1
Q
Non-endocrine tissue in the body that produces estrogen
A
Fat tissue
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2
Q
Role of LH and FSH
A
Cause secretion of Estrogen, Progesterone and other hormones from ovaries
Stimulate thecal and follicular cells to mature an egg
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3
Q
Roles of estrogen
A
Growth of endometrium
Breast in largement
Induces LH surge
Assists in libido
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4
Q
Roles of progesterone
A
Decreases uterine contractility
Promotes breast development and differentiation
Signals lactation as it falls
Maintaining pregnancy
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5
Q
Activins
A
Stimulate FSH secretion
Involved in WBC production and embryo development
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6
Q
Inhibins
A
Inhibit FSH so we don’t use all out follicles at once
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7
Q
Follistatins
A
Inhibit activins
Regulate gonadotropin secretion
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8
Q
Relaxin
A
Relaxes pubic symphisis and pelvic joints in pregnancy
Inhibits uterine contractions
Mammary and follicular development
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9
Q
Positive feedback on the HPO
A
Estrogen at high levels increases GnRH and LH secretion
Activin promotes gonadotropic cell function
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10
Q
Ad===Thelarche
A
Beginning of breast development
First sign of puberty in females
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11
Q
Pubarche
A
Onset of pubic and axillary hair, after breasts and before menstruation
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12
Q
Day one of a period
A
The first day of bleeding
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13
Q
Normal menstrual cycle
A
28 days on average
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14
Q
Follicular phase
A
Length varies - getting a new follicle ready
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15
Q
Hormones of the follicular phase
A
FSH stimulates a few follicles and then realease inhibin to stop more follicles
One grows and secretes Estrogen
Estrogen causes LH surge, triggering ovulation
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16
Q
Typical ovulation day
A
Day 14
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17
Q
Mittelschmerz
A
Pain upon ovulation
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18
Q
Corpus hemorrhagicum
A
Ruptured follicle fills with blood
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19
Q
Luteal phage
A
consistently 14 days
Corpus luteum forms from corpus hemmorrhagicum
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20
Q
Hormones of luteal phase
A
FSH drops
Corpus luteum produces estrogen which inhibits LH which is stimulating the corpus luteum
CL scars up if no pregnancy
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21
Q
Proliferative phase of the uterus
A
Estrogen forms the stratum functionale about days 5-16 - endometrium growth
Glands are made bu don’t work yet
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22
Q
Secretory phase of the uterus
A
About 14 days
CL is formed
Progesterone from the CL decorates the uterus
Glands become coiled and secrete fluid
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23
Q
Menstrual phase
A
Loss of blood flow results in the death of the stratum functionale
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24
Q
Cervical changes during the menstrual cycle
A
Estrogen makes cervicle mucus thinner and more hospitable to sperm - fern like pattern on slide first half of cycle
Progesterone makes the muscous THICK and impenatrable
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25
Q
Cervical ectopy
A
Caused by opening of cervical opening/unrolling exposing columnar epithelium of the inner cervix
Darker area of tissue - looks like an infection
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26
Q
Birth control and cervical ectopy
A
Stays around longer with birth control
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27
Q
Falopian tube cilia and hormones
A
Estrogen - beat faster
Progesterone - beat slower
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28
Q
Muscle and hormones
A
Progesterone - reduces spasms, relaxes smooth muscle, antagonizes insulin
Estrogen - Improves skeletal muscle contractility
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29
Q
Fat skin and Sodium/Water effect of progesterone
A
Maintains skin
Fat gain in pregnancy
Excretion of sodium and water
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30
Q
Cardiovascular changes of pregnancy
A
Laterally displaced PMI
Supine hypotensive syndrome from uterus compressing IVC
Larger heart and HR increase by 15bpm
Drop in BP w/ increase in volume
May see some murmur, SVT, Left shift, ST depression
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31
Q
Pulmonary changes in pregnancy
A
Congested upper respiratory tract from vasodilation
Higher and wider ribcage
Less dead space in lungs with increased tidal volume
Mild respiratory alkalosis
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32
Q
Renal changes during pregnanacy
A
Transient renal hypertrophy
Dilated ureters, hydronephrosis
Risk of UTI
Increased load on kidneys
Increased GFR
Some leakage of protein and glucose but not to excess
Increased renin
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33
Q
GI changes in pregnancy
A
Increased salivation
Gum hypertrophy
Increased transit times
Slow gallbladder emptying
Increased heartburn
NO worsening dental health is normal
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34
Q
Heme/Onc and Fluid changes in pregnancy
A
Increased in blood volume by 50%
More RBCs
Increased WBCs
More blood clots
Less immune function
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35
Q
When is prolactin highest
A
During pregnancy to help mammary glands develop
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36
Q
Thyroid and pregnancy
A
Increase in production
PTH decreases in 1st trimester and increases in 2 and 3
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37
Q
Eye changes in pregnancy
A
Glaucoma gets better, cornea can thicken
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38
Q
Skin changes in pregnancy
A
Increased skin pigmentation
Linea nigra - black line down midline of abdomen
Melasma - Brown butterfly rash on cheeks
Stretch marks -Red to Brown
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39
Q
Other skin changes that may be seen in pregnancy
A
Spider angiomas
Palmar erythema
Cutis marmorata
Varicosities in legs
Brittle nails
Thickening of hair
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40
Q
Metabolic changes in pregnancy
A
Increased fatigue
Increased appetite, weight, thirst
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41
Q
Weight increase during pregnancy
A
Average increase of 25-35 lbs
Loose about 20 lbs at delivery and thereafeter
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42
Q
Calories per day recommended for pregnancy and lactation
A
300 per day during pregnancy
500 per day during lactation
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43
Q
Protein intake recommendation for pregnancy
A
1g/kg/day
Plus 20 g/d in 2nd half
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44
Q
Pregnancy calcium recommendation
A
1200 mg/d
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45
Q
Iron recommendation for pregnancy
A
60-120 mg/day if defficient
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46
Q
Folic acid supplementation in pregnancy
A
.4 mg/day 1 month before conception and first 3 months
1g/d for insulin dependant diabetics, Valproate, or Carbamazepime
4mg/d if hx of tube defects
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47
Q
B6 for pregnancy
A
Helps with nausea
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48
Q
Placenta
A
Part of the fetus - takes up most of the blood brought to the uterus
Eats into the wall
Uterus needs to contract to prevent bleeding
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49
Q
SUbstances that don’t cross the placenta
A
Only very large
Heparin and Insulin
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50
Q
Initial evolution of fertilized egg
A
Zygote, morula, blastocyst
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51
Q
Week at which organ development begins
A
Weeks 5
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52
Q
Landmarks at weeks 6-7
A
Limb buds and heart beat
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53
Q
Week 9 landmarks
A
All essentail organs have begun to form
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54
Q
Week 10 landmarks
A
Fetal heart tones heard on US
End of embryonic period - fetal period begins
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55
Q
Lanugo development
A
Weeks 15-18
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56
Q
Weeks 19-22 landmarks
A
Fetus can hear
Feel movement of fetus
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57
Q
Threshold of survivability
A
Weeks 23-25 some survive
Week 26+ most survive
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58
Q
Week 26
A
Hands and startle reflex
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59
Q
Weeks 27-30
A
Surfactant production begins to occur
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60
Q
Mesonephric ducts
A
Turn into male structures
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61
Q
Paramesonephric ducts
A
Turn into female structures
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62
Q
Time of testes descending
A
About week 28, should be there by week 32
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63
Q
Term baby
A
Born at 37+ weeks
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64
Q
Preterm baby
A
20-37 weeks
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65
Q
Abortion baby
A
ALL pregnancy losses before 20 weeks
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66
Q
Living children
A
Any infant who lives for 30+ days
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67
Q
Primipara
A
Has delivered once AFTER 20 weeks
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68
Q
1st trimester
A
1-14 weeks
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69
Q
2nd trimester
A
15-28
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70
Q
3rd trimester
A
29-42
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71
Q
Amount of pregnancies that are unplanned
A
Up to half
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72
Q
Pre-conceptual care
A
Help modify risk factors before conception to improve pregnancy outcome
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73
Q
Presentation of pregnancy
A
Amenorrhea - May have conception bleeding
Chadwick sign - Bluish red uterus, soft
Breast enlargement and tenderness
Areolar enlargement
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74
Q
Fetal movement
A
May not feel until 20 weeks first time
May feel 16-18 weeks after first time
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75
Q
Pregnancy diagnosis
A
Urine hCG detectable 8-9 days after ovulation, can also detect in blood
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76
Q
3 hormones similar to hCG
A
LH, FSH, TSH
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77
Q
How rapidly should hCG increase?
A
Value doubles every 1.4-2 days
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78
Q
95% detection level for hCG
A
12.3 mIU/mL
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79
Q
First US evidence of pregnancy
A
4-5 weeks
Gestational sack seen
Transvagin*l US
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80
Q
Yolk sac on US
A
Seen at 5-6 weeks
COnfirms location in the uterus (r/o ectopic)
Echogenic ring with anechoic center
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81
Q
Fetal Pole/Embryo
A
Seen after 6 weeks, looks like a hole in the muscle
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82
Q
Crown Rump length
A
Measure from head to butt can be done 6-12 weeks
More reliable estimate of age than LMP
Most accurate at 12 weeks
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83
Q
Naegele’s rule
A
LMP+7 days-3 months
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84
Q
Hx for pregnancy
A
Prior pregnancies
Contraceptive use/desires
Menses interval
Depression
Abuse
Drug/Alcohol use/Drugs
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85
Q
PE for pregnancy
A
Pap smear over 21
Chlamydia and Gonoirrhea testing
Cervical dilation, length, consistency
Bony pelvic architecture
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86
Q
Uterine sizes over time
A
6 week - Small orange
8 week - Large orange
12 week - Grapefruit
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87
Q
When should a Rho gam shot be given
A
at 28 weeks to negative mothers with positive babies
Also for vagin*l bleeding intrapartum
Post delivery of neg mothers with positive babies
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88
Q
Kleihauer-Betke
A
Tests for number of fetal RBCs in circulation, in cases of trauma may need to test and give Rho gam
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89
Q
Rh IgG attack rate on fetal RBCs
A
.3 mg will eradicate 15mL Fetal RBCs (eq. to 30 mL fetal blood)
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90
Q
Rubella
A
MCC of fetal growth restriction
Infection in first trimester can cause abortion
Vaccine needs to be taken 1 month BEFORE getting pregnant
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91
Q
Syphillis
A
T. pallidum
Treat with PCN-G - desensitization recommended if allergic
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92
Q
Prenatal counseling recommendations
A
Prenatal vitamin - 400mcg folic acid and Iron
May work but should not do intense or hazardous work
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93
Q
Pregnancy weight gain
A
25-35 lbs if okay weight
Less if they weigh more
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94
Q
Risks associated with obesity while pregnant
A
Hypertension/Preeclampsia
Gestational diabetes
Macrosomia and C section
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95
Q
Additional diet for pregnancy
A
Increase by 100-300 calories per day
Avoid FISH/SEAFOOD
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96
Q
4 risk factors for lead exposure in mothers
A
Immigrant
Remodeling home with lead
Live near lead source
Contaminated water
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97
Q
Air travel and pregnancy
A
Safe up to 35 weeks
Need to ambulate
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98
Q
Dental treatment and pregnancy
A
Okay to get radiographs
Recommended to have done
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99
Q
Caffeine and pregnancy
A
5+ cups of coffee per day can increase risk
Under 200mg/day is okay
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100
Q
Exercise and pregnancy
A
Do not usually need to limit exercise
Encourage mild to moderate exercise - don’t ramp it up
10 lb lifting is the general rule
Don’t scuba dive, etc.
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101
Q
Smoking and alcohol and pregnancy
A
Need to avoid including vaping
Binge drinking is especially problematic
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102
Q
Breastfeeding recommendations
A
6 months is preferred
2 years by WHO (also recommedning ofr Africa)
8-12 times daily with 15 minutes per session
Helps with weight loss, child obesity, chronic disease, bonding
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103
Q
CI to breastfeeding
A
HIV
Drug/Alcohol use
Galactosemia
Hep C with broken skin
Active TB
Medications
Undergoing breast cancer tx
Active herpes lesions on breast
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104
Q
Pregnancy visit spacing
A
Every 4 weeks until 28
Every 2 until 36
Every week until delivery
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105
Q
Prenatal surveillance
A
Fetal HR
Height of the fundus
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106
Q
Fundus height benchmarks
A
12 weeks -emerging from bony pelvis
16 weeks - Between pubic symphysis and umbilicus
20 weeks - Fundus at the umbilicus
20-34 - correlates with gest age
+/- 2cm
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107
Q
Timing of gestational diabetes screening
A
24-28 weeks
50 g glucose with test right after
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108
Q
Lab tests during pregnancy
A
CBC at 28 weeks
Syphillis and HIV 28 weeks for high risk
Rh testing 28-29 weeks
Group B strep testing 35-37 weeks
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109
Q
Vaccines and pregnancy
A
Hep A and B
Flu vaccine
Tdap
RSV between 32 and 36 weeks
COVID
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110
Q
Tx for nausea and vomiting in pregnancy
A
Small meals
BRAT diet
Ginger
B6
Prochlorperazine
Metoclopramide
Odansetron
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111
Q
Hyperemesis gravidarum
A
Vomiting severe enough to produce weight loss, electrolyte disturbances, ketosis, dehydration, etc.
