Rosh Questions
How do we diagnose endometrial cancer?
- Transvaginal ultrasound (postmenopausal patients) - Endometrial sampling via biopsy
How do we manage postpartum hemorrhage?
Empty bladder [structures are close and this will aid uterine contraction] Bimanual exam and uterine massage Oxytocin and additional uterotonics (e.g., prostaglandins) Tamponade (balloon or surgery) Massage of the uterus is the first-line treatment strategy. If this approach fails, medical intervention should be implemented with uterotonic agents such as oxytocin, methylergonovine, misoprostol, dinoprostone, and 15-methyl prostaglandin F2 alpha. Surgical intervention includes uterine compression sutures (B-lynch or multiple squares), sequential artery ligation, selective arterial embolization, and hysterectomy.
If endometritis is pregnancy related, then..?
Its postpartum and is infection of the decidua: the thick layer of modified mucous membrane which lines the uterus during pregnancy and is shed with the afterbirth.
Risk factors for preterm labor and delivery
Shortened cervix, Hx preterm delivery, low prepregnancy BMI, smoking or substance use, short pregnancy interval, conization or LEEP, GU infection
A 22-year-old woman presents with mild backache and lower abdominal cramping. Her last menstrual period was 14 weeks ago. She reports previous episodes of painless second-trimester pregnancy losses. Physical examination shows a soft and closed cervix. Upon Valsalva maneuver, fetal membranes are seen in the endocervical canal. Cervical length of 20 mm and debris in the amniotic fluid are seen on ultrasound. Which of the following is the most appropriate therapy? A Bedrest B Cerclage C Hydroxyprogesterone D Indomethacin
B Cerclage (12 to 24 weeks) ---- Bedrest (A) may be suggested but is not sufficient for treating cervical insufficiency. Intramuscular hydroxyprogesterone caproate (C) was previously recommended for patients with a history of preterm labor. However, the FDA and ACOG now indicate there is insufficient data to recommend its use for this indication. While indomethacin (D) administration, in addition to cefazolin, may prolong pregnancy by 28 days, no large-scale clinical research has been done to ascertain the effectiveness or the risks of this therapy. Hence, at this time, there is insufficient data to support the use of this therapy.
A 27-year-old G1P0 woman at 36 weeks gestation presents to your office seeking counseling regarding immediate postpartum contraception. She wants to breastfeed her baby exclusively for 6 months and desires the safest, long-acting, reversible form of contraception. Which of the following would you recommend to this patient based on US Medical Eligibility Criteria for contraceptive use? A Combined hormonal contraceptive B Copper IUD C Levonorgestrel IUD D Progestin-only pill
B Copper IUD -- provides long term reversible contraception. -- The combined hormonal contraceptive (A) is category 4, and it should not be used during the first 21 days postpartum because of the increased risk of thrombosis. The levonorgestrel IUD (C) is a US MEC category 2 for breastfeeding mothers, meaning the advantages outweigh theoretical or proven risks. This is based on limited evidence that suggests it might shorten the overall duration of breastfeeding. The progestin-only pill (D) is also considered a category 2 for patients who are breastfeeding. However, it is not a long-acting method, which is what this patient wants.
A 25-year-old G3P2 woman at 12 weeks gestation presents with vaginal bleeding and cramping. Physical exam shows that the cervix is not dilated. Fetal heart tones are heard on ultrasound. Which of the following is the most appropriate management for this patient? A Cerclage B Expectant management C Misoprostol D Surgery
B Expectant management Cerclage (A) is the treatment of choice in cervical incompetence, the inability of the uterine cervix to retain a pregnancy in the second trimester when contractions, labor, or both are absent. McDonald cerclage is the most common type of cerclage used to treat cervical incompetence and is often described as a "pursestring" suturing to the upper part of the cervix. Misoprostol (C) is a synthetic prostaglandin E1 that can be used to treat missed abortion. It works by softening and dilating the cervix and inducing uterine contractions. It is generally safe, cost effective, and less invasive. Surgery (D), or dilation and curettage, may be used to treat missed abortion in patients who have excessive bleeding when treated with misoprostol. Surgery may also be used to evacuate the products of conception in incomplete and inevitable abortions
How do we treat mastitis?
(1) Cool compresses and analgesics between feedings (2) Antibiotics: dicloxacillin [like pcn], cephalexin [1st gen ceph which contains some PCN], TMP-SMX (MRSA), clindamycin (PCN allergy) (3) Continue breast feeding to avoid progression to abscess
How does lactational mastitis primarily manifest? Risk factors?
(1) Lactational mastitis primarily manifests due to a blockage in a milk duct, which leads to engorgement and growth of infectious organisms in the stagnant milk. (2) Risk factors for the development of mastitis include prior history of mastitis, a blocked duct, cracked nipples [breaking skin = bacteria], use of cream on nipples [traps the bacteria in the nipple], and the inconsistent use of a breast pump.
What is gestational HTN?
- Physical Exam: new-onset SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg Two occasions at least 4 hours apart Gestational age ≥ 20 weeks - If proteinuria or signs of end-organ damage develop: preeclampsia - If BP elevation persists > 12 wks postpartum: chronic hypertension - If BP returns to normal by 12 wks postpartum: transient hypertension of pregnancy
Clinical presentation of endometrial cancer?
- Abnormal uterine bleeding - Postmenopausal bleeding
Clinical presentation of breast abscess
- Localized, painful inflammation of the breast - fever, malaise - Flunctuant, tender, palpable mass
Risk factors for endometrial cancer?
- Peak incidence is in postmenopausal patients between age 60-70 yrs (most common type is adenocarcinoma) - Risk factors: Nulliparity, obesity, unopposed estrogen, tamoxifen (postmenopausal patients), early menarche, late postmenopausal bleeding -------- While there had previously been concern about negative impact of endometrium with exposure to Tamoxifen, this has not been supported in follow up studies. Current consensus is that Premenopausal women treated with tamoxifen have no known increased risk of uterine cancer and require no additional monitoring beyond routine gynecologic care ("Tamoxifen and Uterine Cancer" ACOG Committee Opinion Number 601 June 2014 and reaffirmed 2019)
How do we manage preterm labor and delivery?
- Verify gestational age - Assess status of membranes - Assess for regular contractions and cervical dilation - Check for infection, treat - Single course of IM corticosteroids between 24 0/7-33 6/7Consider betamethasone for patients 34 0/7-36 6/7 who did not receive previous antenatal corticosteroids - Antenatal MgSO4 < 32 weeks for - fetal neuroprotection - Tocolytics < 34 weeks gestation to prolong the time to delivery for corticosteroid administration
Clinical manifestations of endometritis
- fever within 36 hours - foul-smelling lochia (vaginal discharge after birth) - Uterine tenderness - Leukocytosis with left shift
1. What is postpartum hemorrhage? 2. What are the four causes of postpartum hemorrhage?
1. Blood loss of ≥ 1,000 mL or bleeding associated with signs and symptoms of hypovolemia within 24 hours of birth regardless of route of delivery 2. Uterine atony, trauma to the birth canal, retention of fetal or placental tissue, coagulopathy of thrombin disorder
Which of the following is the recommended gestational age to screen for gestational diabetes mellitus during pregnancy? A 24 weeks B 29 weeks C 32 weeks D 36 weeks
A 24 weeks
A 22-year-old G1P0 woman presents with an acute onset of vaginal bleeding. She is at 25 weeks of gestation and is known to have asthma and hypertension. Vitals are temperature of 98.6°F, respiratory rate 16 breaths/min, blood pressure 87/48 mm Hg, heart rate 99 beats/min, and oxygen saturation 98% on room air. Physical exam reveals abdominal tenderness. On bimanual exam, the uterus is hypertonic and tender. Laboratory studies show a fibrin level of 100 mg/dL. Transvaginal ultrasound reveals a retroplacental hematoma. Which of the following is the most likely diagnosis? A Abruptio placentae B Placenta previa C Subchorionic hematoma D Uterine rupture
A Abruptio placentae ------ Placenta previa (B) classically presents with painless vaginal bleeding after 20 weeks of gestation, but it may also be associated with uterine contractions, making it very difficult to distinguish from abruptio placentae. Ultrasonography can differentiate placenta previa from placental abruption and usually shows placental tissue over the internal cervical os. Subchorionic hematoma (C) arises from the separation of the chorionic membrane from the uterine wall usually before 20 weeks of gestation. A hypoechoic or anechoic crescent-shaped area behind the fetal membrane is characteristically seen on ultrasound. Uterine rupture (D) shares common features, such as abdominal pain, vaginal bleeding, and fetal distress, with placental abruption. However, cessation of uterine contractions and the recession of the presenting part, when present, are strongly associated with uterine rupture and would be unusual during an abruption.
