Clinical Medicine II Exam 4
Chronic anovulation
What is the most common cause of abnormal uterine bleeding?
Skin injury
What is the most common cause of necrotizing fasciitis?
Lanolin ointment
prevents nipple inflammation-use after each feed and safe for baby (Lansinoh or similar)
Menorrhagia
prolonged or excessive bleeding that occurs at regular intervals (loss of > 80 mL of blood that lasts for > 7 days)
Foley bulb insertion
put inside cervix and inflate bulb-mechanical stretch tells cervix to do labor What mechanical dilation is this that causes cervical ripening and induction of labor?
False labor
regular or irregular uterine contractions that don't result in cervical change What is this?
True labor
regular uterine contractions that cause cervical change contractions start at the fundus and move inferiorly-contract to pull cervix open What is this?
Late decelerations
related to placenta-end of contraction goes down and slowly back up as pressure is relieved on placenta-says placenta not working right Peak after the peak of the contraction Slow decrease, not usually deep, slow return to baseline Uteroplacental insufficiency ABNORMAL IN LABOR Really bad get C section to make sure fetus is not acidotic in utero while in labor What is this with intrapartum fetal surveillance?
Vasal occlusion
reversible Newer technique, done with microsurgery Vas deferens occluded with a silicone plug Easier reversal, not widely available non-reversible Sclerosing agent injected into vas deferens What non-vasectomy procedure is this?
Meconium aspiration syndrome
stool in colon time of delivery-no bowel movements in amniotic sac but if stressed may have one which causes sticky black stool-lots of dead cells-go into amniotic fluid and end up inhaling matter into lungs-cause norm preg to be hypoxic baby What is this that happens with postterm pregnancy?
Meconium
thick dark stool that neonate initially passes May be passed antepartum in times of fetal stress/distress More likely to have "THIS staining" in post-dates pregnancy THIS Aspiration Syndrome Usually occurs prior to onset of labor from chronic meconium Can occur at time of delivery *Deep suctioning doesn't improve outcomes*
Hypomenorrhea
unusually light menstrual bleeding or spotting
Primipara
woman who is giving birth for the first time
Chlamydia (most frequent) Gonorrhea
What are the 2 most common pathogens causing cervicitis?
Levothyroxine
What med should you give a prego woman who has hypothyroidism?
Metabolic syndrome
What should you screen for with PCOS?
Nitrous oxide
Acts on NMDA and GABA receptors 50% Nitrous/50% oxygen, self-administered What is this that helps with pain management in labor?
Micronor (norethindrone)
Most useful in lactation MUST be taken same time every day Doesn't reliably block ovulation What progestin only contraceptive is this?
Benign
Are breast cysts benign or malig?
Endocervix
Estrogens cause secretion of thin, clear, watery mucous Maximal at ovulation Facilitates sperm capture/storage/transport Women monitor this mucous production to optimize timing of intercourse Not reliable What contraception change is this?
Third
Delivery of the placenta-5 mins detaches and is delivered What stage of labor is this?
Placental position
Determine what prior to speculum exam or cervical exam with third trimester bleeding?
Age Tumor size Ultrasound features Labs
Discovery of a pelvic mass should take into consideration 4 things which are?
Mastitis
Fever with tender breast is a sign of what with breastfeeding and seen by provider to treat with antibiotics?
Secondary Amenorrhea
In women who have passed menarche Occurs if a menstruating woman has not menstruated for 3 consecutive months What is this?
DKA Pre-eclampsia Worsening retinopathy
Increased risk of WHAT in type 1 diabetes in pregnancy?
Same
LH levels incr, decr, or the same during menopause?
NST-non-stress test
Measures fetal heart rate activity and autonomic nervous system health 2 or more accelerations > 15 bpm x 15sec in 20 min = reassuring What is this with antenatal fetal testing?
Placental maturity
Placentas mature faster in mothers with hypertension, drug use Seen as calcifications on ultrasound What is this with 3rd trimester US?
Endometrial cancer (obesity, unopposed estrogen, meds-COC, breast cancer, ovarian cancer all seen with endometrial cancer)
Post menopausal bleeding is what unless proven otherwise??
42
Pregnancy beyond WHAT completed wks of gestation is known as postterm pregnancy?
Control symptoms Screening exams
The management of menopause is multifaceted and consists of what else?
NSAIDs
What is the first line treatment for primary dysmenorrhea?
Color Doppler US
What is the preferred dx test for testicular torsion?
Gravidity
What is the term for pregnant?
50 years old
When does screening start with PSA?
Endometrial cancer
*Unopposed estrogen therapy* Obesity Increasing age Tamoxifen therapy (Questionable - may be used for treatment in advanced stage) Early menarche *Late menopause (after age 55)-had more estrogen longer* Nulliparity *Polycystic Ovarian Syndrome (PCOS)* Diabetes Type 2 Estrogen secreting tumor Family history of endometrial, ovarian, or colon cancer What risk factors are these for?
Phenylephrine
, a pure alpha-adrenergic agonist, is considered the sympathomimetic of choice for ischemic priapism by the American Urological Association has minimal risk of cardiovascular side effects compared to other sympathomimetic medications such as epinephrine, norepinephrine, and ephedrine
Perimenopause
Considered from late 30s to early 40s Average age for menopause is 50-52 Median age 51.5 95% of women experience menopause from ages 44-55 FSH levels trending over years from 6-10 IU/L to 14-24 IU/L Begin to develop some unpleasant symptoms and signs of decreased estrogen levels What is this?
Decr renal excretion Trying to incr follicle release
Why do FSH levels rise more than LH during menopause?
Nulligravida
Woman who has never been prego
Premature Ovarian Failure
Women who reach menopause prior to the age of 40
Referral
●Symptoms in the setting of autonomic or severe peripheral neuropathy ●Symptoms following invasive treatment of the urethra or prostate ●Men <45 years old ●Abnormality on prostate exam (nodule, induration, or asymmetry) ●Presence of hematuria in the absence of infection ●Men with incontinence ●Severe symptoms (IPSS ≥20) What does this indicate for BPH?
Prostate Cancer
"Normal" 0-4 ng/ml 25% of men with THIS have PSA levels < 4ng/ml Prostate-specific but NOT cancer-specific What causes elevations of PSA? BPH (1/3-1/2 of men with BPH will have elevated PSA) Acute Prostatitis Prostate Cancer Prostatic Trauma Ejaculation - returns to baseline within 48hrs ? DRE What is this associated with?
Fetal Fibronectin
*Glycoprotein found in the cervix early in pregnancy and near term* Test performed as a swab in the posterior fornix Only valid if NOTHING has been in the vagina in the past 24 hours and the membranes are not ruptured Elevated fFN doesn't rule in labor *NEGATIVE fFN has excellent negative predictive value the labor will occur in the next week.* What is this with preterm labor predictors?
Folic Acid
0.4-0.8mg mg daily prior to and during pregnancy Prevents neural tube defects For women with prior NTD pregnancy 4mg folic acid in a separate supplement What is this with prego?
Premature Ovarian Failure
1% of population who suffer menopause prior to age 40 Suspect in young woman with hot flushes and other symptoms of hypoestrogenism and secondary amenorrhea Diagnosis is confirmed: at least 4 months of amenorrhea & 2-3 serum FSH levels >40mlU/mL obtained at least 1 month apart in women <40 years of age Must perform careful work up on these patients to identify the underlying cause and permit appropriate management What is this?
Domestic abuse
1. Tensions Building= tensions increase, breakdown of communication, victim becomes fearful and feels the need to placate the abuser 2. Incident= verbal, emotional, and physical abuse. Anger, blaming, arguing. Threats. Intimidation. 3. Reconciliation= abuser apologizes, gives excuses, blames the victim, denies the abuse occurred, or says that it wasn't as bad as the victim claims 4. Calm= incident is "forgiven" no abuse is taking place. They "honeymoon" phase. What cycle is this?
Postpartum depression
10+% of moms, Predictor = depression during pregnancy; prior h/o mood issues; multiple stressors-social stressors other children 2 weeks to 12 mos PP; lasts 3-14mos SSRI's and/or psychotherapy Screen with Edinburgh scale What is this?
Nuva Ring
15 mcg ethinyl estradiol and 120 mcg of etonorgestrel daily No fitting needed 3 weeks in, 1 week out What combined contraceptive is this?
Second trimester ultrasound
18-22 weeks Anatomical survey Face Abdominal wall/diaphragm Limb assessment Spine assessment Cardiac eval - 4 chambers Cervical length if patient at risk for preterm delivery Done transvaginally, should be 3-4cm in length Fetal growth BPD - biparietal diameter HC - head circumference AC - abdominal circumference FL - femur length Placentation Location Umbilical cord vessels and flow What is this?
Laceration
1st degree - through perineal skin 2nd degree - through skin and perineal body 3rd degree - to perirectal muscles-common! 4th degree - through rectum-go to OR to be repaired-fecal incontinence later is the risk-put rectum back together What is this?
Ethinyl Estradiol
20-35mcg daily "low dose" preps (20-30 mcg) Strict schedule More risk breakthrough bleeding More risk "oopsie" Less risk of side effects High dose (50 mcg) rarely used d/t side effects Take at same time everyday!! What common COC is this?
Mammogram and/or US
80% sensitive in detecting a palpable mass WHAT under age of 30 is not routine, due to breast density, but can still be used when evaluating a mass. Under age 30 an US is also needed. What exams are these?
G4T2P1A1L3 G4P3
4 pregnancies, one miscarriage, one delivery at 32 weeks, 2 at term, 3 living children G T P A L OR...... G P is what??
Postpartum thyroiditis
5-10% of women w/o thyroid disease Thyroid antibodies (typically anti-thyroid peroxidase) develop during pregnancy Typically presents as new onset hypothyroidism Typically resolves on its own...progresses in only 11% who get it May have relative thyroiditis following delivery and then resolves-3 months post-partum really feels bad check thyroid and see TSH is high have THIS??
Postpartum visit
6 weeks (4 weeks if planning tubal ligation or IUD placement) PAP if indicated, followup on antepartum issues Breastfeeding follow up Mood screen - Edinburgh scale Perineal/Urinary/Bowel issues Relationship with partner Return to work Contraception-breast feeding when want to start contraception What is this?
Postpartum blues
70-80% of moms Resolves <2 weeks Reassurance What is this?
Axillary
75% breast lymph drainage occurs through what nodes?
Pathologic
A 42-year-old female Serous unilateral discharge Ductography- filling defect Cytology - malignant epithelium Biopsy- intraductal carcinoma This tells you what with nipple discharge?
Spontaeous hemorrhage
Corpus Luteum Cyst Second is a rapidly enlarging luteal-phase cyst into which there is WHAT? May rupture late in the luteal phase, resulting in acute pain Possible to present with evidence of hemoperitoneum as well as hypovolemia and require surgical resection of the bleeding cyst
Hand on shoulder-overbearing partner, anxious and distressed with questions, newly prego, severe abdominal pain Do you have bruises or injuries, happy with pregnancy, safe at home, is he happy with pregnancy, is he the father, anyone abusing you or forcing you, anyone you can confide in (Case Conclusion: The patient reveals that her boyfriend is unhappy with the pregnancy, as it is unplanned. He pushed her yesterday, and she has been frightened since. She requests assistance to go and stay with her parents until she can decide what to do about her relationship. Social services are called to assist her with her plans, and her parents pick her up in the ED)
A 25-year-old woman presents to the ED with severe abdominal pain worsening over the last 24 hours The pain coincides with the diagnosis of a new pregnancy for her and her live-in boyfriend. She gives abrupt answers to all questions, and is anxious and distressed during the interview. Her boyfriend is hovering at the bedside, keeping his hand on her shoulder at all times. With some difficulty, he finally agrees to leave the room for her pelvic examination. It is explained that this is standard procedure for the pelvic exams in the ED. What are your initial concerns? What additional questions will help you determine if there is abuse involved?
dull
Corpus Luteum Cyst: 1st is a slightly enlarged corpus luteum which may continue to produce progesterone for longer than the usual 14 days Often associated with WHAT pain PE usually shows an enlarged, tender, cystic, or solid adnexal mass May benefit from OCP
Postpartum Hemorrhage
Active management of 3rd stage of labor: Allow spontaneous delivery of placenta Continue Pitocin-clamp blood down in uterus Don't clamp cord until it stops pulsing Uterine massage after delivery of placenta-on top of abdomen to encourage it to clamp down-decr risk of bleeding 500cc blood loss-placenta and blood from detachment Longer labor more likely bleed more Manage like extreme blood loss-fluid, transfusion, make bleeding stop-meds, uterine massage, operation measures Prevent and treat like in shock What is this?
Uterine Leiomyoma (Fibroids)
Benign tumors within uterus and hormone sensitive-bigger and smaller-enlarge in size-can be anywhere in uterus-pedunculated most common Subserosoal outer edge growing out Submucosal inner edge growing in Intramural stuck within wall of uterus Can bleed like crazy and need emergency surgery See during menopause-uterus atrophies and most often do not get smaller Represent localized proliferation of smooth muscle cells surrounded by a pseudocapsule of compressed muscle fibers See on US-black is fluid filled lesions-cancer is densely filled and have vasculature and different colors What is this?
PMS
Abdominal pain Bloating Breast tenderness Ankle swelling Sense of increased weight gain Skin disorders Irritability Aggressiveness Depression Inability to concentrate Libido change Lethargy Food cravings Headache Acne Fatigue Hot flushes What are these symptoms of?
endometrial ablation or hysterectomy
Abnormal uterine bleeding that does not respond to medical therapy often is managed surgically with what?
Preeclampsia
Cardiovascular Elevated blood pressure due to vasoconstriction and increased cardiac output Hematologic Volume contraction Hemolytic anemia leads to thrombocytopenia possible DIC Third spacing of fluid due to decreased oncotic pressure Renal Decreased GFR leads to proteinuria Serum uric acid increases Neurologic Hyperreflexia Seizures Pulmonary Pulmonary edema due to decreased oncotic pressure, heart failure, or combo Fetal Decreased placental perfusion leads to IUGR Oligohydramnios-low amnio fluid Increased perinatal mortality Decreased placental function during labor may lead to cesarean delivery bc of stressed labor and fetus These are effects of WHAT?
Acute Bacterial Prostatitis
Acute infection of the prostate Category I
Premenstrual syndrome (PMS)
Affects 40% of premenopausal women Typically seen ages 25-40 5-8% have severe symptoms Variable cluster of troublesome physical and emotional symptoms that occur in the luteal phase of the menstrual cycle Symptoms interfere with some aspect of the patient's life Symptoms usually resolve with onset of menses or cessation of menses Dx: Specific symptoms Timing with which symptoms occur Severity of symptoms Absence of hormone or drug ingestion & the exclusion of other diagnoses What is this?
Asthma
Affects < 10% of pregnant patients Can have a variable course in pregnancy If moderate or severe persistent - Routinely check FEV1 Decreased FEV1 can increase risk of low birth weight Continue usual step therapy What is this with pregnancy?
Contraception
Age Smoking-estrogen incr risk for blood clots and smoking does too Blood pressure History of blood clots Migraine w/aura Allergies These are medical issues related to what?
Breast cancer
Age >50 Female Obesity Personal history (atypia, lump, biopsy, CA) Family Hx -BRCA gene or1° relative with breast or ovarian cancer Highestrogen exposure-early menarche, nulliparous, late 1st pregnancy, late menopause, use of oral contraceptives or HRT Alcohol >1 per/day Tobacco use Dense breasts Radiation exposure Diet- high in dairy, processed meat, sugar, hydrogenated oil What are these risk factors for?
Domestic Violence
Age between 17 and 28 years Interracial relationships Interreligious relationships Separation or divorce Mental or physical disability Financial dependence on spouse Wives earning more than spouse Husbands earning less than expected What additional risk factors are these for?
Cancer
Age specific serum PSA reference ranges PSA Velocity Change in PSA ≥ 0.75 ng/ml/yr suggests growth due to *WHAT* and not BPH % Free PSA Total PSA=Free PSA + complexed PSA Can help define risk of *WHAT* in patients w/ nl DRE and PSA 4-10 ng/ml
PCOS
Although androgen levels are typically elevated in women with PCOS, progesterone levels are low due to anovulation The precise mechanism leading to anovulation is unclear, but hypersecretion of LH has been implicated in menstrual irregularity Anovulation may result from insulin resistance When chronic anovulation is present, serum prolactin and LH assays should be done to exclude hypothalamic and pituitary diseases What pathophys of anovulation is this associated with?
Fetal alcohol syndrome
Cause of developmental delay and mental retardation Dose related toxicity Highest risk in the 1st trimester Growth restriction Facial abnormalities CNS dysfunction/behavioral disorders What is this with prenatal care?
Ovarian Cysts
Anatomic variations that arise as a result of normal ovarian function Ovarian follicle fails to rupture during follicular maturation, ovulation does not occur, and a follicular cyst may develop Follicular cyst becomes clinically significant if it is large enough to cause pain or if it persists beyond one menstrual interval Cysts may enlarge beyond 5 cm and continue to fill with follicular fluid from the thickened granulosa cell layer What is this?
Ovarian Hyperthecosis
Androstenedione production is so great that testosterone reaches concentrations that cause virilization Must rule out androgen-producing tumor first Symptoms Temporal balding Clitoral enlargement Deepening of the voice Remodeling at the shoulder girdle Acanthosis nigricans & insulin resistance to a much greater degree Refractory to oral contraceptive suppression Difficult to induce ovulation What is this?
Corpus Luteum Cyst
Another type of functional ovarian cyst Designated a cyst rather than simply a corpus luteum when its diameter exceeds 3 cm Related to postovulatory (progesterone-dominant) phase of the menstrual cycle What is this?
PCOS
Anovuation in women with THIS Charcterized by inappropriate gonadotropin secretion Alterations in gonadotropin-releasing hormone (GnRH) pulsatility leads to preferential production of luteinizing hormone (LH) compared with follicle-stimulating hormone (FSH) Serum LH levels rise 50% of affected women Luteinizing hormone Follicle-stimulating hormone (LH:FSH) ratios are elevated and rise above 3:1 in approximately 60 percent of patients-norm is 1.5:1 What pathophys gonadotropins is this associated with?
Shoulder Dystocia
Anticipate in ANY delivery Anterior shoulder is STUCK at pubic bone DON'T PULL ON THE HEAD!!!! Pulling on the head results in brachial plexus injury Big baby, long labor, or small pelvis Push legs back to ear helps open pelvis What is this?
PID
Appendicitis Ectopic Pregnancy Septic abortion Hemorrhagic or ruptured ovarian cysts or tumors Twisted ovarian cyst Degeneration of a myoma Acute enteritis Acute cholecystitis (Fitz-Hugh-Curtis Sundrome) "Violin string sign" -attached to abd wall Perihepatitis May or may not have signs of PID RARE What DDx is this for?
Benign Painless (unless prego and become painful)
Are fibroadenoma benign or malig? Painful or painless?
Endometrial
Central to the development of endometrial hyperplasia and WHAT cancer is overgrowth of endometrium in response to excess unopposed estrogen Endogenous Source: Glandular Estradiol (Ovary) Estrone (Ovary) Peripheral (Estrone stored in fat & conversion from androstenedione)-from obese pts-risk of breast cancer higher Tumor Exogenous Source Conjugated estrogen Lyophilized (freeze dried) estradiol Cutaneous patches Vaginal Creams What pathophys cancer is this for?
1 2
Augmentation of Labor: If labor fails to progess WHATcm/hour in primipara (during active phase of stage 1) WHATcm/hour in multipara (during active phase of stage 1) May be slower in epidural anesthesia
Pitocin/Pit/Oxytocin
Augmentation of Labor: Various dosing regimens Frequently use IUPC to measure "power" Can hyperstimulate uterus Short half-life allows acute alterations in dosing What is this?
Surgical considerations
Avoid placing patients in 2nd/3rd trimester in fully supine position May require more O2 Delayed gastric emptying increases risk of aspiration Check fetal heart tones before and after procedure. External fetal monitoring considered if available, and appropriate stage of gestation (not reliable before 22-24 weeks EGA) Do not lie flat on back bc belly compresses vena cava which decreases venous return and they will feel faint-after 22-24 wks have them lay on side-during surgery same thing-weight of uterus off vena cava-can have aspiration during surgery and anesthesia What is this with pregnancy?
Thoracodorsal nerve
Axillary Innervates the latissimus dorsi. Adducts, extends and medially rotates the arm. What innervation is this?
Listeria monocytogenes
Bacteria found in undercooked/uncooked foods Maternal infection can result in fetal death Risk significantly decreased with newer USDA regulations What infection is this that affects prego?
Two Day method
Based upon the presence or absence of cervical secretions. ANY secretions on the current or previous day = FERTILE NO secretions today AND yesterday = NOT FERTILE What fertility awareness is this?
Breast Cysts
Benign Most common mass in women age 40-60 Fluctuates in size with menstrual cycle Evaluate with US followed by FNA or core biopsy Treat by Aspirating large symptomatic cysts What is this?
Warm compresses Pumping milk
Blocked milk ducts are painful and tender without fever or systemic signs of illness - treat with what?
Decreases Increases
Blood pressure WHAT throughout first trimester and early second trimester Slowly WHAT with increased placental size through rest of gestation
Anemia
Blood volume is expanded in pregnancy, by about 1 liter Dilutional anemia = Hgb < 10g/dL Maintain iron stores with prenatal vitamins Most have 27-60mg elemental iron Balance iron supplementation with constipation Treat iron deficiency with 60-120mg elemental iron daily What is this with pregnancy?
65
Bone Density Screen needed before age WHAT for patients with the following risk factors: History of fragility fracture Body weight less than 127 lbs. Medical causes of bone loss (Medications or diseases) Parental medical history of hip fracture Smoking/Alcoholism Rheumatoid Arthritis
20 30
Cervical length via diagnostic TVUSG (at time of presentation) < WHATmm = 25% risk of delivery in 7 days > WHATmm = low risk of preterm delivery regardless of other data bc a closed thick cervix
2.5 26
Cervical length via transvaginal ultrasound screening Cervical length > WHATcm prior to WHAT weeks = lower risk of preterm birth
Breast
Breast Pain Nipple Discharge Breast mass Difficulty nursing Rash, Sores, or Skin change Size - cosmetic or functional These are complaints of what?
Breast cancer
Breast feeding Parity Recreational ex Postmenopause body mass index Oophorectomy before age 35 Aspirin What protective factors are these for?
Pelvic Organ Prolapse
Bulge or protrusion in the vagina Urinary and/or fecal incontinence Sensation of incomplete bladder emptying Dyspareunia What presentation is this for?
Contraceptives
Calendar Method Cervical Mucous Method Basal Body Temperature Method Ovulation Tests Detecting Infertility What are these related to?
Clotrimazole or miconazole
Candidal Balanitis May be a presenting symptom of diabetes mellitus Evaluation for diabetes is needed Initial treatment with a topical WHAT 1 percent or WHAT 2 percent applied twice daily
Fetal growth
Checking interval growth in known IUGR, maternal hypertension, other risks (advanced maternal age, etc) Check if fundal height 3cm less or more than expected for EGA What is this with the 3rd trimester ultrasound?
AFI-amniotic fluid index
Checks for level of amniotic fluid - too little or too much can be indicative of complications A 2cm x 2cm pocket of amniotic fluid is reassuring What is this with with 3rd trimester ultrasound?
Premature rupture of membranes
Consider EGA, fetal well-being, contractions, possibility of chorioamnionitis If at TERM Await spontaneous labor, usually within 24 hours If PRETERM Inpatient expectant management on bedrest-watch and wait Give steroids if 24-34 weeks to improve fetal outcomes Monitor for contractions, fever Inverse relationship between EGA and latency to delivery ? Tocolysis ? Stop labor or no bc there is a reason If infection suspected, proceed to delivery, give IV ABX What management is this for?
Spontaneous Abortion
Chromosomal anomalies...50-70% Systemic disease DM Thyroid disease Lupus Environmental SMOKING, Frequent high doses of EtOH >4 cups/day of coffee Infections Bacterial vaginosis Vaginal Group B strep Chlamydia Listeria Toxoplasmosis, Rubella, Cytomegalovirus Advanced maternal age (>35) Risk of spontaneous abortion increases with maternal age (can be over 40% in women over 40) Coagulopathy Assisted reproduction Asherman Syndrome-septic abortion-infectious or elective termination causing scarring in the endometrium-baby can't grow These are risk factors for what?
