal septum - due to failure of paramesonephric ducts to involute - on MRI: normal contour of the fundus

Broad ligament of the uterus:

1. mesosalpinx - descends from fallopian tube 2. mesovarium - inferior to the mesosalpinx, covers the ovarian hilum 3. mesometrium - inferior to the mesoovarium extends from the lateral ureine body to the external iliac vessels and proximal part of the round ligamennt

299 27 yo woman G3P0 has fertility issues. Combined OCP since 22, no periods during that time. Stopped contraception to conceive but has not mensturated. Had 3 elective first triester abortion in teens. Tsh, fsh, lh, proloactin and bHCG are normal. Progesterone withdrawal tet is given. After completing progesterone course, pt has mderately heavy bleeding with cramping. Which endometrial process caused bleeding? a. apoptosis c. granulation d. hyperplasia e. hypertrophy

Apoptosis Path of endometrial shedding during menses: Menses occurs when progesterone stops being secreted by the corpus luteum when it degrades to the corpus albicans Progesterone withdrawal (also can be a progesterone withdrawal test given): 1. prostaglanding production increases -> vasoconstrictio of spiral arteries 2. increased secretion of metalloproteases by endometrial stromal cells - degradatin of ECM -> apoptosis of endometrial epithelium Net effect = dengeneration of functionalis layer -> sloughs away as menstrual flow C. granulation tissue - scar formation that deposits connective tissue and angiogenesis - prior termination put pt at risk for Ashmerman syndrome and amenorhea due to post procedural intrauteirne scarring - do not experience progesterone withdrawal bleeding as endometrium is replaced with scar tissue D. hyperplasia - enlargement of tissue or organ due to increase in number of cells - hyperplasia is precancerous due to excess estrogen that stimulates endometerial proliferation - progesterone and progesterone withdrawl test would ahve supressed endometrial prliferation E. hypertrophy - enlargement of tissue or organ due to increase in size of cells - seen in adenomyosis

What is used to treat chancroid?

Azithro

Where is sperm stored?

Caput of epididymis

What medication is given to pts at risk for preterm labor to increase fetal srvival? (if preterm PROM)

Dexamethosome to promote surfactant production and decrease the risk of RDS and mortality

334 28 yo woman G3P3 comes to ED with severe abdominal pain in LLQ and vaginal bleeding. Saturates a pad every 3-4 hours. LMP was 6 weeks ago. PSH sig for 3 C sections and permanent sterilization via bilateral tubal ligation. Urine preg test is positive and US shows 2 cm mass in L adnexa adjacent to ovary and thickened endometrial stripe. If uterine cutterage were performed which finding would be expected? a. atypical endometrial cells, disorganized glandsa nd multiple mitoses b. dilated, coiled endometrial glands and edematous stroma c. enlarged chorionic villi and avascular edematous stroma d. inflammatory infiltration of endometrial glands e. straight, short endometrial glands and compact stroma

Dilated coiled endometrial glands and edematous stroma Patient has ectopic pregnancy - most common site is ampulla of fallopian tube - appears as adnexal mass on ultrasound - risk factors: tubal pathology, such as from previous infection or surgery - tubla ligation - can become life threatening as embryo and trophoblastic tissue proliferate -> growth compormises blood supply to surrounding tissue -> rupture and profuce intrasbdominal bleeding Ruptured ectopic preg managed surgically b removing preg and hemostasis -terine specimen would show decidualized endometrium consistent with dilated coiled endometrial glands and vascularized edematous stroma - changes occur in luteal phase of menstrual cycle under the influece of progresterone as endometrium prepared for implantation u - embryonic and trophoblastic tissue is absent from uterus A. atypical endometrial cells that form glands would suggest endomatrial adenocarcinoma c. enlarged chorionic villi and vascular edematous stroma suggests molar pregnancy - absent in ectopic pregnancy D. inflammatory infiluration of endometrial glands suggests endometritis infection of decidua -> presents iwth uterine tenderness, fever, adn tachycardia E. short straight endometrial glands and compact sroma are found in early prolierative phase of menstrual cycle 4-7 days after menses

