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PANCE Prep Pearls > Reproductive System > Flashcards

Reproductive System Flashcards

1
Q

Female Tanner Staging: Stage 1

A
  • Breast: Papilla elevation only
  • Pubic hair: None
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2
Q

Female Tanner Staging: Stage 2

A
  • Breast: breast buds palpable, areola enlarge
  • Pubic hair: Small amount (long, downy hair on the labia)
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3
Q

Female Tanner Staging: Stage 3

A
  • Breast: Elevation of areola contour, areola continues to enlarge
  • Pubic hair: Hair becomes more coarse and curly with lateral extension
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4
Q

Female Tanner Staging: Stage 4

A

Breast: secondary mound of areola

Pubic hair: Adult-like, extends across pubis

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5
Q

Female Tanner Staging: Stage 5

A

Breast: Adult breast contour

Pubic Hair: Extends to thighs

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6
Q

What is the most common etiology of dysfunctional uterine bleeding (DUB)?

A

Chronic anovulation (90%)

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7
Q

Workup of DUB (2)

A
  1. Hormone levels, transvaginal US
  2. Endometrial biopsy done if endometrial strip >4mm on transvaginal US or in women >35 years old to r/o endometrial hyperplasia or carcinoma
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8
Q

DUB treatment: acute severe bleeding

A
  1. High dose estrogens, high dose OCPs with reduction in dose as bleeding improve.
  2. D&C if IV estrogen fails
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9
Q

DUB treatment: anovulatory cause (3)

A
  1. OCPs
  2. Progesterone: used if estrogen is CI
  3. GnRH agonists: Leuprolide causes temporary amenorrhea
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10
Q

DUB treatment: ovulatory cause (3)

A
  1. OCPs
  2. Progesterone: orally or IUD
  3. GnRH agonists (leuprolide)
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11
Q

DUB treatment: Surgical options (2)

A
  1. Hysterectomy (definitive treatment)
  2. Endometrial ablation
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12
Q

Primary dysmenorrhea

A

Not due to pelvic pathology. Due to increased prostaglandins. Pain usually 1-2 years after onset of menarche in teenagers

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13
Q

Secondary dysmenorrhea

A

Due to pelvic pathology (ex: endometriosis, adenomyosis, leiomyomas, adhesions, PID). MC seen as women age

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14
Q

Dysmenorrhea: Management (3)

A
  1. NSAIDs. Supportive: local heat, vitamin E 2 days prior and 3 days into menses
  2. OCPs/Depo-provera/vaginal ring
  3. Laparascoopy: If medications fails (endometriosis MC in younger patients, adenomyosis in increasing age)
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15
Q

What is premenstrual syndrome?

A

Cluster of physical, behavioral, mood changes with cyclical occurrence during luteal phase of menstrual cycle and at least 7 days symptom free during the follicular phase

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16
Q

What is premenstrual dysphoric disorder (PMDD)?

A

Severe PMS with functional impairment

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17
Q

Premenstrual syndrome: Management (5)

A
  1. SSRIs
  2. OCPs: Drosperinone-containing OCP for PMDD
  3. GnRH
  4. Refractory breast pain: Danazol, bromocriptine
  5. Bloating: Spironolactone, calcium carbonate, low salt diet
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18
Q

Amenorrhea work-up

A

Pregnancy test, prolactin, FSH, LH, TSH

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19
Q

What is primary amenorrhea?

A

Failurue of onset of menarche by age 13 years (in the absence of secondary sex characteristics) or age 15 years (with secondary sex characteristics)

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20
Q

Amenorrhea: If the uterus and breasts are present, what may it signify?

A

Outflow obstruction: Transverse vaginal septum, imperforate hymen

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21
Q

Amenorrhea: If the uterus is absent but the breasts are present, what may this signify? (2)

A
  1. Mullerian Agenesis (46 XX)
  2. Androgen insensitivity (46 XY)
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22
Q

Amenorrhea: If the uterus is present, but the breasts are absent, what may this signify? (2)

A
  • Elevated: Increased FSH, Increased LH = ovarian causes
    • Premature ovarian failure (46 XX)
    • Gonadal dysgensis (ex: Turner 45XO)
  • Normal/Low: Decreased FSH, Decreased LH
    • Hypothalamus-pituitary failure
    • Puberty delay (ex: athletes, illness, anorexia)
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23
Q

Amenorrhea: If the uterus and breasts are absent, what may this signify?

A

Rare. Usually caused by a defect in testosterone synthesis. Presents like a phenotypic immature girl with primary amenorrhea (will often have intrabdominal testes)

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24
Q

What is secondary amenorrhea?

A

Absence of menses for 3 months in a patient with previously normal menstruation (or 9 months in a patient who was previously oligomenorrheic)

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25
Q

Secondary amenorrhea: hypothalamus dysfunction etiologies (5)

A
  1. Hypothalamus disorder
  2. Anorexia (or weight loss 10% below IBW)
  3. Exercise
  4. Stress nutritional deficiencies
  5. Systemic disease (ex: Celiac)
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26
Q

Secondary amenorrhea: Hypothalamus dysfunction diagnosis

A

Normal/low FSH and LH; low estradiol, normal prolactin

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27
Q

Secondary amenorrhea: hypothalamus dysfunction treatment

A

Stimulate gonadotropin secretion: clomiphene, menotropin (pergonal)

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28
Q

Secondary amenorrhea: Pituitary dysfunction diagnosis

A

Decreased FSH, LH, Increased prolactin. MRI of pituitary sella

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29
Q

Secondary amenorrhea: pituitary dysfunction treatment

A

Transsphenoidal surgery (tumor removal)

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30
Q

Secondary amenorrhea: ovarian disorder clinical manifestations

A

sx of estrogen deficiency (similar to menopause): hot flashes, sleep & mood disturbances, vaginal dryness, dyspareunia, dry/thin skin

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31
Q

Secondary amenorrhea: lab levels for ovarian abnormalities

A
  1. Increased FSH
  2. Increased LH
  3. Decreased estradiol
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32
Q

Secondary amenorrhea: lab values for pituitary or hypothalamus causes

A
  1. Normal/Decreased FSH, LH
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33
Q

With the progesterone challenge test, if there is withdrawal bleeding, what does this signify?