(Category III) Chronic Pelvic Pain Syndrome (CPPS)
Chronic genitourinary pain in the absence of uropathogenic bacteria localized to the prostate gland with standard methodology
Chronic Bacterial Prostatitis
Chronic infection of the prostate Category II
Pelvic Pain
Chronic pelvic pain Pelvic adhesions-surgery-scar tissue-pull up bladder and uterine-surgical excision is treatment GI dysfunction Dysmenorrhea Pelvic Inflammatory Disease Ovarian cysts Symptomatic Uterine Retroversion Ectopic Pregnancy Adnexal Torsion Rupture of a Corpus luteum cyst Neoplasm What is this DDx for?
Endometriosis
Classic symptoms include progressive dysmenorrhea and deep dyspareunia Severity of symptoms may not match either the location or extent of the disease Pain is thought to depend more upon the *depth of invasion* of the implants rather than on the number or extent of the superficial implants Dysmenorrhea: The dysmenorrhea usually worsens over time bc of scaring Consider in patients with dysmenorrhea that do not respond to OCP or NSAIDs Dyspareunia: Often associated with uterosacral or deep posterior cul-de-sac involvement with THIS Reported on deep penetration, although there is not correlation between dyspareunia and the extent of THIS What is this?
Feeding difficulty
Cleft palate will cause what with breast feeding issues?
Cervicitis
Clinical Findings Purulent or mucopurulent vaginal discharge and/or postcoital bleeding Dysuria Urinary frequency Dyspareunia Vulvovaginal irritation No cervical motion tenderness No fever No abdominal pain What is this?
Benign Prostatic Hyperplasia
Clinical Manifestations Symptoms: "Prostatism" LUTS Lower Urinary Tract Symptoms Incomplete bladder emptying Urinary Retention Detrusor instability UTI Hematuria Renal Insufficiency Weak relationship between prostate size & severity of symptoms What is this?
Urethritis
Clinical Presentation History Symptoms generally begin 4 days to 2 weeks after contact with an infected partner Urethral discharge fluid may be: Yellow, Green, Brown or Tinged with blood Dysuria (painful or difficulty urinating) is usually localized to the meatus or distal penis and worse during the first morning void Urinary frequency and urgency are typically absent If present, either should suggest *prostatitis or cystitis* organism went further up the tract Urethral itching or irritation may persist between voids Some patients have itching instead of pain or burning Complaints of heaviness in the genitals Associated pain in the testicles should suggest epididymitis, orchitis, or both. What is this?
Atrophic Vaginitis
Clinical Presentation Vaginal dryness Burning Pruritus Discharge Dyspareunia Dysuria Urinary frequency Diagnosis Clinical diagnosis based on history and physical examination A pH over 5 in the absence of other causes can be indicative What is this?
Candidiasis
Clinical Presentation Vulvar pruritis is most common symptom Thick, white, curdy vaginal discharge ("cottage cheese-like") Erythema, irritation, occasional erythematous "satellite" lesion Dysuria Dyspareunia What is this?
Urethritis
Clinical Presentation Physical Examination Inspecting the underwear for secretions Skin lesions that may indicate other STDs Genital warts- Condyloma acuminatum Herpes simplex Syphilis Examine the lumen of the distal urethral meatus for lesions, stricture, or obvious urethral discharge. Gently "milking" from the base of the penis to the glans Discharge may then be observed from the urethral meatus Examine the testes for evidence of mass or inflammation Palpate the spermatic cord, looking for swelling, tenderness, or warmth Check for inguinal adenopathy What is this?
BPP-biophysical profile
Combine ultrasound evaluation of neurologic activity with NST and amniotic fluid index What is this with antenatal fetal testing?
Fibrocystic Breast Changes
Common and benign- >60% of women. Diminishes at menopause Do NOT lead to cancer- reassure patient Formerly called a 'disease' now called 'changes.' Due to small masses or cysts Causes: Cyclical hormone changes Caffeine Nicotine What is this?
Fibroadenoma
Common benign tumor in younger women Fluctuates in size Affected by cyclical hormone levels Most common in teens and twenties Usually painless (vs. painful fibrocysts) Enlarge in pregnancy and become painful Exam Moveable, solid, round, rubbery singular mass "Runs away" under your fingers What are these?
Parvovirus B-19
Common childhood illness - Erythema infectiosum/Fifth's disease/slapped cheek Acute infection in pregnancy can result in fetal death or fetal hydrops Risk highest in schoolteachers, day care workers, and stay-at-home moms What infection is this that affects prego?
Amenorrhea
Common in pregnancy, during the 2-5 years following menarche, and in perimenopausal women Affects ~ 2.5% of the general population What is this?
GnRH agonist
Comparable symptom relief with fewer effects Down-regulate the pituitary gland and cause marked suppression of LH and FSH What is this medical therapy for endometriosis?
Endometriosis
Conservative Excision-cut it out Cauterization Laser Ablation Allows preservation of reproductive organs to allow for a possible future pregnancy Success rates appear to correlate with the severity of disease Extirpative Total abdominal hysterectomy Unilateral/Bilateral salpingo-oophorectomy Lysis of adhesions Removal of endometriotic implants 1/3 require additional surgery in 5 years What surgical therapy is this for?
Breast cancer Stroke MI DVT Liver dz or dysfunction Vaginal bleeding Hypersensitivity Pregnancy
Contraindications to hormone therapy?
Estrogen
Controls pituitary release of LH and FSH Promotes growth of the uterus and controls its function What hormone is this?
The Ovary
Coordinates the development & release of a mature oocyte Produces hormones-estrogen, progesterone, testeosterone that are critical for pubertal development & preparation of the uterus for conception, implantation, and the early stages of pregnancy What is this?
Testicular Cancer
Diagnosis and differential Painless and slight enlargement of the testicle is a distinguishing factor In 5% of patients, gynecomastia may be a sign, caused by the germ cell tumors producing hCG Signs and symptoms are different from the acute painful scrotal enlargement present in testicular torsion or epididymitis Profound pain is not reported until the later stages Presentation Metastatic Lower back pain, swelling of lower extremities, neck mass, or hemoptysis These symptoms reflect the lymphatic drainage of the scrotum, which connects to the lower extremities, and the lymphatic system of the testes, which connects to the back and abdominal cavity Suspect THIS in an adolescent or young adult with a unilateral, enlarged, and usually painless testicular mass An ultrasound is required to define the characteristics of the mass, such as whether it is cystic or solid, uniform or heterogeneous. What is this?
Spermatocele
Diagnosis and differential The benign retention cyst transilluminates and can be easily differentiated from a testicular neoplasm Ultrasound can resolve uncertainty A small cyst that does not cause any discomfort will resolve and does not require treatment If the cyst is painful or interferes with surrounding structures, a spermatocelectomy is indiacted What is this?
4 40
Diagnosis is confirmed: at least WHAT months of amenorrhea & 2-3 serum FSH levels >WHATmlU/mL obtained at least 1 month apart in women <40 years of age with premature ovarian failure
Nipple Discharge
Discharge exam (the most important factor) Color- clear, milky, red, serosanguinous or green... Unilateral vs. Bilateral Spontaneous vs. Expressed Physical exam Breast(mass+/-), lymph-nodes, skin, and nipple Diagnostic Studies (next slide)-mammography and US with pathologic discharge, physiologic hCG UA test if neg then check meds and TSH and prolactin levels, physiologic tell to avoid nipple stimulation-repeat 3-4mons Referral- breast surgeon What evaluation is this for?
Hormone Therapy
Current recommendation: WHAT should only be used for the short-term relief of menopausal symptoms and should be individually tailored to a woman's need for treatment
Hydrocele
Definition: Arises from an imbalance of secretion and reabsorption of fluid from the tunica vaginalis Most common in newborn males due to the congenital patency of the processus vaginalis Causes development later in life include local injury, testicular torsion, epididymitis, orchitis, gonorrhea, lymph node obstruction, germ cell testicular tumor, and radiation therapy What is this?
Atrophic Vaginitis
Definition: Atrophy of the vaginal epithelium due to decreasing estrogen levels Epidemiology Affects 47% of postmenopausal women Risk factors Menopause Bilateral oopherctomy Use of anti-estrogenic medications Tamoxifen, danazol, etc. Pathogenesis When estrogen levels decrease there is loss of glycogen Lactobacilli convert glycogen to lactic acid This causes the pH of the vagina to increase over 4.5 Thinning of the vaginal epithelium and loss of elasticity What is this?
Androgen Deficiency
Definition: Condition in which the body doesn't produce enough testosterone Etiology: Increasing age, genetic disorders and testicular injury or cancer Symptoms: Erectile dysfunction**, fatigue, decreased libido Diagnosis: Serum total and free testosterone Should check and LH to assess for true deficiency- LH affects leydig cells-if LH high then true deficiency body saying need more but if LH low then normal Treatment: Testosterone supplementation Should start at 100 to 200mg Can fuel cancer with this extra testosterone Can lead to heart issues High maintenance-injectable What is this?
Phimosis
Definition: Inability to retract the skin (foreskin or prepuce) covering the head (glans) of the penis Physiologic: Children are born with tight foreskin at birth and separation occurs naturally over time is normal for the uncircumcised infant/child and usually resolves around 5-7 years of age Pathologic: that occurs due to scarring, infection or inflammation Forceful foreskin retraction can lead to bleeding, scarring, paraphimosis and psychological trauma for the child and parent What is this?
Urethritis
Definition: Infection-induced inflammation of the urethra 2 Categories Gonococcal (GU) Neisseria Gonorrhea Nongonococcal (NGU) *Chlamydia trachomatis*, Mycoplasma genitalium, Trichomonas vaginalis and Herpes Simplex Virus History Helps differentiate between a sexually transmitted disease (STD) and other causes of urethritis Contraceptive use Condoms helps substantially decrease the chance of STD transmission The use of spermicides may cause a chemical THIS associated dysuria findings that mimic those of infectious THIS Number of sexual partners Individuals with multiple partners are more likely to have contracted an STD Previous STDs Prior history of STDs are at an increased risk of contracting another STD In addition, THIS can increase viral shedding of HIV and can increase the likelihood of transmission What is this?
Balantis
Definition: Inflammation of the glans penis Presents as pain, tenderness, or pruritus associated with small erythematous lesions on the glans and/or the prepuce Physical examination Careful inspection for possible paraphimosis (trapping of the prepuce behind the glans penis) Laboratory testing may include serum or urine glucose-rule out diabetes, gram stain and culture of discharge, swab for KOH microscopy, and testing for sexually transmitted disease. Biopsy of lesions should be considered in cases of uncertain etiology or persistence What is this?
Cervicitis
Definition: Inflammatory condition of the cervix defined by the presence of mucopurulent endocervical discharge, easily induced endocervical friability, or edematous cervical ectopy Etiology Typically the consequence of infection with sexually acquired pathogens, most commonly Chlamydia trachomatis or Neisseria gonorrhoeae Epidemiology Chlamydia Most frequently reported infectious disease in the US Majority of cases occurring in individuals aged 25 years or younger 1.3 million cases reported in 2010 Gonorrhea Second most commonly reported infectious disease in the United States 300,000 cases reported in 2010 What is this?
Testicular Torsion
Definition: Rotation of the testicle along its vertical axis around the spermatic cord may constrict the testicular artery and cause ischemia Epidemiology Accounts for 12% to 16% of acute scrotal presentations among children can happen at any age Risk factors Undescended testicles at birth and genetic structural defects such as bell clapper deformity Condition occurs when the tunica vaginalis covers the entire testicle and epididymis, preventing fixation to the posterior wall, and causing the testicle to rotate more freely than normal What is this?
Paraphimosis
Definition: foreskin in the uncircumcised or partially circumcised male is retracted behind the glans penis, develops venous and lymphatic congestion, and cannot be returned to its normal position Epidemiology Relatively uncommon condition and is less common than phimosis Usually caused iatrogenically by keeping the foreskin retracted for long periods of time during examinations and procedures What is this?
Priapism
Definition: persistent erection of the penis that is not associated with sexual stimulation or desire lasting at least four hours Incidence of 0.73 per 100,000 men per year 2 Different types: Primary Idiopathic (cause is unknown) Secondary Associated with medications and some disease states PDE5 inhibitors (Viagra, Cialis) Sickle cell Anemia What is this?
Pregnancy (1 in 8 abused while prego)
Delay in seeking prenatal care Depression Anxiety Injury/bruises on breasts or abdomen Preterm bleeding Spontaneous miscarriages Preterm labor Placental separation Fetal fractures or fetal demise These are concerns during what with domestic violence?
Osteoporosis
Estrogen effects Estrogen receptors are present in osteoblasts Affects the development of cortical and trabecular bone Bone density diminishes at a rate of approximately 0.5% per year in perimenopausal females Bone density diminishes at a rate of approximately 1-2% per year in post menopausal females What complication is this with menopause?
Vagina
Estrogen promotes growth of epithelium and maturation of the mucosa Estrogen aids transudation and lubrication Progesterone leads to decreased secretions What contraception change is this?
2-5 years
Estrogen replacement therapy in a menopausal woman is only used for how long typically?
Combined Oral Contraceptives
Ethinyl Estradiol Progestin Testosterone based Norethindrone, norethindrone acetate, levonorgestrel "New" progestins More estrogenic...but less androgenic... Norgestimate and desogestrel Drospirenone - spironolactone analog-anti androgenic - progestogenic, antiandrogenic, antimineralocorticoid properties What are these?
140 90 300
Criteria for mild preeclampsia BP > WHAT systolic or > WHAT diastolic after 20 weeks in patient with previously NORMAL blood pressure Proteinuria = > WHATmg protein in 24hour urine sample
Tissue-sampling
Cytology- individual cells Histology- individual cells and their relationship to each other. What technique is this?
Intrapartum Fetal Surveillance
DR - determine risk Antenatal and intrapartum C - Contractions Regular? BRA - Baseline RAte V - Variability Should be 10-15 beats around baseline A - Accelerations 15 bpm x 15 seconds D - Decelerations Where in association to contraction O - Overall Assessment Does it vary beat to beat-up and down-normal autonomic function-baby has faster HR bc smaller than us-if move HR goes up Totally flat-sleeping or something isn't right Acceleration-positively reacting to stimulation Deceleration-HR goes down What is this?
Follicular
Days 1-12 (Somewhat variable) Onset of menses to day of LH surge Ovulation occurs within 36 hours of LH surge What phase is this?
Luteal
Days 14-28 (Relatively constant) LH surge to onset of menses What phase is this?
Gestational age
Days elapsed since first day of last menstrual period (FDLMP) Ovulation typically occurs 14 days into cycle, if cycles are regular Menstrual dating Nagele's rule - Add 7 days to FDLMP, subtract 3 months Use a "wheel" Online calculators Ultrasound dating Transvaginal ultrasound during mid first trimester most reliable Prevents complications related to inaccurate dates These are assessment of what?
Amniotic Fluid Index
Deepest pockets of fluid with no fetal parts in each of 4 quadrants of the uterus What is this?
1st trimester complications
Define the bleeding How much for how long Cramping? Chronic medical problems Recent illnesses Meds/herbals Substances since +UPT Alcohol Drugs Caffeine intake Blood type, if known Prior STI's Abnormal Pap Smears History of LEEP/conization of cervix OB History Prior miscarriages Known uterine/tubal abnormalities, Prior elective/therapeutic terminations What Hx is this for?
Varicocele
Definition: A dilation and swelling of the pampiniform plexus, a network of veins supplying the testes, resulting in blood pooling in the testes This dilation typically occurs in the left testicle due to the differences in the right and left testicular vein anatomy the most common cause of male infertility worldwide They are generally acquired due to venous valve dysfunction Varicose veins* There are no known risk factors, and the cause of venous valve dysfunction is idiopathic What is this?
Necrotizing Fasciitis
Definition: A fulminant, life-threatening skin infection of the scrotum and perineum that may spread to surrounding areas at the very rapid rate of 2 to 3 cm per hour Also known as Fournier gangrene or flesh-eating bacteria syndrome Presentation Fever Hypotension Tachycardia Presents with pain, swelling, and erythema of the scrotal skin and surrounding affected areas Those with more severe infection will have skin necrosis, hemorrhagic bullae, and symptoms of septic shock Skin injury is the most common cause Surgery patients and IV drug users are at highest risk Pathogens include Streptococcus pyogenes, Staphylococcus aureus, and methicillin-resistant Staphylococcus aureus (MRSA) What is this?
Spermatocele
Definition: A retention cysts of the scrotum that form above and posterior to the testis and are attached to the epididymis Anatomy The testicle is composed of hundreds of lobules, each containing seminiferous (sperm-producing) tubules These lead into the rete testes, where efferent ducts emerge to lead into the epididymis Sometimes, the efferent ducts that lead into the epididymis can become obstructed by the traveling sperm and form a diverticulum from the tubules, creating a cyst The cyst will grow and typically result in a painless mass What is this?
Peyronie's disease
Definition: An acquired, localized fibrotic disorder of the tunica albuginea resulting in penile deformity, mass, pain, and in some men, erectile dysfunction (ED) Prevalence is approximately 5 percent in men Pathogenesis of PD is unknown Presenting symptoms include penile pain, nodule, induration, curvature, deformity, or shortening during erection, as well as sexual dysfunction. PD is most evident during erection Tunical compliance is compromised and the paired corpora cavernosa are unable to expand normally What is this?
Epididymitis
Definition: An inflammation of the epididymis and/or testis (epididymoorchitis) Most common urologic complaint among men ages 18 to 65 years Most cases are due to microbial invasion of the epididymis Men under age 35 years of age Most common causes are Chlamydia trachomatis and Neisseria gonorrhea In men older than age 35 years, the most common cause of epididymitis is urinary tract infection (UTI) or bladder stasis secondary to obstruction Escherichia coli, Pseudomonas, and gram-positive cocci are common causes What is this?
Inguinal Hernias
Definition: Are protrusions in the groin that form due to muscle weakness 75% of all abdominal hernias are THIS Approximately 600,000 repairs are performed annually in the United States Risk factors Risk factors for the development of inguinal hernias include abdominal wall injury, older age, male sex, and white race Presentation and differential Can vary from harmless and pain-free to life-threatening and painful Light does not transilluminate through the scrotum Light will transilluminate through a fluid (hydrocele) but not a mass (hernia) Scrotal ultrasonography is useful to differentiate a scrotal hernia from other scrotal masses What is this?
Fetal nuchal translucency
Dependent fluid collection at base of fetal neck, measurable between 10-14 wks EGA, Increase indicative of chromosonal, genetic, structural abnormalities What is this screening test with first trimester aneuploidy?
1st trimester complications
Depends on results of exam and TVUSG If viable fetus, rescan in 1 week to assess fetal growth If too early to tell - serial HCG, follow-up scan in 1 week, unless further bleeding If non-viable fetus, discuss options for management Episode of heavy bleeding = ER visit-incomplete AB What is this follow-up for?
Engagement
Descent of the fetal presenting part below through the pelvic inlet Head stuck in there is this which means coming out How far head has descended into pelvis What is this?
Abnormal Uterine Bleeding
Determine if there is a bleeding site on the vulva, vagina, cervix, urethra, or anus Note any suspicious findings (i.e. mass, laceration, ulceration, vaginal discharge, foreign body) Assess the size, contour, and tenderness of the uterus May suggest the presence of fibroids, adenomyosis, pregnancy, or infection Examine the adnexa for an ovarian tumor Evaluate for pain Suggests infection What PE is this for?
Nucleic Acid Amplification Test (Gen-Probe) (determines Gonorrhea or Chlamydia)
Determining the cause of infection of acute cervicitis one should use what?
Vaginitis
Diagnosis Patient history Visual inspection of internal/external genitalia Appearance of discharge Collection of specimen Preparation and examination of specimen slide What Dx is this for?
Gonorrhea Gonococcal urethritis Gonorrhea and Chlamydia trachomatis
Diagnosis Urethritis can be diagnosed based on the presence of one or more of the following: Mucopurulent or purulent discharge on examination Frank Discharge is more suggestive of *WHAT*? ≥2 white blood cells (WBC) per oil immersion field from the Gram stain (or methylene blue/gentian violet stain) of a urethral swab Presence of intracellular diplococci confirms *WHAT?* Positive leukocyte esterase ("dipstick") on first-void urine or the presence of ≥10 WBCs per high power field of the first-catch urine All patients with urethritis should be tested for *WHAT AND WHAT*?
Priapism
Diagnosis Visual inspection reveals an erect penis, and the erection has been present for more than four hours in the absence of sexual excitation Treatment Pain control with oral analgesics Opioids if pain is severe What is this for?
BPH
Diagnostic Tests UA: r/o UTI, hematuria Bladder Ca & UTIs can mimic BPH symptoms Serum Creatinine-kidney function-is there blockage: Optional If elevated --> Upper tract imaging (Renal U/S) PSA: considered limited use. Ages 50-69 and before initiation of therapy Urine cytology: Optional International Prostate Symptom Score (IPSS) Assesses severity of symptoms & response to Rx Same as aua questionnaire with additional quality of life question Additional Diagnostic Tests Consider if non-responsive to Rx If there's a good chance the patient's symptoms are not due to BPH Uroflowmetry Obstruction suspected with flow rates < 15 ml/s Urinary obstruction Postvoid Residual Urine: Non-invasive transabdominal U/S Pressure-Flow Studies (Urodynamics) Helps differentiate between low flow rate from obstruction versus decompensated/neurogenic bladdder Cystoscopy: not routinely recommended unless there are other indications KUB May contribute to diagnosis of Bladder calculus What tests are these for?
Tubo-Ovarian Abscess
Differential diagnosis: Ovarian cyst or tumor with or without torsion Unruptured ectopic pregnancy Periappendiceal abscess Uterine leiomyoma Hydrosalpinx Perforation of a diverticulum or diverticular abscess Perforation of peptic ulcer Urinary tract infection or calculi Any systemic disease that causes acute abdominal distress. What is this associated with?
Thermography
Digital Temperature Scan benign, no radiation exposure Measures Inflammation and vascular function Cancer is represented by increased circulation resulting from local inflammation Detects subtle abnormalities of CA before a mass is seen on a mammogram May identify cancer 10 years before a mammogram More studies need to be done What is this?
Fetal scalp electrode
Directly measures fetal heart rate via electrode "screw" Placed on the babies head Only use when something is wrong with labor What invasive fetal monitoring device is this?
Hypothalamic Dysfunction Clomiphene
Disruption of normal GnRH secretion Leads to decrease in FSH and LH Etiology: hypothalamic disorders, anorexia, exercise, stress, nutritional deficiencies, systemic dz Diagnosis Normal to low FSH/LH What etiology is this with secondary amenorrhea AND what is the treatment?
Station
Distance above (-) or below (+) ischial spines Ischial spines = "0 THIS"-fully engaged If above is minus whatever As come through is +1, +2, etc What is this?
Dilation
Distance between edges of the cervix 0-10cm 10cm = "complete" What is this?
Domestic violence
Do not fall into the trap of profiling! WHAT occurs in all ethnic groups and economic strata Women in higher SES groups often can hide their abuse better
FLM-fetal lung maturity
Done by amniocentesis Measure ratio of lecithin to sphingomyelin in amniotic fluid What is this with antenatal fetal testing?
Prolactin
Drop in estrogen at delivery release WHAT inhibition Suckling stimulates WHAT, causing milk let-down This is how lactation happens
Labor Dystocia
Dysfunctional-bad contractions- labor that doesn't progress through first 2 stages normally Passage - "cephalopelvic disproportion" Android pelvis Narrow ischial spines Ridged pubic bone Passenger Position Size Presentation Power Inadequate uterine contractions Inadequate maternal pushing What is this?
Hormonal contraception
Dysmenorrhea Iron deficiency anemia, due to a reduction in menstrual flow Ectopic pregnancy Combination pills only Benign breast disease - fibrocystic Ovarian cysts Higher dose estrogen COC pills Endometriosis What should be done to help prevent/treat this?
PCOS
ESHRE/ASRM (Rotterdam 2003) To include 2 out of 3 of the following: Oligo- or anovulation Clinical evidence of hyperadngrogenism or biochemical evidence of hyperandrogenemia Polycystic ovaries on ultrasonography (with exclusion of related disorders) NICHD/NIH (1990) To include the following: Oligoovulation or anovulation manifested by oligomenorrhea or amenorrhea Hyperandrogenism and/or hyperandrogenemia Exclusion of other disorders that result in menstrual irregularity and hyperandrogenism AE-PCOS (2009) To include the following: Clinical/biochemical evidence of hyperandrogenism Ovarian dysfunction (oligoovulation and/or polycystic ovaries) Exclusion of other androgen-excess or related disorders SOGC To include 2 out of 3 of the following: Oligoovulation or anovulation Clinical/biochemical evidence of hyperandrogenism Polycystic ovaries on ultrasound (>12 small antral follicles in an ovary) What diagnostic criteria is this for?