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112
Q
Tx for back pain in pregnancy
A
Shoes, maternity belt
Tylenol
Muscle relaxers
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113
Q
Hemorrhoid tx in pregnancy
A
Topical anesthetics
Warm bath
Compression socks for varcosities
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114
Q
Tx for heartburn in pregnancy
A
Antacids
H2 blockers
PPIs
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115
Q
Pica in pregnancy
A
Craving for dirt, ice, starch
Assoc. with iron deficiency
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116
Q
Tx for sleep issues with pregnancy
A
Benadryl and naps
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117
Q
Leukorrhea
A
Increased vagin*l discharge during pregnancy - generally not pathologic
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118
Q
2 MC congenital abnormalities
A
Heart and Cleft palate
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119
Q
Threshold for downs risk
A
35years
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120
Q
Marker for neural tube defects
A
Alpha feto protein
May screen 15-18 weeks
Can use a US for it (more common)
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121
Q
Down syndrome screening recommendation
A
Offer to everyone regardless of risk
Screening NOT diagnostic
NUchal translucency and PAPP-A value
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122
Q
Second trimester down screening
A
hCG
AFP
Unconjugated estriol
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123
Q
Cell free DNA
A
Check for genetic abnormalities and gender
99% detection rate
Blood draw at 9-10 weeks
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124
Q
Amniocentesis
A
15-20 weeks
20 cc of fluid
Assess karytype, can be done for comfort
Evaluate for fetal lung maturity
Chance of fetal loss 1 in 300-500
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125
Q
Chorionic villus sampling
A
10-13 weeks
Assess fetal karyotype
Transabdominal or transcervical
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126
Q
CI to CVS
A
vagin*l bleeding
Higher risk of pregnancy loss - 2%
Uterine ante or retro flexion
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127
Q
Fetal blood sampling
A
For fetal anemia
Cord blood sampling
Perfromed at cord insertion
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128
Q
s/s of fetal stress
A
Low HR
Low fetal movement
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129
Q
Recommendations for antepartum testing
A
Every week starting weeks 32-34 (26-28 if high risk)
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130
Q
Factors effecting fetal movement
A
Diminished by increased movement
Sleeping
Placement of the placenta
Should be consistent in its habits
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131
Q
Non-stress test
A
For a baby not moving Measure heartbeat of fetus - should see 2+ accelerations in a 20 minute time span
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132
Q
What to do to wake baby up for a nonstress test
A
Acoustic stimulator up to three times - should have a positive result after
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133
Q
Biophysical profile
A
Score 0 or 2 in five categories
Non stress test
Breathing
Movement
Tone
Amniotic fluid volume (2x2 pocket)
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134
Q
BPP interpretation 8
A
Normal - deliver if abnormal amniotic fluid index
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135
Q
BPP interpretation 6
A
Deliver if over 36 weeks
Repeat within 24 hours
Deliver if still 6 or lower, observe if above 6
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136
Q
BPP interpretation 4
A
Probably asphyxia repeat or deliver
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137
Q
BPP interpretation 2
A
DELIVER!!
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138
Q
Doppler velocitrimetry
A
Looks at fetal blood flow
Umbilical artery - Shows lack of blood to flow to fetus = growth restriction
Middle cerebral artery - Fetal anemia and growth restriction
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139
Q
Complete dilation
A
10cm - max amount
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140
Q
Effacement
A
How thick the cervix is - 0% is 4cm, 100% is no cervix left
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141
Q
Braxton Hicks contractions
A
False contractions - more likely with more pregnancies, dehydration
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142
Q
Bishop score favorable for labor
A
Greater than 8
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143
Q
Diagnoses for labor
A
Water breaking
Ferning
AFI - Amniotic fluid
Nitrazine
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144
Q
vagin*l bleeding in labor
A
A small amount can be okay
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145
Q
Tx for group be strep vagin*l colonization
A
PCN
Erythromycin or Clinda for allergies
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146
Q
IV pain medication for labor
A
Usually avoided in later stages of labor to avoid fetal respiratory distress
Epidural anesthesia preferred
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147
Q
Where is an epidural given
A
L3-L4 intercostal space
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148
Q
CI to an epidural
A
Bleeding disorder or recent heparin use
Patient preference
Thrombocytopenia
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149
Q
Regional anesthesia
A
One time dose for C section
Pudendal block - less common for pregnancy today
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150
Q
General anesthesia for deliver
A
Usually only used in emergencies and C sections
Danger of maternal aspiration
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151
Q
Bishop score that indicates likely failure of induction and what can be done
A
Less than 5
Cervical ripening
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152
Q
Cervical ripening medication
A
Prostaglandins - Cervidil or Cytotec Both vagin*l, Cytotec is oral as well
Can cause tachysystole, fever, vomiting, diarrhea, uterine rupture
CI - C-section, Hysterotomy, Myomectomy
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153
Q
Induction of labor
A
Pitocin IV infusion that increases over time
Danger of tachysystole and rupture
Stop if fetal distress occurs
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154
Q
Manual induction of labor
A
Balloon catheter or laminaria
More effective with ptosin
Inserted vagnially
Amnio hook to break water
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155
Q
Augmentation of labor
A
Strengthen contractions - Use ptocin
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156
Q
Operative vagin*l delivery
A
Forceps or vacuum
Can cause lacerations (forceps - vagin*lly) (Vaccuum -Perineal)
Use for fetal compromise or if a C section can no longer be done
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157
Q
First stage of labor
A
Onset to complete cervical dilation
1st 6 cms are much slower
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158
Q
Second stage of labor
A
Cervial dilation to fetal expulsion
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159
Q
Third stage of labor
A
Fetal delivery to placental delivery
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160
Q
Fourth stage of labor
A
Placental delivery to one hour postpartum
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161
Q
Adequate labor
A
Over 200 Montevideo unites in 10min as measured by intrauterine catheter
Start ptosin if inadequate
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162
Q
Fetal variabilities that affect labor
A
Fetal size and alignment
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163
Q
Vertex
A
Head first delivery
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164
Q
Breech
A
Butt first delivery
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165
Q
Shoulder/compound
A
Something in front of baby arm
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166
Q
Funic
A
Umbilical cord first - C SECTION!!
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167
Q
Direction baby should be looking when born
A
Down to the floor (posteriorly)
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168
Q
Determinationof fetal position in Uterus
A
Mother lies supine
Leopolds maneuver:
Evaluate fetal lie, weight, position and presentation
Difficult with obesity, multiples, excess amniotic fluid
US is best bet though
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169
Q
C-section indication
A
More than two fetuses
Any non vertex position
5,000+grams
4,500+ grams and diabetic mother
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170
Q
Pelvic shapes
A
Gynecoid - best
Antropoid - Narrow front to back
Android - Triangular
Platypelloid - Narrow side to side
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171
Q
Active phase arrest labor
A
No progression in cervical dilation in 6cm dilated patients despite four hours of adequate contractions or 6 hours of inadequate contraction with augmentation
C-section indicated
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172
Q
Prolonged second stage labor
A
More than 3 hours pushing for nulliparous and 2 hours in multiparous
Indication for C section
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173
Q
IUDC
A
Catheter to measure strength of contractions
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174
Q
Umbilical cord prolapse
A
Emergency if cord get pinched - needs to be propped up manually
Indication for immediate C section while holding baby off the cord
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175
Q
Indications of second stage
A
Pelvic/rectal pressure
Mother has active role in pushing out fetus
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176
Q
Molding
A
Fetal head shaping to shape of pelvis as it works its way out
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177
Q
Perineal laceration first degree
A
Injury to perineal skin and vagin*l mucosa only
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178
Q
Second degree perineal laceration
A
Injury to perineal body (space between vagin* and rectum)
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179
Q
Third degree perineal laceration
A
Injury through external anal sphincter
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180
Q
Fourth degree perineal laceration
A
Injury through rectal mucosa
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181
Q
Episotomy
A
Intentionally making a perineal laceration
Usually causes problems - not popular
Midline or Mediolateral - more painful to the side
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182
Q
Shoulder dystocia
A
Fetal shoulder impaction on the pubic symphysis
Macrosomia, Diabetes, Obesity, Operative deliver are risk factors
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183
Q
Dangers to the fetus in shoulder dystocia
A
Humerus or clavicle fracture, Brachial plexus injury, Death
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184
Q
Management of shoulder dystocia
A
Episiotomy
Mcroberts maneuver - sharp flexion of maternal hips
Suprapubic pressure
Rubin, Wood’s corkscrew - rotate baby
Symphisiotomy
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185
Q
Delivery of the placenta
A
Done with one hand on the umbilical cord with gentle downward traction
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186
Q
Uterine inversion
A
Uterus is pulled out through the vagin*
Replace uterus - use NOX or terbutylline to relax so it can go back inside
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187
Q
Fourth stage of labor risk and definition
A
Postpartum hemorrhage - Uterine atony, Lacerations, retained placental fragments
Defines as 500+cc’s in a vagin*l deliver or 1000+cc’s in a c-section
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188
Q
Tx for uterine atony
Four Meds
A
Pitocin, Methergine, Cytotec, Hemabate
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189
Q
Engagement
A
First movement of delivery
Passage of the widest aspect of the fetal presenting part (typically the head) below the plane of the pelvic inlet (level of ischial spines)
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190
Q
Descent
A
Second maneuver of labor
Moving down into the bony pelvis
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191
Q
Flexion
A
Head flexes to fit through the birth canal
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192
Q
Internal rotation
A
Head of baby either rotates from transverse to anterior or posterior position
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193
Q
Extesnsion
A
Head extends out as the baby passes into the vagin*l
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194
Q
External rotation / Restitution
A
Head rotates back to its original position prior to internal rotation - aligns with fetal torso
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195
Q
Expulsion
A
Rest of baby comes out
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196
Q
7 Cardinal movements of labor
A
Engagement
Flexion
Descent
Internal rotation
Extension
External rotation/Restitution
Expulsion
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197
Q
Normal fetal HR
A
110-160
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198
Q
Fetal bradycardia
A
Under 110 bpm
May be due to lupus heart block or maternal hypotension
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199
Q
Absent fetal HR variability
A
Absent - worrisome
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200
Q
Minimal fetal HR variability
A
1-5bmp variation
Fetus asleep or inactive
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201
Q
Moderate fetal HR variability
A
5-25bpm variation
Considered normal
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202
Q
Marek fetal HR variability
A
25+ bpm variation
Worrisome
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203
Q
Normal acceleration of fetal HR
A
15bpm for 15s after 32 weeks
10bpm for 10s before 32 weeks
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204
Q
Early decelerations
A
Begin and end with contractions
Result of head compression
No intervention required
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205
Q
Late decelerations
A
Begin at peak of contraction and slowly return to baseline after contraction is finished
Result of compromised bloodflow during contractions - uteroplacental insufficiency
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206
Q
Tx for late decelerations
A
Position, Oxygen, Stop Pitocin, Check cervix, consider C section or assisted vagin*l delivery
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207
Q
Variable decelerations
A
V shaped at any time due to cord compression
The deeper and longer, the more concerning
Reposition
Infuse water into the uterus
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208
Q
Sinusoidal fetal HR
A
Most often fetal anemia - always concerning
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209
Q
Category I fetal heart tracing
A
FHR 110-160
Moderate FHR variability
No late or variable decelerations
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210
Q
Category II fetal heart tracing
A
Neither category I or III
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211
Q
Category III fetal heart tracing
A
Absent FHR variability with any of the following
Recurrent late decelerations
Recurrent variable decelerations
Bradycardia
Sinusiodal waveform
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212
Q
Contraction stress test
A
Use pitocin to trigger 3 contractions in ten minutes
Test for poor fetal HR patterns during contractions
Recurrent late decelerations - Positive - Bad
Good looking - Negative test
Equivocal (maybe one deceleration - Wait and see
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213
Q
MC site of ectopic pregnancy
A
Ampulla of fallopian tube
Can also occur in C-section scar (becoming more frequent
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214
Q
Risk factors for ectopic pregnancy
A
Prior
STDs
PID
Endometriosis
IUD
Assistive reproductive technology
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215
Q
Presentation of ectopic pregnancy
A
vagin*l bleeding
Lower abdominal pain
Adnexal mass
Abdominal pain on rupture
Hemodynamic instability
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216
Q
beta hCG at which pregnancy should be visible in the uterus
A
1500-2000mIU/mL
Should be increasing at a steady rate if pregnancy is normal
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217
Q
US for ectopic pregnancy
A
No yolk sac seen in uterus with pseudo gestational sack
Donut sign - thick walls
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218
Q
HCg monitoring if you dont see an intrauterine pregnancy
A
Check every other day
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219
Q
Ectopic pregnancy treatment
A
Methotrexate - Patient needs to be compliant, no fetal cardiac activity, under 3.5 cm, beta hCG under 5000
Check hCG decrease by day 7
Increased abdominal pain afterwards, N/V/D
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220
Q
Surgery for ectopic pregnancy
A
Salpinostomy - open up and remove - creates higher risk of ectopic pregnancy
Salpingectomy - Preferred
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221
Q
Complete abortion
A
Expulsion of all products of conception before 20 weeks - can do analysis of products
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222
Q
Incomplete abortion
A
Not all of the products of conception are expelled
vagin*l bleeding and abdominal cramping
May see protruding POC through cervical os
Curettage, Prostaglandins and removal of tissue for tx
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223
Q
Inevitable abortion
A
No expulsion but vagin*l bleeding and dilation of the cervix such that viability is unlikely
Treat with prostaglandins - keep pregnancy if fetal heartbeat
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224
Q
Missed abortion
A
Death of embryo or fetus before 20 weeks with complete retention of products of conception
US shows nonviable pregnancy
Wait to pass or prostaglandins, Curettage, Expectant management
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225
Q
Threatened abortion
A
Any bleeding before 20 weeks
Cervical os closed
Pelvic rest and close monitoring
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226
Q
Complete Molar pregnancy
A
Excessive growth of placenta
Large for dates
2 sets of paternal chromosomes
Very high hcg
Excessive placental tissue
No POC
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227
Q
Incomplete molar pregnancy
A
Two paternal and one half maternal set of chromosomes
Small for dates
Missed abortion
Fetal parts present
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228
Q
Diagnostics for Molar pregnancy
A
Snowstorm appearance on US
Thickened multicystic placenta
Confirm via pathology
Vomiting
preeclampsia before 20 weeks
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229
Q
Management of molar pregnancy
A
CXR for cancer
CBC
Thyroid
EKG
Suction, dilation and curettage
Pitosin to evacuate uterus
Rhogam if Rh negative
Watch for cancer with serial hCG - should decrease - birth control for some time
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230
Q
Questions to ask about Antepartum bleeding
A
Check where it is coming from (could be UTI or hemorrhoids)
Sexual activity - ask
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231
Q
Placental abruption
A
Separation of the placenta either partially or totally from its implantation site
Concealed or revealed
Usually early in pregnancy - monitor
Can cause hypovolemic shock - deliver immediately
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232
Q
Revealed placental abruption
A
Presents with vagin*l bleeding
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233
Q
Diagnosis of placental abruption
A
Exclusion diagnosis - pay attention if mother has experienced trauma
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234
Q
Couvelaire uterus
A
Purplr/Blue uterus from blood infiltration
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235
Q
Management of placental abruption
A
Deliver -vagin*l preferred for dead fetus; C-section is quicker with bleed risk
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236
Q
Placenta previa
Four Risk Factors
A
Placenta covering cervix
Increases with age, parity, c-section, smoking
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237
Q
Presentation of placenta previa
A
Painless vagin*l bleeding seen after second trimester
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238
Q
Diagnosis of placenta previa
A
Should be excluded in any bleeding patient who presents after the 2nd trimester
Transvagin*l US to visualize
NO DIGITAL EXAM ONCE CONFIRMED!!!