A

Ovarian (patient is anovulatory or oligoovulatory) and there is enough estrogen present

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34
Q

With the progesterone challenge test, if there is no withdrawal bleeding, what does this signify?

A
  1. hypoestrogenic ex. HP failure OR
  2. Uterine (ex: Asherman’s or uterine outflow tract [imperforate hymen])
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35
Q

What is Asherman’s syndrome?

A

Acquired endometrial scarring usually secondary to postpartum hemorrhage, s/p D&C or endometrial infection

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36
Q

Secondary amenorrhea: Uterine disorder diagnosis (2)

A
  1. Pelvic US: absence of normal uterine stripe.
  2. Hysteroscopy: to diagnose and treat
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37
Q

Secondary amenorrhea: uterine disorder treatment

A

Estrogen treatment: to stimulate endometrial regeneration of denuded area

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38
Q

What is adenomyosis?

A

Islands of endometrial tissue within myometrium

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39
Q

Adenomyosis: clinical manifestations (2)

A
  1. Menorrhagia (progressively worsens)
  2. Dysmenorrhea, +/- infertility
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40
Q

Adenomyosis: Physical examination

A

Tender symmetrically (uniformly) enlarged “boggy uterus”*, “globular” enlargement

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41
Q

Adenomyosis: Diagnosis (2)

A
  1. Diagnosis of exclusion of secondary amenorrhea. MRI
  2. Post-TAH examination of uterus: definitive dx
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42
Q

Adenomyosis: Treatment (2)

A
  1. Total abdominal hysterectomy (TAH): only effective therapy
  2. Conservative tx: to preserve fertility, analgesics, low dose OCPs
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43
Q

What is a leiomyoma?

A

Benign uterus smooth muscle tumor. MC benign gynecological lesion

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44
Q

Different types of leiomyomas

A

Intramural, submucosal, subserosal, parasitic

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45
Q

Which population is at the highest risk of having leiomyomas?

A

African-Americans

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46
Q

Leiomyoma: diagnosis

A

Pelvic US: shadowing. Also used to observe for growth

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47
Q

For the majority of patients, what the treatment of leiomyomas?

A

Observation

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48
Q

Medical management of leiomyomas (2)

A
  1. Progestins (ex: medroxyprogesterone)
  2. Leuprolide: Most effective medical tx
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49
Q

Surgical management of leiomyomas (3)

A
  1. Myomectomy: used especially to preserve fertility
  2. Endometrial ablation, artery embolization. May affect fertility
  3. Hysterectomy: Definitive tx***. MC cause for hysterectomy
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50
Q

MC organisms in endometritis (4)

A

GABHS, S. aureus, anaerobes, polymicrobial (vaginal flora)

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51
Q

With endometritis, in patients who have given birth via C-section, what is the antibiotic treatment that is given to prevent endometritis?

A

1st generation cephalosporin x 1 dose during c-section (cefazolin)

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52
Q

Endometritis: Diagnosis

A

Clinical: pts with fever, abdominal pain, and uterine tenderness esp. with C-section or postabortal

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53
Q

Endometritis: Management (2)

A
  1. Infection with C-section: Clindamycin + Gentamicin
  2. Infection with vaginal delivery or chorioamnionitis: Ampicillin + Gentamicin
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54
Q

MC sites of endometriosis

A

Ovaries*, posterior cul-de-sac, broad & uterosacral ligaments, rectosigmoid colon, bladder & distal ureter

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55
Q

Endometriosis: Risk factors (3)

A
  1. Nulliparity
  2. Family history
  3. Early menarche
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56
Q

Classic triad of endometriosis (3)

A
  1. Cyclic premenstrual pelvic pain +/- low back pain
  2. Dysmenorrhea
  3. Dysparenunia; dyschezia (painful defecation). Pre-post menstrual spotting
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57
Q

What is the most common cause of infertility in women?

A

Endometriosis

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58
Q

Endometriosis: Diagnosis (2)

A
  1. Laparoscopy with biopsy: definitive diagnosis*
  2. Endometrioma (endometriosis involving the ovaries large enough to be considered a tumor, usually filled with old blood appearing chocolate colored [chocolate cyst])
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59
Q

Endometriosis: Medical management (4)

A
  1. Premenstrual pain: Combined OCPs + NSAIDs
  2. Progesterone tx
  3. Leuprolide (GnRH analog)
  4. Danazol (testosterone)
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60
Q

Endometriosis: Surgical management (2)

A
  1. Conservative laparoscopy with ablation (used if fertility is desired)
  2. TAH-BSO (if no desire to conceive)
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61
Q