Cervical intraepithelial neoplasia
Early coitarche (first sexual intercourse... younger than 18) Multiple sexual partners History of prior sexually transmitted infections Smokers Immunodeficiency What GYN cancer is this?
1st trimester bledding
Ectopic pregnancy Spontaneous Miscarriage Cervical or vaginal trauma Cervical polyps Cervical cancer Friable cervix, common in pregnancy Gestational trophoblastic disease What DDx is this for?
Bacterial Vaginosis
Etiology: Overgrowth of Gardnerella Vaginalis-some studies suggests polymicrobial Epidemiology: Most common cause of vaginitis Prevalence varies by population: 5%-25% among college students 12%-61% among STD patients Linked to premature rupture of membranes, premature delivery and low birth-weight delivery, acquisition of HIV, development of PID, and post-operative infections after gynecological procedures Risk Factors: Two or more sex partners in previous six months/new sex partner Douching Absence of or decrease in lactobacilli Antibiotic use Pathogenesis Overgrowth of bacteria species normally present in vagina with anaerobic bacteria correlates with a decrease or loss of protective lactobacilli: Vaginal acid pH normally maintained by lactobacilli through metabolism of glucose/glycogen Hydrogen peroxide (H2O2) is produced by some Lactobacilli,sp. H2O2 helps maintain a low pH, which inhibits bacteria overgrowth Loss of protective lactobacilli may lead to this What is this?
Endometriosis
Endometrial glans and stroma in any extrauterine site results when ectopic endometrial cells implant, grow, and elicit an inflammatory response. implants and cysts respond to the hormonal fluctuations of the menstrual cycle Ischemia from spiral arteries dying off and sloughing off-get cramps Only proven tissue biopsy diagnosis is diagnostic Many are asymptomatic Presentation: infertility, pelvic pain What is this?
Trichomonas vaginalis
Etiology: flagellated anaerobic protozoa Only protozoan that infects the genital tract Most common treatable STD Risk factors: Multiple sexual partners Lower socioeconomic status History of STDs Lack of condom use What is this associated with vaginitis?
Ovarian disorders
Etiology: PCOS, premature ovarian failure, follicular failure, Turner's syndrome Sx's of estrogen deficiency Dx: increased FSH/LH, decreased estradiol (ovarian abnormalities) Normal/low FSH, LH (pituitary or hypothalamic abnormalities) Progesterone challenge test (10gm medroxyprogesterone x 10 days) Withdrawal bleeding: ovarian No withdrawal bleeding: hypoestrogenic or uterine What etiology is this with secondary amenorrhea?
CT findings
Enlarged adnexal structure Thick, straight blood vessels draped around the lesion Complete absence of enhancement Hemorrhage or gas in the torsed structure Deviation of the uterus to the affected side Ascites What dx is this with ovarian torsion?
Gynecomastia
Enlarged tender breasts in males. Occurs in infancy, puberty, and in middle-age. Occurs in over 50% adolescent males. Pseudogynecomastia fat deposits in the breast area of obese men Results from over-growth of breast tissue. What is this?
Prenatal Care
Ensure birth of healthy baby Decrease maternal risk Identify high risk pregnancies Early and accurate identification of gestational age By 10 weeks gestational age Health promotion and shared decision making What goals are these?
Mediolateral
Episiotomy: Midline or Mediolateral WHAT has less risk of extension, but higher risk of bleeding and chronic pain
Candidiasis
Etiology: are normal flora of skin and vagina and are not considered to be sexually transmitted pathogens Epidemiology Affects most females during lifetime Second most common cause of vaginitis Estimated cost: $1 billion annually in the U.S. Pathogenesis: Vaginitis is caused by overgrowth of C. albicans and other non-albicans species Yeast grows as oval budding yeast cells or as a chain of cells (pseudohyphae) Symptomatic clinical infection occurs with excessive growth of yeast Disruption of normal vaginal ecology or host immunity can predispose to vaginal yeast infections Risk Factors: Diabetes Mellitus Immunosuppression Steroids, immunosuppressive drugs, HIV, etc. Antibiotic use Contraceptive devices Increased estrogen levels Oral contraceptives, pregnancy, etc. What is this?
Nexplanon
Etonorgestrel, 35 mcg/day, decreases with time (total dose 68 mg) 3 year life span Subdermal insertion Similar but fewer side effects than DepoProvera-biggest is weight gain What contraceptive is this?
Switching
Evaluate estrogen dose High dose = more headaches, higher blood pressures Low dose = more breakthrough bleeding, need to take consistently Evaluate progestin component If possible, change dose of estrogen but not progestin, or vice versa Lifestyle/Usual use issues Can't take pill everyday Patch falls off Nuva Ring causes a discharge What is this with contraceptives?
Baden-Walker Classification System
Evaluated by having the woman perform Valsalva maneuver in the lithotomy position What is this w/pelvic organ prolapse?
Benign Prostatic Hyperplasia
Evaluation: H & P: Previous surgical procedures History of hematuria, UTI, DM, Neuro dz, urethral stricture, urinary retention, worsening of symptoms by cold/sinus meds (anticholinergics, sympathomimetics) Voiding diary Polyuria, sleep apnea, insomnia PE: GU, Neuro, & DRE-digital rectal exam What is this for?
Vasectomy
Excision/ligation/cautery and mechanical occlusion of vas deferens Outpatient procedure, low risk Semen analysis 2-3 months post-procedure Vasectomy NOT immediately effective Reversibility Reanastomosis via microsurgery 50-70% success rate depending on time interval after initial procedure Successful reversal more common in first 3 years following vasectomy; less than 30% success after 15 years What male sterilization is this?
Miscarriage
Expectant management Surgical uterine evacuation (D&C) Heavy bleeding and/or shock Infection/retained products of conception Gestational trophoblastic disease Patient choice What management is this in the 1st trimester?
Toco
External transducer Measures frequency, not strength of contractions Placed on fundus What is this?
Secondary Dysmenorrhea
Extrauterine causes Endometriosis Tumors Inflammation Adhesions Psychogenic Non-gynecologic causes Intramural Causes Adenomyosis Leiomyomata Intrauterine Causes Leiomyomata Polyps Intrauterine contraceptive devices Infection Cervical Stenosis and cervical lesions What is this?
Biopsy
FNA-fine needle aspiration cells are aspirated and smeared on a slide Core-needle: small thin cores of tissue Open: excisional biopsy "Lumpectomy" What types are these?
Normal menstruation
FSH and LH cause maturation of follicle and release Estrogen comes from mature follicle What is this physio for?
2-3 months
FSH and LH for menopause and repeat when to see progressing through menopause?
Victim or perpetrator
Family history of domestic violence should always prompt further evaluation Those who witnessed domestic violence as a child are at risk of being a WHAT?
Emotional symptoms
Fatigue or diminished drive Irritability Apprehension Altered libido Feelings of inadequacy or non-fulfillment What is this w/menopause?
HPV
What is the most common risk factor for GYN cancers?
Septic Abortion
Fever, malodorous vaginal discharge, pelvic and/or abdominal pain; may be septic RARELY associated with legal elective terminations Carefully evaluate an ER patient for cervical, uterine, or vaginal trauma Broad-spectrum IV antibiotics ABC's!!! D&C What is this?
3 cm
Fibroids are equivocally associated with infertility, but some pt do become pregnant Women with myomas greater than WHAT may have significantly increased rates of preterm labor, placental abruption, pelvic pain, and cesarean delivery Bleeding during delivery may be profuse, resulting in hysterectomy Vaginal delivery is controversial
Calcium +/- vit D and bisphos
First line for osteoporosis treatment with menopause?
Menarche
First menstrual period
Time of quickening
First sensation of fetal movements Primigravida = 18-20 weeks Multigravida = 15-17 weeks What is this in estimating gestational age in 2nd and 3rd trimesters?
Eclampsia
Grand mal seizures in a patient with preeclampsia Cannot be explained by neurologic disorder Occur typically within 24h of delivery Can be 2-10 days postpartum - not common very rare-grand mal seizures in pt with preeclampsia-occur before labor, during, or after-typically w/in 24hr delivery What is this with pregnancy?
Malignant stromal cell tumors
Granulosa (estrogen producing) tumor Sertoli-Leydig (testosterone producing) tumor What ovarian cancer is this?
Perimenopause
Period before menopause and considered the transition from the reproductive to the non-reproductive years during which ovarian estrogen production may fluctuate unpredictably-diabetic, smokers, malnourished
Peyronie's Disease
For men with stable, mild curvature (≤30 degrees) who have satisfactory erectile function Observation is suggested If mild curvature worsens or causes sexual dysfunction Medical and/or surgical management is suggested For the initial medical management of men with moderate to severe PD (>30 degrees) Treat with oral pentoxifylline Moderate deformity (30 to 90 degree curvature) and an intact erection Combine an intralesional injection with oral pentoxifylline for treatment What is this treatment for?
Standard Day method
For women with cycles 26-32days No unprotected intercourse on cycle days 8 - 19. "Cycle beads" What fertility awareness is this?
Endometriosis
GI symptoms Rectal bleeding Dyschezia (Painful BM) Urinary symptoms May present with acute abdomen-need to be surgically evaluated Rupture or torsion of endometrioma What are these related to?
Vulvar pruritis
What is the most common symptom of candidiasis?
Cholecystitis (Cholecystitis more common bc of hormones altering bile-US them or appendicitis CT scan them-not going to hurt the baby-protect fetus as much as can but need to work-up the problem-do not want them to have peritonitis very bad! Elevated WBCs is hallmark for appendicitis-have symptoms but WBC is not elevated then not appendicitis WBC has to be elevated-appendix shifts up-pain in diff place)
Gallstones common and often exacerbated in pregnancy Conservative management recommended Surgical management if cholecystitis with bile duct obstruction, pancreatitis, or other acute abdominal process Laparoscopy OK in pregnancy can manage diet-eat low fat food not making stones worse and get through prego before having to take out gallbladder-laparoscopy is fine to do These present early in 3rd trimester What surgical issue is this with pregnancy?
Premature Ovarian Failure
Genetic factors Autoimmune Disorders Smoking Alkylating Cancer Chemotherapy Hysterectomy or Oophorectomy What do these cause?
Neonatal hypoglycemia
Glucose crosses the placenta, insulin does not Mom's high glucose causes baby to produce more insulin Take away mom's glucose, baby still has high insulin (at least temporarily) Baby's glucose drops precipitously In the nursery, they check the baby's glucose at 30min post-delivery What is this?
Abnormal Uterine Bleeding
Goal: ensure regular shedding of the endometrium & regulation of uterine bleeding Medroxyprogesterone acetate Given for a minimum of 10 days Oral contraceptives Uterine bleeding that does not respond to medical therapy often is managed surgically with endometrial ablation or hysterectomy What treatment is this for?
Hyperandrogenism
What may be either clinical and/or biochemical associated with PCOS?
Screening tests
HIV STI's Chlamydia/gonorrhea Syphilis Genetic tests, if applicable, based on racial/ethnic background Offer all women opportunity for CF screening Sickle cell anemia and Alpha and Beta-thalassemia In eastern European Jewish populations Tay-sachs disease Canavan disease and familial dysautonomia Screen men and women What are these done for preconception care?
Pathologic/Cancerous (Normal "lumpy" tissue Breast tissue may be lumpy in younger years)
Hard Immovable Irregular borders Nipple retracton Dimpling Skin change/rash Nipple discharge (red) This indicates what breast lump?
Pregnancy
Headaches Edema Nausea and vomiting Common and treatable with vitamin B6 Heartburn Treat with H2 blocker Small frequent meals Constipation Fatigue Worst in first trimester and late third Leg cramps Back pain Constant anatomic change - increased lordosis Round ligament pain Pain in pelvis around 19-22 weeks Varicose veins and hemorrhoids Increased venous pressure from increased blood volume Vaginal discharge-make sure not bacterial vaginosis Physiologic increase in discharge Due to hormonal effect on vaginal tissue Be sure it's not BV which can lead to PTL-preterm labor These are common complaints of what?
Local law enforcement 48 Misdemeanor
Healthcare providers must report to WHAT if they know or suspect that their patient has been injured as a result of domestic violence. The healthcare provider is required to call or send in a written report within WHAT hours. If the healthcare provider fails to meet these requirements for mandatory reporting of domestic violence, he or she may be found guilty of a WHAT
Amenorrhea
Height & weight, BMI, assess body habitus Palpate thyroid gland Assess visual fields and cranial nerves (pituitary tumor) Abdominal exam for masses *Tanner staging* of breast and pubic hair development Examine genitals and perianal area Clitoromegaly may signify androgen excess Pelvic exam Normal anatomic structures (presence of vagina, uterus); r/o ovarian masses (may need US) What PE is this for?
Domestic Violence
Primary care providers are more likely detect victims of WHAT than the criminal justice system. You have a professional and ethical obligation to recognize and intervene. Screening for and treating WHAT is a routine part of your practice.
HELLP syndrome
Hemolysis, Elevated Liver enzymes, Low Platelets Occurs in 4-12% of patients with severe preeclampsia/eclampsia Criteria Microangiopathic hemolysis Thromobcytopenia Hepatocellular dysfunction Indication for delivery to prevent further maternal morbidity/possible mortality Send emergently to tertiary care center also indication for delivery bc kills moms-has to go to tertiary care center to manage mom and kid bc pts are very sick What is this with pregnancy?
Preterm delivery
History of prior preterm birth Highest risk with subsequent pregnancy or multiple preterm births Assisted reproduction Short interval between pregnancies History of abortion Spontaneous Induced Multifetal gestation Current or prior vaginal bleeding Infection Asymptomatic bacteriuria Group B strep UTI Chlamydia Bacterial vaginosis Trichomonas vaginalis Periodontal disease Maternal Age Race Occupational What are these risk for?
Cystocele
Hernia of the bladder wall into the vagina, causing a soft anterior fullness May be accompanied by urethrocele Sagging of the urethra following its detachment fro the pubic symphysis during childbirth What is this?
Rectocele
Herniation of the terminal rectum into the posterior vagina, causing a collapsible pouch like fullness What is this?
Transrectal Ultrasound Guided Biopsy
High resolution probes Preparation with antibiotics and fleet enema Lidocaine infiltration of periprostatic nerves Prostate measurement Biopsies aimed at high yield areas Number of cores adjusted to size of gland Take several biopsy when doing this 3 cores false negative 3 true positive Only one core tells the "truth": Gleason Score 3+4=7 (Higher the number more aggressive the cancer) What is this?
PCOS
Hirsutism & other virilizing signs Obesity Acanthosis nigricans Signs of metabolic syndrome (i.e. elevated BP) Bilateral enlarged, smooth, mobile ovaries on bimanual exam What PE is this for?
Vaginal Delivery
History Blood loss then slows down-get rid of all tissue n uterine-lochia-tissue and blood loss-diff from menses bc of tissue and getting rid of excess in uterus-prevents body from getting prego Pad counts; patient report Post-anesthesia care - pain at site, headache Lactation Physical Exam Vitals Abdominal Exam Edema Perineum (if had tear or episiotomy) Blood count If have preeclampsia keep them longer bc give them Mg NSAIDS Perineal care - ice packs, tucks pads, hemorrhoid cream, topical lidocaine, Sitz baths Contraception Immunizations and RhoGam Breast Care - lanolin ointment Pelvic Rest Counseling on common mood symptoms What hospital care following is this for?
Cesarean Delivery
History Pain Bleeding Passing Flatus Ambulation/diet Physical Exam Vitals Urine Output CV exam-did have surgery Abdominal Exam Extremity Exam-check edema Pain - NSAIDS and/or narcotics Fluids - D/C IV once tol. PO-may have nausea need this before eat Urine Output/catheter management - D/C catheter once ambulating Incision care - Remove dressing at 24h Contraception RhoGAM, if needed; Pelvic Rest Perineal care (if needed); Breast care Counseling on common mood issues What hospital care following is this for?
Placental Abruption
History Tender uterus Vaginal bleeding Contractions Abdominal pain Physical Can be visible on ultrasound Bleeding can be severe What is this?
Third trimester bleeding
History When did it start How much Any pain Recent intercourse bc cervix is friable but bleeding is not that severe Determine placental position prior to speculum exam or cervical exam!!!!! Vital signs - ABCs External fetal monitoring Abdominal exam Sterile speculum exam Cervix closed or open Continuous bleeding? What is this evaluation for?
NO ACEI Labetalol (alpha-beta blocker) Methyldopa (alpha) CCB Thiazide diuretics
What med is not okay to take if prego with HTN? What meds are okay to take?
Black eyes Stressed and anxious Waited 3 days Overly concerned fiance in the room (Delay in seeking care Illogical explanation of injury Apparent Anxiety/distress)
History: A 40 year-old nurse presents with a headache She was in a MVA three days ago and hit her head on the dashboard Her fiancé is with her and appears very concerned Physical: General: anxious/ distressed HEENT reveals bilateral periorbital ecchymoses Our job, as clinicians is to pick up on any "red flags" during the patient visit What were the "red flags" in this case?
Fibrocystic Breast Changes
History: Tenderness with cycles, caffeine, or nicotine Lumps come and go in one or both breasts Long term issue Physical Exam: Mobile, tender, smooth edge, round, rubbery lumps No lymph enlargement What dx is this for?
Male contraception
Hormonal methods Not commercially available Administration of testosterone shuts down gonadotropic feedback, thereby slowing sperm production Takes months to become effective Anatomic methods Vasectomy (permanent) Vasal occlusion (permanent and reversible) What are these?
Gynecomastia
Hormone imbalance (more estrogen than androgen) Disappears on its own in six months to two years-happens with male babies Disease: Malnutrition Disorders of the testes Klinefelter's syndrome, trauma, infection, aging, and cancer Chronic renal failure-older pts Hyperthyroidism-older pts Drugs-in older pts-does not bother them keep on drugs if do then switch drugs Spironolactone, Calcium channel blockers , ACE inhibitors, some antibiotics , anti-ulcer drugs, anti-androgen or estrogen therapies for prostate cancer, methyldopa (Aldomet), anti-retroviral therapy for HIV, digoxin; diazepam, drugs of abuse alcohol, marijuana, heroin), and lavender and tea tree oil, used in skin-care products. What do these cause?
2-5 years (shorter duration the better only when they need it-stop when symptoms resolve)
How long should one use hormone therapy with menopause?
1800 (continue prenatals)
How many calories per day should someone consume while breastfeeding?
Para
How many live infants delivered is what?
6
How many mons is exclusive breastfeeding recommended by AAP and AAFP?
Gravida
How many times pregnant What is this with GTPAL system?
C section
How should you deliver a baby where there is complete placenta previa?
Crowning Mouth
How to Deliver the Fetus: Gently stretch perineum and labia around fetal vertex Recommend mom to pause pushing during WHAT - decreases risk of tear-give skin chance to stretch Suction WHAT, then NOSE-babies breath through mouth first Gentle downward traction on head and neck to deliver anterior shoulder Pull up to deliver posterior shoulder Keep one hand on back of neck Slide other hand down baby's back to grab legs Flip baby onto arm, football style Don't drop baby in the trash
HAIR-AN Syndrome
HyperAndrogenism Insulin Resistance Acanthosis Nigricans Insulin-sensitizing agents reduces androgen and insulin levels What syndrome is this?
Chronic Hypertension
Hypertension BEFORE 20 weeks EGA Review meds at first prenatal visit NO ACE inhibitor!!! Beta blockers and alpha blockers typically OK Labetalol - alpha-beta blocker Alpha-methyldopa Calcium channel blockers usually OK Thiazide diuretics OK OK to continue chronic meds, maintain BP between 120-160/80-100 HTN before 20 wks really common esp if over 40-should be hypotensive and is called chronic HTN nothing to do with prego where HTN beforehand-NO ACE/ARB bad for fetal kidney-okay to use labetalol or alpha-methyldopa, CCB okay, and Thiazide diuretics-treating chronic med conditions and HTN and make lower cutting off blood supply to the placenta and baby-not worried about mom having kidney issues later on-do not want it to be 120/80 if not normally that and decr growth in baby-not the setline body used to-only treat when close to stroke level-all in the 3rd trimester What is this in pregnancy?
Gestational Hypertension/PIH
Hypertension that develops AFTER 20 weeks EGA 5-10% of pregnancies/ > 30% in multiple gestations 25% will develop preeclampsia/eclampsia Assume preeclampsia if unknown prior h/o hypertension develops after 20 wks esp with twins or triplets bc more placentas. Check urine for protein if did not have HTN before just assume have preeclampsia and check for that What is this in pregnancy?
Preeclampsia
Hypertension, proteinuria, and edema AFTER 20 weeks EGA Criteria for mild BP > 140 systolic or > 90 diastolic after 20 weeks in patient with previously NORMAL blood pressure Proteinuria = > 300mg protein in 24hour urine sample Risk factors Nulliparity Multiple gestation Advanced maternal age Previous h/o preeclampsia Chronic HTN T2D/T1D Vascular/connective tissue disorders Antiphospholipid syndrome Obesity African-American race Pt has proteinuria in office bring jug of 24 hour urine sample and measure protein again. Adv maternal age-does not work as well, Lupus, purely obesity What is this in pregnancy?
PTU (propylthiouracil)
What med should you give a prego woman who has hyperthyroidism?
Domestic violence
IS aggressive control tactics occurring in a family-type relationship. May include: Physical violence Sexual (rape) Emotional (verbal) Financial Most rapes are domestic It is usually silent and difficult to detect It Occurs in 1 in 4 U.S. women It is doubled in Pregnancy. It is the most common cause of physical injury in women What is this?
Tobacco
IUGR Low birth weight SIDS risk postpartum What is this with prenatal care?
Substance abuse
IUGR Placental dysfunction Placental abruption Birth defects Newborn withdrawal What is this with prenatal care?
Tubal ligation
Permanent Can be done postpartum (24h) Minilaparotomy - infraumbilical incision Elevated fundus facilitates procedure Laparoscopic or transvaginal At least 6 weeks post partum Can be done with electrocautery, clips Effective - > 99% Safe If fails, verify intrauterine pregnancy What female sterilization is this?
MRI
If BRCA is pos then what lab should be ordered?
Biopsy
If DRE is abnormal, *WHAT* is recommended regardless of PSA level Majority of Prostate Cancer is in peripheral zone (70%) Hard, nodular, irregular Sites of metastasis: lymph nodes > bone > lung > liver Most effective method for early detection is combined DRE and PSA
Oxytocin (Pitocin)
If cervix already effaced and dilated, can start WHAT IV to begin contractions Helps with uterine stimulation?
Colposcopy (take layer of cervix and analyze it)
If find something abnormal during pelvic exam what should be done to manage the cervix?
Domestic Violence
Inappropriate behavior during PE: Fright or anxiety Embarrassment or laughter Passivity Shyness Avoiding eye contact What PE clues are these for?
Menopause
Permanent cessation of menses after significant decrease of ovarian estrogen production
Gynecomastia
In pubertal males and infants-observation Treat Underlying Physiologic disorder Stop offending medications Treat hormonal disorders, tumors, etc... Selective estrogen receptor modulators (SERMs) tamoxifen (Nolvadex) and raloxifene (Evista) reduce breast volume Reserved for severe or painful conditions Surgical Reduction What is this treatment for?
Expectant
In those with limited disease who symptoms are minimal or nonexistent or patients who are attempting to conceive Older pts with mild symptoms may opt to wait until the natural decrease in levels of estrogen and progesterone occurs with menopause What treatment approach is this with endometriosis?
PCOS
In vitro fertilization Last option that should be considered in the treatment of infertility in anovulatory women Surgery Electrocautery, Laser drilling, multiple biopsy What tx is this for?
Ovarian cancer
Increase in abdominal size *Abdominal bloating* *Fatigue* *Abdominal pain* Indigestion *Inability to eat normally* *Urinary frequency* Constipation Back pain *Urinary incontinence* Unexplained weight loss These are warning signs of what?
PCOS
Increase muscle mass, decreased breasts, deep voice, clitoralmegally-not typical of WHAT-male characteristics-should think androgen producing tumor of ovary or adrenal glands
Syphilis
Increase risk for stillbirth, hydrops fetalis, or prematurity Many long term fetal sequelae if not treated What infection is this that affect prego?
Pap Test
Interpretation of results Negative for intraepithelial lesion or malignancy Organisms: Trichomonas vaginalis Fungal organisms consistent with Candida species Shift in flora suggestive of bacterial vaginosis Cellular change consistent with herpes simplex virus Bacteria consistent with Actinomyces species Epithelial cell abnormalities What results are these?
First 4 4-5
Interval between onset of labor and FULL cervical dilation Latent phase Slower cervical dilation, usually prior to WHATcm-prostaglandins soften cervix and contractions pull cervix out Active phase More rapid dilation, usually begins at WHATcm What stage of labor is this?