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239
Q
Point before which previa is unlikely to persist
A
23 weeks
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240
Q
Management for placenta previa
A
Delivery via C-section as late as possible
Deliver sooner if persistently bleeding
Goal to keep pt pregnant as long as possible
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241
Q
Placenta accrete
A
Abnormally adhered
Accreta - Attached to myometrium
Increta - Attached into myometrium
Percreta - Goes through myometrium
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242
Q
Risk factors for placenta accrete syndromes
A
C section or placenta previa
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243
Q
Presentation of pracenta accrete
A
Found on US
Hard to deliver placenta
Recommended early delivery at 34-36 weeks
May consider leaving placenta insode or hysterectomy -MC
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244
Q
Cervical insufficiency
A
Painless cervical dilation during the second trimester
d/t prior cervical trauma
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245
Q
Eval and management of cervical insufficiency
A
US to confirm
Swab for infection
Trendelenburg psoition
Pelvic rest
Cerclage - stitch in the uterus kept in until week 36
Delivery
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246
Q
Tx of cervical insufficiency for next pregnancy
A
US to measure
Preventative Cerclage - Rescue (wait) or Elective (don’t wait)
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247
Q
Cerclage
A
Stitch in the uterus - what Mary Crawley got
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248
Q
Preterm birth - 4 reasons
A
Delivery of infant before 37 weeks
Spontaneous
Idiopathic
Maternal or fetal indication
Twins+
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249
Q
Fetal fibronectin and early labor
A
Sensitive but not specific for preterm labor - can rule it OUT
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250
Q
Workup for preterm labor
A
Tocolysis - Stops contractions for 48 hours max
Administer steroids for fetal development
Nifedipine
Mag Sulfate
Prostaglandin inhibitors
Beta agonists - Terbutaline
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251
Q
Management for preterm labor
A
Steroid for fetal lung maturation
Betamethazone indicated 24-34 weeks
Cerclage to help prevent
Progesterone NOT helpful unless vagin*l
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252
Q
Reason for magnesium sulfate in preterm labor
A
Prevents neonatal intercranial hemorrhage weeks 24-32 for at least 12 hours
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253
Q
Preterm premature rupture of membranes
A
Check for pooling, nitrazine swab, ferning of vagin*l mucosa to confirm
Risk of cord prolapse - don’t send home
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254
Q
Managementof preterm premature rupture of membranes
A
Patient hospitalized for remainder of pregnancy
Corticosteroids for fetal lung maturity
Tocolysis
Ampicillin or Erythromycin can extedn time before delivery
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255
Q
Intrauterine growth restriction
A
Stick with original due date
May be due to alcohol, smoking, young patients, TORCH infections
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256
Q
Dangers with IUGR
A
Stillbirth
Encephalopathy
Palsy
Still monitor even if parents are small
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257
Q
Diagnosis for IUGR
A
Less then 10th percentile overall growth OR less than 10th percentile abdominal circumference is indicative
US
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258
Q
Management of IUGR
A
Amiotic fluid volume management
US for circumference and weight
Umbillical artery doppler monitor
Serial growth scans
Plan for delivery at 38 weeks
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259
Q
Fetal death risk factors
A
Age
AA race
Smoking diabetes
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260
Q
Dx and management of fetal death
A
Usually incidental - US
Plan for delivery
Karyotyping, Autopsy
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261
Q
Management for future pregnancies after a fetal death
A
Control modifiable risk factors
Offer genetic testing
Anatomy scan at 18 weeks growth US at 32 weeks
Begin antepartum surveillance 1-2 weeks prior to when stillbirth happened
Elective induction or C section at 39 weeks
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262
Q
Hypertension in pregnancy
A
Over 140/90 on two occasions at leat 2 hours apart
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263
Q
Chronic hypertension and pregnancy
A
Present before 20 weeks or persistent 12 weeks after delivery is an underlying chronic HTN
ACEIs and Angiotensin receptor agonists are CI
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264
Q
Prenatal care for chronic HTN
A
EKG, Echo (at risk for cardiomyopathy)
Baseline labs
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265
Q
Medications for HTN in pregnancy
A
Labetolol or Calcium channel blockers
Aspirin reduced preeclampsia risk
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266
Q
Management for chronic hypertension in pregnancy
A
Close observation
Deliver early at 37-39 weeks
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267
Q
Gestational HTN
A
After 20 weeks BP becomes 14/90+
Resolves by 12 weeks postpartum
Treat and manage like chronic HTN in pregnancy
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268
Q
Preeclampsia
A
Hypertension and proteinuria after 20 weeks gestation
0.3g+ urine protein on dipstick
Can also present with: Thrombocytopenia, Renal insufficiency, Liver disease, Pulm edema
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269
Q
Risk factors for preeclampsia
A
Young age
First pregnancy
Multifetal
Obesity
Other vascular disorders
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270
Q
Dx of preeclampsia
A
140/90+ BP
Proteinuria dipstick of 2+
300mg or more in a 24 hour urine collection
Could also be with thrombocytopenia
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271
Q
Eclampsia
A
Occurence of generalized convulsion and or coma in the setting of preeclampsia with no other neuro condition
Before, during, or after labor - hold in hospital after birth
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272
Q
Preeclampsia superimposed on chronic HTN
A
Need to have close monitoring of labs and home blood pressure so that it can be caught
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273
Q
HELLP
A
Hemolysis, Elevated Liver Enzymes, and Low Platelet Count
RUQ pain because liver bleeds and distends capsule
Risk of hepatic hematoma and rupture
Indicates SEVERE preeclampsia
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274
Q
Tx for preeclampsia
A
Delivery
Monitor closely if mild
HTN therapy if 160/110 or greater
Labetolol (IV), Hydralazine (IV), or nifedipine (PO) can be used
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275
Q
Magnesium sulfate and preeclampsia
A
To prevent seizure, NOT BP
Continued after delivery until the patient diureses
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276
Q
Pregestational diabetes
A
Check hemoglobin A1c first trimester
A1c over 6.5%
Higher A1c = More fetal anomalies - significant risk over 12%
Fasting glucose over 125, nonfasting over 200
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277
Q
Complications of pregestational diabetics
A
Spontaneous abortion
Preterm birth
IUGR
Cardiac defects
Hydramnios
Macrosomia
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278
Q
Neonatal effects of pregestational diabetes
A
Baby born with overproduction of insulin - hypoglycemia
Hypocalcemia
Diabetes and Obesity later in life
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279
Q
Preconception care for diabetes
A
Glucose 70-110 mg/dL
A1c 7% or lower
Folic acid supplementation
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280
Q
First trimester care for DM
A
Careful glucose monitoring
HGA1c under 6
81 mg Aspirin for preeclampsia prevention
24 hour urine
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281
Q
Second and third trimester care for diabetic mothers
A
US at 18-20 weeks
Fetal echo at 20-24
Antepartum testing at weeks 32-34
Deliver 36-40 weeks
vagin*l or C section delivery
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282
Q
Postpartum diabetes management
A
Insulin may need to be decreased - mom needs more insulin during gestation
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283
Q
Gestational diabetes
A
Commonly recurrence
Diabetes after the first 20 weeks
Ethnic populations are at higher risk
Increased risk of DM later in life
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284
Q
Screening for Gestational Diabetes
A
50g one hour glucose challenge followed by 100g 3 hour test - fasting
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285
Q
Limits for 3 hour GTT
A
Fasting 95
1 hour 180
2 hours 155
3 hours 140
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286
Q
Management of rgestational diabetes
A
Keep fasting BS under 95 and postprandial under 120
Diet modification - 40-20-40 diet
Insulin - First line
Metformin - also good
May consider early induction or not with vagin*l delivery depending on size
Same risk factors as pregestational diabetes
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287
Q
Postpartum management of gestational diabetes
A
All should receive a 75g 2 hour OGTT at 6-12 weeks postpartum
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288
Q
Vanishing twin
A
Twin vanishes or is lost before the second trimester
10-40% of all twin pregnancy
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289
Q
Diagnosis of multifetal gestation
A
Uterus larger than expected
Determine chorionicity in the first trimester with US
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290
Q
Dichorionic twins
A
Two separate placentas with a thick 2mm+ dividing membrane
Twin peak sign aka lambda or delta sign
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291
Q
Monochorionic twins
A
Thin under 2mm dividing membrane
T sign on US - right angle relationship between membranes
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292
Q
Monoamniotic twins
A
One amniotic sac - the later the split the more the twins share
High risk of fetal death - deliver 32-24 weeks, steroids at 24-28 weeks with antepartum testing
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293
Q
Complications of multifetal pregnancies
A
Congenital malformations
Spontaneous abortions
Low birth weight
HTN
Size dischordance
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294
Q
Twin-Twin Transfusion syndrome
A
In monochorionic twins
One twin gets all the nutrients, one gives all the nutrients
May be able to ablate vascular abnormalities causing TTTS
May need selective abortions
Harms both twins -One anemic, one congested
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295
Q
Weight gain expectation for multifetal pregnancies
A
37-54lbs. weight gain
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296
Q
Labor management for DD twins
A
38 weeks, can be vagin*l - first twin should be vertex!!
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297
Q
Labor management for MD or MM twins
A
Usually C section at 34-37 weeks and 32-34 weeks respectively - first twin should be vertex!!
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298
Q
Maternal hypothyroidism
A
Fetus does not produce own thyroid before 12 weeks
Check TSH every trimester
Cold, Fatigue, Muscle Cramps, Hair loss
MC - Hashimotos thyroiditis
Treat with levothyroxine
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299
Q
Screening for maternal depression
A
Screen for in patients in initial visit and at every visit if at risk
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300
Q
Tx for depression during pregnancy
A
Counselling
SSRI or SNRI are first line
If mother is stable on current antidepressant - don’t change
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301
Q
Zuranlone
A
For post partum depression with and SSRI or SNRI
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302
Q
Substance abuse among pregnant women
A
7.2% abused pain relievers
12% Drank
25+% Smoked including marijuana
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303
Q
Screen for substance abuse in pregnancy
A
Try to screen all patients if possible - tend to use for those with risk factors
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304
Q
Opioid substitution for pregnancy
A
Methadone, Suboxone, Subutex
All associated with neonatal withdrawal
Subutex does not cross the placenta as early
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305
Q
UTI dx and tx in pregnancy
A
Always do a urine screen when first presenting as pregnant
Can cause preterm birth
Macrobid or Keflex and recheck urine a week after
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306
Q
Suppressive UTI therapy in pregnancy
A
Macrobid 100mg PO daily
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307
Q
Pyelonephritis in pregnancy
A
Flank pain
Admit w/ IV abx and prophylaxis
Assess for kidney stone
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308
Q
Definition of infertility
A
1 year of unprtected intercourse of reasonable frequency in under 35
6 months for those over 35
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309
Q
Primary v. Secondary infertility
A
Primary no prior pregnancies
Secondary - prior pregnancy
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310
Q
How often is reasonable to have sex for fertility
A
Once every other day
Make sure you’re having it during the right time
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311
Q
Workup for many pregnancy losses
A
Do genetic testing to see if there is a problem
Look for uterine septum on US
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312
Q
Dx for ovulatory dysfunction
A
Use menstual hx as a predictor
Ask about mittleschmirtz
TSH, Weight over or under
Basal body temperature
US to look at ovarian reserve
Urine LH sticks
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313
Q
Serum progesterone
A
Check around 21 days for ovulation
Relatively cheap
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314
Q
Serum FSH
A
Predictor of ovarian reserve - less inhibin
Check on day 3 of cycle
Estradiol compensation (elevation) indicates a depleated ovarian reserve
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315
Q
Antimullerian hormone testing
A
Expressed by granulosa cells
Possible role in dominant follicle recruitment
Under 1ng/mL can indicate depleated ovaries
High in PCOS
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316
Q
Tx for ovulatory dysfunction
A
Check hyperprolactinemia
Treat any adenoma
Levothyroxine for hypothyroid
Ovulation induction
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317
Q
Clomiphene for ovulation dysfunction
A
Clomiphene - Estrogen antagonist results in increased FSH given around day 3 of cycle
PO
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318
Q
Aromatase inhibitors for ovulation induction
A
Letrozole
Inhibits estrogen and increases FSH
PO
High BMI and PCOS
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319
Q
Gonadotropins
A
Variety of IM formulations
Expensive
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320
Q
COmplications of ovulation induction
A
Multifetal gestation
Ovarian hyperstimulation syndrome - enlarged ovary with cysts - causing abdominal pain, distention
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321
Q
Intrauterine insemination
A
Sperm washed and concentrated and inserted into the uterus - less expensive than and tried before IVF
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322
Q
IVF
A
Sperm and ova combine seperately and inserted into uterus
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323
Q
Tubal and pelvic factors that can lead to infertility
A
Endometriosis
Surgery such as appendectomy
Pelvic infection
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324
Q
Dx for tubal issues
A
Hyerosalpingogram on days 5-10 - uses radio-opaque medium in uterus
Chromopertubation - Methylene blue for tube patency with laparoscopy
Expensive
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325
Q
Tx for tubal and pelvic factors
A
Cannulation to create patency
Reconstruction post op
Removal if dyfunctional tube causing issues
IVF with removal of adhesions
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326
Q
Uterine factors that cause infertility
A
Polyps, Uterine septum, Fibroids
Dx with US or Hysteroscopy, endometrial biopsy before IUI or IVF
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327
Q
Asherman’s syndrome
A
Intrauterine adhesions that can resemble a fetus on US
Form after dilation and curettage
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328
Q
Cervical factors that cause infertility
A
Infection
Thick mucous d/t high estrogen
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329
Q
Dx and tx for cervical factors
A
Postcoital test - how many sperm got through
Bypass with IUI
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330
Q
Male hx for infertility
A
Testosterone use!!