Endometrial hyperplasia: clinical manifestations

A

Menorrhagia, metrorrhagia, postmenopausal bleeding, +/- vaginal discharge

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62
Q

Endometrial hyperplasia: Diagnosis (2)

A
  1. Transvaginal US (TVUS): >4 mm* (screening test)
  2. Endometrial biopsy: definitive diagnosis**
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63
Q

When is an endometrial biopsy used with endometrial hyperplasia? (

A
  1. Women >35 years old
  2. Increased endometrial strip seen on TVUS
  3. Unopposed estrogen tx
  4. Tamoxifen
  5. Atypical glandular cells on Pap smear or persistent bleeding despite endometrial stripe <4mm
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64
Q

Endometrial hyperplasia without atypia: Treatment (2)

A
  1. Progestin tx (PO or IUD-Mirena)
  2. Repeat endometrial biopsy in 3-6 months
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65
Q

Endometrial hyperplasia with atypia: Treatment (2)

A
  1. Hysterectomy
  2. Progestin tx if not surgical candidate or pt wishes to preserve fertility
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66
Q

What is the MC gynecological CA in the US?

A

Endometrial cancer

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67
Q

Endometrial Cancer: With the endometrial biopsy, what is the most common subtype of endometrial cancer?

A

Adenocarcinoma (>80%)

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68
Q

Endometrial cancer: Treatment (2)

A
  1. Stage I: Hysterectomy +/- psot op radiation treatment
  2. Stage II: TAH-BSO + lymph node excision + post-op radiation treatment
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69
Q

What is the most effective treatment for menopausal symptoms?

A

Estrogen only

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70
Q

Risks of estrogen only HRT (2)

A
  1. Thromboembolism
  2. Increased risk of endometrial cancer (often used in patients with no uterus)
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71
Q

What coud vaginal bleeding + abdominal pain + amenorrhea signify?

A

Threatened abortion (MC), ectopic, nonviable pregnancy

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72
Q

Pelvic organ prolapse: Grades

A

Grade I: descent into upper 2/3 of vagina

Grade II: cervix approaches introitus

Grade III: Outside introitus

Grade IV: entire uterus outside the vagina - complete prolapse

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73
Q

Pelvic organ prolapse: Prophylactic treatment

A

kegel exercises, weight control

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74
Q

Pelvic organ prolapse: nonsurgical treatment (2)

A
  1. Pessaries
  2. Estrogen treatment
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75
Q

Pelvic organ prolapse: surgical treatment (2)

A
  1. Hysterectomy
  2. Uterosacral or sacrospinus ligament fixation
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76
Q

Pharmacologic treatment for stress incontinence

A
  1. Alpha agonists: Midodrine, pseudoephedrine
  2. Estrogen: Cream or estradiol-impregnated vaginal ring
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77
Q

Pharmacologic treatment for urge incontinence (3)

A
  1. Anticholinergics (1st line meds): Tolterodine, propantheline, oxybutynin
  2. TCAs: Imipramine
  3. Mirabegron: Beta-3 agonist
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78
Q

Pharmacologic treatment for overflow incontinence (2)

A
  1. Cholinergics: bethanacol
  2. Alpha-1 blockers: Tamsulosin (for BPH)
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79
Q

Functional ovarian cysts: Treatment (2)

A
  1. Supportive: Most cysts <6-8 cm are functional and usually spontaneously resolve. Rest. NSAIDs, repeat pelvic US in 6 weeks.
  2. OCPs
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80
Q

Functional ovarian cysts: complications (2)

A
  1. Ovarian torsion
  2. Bleeding
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81
Q

What is the second most common type of gynecological cancer that also has the highest mortality of all gyn cancers?

A

Ovarian cancer

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82
Q

Ovarian cancer: Risk factors (5)

A
  1. +FH
  2. increased number of ovulatory cycles (infertility, nulliparity, >50 yo)
  3. BRCA1 & BRCA2
  4. Peutz Jehgers
  5. Turner’s syndrome
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83
Q

Ovarian cancer: PE (3)

A
  1. Abdominal or ovarian mass, ascites*
  2. Sister Mary Joseph’s node: METS to umbilical lymph nodes
  3. Constipation
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84
Q

Ovarian cancer: Diagnosis (2)

A
  1. Biopsy: 90% are epithelial tumors (seen esp. postmenopausal). Germ cell tumors in pts <30 years
  2. Transvaginal US useful screening in high risk patietns. Mammography to look for primary in breast
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85
Q

Ovarian cancer: Management (3)

A
  1. Early stage: TAH-BSO + selective lymphadenectomy
  2. Surgery: Serum Ca-125 levels are used to monitor treatment progress*
  3. Chemotherapy: Paclitaxel + Cisplastin or carboplatin
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86
Q

What is the MC type of benign ovarian neoplasm?