Nifedipine
Indicated at any gestational age Decrease in intracellular calcium inhibits calcium-dependent myosin light-chain kinase phosphorylation - *this leads to myometrial relaxation* What med is this with preterm labor management?
Indomethacin
Indicated prior to 32 weeks and for no longer than 48 hours Inhibits cyclooxygenase 1 and 2 - responsible for converting arachidonic acid to prostaglandins, which are key in the process of parturition Risk of NSAIDS after 32 weeks is premature closure of the ductus arteriosus What med is this with preterm labor management?
Myomectomy
Indications for WHAT include A rapidly enlarging pelvic mass Persistent bleeding Pain or pressure Enlargement of an asymptomatic myomas to more than 8 cm in a woman who has not completed childbearing-baseball is 7 cm in diameter This is related to fibroids
32 48 32 ductus arteriosus
Indomethacin Indicated prior to WHAT weeks and for no longer than WHAT hours Inhibits cyclooxygenase 1 and 2 - responsible for converting arachidonic acid to prostaglandins, which are key in the process of parturition Risk of NSAIDS after WHAT weeks is premature closure of the WHAT?
Tubo-ovarian abscess
Inflammatory mass involving the uterine tube, ovary, and occasionally, other adjacent pelvic organs Most common in reproductive age females with upper genital tract infections No douching What is this?
Perimenopause
Influential factors: Genetics Lifestyle Malnourishment Smokers Factors that do NOT seem to influence: Age of menarche Number of pregnancies Lactation OCP use Socioeconomic status Race Education What do these effect?
Osteoporosis (DEXA scan gold standard) Cardiovascular issues (MI, stroke, DVT)
Loss of estrogen protective effects lead to what complications?
Placenta Previa
Initially will have small "sentinel" bleed around 29-30 weeks EGA Partial/marginal previa may resolve around 25-32 wks EGA Complete previa requires monitoring, then delivery via cesarean Pt should not exercise or have sex! What is this?
Contraception
Injectable Depo-Provera Implantable-goes in arm Implanon/Nexplanon Insertable Mirena/Skyla/Kyleena/Liletta Intrauterine System(s) Copper Intrauterine Device (Paragard) NuvaRing vaginal ring Ingestible Combined Oral Contraceptive Monophasic/Biphasic/Triphasic Progestin only oral contraceptive Wearable Ortho Evra patch What pharm methods are these for?
Medial pectoral nerve
Innervates pectoralis minor and major What innervation is this?
Long Thoracic
Innervates the serratus anterior. Abducts and laterally rotates the scapula. What innervation is this?
Chronic Pelvic Pain Syndrome (Nonbacterial prostatitis-male intersitital cystitis?)
Insidious onset, no fever and chills-normal ua Pain: perineal, suprapubic, penis, testes, groin, low back. Pain with ejaculation LUTS: urgency, frequency, hesitancy, poor interrupted flow Significant impact on patients QOL Often times seen in patients with hx of Anxiety/Depression Management: Dietary, life-style, counseling, sitz baths ?? ABX-does not work send to urologist α Blockers, NSAID's, Muscle relaxants, Herbal supplements, Elavil, Neurontin, Elmiron, Hydroxazine, frequent ejaculation/prostate massage What is this?
Prostatodynia
Insignificant # of WBCs in expressed prostatic secretions, postprostatic massage urine sediment or semen Category IIIB-noninflammatory
PCOS
Insulin & LH stimulate androgen production by the ovarian theca cell Affected ovaries secrete elevated levels of testosterone and androstenedione Elevated androstenedione levels contribute to an increase in estrone levels through peripheral conversion of androgens to estrogens by aromatase What pathophys of androgens is this associated with?
Osteoporosis CVD risk Lipids (Bone scans, treating bone loss. Consider screening for HLD, CV disease)
Loss of estrogen's protective effects lead to what being increased?
DepoProvera (depot medroxyprogesterone acetate)
Intramuscular every 3 months Side effects - weight gain, dysfunctional bleeding, bone demineralization after long term use-block estrogen Lower dose subcutaneous form available, but expensive Good for those who can't/won't take pills, shouldn't have IUD, can't do Implanon Used mainly with young teenagers What progestin only contraceptive is this?
Abnormal Uterine Bleeding (AUB)
Irregular bleeding that is unrelated to anatomic lesions of the uterus Annual prevalence rate of 53/1000 women in age 18-50yrs Most are related to: Pregnancy Structural uterine pathology (i.e. fibroids, polyps, adenomyosis) Chronic anovulation Disorder of hemostasis Neoplasia What is this?
Painless
Is placenta previa painful or painless?
Painful
Is placental abruption painful or painless?
Painless
Is spermatocele painful or painless?
Painless
Is testicular cancer painful or painless?
Yes
Is tubo-ovarian abscess a surgical emergency?
Progestin
It is essential to administer a WHAT in conjunction with estrogens in women who have not undergone hysterectomy?
PCOS
LH stimulates theca lutein cells to increase androstenedione production Androstenodione undergoes aromatization to estrone (weak estrogen) Increased LH secretion is seen related to positive feedback from estrone production (LH is secreted due to elevated estrogen) Increased obesity leads to increased conversion of androstenedione to estrone With increased androstenedione, there is coincident increase in testosterone production (Hirsutism and acne) What pathophys of obesity is this associated with?
Nipple Discharge
Lactation Discharge- Milk Due to pregnancy Bilateral Physiologic Discharge Clear or milky color Bilateral These are types of what?
6
Lactational Amenorrhea - 6 mos Exclusive breastfeeding Once menstruates, needs some other form of contraception Wait WHAT weeks postpartum to establish nursing before starting anything Unless stops nursing In first WHAT months post-partum while lactating, only progestin contraceptives After WHAT mos combined contraceptives OK because lactation fully established
Noncyclical
Large breast size- stretched Cooper's ligaments Nicotine or caffeine- causative agents Ductal ectasia- from non-infection inflammation Mastitis- from infection Inflammatory Breast Cancer Other - Hydradenitis sup., pregnancy, medications, referred pain, chest wall muscles, costochondritis. Thinking cancer if unilateral What breast pain timing is this?
Pain
Latch on troubles cause what with breast feeding?
Intercostobrachial nerves
Lateral cutaneous branches of the first and second intercostal nerves. Innervate inner upper arm and axilla. What innervation is this?
Structural changes
Laxity of ligaments Relaxin increases in early first trimester Increased lumbar lordosis Especially 3rd trimester Altered center of gravity Moves superior and anterior What is this with maternal prego?
Theca Lutein Cyst
Least common type of cyst Associated with pregnancy and usually bilateral More common in multiple gestations Stimulated from an excess of HCG May become large and are multicystic Regress spontaneously in most cases without intervention What is this?
Ovarian cyst
Most spontaneously resolve Alternatively an estrogen-and progesterone OCP may be given to suppress gonadotropin stimulation of the cyst May suppress development of a new cyst and allow resolution of existing cysts If the cyst persists despite expectant management - another type of cyst or neoplasm should be suspected What is this treatment for?
Vulvar
Postmenopausal: Typically seen between ages 70-80 Patients commonly present with *pruritus of the vulva* and a visible lesion, typically on labia majora Other findings include: Pain *Bleeding* Ulceration Most patients experience symptoms for weeks or months before diagnosis Clinicians may also contribute to delays by providing medical treatment for up to 12 months before obtaining a biopsy or considering referral Get corticosteroids for itching and will thin skin even more What GYN cancer presentation is this?
Appendicitis (Cholecystitis more common bc of hormones altering bile-US them or appendicitis CT scan them-not going to hurt the baby-protect fetus as much as can but need to work-up the problem-do not want them to have peritonitis very bad! Elevated WBCs is hallmark for appendicitis-have symptoms but WBC is not elevated then not appendicitis WBC has to be elevated-appendix shifts up-pain in diff place)
Leukocytosis may be masked in pregnancy Pain may shift upward as pregnancy progresses Treat early to prevent peritonitis Shield the abdomen for unnecessary exposure to fetus from radiographs Do not forego key studies due to pregnancy Present in 3rd trimester What is this surgical issue with pregnancy?
Contraception
Lifestyle considerations: Schedule Willingness/ability to remember Reliability Sexual history Stage of reproduction Cost: Pay now or pay later Add up annual copays for OCP What is percentage of bill for sterilization (no hosp or anesthesia for vasectomy) Expense of a BABY!!!! Reversibility: Depo-Provera = 6-18 mos OCP = 1-6 mos IUD = 1-3 mos Sterilization = PERMANENT Can cost > $15000 to reverse Vasectomy easier to reverse than BTL Beware women < 25 yo, low health literacy, spousal/cultural pressure What is this related to?
Breast pain
Location bilateral/axillary/moving Timing cyclical Severity 1/10 scale Associated symptoms Fever, nipple discharge, pregnancy Causative symptoms Muscle use, trauma, ADL What hx is this for?
Benign Prostatic Hyperplasia
Lower Urinary Tract Symptoms (LUTS) Obstructive Symptoms ↓ in caliber & force of stream Hesitancy Post-void dribbling Straining Sensation of incomplete emptying of the bladder Irritative Symptoms Dysuria Frequency Urgency Nocturia What is this?
Vulvar
Risk factors can be divided into two distinct profiles by age: Women less than 55 years HPV infection is the main risk factor (serotype 16) Tend to have the same risk profile as other anogenital cancers Women 55 to 85 years These cancers are largely keratinizing*, and HPV DNA is found in only 15 percent Typically no history of smoking or HPV, but with a long standing history of Lichen Sclerosus (thin whitening of the skin) A precursor lesion in some cases of invasive squamous vulvar cancer What GYN cancer is this?
Trauma
MVA Intimate partner violence More likely to occur during pregnancy as well Possible consequences to pregnancy Placental abruption Uterine rupture Premature rupture of membranes/premature labor Direct fetal injury caused by car wrecks and intimate partner violence-more likely to die from partner violence than being prego Car wreck-placenta pulls away and starts bleeding behind itself, uterine rupture-sit far behind wheel and wear seatbelt under belly Considerations in management Stabilize mom Assess fetus via Doppler Consider ultrasound once stabilization achieved In minor: Fetal monitoring for 2-6 hours afterwards If any signs of complication, monitor at least 24 hours Contractions, uterine pain Vaginal bleeding or leaking fluid If cardiac arrest If failed maternal resuscitation efforts after 4 minutes, and in 3rd trimester, consider emergent cesarean Fetal survival unlikely after 15 minutes if no maternal vital signs stable mom regardless of being able to get US or not-major trauma pt stays overnight if not more making sure everyone is stable Cardiac arrest-try to save baby if mom is unresponsive-baby lasts 15 mins until taken out What is this with pregnancy?
Umbilical artery doppler flow
Makes sure blood is flowing in and out of the placenta Umbilical artery carries deoxygenated blood to placenta If there is too much resistance in the placenta, the flow in the umbilical artery will be altered. What is this with antenatal fetal testing?
Malignant epithelial cell tumors
Malignant epithelial serous tumors Most common cell tumors (80%) Up to 30% bilateral at the time of clinical presentation Malignant Mucinous Epithelial Tumor 1/3 of all epithelial tumors 5% cancerous Largest ovarian tumors (20 cm) Hereditary epithelial Ovarian Cancer 1st and 2nd degree relatives with a history of epithelial ovarian cancer What histology classification is this for with ovarian cancer?
Secondary Dysmenorrhea
Management NSAIDS (FIRST LINE) OCP's Danazol and GnRH agonists for endometriosis What is this for?
Urethritis
Management No sexually activity for 7 days after initiating treatment Partners should also be evaluated and treated accordingly Patients who remain symptomatic require follow-up cultures to ensure eradication of infection Patients diagnosed with Chlamydia Trachomatis and N. gonorrhea should be rested in 3 months to assess for reinfection Those with diagnosis of an STD or with risk factors should be offered STD screening What is this?
Inguinal Hernias
Management First assess the hernias reducibility Uncomplicated hernias may be easily pushed back into place and then followed for close observation Incarcerated hernias are irreducible trapped hernias with a high risk of impaired blood supply Incarcerated or strangulated hernias may present with: Fever, nausea, vomiting, pain, and hernial erythema Painful or strangulated hernias should not be reduced but should be repaired surgically What is this for?
Preconception Care
Maternal Assessment Vaccinations Screening tests Counseling When to do it: When counseling for CONTRA-ception After negative pregnancy test When evaluating for STI or vaginal infection Postpartum These are components of what?
Preeclampsia
Maternal vasospasm predominates Inadequate vascular response within the placenta, resulting in IUGR with endothelial damage Increased platelet activation and endothelial factor activation (ATIII, etc) leads to further endothelial damage Typically, in pregnancy, prostacyclin > thromboxane; this is reverse in preeclampsia (Prostacyclin promotes vasodilation) Decreased nitric oxide Increased free radicals also lead to vascular injury Genetic predisposition to inadequate trophoblastic invasion of maternal spiral arteries and any other internal complications leading to placenta ischemia and generalized endothelial cell injury which have less NO so more constriction and have vasospasm-do that to placenta will hurt it and have inflamm mediators leading to more HTN, proteinuria, and edema-vascular permeability come out vascular space and into tissues-risk for DIC incr but more severe-all leading to syndrome of THIS-convulsions are eclampsia and very severe What pathophys is this for?
Endometriosis
May reveal classic sign of uterosacral nodularity associated with endometriosis, but it is often absent Uterus may be relatively fixed and retroflexed in the pelvis because of extensive adhesions Ovarian endometriomas may be tender, palpable, and freely mobile in the pelvis, or adhered What PE is this for?
Fundal height measurement
Measure to top of fundus 20 weeks typically at umbilicus Accurate in singleton pregnancies until 36 weeks "Lightening" = "dropping" of the fetus into the pelvis 20 weeks = umbilicus 1cm for every week to 36ish weeks What is this in estimating gestational age in 2nd and 3rd trimesters?
Intrauterine pressure catheter (IUPC)
Measures true strength of contractions Only use when something is wrong with labor What invasive fetal monitoring device is this?
Emergency Contraception
Mechanisms - Inhibiting or delaying ovulation Interfering with fertilization or tubal transport Preventing implantation by altering endometrial receptivity Causing regression of the corpus luteum. Little/no evidence of post-fertilization demise-take before it implants! What is this?
Induced Abortion
Medical termination of pregnancy (<49 days EGA) Mifepristone (RU-486) Antiprogestion Methotrexate Antimetabolite Removes progestin inhibition Misoprostol Prostaglandin Stimulates myometreium May not complete, need surgical treatment What medical is this used for?
Nipple Discharge
Medications: Sedatives, antidepressants, antipsychotics, antihypertensives, contraceptives Drugs: Cocaine or opioids Herbs: Fennel, anise or fenugreek (Good for breastfeeding moms!) Prolactinoma: noncancerous pituitary tumor Hyperactive pituitary gland Hypothyroidism Chronic kidney disease Excessive breast stimulation Nerve damage to the chest wall or Spinal cord damage What do these cause?
Ovarian cysts
Mild to moderate unilateral lower abd pain Alteration of menstrual interval Pelvic exam - unilateral tenderness with a palpable, mobile, cystic adnexal mass Most cysts spontaneously resolve What clinical presentation is this?
3-6
Milk "comes in" about WHAT days postpartum - sooner if experienced labor-body starts producing milk during labor-takes longer with C section-breast become extra engorged when have the milk-wear milk pads so don't leak milk
Lactation
Milk can be secreted for 6 months after delivery or cessation of breastfeeding! As long as breasts are stimulated, milk will be produced! Benign bloody discharge in milk is often seen in 2nd and 3rd trimesters and postpartum! What is this?
Retained Products
any POC that don't pass during spontaneous or induced abortion, or post-partum What is this?
Oral contraceptives or progestins
Medroxyprogesterone acetate, 5-10 mg Lead to suppression of pituitary function and gonadotropin release Decreases LH production Decreases production of androstenedione and testosterone Ovarian contribution to the total androgen pool is thereby decreased Prevent endometrial hyperplasia by preventing estrogen excess Leads to cyclic, predictable withdrawal bleeding episodes Can diminish signs of hirsutism, acne, maintain menstrual regularity and reduce the number and size of ovarian cysts What tx is this for PCOS?
Cardiovascular Lipid Changes
Menopausal changes lead to: Elevated total cholesterol and LDL Decreased HDL Increased Angina and coronary heart disease New studies underway Should not offer Hormone Therapy to patients with primary goal of protection against heart disease What complication is this with menopause?
12
Menopause is diagnosed retrospectively after how many months of amenorrhea?
PID
Minimum Diagnostic criteria: Uterine, adnexal, or cervical motion tenderness-Chandelier sign-push up and move side to side Additional Criteria PO temp of >38.3 Abnormal cervical or vaginal discharge with white cells on saline microscopy Elevated ESR Lab documentation of cervical infection with N. gonorrhoeae or C. trachomatis Do not delay treatment for culture results What dx is this?
Vulva
Mons pubis Labia majora Labia minora Vulval vestibule Clitoris Bulbs of the Vestibule Urinary Meatus Vaginal opening Bartholin's-lubrication-infection there with cervicitis and vaginitis-also commonly get obstructed-open up to drain it and Skene's vestibular glands.[ What anatomy is this for?
Infertility
More frequent with endometriosis No cause-and-effect relationship found Prostaglandins and autoantibodies have been implicated but not proven Presence of endometriosis in asymptomatic patients varies between 30-50% Not passing viable egg down tube or crowding ovary and making immature eggs be released What is this with endometriosis?
MRI
More sensitive than mammogram >90% sensitive Less specific than mammogram Cost $$$$ Reserve for High risk patients Dense breasts breast implants Scars BRCA + What is this imaging?
Fibroids
Menorrhagia-heavy normal bleeding Progressively heavier menstrual flow that last longer than the normal duration May result from significant distortion of the endometrial cavity by the underlying tumor Progressive increase in "pelvic pressure" bc uterus is bigger Urinary Symptoms Constipation Secondary dysmenorrhea What clinical presentation is this?
Hormonal Changes with Age
Menstrual cycle length decreases Luteal phase remains constant Follicular phase shortens When estrogen levels begin to drop, the follicular phase of the cycle may be shortened, and this can shorten the total cycle from 28-30 days to 24-26 days, resulting in more frequent periods Estradiol levels are lower during portions of the cycle, including active follicular maturation, the midcycle peak, and the luteal phase Luteinizing hormone (LH) levels are no different from those observed in younger women FSH concentrations are strikingly elevated from follicular phase to mid-luteal phase and falls as estradiol increases during follicular maturation Related to inhibin, a polypeptide hormone that is synthesized and secreted by granulosa cells Causes negative feedback on FSH release by the pituitary As the oocyte number decreases, inhibin levels fall, resulting in a rise in FSH levels What is this?
Primary Dysmenorrhea
Menstrual pain in the absence of pathologic findings Due to increased prostaglandins Usually begins within 1-2 years after onset of menarche 50-75% of women are affected at some time 5-6 % will have incapacitating pain Presentation Most common late teens to early 20s, decreases with age No pathologic findings with pelvic exam Diffuse pelvic pain right before or with onset of menses Low, midline wave-like cramping pelvic pain May radiate to thighs and back May be associated with nausea, diarrhea, headache, vomiting What is this?
Urine hCG TSH Prolactin FSH LH (If hirsutism is predominant upon exam add: DHEAS, Androstenedion and 17-OH progesterone to determine organ of cause) (Consider if chronic disease: ESR Liver function tests BUN Creatinine UA)
What are the first line testing for amenorrhea dx evaluation?
Cervical
Most early cancers are asymptomatic Symptoms of advancing may include: Bleeding Watery discharge Signs associated with venous, lymphatic, neural, or ureteral compression from tumor Diagnosis of this cancer usually follows histologic evaluation of biopsies taken during colposcopic examination or biopsies from a grossly abnormal cervix What GYN presentation is this?
Endometriosis
Most Common: in the pelvis Ovaries Peritoneum of the uterus Anterior/Posterior cul- de-sacs Uterosacral ligaments Fallopian Tubes Pelvic LN Infrequent: Rectosigmoid GI sites Vagina Rare Umbilicus Surgical scars (Episiotomy) Kidney Lungs Arms Legs Nasal Mucosa What are these sites related to?
Cytomegalovirus
Most common congenital infection Either primary or reactivation can cause congenital CMV syndrome Congenital CMV due to transplacental transmission Risk highest in women who get CMV during pregnancy Can be asymptomatic at birth, but result in *neurologic issues later* Symptomatic neonatal infection has 30% mortality rate What infection is this that affect prego?
Endometrial
Most common gynecologic malignancy in developed nations, including U.S. In the United States, there were approximately 50,000 new cases and over 8000 deaths from the disease in 2013 Life time risk of developing the disease 1 in 38 Incidence peaks between ages 70 and 74 The majority of women with uterine cancer are diagnosed at an early stage Endometrial Carcinomas represent 97% of uterine cancer Sarcomas represent the other 3% What GYN cancer is this?
Type 2 Diabetes
Most common pre-existing diabetes found in pregnant women Usually OK to maintain on pre-pregnancy regimen May require insulin during the pregnancy Metformin may be discontinued after 1st trimester Emphasize dietary considerations Risk of worsening of diabetic complications diabetics-usually okay to maintain meds-metformin and insulin are okay-will get worse during prego bc prego is insulin resistance state-emphasize diet like balance carbs with protein-not eating smarties-diabetic complications get worse during prego like neuropathy and retinopathy and have to be careful and screened before and after prego What is this in pregnancy?
Endometriosis
Most commonly occurs in white, nulliparous women btw the ages of 35-45 Present with cyclic pelvic pain or pressure, dyspareunia, dysmenorrhoea, dyschaezia, and infertility May occur on the ovaries and occasionally can form large cysts filled with chocolate colored, called "chocolate cysts" or endometriomas Linked to depression What is this?
Fibroids
Most commonly originate in the myometrium Considered hormonally responsive, benign tumors Menopause generally causes cessation of tumor growth and even some atrophy Obesity-produce estradiol-extra estrogen-cause these Highest prevalence during 5th decade Present in 1 in 4 Caucasians Present in 1 in 2 African Americans Prevalence believed to be as high as 80% Based on their anatomic relationship to the layers of the uterus (location and direction of growth) Intramural - centered in the muscular wall of the uterus Subserosal - Originate from myocytes just beneath the uterine serosa, growth outward Pedunculated- remains connected to the uterus by a stalk Submucosal - just beneath the endometrium Considered hormonally responsive benign tumors Estrogen may work by stimulating the production of progesterone receptors in the myometrium Progesterone binding to these sites stimulated the production of several growth factors, causing the growth of myomas Exact mechanisms are unknown What is this?
US findings
Most commonly used modality Ovarian enlargement with Doppler showing little to no ovarian flow Coexistent mass Several cysts along periphery Irregular echogenic areas Twisted pedicle: specific finding of torsion, rarely seen What dx is this with ovarian torsion?
Vulvar
Multifactorial - Depending on the following: Tumor Depth & Size Vascular Invasion Nodal Involvement Single Most Important Prognostic Variable - # of positive groin lymph nodes 5 year survival (decreased to between 20 - 50% with metastatic nodal disease) 5 year survival for all is approximately 70% Stages I and II 60-80% Stage III 45% Stage IV 15% What GYN prognosis is this for?
Domestic Violence
Multiple injuries in suspicious areas: Head, neck, abdomen, chest (most common) Internal injuries Fractures Bruises Burns 2-5 have multiple injuries at different times bc play a lot and get hurt Strange injuries in various healing stages: Fingernail scratches Cigarette burns Rope burns Iron burns on forearm Contusions from a shoe Bilateral symmetric injuries Injuries from forceful restraint. Bite marks What PE clues are these for?
Severe Preeclampsia
Multisystem involvement associated with preeclampsia BP > 160 systolic or > 110 diastolic on 2 occasions at least 6 hours apart while patient AT REST Marked proteinuria = > 5g on 24h urine sample, or > 3+ on urinalysis of two or more samples collected 4 hours apart Oliguria (< 500mL urine in 24hours) Visual or cerebral disturbances - headaches, scotoma Pulmonary edema or cyanosis Epigastric pain Liver dysfunction Thrombocytopenia IUGR An indication for delivery REGARDLESS of gestational age or maturity way more protein, less urine prod-treat with corticosteroids to stable lungs and get them out What is this with pregnancy?
Abuse
Must be clear and complete Quotes (Victim stated, "...) Photos of injuries Complete physical description Police involvement/notes Accurate details Who was there Location Witnesses What help was offered What documentation is this?
SSRIs
What are the gold standard for treatment of Premenstrual Dysphoric Disorder (PMDD) and PMS and used after trying non-pharm treatments such as decreased stress, salt reduction, exercise, and NSAIDS?