Get a sem*n analysis
Mumps, ED, Hx of infection
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331
Q
Lag time for sperm to be impacted
A
Takes 3 months for effects to be felt - look at that in hx
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332
Q
sem*n analysis
A
Refrain from ejacul*tion for 2-3 days
Too much sex can reduce sperm count per time
f/u analyze for antisperm antibodies
f/u low volume with urology
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333
Q
Tx for low sperm count
A
IUI - Under 20 million per mL
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334
Q
Azoospermia
A
Congenital absence of vas deferens d/t cystic fibrosis
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335
Q
Asthenospermia
A
Decreased sperm motility
Prolonged abstinence
Infection
Varicocele
IUI to treat
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336
Q
Antisperm antibodies
A
Can be d/t vasectomy, infection, testicular torsion
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337
Q
Hormonal evaluation of male infertility
A
Look for low FSH and or Testosterone
Giving testosterone can actually suppress sperm production
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338
Q
PMDD
A
Premenstual dysphoric dysorder
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339
Q
Premenopause
A
Erratic hormones, menses begin to be irregular
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340
Q
Postmenopause
A
No menses for a year
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341
Q
Dysmenorrhea
A
Painful menstrual bleeding
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342
Q
Metorrhagia
A
Menstrual bleeding between periods
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343
Q
Menometorrhagia
A
Irregular, unpredictable bleeding
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344
Q
Oligomenorrhea
A
Periods more than 35 days apart
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345
Q
BSO
A
Bilateral salpingo-oophorectomy
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346
Q
TAH
A
Total abdominal hysterectomy - through abdomen
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347
Q
TVH
A
Total vagin*l hysterectomy - comes out through vagin*
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348
Q
Radical hysterectomy
A
Takes out uterus and additional tissue including the cervix
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349
Q
Term pregnancy
A
37-42 weeks
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350
Q
Preterm
A
20-36 weeks
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351
Q
Abortion
A
Before 20 weeks
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352
Q
Puerperium
A
Birth to 6 weeks postpartum
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353
Q
3 trimesters
A
1 - 0-14
2 - 15-28
3 - 29-42
Each is 2 Weeks
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354
Q
FHT
A
Fetal Heart Tones
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355
Q
Grand multigravida
A
More than 5 times pregnant
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356
Q
GTPAL
A
Gravida
Term
Preterm
Abortions
Lived 30 days
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357
Q
Para
A
Pregnancies carried to term
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358
Q
Recommended age for 1st reproductive health visit
A
Age 13-15
Only screen if STD suspected or symptomatic
359
Q
Age to begin pelvic exams and pap smear
A
21 years old
Frequency of pelvic depends on risk factors with pap every 3-5 years
360
Q
General breast exam screening
A
Every 1-3 years 20-39, yearly after 40 with mammograms done starting at 40
361
Q
Speculum lubrication for pap smear
A
Use warm water (officially)
362
Q
Two ways to do pap smear
A
Use scraper and brush, or use the combo tool
363
Q
General breast exam method
A
Palpate 4 quadrants and 4 positions
Palpate for regional lymphadenopathy
Palpate tail of spence
364
Q
Bimanual exam
A
One hand in vagin* and one on lower abdominal wall
Test for size shape, mobility, and consistency of organs
365
Q
Skin exam recommendations
A
Q3 years 20-40 and then yearly 40+
Same as pap smears!!
366
Q
Pap screening recommendations
A
21-29 every 3 years
30-65 every 3 years or HPV with pap every 5 years
Stop screening at 65
367
Q
Reasons to stop pap smears after 65
A
No hx of dysplasia/cancer
3 negative smears or 2 negative Pap+HPV in a row
368
Q
When do pap smear guidelines NOT apply
A
Hx of cervical cancer, HIV+, Immunedeficient, DES exposure
369
Q
STD screenings for ALL pregnant women
A
Hep B, HIV, Syphillis
370
Q
STD screenings in all women under 25
A
Gonorrhea and Chlamydia
371
Q
STD to screen for in high risk sexual behavior women
A
Hep C
372
Q
STD screening for all sexually active women
A
HIV - One time screen
Gonorrhea and Chlamydia - Yearly if under 25
373
Q
STD screenings for High risk sexual behavior women
A
Annual for All:
HIV
Syphillis
Trichom*oniasis
Hep B and C
G/C
HSV
374
Q
Breast cancer screening
A
Depends on agency - start yearly 40-50 years old - definitely by 50
Clinical breast exam optional, Mammogram required
375
Q
When to stop mammograms
A
When you wouldn’t treat cancer if you found it
74 per official guidelines
376
Q
Colon cancer screening recommendations
A
FOB, FITm CT Colonoscopy 45-75 - recommended against after 75
377
Q
Bone density screening recommendations
A
65 years old
Or any woman who’s risk is equal to a 65 year old woman
378
Q
Bethesda system
A
Pap smear evaluation - grades pap cells for cancer
379
Q
Atypical squamous cells
A
ASC - Lowest concern abnormal pap smear cells, can see in infection or atrophy
Undetermined significance = ASC-US
Cannot exclude High Grade = ASC-H
380
Q
Low grade squamous intraepithelial lesion
A
LGSIL or LSIL
Corresponds to CIN-I
381
Q
High grade squamous intraepithelial lesion
A
HGSIL or HSIL
Corresponds to CIN II or CIN III
382
Q
Atypical glandular cells
A
Do not match normal cervical glandular cells but are also not cancer
Associated with adenocarcinoma of endocervix or of endometrium
383
Q
CIN I
A
Disordered growth of lower 1/3 of epithelial lining - mild
384
Q
CIN II
A
Disordered growth of lower 2/3 of epithelial lining - moderate
385
Q
CIN III
A
Disordered growth of over 2/3 of epithelial lining of cervix - considered full thickness
386
Q
CIN
A
Cervicle Intraepithelial Neoplasia
387
Q
Treatment for CIN stages
A
Always treat CIN II or III
Except for in pregnant women (wait till after birth) or in adolescents with CIN II we can observe
388
Q
Risk factors for cervicle dysplasia
A
Multiple sexual partners
High risk partner
HPV hx
Other STIs
Immune suppressed
Contraceptive use long term
Multiparous
389
Q
Management for ASC-US
A
Repeat pap in 6 months and then again in 6 more months
Second abnormal smear - refer for colposcopy
Test for HPV - colposcopy if positive
Colposcopy
390
Q
Colposcopy
A
Like a cervicle exam - use a magnifying light as well as acetic acid
Curette or brush endocervical canal
391
Q
Indications for coloposcopy
A
Abnormal cervicle cytology
CLinically abnormal cervix
Unexplained intermenstrual or postcoital bleeding
Vulvar or vagin*l neoplasia
In utero DES exposure
392
Q
CIN I on colposcopy management
A
Expectant management
2 pap q6 months as with ASC-US
Repeat colpscopy if positive or +HPV
393
Q
CIN II-III or cancer on colposcopy management
A
Surgery
394
Q
Cervix surgery
A
Take out part of the cervix for cancer
395
Q
3 estrogens in women
A
Estrone (E1) - Order when worried that thye have little estrogen
Estradiol (E2) - What we are usually talking about when talking about estrogen - ordered to monitor menopause, etc.
Estriol (E3) - Screen for fetal pathology and assess preterm labor risk
396
Q
Where progesterone is produced
A
Corpus luteum
Placenta
Biotin - causes flase elevation
Should not be present post menopause
397
Q
Percent of pregnancies that are unintended
A
50%
398
Q
Percent of pregnancies that were unwanted but women not using birth control
A
40%
399
Q
Coitus Interruptus
A
Pull out method
Very ineffective - very high failure rates
sem*n can leak out before org*sm
Not recommended
400
Q
Postcoital Douche
A
Fluch sem*n out of vagin*
Not reliable - sperm are fast
Not recommended
401
Q
Lactational amenorrhea
A
Suckling to reduce GnRH to suppress ovulation
Pregnancy rate of 7.4% after 12 months - less effective with time
Need to be amenorrheic
Start other birth control at 3 months postpartum
402
Q
Periodic abstinence
A
Calendar methods - 11-25% failure rate
May be related to birth defects
403
Q
Most effective determinant for ovulation
A
serum LH - not practical
404
Q
Fertile period for periodic abstinence
A
2 days before and after ovulation - not very reliable
405
Q
Temperature method of birth control
A
Check temp in the morning
first three days of elevated temperature after drop are the fertile period
406
Q
Failure rate of combined temp/calendar method
A
5 per 100 couples per year - if consistent, need to be consistent
407
Q
Cervical mucous method
A
Billings method
Check cervical mucus - when its thin, patient is fertile
408
Q
Symptothermal method
A
Notice ovulation symptoms and be aware - most effect natural method
409
Q
2 types of OCP
A
Combo or Progestin only pills
410
Q
Combination OCPs
A
Include estrogen and a progestin -some kind of both
411
Q
3rd or 4th generation progestins
A
Better to avoid male secondary sex characteristics
Worse for risk of clotting - DVT, etc.
412
Q
Monophasic COC
A
Same hormones daily
413
Q
Multiphasic COC
A
Different doses during the cycle
May give placebo at some points
414
Q
Administration of COC
A
Ideally start on first day of cycle or just start the day you pick it up and your body will adjust
415
Q
Single missed dose COC
A
Single high monophasic - makeup on the next day
416
Q
Multiple missed doses for COC
A
Double dose and use added barrier contraceptive for 7 days
417
Q
Tx for missed COC w/ coitus in past 5 days,
A
consider emergency contraception
418
Q
MOA of COCs
A
Suppress LH and FSH
Alter cervical mucus
Make endometrium less receptive to implantation
419
Q
Drug interactions with COCs
A
Antibiotics, Anticonvulsants, NSAIDs, SSRIs
420
Q
Benefits of COC
A
Lower risk of ovarian and endometrial cancer
MSK benefits
Lower ectopic pregnancy
Less menstrual pain
421
Q
Major side effects of COCs
A
Increased thromboembolic risk
MI risk increases
Stroke
Liver disease
Cervical and Breast cancer increase
422
Q
Cautions for COCs
A
No use in migraine HAs with aura
May impair breast milk
423
Q
Four Minor SEs for COCs
A
Nausea, dizziness, fatigue
Weight gain 2-5lbs
Abnormal menses
Melasma
424
Q
8 Contrindications for COCs
A
Pregnancy
Undiagnosed vagin*l bleeding
Migraine with Aura
Prior history of thromboembolic event
Uncontrolled HTM DM, or SLE
Smokers over 35
Breast cancer hx
Active liver disease
425
Q
Progestin only contraceptives
A
Does not suppress ovulation
Thicken cervical mucous and make endometrium unsuitable
Need to be very compliant
426
Q
Disadvantages of POCs
A
Must take at same time of day daily
Higher bleeding and pregnancy rates
Cancer is still a risk
427
Q
CI to POCs
A
Unexplained uterine bleeding
Breast cancer
Hepatic neoplasms
Pregnancy
Active severe liver disease
428
Q
Three ,method of emergency contraception
A
Yuzpee method
Levonorgestrel
Copper IUD
429
Q
Yuzpee method of contraception
A
Emergent
COC with levonorgestrel
1st dose within 72 hours of intercourse - sooner is better
Causes nausea
430
Q
Levonorgesterol alone
A
Plan B - OTC
Single dose of 1500mcg
Within 72 hours ideally, stops LH surge - not useful if already ovulated
431
Q
Ulipristal
A
Ella - OTC
Single dose of 30mg
Within 72 hours recommended
Prevents LH surge - slightly better than plan B
432
Q
Emergent Copper IUD
A
May inhibit implantation or interfere with sperm function
Insert up to 5-7 after
OTC
Emergency contraception
433
Q
Levonorgestrel IUD for emergency contraception
A
52 mg for emergency contraception
Insert up to 5 days post intercourse
434
Q
vagin*l ring
A
Combination contraception
3 weeks per month
No fitting, can remove for three hours and still work
435
Q
Failure rate of vagin*l ring
A
0.65 per 100 women per year
436
Q
Transdermal patch contraception
A
New patch weekly for 3 weeks a month, not directly on breast - rotate sites
Less than 1% failure with less efficacy in obese patients
437
Q
CI of transdermal patch and detachment
A
Have to restart if it has been off for 24 hours
438
Q
Depot Medroxyprogesterone Acetate
A
SepoShot
Progesterone Q3 months
3% failure rate for typical (imperfect) use
0.3 - Ideally
439
Q
Benefits of Depot Medro shot
A
Lower risk of ectopic pregnancy
Lower risk of endometrial cancer
Lower sickle cell crises
May help endometriosis
440
Q
Side effects of Depot Medroxyprogesterone Acetate Shot
A
Decreased bone density
Irregular menses
Takes 10 months to return to baseline and get pregnant
441
Q
Levonorgestrel implant
A
Implanted in arm
Contains a progesterone - etonogesterol
Almost 100%
Up to 3 years - some studies is 5
442
Q
SE of implants (nexplanon)
A
Minor bruising, swelling, and itching at insertion site
Irregular menses
Weight gain
HA
443
Q
Copper IUD non-emergent
A
FDA approved for 10 years
Uncertain MOA
0.6-0.8 per 100 woman-years
444
Q
Risks/SEs of Copper IUD
A
Ectopic pregnancy
Spontaneous abortion
Uterine perforation
Menstrual irregularities, cramping, vaginitis
445
Q
Contrindication to copper IUD
A
Pregnancy
Active infection
Wilson disease
Cancer or unknown bleeding
PID
446
Q
Levonorgestrel IUD