Which of the following is the first-line therapy for mastodynia? A Acetaminophen B Danazol C Primrose oil D Tamoxifen
A Acetaminophen Second-line treatment of severe mastodynia refractory to conservative treatment include danazol (B) and tamoxifen (D). Danazol is an androgen, so given its androgenic effects (weight gain, menstrual irregularity, hot flashes, and deepening of voice), the use of danazol is limited. Restricting the use to the luteal phase of the menstrual cycle reduces side effects without compromising its effectiveness. Tamoxifen is associated with menopause-like symptoms, such as hot flashes, vaginal dryness, joint pain, and leg cramps. Tamoxifen may also increase the risk of blood clots, stroke, uterine cancer, and cataracts. Hence, it is infrequently used to treat mastalgia. Primrose oil (C) has been shown not to be more effective than placebo in some randomized controlled trials. some studies showed that primrose oil applied vaginally was effective at ripening the cervix, which is when the cervix softens to get ready for labor and delivery.
A 31-year-old woman reports to the clinic complaining of unilateral breast pain. She gave birth to her son three weeks ago. Vital signs reveal HR 89, RR 16, T 102.5°F, BP 125/87, and SpO2 99% on room air. Physical examination demonstrates a localized, red, and swollen area on the right breast with a fluctuant mass. She has been breastfeeding her child but has noticed a decrease in milk supply since the pain onset. Which of the following is the most likely diagnosis? A Breast abscess B Engorgement C Galactocele D Mastitis
A Breast abscess Engorgement (B) presents with gradual onset bilateral pain and diffuse swelling. The patient is otherwise healthy and does not present with fever. A galactocele (C), or plugged milk duct, presents with a gradual onset of unilateral localized swelling and pain without fluctuance or systemic symptoms. Mastitis (D) also presents with unilateral, localized swelling and pain, however, it is found in an unwell patient with the clinical finding of fever. This condition does not demonstrate fluctuance at the point of tenderness.
A 33-year-old G1P0 woman at 23 weeks gestation presents to the maternity ward with premature rupture of membranes without active contractions. She is not experiencing any pain. The cervical length of the patient measured earlier in this pregnancy was less than 25 mm. Physical exam reveals cervical dilatation with vaginal discharge. The fetus is delivered rapidly and is nonviable at birth. Which of the following is the most likely diagnosis? A Cervical incompetence B Placental abruption C Preeclampsia D Spontaneous preterm premature rupture of membranes
A Cervical incompetence Patients with placental abruption (B) will present with active vaginal bleeding, uterine contractions, uterine tenderness, and fetal distress. Preeclampsia (C) is characterized by hypertension and proteinuria and is a known cause of preterm labor, but since the patient does not have any history of this condition, it is incorrect. It is also not associated with a short cervix. Spontaneous preterm premature rupture of membranes (D) occurs when the membranes rupture prior to 37 weeks gestation. This does describe this patient's condition, however, it is not the best answer because it does not take into account the patient's history of a shortened cervix which points to the more likely diagnosis of cervical incompetence.
A 29-year-old woman who is 38 weeks gestation presents to the maternity ward in active labor and undergoes a cesarean section. She develops a fever and lower abdominal pain 12 hours later. Physical exam reveals uterine tenderness. Which of the following is the strongest risk factor for developing this condition? A Cesarean section B Group B Streptococcus anovaginal colonization C History of urinary tract infection D Premature rupture of membranes
A Cesarean section Group B Streptococcus anovaginal colonization (B) is not the best answer, because although it is a risk factor for endometritis, it is not the strongest risk factor. Cesarean delivery remains the strongest risk factor for the development of endometritis. History of urinary tract infection (C) is not a direct risk factor for endometritis, since endometritis arises from infection of the lower genital tract. Premature rupture of membranes (D) is not a risk factor for endometritis, although prolonged rupture of membranes is.
A 34-year-old woman presents at 38 weeks gestation in active labor. Upon vaginal examination, a soft, pulsating mass is palpated. With every contraction, increasingly profound fetal bradycardia is noted that lasts more than one minute. Which of the following is the definitive management of this condition? A Emergency cesarean section B Manually elevate the fetal presenting part C Readjust the patient's position D Spontaneous vaginal delivery
A Emergency cesarean section B would be right if there was no fetal distress C Readjusting the patient's position would be fine, but compression can recur D Not the best answer because there is profound fetal distress
A 22-year-old woman presents to the clinic with complaints of painful pelvic cramping around menstruation. She states that the pain typically begins a few hours before menstruation and lasts for the first several days of her menstrual cycle. She has had this for years but states that she has missed work a few times and is wondering if there are some treatment options. She has tried acetaminophen for the discomfort without relief. She is sexually active with one partner, and she does not wish to get pregnant at this time. She uses condoms for birth control currently and would like more effective protection. Which of the following would be the best pharmacologic treatment at this time? A Estrogen-progestin hormonal contraceptive B High-dose ibuprofen C Magnesium D Nifedipine
A Estrogen-progestin hormonal contraceptive High-dose ibuprofen (B) is an acceptable option for women who wish to maintain fertility or those who are unable to get pregnant. Magnesium (C) has not been proven to be helpful in treating dysmenorrhea. There is a lack of evidence that this is a useful treatment option. Nifedipine (D) is effective at reducing uterine contractions, however, it can cause facial flushing, tachycardia, and headache and is generally not used as a first-line treatment option. -------- For our patient, we could have treated with NSAIDS (first line) or estrogen progestin, but we chose the later because she also wants the birth control.
A 49-year-old woman presents to the office complaining of irregular menses with a shorter duration between menstrual cycles. She has associated sleep disturbances and hot flashes, as well. Menarche was age 11, and she has had regular menstrual cycles typically lasting about 27 days. Now she is having cycles that are 23 to 25 days in length. Which of the following diagnostic tests would be most helpful in establishing the diagnosis? A Follicle-stimulating hormone level B Pelvic ultrasound C Prolactin level D Thyroid-stimulating hormone level
A Follicle-stimulating hormone level Pelvic ultrasound (B) would not be helpful in establishing the diagnosis of perimenopause or menopause. This patient is having symptoms that are consistent with perimenopause. A prolactin level (C) would be useful if the patient was having symptoms of galactorrhea in addition to absent periods. Thyroid-stimulating hormone level (D) should be tested, particularly in a patient who also has fatigue, cold intolerance, or constipation, however, it would not be most helpful in this situation.
What is Lichen Planus?
A scarring inflammatory disorder of the skin, oral mucosa, and vulvovaginal area. The condition is thought to be associated with a dysfunction of cell-mediated immunity, and approximately one-third of individuals affected have one or more autoimmune disorders. Symptoms include dyspareunia, burning, soreness, itching, and increased purulent vaginal discharge.
A 42-year-old woman presents to your office seeking counseling. She had cervical cytology testing performed 1 year ago. She had a screening mammography 8 months ago and a pelvic exam performed at the same time. No abnormalities were present. Both the patient and her 44-year-old biological sister are adopted. Her sister was recently diagnosed with breast cancer, and the patient is worried. What is the best next step in the management of this patient? A Genetic counseling B Human papillomavirus testing C Screening mammography D Transvaginal ultrasonography
A Genetic counseling Genetic counseling is recommended to women who have a personal or family history of breast or ovarian cancer. Certain criteria need to be fulfilled in order to refer a patient for genetic counseling, including (as in this case) a first-degree relative diagnosed with breast cancer at an age younger than 45 years and unknown family history. Human papillomavirus testing (B) would not be recommended for this patient at this point since she had a normal cytology 1 year ago. Screening mammography (C) is recommended to be performed annually. In the event that this patient tests positive for a BRCA mutation, then mammography should still be performed annually with the addition of annual breast MRI. Transvaginal sonography (D) is generally not recommended as a screening test for asymptomatic women, including those women who test positive for BRCA mutation or have a history of ovarian cancer.