Indirect vs direct vs femoral hernias

Direct - abdominal contents protrude through a weakness in abdominal wall - do not pass through inguinal canal arnd are MEDIAL to the inferior epigastric vessels - covered by external spermatic fascia Indirect - abdomen contents through deep inguinal ring - LATERAL ot inferior epigastric vessels - covered by internal spermatic fascia Femoral hernia - acquired protrusion of abdominal contents through a weakness of the femoral canal - least common type

If twin fetuses are of the same sex, they can be

Dizygotic -> dichorionic/diamniotic OR Monozygotic -> - di/di: 0- 4 - mono/di: 4-8 - mono/mono: 8 -12 Fused if > 13 day divisn depending on when the zygote division occyrs

If twin fetuses are of different sexes, they are always

Dizygotic, dichorionic, diamniotic - can falsely appear monochorionic/monoamniotic if fuse

What is used to treat lymphgranuloma venerium?

Doxy

Histopath of DCIS

Ducts distended by pleomorphic cells with prominnet central necrosis without invading BM + microcalcifications

11762 Undescended testicle is palpated superior to the scrotum, medial to the R mid inguinal point. During orchiopexy, undescended testis will be pulled through physio opening in which structure? a conjoint tendon b. external oblique muscle aponeurosis c. femoral ring d. internal oblique muscle aponeurosis e. rectus muscle sheath f. transversalis fascia

External oblique muscle aponeurosis Normal path when testicle descends: Deep inguinal ring (opening in transversais fascia) bound by transversus abdominis muscle laterally and infeior epigastric vessels medially -> testis then passes anteromedially to exit the canal via the superficial inguinal ring (formed by external oblique muscle aponeurosis) In this pt, the testicle is between the ingunal canal and must be mobilized through the superficial inguinal ring - external oblique muscle aponeurosis a. conjoint tnedon - forms posterior wall of inguinal canal - common tendon of transversus abdominis and internal oblique muscles c. femoral ring - opening between the abdominal cavity and femoral canal - transmits lymphatic vessels but not spermatic cord d. internal oblique muscle aponeurosis - forms conjoint tendon and rectus sheath - where cremaster muscle originates e. rectus muscle sheath f. transversalis fascia - forms the deep inguinal ring but the testis has already gone through this bc it is palpable medial to the deep inguinal ring

What is the differnce in femoral and inguinal hernias?

FEmoral hernias are not reducible, inguinal hernias are

502 Pregnant woman undergoes amniocentesis and shows elevated Ach esterase. Suggests failure of which process? a. epithelial cell apoptosis in embryonic duodenum b. fusion of neural plate edges c. involution of thyroglossal duct d. meiotic disjunction of chromosome 21 e. migration of neural crest cells f. obliteration of processus vaginalis

Fusion of neural plate edges Neural tube defects are indicated by increase in AFP and Ach esterase in the amniotic fluid - occur due to failure of fusion of neural plate edges during 4th week of development - begins cervically-> extends out cranially and caudally a. epithelial cell apoptosis in embryonic duodenum - duodenal atresia c. involution of thyroglossal duct - cyst e. migration of neural crest cells - Hirschsprung f. obliteration of processus vaginalis - hydrocele or indirect inguinal hernia

What does blockade of mammary sinuses causes?