A

Dermoid cystic teratomas

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87
Q

Benign ovarian neoplasms: treatment

A

Surgery

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88
Q

PCOS: Labs

A

Increased testosterone, increased DHEA-S (Intermediate of testosterone); Increased LH: FSH ratio 3:1

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89
Q

Anti-adrogenic agents for hirustism in PCOS

A

Spironolactone*, leuoprolide, finasteride

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90
Q

Pap smear results: Negative for intraepithelial lesion or malignancy (no neoplasia)- No HPV management (4)

A

Follow routine PAP screening

  1. Every 2 years starting age 21 until 29 y
  2. Every 3 years ≥30y (if h/o 3 negative cytologies previously)
  3. Yearly if HIV, in-uteruo DES exposure, increased risk factors
  4. D/C age 65-70 y (if last 3 PAP’s were normal)
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91
Q

Pap smear results: Negative for intraepithelial lesion or malignancy (no neoplasia): Greater than 25 yo and HPV management (2)

A

Two options:

  1. cytology and HPV testing in 12 months OR
  2. Genotype for HPV 16, 18
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92
Q

ASC-US: Management if greater than 25 (2)

A

Two possible options

  1. Do HPV testing*: HPV negative –> repeat PAP and HPV cotesting in 3 years; HPV positive –>colposcopy with biopsy
  2. Repeat PAP in 1 y. If negative, resume PAP screening. Colposcopy if positive
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93
Q

ASC-US or LSIL Management if 21-24yo

A

Repeat PAP in one year or HPV testing

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94
Q

ASC-US Management if <21 yo

A

Repeat PAP in one year

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95
Q

ASC-H Management

A

Colposcopy allows for visualization of cervix using magnification after applying dilute acetic acid for accentuation of lesions

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96
Q

LSIL (inlcudes CIN I): Management for 25-29yo

A

Colposcopy with biopsy

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97
Q

LSIL (includes CIN I): Management for ≥ 30yo (2)

A
  1. HPV negative –> repeat cytology in 1 year
  2. HPV positive –> colposcopy with biopsy
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98
Q

HSIL (Includes CIN II, CIN III, and carcinoma in situ) Management

A

Colposcopy in all ages

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99
Q

Pap smear: Glandular cell abnormalities management (2)

A
  1. Colposcopy for all glandular cells abnormalities
  2. Glandular abnormalities may be indicative of endometrial hyperplasia
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100
Q

LSIL (CIN I) : Managment (3)

A
  1. Observation: 75% resolve by immune system within one year. May be an option if <20 y
  2. Excision: LEEP procedure or cold knife cervical conization
  3. +/- Ablation
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101
Q

HSIL (CIN 2, CIN 3, and carcinoma-in-situ) Management (2)

A
  1. Excision: LEEP, cold knife cervical conization
  2. Ablation: Cryocautery, laser cautery, electrocautery
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102
Q

2 types of cervical carcinomas

A

Squamous (90%) and adenocarcinoma (10%)

Clear cell carcinoma linked to DES

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103
Q

Cervical carcinoma: Stage 0 (carcinoma in situ) treatment (3)

A
  1. Exicision (LEEP, cold knife cervical conization); preferred
  2. Ablation tx (cryotherapy or laser)
  3. TAH-BSO
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104
Q

Cervical carcinoma: Stage Ia1 (microinvasion)

A

Surgery: Conization, TAH-BSO, XRT

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105
Q

Cervical carcinoma: Other Stage I, IIA

A

TAH-BSO; XRT + chemo tx (cisplatin)

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106
Q

Cervical carcinoma: Stage IIb-IVa (locally advanced) management

A

XRT + Chemo (Cisplatin +/- 5FU)

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107
Q

Cervical carcinoma: Stage IVb or recurrent (distant METS)

A

Palliative XRT, chemo (surgery is not likely to be curative)

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108
Q

What is cervical insufficiency (incompetent cervix)?

A

Premature cervical dilation especially in 2nd trimester

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109
Q

Cervical insufficiency: PE

A

Painless dilation and effacement of cervix

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110
Q

Cervical insufficiency: Management (2)

A
  1. Bed rest, weekly injection of 17 α-hydroxyprogesterone (increases progesterone)
  2. Cerclage (suturing of cervical os)
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111
Q

What is the most common subtype of vulvar cancer?

A

90% squamous

112
Q

Vulvar cancer: clinical manifestations (2)

A
  1. Pruritus MC presentation (70%), vaginal itching, irritation
  2. Asymptomatic (20%). Post-coital bleeding, vaginal discharge
113
Q

Vulvar cancer: diagnosis

A

Red/white ulcerative, crusted lesions. Biopsy

114
Q

Vulvar CA: Treatment (4)

A

Surgical excision, XRT, chemo (ex: 5-FU), laser treatment

115
Q

Vulvovaginal atrophy: management (3)

A
  1. Vaginal estrogens
  2. Ospemifene: SERM (estrogen agonist in vagina; antagonist in breast, uterus)
  3. Vaginal moisturizers (won’t help with atrophy)
116
Q

What is the MC cause of vaginitis?

A

Bacterial vaginosis

117
Q

MC organisms for bacterial vaginosis

A

Gardnerella vaginalis, anaerobes

118
Q

Bacterial vaginosis: Vaginal discharge

A

Thin, homogenous, watery grey-white “fish rotten” smell

119
Q

Bacterial vaginosis: urinary pH

A

>5

120
Q

Bacterial vaginosis: Microscopic (2)

A
  1. Clue cells*
  2. Few WBCs, few lactobacilli
121
Q

Bacterial vaginosis: Management (2)

A
  1. Metronidazole (Flagyl) x 7 days
  2. Clindamycin
122
Q

Trichomoniasis: vaginal discharge (3)

A
  1. Copious malodorous discharge
  2. Frothy yellow green discharge*
  3. Strawberry cervix* (cervical petechiae)
123
Q

Trichomoniasis: pH

A

>5

124
Q

Trichomoniasis: Microscopic (2)

A
  1. Mobile protozoa (wet mount)
  2. WBCs
125
Q

Trichomoniasis: Management (2)

A
  1. Metronidazole (Flagyl): Oral preferred
  2. Tinidazole
126
Q

Trichomoniasis: Prevention (2)