A 64-year-old woman presents with complaints of vaginal dryness and dyspareunia. She has tried vaginal lubricants in the past with little relief. On physical exam, the vulvovaginal tissues appear smooth and shiny, and there is loss of vaginal rugae. Which of the following clinical therapeutics would be best to begin at this time? A Low-dose vaginal estrogen B Vaginal dehydroepiandrosterone (DHEA/androgen and estrogen) C Vaginal estrogen with oral progestin D Vaginal testosterone
A Low-dose vaginal estrogen Vaginal dehydroepiandrosterone (B) can be used for dyspareunia associated with atrophic vaginitis, however, it is not used as a first-line therapy for atrophic vaginitis. Vaginal estrogen cream is the preferred first-line treatment, however, oral progestin (C) is typically not necessary to prevent endometrial hyperplasia since the estrogen used is low dose. Vaginal testosterone (D) has demonstrated efficacy in helping with dyspareunia and loss of libido, however, this is not used as first-line but rather when other treatment options have failed.
What is threatened abortion?
Abdominal pain or bleeding in the first 20 weeks of gestation Cervical os is closed Passage of tissue none
PE findings in a patient with Abruptio placentae
Acute vaginal bleeding, severe abdominal pain, or back pain. A physical exam may reveal hypotension, fetal heart rate abnormalities, and abdominal tenderness. On bimanual examination, the uterus may become hypertonic, irritable, or tender when the placenta has abrupted.
How do we manage chancroid?
Any: Azithromycin Ceftriaxone Consider empiric treatment for syphilis
How to treat neurosyphilis?
Aqueous PCN 3-4mill units or PCN 2.4 plus probenecid
A 26-year-old female presents for a screening Pap smear. The results demonstrate atypical squamous cells of undetermined significance. What is the best next step in evaluation? A Cotesting in five years B Human papillomavirus testing C Immediate colposcopy D Repeat cytology in three years
B Human papillomavirus testing Cotesting is concurrent testing of cytology and HPV testing. Cotesting may be initiated at 30 years of age and is offered every five years to women who have negative cytology and negative HPV. Cotesting in five years (A) would not be the best next course of action for this patient as she has abnormal cytology. Immediate colposcopy (C) is not the best next course of action for a woman less than 30 years of age with an unknown HPV status. It is acceptable to perform HPV testing, and if HPV is positive, colposcopy is then recommended. Repeat cytology in three years (D) is offered to women 21-29 years of age that have a negative cytology screening. This patient has an abnormal cytology screening, thus, this is not the best next course of action. Pap smears are used to screen for cervical cancer. Current American Society for Colposcopy and Cervical Pathology guidelines recommend screening Pap smears begin at 21 years of age regardless of sexual activity. Cytology alone every 3 years is performed in women 21 to 29 years of age and cotesting every 5 years is performed in women 30 to 65 years of age. Human papillomavirus (HPV) testing is the preferred method of follow-up care in this patient with an atypical squamous cells of undetermined significance (ASC-US) Pap. If HPV testing is negative, it is recommended that she repeat cotesting at 3 years. If HPV testing is positive, colposcopy is recommended. HPV-/ASCUS = 3 yr co test again
A 78-year-old woman presents to your office with chronic vaginal itching and burning. She states that, though she has had these symptoms for many years, she has not yet seen a gynecologist for management options. On exam, there is extensive scarring of the vaginal epithelium along with multiple erosions of the introitus, clitoris, and labia. Additionally, she reports occasional oral ulcerations. Which of the following is the most likely diagnosis? A Contact dermatitis B Lichen planus C Lichen sclerosus D Lichen simplex chronicus
B Lichen planus
A 53-year-old woman presents to the clinic complaining of "hot flashes." She states that she has had irregular menstrual cycles until the past three months when she has not had a menstrual cycle at all. Her past medical history is only significant for hypertension, for which she takes hydrochlorothiazide daily. She has tried some natural remedies for the vasomotor symptoms without much relief. Which of the following would be the best pharmacologic therapy at this time? A Conjugated estrogens-bazedoxifene B Oral estrogen-progestin C Transdermal estrogen D Vaginal estrogen
B Oral estrogen-progestin Conjugated estrogens-bazedoxifene (A) is used in women who cannot tolerate progestin. The selective estrogen receptor modulator does not cause endometrial hyperplasia. Transdermal estrogen (C) is an effective first-line therapy, however, this medication should not be administered without progestin because of the risk of endometrial hyperplasia and subsequent cancer. Vaginal estrogen (D) is used more in treating vaginal symptoms of menopause such as vaginal dryness, tissue frailty, and dyspareunia. *estrogen is the mainstay treatment, but we need to give progestin
A 24-year-old G3P2 woman at 39 weeks of gestation presents to the clinic with leakage of clear, watery fluid from the vagina. She has no fever, chills, nausea, or vomiting. Physical exam shows fluid leaking from the cervical os and pooling of fluid in the vaginal vault. A characteristic ferning pattern is seen on microscopy after the fluid is spread on a slide. Which of the following is the most likely diagnosis? A Cervical mucus B Prelabor rupture of membranes at term C Preterm prelabor rupture of membranes D Urinary incontinence
B Prelabor rupture of membranes at term ---------- Cervical mucus is clear and has alkaline pH which is similar to amniotic fluid, but no more than a small amount of pooling is seen and leakage is self-limiting. Preterm prelabor rupture of membrane is rupture of membranes before 37 weeks of gestation. Not urinary incontinence because the leakage persists in this patient. Also it is odorous. Urine leakage ceases after the bladder is empty and kept at low volume.
Contractions before 20 wks vs after 20 wks
Before 20 weeks: abortion After 20 weeks: preterm labor
Placenta pevia vs abruptio placenta
Both are after 20 weeks gestational age, but placenta previa is painless and abruptio placenta is painful
A 35-year-old G2P1 woman at 34 weeks gestation presents to your office for her routine prenatal appointment. Her blood pressure is 170/115 mm Hg and 165/120 mm Hg, measured 15 minutes apart. The patient was previously diagnosed with gestational hypertension which did not require antihypertensive treatment. What is the best next step in the management of this patient? A Administration of intravenous nifedipine B Administration of oral methyldopa C Administration of oral nifedipine D Administration of sublingual nifedipine
C Administration of oral nifedipine This patient's blood pressure has progressed to acute severe range hypertension, defined as systolic pressure > 160 mm Hg or diastolic > 110 mm Hg, or both, and requires urgent antihypertensive therapy to prevent maternal stroke
A 20-year-old woman presents to the emergency department with lower abdominal pain. She reports having multiple sexual partners. On pelvic examination, she has mucopurulent vaginal discharge and cervical motion tenderness. The patient is afebrile and without peritoneal signs. Her urine pregnancy test is negative. She is discharged with outpatient antibiotics. Which of the following is the best antibiotic choice? A Azithromycin B Ceftriaxone and azithromycin C Ceftriaxone and doxycycline D Ceftriaxone and metronidazole
C Ceftriaxone and doxycycline ------ Azithromycin (A) is a macrolide antibiotic used to treat cervical chlamydial infections in pregnancy. Ceftriaxone and azithromycin (B) is the antibiotic regimen used to treat uncomplicated cervical gonococcal infection in pregnancy but not in nonpregnant patients. Ceftriaxone and metronidazole (D) is incorrect because doxycycline must be included in the regimen. Metronidazole should also be added in patients with a pelvic abscess, gynecological instrumentation in the past two weeks, documented Trichomonas vaginalis infection, or bacterial vaginosis.
A 28-year-old woman who is 38 weeks gestation presents to the maternity ward with a fever of 101.3°F and purulent fluid from the cervical os. A fetal ultrasound reveals baseline fetal tachycardia. Which of the following is a risk factor for this patient's condition? A Epidural anesthesia B History of preeclampsia C History of rectovaginal colonization with group B Streptococcus D Labor lasting for 12 hours
C History of rectovaginal colonization with group B Streptococcus Epidural anesthesia can cause fever and prolong labor, but not direct risk factor of chorioamnionitis Increased chorioamnionitis increases after 18 hours not 12 hours
A 60-year-old nulliparous woman presents with a mass on her right breast. Physical examination reveals a nontender, immobile mass on the upper outer quadrant of the right breast. A peau d'orange appearance of the right breast is noted without nipple discharge. Fine-needle biopsy shows high-grade cells with necrosis and dystrophic calcification in the center of the ducts. Which of the following is the most likely diagnosis? A Fibroadenoma B Fibrocystic changes C Infiltrating ductal carcinoma D Mastitis
C Infiltrating ductal carcinoma Fibroadenoma (A) is a benign tumor of fibrous tissue and glands that presents as a round, firm, smooth, mobile, and nontender mass. It may grow in size with pregnancy or become tender with menstruation. Women with fibrocystic change (B) typically present with multiple bilateral tender masses that change size with the menstruation cycle. Fine-needle aspiration in these women shows cysts that contain straw-colored fluid. Mastitis (D) is a unilateral infection of the breast by Staphylococcus aureus primarily in lactating women. It presents with unilateral tenderness, erythema, fever, chills, and warmth.