Acute Prostatitis
NIH Classification (Category I) Diagnosis: Acute onset of pain combined with Irritative and obstructive voiding symptoms in a patient with a systemic febrile illness Frequency, urgency, dysuria; hesitancy, poor stream, AUR Perineal or low back pain F/C, Malaise, N/V Usually "sick" PE: toxic, febrile, tachycardic, tachypneic, even hypotensive; suprapubic pain, AUR DRE: Classically described as "hot, boggy, and exquisitely tender" Do not massage prostate Labs: UA, +/- blood cultures, CBC shows elevated WBC Etiology: E.Coli, Klebsiella, Proteus, Enterobacter, and Staph What is this?
Pain + Mastitis risk
Nipples-inverted or cracked can cause what with breast feeding?
Variable decelerations
No direct correlation to timing of contraction Rapid and deep deceleration, return to baseline can overshoot Umbilical cord compression ABNORMAL IN LABOR Can be normal when pushing baby out but keep eye on baby If happens for hours bad for baby leading to fetal acidosis-hypoxic state What is this with intrapartum fetal surveillance?
Maternal
Prior OB history Preterm birth, fetal loss, birth defects/neural tube defects Medical history Age Chronic conditions Diabetes Hypertension Thyroid disease Hypercoagulable states - lupus, Factor V Leiden, MTHFR mutation Medications Anticonvulsants Anticoagulants Isotretinoin ACE inhibitors Tetracyclines Occupation Manual labor Chemical contact(s) Family and genetic history Hemoglobinopathies Cystic Fibrosis Tay-Sachs Fragile X/autism Substance use/abuse Both current and prior Social issues Intimate partner violence - Risk increases in pregnancy Food insecurity Risk of STI What are these assessments of?
Primary Amenorrhea
No menstruation by 13 & without secondary sexual development N0 menstruation by 15 regardless of secondary sexual development What is this?
Paragard Copper T
Non-hormonal intrauterine contraceptive Stays in for 10 years Free copper and copper salts Enhance the cytotoxic inflammatory reaction within the endometrium Toxic to sperm and ova Copper interferes with Sperm migration, viability, and acrosomal reaction Postfertilization effects also appear to contribute as a secondary contraceptive mechanism Side effects - dysmenorrhea, heavy bleeding What contraception is this?
Rubella
Non-immune patients carry risk of infection during pregnancy Rare in developed countries with immunization programs Congenital syndrome = defects in neurologic, cardiac, and endocrine systems What infection is this that affect prego?
Premenstrual Dysphoric Disorder (PMDD) and PMS
Non-pharmacologic Add fresh foods, avoid processed foods Stress reduction Aerobic exercises Avoid caffeine/alcohol Salt reduction Pharmacologic NSAIDs Vitamin B6 & E SSRI's are Gold standard OCP's Drosperinone containing OCP for PMDD Others: spironolactone, calcium carbonate What treatment is this for?
Cesarean Delivery
Non-reassuring fetal heart tones Watch for decrease in fetal reserve Decreased variability, poor return to baseline after contractions Maternal request Elective repeat-had one prob better to get another one Risks Abnormal placentation in next pregnancy Uterine rupture during next labor Need for repeated ones These are indications for what??
US
Noninvasive Use first if <30 years old or pregnent Characterizes palpable masses or suspicious areas on mammogram Solid vs cystic Simple vs complex Benign: sharp borders, central enhancement, absence of internal echoes. Suspicious: poorly defined margins, heterogeneous internal echoes, irregular shadowing. What is this imaging?
Vaginal Ecosystem
Normal vaginal discharge is clear to white, odorless, and of high viscosity Normal bacterial flora is dominated by lactobacilli - other potential pathogens present Acidic environment (pH 3.8-4.2) inhibits the overgrowth of bacteria Some lactobacilli also produce H2O2, a potential microbicide What is described here?
Pituitary Dysfunction Tumor removal (Transphenoidal surgery)
Prolactin secreting pituitary adenoma Diagnosis Decreased FSH/LH, increased prolactin MRI of pituitary What is this etiology associated with secondary amenorrhea AND what is the treatment?
Breast Exam
Observe/inspect all four quadrants of both breasts Skin- rash, changes, color, dimples, retractions Symmetry Nipples, areola Palpate with pads of fingers All four quadrants of both breasts Nipple Tail of Spence Lymph Nodes Axillary Infra and supraclavicular Inspection and palpation Sitting arm at side, elevated, on waist. Palpate breast and axillae. Sitting and lying Palpate from sternum to the axilla and from the clavicle to below the 6th rib. Use: Strip, spokes of a wheel, or spiral pattern What is this?
Endometrial cancer
Occurs ~ 25% of cases Improved survival if recurrence in vagina vs. pelvic vs. distant metastatic disease Multiple approach with better prognosis: Radiation Therapy Short term improvement, but long term remissions are rare Chemotherapy Hormonal Therapy Progestin Surgery Still comes back with radical hysterectomy What prognosis and recurrence is this for?
Pregnancy
Quit smoking Limit alcohol intake Don't do drugs EXERCISE! Get down to a reasonable weight Take Folic Acid Get metabolic conditions under control Manage risk for STI's This counseling is done prior to what?
Sentinel lymph node biopsy
Radioactive substance and/or blue dye is injected near the tumor, the injected material is followed visually or with a probe and the first lymph nodes to take up the material are removed and checked for cancer cells What is this?
Stroke level
Only treat chronic HTN in pregnancy if close to what which is during 3rd trimester??
Menopause
Oocytes become increasingly resistant to FSH Increased FSH produced Plasma concentrations of FSH begin to increase several years in advance of actual menopause Typical value of FSH is generally >30 mIU/mL Ovary is still active Produce testosterone and androstenedione What physio is this for?
Medical
Optimal for pts who are currently symptomatic, have documented endometriosis beyond minimal dx, or who desire pregnancy in the future Recurrence after completion is common Medical tx does not affect adhesions and fibrosis caused by the endometriosis May be instituted empirically w/o a definitive surgical dx if other causes ruled out What treatment is this with endometriosis?
Ovarian
Presents most commonly in the 5th & 6th decade of life (age 40s & 50s) 5- to 7- fold greater incidence in the U.S. and Western Europe Caucasians are 50% more likely to develop THIS CA than African Americans Lifetime risk for developing THIS cancer is 1 in 70 2nd most prevalent gynecological cancer Malignant ovarian epithelial cell tumors spread primarily by direct extension within the peritoneal cavity as a result of direct cell sloughing from the ovarian surface Late clinical presentation relates to this finding May spread by lymphatic and hematogenous routs as well, although distant metastasis is rare What GYN cancer is this?
Phimosis
Other complications include: Penile irritation or bleeding Urinary retention Painful urination (dysuria) Painful erections Recurrent infections of the foreskin (balanoposthitis) Paraphimosis (foreskin stuck in the retracted position behind the head of the penis) Patients need urological evaluation What is this?
PCOS
Ovarian Hyperthecosis Congenital adrenal hyperplasia Cushing's syndrome Hyperthyroidism/Hypothyroidism Medications (androgenic progestins, Danazol) Hyperprolactinemia Hypogonadotropic hypogonadism Primary ovarian failure Exogenous androgen use (anabolic steroids) Acromegaly Androgen-secreting adrenal tumor Ovarian tumors What DDx is this for?
Ovarian Torsion
Ovarian Tumor Tubal ovarian abscess Ureteral calculus Perforated Colonic carcinoma Appendicitis Ectopic Mesenteric Ischemia Endometriosis Diverticulitis PID Infection Peritonitis Sepsis Adhesions Chronic pain Infertility (Rare) What DDx is this associated with?
Domestic violence
Overbearing Insists on accompanying the patient Acts overly concerned Hostile to the health care team Never probe about WHAT if the perpetrator is in the room - this may escalate the violence and put the patient in danger.
Indirect Direct
PE: Insert finger into the inguinal canal and asking the patient to perform the Valsalva maneuver (cough) WHAT inguinal hernia will travel inferiorly to touch the tip of the examining finger WHAT inguinal hernia will travel inferior to touch the side of the examining finger
Visceral (T10-L1)
Pain during labor is WHAT AREA where cervical dilation, uterine contraction occurs?
Somatic (S2-4)
Pain during labor is WHAT AREA where fetus descends through vagina?
Mastitis
Painful infection of breast 3% of Lactating Women Cause: Staphylococci, streptococci, or fungal Treatment Don't stop breastfeeding-back up more and cause more inflamm Antibiotics- dicloxacillin or clinadamycin Surgical drainage if abscessed What is this?
Placental abruption
Painful vaginal bleeding in the third trimester Abnormal premature separation of otherwise normally implanted placenta Bleeding in the decidua basalis induces separation of the placenta, resulting in more bleeding Risks Chronic hypertension Preeclampsia Multiple gestation Advanced maternal age Multiparity Cocaine use and smoking Chorioamnionitis-infection of tissue surrounding baby and amniotic fluid Trauma Prior h/o abruption = 15-20x risk Elevated 2nd trimester MSAFP-maternal serum alpha feta protein-abnorm function-at risk for THIS What is this?
Placenta previa
Painless vaginal bleeding Placental location overlies the cervix Risks Prior previa Previous uterine surgery-fibroid or septum incr risk bc of scar Multiparity-figure out where to put placentas Advanced Maternal Age Cocaine use and smoking bc of vasoconstrictors-not developing normally or moving the way need to What is this?
Pelvic Organ Prolapse
Risk Factors: Vaginal birth Genetic predisposition Advancing age Prior pelvic surgery Connective tissue disorders Increased intra abdominal pressure from obesity What are these for?
Urological (cut off blood supply)
Paraphimosis is a WHAT emergency?
Indirect inguinal hernias
Pass lateral to the inferior epigastric vessels to enter the deep inguinal ring Most common type of inguinal hernia Accounts for more than 2/3 of cases More common in younger men due to the congenital patency of the processus vaginalis In the ring
Bloody Unilateral
Pathologic nipple discharge includes what?
Benign Prostatic Hyperplasia
Pathophysiology: Hyperplasia increases urethral resistance Increase resistance in the urethra causes compensatory changes in bladder function-go on a quicker pattern Changes in bladder function along with age related changes to the bladder and nervous system lead to the symptoms of BPH Urinary frequency Urinary urgency Nocturia What is this?
ceftriaxone plus doxycycline
Patients age 35 years and younger should be treated with what when have epididymitis?
Ciprofloxacin
Patients over age 35 years should be started on what with epididymitis?
Early decelerations
Peak before the peak of contraction; mirrors contraction Gradual decrease and gradual return to baseline Compression of fetal head in pelvis NORMAL IN LABOR What is this with intrapartum fetal surveillance?
Miscarriage
Pelvic rest for 2-4 weeks-no tampons, fingers, penis (OK to have intercourse once bleeding has stopped) RhoGam for non-sensitized patients (Rh neg) May attempt pregnancy again when emotionally ready Continue prenatal vitamins, recommend folic acid supplement Manage risk factors If pregnancy was unplanned, IUD may be inserted at time of surgical evacuation What followup is this for?
Hysteroscopic device insertion - Essure
Placement of titanium-Dacron spring device into tubal ostia Tubes scar around device Post insertion hysterosalpingogram (HSG) to verify efficacy Useful for patients that are not candidates for laporoscopy Morbidly obese Surgical risk Adhesions What female sterilization is this?
Paraphimosis
Presentation Adult population Symptomatic most often report penile pain Pediatric population May manifest as acute urinary tract obstruction and may be reported as obstructive voiding symptoms The glans penis is enlarged and congested with a collar of edematous foreskin If left untreated for too long necrosis of the penis could occur What is this?
Emergency Contraception
Plan B One-Step - levonorgestrel-high dose progesterone Up to 72 hours after unprotected intercourse Combinations of levonorgestrel 0.1-0.15mg and 20-30mcg ethinyl estradiol - 4-6 pills at a time x 2 separated by 12h (total dose EE 100-120 mcg) Ella (ulipristal acetate) - Up to 5 days after unprotected intercourse Progesterone agonist/antagonist delays/inhibits ovulation Approved in 2010 Copper T IUD What are these?
Diabetes
Polyhydramnios - increased amniotic fluid Macrosomia - baby > 4500g Operative vaginal delivery Cesarean delivery Shoulder dystocia Neonatal hypoglycemia Glucose crosses the placenta, insulin does not Mom's high glucose causes baby to produce more insulin Take away mom's glucose, baby still has high insulin (at least temporarily) Baby's glucose drops precipitously In the nursery, they check the baby's glucose at 30min post-delivery These are risks of any what in pregnancy?
24 to 34 48 7
Preterm labor management: Treatment with corticosteroids if WHAT TO WHAT weeks to improve lung maturity IM betamethasone or dexamethasone - take WHAT hours to be effective Max benefit within WHAT days of delivery Improves neonatal outcomes
Endometrial cancer
Post-menopausal bleeding Postmenopausal women with endometrial cells on a Pap smear Perimenopausal patients with intermenstrual bleeding Premenopausal patients with a history of anovulation and irregular bleeding Pelvic pain Get US the day of!! Screening Tools: No ideal method No blood test Transvaginal ultrasonography? Normal endometrial stripe < 5 mm thick What pt presentation is this for?
Benign Prostatic Hyperplasia
Prevalence ↑ with age Etiology Increase in # of epithelial & stromal cells in the periurethral PORTION of the prostate (transition zone) Under endocrine control Testosterone converted to Dihydrotestosterone (DHT) in the prostate by 5-alpha reductase Prostatic Smooth Muscle Stimulation of adrenergic nervous system increases urethral resistance What is this?
Long-term contraception
Pre-treat with usual or injectable contraceptive Screen for appropriateness of method Plan insertion - IUD 1st week of cycle when cervix is most favorable Almost definitely not preggers during menses Implantable First two weeks of cycle This is using what?
Testicular Torsion
Presentation There is unilateral torsion in which the descended testis rotates within the tunica vaginalis Severe scrotal pain and swelling and may also present with nausea, vomiting, and lower abdominal pain There is extreme tenderness and firmness to palpation The absence of the cremasteric reflex and Phren sign differentiate torsion from epididymitis The normal cremasteric reflex, which involves testicular retraction of at least 0.5 cm and is induced by stroking the medial aspect of the thigh, is absent in patients with testicular torsion The normal Phren sign, in which pain is relieved by scrotal elevation, is also absent in these patients What is this?
Varicocele
Presentation Abnormal feeling of unilateral heaviness in the scrotum Common presentation Palpation of the scrotum will reveal collection of dilated veins typically described as a "bag of worms" What is this?
Hydrocele
Presentation and differential Physical examination Presents as an enlarged scrotum Usually unilateral Depending on the weight of the fluid, the patient may have no pain or may experience discomfort and pain What is this?
Tubo-Ovarian Abscess
Presentation: Acutely ill High fever Tachycardia Severe pelvic and abdominal pain with a palpable "lump" in the lower abdomen N/V Typically symptoms have developed over a week or so Typically there is a history of recent/remote pelvic inflammatory disease What is this?
PAPP-A
Pregnancy associated plasma protein A, glycoprotein produced by the trophoblast is reduced in Down Syndrome pregnancies levels <1st percentile also strongly associated with IUGR, <5th percentile early pregnancy loss What is this?
Postterm Pregnancy
Pregnancy beyond 42 completed weeks of gestation 10% of pregnancies Most common "cause" = inaccurate dates Can happen in successive gestations Increased maternal AND fetal morbidity and mortality Dysfunctional labor-placenta stops working when in there too long and grows huge Cesarean section Vaginal trauma Stillbirth Meconium aspiration syndrome-stool in colon time of delivery-no bowel movements in amniotic sac but if stressed may have one which causes sticky black stool-lots of dead cells-go into amniotic fluid and end up inhaling matter into lungs-cause norm preg to be hypoxic baby What is this?
Amenorrhea
Pregnancy is the most common cause!!! History of breast fullness, weight gain and nausea suggest diagnosis Must be confirmed by a positive hCG assay (urine or blood) **Must first rule out pregnancy before any further testing is performed What is this?
Abortion (Miscarriage)
Pregnancy loss "expulsion of fetus", spontaneous or otherwise, prior to 20 completed weeks EGA
Primagravida
Prego for the first time
Cyclical
Premenstrual hormone changes (luteal phase) Resolves with menses Bilateral Also associated with hormone replacement therapy-give NSAIDs or take off HT What breast pain timing is this?
Urologist
Primary care clinicians should refer the pt to a WHAT once the dx of peyronie's sz is established or in any pt with a penile deformity?
Progesterone
Promotes breast development Increases fat storage Decreases smooth muscle tones Decreases vascular tone Increases pulmonary ventilation Increases temperature What hormone is this?
Barrier Methods
Pros: Control Some STI protection, depends on method Cons: Risk of failure with imperfect use Uncomfortable Some are expensive Some need to be fitted Diaphragm and cervical cap can increase risk for toxic shock What are these?
Second and third trimester
Quad screening MSAFP Estriol hCG Inhibin-A GTT (glucose tolerance test)-protective mechanism for hypoglycemia but now have access to a lot of food 50g nonfasting glucose load = screening after 22 weeks 100g fasting glucose load = diagnostic anytime in pregnancy GBS (group B strep)-perineum hangs out there 32-36 week - perineal swab If positive, treat with antibiotics during labor to prevent neonatal sepsis Repeat HIV and RPR at 36 weeks (recommended in high risk populations) TdaP between 27-36 weeks What screening is this for?
Tubo-Ovarian Abscess
Recommended Regimen B Cefotetan 2 g IV every 12 hours, or Cefoxitin 2 g IV every 6 hours, plus Doxycycline 100 mg orally or IV every 12 hours Recommended Regimen B Clindamycin 900 mg IV every 8 hours, plus Gentamicin loading dose IV or IM (2 mg/kg body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3-5 mg/kg) can be substituted. Effective in 70% of cases; duration at least 14 days What is this for?
Chronic Bacterial Prostatitis
Recurrent UTIs Asymptomatic between acute episodes Account for 5-15% of cases Consider suppressive antibiotics Treat with antibiotics for 4-6 weeks What is this?
Hot flashes
Recurrent, transient episodes of flushing, perspiration, and sensation ranging from warmth to intense heat on the upper body and face, sometimes followed by chills "Night Sweats" common, leading to sleep disturbance Affects ~ 75% of women in the U.S. Variable by ethnicity and body mass index (BMI) Typically resolve in 2-3 years, may last up to 10 years What is this with menopause?
PCOS
Reduced glucose-uptake response to a given amount of insulin The mechanism of this decreased insulin sensitivity appears to be due to a postbinding abnormality in insulin-receptor-mediated signal transduction Has been associated with an increase in several disorders including type 2 diabetes mellitus (DM), hypertension, dyslipidemia, and cardiovascular disease What pathophys insulin resistance is this associated with?
Breasts
Reproductive changes in these are related to progesterone effect Women may notice tenderness and fullness in the luteal phase due to progesterone-mediated changes What contraception change is this?
Proliferative Secretory
Reproductive cycle is divided into two phases related to the endometrium What phases are these?
Polycystic Ovarian Syndrome
Responsible for 20% of secondary amenorrhea Affects approximately 4-12% of women Equally affects all races and nationalities Associated with abnormal function of hypothalamic-pituitary-ovarian axis Primary defects of insulin activity (i.e. insulin resistance, hyperinsulinemia) Implicated factors Genetics CYP11a gene 19p13.2 insulin receptor gene Obesity Other causes of LH excess Characteristics Oligo-ovulation or anovulation Signs of androgen excess Multiple small ovarian cysts What is this?
Infertility or subfertility
Results from anovulatory cycles In women with infertility secondary to anovulation, PCOS is the most common cause and accounts for 80-90% of cases Pregnancy & PCOS have increased rate (30-50%) of early miscarriage compared with a baseline rate of approximately 15% in the general population What complication is this with PCOS?
Epididymitis
Risk factors Sexual activity Bladder obstruction Prolonged bicycle riding Prolonged motorcycle riding Strenuous physical activity Running sports Presentation and differential Similar to that of testicular torsion There is unilateral scrotal pain, erythema, and edema on the affected side Onset of pain typically progresses over days rather than hours Fever, rigors, dysuria, urgency, and frequency Palpation reveals an indurated, tender, or swollen epididymis A positive cremasteric reflex (in which the testicle rises) will not confirm epididymitis but will help rule out torsion An elevated C-reactive protein (CRP) level (greater than 24 mg/L) and increased blood flow to the epididymis on ultrasonography help to differentiate epididymitis from testicular torsion Color Doppler ultrasound has 92% to 100% sensitivity and 100% specificity in detecting epididymitis Common laboratory tests include urinalysis (with findings of pyuria or bacteriuria), urine culture, and urethral culture (if discharge is present). What is this?
RISUG
Reversible inhibition of sperm under guidance Polymer injected into vas deferens kills sperm Reversal entails injecting DMSO to dissolve polymer What non-vasectomy procedure is this?
Contraceptive
Review hormonal contraceptive use ~ 3 mos following initiation Consistency of use Changes in menstruation/breakthrough bleeding Mood changes/Headaches Blood pressure Libido-anti androgen pill decr testosterone and sex drive in women What followup is this?
Preeclampsia
Review obstetric record, if available Do they have current signs of vasospasm? Headaches Scotoma-seeing black spots bc going to pass out Pay attention to rapid weight gain between visits Check for edema in upper extremities, or that which doesn't respond to supine positioning ("I wake up swollen") Check BP in supine, resting position Check reflexes and ankle clonus Examine abdomen for RUQ tenderness Check urine for protein Monitor fetal well-being with nonstress test Refer to OB or labor and delivery triage managing later in prego check the risks and follow overtime-think have this send to hospital for workup What is this workup for?
Amenorrhea
Review pediatric growth and development charts Comprehensive menstrual history (menarche, duration of menses, symptoms) Childhood or chronic illnesses Medication use Sexual history Use of illicit drugs Eating habits, exercise patterns, self-image concerns Hyperprolactinemia Galactorrhea and amenorrhea Hyperthyroidism Nervousness, heart palpitations, weight loss, heat intolerance Hypothyroidism Fatigue, weight gain, cold intolerance Hypothalamic dysfunction or tumor Visual changes or hearing loss Outlet obstruction Cyclic pain or bloating Ovarian follicle depletion or dysfunction Vasomotor symptoms Hyperandrogenic states Hirsutism or signs of virilization (e.g. clitoromegaly, deepening voice, increased muscle mass What hx is this for?
Prostate Cancer
Risk Factors: Advanced Age Ethnicity Family History (twofold increased risk) Dietary factors Red meat, high intake of fats, dairy products Protective Factors Vegetarians, high soy intake, selenium, Vitamin E, lycopene Clinical Evaluation Most men are asymptomatic or have mild obstructive voiding symptoms Evaluation is usually DRE and PSA DRE + PSA detect more cancers than either alone Since the initiation of PSA as a screening tool there has been a shift in the age and stage at diagnosis. Cancer screening is very controversial Advocates: earlier detection & cure with local therapy Opponents: No proof that earlier detection changes mortality & increased treatment may do more harm than good (erectile dysfunction, urinary incontinence, and bowel problems) U.S. Preventive Services Task Force- Indeterminate recommendation ACS & AUA recommends informed decision making by the patient What is this?
PID
Risk factors: Young nulliparous sexually active women with multiple partners Nonwhite race Douching Smoking Protective factors: OCP Barrier method contraception Lower abdominal pain Chills/fever Menstrual disturbances Purulent cervical discharge Cervical and adnexal tenderness Less commonly: Post-coital bleeding Urinary frequency Low back pain What is this?
160 100 Fetal growth restriction
Risk for development of preeclampsia later in pregnancy Monitor for worsening of HTN or development of proteinuria In chronic hypertension Avoid getting blood pressure too low - need to maintain perfusion through the placenta No meds needed if SBP < WHAT or DBP WHAT Meds reduce risk of maternal stroke Monitor fetus for appropriate growth Treatment of chronic hypertension in pregnancy can increase risk for WHAT??
Hep B
Risk of transmission at birth = nearly 90% If known, treatment of newborn includes immediate vaccination and Hepatitis B immune globulin Mothers with high viral load can be treated with lamivudine What infection is this that affect prego?
Varicella
Risk of transmission highest with maternal primary infection during 8-20 weeks gestation Neurologic and musculoskeletal malformations common What infection is this that affect prego?
Hormone Therapy
Risks CHD events Stroke Thromboembolic disease Breast Cancer Benefits Improvement in the vasomotor symptoms of menopause Reduction in osteoporotic fracture Colorectal cancer risk decreased What cautions are these for with menopause?