A
  1. Spermicidal agents
  2. MUST TREAT PARTNER
127
Q

Candida vulvovaginitis: vaginal discharge

A

Thick curd-like/cottage cheese discharge

128
Q

Candida vulvovaginitis: urinary pH

A

Normal

129
Q

Candida vulvovaginitis: Microscopic

A

Hyphae, yeast on KOH prep

130
Q

Candida vulvovaginitis: Management (2)

A
  1. Fluconazole
  2. Intravaginal antifungals: Clotrimazole, nystatin, butoconazole, miconazole
131
Q

Cytolytic vaginitis: Pathophysiology

A

Overgrowth of lactobacilli

132
Q

Cytolytic vaginitis: vaginal discharge

A

Nonodorous discharge white to opaque

133
Q

Cytolytic vaginitis: Urinary pH

A

Normal

134
Q

Cytolytic vaginitis: Management (2)

A
  1. Discontinue tampon usage (to decrease vaginal acidity)
  2. Sodium bicarbonate (sitz bath or douche)
135
Q

What is the MC cause of cervicitis?

A

Chlamydia

136
Q

Chlamydia: Diagnosis (2)

A
  1. LCR test most spp/sensitive
  2. Cultures, DNA probe
137
Q

Chlamydia: Treatment (2)

A
  1. Azithromycin OR doxycycline
  2. Treat for gonorrhea
138
Q

Chlamydia: second line treatment (2)

A
  1. Erythromycin, ofloxacin, levofloxacin
  2. Cultures, DNA probe
139
Q

Chlamydia: Prevention

A

Avoid sexual intercourse 7d after treatment

140
Q

Chlamydia: Complications

A

PID, infertility, ectopic pregnancy, premature labor

141
Q

Gonorrhea: Diagnosis

A

Culture, DNA

142
Q

Gonorrhea: Management (3)

A
  1. Ceftriaxone IM
  2. Cefixime
  3. Treat for chlamydia
143
Q

Gonorrhea: Complications (2)

A
  1. PID, infertility, ectopic pregnancy
  2. Reactive arthritis
144
Q

Chancroid: Clinical manifestations (3)

A
  1. Genital ulcer: soft, shallow, painful*
  2. +small vesicles or papules
  3. PAINFUL inguinal LAD
145
Q

Chancroid: Management (4)

A
  1. Azithromycin
  2. Ceftriaxone IM
  3. Erythromycin
  4. Ciprofloxacin
146
Q

PID: Outpatient treatment

A

Doxycycline + ceftriaxone (cover gonorrhea & Chlamydia) OR clindamycin + gentamicin

147
Q

PID: Inpatient treatment

A

Doxycycline + 2nd generation cephalosporin (ex: Cefoxitin or Cefotetan)

148
Q

Toxic shock syndrome: Diagnosis

A

CBC, cultures, clinical. Isolation of organism is NOT required

149
Q

Toxic shock syndrome: Management (3)

A
  1. Hospital admission, supportive measures
  2. Anti-staphylococcus abx x 1-2 weeks: Clindamycin + Oxacillin or Nafcillin
  3. If MRSA: Clindamycin + Vancomycin (or Linezolid)
150
Q
A
151
Q

Management of cystitis in pregnancy

A
  1. amoxicillin*, augmentin, cephalexin, macrobid, cefpoxidime, fosfomycin
  2. Sulfisoxazole
152
Q

SERM (tamoxifen) is an agonist in what systems?

A

Bone, endometrium, liver, and coagulation system

153
Q

Ectopic pregnancy: Physical examination

A

Cervical motion tenderness, adnexal mass

154
Q

Indications for methotrexate in ectopic pregnancy

A

Hemodynamically stable patients, early gestation <4 cm, beta-HCG <5,000

155
Q

Shoulder dystocia: nonmanipulative treatment

A

McRoberts maneuver

156
Q

Shoulder dystocia: manipulative treatment

A

Woods “Corkscrew” maneuver; C section

157
Q

What is a hydatidiform mole?

A

Neoplasm due to abnormal placental development with trophoblastic tissue proliferation arising from gestational tissue (not maternal) origing

158
Q

What is a complete molar pregnancy?

A

Egg with no DNA fertilized by 1 or 2 sperm. 46XX all paternal chromosomes. Associated with a higher risk of malignant potential (choriocarcinoma development)

159
Q

Gestational Trophoblastic Disease (Molar pregnancy): Clinical manifestations (4)

A
  1. Painless vaginal bleeding
  2. Uterine size/date discrepancies
  3. Hyperemesis gravidarum
  4. Choriocarcinoma
160
Q

With choriocarcinoma, where is the most common METS location?

A

Lungs

161
Q

Gestational Trophoblastic Disease (Molar Pregnancy): Diagnosis (2)

A
  1. Beta-HCG: Markedly elevated (>100,000)
  2. Ultrasound: “Snowstorm” or “cluster of grapes” appearance
162
Q

Gestational Trophoblastic Disease (Molar Pregnancy): Treatment (2)

A
  1. Uterine suction curettage ASAP
  2. METS: chemotherapy (ex: Methotrexate*) destroys trophoblastic tissue
163
Q

When is gestational DM usually diagnosed?

