OB-GYN EOR

What term defines the first awareness of fetal movement?

"Quickening" - usually occurs at 18-20 wks primigravida, 14-18 wks multigravida

Spontaneous abortion MC occurs in which trimester? And most are a/w what?

-1st trimester -most a/w chromosomal abnormalities

Evaluation of abnormal findings: 1. Palpable cystic lesion means ____. 2. Recurrent cyst, bloody fluid means ____. 3. Solid, palpable mass <30yo means _____. 4. Solid, palpable mass >30 yo means _____. 5. Nondiagnostic FNA of solid mass means _____. 6. Nondiagnostic core-needle biopsy means _____. 7. Nonpalpable abnormal mammogram finding ____.

1. needle drainage 2. excision 3. FNA 4. core needle biopsy 5. excisional biopsy 6. excisional biopsy 7. wire guided excision

At how many weeks is uterine fundus at the level above the pubic symphysis?

12 weeks (And at 20 wks - umbilicus)

During which trimester do we screen for risk of trisomy 21 and other genetic d/o's?

1st trimester (abnormally low PAPP-A & high B-hCG is a/w trisomy 21)

Abortion is the termination of any means (even spontaneous) prior to how many weeks gestation?

20 weeks

At how many weeks gestation can you begin to appreciate fetal heart tones?

9-12 weeks w/ Doppler

Fundal height at 20 weeks gestation?

At umbilicus

____&____ are the two highest risk factors for ovarian cancer followed by FH of ovarian cancer and PMH of breast cancer.

BRCA1/BRCA2 gene and HPNCC (hereditary non-polyp colon cancer)

_____is the most common cancer in women and 2nd leading cause of death in women.

Breast cancer

In 80% of women (50% in early disease) with epithelial ovarian cancer, ____tumor marker may be elevated. ___&___are also present.

CA-125; alpha-fetoprotein, hcG

For a woman with abnormal vaginal bleeding, what is included in the work up?

CBC for anemia, TSH, prolactin, FSH/estradiol, CA-125 for ovarian cancer

Treatment for CINI? CINII?

CINI: colposcopy every 3-4 months - may resolve spontaneously CINII: destruction/excision of lesions -- cryotherapy, laser therapy, LEEP, conization, CO2 laser

___ ___is thought to be a precursor to cervical cancer.

Cervical dysplasia

Bluish discoloration of vagina and cervix?

Chadwick sign (A sign of pregnancy)

Chemotherapy and hormone/anti-estrogen therapy are indicated in lymph node positive or high risk lymph node negative patients. _____includes CMF ie. cyclophosphamide, methotrexate, and 5-fluoracil. Most common hormone treatment is ___if estrogen receptor positive.

Chemotherapy; tamoxifen

Common gyn procedures: _____is visualization of cervical, vagina, or epithelium under 5-50 magnification with or without dilute acetic acid to identify abnormal areas required biopsy. Office procedure.

Colposcopy

Type of spontaneous abortion? : -vaginal bleeding, cervix open, products of conception passed

Complete abortion

Treatment continued -- _______is more likely to lead to incompetent cervix than LEEP. ____is a well controlled method that minimizes tissue destruction -- it is colposcopy directed and requires special training.

Conization; CO2 laser

Dysfunction uterine bleeding: ____is the first surgical TOC. Both dx & curative. ____is the definitive surgery used in refractory cases.

D&C; hysterectomy

What is the only cure for severe preeclampsia or eclampsia?

Deliver of fetus

Unilateral adnexal pain, amenorrhea/spitting, and tenderness or mass on pelvic exam is a classic presentation of?

Ectopic pregnancy

____cancer is the most common gynecological cancer in the US. The MC type is ____followed by mucinous, clear cell, and squamous cell.

Endometrial, Adenocarcinoma

T/F: ACE-I and ARBs can be used to treat HTN during pregnancy.

FALSE! - C/I'd throughout pregnancy! They're teratogenic

When does each of the following hormones rise during a normal menstrual cycle? Explain. FSH Estradiol LH Progesterone

FSH -- increases around 2 days before onset of menstruation and involved in maturation of new follicles Estradiol -- begins to rise on CD#4 and peaks 1 day before ovulation LH -- surge midcycle with ovulation, ends at onset of next menses progesterone -- rises with LH surge

MC site of ectopic pregnancy?