Galactocele -> can lead to breast abscess

11888 In response to increasing estrogen levels in pregnancy, myometrial cells start to express genes that encode connexin 43 and oxytocin R. These molecular changes would result in increased formation of which of the following? a. adherens junctions b. desmosomes c. fenestrae d. gap junctions e. hemidesmosomes f. tight junctins

Gap junctions Permit diffusion of molecules between neighboring cellular cytoplasms connexons - cylinder with central channel composed of 6 connexin proteins - estrogen upregulates gap junctions prior to delivery between individual myoetrial SM cells -> heightens mymetrial excitability - gap junctions consist of aggregated connexin proteins that allow passage of ions between myometrial cells - estrogen also increases expression of oxytocin (uterotonic) Rs -> mediate Ca transport through lgand activated Ca channels - combo of increase in gap junction density and Rs results in coordinated synchronous labor contractins a and b. adherens junctions and desmosomes are composed of cahderins and are involved in intercellular adhesion - cytoplasmic anchor of adherens junctions is actin filament - cytoplasmic anchor of desnosomes is intermed. filament - autoAbs against desmoglein, cadherin protein for desmosomes are found in pemphigus vulgaris C. fenestrae - gaps between endothelial cells that allow for paracellular transport - swollen fenestrae in renal flomerular cap endothelail cells are implicated in preeclampsia -> new onset HTN, proteinuria and end organ dysfunction E. hemidesmosomes - link cells to BM via integrin - transmembrane anchor - autoAbs = bullous pemphigoid F. tight junctions - claudins and occludins - paracellular barriers to water and solutes - enterotoxin from clostridium perfringens binds claudin and interferes with tight junctions in intestinal barrier -> water loss from tissue -> watery diarrhea

What type of signaling molecule is oxytocin?

Gq via phosphoinositide hydrolysis Know bc smooth muscle contraction -> increase in IC Ca+ -> increase in IP3 GnRH, Oxytocin, ADH (V1-receptor), TRH, Histamine (H1-receptor), Angiotensin II, Gastrin

1831 25 yo woman is G4P0 with recurrent pregnancy loss. PMH: L renal agenesis, has a bicornuate uerus with abnormal contour to uterine fundus. No anticardiolipin and lupus anticoag. Failure of which process is underlying mechanism of condition? a. development of paramesonephric duct b. fusion of mesonephric ducts c. involution of paramesonephric ducts d. lateral fusion of paramesonephric ducts e. veritical fusion with urogenital sinus

Lateral fusion of paramesonephric ducts Female tract development involves lateral and vertical fusion and involution of paramesonephric ducts (mullerian ducts) -> rise to fallopian tubes, uterus, cervix, and upper vagina - failed lateral fusion of pmn ducts result in anomalies of upper segments: bicornuate uterus characterized by indentation in center of fundus - complete lack of fusion: uteirne didelphys - double uterus and cervix Failed involution of pmn ducts can result in longitudinal uteirne septum Pt hysterosalpingogram shows 2 unfused uterine horns with central filling defect - can represent bicornuate uterus or longitudinal uterine septum - MRI can distinguish: 1. septate uterus has normal outer uterine contour and 2. bicornuate has abnormal contour to uterine fundus Development of pmn and mesonephric ducts are closely linked so renal anomalies can result in repro tract anomalies a. agensis of pmn ducts leads to Mayer-Rokitansky-Kuster-Hauser syndrome - lower vagina originates from urogenital sinus -> affected pts would experience infertility due to blind vaginal pouch and lack of mulerrian structures (upper vagina, uterus, cervix, fallopian ubes) b. mesonephric ducts (wolffian) do not fuse in embryonic deveolopment - females: form gartner ducts - males: form epididymis, ductus deference, seminal vesicles, ejaculatory ducts e. transverse vaginal septum - failed vertical fusion of pmn ducts with urogenetical sinus - obstructive septum causes primary amenorrhea with cyclic pelvic pain from hematometra - menses retained in the uterus - hsg cannot be performed Look in FA pg. 604-605

Spermatic cord - structure that originate in abdominal cavity and course downward towards the testes

Layers: (inward to external) 1. internal spearmatic fascia - derived from transversalis fascia 2. cremasteric fascia - derived from internal oblique 3. external spermatic fascia - derived from external oblique