A 40-year-old G0P0 woman presents to clinic with vaginal bleeding. Her periods typically last 3-4 days and occur every 29 days. She has now noticed bleeding in between her last three periods. She has not had any pelvic pain or pressure. Urine pregnancy test is negative. Pelvic exam reveals a mobile, irregularly enlarged, nontender uterus and normal adnexa. Which of the following is the most likely cause of her abnormal uterine bleeding? A Adenomyosis B Ectopic pregnancy C Endometrial carcinoma D Leiomyoma
C Leiomyoma ----------- Adenomyosis (A) refers to ectopic endometrial tissue within the uterine musculature (myometrium). Adenomyosis also causes abnormal uterine bleeding and an enlarged uterus on exam. However, pelvic exam will show a uniformly enlarged, boggy and soft uterus. Ectopic pregnancy (B) often presents with vaginal bleeding and acute abdominal or pelvic pain. Urine pregnancy test is positive, and pelvic exam may reveal adnexal tenderness, or peritoneal signs in the case of ruptured ectopic pregnancy. Ultrasound would confirm a pregnancy outside of the uterine cavity. Endometrial carcinoma (C) should always be excluded in postmenopausal women with vaginal bleeding and in women with abnormal uterine bleeding and risk factors such as obesity, anovulation, or exposure to unopposed estrogen. Physical exam findings may include an enlarged uterus or pelvic mass, but the uterus is normal-sized in many early cases. Diagnosis is achieved with endometrial sampling by office biopsy or dilation and curettage.
What is the mainstay treatment for cervical incompetence?
Cervical cerclage (a stitch placed at the cervicovaginal junction) during the second trimester is the mainstay of surgical treatment for this condition to try to improve the tensile strength of the cervix. It is not recommended for women with a short cervix who do not have a history of preterm delivery and is not recommended for women with multiple gestation with a short cervix.
What is chlamydia
Chlamydia trachomatis (A) infection may be asymptomatic or may cause cervical or penile discharge. Inguinal lymphadenopathy may be present, but widespread lymphadenopathy and rash are rare. Chlamydia trachomatis infection may also cause reactive arthritis, conjunctivitis, pelvic inflammatory disease, and prostatitis. Diagnosis is through nucleic acid amplification of vaginal or urethral swabbings. Treatment is with 1 g azithromycin in a single dose in pregnancy or a week long course of doxycycline in the general population. Concurrent treatment for Neisseria gonorrhoeae infection is advised.
Classic signs and symptoms of chorioamnionitis
Classic signs and symptoms include maternal fever of > 100.4°F, maternal leukocytosis (> 15,000 cells/μL in the absence of corticosteroids), purulent fluid from the cervical os, and baseline fetal tachycardia.
Uterine fibroids are common during?
Common during reproductive ages
What is the etiology of breast abscess?
Complication of mastitis
What is chorioamnionitis?
Complication of pregnancy caused by infection or inflammation of the fetal amnion membrane (inner lining of the amniotic sac) and the chorion membrane (outer lining). Patients may have a history of premature birth, premature labor, preterm premature rupture of membranes, prolonged rupture of membranes (> 18 hours), and history of colonization with Group B Streptococcus (GBS). The infection is caused by migration of the cervicovaginal flora to fetal membranes or by hematogenous spread
Confirmatory diagnosis of prelabor rupture of membranes
Confirmatory diagnosis is made by microscopic examination of dried vaginal fluid spread on a slide that shows a characteristic ferning pattern. Nitrazine paper also confirms the alkalinity of the fluid, changing from orange to a dark blue color. Digital cervicovaginal examination should be avoided, as it is associated with an increased risk of infection. Fetal well-being should be evaluated by nonstress testing. Leopold maneuvers and ultrasound examination may be used to determine the position of the fetus. Ultrasonography may also show a low amount or absence of amniotic fluid in the uterine cavity.
Management of chorioamnionitis?
Delivery Ampicillin and gentamicin (broad spectrum antibiotics) Antipyretics
A 27-year-old woman presents to the clinic complaining of intense right breast pain with associated malaise and myalgias that began yesterday. She indicates the upper inner quadrant as her area of concern. Physical examination reveals a firm, localized erythematous area with tenderness to palpation. She has been breastfeeding her 2-month-old infant and has noticed a reduced milk supply since onset of her symptoms. Which of the following is the most likely diagnosis? A Breast abscess B Engorgement C Galactocele D Mastitis
D Mastitis -------- A breast abscess (A) differs from mastitis by the presence of a fluctuant mass. This condition should be suspected if mastitis is recurrent or resistant to empiric treatment. Engorgement (B) occurs due to interstitial edema with onset of lactation or secondary to accumulation of excess milk. It has a more gradual onset than mastitis and presents bilaterally, with generalized swelling and pain in an otherwise well patient. A galactocele (C) is a cystic collection of fluid secondary to an obstructed milk duct. It has a localized, unilateral presentation of pain and swelling that is similar to mastitis, but it demonstrates a gradual onset in a patient without systemic symptoms or fever.
Which of the following treatments would be most appropriate for a patient with a suspected low-stage, low-grade endometrial cancer and a desire for future pregnancy? A Copper intrauterine device B Estradiol C Hysterectomy D Medroxyprogesterone acetate
D Medroxyprogesterone acetate Why not the other options? Copper intrauterine device (A) does not contain progesterone and will not lead to regression of endometrial cancer. Estradiol (B) is an estrogen and may exacerbate endometrial cancer. Hysterectomy (C) removes the uterus, so a patient will not be able to carry her own pregnancy.
A 23-year-old woman gives birth to a healthy infant via vaginal delivery at 39 weeks gestation. After 20 minutes, the patient continues to have significant blood loss, which is approximated at 650 mL. Oxytocin has been administered since delivery of the newborn, and the flow rate has subsequently been increased with inadequate response. Vitals reveal HR 112 bpm, RR 19/min, BP 151/102 mm Hg, T 98.8°F, and SpO2 99% on room air. Bimanual examination reveals a soft, boggy uterus. In addition to uterine massage, which of the following medications should be initiated? A Methylergonovine B Methylprednisolone C Mifepristone D Misoprostol
D Misoprostol Methylergonovine (A) is an appropriate uterotonic agent to treat uterine atony but is contraindicated in patients with hypertension, as it can worsen this condition. It is always administered as an intramuscular formulation, as rapid intravenous infusion results in dangerous hypertensive values. This agent is a potent option and can cause uterine contractions within several minutes. Methylprednisolone (B) has no role in the treatment of postpartum hemorrhage. It is given routinely to women at risk of preterm labor to promote fetal pulmonary maturity. Mifepristone (C) is not indicated in the treatment of postpartum hemorrhage. This medication is used for medical termination of an intrauterine pregnancy through 70 days gestation and is followed by vaginal administration of misoprostol. Mifepristone is a drug that blocks a hormone called progesterone that is needed for a pregnancy to continue.
Which of the following is the best recommendation for tocolysis for a patient at 33 weeks gestation in preterm labor? A Bedrest B Hydration C Indomethacin D Nifedipine
D Nifedipine Nifedipine is a CCB used for 48 hrs to delay labor for enough time to give corticosteroids. Caution should be used when nifedipine is used in conjunction with magnesium sulfate, as it can cause a neuromuscular blockade, leading to suppression of heart contractility and suppression of heart rate. Indomethacin (C) is not typically given after 32 weeks gestation due to the risk of premature closure of the ductus arteriosus.