A
Good for people having heavy periods and cramping
8 year lifespan
Very low failure
Bleeding as a SE, helps with cramping, breast pain
52 mg
447
Q
Low dose levonorgestrel IUD
A
Kylea - 5
Skylea - 3
Not for cramps or menorrhagia
448
Q
IUD expulsion
A
Check for strings
Happens in up to 5% in first year of use
Test for pregnancy if expelled
449
Q
Spermicides
A
Most based on Nonoxynol-9
Phexxi - More natural
Most OTC
Placed in vagin* and last around an hour
High pregnancy due to non-compliance
450
Q
Contraceptive sponge
A
Nonoxyl-9 impregnated disk
Inserted up to 24 hours before and keep in 6hrs post coitus
Less effective than condom
451
Q
Lamb skin condoms
A
Don’t protect against STD’s - latex DO
452
Q
Female condom
A
May prevent STDs, not as effective as a male condom
453
Q
DIaphragm and Spermicide
A
Rubber dome over cervix
Must use the spermicide
6 hours before and 24 hour max placement
6 per 100 with perfect use
15-20 per 100 with typical use
454
Q
Cervical cap
A
Smaller than a diaphrage -can stay in up to 48 hours
Just on cervix
May be hard to place
455
Q
Regret frequency for sterilization contraception
A
20% for women under 30 6% for women over 30
456
Q
Legal limitations to sterilization
A
Federal won’t pay for under 21 - some states may
None for incompetent patients
457
Q
4 types of female tubal sterilization
A
Electrocoagulation
Mechanical occlusion
Ligation with suture material
Salpingectomy
458
Q
Concerns with tubal sterilization
A
Tubal pregnancy
Chronic pelvic pain - tubal ligation syndrome
Irregular menses
Decreased ovarian cancer when removed
459
Q
Tubal occlusions
A
No longer done, used a hysteroscopic precedure
460
Q
Chemical tubal occlusion
A
Usually not done in US, never approved - seen in immigrants
461
Q
Vasectomy
A
30x less failure, 20x less post-op complications
Need 1-2 consecutive sperm counts of zero to confirm it is working
Easier reversal
462
Q
Suction curettage
A
Elective abortion performed 12 weeks for earlier
90% of US abortions
Cervical dilation and suction catheter insertion
463
Q
Surgical curettage
A
Scrape out fetal parts - more bleeding less common than suction
464
Q
Phamraceutical abortion
A
(Mifepristone OR methotrexate) and/or Misoprostol
Used in first trimester
SE of cramping/bleeding
CI in active liver/renal disease, anemia, bleed risk, IBF -may not expel everything
465
Q
Intraamniotic instillation
A
Hypertonic solution put into uterus to kill the fetus - lots of side effects
466
Q
vagin*l prostaglandins
A
For elective abortions - suppository containing misoprostal etc. to trigger preterm delivery
Can cause GI side effects, live abortion
467
Q
MOA of misoprostol
A
Causes uterine contractions and cervicle ripening
Used for abortions and induction
468
Q
Dilation and evacuation
A
Most common elective abortion for 2nd trimester
Cervical ripening agents used and forceps to break up tissue
Infection and blood loss - does not feel like a delivery
469
Q
Post abortion follow up
A
Rho-Gam
Avoid anything intravagin*l for 2 weeks
Birth control
2+ elective abortions lead to higher risk of miscarriage
470
Q
Climacteric
A
Phase of aging from reproductive to non-reproductive age, before actual menopause occurs
471
Q
Average langth of per menopausal transition
A
1-3 years
Part of climacteric period
472
Q
Average age of final menstrual cycle
A
51
473
Q
Premature menopause
A
Menopause at 40 or younger
474
Q
Perimenopausal
A
Going through menopause but still having periods
475
Q
Change in follicles over time
A
Ones most responsive to FSH are ovulated first
476
Q
Estradiol of menopause
A
May see bursts of estradiol because follicles are not responding as well
477
Q
Predisposing factors for menopause
A
Smoking advances by 2 years
Reproductive tract disease
GU infections
Chemo or radiation
Surgical impairment to ovarian blood supply
478
Q
Artificial menopause
A
We do something that destroys the ovaries or take them out
May be due to endometriosis, cancer
479
Q
Postmenopausal androgens
A
Decreased production, but still have androgenic symptoms because ovaries make some testosterone and binding protein is not produced
480
Q
Gonadotropins in menopause
A
Increase because no estrogen - can be used for diagnosis
481
Q
Common classic menopause symptoms
A
Irregular bleeding
Irritability and mood swings
vagin*l dryness
Decreased libido
Hot flashes
Hair loss
Hirsutism
Weight gain
482
Q
Physical changes of menopause
A
Atrophy of cervix, uterus, tubes
Flattening of vagin*l rugae
483
Q
Urinary and mammary changes of menopause
A
Urgency, frequency, dysuria
Urethral prolapse
Regression and flattening of mammary glands
484
Q
Atrophic vaginitis
A
Epithelium becomes thinner and rugae flatten out
Painful intercourse and friability
Smooth pale and shiny late
Diffuse patchy and red early
Increased pH
485
Q
Diagnosis of atrophic vaginitis
A
Clinical dx - may see atrophic cells in cytology
486
Q
Initial tx for atrophic vaginitis
A
Conservative first
vagin*l moisturizers AND lubricants - not the same thing
Moisturizers daily - not just for sex
487
Q
Treatment for moderate/severe atrophic vaginitis
A
vagin*l estrogen, restores pH and microflora
Fewer UTIs and overactive bladder symptoms
Can go systemic
DOn’t need a vagin*l estrogen if systemic
488
Q
Ospemifene
A
For atrophic vaginitis
Only targets vagin*l estrogen receptors, MC MC SE is hot flashes
489
Q
Prasterone
A
vagin*l DHEA that turns into estrogen for estrogen sensitive individuals
490
Q
Presentation of hot flashes
A
Elevated HR - normal rhythm and BP
Night sweats, Insomnia
Cutaneous dilation - flushing
491
Q
Risk factors for hot flashes
A
Obesity, Lower physical activity, Smoking, African american race
492
Q
Normal hot flash length
A
seconds to 10 minutes
493
Q
Tx for hot flashes
A
Estrogen = mainstay, give progestin if they cannot take it alone
494
Q
Reasons to take eastrogen with progestin
A
Intact uterus due to endometrial cancer risk
495
Q
First line for patients who don’t want hormones for hot flashes
A
SNRI/SSRI
Citalopram or Venlafaxine, Paroxetine but it reacts with tamoxifen
Gapapentin, Clonidine can also be used
496
Q
Protections of estrogen alone
A
CHD
Fractures
Diabetes
Not used to treat these conditions
497
Q
Risks of MHT (Hormone therapy
A
Estrogen causes endometrial cancer - add progestin to prevent
Increased risk of breast cancer with combo therapy - d/t progesterone!!
498
Q
Non-cancer risks of MHT
A
Thromboembolic diesease
Gallbradder disease
499
Q
MHT contraindication
A
Hx of breast cancer
Unknown bleeding
Endometrial cancer
Thromboembolic disease
Liver dysfunction
Pregnancy
500
Q
1st line MHT for vasomotor symptoms of menopause
A
Patch before pill - less risk of blood clots but insurance doesn’t like to pay so oral is often used
501
Q
Starting MHT
A
Increase at one month intervals if still symptomatic
Recommended not to use for more than 5 years - taper
502
Q
Progesterone only therapy for menopause
A
Can be oral or IM if we don’t want estrogen
503
Q
Tissue selective estrogen complex
A
SERM and estrogen
Reduces some of the risk of using a progesterine
504
Q
Oral estrogen and levonorgestrel IUD
A
May or may not help reduce risk of breast cancer - dubious
505
Q
Alternative hot flash pharm and GU symptoms
A
Doesn’t really help except oxybutynin
506
Q
CAM for menopause
A
Isoflavone/Phytoestrogens - soy, lentils, etc.
Black Cohosh
Vitamin E
Weight loss
CBT
Supplements can still have problematic effects
507
Q
Preparations for atrophic vaginitis
A
Ring, cream or tablet - every night for two weeks then two times per week
May use testosterone if estrogen is contraindicated
508
Q
Lobes per breast
A
12-20 lobes
509
Q
Apex of breast
A
Contains major excretory duct
510
Q
Base of breast
A
Near ribs
511
Q
Montgomery glands
A
Sebacecous glands of the areola - help the breast stay healthy while breastfeeding
512
Q
Percent of the breast that is adipose tissue
A
80-85% adipose tissue
513
Q
Coopers ligaments
A
Hold the breast to the chest wall - deeper
514
Q
Beginning age for breast deveopment
A
Ages 10-13
515
Q
Breast changes during menstrual cycles
A
Premenstrual - Epithelial cells proliferate - increased size by a little
Post menstrual - Epithelial cells die off, decreased turgor with some tenderness
516
Q
When does the breast reach full development
A
End of a full term pregnancy only
517
Q
Pregnancy changes of breast
A
Darkened areola - bulls eye for infant
Increased lubrication and milk ducts
Fatty tissue almost completely replaced by glands and ducts
518
Q
Trigger and regulator of breast milk production
A
Progesterone drop triggers and prolactin maintains
519
Q
Menopausal breast changes
A
Atrophy and loss of functional breast tissue
520
Q
Fluids from breast commonality
A
40% of premenopausal women
55% of parous women
75% who have lactated in the past 3 years
521
Q
Physiologic breast discharge
A
Expressed when pressure is applied and from multiple ducts/ both breasts
522
Q
Causes of physiologic breast discharge
A
Normal lactation
Galactorrhea
Benign phys discharge
Can be an intraductal papilloma
523
Q
Classical presentation of galactorrhea
A
Bilateral multiductal milky discharge, otherwise normal PE - may want to test for pregnancy
524
Q
Classic pathologic discharge
A
Unilateral spontaneous bloody for serous discharge from a single duct
Bloody is more suggestive of cancer but also more likely due to benign papilloma
525
Q
Cytology of breast discharge
A
Very los sensitivity - usually skip to imaging
526
Q
Ductography
A
May show a filling defect in cancer - flush contrast into ducts
527
Q
Ductoscopy
A
Use tiny endoscope for viewing
528
Q
Definitive diagnostic for pathologic discharge
A
Microductectomy - excise ducts below areola and send to pathology
529
Q
Gynecomastia
A
Glandular breast tissue in a biologic male
Normal in 60% of pubertal boys - usually resolves in a year
Anabolic steroids
530
Q
Psudogynecomastia
A
Fat tissue that looks like gynecomastia - should not seem a firm tender area beneath the areola - firm
Glandular tissue not enlarged
531
Q
Dx for gynecomastia
A
Elevated PRL or hCG
Can also chack testosterone, estradiol
Thyroid
532
Q
Tx for gynecomastia
A
If painful and persistent for 9-12 months
SERM - raloxifine or tamoxifen
Anastrozole - not recommended long term in teens
533
Q
When would we give testosterone to a male
A
Only for true hypogonadism
534
Q
MCC of mastitis
A
Staph areus
535
Q
Risk factors for mastitis
A
Seen in lactation and nursing in primiparous patients, rare before fifth day postpartum
536
Q
Presentation of mastitis
A
Painful, erythematous lobule in the outer quadrant of the breast 2nd or 3rd week after birth
Systemic signs of infection - high fever not due to simple breast engorgement
Antibody coated bacteria in breast milk
537
Q
Presentation of breast abcess
A
Pitting edema and fluctuation
538
Q
Tx for mastitis
A
Keep draining breast - feed or pump
Local heat, warm compress
Well fitted bra
Instruct on techniques
Acetominophen/ibuprofen
539
Q
Antibiotics for mastitis
A
Dicloxacillin of Keflex
Clinda or Bactrim (not for under 1 month old infants)
540
Q
Abx for severe mastitis
A
Van and Ceftriaxone OR Zosyn
541
Q
Tx for breast abcess
A
I&D with abx tx - oral abx usually not sufficient without draining
542
Q
Non nursing breast abcess - peripheral
A
On side is often because of folliculitis or infected cyst
I&D and mastitis abx
543
Q
Subareolar breast abcess
A
Due to keratin plugged milk ducts behind nipple
Simple I&D not enough
Requires duct excision with biopsy to rule out cancer
544
Q
Breast fat necrosis presentation
A
Presents with nipple and skin retraction
May have signs or hx of trauma
Indistinguishible from breast cancer clinically
Biopsy if persistent
545
Q
Fibrocystic breast changes
A
MCC of cyclic breast pain or mastalgia in women 30-50
Epithelial cells become cystic
May be increased in drinkers and estrogen users
Worsened by caffeine
546
Q
Age of fibrocystic breast changes
A
30-50 - correlated with reproductive age, goes away with menopause
547
Q
Presentation of fibrocystic breast changes
A
Pain or tenderness with lump
Present or worse during the premenstrual phase (later half of cycle)
Multiple lesions that change in size
548
Q
Discharge of fibrocystic breast changes
A
Green or brown
549
Q
Dx for fibrocystic breast changes
A
Mammogram for over 30
US and aspiration -US can be better than an ultrasound to see if lesions are cystic
Be on the lookout for odd one out
550
Q
Tx for fibrocystic breast changes
A
Avoid trauma, well fitting bra
Avoid caffeine
Low fat diet may help
551
Q
Tx for severe fibrocystic breast changes
A
Danazol and Tamoxifen
Surgery for most refractory cases
552
Q
Prognosis for fibrocystic breast changes
A
Will subside with menopause
Usually not associated with breast cancer
553
Q
Fibroadenoma
A
Enlarged lobule in young women - early and mid 30s
Larger with hormones and usually solitary
554
Q
Presentation of fibroadenoma
A
Round, smooth, and nontender mass, discrete
Can dx clinically but usually get image to be sure
555
Q
Fibroadenoma on imaging and def dx
A
Well defined solid mass with benign features
Def. dx is core biopsy or mass excision
556
Q
Phyllodes tumor
A
Can become malignant - similar to a fibroadenoma
557
Q
Tx for fibroadenoma or phyllodes tumor
A
Unclear or rapid growth -surgical excision with wide margins
Can monitor/follow-up fibroadenoma if asymptomatic with biopsy or US breast exam
558
Q
Inheritance pattern of BRCA1 and 2
A
Autosomal dominant
Also causes risk in MEN!!