11820 52 yo woman comes to office due to urine leakage with coughing and sneezing. Mild cystocele. Advised to perform exercises to strengthen pelvic floor. Which structure is target of exercise a. bulbospngiosus b. detrusor msucle c. external urethral sphincter d. internal urethral sphincter e. levator ani f. uterosacral ligamaent

Levator ani Pelvic floor injury: - risk: prolonged 2nd stage of labor, multiple vaginal deliveries, previous pelvic surery (hysterectomy) -> increased risk for pelvic floor injury - composed of: leavator ani muscles and forms a U shaped sling around pelvic viscera -> hold bladder, urethra in approp. position - injury: results in urethral hypermobility and pelvic organ prolapse( cystocele) -> results in incomplete closure of urethra and bladder neck against the anterior vaginal wall -> stress urinary incontinence -> involuntary urine loss with increased intraabdomina pressure - coughing, laughing, straining and no baldder contraction - fist line management: kegel exercise, increased fiber to prevent straighint a. bulbospongiosus - compresses vestibular bulb and constricts vagina orifice b. detrsuor - smoothmuscle lining bladder that contracts to release urine from baldder (increase tone withh PNS activity and decreased tone with SNS activity) -> overflow incontinence if sacral or autonomic neuropathy f. utetrosacral ligament - runs along lateral pelvic wall and anchors the uterus and vaginal apex by attaching to the sacrum - weakening of these ligaments contributes to uterine and vaginal apical prolapse

CA-125 is a tumor marke r for which time of cancer

Ovarian cancer arising from epithelial cells!!

11920 29 yo woman 8 days post vaginal delivery has a fever, tenderless in RLQ and flank. Hospitalized and given IV antibiotics for presumed UTI but her fever persists. No bacterial growth on urine and blood culture. What does she have?

Ovarian vein thrombosis related to vaginal deliveries Risk factors: 1. stasis from pregnancy related venous dilation and compression of IVC and iliac veins by gravid uterus 2. physio increase in clotting factors adn vwf and fibrinogen to prevent hemorrhage duering birth 3. endothelial damaage due to intrapartum vascular trauma or uterine infection Clinical features: 1. persistent fever post delivery 2 localized abdominal/flank pain 3. no response to antibiotics Thrombosis can also occur in other proximal veins - iliac, femoral, or deep popliteal - due to venous stasis and hypercoaglability

1027 Women given ceftriaxone due to PID but has trouble conceiving later. Why is this insufficient treatment of PID?

PID can occur due to gonorrhea or chlamydia - gonorrohea was treated with cephalosporin but need to give doxy or azithro to get rid of subclinical chlamydia or asymptomatic - chronic infection resulted in fallopian tube scarring or occlusion, loss of ciliary action and subsequent infertility PID: - inflammation of endometrium, faloppian tubes or peritoneal cavity (Fitz Hugh Curtis syndrome)

1739 Pudendal nerve block

PN derived from S2-S4 nerve roots and provides sensory innervation to perinuem and genitals - landmarks: ischial spines - [psteroplateral to vaginal wall and sacrospinous lgamanet - medial and posterior from ischial spine to sacrum - anesthetic should be injected medially in close prox to ischial spine through sacrospinous ligament

11890 34 yo woman has bleeding from R nipple. Noticed blood staining her undergarments on several occaisons. No masses or skin changes. No enlarged nodes. What is likely finding? a. atypical cells nfiltrating the nipple skin b. cysts lined by metaplastic apocrine cells c. liquefactiv enecrosis of adipocytes with hemorrhage d. papillary cells with fibrovascular core e. stromal prolifearting compressing ducts to slits