A

24-28 weeks of gestation

164
Q

Gestational DM: Pathophysiology

A

Caused by placental release of human placental lactogen (HPL), which antagonizes insulin

165
Q

Gestational DM: Diagnosis (3)

A
  1. Screening: 50g oral glucose challenge test (nonfasting) @ 24-28 weeks gestation. If >140mg/dL in one hour –> proceed to 3 hour oral GTT
  2. 3 hour 100g oral GT: Gold standard*
  3. Glucosuria
166
Q

When is a 3 hour oral GTT considered to be positive?

A

1 hour >180

2 hour >155

3 hour >140

167
Q

Gestational DM: Treatment (3)

A
  1. Insulin: Tx of choice! (does not cross the placenta)
  2. Glyburide: higher risk of eclampsia
  3. Early delivery @ 38 weeks
168
Q

With gestational DM, what is the fasting glucose goal?

A

<95

169
Q

Gestational DM: Insulin requirements (2)

A
  1. NPH/regular insulin: 2/3 in the AM and 1/3 in the PM
  2. 0.8 IU/kg 1st trimester; 1.0 IU/kg in 2nd trimester; 1.2 IU/kg in 3rd trimester
170
Q

RH alloimmunization: Clinical manifestations

A
  • If subsequent newborn is Rh positive: hemolytic anemia, jaundice, kernicterus, hepatosplenomegaly
  • Fetal hydrops, congestive heart failure in the newborn
171
Q

What is fetal hydrops?

A

Fluid accumulation in 2 spaces: Pericardial effusion, ascites, pleural effusion, SQ edema

172
Q

When is RhoGAM given in the mother?

A

At 28 weeks gestation and also within 72 hours of delivery of the Rh positive fetus

173
Q

Treatment of erythroblastosis fetalis in the newborn (in Rh alloimmunization)

A

Moderate to severe anemia treated with Ag negative RBCs through ultrasound-guided umbilical vein transfusion

174
Q

Premature rupture of membranes (PROM): Risk factors (4)

A
  1. STDs
  2. Smoking
  3. Prior pre-term delivery
  4. Multiple gestations
175
Q

PROM: Diagnosis (3)

A
  1. Nitrazine test: amniotic fluid pH>7.1
  2. Fern test: amniontic fluid: fern pattern
  3. Sterile speculum exam: look for infection
176
Q

PROM: Management (2)

A
  1. Await for spontaneous labor or induction of labor (with oxytocin or prostaglandin gel)
  2. Monitor for infection (infection MC complication of PROM)
177
Q

If the cervical dilation is ≥3 cm and the effacement is 80%, what is the diagnosis?

A

Premature labor (PTL)

178
Q

If the cervical dilation is 2-3 cm and the effacement is <80%, what is the diagnosis?

A

Premature labor likely

179
Q

If the cervical dilation is ≤2 cm and the effacement is <80%, what is the diagnosis?

A

PTL unlikely

180
Q

Premature labor: diagnosis (3)

A
  1. Tocolytics: Given for 48 hours to delay delivery so steroids can take full effect on the fetus
  2. Antenatal corticosteroids
  3. Antibiotics: GBS prophylaxis if needed (penicillin G)
181
Q

Tocolytics given in premature labor (4)

A
  1. Beta2 agonist: Terbutaline, ritodrine
  2. Magnesium sulfate
  3. Nifedipine: not given concurrently with Mg
  4. Indomethacin
182
Q

S/E of terbutaline

A

pulmonary edema

183
Q

1st-line anti-emetics given in hyperemesis gravidarum

A

Pyridoxine (vitamin B6) +/- doxylamine

184
Q

Threatened abortion: Definition (2)

A
  1. Pregnancy may be viable (progress) or abortion may follow
  2. MC cause of 1st trimester bleeding
185
Q

Threatened abortion: Products of conception

A

No POC expelled from the uterus

186
Q

Threatened abortion: Cervical os

A

Closed

187
Q

Threatened abortion: Clinical manifestation (3)

A
  1. Bloody vaginal discharge (Spotting–>profuse)
  2. +/- contraction of uterus
  3. Uterus size compatible with dates
188
Q

Threatened abortion: management (3)

A
  1. Supportive
  2. Serial beta-HCG to see if doubling
  3. No sex or douching
189
Q

Inevitable abortion: definition

A

Pregnancy not salvageable

190
Q

Inevitable abortion: Products of conception

A

No POC expelled

191
Q

Inevitable abortion: Cervical os (2)

A
  1. Progressive cervix dilation (>3 cm, effaced)
  2. +/- Rupture of membranes
192
Q

Inevitable abortion: Clinical manifestation (3)

A
  1. Moderate bleeding >7 days
  2. Moderate-severe uterus cramping
  3. Uterus size compatitble with dates
193
Q

Inevitable abortion: Management (2)

A
  1. D&E 2nd trimester, suction curettage in 1st
  2. RhoGAM if indicated
194
Q

Incomplete abortion: Definition

A

Pregnancy not salvageable

195
Q

Incomplete abortion: Products of Conception

A

Some POC expelled, some retained

196
Q

Incomplete abortion: Cervical os

A

Dilated

197
Q

Incomplete abortion: Clinical manifestation (3)

A
  1. Heavy bleeding
  2. Mod-severe cramping
  3. Retained tissue. Boggy uterus
198
Q

Incomplete abortion: Management (3)

A
  1. D&C in 1st, D&E after 1st
  2. Pitocin
  3. RhoGAM if indicated
199
Q

Complete abortion: Definition

A

Pregnancy not salvageable

200
Q

Complete abortion: Products of conception

A

All POC expelled from uterus

201
Q

Complete abortion: Cervical os

A

Usually closed

202
Q

Complete abortion: Clinical manifestation (2)