A 24-year-old G1P0 woman presents to her obstetric appointment at 24 weeks and 3 days gestation. When reviewing her blood work, you note she is positive for syphilis. She has no symptoms now and thinks she had a rash over her body over a year ago. Which of the following is the most appropriate treatment for this patient? A Doxycycline orally for 2 weeks B Doxycycline orally for 4 weeks C Penicillin G benzathine once D Penicillin G benzathine once weekly for 3 weeks
D Penicillin G benzathine once weekly for 3 weeks because she has late latent syphilis Early Latent: (+) serology, Ø s/sxs (within 1y of 1o) Late Latent: (+) serology, Ø s/sxs (>1y after 1o)
A 28-year-old woman presents to the clinic with four months of pelvic pain, metrorrhagia, and postcoital bleeding. Her vital signs are normal, and laboratory analysis is negative for leukocytosis, anemia, and pregnancy. Which of the following test results would be most helpful in confirming a diagnosis of chronic endometritis? A Abnormal cells of unknown significance on Pap smear B Intramural fibroids noted on transvaginal ultrasound C Mucosal pallor and ulcerations on hysteroscopy D Plasma cells in the endometrial stroma on endometrial biopsy
D Plasma cells in the endometrial stroma on endometrial biopsy Plasma cells are differentiated B-lymphocyte white blood cells capable of secreting immunoglobulin or antibodies.
A 67-year-old woman with diabetes presents with uterine bleeding. Her last menstrual cycle was 10 years ago. Pelvic examination reveals a pelvic mass. Urine beta-human chorionic gonadotropin is negative. Laboratory studies are within normal limits. Which of the following diagnostic studies is indicated first in this patient? A Dilation and curettage B Endometrial sampling C Hysteroscopy D Transvaginal ultrasound
D Transvaginal ultrasound In most postmenopausal women whose endometrial thickness is < 4 mm, a biopsy is not typically indicated. Endometrial sampling (B) is considered the gold standard for the evaluation of endometrial neoplasia and is indicated when the endometrial thickness is > 4 mm or in the setting of continuous uterine bleeding with an endometrial stripe of < 4 mm. Dilation and curettage (A) may be indicated in women who cannot tolerate an in-office endometrial biopsy, those with heavy bleeding, and those who have a very high risk of endometrial cancer (e.g., women with Lynch syndrome). Hysteroscopy (C) is typically performed with dilation and curettage to ensure that lesions are identified and biopsied.
How is mastitis diagnosed?
Diagnostic and laboratory tests are not necessary to diagnose mastitis. If the infection is severe, hospital-acquired, or resistant to empiric antibiotics, breast milk can be cultured to tailor antibiotic selection.
Which of the following is the most common cause of postpartum hemorrhage? A Bleeding diathesis B Cervical laceration C Placenta accreta D Uterine atony
D Uterine atony Inherited or acquired bleeding diathesis (A) may cause postpartum hemorrhage in women with the disorder but is not the most common cause of postpartum hemorrhage. As bleeding progresses, there is a severe reduction in the clotting factors and a hemodilution of the remaining clotting factor, which in turn cause more severe hemorrhage. Treatment is with transfusion of blood and blood products. Cervical laceration (B) may result naturally during the birthing process or may be related to clinical interventions done to facilitate delivery and is not usually noted until excessive hemorrhage prompts lower genital examination. Lacerations should be repaired surgically, either transvaginally or transabdominally. Placenta accreta (C) is an attachment of the placenta deeply into the uterine myometrium, resulting in heavy postpartum bleeding and difficulty with placental delivery. Treatment is with cesarean hysterectomy. Placenta accreta, placental abruption, as well as severe preeclampsia and intrauterine fetal demise, are the most common reasons for massive transfusion at delivery. They are not the most common cause of postpartum hemorrhage.
First signs of umbilical prolapse
During labor, fetal bradycardia may indicate compression of a prolapsed cord and will present with recurrent, variable, sudden, severe, or prolonged heart rate decelerations lasting more than one minute.
Dx of leiyomyoma
Dx: pelvic ultrasound
Three D's of endometriosis
Dysmenorrhea Dyspareunia Dyschezia
Complications of syphillis treatment
Jarisch-herxherimer reaction: an acute febrile reaction accompanied by headache and myalgias within the first 24 hours of treatment The Jarisch-Herxheimer reaction is a feverish condition, occurring after the initial dose of benzathine penicillin, because of lysis of the bacteria caused by the drug's action.
Most common gynecologic cancer in resource rich vs resource limited countries?
Endometrial cancer: resource rich Cervical cancer: Resource poor
What underlying pathology should be considered if both nonsteroidal anti-inflammatories and hormonal therapies are ineffective in treating dysmenorrhea?
Endometriosis Surgery is the only way to correct this one.
Endometriosis vs PCOS
Endometriosis: Retrograde menstruation causes the blood to flow up the fallopian tubes and so the cysts are (chocolate cysts) as they are filled with the blood that traveled up. Also reason why the cells are changing outside the uterus. The cyst pushes the follicles aside. PCOS: Follicles are underdeveloped sacs. In PCOS, these sacs are often unable to release an egg, which means ovulation does not take place. Cysts form and look like chocolate chip on a cookie cause of so many hyperechoic cysts that just looks like a necklace of pearls.
*Read about endometriosis
Endometritis is the inflammation of the endometrial lining of the uterus and may involve the myometrium and perimetrium. It can occur in both pregnant and nonpregnant women. It is referred to as pelvic inflammatory disease in nonpregnant women and is considered a sexually transmitted disease in those cases. The infection of the endometrium usually arises from the lower genital tract as an ascending infection found in normal vaginal flora. In pregnant women, the most common cause of endometritis is from postpartum infection depending on method of delivery. Women who have cesarean delivery have much higher risk of developing endometritis than those who deliver vaginally, especially when the cesarean delivery occurs after labor has begun. Other risk factors for endometritis include prolonged rupture of membranes, long labor with multiple vaginal examinations, manual placenta removal, and low socioeconomic status. Chronic endometritis in the obstetric population is associated with retained products within the uterus after delivery or elective abortion. Women are particularly vulnerable to endometritis after birth or abortion due to the cervical os being open, the use of uterine instrumentation, and the presence of blood and debris within the uterus. The infection is polymicrobial in nature, and usually two or three organisms are found. The most common organisms found are Ureaplasma urealyticum, Peptostreptococcus, Gardnerella vaginalis, Bacteroides bivius, group B Streptococcus, Chlamydia, and Enterococcus. Pregnant patients will present postpartum with fever, lower abdominal pain, foul-smelling lochia, abnormal vaginal bleeding or discharge, dyspareunia, dysuria, and malaise. Fever will occur within 36 hours of delivery. Other physical exam signs are uterine tenderness (a hallmark symptom), lower abdominal pain, and tachycardia. The diagnosis of endometritis is based on clinical findings, but a complete blood count will reveal leukocytosis with a left shift, although it may be unreliable for diagnosis in the postpartum period due to physiological leukocytosis of pregnancy. A blood and urine culture should be ordered. A computed tomography study should be ordered if patients do not respond to antimicrobial therap
How can we treat perimenopause?
Estrogen or estrogen-progestin combination therapy Vitamin E can also help with hot flashes and night sweats.
How to fix fetal position back to vertex
External cephalic version
How do you treat outpatient PID vs Inpatient PID
Outpatient: Ceftriaxone and doxycycline and metronidazole Inpatient: Second gen cephalosporin; cefotenan and doxycycline
How do you treat placental abruption?
Fetal monitoring, hemodynamic stabilization, delivery
What is fetal position
Fetal position is evaluated throughout pregnancy and is followed closely in the weeks leading up to delivery. Fetal presentation is defined as the portion of the fetus that directly overlies the pelvic inlet that is typically evaluated at onset of labor. In instances of compound fetal presentation, an extremity (most commonly, a hand) presents alongside the part of the fetus closest to the birth canal. Risk factors for compound fetal presentation include small gestational size, multiparity, and polyhydramnios. While many deliveries involving compound fetal presentation occur without issue, dystocia and subsequent arrest of labor are dangerous consequences of compound fetal presentation. Intrapartum management is often expectant, since many times the fetus will withdraw the presenting extremity and labor can progress as normal. Gentle repositioning of the presenting extremity is possible yet controversial. In most cases of compound presentation, labor results in an uncomplicated vaginal delivery. Antepartum (during pregnancy), intrapartum (during labor and delivery)
Lab findings in severe abruptio placentae
Fibrin level ≤ 200 mg/dL, which is consistent with disseminated intravascular coagulation. ---------------------- In placental abruption, local consumption of fibrinogen, under the action of thromboplastin, might be the principal cause of fibrinogen drop.