559
Q
Risk factors for breast cancer
A
Nulliparity
First full term pregnancy after age 30
Early menarche or late menopause (reverse decreases risk)
Combo HRT
Hx of uterine or breast cancer
560
Q
Usual presentation of breast cancer
A
Painless breast mass
Hard, fixed, irregular margins, nonmobile
May see metastatic symptoms first
May also see pain, discharge, erosion, retraction
561
Q
MC site of breast cancer
A
Upper outer quadrant
562
Q
4 positions for breast exam
A
Arms over head
Laying on back with arms up
Arms on hips
Leaning forward
563
Q
Concerning PE findings for breast cancer
A
New unilateral side change in size, contour
Unilateral retraction of nipple
Edema or erythema
Firm, non mobile, matted lymph nodes
564
Q
Main lymph nodes for breast drainage
A
85% goes to axillary but palpate everything
565
Q
Paget’s disease of the breast
A
Eczematoid eruption and ulceration - arises from nipple areola
Pain itching, burning discharge and superficial erosion or ulceration
Biopsy
Excision/Mastectomy to treat
566
Q
Inflammatory carcinoma
A
Diffuse, brawny edema with erysipeloid border
Orange peel skin may be seen
No mass
Aggressive but rare - rule out in refractory or unexplained mastitis
567
Q
BIRAD 1 and 2 on mammogram
A
Okay, anything higher is concerning
568
Q
Definitive diagnosis for breast cancer
A
Biopsy
Fine needle - less invasive but less sensitive
Core needle - MOre invasive better
Can also excise
569
Q
Hormone receptor sites for cancer
A
Can have estrogen, progesterone, and HER2 receptors - change how the cance will metastasize
Triple neg goes to lungs/liver
570
Q
Indication for hormonal therapy
A
Positive for ER/PR/HER2 hormone receptors
571
Q
Tamoxifen
A
Historically drug of choice for hormonal breast cancer - can cause clotting and endometrial cancer
572
Q
Newer treatment for hormonal breast cancer
A
Anastrozole - aromatase inhibitor, more effective than tamoxifen
573
Q
Therapy for non hormonal (triple neg) breast cancer
A
Consider an adjuvant -pembrolizumab (keytruda)
574
Q
Selective estrogen receptor modulators
A
Bind to estrogen receptors and block estrogen SERMs -selective for tissues, tamoxifen is specific to breast tissue
Roloxifene blocks in breast and uterus
575
Q
SEs of SERMs
A
Hot flashes, thin hair, thrombosis
Can stimulate OR inhibit estrogen
576
Q
Aromatase inhibitors
A
Anastrozole, exemastane, letrozole
Inhibit aromatase which produces estrogen
Menopausal symptoms - hot flash, brain fog, thinning hair
Newer for breast cancer
577
Q
Fulvestrant
A
Little brother elacestrant
Destroys estrogen receptors
Used for metastatic breast cancer
No blood clots or cancer
Need receptors to work
578
Q
Breast cancer follow ups
A
Q4 months for 2 years
then Q6 for 3 years for PE
Mammogram in 6 months then yearly
579
Q
Median time of breast cancer recurrence
A
At 4 months
580
Q
Percent of those trafficked who are female and minors
A
55-70% female
About half minors
581
Q
Warning signs of human trafficking
A
Social withdrawal
Physical abuse
Neglect
Practiced hx
Living in unsuitable conditions
582
Q
What to do if you suspect human trafficking
A
Send tip to national hotline
Give resources to patient
DOCUMENT
583
Q
Percent of domestic violence victims who are female
A
85%
584
Q
Women killed by male partner or ex 2001-2012
A
11,766, more than died in the iraq war in the same period
585
Q
DV
A
Domestic violence
Controlling with disregard for wellbeing
586
Q
Risk factors for DV/IPV
A
Race - AA
Pregnancy is a huge risk factor - DV is the leading cause of death in pregnant women
Younger age (16-24)
Childhood exposure to violence
587
Q
Presentation of domestic violence
A
Often vague
Chronic pelvic pain
Sexual dysfunction
Recurrent vaginitis
Anxiety and tearfulness during breast and pelvic exam
588
Q
Body complaints of DV
A
HA
Fatigue
Sleep disturbance
Seems like a somatoform disorder
589
Q
Percent of pregnancies with violence
A
4-9%
590
Q
Cycle of abuse
A
Tension building
Incident
Reconciliation
Calm “Honeymoon” phase
591
Q
Screening for domestic violens
A
Screen everybody at all checkups, especially in pregnancy screen at least once per trimester and postpartum
592
Q
Bestway to screen for domestic violence
A
Do it in person
Say something universal first: Because so many people are abused…..I want to ask
Ask about specific behaviors - not general like “rape” or “abuse”
593
Q
Mandatory report events in WV for abuse
A
Gunshot, Stab, Burn
594
Q
After dx tx for DV
A
Acknowledge trauma
Document with photographs - flag to withold
Assess safety and lethality, substance abuse
Create safety plan
595
Q
What to do if patient does not want to leave abusive situation
A
Don’t place blame
Document
Support patient
Follow up with patient
596
Q
Majority of teenage rapes
A
Acquaintance rape - by someone they know
597
Q
Presentation of sexual assault
A
May say they were mugged, May be asking AIDS or STD screening
60-70% have no obvious physical injury
May have bleeding and vagin*l irritation, few have major injuries
598
Q
Rape trauma syndrome
A
Detached shock like state
Acute phase - hours to days, tired, HA, startled abates after about two weeks
Delayed phase - Months to years, chronic anxiety, mistrust, depression, sexual dysfunction
599
Q
PE for sexual assault
A
Have a trained person do a sexual assault assessment kit
Sexual assault nurse examiner - take care not to tamper with evidence
600
Q
Hx for sexual assault
A
Describe what happened
Any consensual sex
What happened between
Any infections
State “Use of Force”
601
Q
Tx for sexual assault
A
Emergency contraception after pregnancy test - IUD
Ceftriaxone and potentially metronidazole or Doxycycline
Hep B and HIV prophylaxis
HPV vaccine
602
Q
Psych tx for sexual assault
A
Refer to counseling even if they appear calm, admit if unstable
603
Q
Follow up for sexual assault
A
2 weeks - for psych and other issues
604
Q
3 things we need for intact menses
A
Intact HPO axis
Endometrial response to stimulation
Way for blood to exit
605
Q
Primary amenorrhea
A
Have never had a period
Often due to a genetic abnormality
606
Q
Secondary amenorrhea
A
Misses 3 cycles or 6 consecutive months
MCC is pregnancy
607
Q
2nd MCC od secondary amenorrhea
A
PCOS
608
Q
Sheehan’s syndrome
A
Blood loss during birth leads to pituitary necrosis
609
Q
Mullerian dysgenesis
A
No internal female sex hormones except for ovaries
610
Q
Asherman’s syndrome
A
Uterine fibroids cause unable evacuation of blood
611
Q
Anatomical blockages causing amenorrhea - 2
A
Transverse septum
Imperforate hymen
612
Q
Dx for asherman’s syndrome
A
Hyerosalpingogram
613
Q
Progesterone challenge test
A
Give progesterin - if they bleed afterwards they are anovulatory
614
Q
Estrogen and Progesterone challenge test
A
No bleed afterwards means blockage
Bleading afterwards = hypogonadism
615
Q
Secondary dysmenorrhea
A
Casued by something demonstrable
616
Q
Membranous dysmenorrhea
A
Due to passage of a cast of the uterus through the cervix
617
Q
Primary dysmenorrhea
A
No known cause - MC type of dysmenorrhea
618
Q
First line tx for dysmenorrhea
A
NSAID - 400-800 with no more than 1200mg per day
May take prophylactically
Acetaminophen less effective
Continuous heat helps - need a break
619
Q
Erythema ab igne
A
Rash associated with chronic heat pad use
620
Q
2nd line tx for dysmenorrhea
A
Hormonal contraceptives
Lyletta, Morena - Progesterone IUD
621
Q
Percent of women with PMS or PMDD
A
75%
Highest in 20s to 30s
622
Q
Tx for mild to moderate PMS/PMDD
A
Dietary changes - caffeine, alcohol, sodium
Exercise - aerobic
Chasteberry, Calcium carbonate - OTC
NSAID for pain
Spironolactone for bloating
Bromocryptine for breast pain
623
Q
Tx for severe PMS/PMDD
A
SSRI - 1st line with 50% helped, can be used periodically
2nd line - Hormonal therapy
May consider alprazolam
GnRH agonist - put pt in menopause
624
Q
Transvagin*l US taking
A
Need an empty bladder - see pelvic organs
625
Q
Transabdominal US taking
A
Full bladder, less visualization of pelvic organs
626
Q
Sonohysterography
A
Saline injected into intrauterine cavity - increased sensitivity
627
Q
Gold standard for uterine pathology evaluation
A
Hysteroscopy - camera in the uterus
628
Q
Tx for Dysfunctional Uterine Bleeding
A
r/o pregnancy or cancer - oral contraceptives, observation if asymptomatic and no cancer
Levonorgestrel IUD, D&C for short term ablation
629
Q
Postmenopausal DUB
A
MCC - exogenous hormones
Always investigate
May actually be bleeding from vagin*
630
Q
Workup to r/o tumors of reproductive tract in DUB
A
Endometrial sampling
631
Q
Endometrial ablation
A
Need to take birth control, not want to be fertile
Reduces flow in 70-80%
632
Q
Pretreatment for endometrial ablation
A
Abx NOT needed
GnRH agonist or D&C to thin out endometrium
633
Q
CI to endometrial ablation
A
Pregnancy, Desire to have children, Endometrial hyperplasia, Postmenopause, IUD in place
634
Q
Vaporization endometrial ablation
A
Nd-Yag laser
Early method
Scar endometrium
635
Q
Roller ball
A
Similar to vaporization
Old method
636
Q
Endometrial resection
A
Old method - caused a lot of perforation
637
Q
Hysteroscopic thermal endometrial ablation
A
2nd generation
Heated saline put in uterus
Good for anatomic abnormalities
Higher burn risk
638
Q
Radiofrequency thermal ablation endometrial ablation
A
2nd gen
No D&C or progesterin needed
Uses a heasted mesh
639
Q
Thermal + RF Endometrial ablation
A
Brand - Minerva
Silicone contours to shape of cavity
Balloon filled with RF heated Argon gas
Endometrial prep not needed
Higher success rates
2nd gen
640
Q
Water vapor termal endmetrial ablation
A
Seal with baloons and fill with water
2nd gen
Safer
641
Q
Cryoablation endometrial ablation
A
Less pain but less effective
2nd gen
642
Q
Theraml balloon endometrial ablation
A
Use balloon to conform to contours of uterus
No longer done in US - too much burning
643
Q
Sites of endometriosis
A
Other sites in the abdomen
Or distant site outside of the abdomen - can be anywhere
644
Q
Risk factors for endometriosis
A
Fam hx
Early menarchy
Nulliparity
LOng flow
Heavy periods
Shorter cycles
IE. anything that increases menstrual bleeding
645
Q
Presentation of endometriosis
A
Dysmenorrhea
Pelvic pain
Dyspareunia
Infertility
May worsen with period
Severity does not corespond to amount of ectopic tissue
646
Q
PE for endometriosis
A
Tender nodules in posterior vagin*l fornyx
Pain with uterine motion
Tender adnexal masses may be felt
May have no findings
647
Q
Dx for endometriosis
A
Imaging is usually not helpful
Laparoscopy to diagnose definitively
648
Q
Lesions of endometriosis
A
Powder burns
Chocolate cysts
Red/Purple raspberry spots
649
Q
Tx for mild/moderate endometriosis
A
NSAID
Progesterone contraceptives
650
Q
Tx for moderate to severe endometriosis
A
Hormonal - GnRH agonists or antagonists - ie. danazole, letrozole
Gabapentin
TCAs
Surgery
651
Q
Reason to use surgery for endometriosis
A
Do it when they are wanting to have children b/c they can come back
652
Q
Danazol
A
Testosterone derivative that acts like progestin
Inhibits gonadotropic release
SE - Oily skin, acne, deep voice
653
Q
Anastrozole/Letrozole
A
Aromatase inhibitors
Can be used as an adjuvant to Danazol
654
Q
GnRH agonists
A
Leuprolide, Goserelin, Nafarelin
For endometriosis
Use for max 6 months
Menopause like symptoms
655
Q
GnRH antagonists
A
Elagolix (Orlissa)
Most studied
Max 6 months at high or 24 months at low dose
Menopause like symptoms
656
Q
Pelvic inflammatory disease presentation
A
Lower abdominal pain - insidious or acute usually for 2 ish weeks
Oral temp > 101F
Bilateral lower quadrant tenderness
Skene or Bartholin glands around introitus
657
Q
Fitz-Hugh-Curtis syndrome
A
Liver inflammation with PID
658
Q
Classic sign of pelvic inflammatory disease
A
Cervical motion tenderness (chandelier sign
659
Q
Dx for PID
A
Pregnancy test to r/o
WBCs in vagin*l fluid
ESR/CRP may be elevated
660
Q
Imaging for PID
A
May see thickening, tubo-ovarian complex, may be normal
661
Q
Tx for pelvic inflammatory disease
A
Outpatient abx if they are not too sick and compliant, IV for inpatient
3 Drugs at same time:
Rocephin shot
Doxy
Metronidazole
14 day course overall
662
Q
Presentation of tubo-ovarian abcess
A
Tenderness and guarding
Mass in abdomen
Multi-loculated lesion on US
663
Q
Tx for unruptured tubo-ovarian abcess
A
Same abx as PID (Metro, Doxy, Rocephin) but for 4-6 weeks
664
Q
Tx for ruptured tubo-ovarian abcess
A
Life threatening emergency
TAH (total abdominal Hysterectomy) and BSO (bilateral salpingo-oophorectomy) with aggressive fluid resuscitation
665
Q
Cystocele
A
Prolapse of the bladder d/t anterior vagin*l wall weakness. Visualized through the vagin* and better seen when bearing down
666
Q
Rectocele
A
Rectal prolapse d/t posterior vagin*l weakness
Seen in bearing down
667
Q
Uterine prolapse
A
Uterus slides down towards the introitus
668
Q
Pelvic organ prolapse stages 0-4
Halfway system
A
0 - Normal
1 - Halfway to hymen
2 - To hymen
3 - Halfway past hymen
4 - Maximal descent
669
Q
Presentation of pelvic organ prolapse
A
Feeling of heaviness in vagin*, urinary symptoms with cystocele
Talk about putting fingers in vagin* to brace it when urinating/defecating
670
Q
Dx for pelvic organ prolapse
A
Pelvic exam with bearing down
Imaging only if worried about secondary problem
671
Q
Tx for pelvic organ prolapse
A
Pessary - reexamine in 1-2 weeks for first one, then every 2-3 months after that
Kegal exercises
672
Q
Surgical tx for POP
A
May use mesh or other surgery - mesh can cause irritation
673
Q
Adenomyosis
A
Endometrial tissue implants in the myometrium
Focal or diffuse
674
Q
Risk factors for adenomyosis
A
Parity and age
675
Q
Presentation of adenomyosis
A
More areas of invasion = more s/s
Menorrhagia, dysmenorrhea
Global uterine ENLARGEMENT with uterine softening
676
Q
Imaging for adenomyosis
A
TVUS
Focal thickening of myometrium on US
Heterogenous texture on US
677
Q
Tx for adenomyosis
A
NSAIDs for pain
Combo oral contraceptives
Endometrial ablation/resection may help somewhat
678
Q
Definitive tx for adenomyosis
A
Hysterectomy
Symptoms also get better after menopause - ride out
679
Q
Leiomyoma
A
Benign neoplasm of the female genital tract - uterine fibroids
680
Q
Submucous leiomyoma
A
Directly beneath endometrial lining - on the inside!!