A
  1. Pain, cramps, and bleeding usually subsides
  2. Pre-pregnancy size of uterus
203
Q

Complete abortion: Management

A

RhoGAM if indicated

204
Q

Missed abortion: Definition

A

Embryo not viable but retained in uterus

205
Q

Missed abortion: Products of conception

A

No POC expelled

206
Q

Missed abortion: Cervical os

A

Closed

207
Q

Missed abortion: Clinical manifestation (2)

A
  1. Loss of pregnancy sx
  2. +/- brown discharge
208
Q

Missed abortion: Management (2)

A
  1. D&C if 1st trimester, D&E OR
  2. Misoprostol
209
Q

Septic abortion: Definition

A

Retained POC becomes infected –>infection of uterus and organs

210
Q

Septic abortion: Products of conception

A

Some POC retained

211
Q

Septic abortion: Cervical os (2)

A
  1. Closed
  2. Cervical motion tenderness
212
Q

Septic abortion: Clinical manifestation (3)

A
  1. Foul, brownish discharge, fevers, chills
  2. Uterine tenderness
  3. Spotting –> heavy bleed
213
Q

Septic abortion: Management (3)

A
  1. D&E to remove POC +
  2. Broad spectrum abx
  3. +/- Hysterectomy if refractory
214
Q

Placenta Previa: Definition

A

Abnormal placental implantation on or close to cervical os

215
Q

Placenta Previa: Clinical manifestations (2)

A
  1. 3rd trimester bleeding - sudden onset of PAINLESS bleeding (bright red)
  2. No abdominal pain; uterine soft and nontender
216
Q

Placenta Previa: Fetal heart rate

A

Normal

217
Q

Placenta Previa: Diagnosis

A

Pelvic US

218
Q

Placenta Previa: Management (3)

A
  1. Hospitalization
  2. Stabilize fetus (tocolytics, amniocentesis)
  3. Delivery when stable
219
Q

When is a C-section done in placental previa?

A

If it is complete

220
Q

Placenta Previa: Risk factors

A

Multiparity, increasing age

221
Q

Abruptio placenta: Definition

A

Premature separation of placenta from the uterine wall

222
Q

Abruptio placenta: Clinical manifestations (3)

A
  1. 3rd trimester bleeding - continuous and often dark red
  2. Severe abdominal pain* (painful uterine contractions), rigid uterus*
  3. +/- back, abdominal pain, shock sx
223
Q

Abruptio placenta: Fetal HR

A

Fetal bradycardia (fetal distress!!)

224
Q

Abruptio placenta: Diagnosis (2)

A
  1. Pelvic US
  2. Do not perform a pelvic exam
225
Q

Abruptio placenta: Management (2)

A
  1. Hospitalization
  2. Immediate delivery: may lead to DIC
226
Q

Abruptio placenta: Risk factors (6)

A
  1. Maternal HTN MC cause
  2. Smoking, etoh, cocaine
  3. Folate deficiency
  4. High parity
  5. Increased age
  6. chorioamnitis
227
Q

Vasa previa: Definition

A

Fetal vessels traverse the fetal membranes over the cervical os

228
Q

Vasa previa: Clinical manifestations

A

Rupture of membranes ⇒ PAINLESS vaginal bleed

229
Q

Vasa previa: Fetal HR

A

Fetal bradycardia (fetal distress!!)

230
Q

Vasa previa: Diagnosis

A

Pelvic US

231
Q

Vasa previa: Management

A

Immediate C-section

232
Q

Preeclampsia: Definition

A

HTN + Proteinuria* +/- edema after 20 weeks gestation

233
Q

Preeclampsia: Diagnosis (mild)

A
  1. BP ≥ 140/90 on 2 separate occasions @ least 6 hours apart
  2. Proteinuria ≥300mg/24 hr (or >1+ on dipstick)
234
Q

Preeclampsia: Diagnosis: Severe

A
  1. BP ≥160/110
  2. Proteinuria: ≥5g/24h (or >3+ on dipstick)
  3. Oliguira (<500 ml/24h)
  4. Thrombocytopenia, +/-DIC
  5. HELLP syndrome
235
Q

Preeclampsia: Management (Mild)

A
  1. Delivery is the only cure (performed at 34-36 weeks)
  2. Steroids to mature lungs 26-30w
  3. Supportive: daily weights, BP and dipstick weekly, bed rest
236
Q

Preeclampsia: Management (severe)

A
  1. Delivery is the only cure (Performed at 34-36 weeks)
  2. Hospitalization: low salt, Mg sulfate
  3. BP meds: started if BP ≥180/110
237
Q

BP meds used in pregnancy

A

Hydralazine*, labetalol, nifedipine

238
Q

Eclampsia: Definition

A

Seizures or coma* in patients who meet preeclampsia criteria

239
Q

Eclampsia: Clinical manifestations (2)

A
  1. Abrupt tonic clonic seizures**
  2. +/- HA, visual changes, cardiorespiratory arrest
240
Q

Eclampsia: Diagnosis (2)

A
  1. Same as preeclampsia + seizures
  2. Hyperreflexia
241
Q

Eclampsia: Management (4)

A
  1. ABCDs 1st
  2. Mg sulfate: for seizures (Lorazepam 2nd line)
  3. Delivery of fetus: once pt is stabilized
  4. BP meds: Hydralazine*, labetalol
242
Q

What is DOC for chronic HTN in pregnancy?