Difference between 1-4 degree lacerations
First-degree: skin of the perineum or vaginal epithelium, no muscle involvement Second-degree: fascia or musculature of the perineal body, anal sphincter muscles are NOT involved Third-degree: through the fascia or musculature of the perineal body and involve the anal sphincter Fourth-degree: involve the perineal structures, external anal sphincter, internal anal sphincter, and rectal mucosa
How does endometriosis present in PE?
Fixed or retroverted uterus or adnexal mass
Commonly detected bacteria for BV is?
Gardnerella vaginalis (usually due to decrease in Lactobacillus sp)
Which of the following organisms is responsible for chancroid infection?
Haemophilus ducreyi
How can we treat Vulvar Lichen Planus?
High-potency corticosteroids triamcinolone acetonide or clobetasol propionate
What are symptoms of perimenopause?
Hot flashes, mood changes, and irregular menstrual cycles and can occur years before menopause.
How can you treat pelvic organ prolapse?
Hysterectomy is definitive treatment for those who failed conservative treatment. If someone has not tried conservative treatment and has severe coronary artery disease, surgical option is not the best. Pelvic Sling is also a surgical option. Pelvic floor rehabilitation is best for less severe prolapse. Most commonly used device would be ring pressaries.
What are first line treatments for first-line medications for the management of acute-onset, severe HTN in pregnant patients and patients in postpartum period?
IV labetalol IV hydralazine Oral nifedipine Magnesium sulfate: seizure prophylaxis
Management for umbilical cord prolapse
If the membranes are intact, a prolapsed cord may resolve spontaneously or be reduced manually at the onset of labor by elevating the fetal presenting part through the vagina and putting the patient in the steep Trendelenburg or knee-chest position. If there is evidence of fetal distress, immediate delivery is required. An emergency cesarean delivery is typically the method of choice, and is the definitive management of this condition, but vaginal or instrumental delivery can be done if it is deemed quicker.
What is cervical incompetence or cervical insufficiency?
Inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of uterine contractions. This condition is usually diagnosed based on a previous history of pregnancy loss. Risk factors include congenital cervical abnormalities (Ehlers-Danlos syndrome (your connective tissues are loose, uterine abnormalities, in utero diethylstilbestrol exposure, and biologic variation) and trauma (labor, delivery, rapid mechanical cervical dilation before a gynecologic procedure, or treatment of cervical intraepithelial neoplasia).
Yeast infection labs
Labs: normal pH < 4.5, wet prep: budding yeast, pseudohyphae, hyphae
What is a leiomyoma
Leiomyoma, or uterine fibroids, are benign growths of uterine musculature. They affect up to 80% of women, over half of whom are asymptomatic during their lifetimes. When symptoms do arise, the most common is abnormal uterine bleeding (AUB), as in this patient. AUB may be severe enough to cause iron deficiency anemia. If large enough, fibroids may cause pelvic pressure, hydroureter, and torsion. There are three categories of fibroids, depending on their location: submucosal, which protrude internally into the uterine cavity; subserosal, which are located on the exterior surface of the uterus; and intramural, which are contained within the muscular wall of the uterus. A diagnostic workup is first based on clinical presentation. Physical exam findings include an irregularly enlarged uterus with solid protrusions. Further workup is dependent on the type of fibroid and concern for malignancy. First-line imaging for fibroids is pelvic ultrasound. Further evaluation may include evaluation of the uterine cavity with saline infusion sonography or hysteroscopy. Magnetic resonance imaging may be used in select cases for surgical planning prior to myomectomy
Lichen Planus vs Lichen Sclerosis vs Lichen Simplex Chronicus
Lichen Planus Bright red, glassy-looking erosions Lichen Sclerosis hypopigmentation Lichen Simplex Chronicus Localized variant of atopic dermatitis and is characterized by erythematous, scaling, or lichenified plaques. Skin appears thickened and leathery, and areas of hyperpigmentation and hypopigmentation are common.
Most common non-neoplastic epithelial vulvar disorder that can develop into vulvar carcinoma?
Lichen sclerosus. -------------- Vulval LS is not cancer. But it is thought that, over a long period of time, the inflammation caused by this skin condition increases the risk of cancer developing. A small number of people who have vulval LS may develop vulval cancer. This rarely happens when the condition is well controlled. put it this way: inflammation to the skin over a long period of time means that cells are constantly turning over. cancerous cells can form during: DNA Synthesis (S phase)In many cancer cells the number of chromosomes is altered so that there are either too many or too few chromosomes in the cells. These cells are said to be aneuploid. Errors may occur during the DNA replication resulting in mutations and possibly the development of cancer.
Major criteria for diagnosing PID
Lower abdominal pain in high-risk sexually active women PLUS Uterine tenderness OR Adnexal tenderness OR cervical motion tenderness ------------- PE will show mucopurulent cervical discharge
Genitourinary Syndrome of Menopause (Atrophic Vaginitis) Treatment
Lubricants, moisturizers, topical estrogen
Fetal risks with gestational diabetes mellitus
Macrosomia, respiratory distress syndrome, neonatal hypoglycemia
Tx for leiyomyoma
Majority do not require surgical or medical treatment Leuprolide to shrink the fibroids Tx severe cases: myomectomy (fertility can be preserved) or hysterectomy
How do we diagnose breast carcinoma?
Mammography and core biopsy
What is Mastitis?
Mastitis is an infection of the breast tissue that most commonly occurs in lactating women, particularly in the first three months of breastfeeding.
What is mastodynia?
Mastodynia is breast tenderness that is commonly seen in women taking contraceptive pills or hormone therapy. Mastodynia is rarely a symptom of breast cancer and may be classified into cyclical, noncyclical, and extramammary. Cyclical mastodynia is usually bilateral and presents one week before the start of menses and is associated with fluctuation of hormones during the menstrual cycle.
Define Menopause
Menopause is characterized by the absence of menstrual cycles for a period of 12 consecutive months without any pathologic cause. Typically, this occurs naturally in women around the age of 51. This is the result of low levels of estrogen and primary ovarian failure. In response, follicle-stimulating hormone (FSH) levels will increase, trying to stimulate the nonresponsive ovaries. Labs: decreased estrogen and elevated follicle-stimulating hormone levels
How does cervical incompetence present?
Most patients are asymptomatic but some may present with pelvic pressure, cramping, back pain, and increased vaginal discharge. Other signs and symptoms include painless cervical dilatation and bulging fetal membranes during the second trimester of pregnancy, preterm premature rupture of membranes, and rapid delivery of a preterm infant that is often not viable, all in the absence of uterine contractions.
How does a chancroid present?
Multiple painful papules that ulcerate and inguinal bubo
What confirms the diagnosis of chorioamnionitis?
Needle aspiration and analysis of amniotic fluid
Difference between PPROM and PROM
PPROM < 37 weeks, PROM ≥ 37 weeks
Define Abruptio placentae (also called placental abruption)
P\artial or complete separation from the uterine wall of a normally implanted placenta after 20 weeks of gestation but prior to the delivery of the fetus. ---- The major pathogenic mechanism of abruptio placentae is the rupture of maternal vessels in the decidua basalis of the endometrium
Low estrogen levels in menopause leads to what?
Sx: dyspareunia, vulvar and vaginal dryness, bleeding, itching PE: pale, dry, shiny epithelium
Sx and Sx of leiyomyoma
Sx: heavy menstrual bleeding, dysmenorrhea PE: enlarged, asymmetric, nontender uterus
what is gonorrhea
Neisseria gonorrhoeae (C) is a gram-negative organism found worldwide. Symptoms can include cervical or penile discharge, pelvic inflammatory disease, pharyngitis, conjunctivitis, reactive arthritis, and hepatitis. Diagnosis is through nucleic acid amplification testing or culture of genital discharge. Treatment is with ceftriaxone 500 mg intramuscular in a single dose and azithromycin 1 g oral in pregnancy or doxycycline for one week in the general population.
Does BV cause dysuria, dyspareunia, vaginal edema, and vaginal erythema?