Premature Rupture of Membranes
Risks Smoking Lower genital tract infections - BV, GC, GBS, etc Smoking = 2+x risk Prior h/o PROM = 2x risk Prior preterm delivery Multiple gestations-not a lot of space Symptoms Gush of fluid Slow leak Can be confused with urinary leakage What are these risks and symptoms for?
Type 1 Diabetes
Risks if uncontrolled Congenital anomalies and birth defects if not well controlled prior to conception Spontaneous abortion Increased risk of fetal demise in poorly managed in the 3rd trimester Sugars may be more difficult to manage the further along in pregnancy Increased risk of: DKA Pre-eclampsia Worsening diabetic retinopathy can be bad during prego especially if uncontrolled-when not managed appropriately get DKA-need more insulin during prego and widening sugars-managed by high risk OB and endocrinologist-need to keep track of sugars! What is this in pregnancy?
FEV1 (decreased can increase risk of low birth wt)
Routinely check what with asthma in prego?
Premature Rupture of Membranes (PROM)
Rupture of membranes prior to the onset of labor 12% of all pregnancies, 8% at term PPROM Major complication = intrauterine infection Risk of infection greatest in 1st 24 hours of rupture Presence of GC or GBS in vagina increases risk on infection Other complications Prolapsed umbilical cord-baby sits on cord and cut blood supply off to baby-is an emergency!! Hold fetal head up off cord until get to surgery Placental abruption What is this?
Chorionic Villus Sampling (CVS)
Used for prenatal diagnosis of fetal disorders (usually trisomies) in patients at risk After 10 weeks gestation Aspiration of chorionic villi (immature placenta) via ultrasound guidance Accuracy similar to amniocentesis Risk of fetal loss around 1%, greater with transcervical approach Complications include vaginal bleeding, more common with transcervical approach Not testing fetal tissue just villi and done sooner What is this?
Uterine disorder Estrogen
Scarring of uterine cavity Asherman's syndrome Secondary to post partum hemorrhage or s/p D7C or endometrial infection Diagnosis: Pelvic US (absence of normal uterine stripe) or hysteroscopy (dx and treat) What etiology is this with secondary amenorrhea AND what is the treatment?
Menopause
Sleep disturbance Hot flashes/flushes Vaginal dryness & genital tract atrophy-flora changes-uterus more smooth and decr in size and ovaries, decr muscle tone, prolapse-kegel Skin/hair/nail changes-thin Weight gain Mood/memory changes Headache Signs of osteoporosis Cardiovascular lipid changes What presentation is this for?
Trial of Labor after Cesarean Delivery
Selection criteria useful in identifying candidates for VBAC (Vaginal birth after C-sec delivery): 1 previous low-transverse cesarean delivery Clinically adequate pelvis No other uterine scars or previous rupture Physician immediately available t/out active labor who is capable of performing an emergency c-sec delivery Availability of anesthesia, facility, and personnel for emergency c-sec delivery Circumstances under which a trial of labor should not be attempted: Previous classical or T-shaped incision or extensive transfundal uterine surgery Previous uterine rupture Medical or obstetric complication that precludes vaginal delivery 2 prior uterine scars and no vaginal deliveries Lack of anesthesia, facility, or personnel for an emergency c-sec delivery This is known as what?
Breast Cancer
Self breast awareness or monthly SBE Mammogram Every 2 years age 50-70 (USPTF) Ultrasound if age <30 with a lump Clinical Breast Exam Annual after age 40 & Every three years age 20-39 BRCA- detects susceptibility if family history MRI if +BRCA Future- blood tests? What screenings are these for?
Cell-free DNA
Sequencing of "cell-free" DNA in maternal circulation. Detects 99% of Down syndrome pregnancies Apoptosis of placental cells = fetal source of cell-free DNA Recommended to be done after 10 weeks EGA (though can be detected after 5 weeks) What is this screening for aneuploidy?
PCOS
Several pregnancy and neonatal complications Shown to have a two- to threefold higher risk of: Gestational diabetes Pregnancy-induced hypertension/Preeclampsia Preterm birth Perinatal mortality, unrelated to multifetal gestations C-section delivery Neonates are more likely to be admitted to ICU with a higher perinatal mortality rate, unrelated to multiple pregnancy What complication is this associated with?
Estrogen therapy
Several routes of administration Oral medications Transdermal Preparations Topical Preparations Vaginal cream or tablet 17 Beta estradiol orally Oxidized to E1 in the enterhepatic circulation-menopause Transdermal E2-estradiol Steady, sustained estrogen blood levels Preferable alternative to oral dosing for many patients What treatment is this with women without uterus?
160 110 5 500
Severe Preeclampsia BP > WHAT systolic or > WHAT diastolic on 2 occasions at least 6 hours apart while patient AT REST Marked proteinuria = > WHATg on 24h urine sample, or > 3+ on urinalysis of two or more samples collected 4 hours apart Oliguria (< WHATmL urine in 24hours)
Delivery
Severe preeclampsia is an indication for WHAT REGARDLESS of gestational age or maturity??
160 105
Severe preeclampsia: Antihypertensive therapy if SBP > WHAT or DBP > WHAT Hydralazine IV to reduce diastolic BP to 90-100 Labetalol IV
Hyperemesis gravidarum
Severe vomiting in pregnancy Results in dehydration and weight loss Fairly rare Treatment Brief hospitalization if necessary Lifestyle modifications - foods, scheduling Acupressure Ginger supplements Pyridoxine 25mg orally q6-8h Antiemetics What is this?
Prenatal care
Sexual activity No restrictions unless preterm labor or bleeding Employment No restrictions unless strenuous with heavy lifting Avoid chemical exposure Seat belt usage Wear lap belt UNDER the belly Do not rely on airbag Travel Up to 36 weeks OK Think about decrease O2 in "pressurized" cabin Postpartum planning Car seat BREASTFEEDING Childbirth classes Foods to avoid Non-pasteurized cheeses and smoked meats carry risk of listeria infection Heat all pre-prepared meats to boiling prior to eating King mackerel, tilefish, tuna may have increased mercury levels What is this anticipatory guidance for?
Vertex, Breech (push harder), Brow Face (not coming out), compound (obstruct labor gets in way), shoulder (not going to work)
What fetal presentations will constitute vaginal delivery? Which ones will not?
PCOS
Short-term Obesity Infertility Irregular menses Abnormal lipid levels Hirsutism/acne/androgenic alopecia Glucose intolerance/acanthosis nigricans Long-term Diabetes mellitus Endometrial cancer Cardiovascular disease What are these complications for?
No
Should you offer Hormone Therapy to pts with primary goal of protection against heart dz with menopause?
Regional anesthesia ( epidural, spinal, spinal/epidural)
Side effects: Hypotension May slow labor May increase risk for operative delivery Over 90% of deliveries at many US hospitals Give well in first stage of labor What is this with pain management in labor?
Nonbacterial Prostatitis
Significant # of WBCs in expressed prostatic excretions, postprostatic massage urine sediment (VB3), or semen Category IIIA-inflammatory
Breast Mass
Size of mass- In cm. Location- Side & "time" or quadrant Pain- Tender vs. non-tender Mobility- Mobile vs. non-mobile Texture- rubbery, smooth, hard, firm etc. Discharge- color/type Spontaneous Bloody Bilateral Serosanguinous What note findings is this for?
Breast lump
Skin changes Asymmetry Nipple inversion Nipple discharge Palpable mass Shape Margins Mobility Consistency Tenderness Lymph- Adenopathy The Objective on note might read: Breasts: Symmetrical with no skin changes, rash, nipple inversion, nipple discharge, tenderness, or lymph node enlargement. A 1 cm rubbery, mobile, non-tender mass with well defined margins is located at the 3:00 position on the right breast. What PE is this for?
Stop ACE inhibitor/ARB immediately Stop anticonvulsants with medical provider assistance (SSRI use in pregnancy Inconclusive data Individualize counseling)
What meds should be stopped when prego?
Estrogen
Smokers >35 Prior h/o blood clot or known coagulopathy Migraine with aura Estrogen-receptive tumors Hypertensive with SBP > 160 Known CAD or prior stroke Known vascular disease These are contraindications to using what??
PID
Spectrum of inflammatory disorders of the upper female genital tract Any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis Most common causes: N. gonorrhea and C. trachomonatis Other causes include: Anaerobes H. influenza Streptococci Mycoplasma hominis Ureaplasma urealyticum Mycoplasma genatilium What is this?
Pill/patch/ring
Start at any time Traditionally Sunday/Monday after cycle starts Active pills for 3 weeks/11 weeks, one week off for "period" Patch/ring - 3 weeks on, 1 week off Backup contraception for 7 days following initiation of hormonal contraception if not in first week of cycle This is how to start the what?
DCIS or Papilloma (Ductal tumors causing unilat bloody discharge) Ductal ectasia (thickened blocked duct) Paget's disease (discharge producing nipple lesion) Infection (Abscess, Mastitis) (10% unilat bloody d/c is malig)
What is the common cancers of pathologic nipple discharge?
Preterm Labor (PTL)
Spontaneous preterm births 40-50% with intact membranes and start of labor 25-40% with ruptured membranes and progression of labor Indicated preterm births 20-30% of preterm births Causes Activation of fetal or maternal HPA axis due to stress Decidual-chorioamniotic or systemic inflammation/infection Decidual hemorrhage (abruption) Pathologic uterine distention-more than one baby or fibroids grow to be too full and uterus is like time for labor-once cascade of hormones start it is hard to stop it What is this?
Toxoplasmosis
Spores live in soil, animal feces (think cat litter) Primary infection during pregnancy can result in congenital toxoplasmosis syndrome What is this infection that affect prego?
Bethesda System Classification
Squamous cell Atypical squamous cells (ASC) of undetermined significance (ASC-US) cannot exclude HSIL (ASC-H) Low-grade squamous intraepithelial lesion (LSIL) High-grade squamous intraepithelial lesion (HSIL) Squamous cell carcinoma Glandular cell Atypical glandular cells (AGC) Endocervical, endometrial, or not otherwise specified Atypical glandular cells, favor neoplastic Endocervical or not otherwise specified Endocervical adenocarcinoma in situ (AIS) Adenocarcinoma What classification is this?
Prostate Cancer
Staging Goal is to predict prognosis & to help the patient select an appropriate treatment TNM Staging Histologic Grade of Cancer What does the cancer look like under the microscope? Gleason Score The most common and second most common patterns are identified & assigned a grade from 1 to 5. They are then added together Ex: 4+3=7, 3+4=7, 3+3=6 The higher the Gleason score the more aggressive the cancer What is this for?
Breast
Superficial to pectoralis major From clavicle to sixth rib. Midsternal line to the axillary process What anatomic location is this for?
Progesterone
Subcutaneous depot depomedroxyprogesterone acetate (DMPA) or implants Suppress gonadotropin release and ovarian steroidogenesis Directly affects the uterine endometrium and endometrial implants What treatment is this with endometriosis?
Induced Abortion
Suction currettage Dilation and Evacuation (for later gestations) Complications Uterine perforation Cervical laceration Hemmorrhage Incomplete evacuation Infection What surgical is this used for?
Ovarian Torsion
Sudden onset of severe, unilateral lower abdominal pain that worsens over hours Typically follows exercise or other agitating movement Pain may radiate to the back pelvis, or thigh Usually described as sharp or stabbing N/V: occurs 70% of the time Physical examination is generally nonspecific Unilateral, tender adnexal mass common Peritoneal findings are uncommon Need to get treatment! What is this?
Danazol
Suppresses both LH and FSH mid-cycle surges-hirsuitism and wt gain side effects-liver damage Side effects of this medication do not always resolve with the discontinuation of tx What medical therapy is this with endometriosis?
BPH
Surgical Treatment Indications for surgery: Refractory symptoms that interfere with QOL Acute urinary retention Recurrent Urinary Tract Infections Recurrent Hematuria Renal Insufficiency Bladder Stones Surgical Options TURP (gold standard) Simple open prostatectomy What is this surgical treatment for?
Pregnancy
Symptoms Fatigue, nausea, breast tenderness Signs Enlarged uterine fundus Chadwick sign - vaginal vascular congestion-gets blue/purple Hegar sign - Increased friability and softening of the cervix What dx is this?
Preterm Labor
Symptoms Menstrual cramps/dull backache Abdominal/pelvic pressure Increased vaginal discharge Observation and external monitoring UA and culture Drug screen if indicated Sterile speculum exam first ? Rupture of Membranes ? Check GC/CHL and wet prep fFN - fetal fibronectin if available Digital cervical exam second Factors associated: Prior hx Preterm uterine contractions Premature rupture of membranes (PROM) African-Am Race Cervical insufficiency-primary, secondary to surgery-cone biopsy of cervix Infections-urinary, BV, intra-amniotic Excessive uterine enlargement-polyhydamnios, multiple gestation Uterine distortion-fibroids, septate uterus, uterine didelphys, and other anomalies Placental abnormalities-placental abruption, placenta previa Maternal smoking associated with PROM Iatrogenic: induction of labor What is this?
Gynecomastia
Symptoms Tender enlargement of male breasts Physical exam Symmetrical, rubbery enlargement Differentiate from breast cancer Unilateral, asymmetrical, hard, and associated with skin dimpling, nipple retraction, nipple discharge, and enlarged axillary nodes. What symptoms and physical is this for?
DEXA
The World Health Organization has established diagnostic criteria for osteoporosis that are based on bone density measurements determined by WHAT gold standard method?
Testicular Torsion
The absence of all four clinical variables—nausea and vomiting, pain duration of less than 24 hours, high position of the testis, and absent cremasteric reflex—has very high negative predictive value for WHAT?
Premenstrual Dysphoric Disorder (PMDD)
Symptoms that begins in the final week before menses, improves in the days after onset of menses and are absent in the postmenstrual week Occurs in only 3-8% of women and impairs daily living Characteristics: (1) sadness, hopelessness, or being self-critical (2) tension or anxiety (3) labile mood interspersed with frequent tearfulness (4) persistent irritability or anger (5) increased relational conflicts **Additional emotional and physical symptoms may also be present, and other psychiatric illnesses must be ruled out What is this?
Breast Abscess
Symptoms: Red painful swelling Fever nipple discharge Labs: WBC Gram stain of nipple discharge Treatment Broad-spectrum antibiotics Cephalosporins, Erythromycin or Penicillins Surgical drainage What is this?
2nd trimester fetal loss
Systemic disease - DM, thyroid disease, Lupus Coagulopathy Uterine Anomaly Leiomyoma Uterus didelphys, uterine septum, cornuate uterus Infection - vaginal or intrauterine "incompetent" cervix h/o LEEP or conization of cervix What are these risk factors for?
Levonorgestrel Intrauterine Systems
T-shape Denudes endometrium, glands atrophy-no implantation occurs Thickens cervical mucus Partial inhibition of ovarian follicular development and ovulation Mirena - 5 years, highest dose Kyleena - 5 years, lowest dose Skyla - 3 years Liletta - 4 years, low cost, meant for health departments Remains in place for 3-5 years Can easily be removed at any time Quick return to fertility after removal > 99% effective Prior to insertion Screen for sexually transmitted infection Indicated for any patient desiring long term contraception Some providers will not place in non-monogamous patients What contraceptive is this?
Endometrial cancer
TAH/BSO (Total abdominal hysterectomy with bilateral salpingo-oophorectomy): Primary treatment of endometrial cancer Assessment of myometrial invasion (Pathology) Lymph node sampling/Staging as indicated If fertility desired: High dose progestin monitored by serial endometrial sampling Postoperative: Radiation Stage III c or higher is critical in improving survival rates What treatment is this for?
Tubo-ovarian abscess
TOA formation may occur after an initial episode of acute salpingitis, but it is usually seen with recurrent infection superimposed on chronically damaged adnexal tissue Sapingitis becomes distended with pus forming a pyosalpinx Fallopian tube necrosis and epithelial damage by bacterial pathogens create an environment conducive to anaerobic invasion and growth Pressure of the purulent exudate may cause rupture of the abscess with resultant fulminating peritonitis, necessitating emergency laparotomy What is this?
False
TRUE OR FALSE? Patients who present with a significant other or spouse should be interviewed while that person is present in the room? True False
Tubo-Ovarian Abscess
Treatment: Unless rupture suspected, can use in-patient high dose abx therapy with serial U/S 70% curative If no response in 48-72 hours, surgical intervention Hysterectomy with BSO may be required for overwhelming infections or in cases of chronic disease with intractable pain Laparotomy is usually reserved for surgical emergencies, such as ruptured abscesses, those who do not respond to medical management or laparoscopic drainage, and those who are not candidates for laparoscopy What is this for?
Severe preeclampsia
Tertiary care center with maternal-fetal medicine specialists Daily testing and fetal surveillance Magnesium sulfate, IM or IV to prevent convulsions Monitor closely to prevent magnesium toxicity Loss of reflexes, decreased consciousness, Antihypertensive therapy if SBP > 160 or DBP > 105 Hydralazine IV to reduce diastolic BP to 90-100 Labetalol IV Delivery via induction of labor or cesarean Monitor for 24h post-delivery and continue magnesium Mg to prevent convulsions but can incr risk of heart failure-is toxic-do reflex check and SOB every 2 hours if on Mg drip bc continuous-induce labor stress baby out and get C-section What is this management of?
Fourth
The 2 hours immediately post-partum-everything is calming down What stage of labor is this?
Second
The PUSHING stage-push while contraction happens then rest etc-3-4 pushes for contraction which lasts 1 min The period from full cervical dilation until the baby is delivered What stage of labor is this?
Tissue biopsy
What is the confirmed and required test for endometriosis?
Vaginal pH over 4.5 Presence of >20% per HPF of clue cells on wet mount exam Positive amine or whiff test Homogeneous, non-viscous, grayish-white discharge adherent to the vaginal walls (if microscopy unavailable DNA probe is useful)
What is the amsel criteria for the dx of BV and must have at least 3 of the following findings out of 4?
Amniocentesis
Used in diagnosis of neural tube defects, fetal structural defects, chromosomal anomalies Withdrawal of 20-40mL of amniotic fluid using 20-22 gauge needle under ultrasound guidance Risks and complications Pregnancy loss approximately 1% Chorioamionitis (infection of the amniotic sac) in 1/1000 Transient amniotic fluid leak or vaginal spotting = 1-2% Confirmed test Done later What is this?
PE Mammogram (over 30) US (if prego or under 30) Core Needle Biopsy (solid mass identified-guided by MRI-with specialist doing this)
What is the breast cancer evaluation?
Hormone replacement therapy
Used to alleviate menopause symptoms Increased estrogen exposure increases: Breast density Breast cancer Cardiovascular disease Decreases: Sensitivity of mammography What is this?
Pelvic US
What is the confirmed diagnosis of ovarian cysts?
Negative
What of fetal fibronectin has excellent THIS predictive value the labor will occur in the next week?
Nutrition and exercise
Weight gain in pregancy 25-35 lbs if normal prepregnancy BMI 35-45 lbs if underweight 15-25 lbs if overweight/obese NOT eating for 2 Nutrition Maintain balanced diet Take pregnancy vitamins Avoid eating non-foods Pica More common in malnourished women Maintain calcium intake Get sun exposure to increase vitamin D Omega-3 fatty acids good for mom AND baby Exercise OK to continue pre-pregnancy exercise program Avoid prolonged strenous exercise No hot tubs Not supine after 18 weeks EGA Contact sports Avoid after week 10-12 Contraindications Incompetent cervix Bleeding Placenta previa PIH What is this with prego?
Leopold's maneuvers (after 36 wks EGA) US
What 2 things are used to determine the fetal presentation in 3rd trimester?
Cervical
The pattern of local growth may be exophytic (growing outward) if a cancer arises from the ectocervix, or may be endophytic (grows inward) if it arises from the endocervical canal Lesions lower in the canal and on the ectocervix are more likely to be clinically visible during physical examination Alternatively, growth may be infiltrative, and in these cases, ulcerated lesions are common if necrosis accompanies this growth As tumor invades deeper into the stroma, it enters blood capillaries and lymphatic channels Lymphovascular Space Involvement(LVSI) This type of invasive growth is not included in the clinical staging of cervical cancer Presence of LVSI is regarded as a poor prognostic indicator, especially in early-stage cervical cancers With extension to the pelvic sidewall, ureteral blockage frequently develops, resulting in hydronephrosis Additionally, the bladder may be invaded by direct tumor extension through the vesicouterine ligaments (bladder pillars) The rectum is invaded less often because it is anatomically separated from cervix by the posterior cul-de-sac Distant metastasis results from hematogenous dissemination: Lungs Ovaries Liver Bone What metastasis is this for with GYN cancer?
hPL (Human Placental Lactogen) (Hormone acts as "anti-insulin" and worsens pre-existing insulin resistance hPL increases during late 2nd and 3rd trimester as placenta matures Estrogen and progesterone - relative effect Dietary issues)
The placenta produces worse which is why sugars get worse in pregnancy?
6 (4 weeks if planning postpartum tubal ligation or IUD placement)
The postpartum visit is how many weeks from delivery?
Chlamydia trachomatis
What is the most common bacteria with nongonococcal urethritis?
Ovarian
There is no simple and reliable way to screen for THIS CA-125 is not reliable for screening but can be used to assess response to therapy Screening U/S not recommended currently. It cannot definitively rule out ovarian cancer. Use caution with biopsy, direct spread is common Physical exam may reveal: Ascites Mass on bimanual and/or rectovaginal exam Distended abdomen Palpable ovary What PE and Dx is this for with GYN cancer?
Nonseminomatous germ cell tumors
These tumors may produce a mass of one type of cell or mixed cells Nongerminomatous germ cell tumors can be further subdivided into the following: Embryonal carcinoma, yolk sac tumor, choriocarcinoma, teratoma, polyembryoma, and gonadoblastoma. The peak age for developing these tumors is ages 20 to 30 years What testicular cancer is this?
Gunpowder burns (blue-black lesions, gunmetal lesions) Red and purple raspberry spot Chocolate cyst
What 3 things are found on the ovaries or uterus with endometriosis?
Oral contraceptives or progestins
What Can diminish signs of hirsutism, acne, maintain menstrual regularity and reduce the number and size of ovarian cysts associated with PCOS?
Caffeine Nicotine
What are 2 causes of fibrocystic breast changes?
Pain
What is the most common breast complaint?
Squamous cell carcinoma Adenocarcinoma
What is the most common cancer with cervical cancer? What is the second most common?
Endometrium
Thickening Sloughing Only biopsy will identify proliferative What contraception change is this?
Squamous Cell Carcinoma (think caused by HPV-keratinocytes invaded and have growth-will have itching)
What is the most common malignant tumor of the vulva?
SSRI's (Paroxetine, paxil, or brisdelle-first line-low doses for vasomotor symptoms) Progesterone Gabapentin Herbal supplements (black cohosh) Advocate lifestyle changes (Heart healthy lifestyle Exercise Weight loss Avoid smoking/alcohol use Seek regular health care)
What are alternative therapies for menopause?
Hydralazine (IV to reduce diastolic BP to 90-100) Labetalol (IV)
What are antihypertensive meds given to prego women with severe preeclampsia when SBP is over 160 and DBP over 105?
Low
Tight clothing and prego again means what with milk production with breast feeding?
Stop caffeine and nicotine! Breast awareness Annual breast exam with medical provider NSAIDs for pain PRN Contraceptives for hormonal irregularities Natural Treatments (Vitamin E 600 IU daily Evening Primrose Oil 3 grams at bedtime Ginger compresses- reduce swelling)
What are fibrocystic breasts treatments?
Mass margins: irregular or speculated (needs to be biopsied) Microcalcifications
What are suspicious mammogram findings?
48
Tocolytics usually discontinued at WHAT hours and just let things happen with preterm labor management?
Infertility and pelvic pain
What are the 2 common symptoms of endometriosis?
Soft tissue obstruction Shoulder dystocia
What are the 2 conditions that warrant an episiotomy?
Herpes simplex virus 2 (HSV-2)
Transmitted to fetus during labor Highest risk of transmission is primary infection near the time of delivery Also, risk of transmission if reactivation at time of delivery What infection is this that affect prego?
Narcotic (IV)
Transmitted to fetus, can cause fetal respiratory depression at birth Not very effective Side effects: nausea and vomiting; What is this in pain management in labor?
PCOS
Transvaginal ultrasound Bilateral enlarged ovaries with peripheral cysts "string of pearls" appearance Pelvic CT or MRI to visualize adrenals & ovaries Endometrial biopsy Ovarian biopsy (histologic confirmation) What Dx tests are these for?
Direct inguinal hernias
Travel medial to the inferior epigastric vessels Usually acquired during events that weaken or disrupt the abdominal wall Such as heavy lifting exercises that significantly increase intra-abdominal pressure Above external inguinal ring
Corticosteroids
Treat severe preeclampsia with what to help stable fetal lungs when delivering the fetus?