A

Methyldopa

243
Q

Ladin’s sign

A

Uterus softening after 6 weeks

244
Q

Hegar’s sign

A

Uterine isthmus softening after 6-8 weeks gestation

245
Q

Piscacek’s sign

A

Palpable lateral bulge or softening of uterus cornus 7-8 weeks gestation

246
Q

Goodell’s sign

A

Cervix softening 4-5 weeks gestation

247
Q

Chadwick’s sign

A

Cervix and vulva bluish color 8-12 weeks

248
Q

When is fetal heart tones first heard and what is the normal rate?

A

10-12 weeks. Normal is 120-160 bpm

249
Q

When does a pelvic US detect a fetus?

A

5-6 weeks

250
Q

When is quickening (fetal movement) first noticed?

A

16-20 weeks

251
Q

When is triple screening (alpha-fetoprotein, beta-HCG, estradiol) first measured?

A

15-20 weeks

252
Q

Down syndrome: Alpha-fetoprotein, beta-HCG, and estradiol levels

A
  1. Alpha-fetoprotein: Low
  2. Beta-HCG: High
  3. Estradiol: Low
253
Q

Open neural tube defects (ex: spina bifida): Alpha-fetoprotein, beta-HCG, and estradiol levels

A
  1. Alpha-fetoprotein: High
  2. Beta-HCG: N/A
  3. Estradiol: N/A
254
Q

Trisomy 18: Alpha-fetoprotein, beta-HCG, and estradiol levels

A
  1. Alpha-fetoprotein: Low
  2. Beta-HCG: Low
  3. Estradiol: Low
255
Q

When is GBS screening done?

A

35-37 weeks

256
Q

APGAR score: Appearance (skin color changes)

A

0=Blue all over

1=Acrocyanosis (body pink but blue extremities)

2= Pink baby (no cyanosis)

257
Q

APGAR score: Pulse

A

0=0

1=<100

2=≥100

258
Q

APGAR score: Grimace

A

0=No response to stimulation

1=Grimaces feebly

2=Cry or pull away

259
Q

APGAR score: Activity

A

0=None

1=Some flexion

2=Flexes arm and legs resist extension

260
Q

APGAR score: Respiration

A

0=Absent

1=Weak, irregular

2=Strong cry

261
Q

Post-partum hemorrhage: etiologies (2)

A
  1. Uterine atony: MC cause
  2. Others: uterine rupture, congestion, bleeding d/o, DIC
262
Q

Post-partum hemorrhage: Risk factors (3)

A
  1. rapid or prolonged labor
  2. Overdistended uterus
  3. C-section
263
Q

Post-partum hemorrhage: Management (2)

A
  1. Uterotonic agents: Oxytocin IV, misoprostol
  2. Bimanual massage. Treat the underlying cause.
264
Q

Fibrocystic breast disorder: Clinical manifestations (2)

A
  1. Usually multiple, mobile, well demarcated areas in breast tissue. Often tender*, bilateral. Often no axillary involvement nor nipple discharge.
  2. Breast cysts may increase or decrease in size with menstrual hormonal changes
265
Q

Fibrocystic breast disorder: Diagnosis (3)

A
  1. US
  2. Biopsy shows straw-colored fluid (no blood)
  3. +/- Seen on mammogram
266
Q

Fibrocystic breast disorder: Management

A

Most spontaneously resolve. Can do FNA of fluid if symptomatic

267
Q

Fibroadenoma of the breast: Clinical manifestations (3)

A
  1. Smooth, well-circumscribed, mobile rubbery lump with no axillary involvement or nipple discharge
  2. Gradually grows over time and does not usually wax and wane with menstruation*
  3. May enlarge in pregnancy
268
Q

Fibroadenoma of the breast: Management

A

Most small tumors resorb with time. +/- excision (not usually done)

269
Q

Breast CA: Types (3)

A
  1. Ductal carcinoma
  2. Lobular carcinoma
  3. Medullary, mucinoid, tubular, papillary, metastatic, mammary Paget’s disease
270
Q

Breast CA: Ductal carcinoma (2)

A
  1. Infiltrative ductal carcinoma MC (75%). Associated with lymphatic METS especially axillary
  2. Ductal carcinoma in situ (DCIS). Does not penetrate the basement membrane.
271
Q

Breast CA: Lobular carcinoma (2)

A
  1. Infiltrative lobular carcinoma
  2. Lobular carcinoma in situ (may not progress but associated with risk of invasive BRCA in either breast)
272
Q

Breast CA: Clinical manifestations (2)

A
  1. Breast mass that is usually painless, hard, fixed (non-mobile) lump*
  2. Unilateral nipple discharge (may be bloody)
273
Q

Which medication is useful for breast CA tumors that are ER (estrogen receptor) positive?

A

Anti-estrogen (Tamoxifen)

274
Q

Which medication is useful for postmenopausal ER positive breast CA patients?

A

Aromatase inhibitors (ex: Letrozole, Anastrozole, Exemestane)

275
Q

Which medication is useful for HER2 positivity in breast CA patients?

A

Monoclonal Ab treatment (Trastuzumab [Herceptin], Lapatinib)

276
Q

Which medications can be used in postmenopausal women or women >35 years old with a high risk of breast CA?

A

Tamoxifen or Raloxifene (SERM). Treatment is usually for 5 years. Tamoxifen is preferred. Aromatase inhibitors are an alternative.

277
Q
A

PANCE Prep Pearls (7 decks)

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