No
How do we treat endometriosis
Nonsteroidal anti-inflammatory drugs, combined oral contraceptives or progestins, gonadotropin-releasing hormone agonists (danazol), or surgery may be employed in treating endometriosis. A total abdominal hysterectomy with salpingo-oophorectomy is performed if there is no desire to conceive. Prolonged activation of GnRH receptors by GnRH leads to desensitization and consequently to suppressed gonadotrophin secretion. This is the primary mechanism of action of agonistic GnRH analogues. GnRH agonist acts like GnRH. When GnRH agonist is first given, it causes the pituitary to become more active. However, after a while, the pituitary stops responding to the constant GnRH agonist. By contrast, the GnRH antagonist directly blocks the pituitary from responding to GnRH. In addition, continuous noncyclical administration of COCPs, omitting the placebo menstrual tablets, for 3-4 months helps avoid any menstruation and associated pain. These agents are generally progestin dominant and work to suppress the hypothalamic-ovarian axis and, thus, endometriosis implants.
How do we treat outpatient vs inpatient PID
Outpatient: Ceftriaxone IM plus Doxy AND Metronidazole Inpatient: second generation ceph (cefotetan or cefoxitin) plus doxy
What will patients complain of if they have pelvic organ prolapse?
Patients experiencing symptomatic pelvic organ prolapse may report difficulty with bladder or bowel function, abdominal pain, vaginal fullness, or the sensation of "sitting on a ball."
How do patients with PROM present?
Patients with prelabor rupture of membranes at term usually present with leakage of clear, watery fluid, vaginal discharge, and pelvic pressure without the onset of contractions.
What is Fitz-Hugh-Curtis syndrome?
Perihepatitis + PID *Violin like adhesions ----------- Fitz-Hugh-Curtis syndrome (FHCS), or perihepatitis, is a chronic manifestation of pelvic inflammatory disease (PID). [1] It is described as an inflammation of the liver capsule, without the involvement of the liver parenchyma, with adhesion formation accompanied by right upper quadrant pain.
Syphilis Signs and Symptoms
Primary (10 days to 12 weeks): painless chancre Secondary (6 weeks to 6 months): lymphadenopathy, condyloma lata, rash on palms and soles Tertiary: gummas and CV
Symptoms of yeast infection
Sx: vulvar pruritus, dysuria, dyspareunia
What are perineal lacerations?
Perineal lacerations occur frequently in women during vaginal delivery of a fetus due to labor or iatrogenic causes (via episiotomy or instrumental delivery). The tears can occur anteriorly, but the majority of the tears occur posteriorly, affecting the anus. There are several risk factors that may increase the risk of perineal lacerations including: nulliparity, Asian ethnicity, vaginal birth after caesarean section, shortened perineal length, large fetal weight, shoulder dystocia, fetal position at birth (particularly occipito-posterior position), instrumental delivery (e.g., using forceps or vacuum), prolonged second stage of labor, epidural use, oxytocin, and maternal delivery position (especially with delivery on the back with knees flexed or in squatting position).
Placental abruption vs placenta previa
Placenta precva is painless and to tell these two a apart, you need ultrasound. Both are after 20 weeks of gestation.
Risk factors of chorioamnionitis
Risk factors: nulliparity, prolonged rupture of membranes, meconium-stained amniotic fluid, internal fetal or uterine contraction monitoring Genital tract infection: STIs, group B Streptococcus, bacterial vaginosis
*read about post partum hemorrhage
Postpartum hemorrhage is defined as an obstetric emergency wherein classically more than 500 mL of blood is lost following a vaginal delivery or more than 1,000 mL of blood is lost following a cesarean delivery. This definition has been updated to a cumulative blood less of greater than or equal to 1000 mL or bleeding that is associated with hypovolemia within 24 hours of delivery. More commonly, excessive blood loss is clinically suspected by the resultant signs and symptoms. It is one of the leading causes of maternal mortality worldwide, with over half of maternal deaths occurring within 24 hours following delivery. Primary (early) postpartum hemorrhage occurs within 24 hours after delivery while secondary (late) postpartum hemorrhage occurs after more than 24 hours and up to 12 weeks later. Uterine atony, the most common cause of postpartum hemorrhage, is the failure of the uterus to contract and constrict the spiral arteries that supply the placenta following its delivery. Overall signs of hemodynamic compromise secondary to postpartum hemorrhage from any cause initially manifest as tachycardia, tachypnea, delayed capillary refill, orthostatic changes, and narrowed pulse pressure. Further volume depletion results in overt hypotension, oliguria, shock, coma, and death. Once severe hemorrhage is identified, primary intervention should be implemented with assessment of hemodynamic stability, placement of two large-bore intravenous catheters, rapid infusion of crystalloid fluids, and investigation of potential etiologies. Type and crossmatch of blood should be ordered with early infusion of packed red blood cells to replete blood volume. Severe, ongoing hemorrhage is defined in a patient who requires 4 or more units of packed red blood cells in 1 hour or 10 or more units in 12 to 24 hours. Such patients should be additionally administered fresh frozen plasma and random donor platelets in a 1:1:1 unit ratio with packed red blood cells. Uterine atony is diagnosed on bimanual exam as a soft, boggy uterus. Massage of the uterus is the first-line treatment strategy. If this approach fails, medical intervention should be implemented with uterotonic agents such as oxytocin, methylergonovine, misoprostol, dinoprosto
Diagnosing PID is clinical, but recommended diagnostic tests for patients include:
Pregnancy test, vaginal microscopy, nucleic acid amplification tests for gonorrhea and chlamydia, HIV screening, and serologic testing for syphilis.
What is primary dysmenorrhea
Primary dysmenorrhea is defined as painful menstrual cycles. The pain cannot be explained by any underlying disorder or disease process. The risk of primary dysmenorrhea is decreased in women who have had multiple children. Prostaglandin stimulation results in mild uterine ischemia when intrauterine pressure increases during irregular uterine contractions. Symptoms typically begin a few years after menarche. The pain is usually described as pelvic cramping that is bilateral and can radiate to the low back or thighs. This is a clinical diagnosis.
What is considered early syphilis and how do we treat?
Primary, secondary, and early latent IM benzathine penicillin G, 1 dose
PCOS and IUD
Progestin Intrauterine devices (IUDs) are another option for women with PCOS. Progestin IUDs thin the lining of the uterus and therefore protect against endometrial cancer which is highly increased in PCOS women. IUDs are not the best, nor are they a primary intervention for PCOS.
PID is most commonly caused by what disease?
STI (gonorrhea and chlamydia), but may also be caused by enteric or respiratory pathogens.
Ultrasonographic feature of placental abruption
Retroplacental hematoma: bleeding behind the placenta from where the attachment would have been A retroplacental hematoma occurs when the placenta detaches over a large area and causes a hematoma between the uterine wall and placenta
What are risk factors for pelvic organ prolapse?
Risk factors for pelvic organ prolapse include postmenopausal status, parity, advancing age, obesity, atrophy of the vaginal muscles and vaginal wall, and chronic constipation.
Who is prone to get yeast infection
Risk factors for vulvovaginal candidiasis include diabetes mellitus, antibiotic use, increased estrogen levels, and immunosuppression
Risks of breast carcinoma
Risk factors include nulliparity, early menarche, late menopause, delayed childbearing, family history of breast cancer, female sex, increasing age, and BRCA1 and BRCA2 gene mutations.
Risk factors of endometriosis
Risk factors include nulliparity, family history, early menarche, alcohol use, low body weight, and increasing age.
Risk of Abruptio placentae
Risk factors include previous placental abruption, cocaine use, smoking, hypertension, uterine anomalies, asthma, and family history of placental abruption.
Most common bug of breast abscess
Staph aureus
What is considered late syphilis and how do we treat?
Tertiary and late latent IM benzathine penicillin G qwk for 3 weeks
What is the main difference between Lichen Planus and Lichen Sclerosis?
The difference between lichen planus and lichen sclerosus is that lichen sclerosus rarely affects the mucous membranes in your mouth. -- LP does!
Presentation of breast carcinoma
The most common type of breast carcinoma is infiltrating ductal carcinoma, while the remaining are lobular carcinoma. Patients usually present with a single, nontender firm, immobile mass mostly seen on the upper outer quadrant of the breast but may also be seen under the nipple and areola. A physical exam may show nipple discharge or retraction, dimpling, breast enlargement or shrinkage, peau d'orange (orange peel skin), fixed mass, and axillary or supraclavicular lymphadenopathy.