Fallopian tube

Schedule for prenatal visits: 1st visit? Follow ups?

First visit is 6-8 weeks after LMP, followed by q4wks until 32 weeks gestation, then q2wks until 36 weeks gestation, then qweek til delivery

Vaccine against HPV is recommended for all boys and girls aged 11-12 (3 injections over 6 months). What are the vaccinations and what strains do they cover?

Gardasil - HPV 6, 11, 16, 18 Cervarix - HPV 16, 18

_____infection is strongly linked to cervical neoplasia.

HPV infection 6, 11, 16, 18 -- 16 & 18 more linked

What sign?: -softening between fundus & cervix

Hegar sign

Type of spontaneous abortion? : - vaginal bleeding, cervix open, partial passage of products of conception

Incomplete abortion

Type of spontaneous abortion? : Vaginal bleeding, cervix open, no products of conception passed but no way to maintain prego

Inevitable abortion

GnRH from the hypothalamus is released in a pulsatile fashion. High GnRH frequency favors ____secretion. Low GnRH frequency favors ____secretion. Ovaries release estrogen and progesterone in response to FSH/LH.

LH, FSH

Surgical tx options: a. ____can be used if tumor is <4cm b. _____includes removal of breast tissue, nipple-areolar complex and skin. c. _____includes removal of breast tissue, nipple-areolar complex, skin, axillary lymph nodes, and pectoralis fascia d. _____includes removal of breast tissue, nipple-areolar complex, skin, axillary lymph nodes, and pectoralis major and minor.

Lumpectomy, Simple Mastectomy, Modified radical mastectomy, Radical Mastectomy

____masses in the ovary tend to be >8cm, solid, multilocular, bilateral with ascites, peritoneal masses, and lymphadenopathy.

Malignant

What medical treatment can be used to treat a majority of early ectopic pregnancies?

Methotrexate (If MTX cannot be used, sgx by laparoscopy) -w/ Tx'd ectopic, follow up hCG is crucial to make sure there is no remaining pregnancy

Type of spontaneous abortion? -no vaginal bleeding, cervix closed, no products of conception passed but fetal demise has occurred

Missed abortion

Abnormally high levels of alpha feto protein (AFP) in pregnancy can be a/w what disorders?

Neural tube defects (I.e spina bifida, anencephaly)

What does the hCG look like in ectopic pregnancy?

Normally serum hCG doubles q48 hrs, w/ ectopic the levels are less than expected

What screening test combination is used to detect trisomy 21 disorders?

Nuchal translucency measurement and PAPP-A and B-hCG

_______dx test is used to help determine the need for chemotherapy for stage I or II hormone receptor positive. It looks at 21 genes with tumor to determine the likelihood of cancer recurring or spreading.

Oncotype

______has the highest mortality rate of all gyn cancers. Increased risk because of lack of effective screening tools.

Ovarian cancer

The causes of abnormal uterine bleeding have a PALM-COEIN classification system. Explain the causes in the mneumonic.

PALM-COEIN polyp, adenomyosis, leiomyoma, malignancy/hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified

Blood pressure >= 140 or >=90 diastolic after *20 weeks gestation* defines what condition?

Pre-eclampsia (Also based on presence of proteinuria)

OVARIAN CANCER 1. ____are family history of ovarian and breast cancer, PMH of breast cancer, increased age, early menarche, infertility, nulliparity, late menopause, and obesity. 2. ____are the use of OCPs, multiparity, breastfeeding, tubal ligation, and hystectomy.

Risk Factors, Protective Factors

Vulvar cancer is most common ~ age 60s, most common type is _____. In younger women, it's associated with ___&___.

SCC, HPV and smoking -- 25% have associated cervical cancer

What differentiates preeclampsia from eclampsia?

Seizure presence

What differentiates mild preeclampsia from severe preeclampsia?