Papillary cells with fibrovascular core Intraductal papilloma - no masses or skin changes - proliferation of papillary cells in duct or cyst wall with fibrovascular core - can be atypical or have DCIS underlying - blood discharge - twisting of vascular stalk of papilloma in duct a. atypical cells nfiltrating the nipple skin - Paget disease of the nipple b. cysts lined by metaplastic apocrine cells - fibrocystic change with diffuse small cysts with or without metaplasia - cyclic brast pain w/o bresat discharge c. liquefactiv enecrosis of adipocytes with hemorrhage- fat necrosis - trauma precedes it - no discharge - hemorrhage e. stromal prolifearting compressing ducts to slits - fibroadenomas small firm mobile breast masses that occur due to proliferation of breast stroma and ducts - copress the ducts to slits

2021 Man with R sided testicular mass. If malignant, it would spread to which lymph node group? a. superficial inguinal b. deep inguinal c. external iliac d. common iliac e. inferior mesenteric f. para aortic

Para aortic Testesarterial supplt from abdominal aortia and take arterial, venous and lymph when they descend -> lymph from testes drains through lymph channels abck to para aortic (retroperitoneal) lymph nodes

11823 Woman has an episiotomy to expedite delivery. A cut is made at the posterior vaginal opening through vaginal adn subvaginal mucosa. Which sturecture is most likely involved in this incision? a. levator ani b. perineal body f. transverse perineal muscle

Perineal body - tendinous center point of perineum which separates urogenital and anal triangles Essenital to integrity of the pelvic floor - blends anteriorly with pernieal membrane and superiroly with rectovesical or rectovaginal septum - following structures are anchored to the perineal body: bulbospongiosus, external anal sphincter, superficial and deep transverse perineal muscles, fibers from external urethral sphincter, levator ani and muscualr coat of rectum Improper repair -> pelvic organ prolapse or dysparenuia a. levator ani - supports the pelvic floor and can be strengthened by Kegel exercises - often stretched, pushed aside and torn by fetal crowning and delivery but not incides during episiootomy f. transverse perineal muscle is cut during mediolateral episiotomy (not midlien) A

583 How does mifepristone help abortion?

Progesterone R antagonist Since progesterone maintains endometrium secretory phase for environment favorabel for implantation -> R blockade results in apoptosis and necrosis of the uterine decidua and prevents further development of first trimester preg Used with prostaglandin E1 analog Misopristol -> cervical softening and uterine contractins expulse the pregnancy

335 28 yo aoman g2p2 has worsening SOB over past week + recent hemoptysis. Ongiong vaginal bleeding after uncomplicated vaginal delivery of her son 9 weeks ago. No bleeding elsewhere. Uterus is enalrged and dnexa is normal. Lab shows increased b-hcg and CXR shows multiple bilateral lung nodules. Which would likely be found on endometrial curettae? a. bundles of smooth muscle cells with fibrosis b. diffuse hydropic chorionic villi c. fetal tissue with triploid karyotype. c. glands lined by atypical columnar epithelial cells e. proliferation of cytotrophoblasts and synctiotrophoblasts

Prolif of cyto and synctiotrophoblasts Gestational choriocarcinoma - arises from trophoblast - commonly preceded by normal preg but can occur following molar, actopic, aborted or normal preg - clinical: 1. abnormal vaginal bleeding 2. uterine enarlgement 3. increased b hcg 4. aggressive and rapidly invades uterine wall with hematageous spread thereafter - lungs are common metastasis (One of 4 carcinomas that invades hematogenously: RCC, HCC, follicular carcinoma of the thyroid) - exam: bulky intrauterine mass that is soft and yellow white with extesive necrosis and hemorrhage - histo: mononuclear cytotrophoblasts and multinuclear syntiotrophoblasts + NO villi a. bundles of smooth muscle cells with fibrosis - myoma (fibroids) - menstrual irregularities and pelvic P b. diffuse hydropic chorionic villi - complete mole - can lead to choriocarcinom c. fetal tissue with triploid karyotype - partial moles c. glands lined by atypical columnar epithelial cells - endometrial hyperplasia

What is a placental site trophoblastic tumor?