Nipple Discharge
Treat underlying cause If discharge is minimal and tests are normal- provide reassurance and f/u in 3 months For copious discharge- offer referral/ surgical referral for duct excision What management is this for?
Hydrocele
Treatment Depends on the amount of fluid present and the patient's level of discomfort Minimal fluid accumulation may not require analgesia or surgery Excess fluid accumulation may require surgery to drain the fluid Rule out secondary cause with history and physical examination What is this for?
Testicular Cancer
Treatment Inguinal orchiectomy, that is performed at the same time the tissue is obtained for histology and staging More extensive surgical therapy, such as retroperitoneal lymph node dissection, may be necessary based on the tumor's histologic characteristics and stage Metastases requires adjuvant therapy involving chemotherapeutic drugs such as cisplatin and carboplatin The prognosis and the success of treatment depend on the stage of the cancer at the time of clinical presentation The cure rate for testicular neoplasms is 90% with early detection What is this for?
Varicocele
Treatment May not require treatment if symptoms are not bothersome Analgesics may be prescribed for pain Long-term dilation of the pampiniform plexus may cause hypertrophy to the veins, affecting sperm concentration, sperm motility, male fertility, and testicular function High-risk male infertility varicocelectomy or surgical repair of the affected veins is recommended What is this?
Primary Dysmenorrhea
Treatment NSAIDs (FIRST LINE) Started 1-3 days prior to menses Supportive Local heat, Vit E started prior to menses and continued into menses OCP's/Depo-Provera/Levonorgestrel-releasing IUD What is this for?
PCOS
Treatment aimed at individual components of the syndrome (hirsutism, oligomenorrhea, infertility, obesity, and glucose intolerance) depending on the patient's goals with WHAT?
Fibroids
Treatment is generally directed toward symptoms Pharmacologic inhibition of estrogen secretion: Gonadotropin-releasing hormone agonist (GnRH analogs) which can reduce size by as much as 40-60% What treatment is this for?
Transillumination (indicates a fluid filled mass) US (Better for visualization of fluid accumulation Also helps rule out testicular cancer)
What are the 2 dx tests for hydrocele?
Menstruation and follicular phase Ovulation Luteal Phase
What are the 3 phases related to the ovary during the reproductive cycle?
Seminomas
Tumors account for half of germ cell tumors, and originate from the germinal epithelial lining of the seminiferous tubules The peak age for developing is between ages 40 and 50 years This tumor grows into a mass composed of a uniform type of cell that secretes one type of tumor marker: Human chorionic gonadotropin (hCG) What testicular cancer is this?
1) serum PAPP-A levels (week 9/10) 2) serum free beta-hCG ( week 9/10) 3) fetal nuchal translucency ultrasound (week 12) (90% + accuracy when combined with "quad screen" in second trimester) (similar false positives to quad screen alone)
What are the 3 separate tests combined to detect rate of Down Syndrome?
Male condom Female condom Diaphragm Cervical cap
What are the 4 barrier methods?
Vaginal discharge Vulvar itching Irritation Odor
What are the 4 characteristics of vaginitis?
Trichomoniasis (15%-20%) Vulvovaginal candidiasis (20%-25%) Bacterial vaginosis (40%-45%) Atrophic vaginitis
What are the 4 common causes of vaginitis?
HPV Vaccine
Two dose regimen recommended as a routine vaccination for all girls aged 11-14. Second dose give 6-12 months after first dose Women with prior abnormal cervical cytology can be given vaccine May be less effective with prior HPV exposure Three dose rgimen given for ages 15-26 Second dose: 2 months after 1st dose Third dose: 6 months after 1st dose Testing for HPV infection prior to vaccine not currently recommended Not safe for pregnant women, but may be given while breastfeeding HPV screening recommendations are unchanged regardless of vaccine status vaccine that includes capsid proteins against four HPV types (6, 11, 16, and 18) has been approved for use in girls and boys aged 9-26 years to prevent disease associated with these HPV types Recent trials show that vaccination against HPV 16 and HPV 18 reduces incident and persistent infections with 95-percent and 100-percent efficacy, respectively Effective duration of these vaccines is not yet known. What is this?
Mammary Gland
Type: Modified excretory apocrine glands Development timing: during pregnancy and postpartum Stimulation to develop: progesterone & estrogen Stimulation to produce milk: Prolactin Stimulation to eject milk from glands: oxytocin After menopause breast tissue is replaced with adipose tissue What physiology is this?
PCOS
Typical onset from late adolescence to early 20s Symptoms Menstrual irregularities Infertility Hirsutism Acne Metabolic syndrome Insulin resistance DM II, obesity, HTN What clinical presentation is this for?
Mild preeclampsia
Typically hospitalized overnight for evaluation and monitoring 24h urine Labwork Bedrest Frequent (biweekly) monitoring of mother and fetus Monitor with biophysical profile and non-stress test Monitor fetal growth every 3 weeks with ultrasound Continue until time of delivery recommend bed rest with freq monitoring of mother and fetus-coming to the doctor a lot the last couple wks What is this management of?
External Fetal Monitoring
Typically, a continuous monitor applied to maternal abdomen Measures rate and pattern of fetal heart rate During labor, can indicate fetal distress, or decreased fetal reserve No effect on fetal outcomes, possible increased risk of cesarean delivery due to healthcare provider anxiety re: what tracing indicates What is this?
Love Hope Dependence (financially) Fear Helplessness (Unless address these issues, your pt is likely to stay in the situation)
What are the 5 reasons victims stay with domestic violence?
6, 11, 16, 18 16
What are the HPV numbers associated with vulvar cancer? What is the more common one?
Uterine Sarcoma
Uncommon, 3% of all uterine cancer Presentation Progressive uterine enlargement occurring in the postmenopausal years Postmenopausal bleeding Unusual pelvic pain with uterine enlargement Treatment : Hysterectomy What is this?
Hormone Therapy
Undiagnosed abnormal genital bleeding Known or suspected estrogen-dependent neoplasia except in appropriately selected patients Active deep vein thrombosis, pulmonary embolism, or a history of these conditions Active or recent arterial thromboembolic disease (stroke and myocardial infarction) Liver dysfunction or liver disease Known or suspected pregnancy Hypersensitivity to hormone therapy preparations What are these CI for w/menopause?
Pathologic
Unilateral Non-milk - serous or sanguineous Localized to a single duct Persistent Spontaneous Mass associated What nipple discharge is this?
Combined Estrogen and Progestin Therapy
Unopposed estrogens can lead to endometrial hyperplasia It is essential to administer a progestin in conjunction with estrogens in women who have not undergone hysterectomy Progestin can be given in low dose continuously or in sequentially higher doses Most patients opt for continuous dosing of progestin Otherwise, they have monthly bleeding Benefits Symptomatic relief, decreased cardiovascular risk, decreased osteoporosis Protective against endometrial cancer Risks Venous thromobembolism What treatment is this with menopause?
Endometrial hyperplasia
Unopposed estrogens can lead to what with women with uterus still?
Urologic
Urgent WHAT consultation is indicated for priapism?
Prostatitis or cystitis
Urinary frequency and urgency typically absent with urethritis but if present this suggests what?
Pregnancy (before and after and 6 mons after nursing) Ductal ectasia (Clogged Duct) Ductal papilloma (benign mass)
What are the benign causes of nipple discharge?
Malignant germ cell tumors
What is the most common ovarian cancers in women younger than 20 years of age?
Physiologic
Usually Benign AKA Galactorrhea Due to High Prolactin Level from: Excessive breast stimulation, injury, or trauma Stress Medications/Drugs Tumor... What nipple discharge is this?
Primary Amenorrhea
Uterus present & breast present Outflow obstruction (transverse vaginal septum, imperforate hymen) Uterus absent & breast present Mullerian agenesis, androgen insensitivity Uterus present & breast absent Premature ovarian failure, gonadal dysgenesis (elevate FSH& LH)---hypothalamic pituitary failure or puberty delay (normal to low FSH/LH) Uterus absent & breast absent (rare) What etiology is this?
Postpartum psychosis
VERY rare Risk factor - prior h/o mood disorder; untreated mood disorder during pregnancy-need to be treated Presents with confusion, distractibility, paranoia within 1 week of delivery Wise to hospitalize and treat with antipsychotics-VERY SEVERE ADVERSE EFFECTS ON BABY What is this?
1st trimester complications
VITALS!!! General physical exam as indicated Speculum exam GC/Chlamydia cultures Wet prep depend on findings Bimanual exam - Uterine size and position, Tenderness, Masses/tenderness in adnexa If EGA > 9 weeks, attempt Doppler auscultation of fetal heart tones Transvaginal ultrasound What exams are these for?
Enterocele
Vaginal vault hernia containing small intestine Usually in the posterior vagina and results from deepening of the pouch of Douglas What is this?
Domestic Violence
Validate the problem and the solution: Help the victim understand that abuse is unacceptable & illegal, and nobody has the right to abuse him/her. Help the victim know you are an ally in finding a solution. Provide safety information and appropriate referral. Assess the patient's safety Develop an emergency escape plan Help the victim seek help Family Shelter Legal advice Financial This is after detection of what?
Dysuria Urinary Frequency Dyspareunia Vaginitis that is frothy gray or yellow-green malodorous vaginal discharge, pruritis, strawberry cervix (cervical petechiae-may also infect skene's glands and urethra)
What are the clinical presentation of trichomonas vaginitis?
Cyst or fibroadenoma (A common causes of litigation is missed diagnosis of breast cancer!)
What are the common etiologies of breast lumps?
Pruritus (new onset at age 70-80) Bleeding
What are the common pt presentation of vulvar cancer?
Incr serum FSH Decr estradiol and inhibin Repeated measurements of FSH and LH at 2-3 month intervals (to determine if woman is progressing through menopause)
What are the dx markers for menopause?
(Category IV) Asymptomatic inflammatory prostatitis (AIP)
WBCs (&/or bacteria) in expressed prostatic secretions, postprostatic massage urine sediment or semen
SERM
WHAT added with conjugated estrogen 1 tablet lowers risk of uterine hyperplasia elimanted need for progestin-safer-for hot flashes, post menopausal osteoporosis
Domestic violence
WHAT presents as Chronic abdominal/pelvic pain Headaches Substance abuse (coping mechanism) Eating disorders Trauma Suicide attempt-1 in 10 attempt suicide
Metabolic syndrome
Waist circumference 35 inches or greater Triglyceride levels 150 mg/dL or higher High density lipoprotein (HDL) cholesterol less than 50 gm/dL BP 130/85 mm Hg or higher Fasting glucose level 100 mg/dL or higher 40% with impaired glucose tolerance 8% with overt DM II Increased risk of cardiovascular disease What complication is this with PCOS?
Prostate Cancer
Watchful Waiting Surgery Open, Laproscopic, Robotic 6% incontinence rate and 10%-100% Erectile Dysfunction at one year; rates increase over time Radiation External-Beam/IMRT 6 weeks of treatment Proctitis, radiation cystitis Brachytherapy Implantation of radioactive seeds Less risk of incontinence and Erectile Dysfunction but not zero Hormone Manipulation - Advanced disease LHRH agonists (lupron) antiandrogens Medical Castration vs. Surgical Castration Chemotherapy Poor response rate Reserved for patients who are hormone refractory What management is this for?
Routine Prenatal Visits
Weight BP - lowest around 19 - 21 weeks Fundal Height Urine for protein, glucose Fetal HR - normal 110-160 Fetal movement - usually felt after 18 weeks Any significant events since last visit Exposures Travel Signs of Preterm labor/pregnancy complications Contractions Loss of fluid Pelvic pain Decreased fetal activity Peripheral edema Assessment of fetal presentation in 3rd trimester What is this?
Guiac (occult blood) Cytology
What are the dx studies for pathologic nipple discharge?
Hx PE Possible mammogram or US (yield of imaging with a norm exam is very low) (If imaging and exam are normal, treat cause and offer supportive treatment and reassurance)
What are the evaluation steps for breast pain?
CT/MRI (MRI is superior to CT for determining cervical carcinoma size, local tumor extension, and lymph node involvement MRI is most commonly performed in patients being considered for fertility-sparing radical trachelectomy) (removal of the cervix). PET scan (can be used to compliment CT/MRI if small volumes of disease and with tissue foci in which cancer cannot be differentiated from other tissues such as scar or necrosis)
What are the imaging done for cervical cancer?
Hirsutism Amenorrhea Obesity Excess androgen
What are the main clinical presentation of PCOS?
Medroxyprogesterone acetate (Given for a min of 10 days orally) Oral contraceptives pills
What are the meds for treatment for AUB?
Uterine, adnexal, or cervical motion tenderness
What are the min dx criteria for PID?
Chlamydia trachomatis and Neisseria gonorrhea
What are the most common organism causes of epididymitis in men under age 35 years of age?
N. gonorrhea and C. trachomonatis
What are the most common organisms that cause PID?
Escherichia coli, Pseudomonas, and gram-positive cocci
What are the most common organisms that cause epididymitis in men older than age 35?
DRE and PSA
What are the most effective methods for early detection of prostate cancer?
GS= gestational sac CRL= crown rump length YS= yolk sac
What are the parameters for US dating in 1st trimester?
Combination oral contraceptives (mainstay of tx) (i.e. ethinyl estradiol, medroxyprogesterone) SERM (Clomiphene citrate) Antiandrogens (Sprinoloactone, leuprolide, finasteride) Aromatase inhibitors (Letrozole, Anastozole) Insulin sensitizers (Metformin)
What are the pharm tx for PCOS?
CBC and blood type, Rh type RPR, HepB Ab, Rubella Ab HIV Urine culture Hepatitis C if at risk Genetic screening as indicated Thyroid function in select patients Screening for diabetes in high risk patients (A1C, random glucose) Infection exposures ( Zika, etc.)
What are the prenatal labs to get with first prenatal visit?
HPV vaccination (Gardasil guards against types 6, 11, 16, 18) Postponing sexual debut Monogamous relationship Condom use An important focus of cervical cancer prevention is pap smear screening Avoidance of smoking
What are the primary prevention of cervical cancer?
Delay in seeking care Illogical explanation of the injury Vague or somatic complaints, "shielding" (Vague health complaints that do not reveal the origin of the problem) Depression, anxiety, mental disorders Substance abuse (by either partner) Homeless New diagnosis of HIV Family history of domestic violence Overbearing partner Eating disorder Pregnancy (with warning signs) Physical Symptoms related to stress (Sleep disturbances Appetite change Fatigue Decreased concentration Sexual dysfunction Headaches GI complaints Palpitations Dizziness Dyspnea Atypical chest pain)
What are the red flags of domestic violence?
Menstrual irregularities Infertility Hirsutism Acne Metabolic syndrome Insulin resistance
What are the symptoms of PCOS?
Tamoxifen or Danazol
What are the treatment for severe breast pain?
AFP hcG (Seminomas only, nonseminomas can produce hcG and AFP) Lactate dehydrogenase
What are the tumor markers for testicular cancer?
Over age 40 Lump in breast Bloody Unilateral
What are the warning signs for breast cancer nipple discharge?
Alpha 2
What blockade helps with symptoms of benign prostatic hyperplasia?
Cancerous
What breast lumps are usually singular, non-tender, hard, immobile masses with irregular boarders?
Endometrial carcinomas
What cancer is the most common with endometrial cancer?
True labor Prior to 37 completed weeks gestation Cervical dilation over 3cm
What characteristics make up preterm labor?
Bazedoxifene SERM + conjugated estrogen (1 tablet daily 20mg)
What combo treatment includes estrogen therapy and lowers risk of uterine hyperplasia with women that still have a uterus eliminating the need for progestin and is safer and used to treat hot flashes and post menopausal osteoporosis?
Vulvar Uterine Ovarian Cervical
What common pelvic tumors are included with GYN cancer?
US (Transabdominal approach if after 9 weeks Transvaginal approach if Earlier than 9 weeks No FHT heard on doppler Patient is obese Poor visualization on transabdominal) Quantitative beta HCG (Predicts viability Should DOUBLE in 48 hours Check one now, and one 48 hours from now) CBC Blood type and screen Progesterone (Poor outcome if < 5ng/mL Not really necessary if confirmed fetal viability after 9 weeks EGA)
What diagnostic tests are ordered in the 1st trimester with complications?
TSH Prolactin Total and free testosterone DHEA-S Serum hCG 17α-Hydroxyprogesterone Cortisol Insulin level (Others: Gonadotropins Lipid panel Glucose)
What diagnostic tests should you get with PCOS?
3 termed 2 preterm 4 living-1 died or currently prego
What does G5P3204 mean?
8 miscarriages
What does G8P0080 mean?
PAP smear (if indicated), GC/Chl screen Evaluation of pelvic anatomy (helps see how baby will come out)
What does the pelvic exam include with first prenatal visit?
UPT (3-4wks EGA) Serum HCG (3-4wks EGA) US (4-6wks EGA TA/3-4wks EGA TV) Fetal heart tones via doppler (10-12wks EGA)
What dx tests are done with prego?
Mammogram Ultrasound (for ductal ectasia) MRI with galactography Ductography / Ductoscopy Skin biopsy (for suspected Paget's disease)
What dx tests are there for nipple discharge?
Pelvic cultures Pelvic imaging Laparoscopy MRI Hysteroscopy U/S
What dx tests are used with secondary dysmenorrhea?
US (Mammogram and Biopsy if solid mass is coincidentally found)
What evaluation is done with fibrocystic breast changes?
Increase TBG (serum thyroxine-binding globulin) Stimulation of hCG (thyrotropin receptor) Increase total T4 and T3 with reduction in TSH (in 1st trimester bc of incr in hCG) Free T4 and T3 will increase minimally (Free T4 looks like going down but not bc more binding proteins-more protein bound-may look like more TSH bc of stimulation of it-keep eye on it-babies thyroid behaves according to the mom's-change thyroid dosing in prego during each trimester-every 1-2 months especially beg of prego make sure getting enough thyroid for the mom and the baby)
What happens with thyroid levels in pregnancy?
Esterone
What hormone is seen during menopause?
Estriol
What hormone is seen during prego?
US
What imaging do you get to see placenta previa and use to monitor the fetus?
Lichen Sclerosus
What is a long standing history that is a precursor lesion leading to invasive squamous vulvar cancer?
Theca Lutein Cyst
What is associated with prego and usually bilateral?
HIV Active TB (breath on baby) Chemotherapy (pass through breast milk) Substance abuse or heavy alcohol use (narcotic dose during C section is fine-mom high then baby high) Contraindicated meds
What is contraindicated in terms of breastfeeding?
Expectant management Induction of labor If rupture of membranes, induction of labor is indicated
What is done with miscarriage btw 13-24 wks?
Hot flashes Weight gain Sleep disturbance Night sweats Vaginal atrophy Incr urinary symptoms Osteoporosis (complication-fractures) Irritability/hostility
What is hallmark sign of menopause? Other signs?
Polyhydramnios
What is increased amniotic fluid?
Permanent cessation of menstrual period Loss of ovarian follicular function leading to decreased estrogen
What is menopause? Cause of it?
Facing backward Occiput anterior Occiput posterior
What is normal fetal position called? What is another name for it? What position results in prolonged/dysfunctional labor?
OCP in conjunction with NSAIDS
What is often the first line of tx for pain in endometriosis?
Symptoms of decreased estrogen because waxing and waning around 4 years average
What is perimenopause?
Monophasic/Biphasic/Triphasic (most are monophasic)
What is related to dose of progestin over time that is related to common COC prep?
Estradiol
What is seen before menopause and is potent hormone?
Radical (involves removing part of the vulva) (partial vulvectomy) (or the entire vulva) (radical vulvectomy). (Harder time urinating since near urethra and harder time making BM) Conservative (surgical removal of the least amount of tissue possible, with the goal of minimizing deformity while maintaining sexual function and quality of life. Often followed with chemotherapy and/or radiation.) (Benefits of conservative treatment vs. Radical Approaches: Elimination of routine pelvic lymphadenectomy Avoidance of groin dissection in unilateral lesions 1 mm deep Elimination of contralateral groin dissection in unilateral lesions 1 cm from the midline with negative ipsilateral nodes Separate groin incisions for patients with indicated bilateral groin dissection Postoperative radiation therapy to decrease groin recurrence in patients with 2 or more positive groin nodes Concomitant use of radiation and chemotherapy is gaining favor for treatment of vulvar cancers)
What is the 2 treatment for vulvar cancer?
T = Term Deliveries after 37 completed weeks of pregnancy P = Preterm Deliveries prior to 37 completed weeks of pregnancy A = Aborta How many miscarriages L = Living How many children currently living M = Multiple gestations How many pregnancies were multiples
What is the GTPAL (M) system?
Preterm premature rupture of membranes (PPROM)
What is the Leading cause of neonatal morbidity and mortality Associated with 30% of preterm deliveries??
Large, midline, irregular contoured mobile mass with hard feel Lumpy-bumpy or cobblestone (Measured in weeks gestation)
What is the PE of the uterus with fibroids?
Stress/Safety (What causes stress in your life? Do you feel safe at home?) Afraid/Abused (Are you afraid, threatened, or abused by anyone?) Friends/Family (Do you have friends or family you trust?) Emergency/Escape (Are you in danger and feel you cannot escape?) (Has a partner ever hit, hurt, or threatened you? What happens when you fight at home? Does your partner ever force you to engage in sex? Does your partner threaten, hit, or abuse your children?)
What is the SAFE screening mnemonic for domestic violence?
Ovarian enlargement with Doppler showing little to no ovarian flow
What is the US finding with ovarian torsion?
Surgery (should not be delayed to perform US) 6 hours (If surgical intervention is delayed, the best immediate treatment is manual detorsion by twisting the affected testicle in an outward motion or using the "open book")
What is the definitive treatment of testicular torsion and when should be performed within symptom of onset?
Pelvic US CT/MRI (assess large masses) Surgical evaluation (When PE and ultrasound cannot differentiate whether the patient has a fibroid or other potentially more serious disease - such as adnexal neoplasm)
What is the diagnosis tests for fibroids?
Visualization of pseudohyphae (mycelia) and/or budding yeast (conidia) on KOH or saline wet prep pH normal (4.0 to 4.5) (If pH > 4.5, consider concurrent BV or trichomoniasis infection) (Cultures not useful for routine diagnosis If clinical features of vulvovaginal candidiasis, normal vaginal pH, and no pathogens (yeast, clue cells, trichomonads) visible on microscopy a positive culture in these patients confirms the diagnosis and reveals the species of Candida Persistent or recurrent symptoms could indicate non-albicans infection resistant to azoles)
What is the dx labs for candidiasis?
Motile trichomonads seen on saline wet mount Vaginal pH over 4.5 (Nitra Test Phenaphthazine paper) Nucleic Acid Amplification Test (Gen-Probe, NuSwab VG, used when there are suggestive clinical findings but absence of trichomonads or no microscopy available)
What is the dx of trichomonas vaginitis?
Hormone levels (LH, PRL, TSH)
What is the dx test for physiologic nipple discharge with neg prego test?
US (Will reveal retrograde blood flow to the scrotum due to the incompetent venous valves)
What is the dx test for varicocele?
History and Physical Exam Mammogram or US (if mass is found) Biopsy (if mass is found) (same as for females)
What is the dx workup for gynecomastia?
Ceftriaxone (250 mg IM) with azithro (1g orally single dose) If BV or Trich then metronidazole (Patients diagnosed with Gonorrhea, Chlamydia or Trichomonas should be offered counseling and testing for HIV and syphilis Partner also needs treatment)
What is the empiric treatment for cervicitis? What if BV or Trich is suspected?
Urine hCG Cervical cytology (All women Exclude cervical cancer Any visible cervical lesion should be biopsied, even if cervical cytology is negative for malignancy) Endometrial biopsy (All women over age 35 Rule out endometrial cancer or a premalignant lesion )(endometrial hyperplasia) (Thyroid function studies Coagulation tests CBC Pelvic cultures for Neisseria gonorrhea and Chlamydia trachomatis Prolactin level Androgen levels)
What is the evaluation for abnormal uterine bleeding?
Paroxetine (PAXIL or brisdelle)
What is the first line treatment SSRI for alternative therapy for menopause?
Lifestyle modifications (diet, exercise and weight loss)
What is the first line treatment for PCOS?
NSAIDs
What is the first line treatment for secondary dysmenorrhea?
PE every 3 months CA-125 with each exam (it is known to be a reliable marker) ("Routine" radiographic evaluation is not recommended)
What is the follow up with ovarian cancer?
ACOG form
What is the full hx and PE that has all the pertinents?
Nucleic Acid Amplification Test
What is the gold standard dx for trichomonas vaginitis?