Severe preeclampsia has SBP >=160 OR DBP >=110, may also have proteinuria >=5 g in 24hr

Ovarian cancer -- patients are often asymptomatic until disease is advanced. ______or a metastatic tumor implant in umbilicus can be associated with ovarian cancer.

Sister Mary Joseph nodule

Ovarian cancer staging: _____: growth limited to ovaries. _____: extension from ovaries to pelvis. _____: extension to abdomen. _____: distant metastasis (liver, lung).

Stage I, II, III, IV

Nageles rule for estimating due date

Start at 1st day of LMP, add 1 year, subtract 3 mos, add 7 days

Type of spontaneous abortion?: Vaginal bleeding, closed cervix, no products of conception passed

Threatened abortion

What is diagnostic in 90% of ectopic pregnancies?

Transvaginal ultrasound (Paired with clinical picture)

T/F: at 21 weeks gestation and on the height of uterine fundus should correlate to number of weeks gestation

True

Other dx testing: ____is used to separate fluid-filled cysts from solid masses. ___, ___, or ___ are needed to make official diagnosis.

Ultrasound; FNA, biopsy, or excisional biopsy

What are the recommendations concerning self breast examinations?

Used to be SBE monthly >20yo and 5 days after menses -- NOW NOT recommended bc of increased incidence of unnecessary biopsy -- "self awareness now"

Treatment of vaginal cancer: a. Stage I lesions <2cm -- __________. b. Lower 2/3 of vagina & stage III/IV -- _________. Survival rate has improved to 45-55%.

a. radical hysterectomy, upper vaginectomy, & b/l pelvic lymph node dissection b. radiation therapy

What are the recommendations concerning mammograms and clinical breast exams?

annual mammogram >age 40; clinical breast exam annually after age 40, every 1-3 years ages 20-39 year old

What is included in the work up for dysfunctional uterine bleeding?

b-HCG, CBC, Fe, PT/PTT, documentation of ovulation, thyroid function, serum progesterone, LFTs, prolactin, FSH, Pap, endometrial biopsy, pelvic u/s, hysterosalpin, hysteroscopy, D&C

Pap Smear reduces CIN incidence by 95% -- what are the recommendations for pap smear?

begin with in 3 years of becoming sexually active or age 21 whichever comes first -- until age 65 if 3 consecutive negative results

Vaginal neoplasms are the rarest of gynecological neoplasms. There is an increased risk of ____with exposure to DES (diethylstilbestrol) in utero. MC in women <20.

clear cell adenocarcinoma

Women with a family history of ____are at a significantly increased risk -- lifetime incidence up to 30%. What screening must these patients undergo?

colon cancer/Lynch syndrome, yearly endometrial biopsy starting at age 35

What's the most appropriate technique for histological evaluation of CIN?

colposcopy with biopsies

HPV 6 & 11 is associated with ____ or genital warts.

condylomata acuminata

With stage I disease, the _____is the strongest predictor of survival?

depth of myometrial invasion

Types of noninvasive breast cancer: a. ____, age 50's, mammogram showing microcalcifications, dx with needle or excisional biopsy, tx: surgical excision b. ____, age 40's, not seen on mammogram, diagnosed incidentally, tx: local excision

ductal carcinoma in situ, lobular carcinoma in situ

Oral contraceptives, conjugated estrogens for excessive bleeding, cyclic progestins in younger patients, or surgical treatment is used in _____.

dysfunctional uterine bleeding

What is the gold standard to determine if ovulation is occurring?

endometrial biopsy

What is the test of choice for endometrial cancer?

endometrial biopsy

The most common precursor of endometrial cancer is ____.

endometrial hyperplasia

Pathology: 80% is Type I and occurs in women with history of chronic ____unopposed by progestin. 20% is Type II and ____independent --- associated with mutation in p53 tumor suppressor gene...no identifiable risk factors

estrogen exposure; estrogen independent

_____increase causes cellular proliferation of epithelial lining, the endometrial glands, and connective tissue of stroma. _____from corpus luteum stimulates glandular cells to secrete glycogen, mucus.

estrogen, progesterone

Dysfunctional uterine bleeding is a diagnosis of ____.