What is vertex vs breech vs funic
The vertex (D) presentation is the typical and desired fetal presentation. It refers to the presentation of the fetal head in the birth canal. Many types of vertex presentations exist that refer to the position of the occiput of the scalp in relation to the birth canal. The breech (A) fetal presentation is the second most common fetal presentation and refers to presentation of the fetal buttocks at the birth canal. There are three types of breech presentation: frank breech, where both hips are flexed and both knees are extended; complete breech, where both hips and knees are flexed; and incomplete breech, where one or neither hip is flexed. The funic (C) fetal presentation is also known as umbilical cord prolapse, where the umbilical cord passes in front of the fetus and protrudes into the cervical canal or vagina. Funic fetal presentation is an emergent condition since blood supply to the fetus can be compromised.
Risk factors of primary dysmenorrhea
There are many risk factors for developing primary dysmenorrhea including: age less than 30, menarche before age 12, tobacco use, low body mass index (BMI), longer or irregular menstrual cycles, and history of sexual assault. cigarette smoking causes coronary vasoconstriction, an increase in coronary vascular resistance, and a decrease in coronary blood flow, despite an increase in myocardial oxygen demand.....and if this is happening in the uterus, it has the same MOA as prostaglandins
Types of spontaneous abortion
Threatened abortion: vaginal bleeding with closed internal os Inevitable: vaginal bleeding with open os Incomplete: partial passage of products of conception (POC) Complete: complete passage of POC Missed: fetal death < 20 weeks without POC passage Missed abortion complications: infection, coagulopathy Rh-negative women → Rho(D) immune globulin
How do we treat endometrial cancer?
Total hysterectomy (removal of uterus and cervix) and bilateral salpingo-oophorectomy (removal of ovaries and fallopian tubes)
What is a potential complication of PID and what ddx can we use to identify it?
Transvaginal ultrasound can be used to identify tubo-ovarian abscess.
In post-menopausal women, what is the first line imaging for vaginal bleeding?
Transvaginal ultrasound to measure endometrial thickness. Endometrial sampling may be deferred if the endometrial thickness is < 4 mm. However, if a woman continues to bleed even with an endometrial stripe of < 4 mm, a biopsy should be performed. Ultrasound may not be accurate in evaluating endometrial cancer in premenopausal women.
treatment for primary dysmenorrhea
Treatment includes maintaining a healthy diet and exercise regimen as well as supportive care. Heat applied to the lower abdomen can help ease discomfort. Pharmacologic treatment includes nonsteroidal anti-inflammatories (NSAIDs) or hormonal contraceptives. Both fenamates and propionic acid derivatives decrease the synthesis of prostaglandins. Hormonal contraceptives are an excellent option for women who desire both contraception and relief from dysmenorrhea. The goal of treatment is that the patient should be able to resume normal daily activities. Using hormonal birth control usually relieves dysmenorrhea within several months of starting it. These methods work by thinning the lining of the uterus, where prostaglandins are formed, thereby decreasing the uterine contractions and menstrual bleeding that contribute to pain and cramping.
Treatment for breast carcinoma
Treatment is breast-conserving therapy (lumpectomy followed by radiation therapy) or mastectomy (with or without radiation therapy)
PROM Treatment
Treatment is by prompt induction of labor, followed by delivery. For women who have contraindications to labor or vaginal delivery, cesarean section should be done as soon as possible.
What can differentiate between mastitis from a breast abscess if the condition does not respond to antibiotic therapy within 72 hrs?
Ultraosund imaging.
How is umbilical cord prolapse diagnosed?
Umbilical cord prolapse is diagnosed when the prolapsed cord is seen or palpated outside of or within the vagina in the setting of abnormal fetal heart rate patterns. In overt umbilical cord prolapse, the prolapsed cord will feel like a soft, pulsating mass during vaginal examination.
What is umbilical cord prolapse?
Uncommon obstetric emergency that occurs when the cord prolapses through the cervix into the vagina ahead of the presenting part of the fetus. It most commonly occurs when the membranes are ruptured.
Syphilis testing
VDRL and RPR positive 1-4 weeks after infection Initial screening: Nontreponemal tests (nonspecific) •VDRL, RPR If (-) & asxs à no further testing needed If (+) à confirm w/ treponemal test Treponemal tests (specific) •FTA-ABS
PID Lab results need to show?
WBC
What do patients who have mastitis usually complain of?
Women complain of a painful, swollen, and red breast that progresses to a firm, red, painful, and swollen area of the breast with associated fever. Systemic symptoms such as myalgia, chills, malaise, and flu-like symptoms may also be present, and nursing mothers often report diminished milk supply.
When do we treat endometrial cancer with progesterone such as medroxyprogesterone or the levonorgestrel intrauterine device?
Young patients who desire pregnancy with low-risk endometrial cancer. --------------------------- They should be thoroughly counseled that the risk of persistent or recurrent disease is higher than with traditional treatment. In addition, if they are found to have persistent or progressive disease, they should be counseled to consider more definitive management. Patients should have their endometrium sampled with endometrial biopsy 3 months after initiating treatment to assess for regression or progression. Once the patient has had two negative endometrial biopsies, she should be encouraged to become pregnant as quickly as possible. If she is found to have persistent disease, her progesterone dosage should be increased, and she should undergo repeat biopsy three months later. If the patient has persistent or progressive disease after nine to twelve months of therapy, the patient should be advised to undergo a hysterectomy. This treatment prevents endometrial hyperplasia and potential carcinoma by blocking the persistent estrogenic effects on the uterus and induces menses and shed of the endometrium.
Treatment of endometritis
clindamycin + gentamicin GBS colonized: add ampicillin or use ampicillin-sulbactam
How will people with pelvic organ prolapse report their symptoms with pelvic organ prolapse?
difficulty with bladder or bowel function, abdominal pain, vaginal fullness, or the sensation of "sitting on a ball."
How do we treat breast abscess
empiric therapy with dicloxacillin and cephalexin If MRSA sus - bactram or clindamycin DO not stop breast feeling drainage
What is endometritis?
infection of the uterine endometrium most commonly in women who have just had c section, prolonged labor, PROM, multiple vaginal examinations, internal fetal monitoring, meconium, preterm birth, postterm birth, etc., GBS most common infection: chlamydia. The infection is polymicrobial in nature, and usually two or three organisms are found. The most common organisms found are Ureaplasma urealyticum, Peptostreptococcus, Gardnerella vaginalis, Bacteroides bivius, group B Streptococcus, Chlamydia, and Enterococcus. P
what is H. ducreyi
is the organism responsible for chancroid, which is a sexually transmitted disease that can cause inguinal lymphadenopathy and abscess formation, as well as deep and painful genital ulcerations. Definitive diagnosis of chancroid is difficult because the culture medium for Haemophilus ducreyi is not readily available. Presumptive diagnosis can be made in the presence of a compatible clinical syndrome along with a negative serologic test for syphilis and a negative polymerase chain reaction test for herpes simplex virus. Treatment of chancroid is with oral azithromycin or intramuscular ceftriaxone.
If endometritis is not pregnancy related, then...?
its an extension of pelvic inflammatory disease
Endometriosis definitive diagnosis is made by
laparoscopy and histology
A cervical length of _____________ has been associated with increased risk for preterm birth.
less than 25 mm
What is endometriosis
presence of endometrial glands and stroma outside the uterine endometrial lining, particularly the dependent parts of the pelvis and in the ovaries, often manifesting as dysmenorrhea, deep-thrust dyspareunia, and dyschezia. Endometriosis is likely due to retrograde menstruation with implantation at an ectopic site. Most common site are ovaries
Compression of the umbilical cord can lead to
profound or total acute asphyxia or subacute hypoxia of the fetus leading to fetal demise.
Common organism responsible for mastitis
staph aureus
Who do we treat in patients with yeast infection?
symptomatic patients
Medication for yeast infections What is the recommended suppressive maintenance therapy regimen for women with recurrent vulvovaginal candidiasis?
topical azoles, oral fluconazole Miconazole cream is good for the skin if there is irritation everywhere or nystatin Initial induction therapy with fluconazole 150 mg every 72 hours for three doses, and then maintenance therapy with fluconazole 150 mg once per week for six months.
Postpartum hemorrhage is most commonly caused by what?
uterine atony PE will show an enlarged boggy uterus