Proliferation of intermediate trophoblasts -> produces human placental lactogen

11919 35 yo woman G1P0 at 40 weeks gestation has protrated labor course and has C section. Shortly after delivery she has chest pain and difficulty breathing. She becomes hypotensive, bradycardic, hypoxic and unresponsive and undergoes emergency intubation. Surgical incision begins to bleed profusely and goes into cardiopulm arrest. Declared dead after 30 min of cardiopulm ressucitation. What is most likely finding in her lungs? a. alveolar ducts lined with hyaline membranes b. elargement of air spaces adn alveolar septal destruction c. giant cell foreig body response in lower lobe of R lung d. pulmonary arterioles with lipid globules e. pulm a. brach with swirls of fetal squamous cells

Pulm a branch with swirls of fetal squamous cells Patient has amniootic fluid embolism - rare complication during preg or shortly after delivery - Amniotic fluid contains AA metabolistes that enter maternal circulation through sites of uterine trauma or cervical lacerations -> anaphylactoid rxn (due to metabolites) -> occlusion and vasospasm of maternal pulm circulation -> LV failure -> decreased CO and severe VQ mismatch -> cardiopulm arrest due to hypoxia and hypotensive shock - tissue factor is also reselased from amniotic fluid and triggers disseminated intravasc coagulation - histo: fetal squamous cells and mucin in maternal pulmonary arteries a. ARDS - can develop in patients who survive early phase of amniotic fluid embolism but this pt did not c. Giant cell foreign body response - aspiration pneumonia - involves lower lobe of R lung -> histo shows inflammation and foreign body response with giant cells - risk: recumbent position with impaired consciousness (general anesthesia), symptoms include hypxia but patietns have fever and focal crackles

1795 Raloxifene vs Tamoxifen

Raloxifene - estrogen agonist at bone, antagonist at breast and uterus Tamoxifen - estrogen antagonist at breast, agonist in uterus and bone

What structures do the deep inguinal nodes drain?

Reside under the fascia late on medial side of the femoral vein Receive drainage from superficial inguinal nodes, deep lymphatic trunks along the femoral vesseels, from the glans penis and clitoris also drain directly to thse nodes, cutaneous portion of the calf

What structure is clamped and divided to enter the peritoneum of the broad ligament during a hysterectomy?

Round ligament - contains artery of Sampson Originates at uterine fundus -> courses through inguinal canal out to labia majora

11961 Woman 2 days post abortion has pelvic pain, fever and chills. temp of 101, bp of 92/60 and pulse is 102/min. Speculum shows open cervical os with foul smelling tissue in vaginal canal. Bimanual exam shows moderate uterine tenderness and no adnexal masses. Which s the most likely cause of this patient's condition? a. gardeneralla b. staph aureus

Staph aureus This pt has a septic abortion - infected retained products of conception in the uterine cavity - prx: fever, abdominal pain, uterine tenderness, foul smelling vaginal discharge - common pathogens: s aureus, gram negative bacilli (E coli), group B strep - all part of normal vaginal flora that seed the uterine cavity during instrucmentaiton -> proliferating in retained tissue - most infections associated with septic abortion are confined to placental tissue -> pts can become septic if toxin producting bacterial gain access to intervillous space and bloodstream - trx: Abc and surgical evaculation - complications: adhesions in uterine cavity that can lead to amneorrhe and infertility (asherman syndrome) a. Gardeneralla is also part of normal vaginal abcterial flora - imbalance in vaginal exosystem causes overgrowth but this does not present with fever or uterine tenderness

What structures does the infeiror mesenteric nodes drain?

Structures suppled by inferior mesenteric artery - L colic, sigmoid, superior rectal arteries - nodes drain the descending and sigmoid colon as well as upper rectum - efferents drain to pre aortic nodes

What structures does the external iliac nodesdrain?