exclusion

Phases of Menstruation: Days 1-14 is the ____phase. Day 1 is the start of ____. Day 14 is ____which is part of the luteal phase. Day 14-28 is the ____phase.

follicular, menstruation, ovulation, luteal

Types of invasive breast cancer: a. 80-85% are _____. b. 15-20% are _____ - estrogen receptor positive c. ____are eczematous lesions. d. ____breast carcinoma.

infiltrating invasive breast cancer, invasive lobular carcinoma, Paget's disease of the breast, Inflammatory

MC s/s for endometrial cancer?

irregular bleeding

Most common s/s of cervical cancer are __, __, & __. Late symptoms are bladder and rectal dysfunction or fistulas and pain.

menorrhagia, postcoital bleeding, and cervical ulceration

What is breast mass like if found?

nontender, irregular, firm, and immobile

What are the 6 risk factors for endometrial cancer?

nulliparity, DM, obesity, late menopause, tamoxifen, unopposed estrogen therapy

In pre-menopausal women with simple cystic mass <7.5cm, it may be ____for 4-6weeks. Most resolve spontaneously. ____may be used for ovarian masses small enough to be removed with this approach.

observed; laparoscopy

What are the top 4 prognostic factors for endometrial cancer?

older age, histological grade, histological type, myometrial invasion

The risk of endometrial hyperplasia can be reduced almost completely with the use of _____or_____.

oral contraceptives or cyclic progestin therapy

In more advanced disease, what might be seen?

pelvic pain/mass, weight loss, stigmata of DM, patulous cervical os/firm/expanded, ascites, hepatosplenomegally

_____is the test of choice for ovarian cancer.

pelvic u/s -- color Doppler imaging may enhance specificity

If bleeding stops after a _____trial, anovulatory cycles are confirmed.

progestin

What are the two endometrial phases?

proliferative and secretory phases

What are the s/s of vulvar carcinoma? How is the diagnosis made?

pruritis, vulvodynia, bleeding, mass -- dx with biopsy (w application of acetic acid or staining with toluene blue to direct biopsy)

Other _______for CIN ie. cervical intraepithelial neoplasia include early age of 1st intercourse, early child-bearing, multiple sex partners, history of STI, low socioeconomic class, African American, or smoking.

risk factors

In epithelial tumors (20% 5 year survival rate) and germ cell tumors (60-85% 5 year survival rate), multi-drug chemo is used. Chemo is not used in ____which has a 90% 5 year survival rate.

sex cord stroma

What mammogram findings are suspicious for breast cancer?

speculated mass, asymmetric local fibrosis, microcalcifications

Invasive _____ of the vagina is often complicated by involvement with local structures such as the rectum, bladder. Therefore, patients should undergo pre-op chest imaging, cystoscopy, proctosigmoidoscopy, and IVP to access for spread.

squamous cell carcinoma (SCC)

What is the treatment of choice for vulvar carcinoma?

wide local excision with regional lymphadenectomy

What is the primary treatment for endometrial cancer?

TAH-BSO (total abdominal hysterectomy-bilateral salpingo-oophorectomy), radiation, and lymph node sampling

Ovarian cancer: 75% of patients present with stage III/IV. What's involved in the primary staging?

TAHBSO, omentectomy, peritoneal washings, pap smear of diaphragm, sampling of pelvic & para-aortic lymph nodes

If postmenopausal, ____should be used to measure endometrial thickness. </= 4mm indicates low likelihood of hyperplasia or endometrial cancer.

transvaginal sonography

Most vaginal intraepithelial neoplasms occur in what part of the vagina? What are the most common presenting problems?

upper 1/3; postmenopausal bleeding or bloody discharge

Greater than 50% of breast cancer occurs where?

upper outer quadrant

Diagnosis is via _____directed by colposcopy or lugol staining.

vaginal biopsy

Cervical cancer: ______is the cause of death in 10-20% of patients.

vaginal hemorrhage -- ligation of hypogastric arteries may be lifesaving

Endometrial cancer: The most common route of spread is _____.

via direct extension of tumor downward toward cervix or outward through myometrium and serosa