681
Q
Subserous leiomyoma
A
Directly beneath serosal lining - on the outside!!
682
Q
Intramural leiomyoma
A
Completely within the myometrium
683
Q
Presentation of leiomyomas
A
Most are asymptomatic
MC symptoms are - Abnormal bleeding, pelvic pressure/pain
May torse - causing pain
May compress nearby organs
684
Q
PE for leiomyomas
A
Enlarged uterus with irregular contour
685
Q
Dx for leiomyomas
A
Iron deficiency on labs
US can detect
MRI for more detail
Hysterography/Scopy can also help
686
Q
Tx for asymptomatic leiomyomas
A
Can monitor with a yearly US - not a big threat to health
687
Q
Tx for sympomatic leiomyomas
A
NSAIDs or hormonal therapy depending on sx
Regress spontaneously during menopause - menopausal hormone therapy may bring it back
688
Q
Surgical tx for leiomyomas
A
Total hysterectomy
Myomectomy - just remove fibroid
Embolization - Clot it up - good results
689
Q
Peak onset for endometrial cancer
A
70s - many cases can occur younger
Obestity increases risk
690
Q
Precursor to endometrial cancer
A
Endometrial hyperplasia
Excess estrogen!!
691
Q
MCC of endogenous over production of estrogen
A
Obesity - From the fat!
692
Q
Other risk factors for endometrial cancer
A
PCOS
Exogenous unapposed estrogen therapy (w/o progestin and no hysterectomy)
More peiords (ie. early menarche, less pregnancies)
693
Q
Risk reduction for endometrial cancer
A
Progestin or combination contraceptives
694
Q
MC symptoms of endometrial hyperplasia
A
Abnormal uterine bleeding
Simple or complex atypia (complex more likely to become cancer but progesterone cures both)
695
Q
Endometrial hyperplasia with atypia
A
More concerning that simple/complex
Progesterone will not cure
696
Q
Type I endometrial cancer
A
Not as aggressive
YOunger patients
Better prognosis
697
Q
Type II endometrial cancer
A
Less common
Poorer prognosis
Independant of estrogen
698
Q
Classic endometrial cancer patient
A
Obese
Nulliparous
Infertile
HTN
DM
White
699
Q
MC type of endometrial cancer
A
Adenocarcinoma
700
Q
Presentation of endometrial cancer
A
Abnormal bleeding in 80% of patients - postmenopausal bleeding may be an indicator
vagin*l discharge
Cervical os stenosis
701
Q
Tx for endometrial cancer WITHOUT atypia
A
Progesterone
702
Q
PE for endometrial cancer
A
May feel inguinal lymph nodes
Normal in early stages
703
Q
Imaging for endometrial cancer
A
US with endometrial thickness over 4 mm is high suspicion for cancer
DDx - Biopsy
704
Q
Other tests that may pick up endometrial cancer
A
D&C - even better than biopsy
Sometimes picked up on pap smear
705
Q
Tx for endometrial cancer
A
Surgery is mainstay - total hysterectomy with BSO - curative in low risk
706
Q
Adjuvant pharm for endometrial cancer
A
Radiation, Progesterone, Chemo - Doxyrubicin and Cisplatin
707
Q
Tx for excess bleeding in endometrial cancer
A
NO IV estrogen like we would with other bleeding
Tamponade and Packing
708
Q
Functional ovarian cysts
A
Due to cyclic ovarian changes - do not always cause symptoms
Can rupture causing peritonitis
Impinge organs
709
Q
Dx for ovarian cyst
A
Pelvic US is MC way to dx
710
Q
Follicular cyst
A
MC type of ovarian cyst
Follicle doesn’t rupture appropriately
Usually asymptomatic
May cause irregular menstual bleeding
711
Q
Management of follicular cyst
A
Usually resolve in 2 months
OCP can keep cysts from forming
May aspirate or surgically remove - usually not necessary
712
Q
Corpus luteum cyst
A
Corpus luteum did not regress
Progesterone abnormalities may lead to late period
Torsion, pain, can look like ectopic pregnancy
713
Q
Tx for corpus luteum cyst
A
Manage symptomatically
OCP questionable
Surgery if problematic
Ring of fire on US
714
Q
Theca Lutein cyst
A
Caused by elevated hCG
Often bilateral and multiple
Resolve once hCG goes down
May aspirate in pregnancy
715
Q
Endometriomas
A
Implant of endometrial tissue on the ovary
Endometriosis symptoms - chocolate cysts
716
Q
Dermoid cyst
A
Filled with improper tissue - fat, teeth, etc.
Not cancer
May rupture
717
Q
Cystadenomas
A
Cysts that get massive - pain and discomfort
Pop, drain, remove
718
Q
PCOS
A
Stein Leventhal syndrome
Enlarged ovaries with multiple cysts
Anovulaotry, amennorheic
Obese, overweight patients
719
Q
Diagnosis of PCOS
A
Pt. with variable periods, obesity, hirsutism, oligomenorrhea
Polycystic ovaries on US - Oyster ovaries
720
Q
Presentation of PCOS
A
Menstural abnormalities, early pregnancy loss, Pelvic pain/pressure, T2DM
Young endometrial cancer dx
Acanthosis nigricans
721
Q
Hormones in PCOS
A
Mild elevation of androgens
Lower sex hormone binding globulin
Increased LH:FSH ratio
722
Q
US of PCOS
A
Ovary with many cysts in it - look like dark pockets
723
Q
Tx for PCOS - conservative
A
Observe symptoms - should be having at least 8 periods a year
Lifestyle changes -loose weight, well balanced diet
724
Q
PCOS moderate therapy
A
Pregnancy test
COC - if not trying to conceive or ring patch if eligible, helps with hyperandrogenism
Progesterone alone - second line
725
Q
PCOS insulin sensitization
A
Metformin is MC drug - safe in pregnancy
May also use GLP-1 agonist
726
Q
Tx for PCOS hirsutism
A
Takes 6-12 months to work
COC or GnRH agonist
Laser removal, etc.
Spironolactone - androgen antagonist
5 alpha reductase inhibitors - finasterid/dutasteride
727
Q
Vaniqua
A
Expensive hair removal medicine
728
Q
Novel PCOS therapies
A
Myo-inositol
NK34 antagonist
729
Q
PCOS tx for patients who want to get pregnant
A
Weight loss and lifestyle
Letrozole on days 3-7 of period
Not safe once pregnant
(Clomid used to be first line - SERM - blocks estrogen in hypothalamus)
730
Q
MOA of letrozoleand 4 SEs
A
Inhibits aromatoase
SE - hot flashes, dizziness, fatigue, pain
731
Q
Clomid for PCOS
A
causes ovarian enlargement, hot flashes, bloating
Not great
732
Q
FLuid retention of PCOS tx
A
Can be extreme - present with hypovolemia and swelling
MC with Clomid, FSH
LC with Letrozole
733
Q
Surgery for PCOS
A
Ovarian drilling - laparoscopic laser biopsies jump start the ovaries
734
Q
Ovarian torsion
A
Emergent condition like testicular torsion
Often due to enlarged ovaries
May occur in early pregnancy
735
Q
Presentation of ovarian torsion
A
Sudden onset severe, one sided unilateral abd pain
Painful adnexal mass
May radiate to thigh, flank, or groin
Women may be used to abdominal pain!!
736
Q
Dx for ovarian torsion
A
Sonography - dx of choice
Bull’s eye, whirlpool, snailshell pattern
Doppler flow disruption
Do pregnancy test
Transvagin*l US may be better
737
Q
Tx for ovarian torsion
A
Laparoscopic detorion ( can do laparotomy)
Remove cyst causing problem
Remove if 12+ hours - obvious necrosis
738
Q
MC source of ovarian cancer
A
Epithelial ovarian cells
739
Q
Ovarian cancer
A
CA-125 marker - from serous cystadenomas
Typical in menopausal patients
740
Q
Other types of ovarian cancer
A
Germ cell tumor - younger patients
Sex cord stromal tumors
741
Q
Risk factors for ovarian cancer
A
Anything that increases cell turnover
Talcum powder
742
Q
Presentation of ovarian cancer
A
Vague early symptoms
Early satiety
Fatigue, back pain
Late - abdominal pain, ascites, solid irregular adnexal mass
743
Q
Sister Mary Joseph nodule
A
Belly button nodule due to ovarian cancer
744
Q
CA-125 marker for ovarian cancer
A
Elevated in 50% of ovarian cancer
Associated with many other things - fibroids, endometriosis
More specific for postmenopausal women
745
Q
Dx for ovarian cancer
A
Various markers
Pelvic US w/ solids, separation, ascites
CT/MRI for more exact
Bx for definitive
746
Q
Tx for ovarian cancer
A
Remove omentum, ovaries, uterus
Watch CA-125 to see if cancer resolved
747
Q
Tx for germ cell ovarian cancer
A
Often try to save the uterus - not as aggressive
748
Q
MC GYN malignancy
A
Uterine cancer
Ovarian - 2nd
749
Q
Sexual response stages - 4
A
Desire
Arousal
org*sm
Resolution
750
Q
Hormones that increase libido
A
Estrogen
Testosterone - uspraphysiologic
Dopamine
Norepinephrine
Oxytocin
Melanocortins
751
Q
Hormones that inhibit libido
A
Serotonin - at high levels
Prolactin
Opioids
Endocannabinoids
752
Q
Average female puberty onset
A
8-13 years old
753
Q
MC sexual dysfunction in women
A
Low sexual desire - 39% of disorders
754
Q
Female arousal/interest disorder
A
Low desire or abnormal arousal - must occur 75%+ of the time, lasts for 6+ months
Causes distress
755
Q
6 criteria for female interest arousal disorder
A
Must report 3:
Absent interest in sex
Reduced fantisizing
Reduced initiation
Reduced interest/arousal to stimuli
Reduced excitment/pleasure
Reduced sensation
756
Q
Genitopelvic pain/Penetration disorder
A
Pain majority of time with sex
TIghtening of muscles
Avoid vagin*l sex
Common hx of trauma or abuse
757
Q
Female org*smic disorder
A
Don’t feel like they finish the way they want to
May be due to neuropathy, partner issues, etc.
758
Q
Medications related to sexual disorders
A
SSRI!
TCA
Benzos
Lithium
Anticholinergic
HTN meds - BB
SERM/Aromatise inhibitors
759
Q
Estrogen for sexual disorders
A
Increases libido, vagin*l lubrication, blood flow to genitalia
CI - Blood clots, endometrial cancer
Recommended if more than just libido
760
Q
Androgens for sexual disorders
A
Generally not recommended - may be used in menopause
Cause hirsutism, acne, liver disease
Last line
761
Q
Dosing testosterone for women
A
Much lower dose than used for men
762
Q
Serotonin/Dopamine for sexual disorders
A
Flibanserin - post menopause serotonin agonist/modulator helps with SE of SSRI
CI with alcohol, hypotension
763
Q
Bupropion for sexual dysfunction
A
Helps with norepi and dopamine
Helps with arousal response, etc.
CI in seizures, anorexia, MAOI use
764
Q
PDE-5 inhibitors in womens sexual dysfunction
A
Slidenafil
Most helpful with physiologic problems - ie. vascular, neuro
CI with nitrates
765
Q
Bremelanotide
A
Agonist of melanocortin receptors for sexual dysfunction
New drug -PRN injection stop if no benefit in 6 weeks
CI in liver disease, pregnancy
766
Q
Other tx for female org*smic disorder
A
Sexual devices
Directed masturbation - usually best for partner not to participate at first
No scientific evidence for genital cosmetic precedures
767
Q
Tx for sexual pain disorders
A
Lubricants and estrogen for vagin*l atrophy
PT for pelvic floor if estrogen fails
768
Q
Tx for vaginismus
A
PT, Counseling, Gabapentin/Botox
769
Q
Tx for vulvodynia
A
Lidocaine, TCA, Remove irritants, PT
770
Q
MC symptom of cevicitis
A
Discharge -many are asymptomatic
771
Q
Cervicitis v. Vaginitis
A
Discharge see from cervcle os in cervicitis
772
Q
Strawberry cervix
A
Indicates trichom*oniasis
773
Q
Presentation of chronic cervicitis
A
Often asymptomatic
Discharge - less than acute
vagin*l bleeding
Cervical tenderness
Proximal vagin* may look okay
Urethritis, pelvic pain
774
Q
Microscopic analysis for cervisitis
A
Gram stain, Wet mounts - clue cells
KOH prep
PCR
775
Q
Pap smear/ Colposcopy for cervicitis
A
Double hairpin capillaries for trichom*onas
Excess leukocytes
Cell enlargement - HPV
Multinucleated cells with ground glass cytoplasm - HSV
776
Q
Biopsy where cell properties have changed
A
Indicative of a virus!!