Superficial and inguinal nodes and deep lymphatics of abdominal wall below the umbilicus

Function of bulbospongiosus

Superficial perineal muscle men: penile erection and ejaculation women: vaginal canal closure and orgasm in women Dysfunction leads to sexual impairment but not defecatory dysfunction

1632 A woman is getting her R ovary and a mass removed. To acoid excess bleeding, surgeoun should ligate which structure? a. mesosalpinx b. ovarian ligament c. roung ligament of the uterus d. suspensory ligament of the ovary e. transverse cervical ligament

Suspensory ligament of the ovary Ovaries are suspended by the mesovarium superiorly, ovarian ligament medially and suspensory ligament of ovary laterally - suspensory ligament of ovary isa fold of peritoneum that attaches the ovary to the pelvic sidewall and contains ovarian artery (major ovarian blood supply from abdominal aorta entering the ovary at the hilum) vein, lymphatics and nerves - must be ligated to prevent heavy ovarian bleeding in oophorectomy

1056 61 yo woman comes to office due to skin dimpling on R breast. She first noticed skin changes 3 months ago while on vacay and is cnocerned they haven't resolved. There is prominent, notender skin retraction without discoloration or swelling of the R breast. Also 6 cm irregular, immobile firm mass in RUQ of breast. L breast is normal. Skin findings are due to malignant infiltration of what? a. axillary lymph nodes b. lactiferous ducts c. mammary vein d. nipple e. suspensory ligaments

Suspensory ligaments Invasive breast cancer presents as irregularly shaped, adherent breast mass - upper outer quadrants of breast are most common site of breast cancer - overlying skin retractions (puckering) - singal involvement of suspensory ligaments of breast (cooper ligaments) - malignant infiltration of ligaments causes fibrosis and shortening -> traction on skin with distortion in breast contour A. axillary lymph nodes - common site of metastasis - maligant cells spread through lymphatics -> block flow -> peau d'orange = thickened dimpled skin like orangle peel but this is different from skin retractinos and shows swelling and discoloration B adn D: lactierous ducts connects niiple to mammary lobules to allow lactations - malignant spread of ductal carcinoma through ductal system may cause nipple discharge - spread to nipple surface causes Paget disease of the nipple - eczematous exudate over nipple and areola C. internal mammary vein runs along thoracic lymphatics, draining medial portions of breast and may be site of metastasis from lesions in that area - spread to vasculature results in distant hematogenous metastasis

What is most common germ cell tumor in women?

Teratomas Women 10-30

What is the earliest sign of secondary sex characteristics in boys?

Testicular growth -> penile growth -> pubarche -> growth spurt -> spermatogenesis Look at Tanner chart FA pg. 623

How are nifedipine and indomethacin used in pregnancy?

Tocolytics Nifedipine - CCB blocks myosin kinase phosphrylation -> myometrial relaxation Indomethacin - inhibits prostaglanding production -> decreases uterine contractility

In what structure is the uterine artery and when is it ligated?

Transverse cervical ligament - from cervix and lateral fornix of vagina to lateral pelvic walls - ligated during hysterectomy but not adnexal surgery

How does progesterone prevent pregnancy?

Thins uterins lining -> impairs embryo implantation Thickens cervical mucous -> prevents sperm from accessing uterus

In Peyronie's disease, where does excess collagen deposit?

Tunica albuginea - fibrous tissue that overlies the testicles beneath the tunica vaginalis

What structures do infraclavicular nodes drain?

Upper limb and breasat

8468 Why are there still viable sperm in the ejaculate 3 months post vasectomy?

Vasectomy involves transection of vas deferens - functions as transport duct from epididymis to ejaculatory duct and stores and protects sperm following spermatogeneiss Vasectomy blocks transport of new sperm from epididymis but has no effect on serpm distal to the ligation already in the VD - pts can have viable sperm in distal vas for 3 months and 20 ejaculations following vasectomy - intercourse can be resumed within a week following the procedure

What structures does the common iliac nodes drain/?

internal and external iliac nodes

Labialscrotal anesthesia + loss of sensation of medial thigh occurs due to injury to what nerve?

genitofemoral