TURP (transurethral resection of prostate)
What is the gold standard surgical therapy for BPH?
Laparoscopy
What is the gold standard treatment for endometriosis?
FSH 30
What is the initial dx marker for menopause? What number is it greater than?
US followed by FNA or core biopsy
What is the lab exams for fibroadenoma?
Combo Oral Contraceptive
What is the mainstay pharm tx of PCOS?
Screen ABO and Rh status (and for antibodies to RBC antigens at first prenatal visit, or if 1st trimester bleeding) Rescreen antibody status at 28 weeks and give RhoGam (Immunglobulin prevents sensitization of mom to fetus if occurrence of fetal-maternal hemorrhage) and repeat dose post-delivery (Any other positive RBC antibodies (besides Rh) should be carefully evaluated, as they may increase risk of fetal hemolytic disease These patients are carefully monitored with serial ultrasounds by a high risk OB Follow antibody titers in mom and frequently monitor fetal growth Rh neg mom had Rh pos baby can develop antibodies check her for next prego-if next baby Rh pos then antibodies will attack baby-have RhoGam an immunoglobulin-given early mid-3rd trimester to be prepared-binds any antigens crossing in mom's blood and then post-delivery gets shot again)
What is the management of isoimmunization in pregnancy? What if mom is Rh negative?
HT Education Healthy Lifestyle
What is the management of perimenopausal?
Fluids, transfusion if necessary If severe, emergent delivery
What is the management of placental abruption?
Increased antenatal testing Induction of labor at 41 weeks if favorable cervix
What is the management of postterm pregnancy?
(No uniformly effective intervention for prevention but try to stop it Transfer to tertiary care) Treatment with corticosteroids (if 24 to 34 weeks to improve lung maturity IM betamethasone or dexamethasone - take 48 hours to be effective Max benefit within 7 days of delivery Improves neonatal outcomes) (Tocolysis=stop contraction) Indomethacin (NSAID - COX inhibitor) (inhibit prostaglandins trying to soften cervix) Nifedipine (calcium channel blocker) (slow contractions down Better data than MgSO4 Tocolytics usually discontinued at 48 hours and just let things happen) Magnesium sulfate (for fetal neuroprotection-replaces calcium and slows muscles down)
What is the management of preterm labor?
Misoprostol (800mcg vaginally Increased risk of failure to pass all of the products of conception compared to expectant management. More bleeding.)
What is the medical management in the 1st trimester that cause miscarriage?
Upper outer quadrant (bc axillary nodes)
What is the most common area where breast cancer is found?
No earlier than age 21 (no matter age on sexual debut, even if sexual abstinence) Every 3 years Co-testing Pap and HPV test every 3 years (HPV testing if over age 25) After 30, every 3 years Discontinue screening at age 65 (if never had one then screen twice at 65-or post-hysterectomy if low risk for dz)
What is the pap testing indications from ACOG?
TAH/BSO (Total abdominal hysterectomy with bilateral salpingo-oophorectomy)
What is the primary treatment of endometrial cancer?
US (Typically demonstrates complex multiloculated adnexal masses that obscure normal adnexal structures These masses may contain internal echoes consistent with inflammatory debris Computed tomography (CT) Preferable in a patient in whom other abdominal pathology cannot be excluded)
What is the radiologic modality of choice for tubo-ovarian abscess?
Pooling of fluid in posterior fornix Nitrazine test (pH paper-turns pink not amniotic fluid Amniotic fluid is alkaline, paper turns blue) Ferning (Streak vaginal swab across slide. Let it dry. Salts in amniotic fluid cause a "fern" pattern) Visualize cervical dilation (Avoid digital exam to avoid bacteria in the uterus) US (oligohydramnios-fluid, check position of fetus)
What is the sterile speculum exam done for premature rupture of membranes?
Metronidazole (2 g orally in a single dose Metronidazole 500 mg twice a day for 7 days) (Follow up is advocated but not cost effective STD testing should be performed Partner should also be treated Patients should be instructed to avoid sex until they and their sex partners are cured) (when therapy has been completed and patient and partner(s) are asymptomatic)
What is the treatment and management of trichomonas?
Watchful Waiting (Reassurance, life-style modification, ↓ fluid intake before bedtime, moderation of ETOH & caffeine, timed-voiding schedule) Medical Treatment: α-Adrenergic Blockers (Non-selective vs. Selective Terazosin (Hytrin), Doxazosin (Cardura), Alfuzosin SR (Uroxatrol), Tamsulosin (Flomax) Side effects: orthostatic hypotension, dizziness, sexual, interaction w/ pde5 inhibitors Act fast with maximum response in 1-2 weeks Often first line) Androgen suppression (5 α-reductase inhibitors: work best with larger prostates (>30-35g) (Finasteride) ( Proscar) (Dutasteride) (Avodart) (May take up to 6-9 months to see maximum results Shrink the prostate by 20-30% Falsely lowers PSA by 50% Double the PSA for "True PSA")
What is the treatment for BPH?
Ceftriaxone (250 mg IM) plus doxycycline (100 mg PO BID X 14 days w/or w/out metronidazole 500mg PO BID for 14 days) (OR: Single dose of cefoxitin 2 grams IM with Probenecid 1 gram PO Surgery for TOA)
What is the treatment for PID?
(Typically gram negative uropathogen) Fluoroquinilone or Bactrim X 30 days (-hard to get to prostate) Hospitalized patients: IV Ampicillin & Gentamycin or IV Quinolone (If AUR consider suprapubic cystotomy)
What is the treatment for acute prostatitis?
Iron (elemental 27-60mg or elemental 60-120mg for iron def anemia)
What is the treatment for anemia in prego?
Water based lubricants (first line) Topical and oral estrogen
What is the treatment for atrophic vaginitis?
Cephalosporins, Erythromycin or Penicillins (broad spectrum antibiotics) Drainage
What is the treatment for breast abscess?
Aspirating large symptomatic cysts
What is the treatment for breast cysts?
Conization or radical hysterectomy Chemoradiation with advanced disease (In young women desiring to maintain fertility, *radical trachelectomy* removes the cervix with subsequent anastomosis of the upper vagina to the uterine corpus. About 50% success rate for pregnancy Larger cervical tumors confined to the cervix can be treated with either surgical resection or radiation therapy in combination with cisplatin-based chemotherapy with a high chance of cure Larger tumors that extend down the vagina or into the paracervical soft tissues or the pelvic sidewalls are treated with combination chemotherapy and radiation therapy)
What is the treatment for cervical cancer?
Expectant (watchful waiting) Hormonal (low dose OCP a Surgical Combo (Choice of tx depends on pts circumstances The presenting symptoms and their severity The location and severity of endometriosis The desire for future childbearing No treatment provides a permanent cure)
What is the treatment for endometriosis?
PDE 5 inhibitors (Viagra, Cialis) and Testosterone (Testosterone should be initiated by a urologist)
What is the treatment for erectile dysfunction?
Disappear on their own at menopause (watch and wait) If severe lumpectomy
What is the treatment for fibroadenoma?
Ceftriaxone (250mg IM) (and 1 gram) Azithromycin (When testing is not readily available empiric therapy should be aimed at treating N. gonorrhea This regimen will also treat Chlamydia Trachomatis Fluoroquinolones should not be used to treat gonococcal urethritis bc of resistance)
What is the treatment for gonococcal urethritis?
Acyclovir
What is the treatment for herpes simplex virus non-gonococcal urethritis?
Progesterone challenge test
What is the treatment for hypothalamus-pituitary-ovarian axis amenorrhea?
Dicloxacillin or clindamycin
What is the treatment for mastitis?
Support Garments Compresses/Cold cabbage Acetaminophen or NSAIDS OCPs or Progesterone
What is the treatment for moderate breast pain?
Ampicillin or clindamycin Surgical emergency (Diagnosis is made clinically Imaging may be useful in assessing the extent of necrosis CT scan or MRI A gram stain and culture should also be obtained to guide antibiotic therapy Treating with antibiotics alone there is still a 100% mortality rate Emergent surgical intervention is crucial to explore the extent of necrosis and to debride affected sites)
What is the treatment for necrotizing fasciitis?
Metformin (insulin sensitizers) alone or with clomiphene citrate (ovulation inducer)
What may be used to reduce insulin resistance, control weight, and facilitate ovulation No antidiabetic agents are currently FDA-approved for PCOS related menstrual dysfunction associated with PCOS?
Recommend calcium +/- vitamin D Biphosphonates (Alendronate Ibandronate Risedronate Reduce bone resorption through inhibition of osteoclastic activity) Selective Estrogen Receptor Modulators (SERMs) Tamoxifen Raloxifene (Nonhormonal management option Act like estrogens in some tissues but block estrogen actions in others Lack the capability of many of the other estrogen deprivation symptoms, such as hot flashes, sleeplessness, and may exacerbate them)
What is the treatment for osteoporosis complication with menopause?
Surgery Adjunctive therapy includes chemotherapy: paclitaxel (taxol) combined with carboplatin or cisplatin (All adjunctive therapies are more effective when tumor masses are less than 1 cm in size) (For recurrence: Persistent disease- other chemotherapeutic agents used Radiation therapy has limited role)
What is the treatment for ovarian cancer?
Laparoscopy Pain control
What is the treatment for ovarian torsion?
High fiber diet Laxatives for constipation Weight reduction Kegel exercises Pessaries Surgery (Vaginal or abdominal hysterectomy with vaginal vault suspension)
What is the treatment for pelvic organ prolapse?
Clomiphene citrate Human menopausal gonadotropins Pulsatile GnRH Aromatase inhibitors
What is the treatment for prego desired-ovulation induction amenorrhea?
cabergoling (Dostinex) or bromocriptine (Parlodel)
What is the treatment for sx of amenorrhea and galactorrhea when pit adenoma is ruled out?
Pulsatile GnRH Human menopausal gonadotropins
What is the treatment for sx of hypogonadotrophic hypogonadism with amenorrhea?
Clomiphene citrate
What is the treatment for sx of oligo-ovulatory or anovulatory PCOS with amenorrhea?
Require surgery to create a vagina or to restore genital tract integrity (Menstruation will never be established if the uterus is absent)
What is the treatment for sx or dx of genital tract obstruction with amenorrhea?
May require exogenous estrogen
What is the treatment for sx or dx of premature menopause with amenorrhea?
Metronidazole
What is the treatment for trichomonas vaginalis non-gonococcal urethritis?
High dose abx with serial US
What is the treatment for tubo-ovarian abscess?
Estrogen (intravaginally or transdermally)
What is the treatment for vaginal atrophy with menopause?
Estrogen (transdermal, intravaginal)
What is the treatment for vaginal atrophy with menopause?
Estrogen and progesterone Clonidine, SSRIs, gabapentin
What is the treatment for vasomotor insufficiency/hot flashes?
Estrogen (main one-do not give to ppl with uterus leads to endometrial hyperplasia leading to cancer-put progestin-micromist is the prometrium-100mg daily or 200mg for 12 days in each month- with it) SSRIs (paxil-main one-7.5 mg, other ones are venlafaxine, citalopram, lexapro) Lifestyle changes Gabapentin Progestin NSAIDs Herbal supplements (black cohosh unless have breast cancer)
What is the treatment for vasomotor symptoms with menopause?
Metronidazole (500 mg orally twice a day for 7 days, OR Metronidazole 2 g orally in a single dose, OR) Clindamycin cream (2%, 5 grams intravaginally at bedtime for 7 days) (Pregnant women with symptomatic disease should be treated Metronidazole 250 mg orally 3 times a day for 7 days, OR Clindamycin 300 mg orally twice a day for 7 days Not associated with teratogenicity Asymptomatic high-risk women) (those who have previously delivered a premature infant) (May be screened at first prenatal visit Follow up 1 month after completion of therapy)
What is the treatment of BV?
Fluconazole (150mg single dose) Topical antimycotics (miconazole or clotrimazole) (Treatment duration is 7 days Suggested in pregnancy and for those with allergy Not sexually transmitted* Possible role in transmission remains unresolved Recurrent infections Investigate risk factors)
What is the treatment of candidiasis?
Hysterectomy
What is the treatment of choice if pt has completed child bearing with secondary dysmenorrhea?
Azithromycin or doxycycline (doxycycline have been proven equally efficacious in treating C. trachomatis infections Azithromycin are also effective against other non-gonococcal urethritis infections (NGU) Mycoplasma genitalium If the initial Azithromycin did not treat effectively then use Ofloxacin)
What is the treatment of non-gonococcal urethritis?
Manual reduction (tried first) Aesthetics and pain med Ice packs for swelling Urologic evaluation
What is the treatment of paraphimosis?
Gentle daily manual retraction topical corticosteroid ointment application or circumcision
What is the treatment of phimosis?
Hysterectomy
What is the treatment of uterine sarcoma?
Hyperandrogenism Insulin Resistance Anovulation
What is the triad for PCOS that is a heterogenous disorder?
PE Mammogram/US (US in pregnancy and under 30 years old Cystic lesions are most common in this population) MRI Guided Core Needle Biopsy (Ordered on all Solid (Non Cystic)masses) (Open and Fine Needle biopsy are alternate biopsy options)
What is the triple tree tier test that significantly reduces missed breast cancer?
Urinalysis (Patients with gonococcal urethritis may have leukocytes in a first-void urine specimen) Nucleic acid-based tests for C. trachomatis and N. gonorrhoeae (Can also be performed on urine specimens but require a first-voided specimen Chlamydia species- endourethral samples are more accurate) Nucleic acid amplification Test (are also available for: Mycoplasma species and Trichomonas vaginalis)
What is the workup for urethritis?
Coopers ligaments
What keeps tissue connected in the breast?
UA Blood cultures CBC
What labs should you order with acute prostatitis?
CBC (Leukocytosis) ESR (Elevated, pathognomic if adnexal mass) UA (pyuria w/out bactermia)
What labs should you order with tubo-ovarian abscess?
Mg sulfate (Monitor closely to prevent magnesium toxicity Loss of reflexes, decreased consciousness-heart failure-toxic-do reflex check and SOB every 2 hours if on continuous drip)
What should you give a prego woman with severe preeclampsia to precent convulsions?
Influenza (inactivated) TdaP (in the third trimester of each pregnancy regardless of prior booster history Close relatives/those to contact baby should also get vaccinated) (Contraindicated: Live virus vaccines Varicella MMR Flumist)
What vaccines should be given during prego?
Bilateral enlarged ovaries with peripheral cysts "string of pearls" appearance
What would you see on a transvaginal US with PCOS?
Prolactin LH
When chronic anovulation is present, serum WHAT and WHAT assays should be done to exclude hypothalamic and pituitary diseases associated with PCOS?
Abnormal Uterine Bleeding (AUB)
When did the bleeding start? Were there precipitating factors, such as trauma? What is the nature of the bleeding (frequency, duration, volume, relationship to activities such as coitus)? Any associated symptoms? Is there a personal or family history of a bleeding disorder? Does she have a systemic disorder and is she taking any medications? Is she having coital relations? Pregnancy-related bleeding Has there been a change in weight, possibly associated with an eating disorder, excessive exercise, illness, or stress? This suggests anovulatory bleeding What Hx is this for?
Breast lump
When was it discovered Location Any pain Consistency Size & shape Symmetry Skin changes Nipple change Discharge Does the lump change could indicate an actual lump or a general change in breast tissue What hx is this for?
Fetal Position
Which direction the fetus is facing Facing backward is "normal" position Described in relation of the fetal occiput to the maternal pelvis Left occiput anterior, etc Occiput posterior, "OP" position results in prolonged/dysfunctional labor ROP-come out but take longer-pointy part take while to get out LOP-dysfunctional labor What is this?
Ovaries
are made up of 3 different types of cells: Epithelial cells make up the outer layer covering the ovary (epithelium). Germ cells are inside the ovary. They develop into eggs. Stromal cells form the supportive or connective tissues of the ovary (stroma). What histology is this for?
Effacement
as cervix thins due to prostaglandins Thickness of the cervix 0-100% happens first in primips What is this?
Macrosomia
baby > 4500g Operative vaginal delivery Cesarean delivery Shoulder dystocia What is this called?
Threatened AB
bleeding of uterine origin prior to 20 weeks What is this?
Inevitable AB
bleeding prior to 20 weeks with cervical dilation What is this?
Fetal presentation
Which part of the fetus points out Determines likelihood of vaginal delivery Vertex Breech-push harder Face-not coming out Compound-obstruct labor gets in way Shoulder-not going to work What is this?
No
Will cervicitis have cervical motion tenderness, fever, or abdominal pain?
Sentinel
With placenta previa, initially will have small WHAT bleed around 29-30 wks EGA?
PCOS
With reduction of body weight alone, many women resume regular ovulatory cycles and may conceive spontaneously Ovulation induction with clomiphene citrate is sometimes needed and is facilitated by weight reduction Factors that affect resistance to clomiphene or failure to achieve pregnancy Hyperandrogenemia Obesity Ovarian volume Menstrual dysfunction What tx is this for?
Erectile Dysfunction
can be a sign of a physical or psychological condition It can cause stress, relationship strain, and low self-confidence Etiology: Psychological, hormonal, atherosclerosis and medications Epidemiology: affects approximately 3 million people in the US per year Diagnosis: Differentiating psychological from physical ED Nocturnal tumescence
Amenorrhea
cessation of menses
PCOS
Women with PCOS display decreased levels of sex hormone-binding globulin (SHBG) Because of suppressed SHBG production, less circulating androgen is bound and thus more remains available to bind with end-organ receptors Due to this, women with PCOS will have total testosterone levels in the normal range, but will be clinically hyperandrogenic due to elevated free testosterone levels Low SHBG levels have also been linked to impaired glucose control What pathophys of sex hormone binding globulin is this associated with?
Pregnancy
Women with elevated but not postmenopausal FSH levels are still at risk for WHAT?? Should continue to use contraception until FSH levels remain in postmenopausal range
Mammogram
X-ray image of breasts Somewhat controversial "The benefit is marginal, the harm caused is substantial, and the costs incurred are enormous..." -- The Lancet 70% false positive Radiation Exposure 1000x that of bone or CXR Breast CA risk increases 2% with every mammogram DCIS is increased 328% in those who get annual mammogram What is this imaging?
Braxton-Hicks
contractions-squeeze in middle of uterus-rest put feet up drink water then back to norm goes away-norm indication doing too much-water will not break Irregular squeezing type contractions that occur during the third trimester Can be daily or rare and be normal What is this?
Episiotomy
cutting the perineum prior to crowning-not as common Increases risk of bleeding Increases risk of extension of tear through rectum Unnecessary unless soft tissue obstruction of delivery, or in case of shoulder dystocia What is this?
Ortho Evra Patch
delivers 20 mcg of ethinyl estradiol and 150 mcg of norelgestromin daily Can have local skin reactions May be ineffective in women >90kg-obese Change patch weekly Do not place on breast tissue Avoid placing on "creases", may peel or not stick What combined contraceptive is this?
Nullipara
a woman that has never given birth
Multiparaa
a woman who has had more than one pregnancy resulting in viable offspring
Multigravida
a woman who is or has been pregnant for at least a second time
Misoprostol (Cytotec)
administered vaginally-soften cervix and stimulate contractions-can't make go away Contraindicated in VBAC What prostaglandin analog is this for cervical ripening that induces labor?
Complete AB
all POC expelled from uterus
Polymenorrhea
frequent cycle interval; bleeding that occurs more often than every 21 days
Menometrorrhagia
frequent menstrual bleeding that is excessive and irregular in amount and duration
Free beta HCG
hCG is a glycoprotein hormone produced by the trophoblast Beta subunit confers the biologic activity on the intact hormone hCG increases with increase in trophoblast mass, and extremes of hCG levels can indicate placental dysfunction In Down Syndrome, average level in 1st trimester is 1.98 MoM (multiples of mean) What is this?
Cervical
have normal general physical examination findings With advancing disease: Enlarged supraclavicular or inguinal lymphadenopathy Lower extremity edema Ascites (abnormal buildup of fluid in the abdomen) Decreased breath sounds with lung auscultation may indicate metastases What GYN PE cancer is this for?
Septic AB
infection of uterus/endometrium during/following spontaneous or induced abortion What is this?
Oligomenorrhea
infrequent menstruation; bleeding that occurs less often than every 35 days
Metorrhagia
irregular menstrual bleeding or bleeding between periods
Vulvar Intraepithelial Neoplasia (VIN)
is a pre-invasive skin lesion of the vulva similar to cervical intraepithelial neoplasia (CIN). It is associated with the loss of epithelial cell maturation. HPV 16 is likely cause of up to 77% of VIN lesions Progression appears to be lower with VIN than with cervical intraepithelial neoplasia Sit and brew for many years before becomes a major problem unlike cervical cancer What GYN cancer is this?
Nullipara
is been prego but never given birth
Cervicitis
is clinical and based upon the presence of: Purulent or mucopurulent cervical exudate and/or Sustained endocervical bleeding (friability) easily induced by gently touching the area with a swab Determining the cause of infection use a Nucleic Acid Amplification Test Ex. Gen-Probe This will determine if the infection is caused by Gonorrhea or Chlamydia What Dx is this for?
Multipara
is delivered more than one baby
Gestational Diabetes
is diagnosed in late 2nd trimester Screening with 50g glucose load, non-fasting > 140 mg/dL at 1 hour is positive Follow with 3 hour GTT - fasting; 100g load Measure at 1, 2, and 3 hours Treatment Risk of adverse pregnancy outcomes increase as fasting blood glucose goes above 75mg/dL Strict dietary management with frequent blood sugar checks May use glyburide or insulin if needed. Metformin is also used. Some studies question short and long term outcomes/metabolic effects with glyburide or metformin Risk of T2D post-partum is high Screen patients with h/o GDM at least annually for development of T2D obese, inactive, family hx incr risk-screen early trimester and if non-fasting pos then follow with 3 hour fasting and measure at 1, 2, and 3 hours-mom sugar high and baby sugar high too much insulin then baby produces own insulin and becomes a big baby and have incr risk of diabetes later on-end up with low sugar after delivery and become hypoglycemic-small babies are at risk for diabetes later-starve itself not getting enough nutrient baby has insulin resistant to get enough sugar-also started type 2 diabetes for prego women after baby born later on-screen 6 mons, 2yrs, 4yrs, etc What is this in pregnancy?
Primipara
is first delivery. abbreviated primip
Primigravida
is first prego
Nulligravida
is never been prego
Uterine artery embolization
is now considered a viable alternative to hysterectomy and myomectomy for select pts Uterine artery catheterization and embolization with polyvinyl alcohol particles What is this with fibroids?
Gravida
is or has been prego
Multigravida
is prego more than once
Testicular Cancer
is responsible for 1% of all cancers in men and 3% of male genitourinary cancers About 95% originate in germ cells Testicular germ cell cancer is the most common malignant tumor among men ages 15 to 44 years The germ cell tumors are divided into seminomas and nonseminomas What is this?
Cervical
is the 3rd most common gynecologic cancer in U.S. 10,000 new cases of invasive cancer in US each year and approximately 4000 cancer-related deaths occur each year African-Americans and women in lower socioeconomic groups have the highest death rates from this cancer, and Hispanic and Latino women have the highest incidence rates The median age at diagnosis is 50 years Majority of cases stem from infection with the human papillomavirus (90%) which is sexually transmitted... Prevention is key! Vaccination Gardisil 12-26 after 12 give 2 doses-condoms do not work Major Histologic Types are: Squamous cell carcinoma (SCC) 80% Squamous cell carcinoma of the cervix typically arises at the squamocolumnar junction from a preexisting dysplastic lesion, which in most cases follows infection with HPV Adenocarcinoma 15% What GYN cancer is this?
Vulvar
make up approximately 5 percent of all gynecologic malignancies, and is primarily a disease of older females Squamous Cell Carcinoma - Most common (90%) malignant tumor of the vulva Melanoma- 2% of vulvar cancers Sarcoma Less common findings: Basal Cell Carcinoma Adenocarcinoma Verrucous Carcinoma Bartholin's Gland Carcinoma Paget's Disease What GYN cancer is this?
Missed AB
non-viable POC retained in uterus What is this?
Incomplete AB
not all POC-product of conception are expelled from uterus What is this?
Laminaria
not common-seaweed-stimulate cervix-put in there and swells up-expensive What mechanical dilation is this that causes cervical ripening and induction of labor?
Colostrum
nutrient and IgA rich "milk" before the true milk comes in
Cervical
originate from cells infected with HPV, which is sexually transmitted Most common HVP viral types: 16, 18, 31, 45 Greatest risk is lack of reg pap smear screening what is this GYN cancer?
Menopause
permanent cessation of primary function of the ovaries
Climacteric
phase of the aging process during which a woman passes from the reproductive to the non-reproductive stage