777
Q
Cervicitis prevention and screening
A
Barrier contraception
Routine screening in 19-25
Remove cervix with hysterectomy
778
Q
Incompetent cervix
A
Cervix shortens before 28 weeks gestation
Painless
779
Q
Risk factors for cervicle insufficiency
A
Cervical conization or Hx of previous episode
780
Q
Presentation of cervical insufficiency
A
2+ cm dilation with minimal contractions
2nd trimester
781
Q
Screening for cervical insufficiency
A
US at 14-16 weeks
Look for funneling and shortening abnormalities
No way to predict
782
Q
4 cervical insufficiency abnormalities
A
TYVU - Trust Your vagin*l Ultrosound
Shape of cervix -increasing risk and progression from T to U
783
Q
Tx for cervcal insufficiency
A
Circlage
784
Q
3 things to look for before circlage -Contraindications
A
Make sure fetus is still viable 1st
Rupture of membranes
Look for infection - treat first
785
Q
Pharm tx for cervical insufficiancy
A
Adjunct to circlage - progesterone
786
Q
Nabothian cysts
A
Blocked glands on the cervix
Smooth rounded, whitish area that does not hurt
Benign!!
787
Q
CIN I-III
A
I - 1/3
II - 2/3
III - In theory entire cervix
788
Q
When do we NOT treat CIN I and II
A
Pregnant women - wait for delivery
Adolescents - observe at first
789
Q
Main risk factor for cervicle dysplasia
A
HPV!!!
790
Q
Pap smear screening
A
Start at 21 3 years
Every 3 years or PAP+HPV every 5 years 30-65
791
Q
Pap screening after 65
A
Stop screening if:
No hx of mod-severe dysplasia/cancer
3 negative Pap or 2 neg PAP+HPV
792
Q
ASC-US cells on pap smear
A
Undetermined significance
793
Q
ASC-H cells on pap smear
A
Cannot exclude a high grade lesion
794
Q
LGSIL/LSIL on pap smear
A
Corresponds to CIN I
795
Q
HGSIL or HSIL on pap smear
A
Corresponds to CIN II or III
796
Q
Atypical glandular cells
A
Rare - cells from endocervix - MAY indicate cancer, may not
797
Q
Management for ASC-US
A
2 pap smears over 6 months - send for colposcopy if abnormal
Might try vagin*l estrogen
798
Q
Management for anything that is NOT ASC-US
A
Send for colposcopy
799
Q
Colposcopy
A
Low power magnification of cervix - uses camera
Add acetic acid to light up abnormal areas
Bx abnormal areas
800
Q
Indications for colposcopy - 5
A
Abnormal pap smear
Clinically abnormal cervix
Unexplained bleeding
Vulvar/vagin*l neoplasia
Hx of in utero DES exposure
801
Q
Tx for CIN II-III after biopsy
A
Surgery with evaluation afterwards
802
Q
Management of cervical dysplasia - cryotherapy
A
Probe to blanch tissue in cervical os - 7mm margin
Makes it hard to visualize for later colposcopy
803
Q
Carbon dioxide laser for cervical dysplasia
A
More often in operating room
Very precise
More depth of excision
Can biopsy
804
Q
Loop electrosurgical excision procedure
A
LEEP - Small wire loop to remove with electrical generator
Can biopsy
Best procedure
For cervical dysplasia
805
Q
Cold knife
A
Cervical displasia
For large areas
No risk to being able to biopsy
806
Q
Prognosis for cervical dysplasia
A
80-90% success rates for any method
807
Q
Risk factors for cervical dysplasia recurrence -4
A
Large lesions
Gland involvement
Positive margins
Positive endocervical curretage
808
Q
MC type of cervical cancer
A
Squamous cell carcinoma
809
Q
Presentation of cervical cancer
A
MC symptom = Abnormal vagin*l bleeding
Bloody leukorrhea, spotting, postcoital
810
Q
Late signs of cervical cancer
A
Fistula to recum or bladder leading to incompetence
Radiating pain
Weight loss, fever
811
Q
Signs of cervicle cancer
A
Cervix appears abnormal
Ulceration
812
Q
Endophytic cervix
A
Barrell shape, enlarged - cancer
813
Q
Exophytic cervix
A
Friable, bleeding, cauliflower lesions
814
Q
Dx for cervical cancer
A
Cancer may be present despite negative cytology - if the cervix look suspicious, still suspect
815
Q
Tx for cercal cancer
A
Radical hysterectomy with lymphadenectomy
Chemo is mostly palliative
816
Q
Normal vagin*l flora
A
Aerobes, anaerobes, yeast
Lactobacilli that make it acidic
817
Q
Normal vagin*l pH before and after menopause
A
Before - 4-4.5
After - 6.5-7
818
Q
Things that can alter vagin*l flora
A
Low estrogen - decrease
Menses - Increase
Abx
Pregnnacy, Hysterectomy
Foreign substances
DM/Poor diet - worse
819
Q
Candidal vulvovaginitis presentation
A
Often in DM
Pruritis
THick white cottage cheese discharge
Minimal odor
820
Q
Dx for vulvovagin*l candidiasis
A
Normal pH
Branching filaments and psudohyphae on wet prep/KOH
821
Q
Pharm tx for vulvovagin*l candidiasis
A
Azole - 1st line ie. fluconazole
May extend therapy for recurrent cases
822
Q
Alternative vulvovagin*l candidiasis tx
A
Boric acid
Gentian violet
823
Q
vagin*l antifungal administration
A
Administer at night
824
Q
MOA of azoles
A
Inhibit enzyme for cell membrane synthesis
825
Q
MOA of nystatin
A
Increase permeability of cell walls
826
Q
Ibrexafungerp MOA
A
Inhibits glucan synthesis - cell wall production
DO NOT TAKE with an azole
827
Q
MOA of boric acid
A
Interferes with metabolism
CI in pregnancy
828
Q
Gentian Violet MOA
A
May inhibit protein synthesis
Not many drug interactions
829
Q
Presentation of bacterial vaginosis
A
Milky, hom*ogenous, malodorous discharge
No inflammation
Malodorous esp. after intercourse - fishy
830
Q
Dx of bacterial vaginosis
A
vagin*l pH 5.5-7
Clue cells - covered in bacteria
Fishy odor on KOH prep - wiff test
831
Q
Tx for Bacterial vaginosis
A
Metronidazole or Clinda
Can also use an expensive -azole
832
Q
MOA of metronidazole
A
Bind to and deactivate enzymes
Dizziness, HA, Fatigue
Disulfiram reaction
833
Q
Clindamycin MOA
A
Binds to ribosomes
C diff - and not with imodium
834
Q
vagin*l douche
A
Washing out of vagin* - only for bacterial vaginosis - NOT for regular cleaning
835
Q
Presentation of trichom*onal vaginitis
A
Frothy, copious green, foul smelling vagin*l discharge
Strawberry cervix
836
Q
Dx for trichamoniasis
A
pH 5-5.5
Motile wet prep - look at right away before they die
Culture = Best test
837
Q
Tx for trichom*onal vaginitis
A
Metronidazole or other ~idizole’s
Cross reactivity to alcohol
Liver disease
838
Q
Presentation of gonorrhea
A
80-85% asymptomatic
Copious mucopurulent discharge
839
Q
Dx for gonorrhea
A
Nucleic acid probe
Or culture of discharge
840
Q
Tx for gonorrhea
A
One shot IM rocephin
Treat partners
841
Q
CHlamydia presentation
A
Cervicitis, dysuria, bleeding
May progress to PID or lymphogranuloma venereum
CERVIX MAY LOOK NORMAL
842
Q
Dx for chlamydia
A
Culture
Immunoassay
Pap smear
843
Q
Tx for chlamydia
A
Doxycycline
ALT: Zmax
844
Q
Noninfectious vaginitis
A
Irritants, Allergens (latex), Atrophic, Excess sexual behavior
845
Q
Presentation of noninfectious vaginitis
A
Itching with no bacteria detectable - get a good hx
846
Q
Tx for noninfectious vaginitis
A
Lubricants
SERM
Sitz bath
Steroid if very painful/inflamed
847
Q
Alternitive tx for vaginitis
A
White vinegar - better option
Herbals
Iodine
Tea tree oil
May kill of good bacteria!
848
Q
Presentation of genital herpes
A
Vescicles that become painful erosions or ulcers
My have a buringing prodrome with inguinal lymphadenopathy
849
Q
Dx for genital herpes
A
Most often clinical
Tzank smear
850
Q
Initial tx for herpes outbreak
A
7-10 days valacyclovir, Famcyclovir, Acyclovir
1-5 days for recurrent
Same drugs for prophylaxis
851
Q
Condyloma acuminatum MC strains
A
MC HPV 6-11
852
Q
Presentation of condyloma
A
Culiflower growths - can be anywhere
May also be flat with rough surface
853
Q
Before tx analysis for condyloma
A
PAP smear and biopsy
854
Q
Tx for condyloma
A
Cryotherapy
Podofilox, Imiquimod, Interferon
855
Q
Molluscum contagiousum cause
A
Pox virus
856
Q
Presentation of molluscum contagiosum
A
Up to 1cm sized umbilicated papules
Inclusion bodies in cell cytoplasm
857
Q
Tx for molluscum contagiosum
A
Dessication, Freezing, Imiquimod
May observe - can cause scarring when removed
858
Q
Presentation of syphillis - 3 stages
A
1 - Painless sore
2 - Palm and sole rash
3 - Involves heart, brain, etc.
859
Q
Tx for Syphillis
A
PCN 1st line
ALT: Doxy
860
Q
Bartholin gland disease
A
Glands near vagin*l orifices get infected or plugged
Red flag post menopause
861
Q
Presentation of bartholin gland disease
A
Tenderness - have to duck waddle
Fluctuant tender mass
Systemic signs of infection
862
Q
Tx for bartholin gland disease
A
Draining won’t help
Catheter inflation
Marsupialization - create a pouch
Check for cancer post menopause
863
Q
Abx for Bartholin gland disease
A
Usually not needed - may still use for prophylaxis
864
Q
Lichen sclerosis
A
MC non-neoplastic epithelial vulvar disorder
Usually women over 60
865
Q
Presentation of lichen sclerosis
A
Pruritis is MC sx
May see pain, white lesions, dyspareunia
866
Q
Progression of lichen sclerosis
A
Erythema w/ no response to yeast tx
White plaques develop
Scratching worsens and inflammation does
867
Q
Chronic presentation of lichen sclerosis
A
Ciggarette paper
Phimosis of cl*toral hood
Labial fusion
General loss of structure
868
Q
Complication of lichen sclerosis
A
SCC - send for biopsy
869
Q
Tx for lichen sclerosis
A
Potent steroid - Clobetasol with a taper BID to QD eventually PRN for life
870
Q
Adjuncts for lichen sclerosis
A
Antihistamine, Tacrolimus, Methotrexate
871
Q
Lichen Simplex Chronicus
A
Due to a specific trigger or chrinic irritation
No loss of structure like in Lichen Sclerosis
Lots of itching
872
Q
Dx of LSC
A
Biopsy of lesion
873
Q
Tx for LSC
A
Hygeine and Sitz bath
Medium potency steroid - fluocinolone, triamcinolone)
874
Q
Lichen planus
A
Flat white plaques on vagin*
Papules on skin
Send to GYN for biopsy
Steroids
875
Q
Dark non cancer vulvar lesions
A
Melanosis lentigo, etc.
876
Q
Vulvar varicosities
A
Common in pregnancy, concerning in elderly or non-pregnant
Sclerosing agent to tx
877
Q
Preinvasive vulvar disease
A
Strong association with HPV
White hyperkeratotic papules with pruritis
Dx through biopsy
878
Q
Tx for preinvasive vulvar disease
A
More aggressive for higher grade
Excision, ablations, laser
879
Q
Paget’s disease - vulvar
A
Itching, soreness
Red velvet cake presentation with white plaques
Can cause structural breakdown
880
Q
Tx for paget’s disease
A
WIDE local excision - need to recheck
Stop as soon as possible
Very poor prognosis if mets to lymph nodes
881
Q
Vulvectomy
A
Partial or radical
Removes area of skin +/- lymph nodes
Not great - last resort for cancer
882
Q
Vulvar cancer
A
90% SCC
Older patients with chronic inflammation or HPV
883
Q
Presentation of vulvar cancer
A
Itching or macerous skin lesion
May just be a “weird spot” w/ no sx
884
Q
Tx for vulvar cancer
A
Remove tumor - excise
Rad vulvectomy - may radiate to reduce
Pelvic exenteration if widespread
885
Q
Pelvic exenteration
A
Removal of everything in the pelvis - diversion of GI and GU tracts
886
Q
vagin*l Intraepithelial Neoplasia
A
vagin* rather than vulva
Colposcopy andbx to dx
Condylomatous lesions or flat and granular
887
Q
Tx for Preinvasive vagin*l disease
A
Resection, 5FU not as effective
Difficult to get everything out
888
Q
True vagin*l cancer
A
Not spread from the cervix
HPV, Smoking are RF
889
Q
vagin*l SCC
A
Exophytic or ulcerative lesions in the upper 1/3 of vagin*
890
Q
vagin*l adenocarcinomas
A
MC vagin*l primary tumor in young patient
891
Q
vagin*l sarcoma
A
Highly aggressive with grape like masses
Older pts -upper vagin*l wall
892
Q
vagin*l melanoma
A
Usually towards the distal vagin*
893
Q
Tx for vagin*l cancer
A
Exenteration, Radiation
Poor prognosis
