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Flashcards in GYN Deck (54):
1

ovarian cysts

in postmenopausal women--> consider malignancy

bening: common in reproductive age
-many resolve on own

most common type is functional ( follicular test),
- resolve in 60 days

dx: sonogram
management: observation 30-60 days
-follicular or theca lutein- surgical evaluation is present

nonfunctional: endometraiona ( chocolate cyst)-- surgery

2

PCOS

# 1 cause of androgen excess ad hirsutism

- bilat cysts

- presentation: hirsutism, infertility
- women with regular periods in young years and in 20s periods are very

sonogram/labs: string of pearls, oyster ovaries
elevated androgen, high FSH, LH, lipid abnormality , insulin resistant

tx: OCPs, DepoProvers, weight loss

if wants pregnancy:climid with metformin

3

ovarian cysts- neoplastic masses

bening neoplastic process
- serous cyst adenoma- -uniloular, most common

-bening cystic teratoma- mobile on long pedicles ( have teeth and hair)

mangement: surgery

4

ovarian cancer

2nd gyn malignancy
- mean age 69

RF: BRCA 1 gene, fix, nulliparity, late menopause, caucuasian/ asian, diet high in sat fat

screenin: biannual pelvic exam
-sonogram not done for routine screening

tumor types: epilethial

s/s: early - most asymptomatic
later: abd distenction, pain, early satiety, urinary frequency, change in bowel habits

exam: fixed, bilat nodualr pelvic mass, abd distenion, ascities, sister mary joseph's nodule in the umbilicus

dx: sonogram, biopsy

tumor markers: CA 125 and CEA

tx: TAH/ SBO

chemo -IV or IP

-rad tx

5

Pap smear screening

who gets tested:

women under 21 should be tested regardless of sexual initiation
- 21-29- every 3 years
30-65- Pap and HPV every 5 years or Pap one every 3 years

over 65--> previous normal Paps- no testing

h/o pre-cancer- Paps 20 years after that dx


check for statement of adequacy: most have endocervical cells,

if adequate:
negative, atypical squamous cells, low grade spumous, or high grade , or cancer

management:
ASCUS- repeat 4-6 months, if second is same do colposcopy

ASC-H, LSIL, HSIL-colposccopy/ bx/ HPV testing

treat histology not pap results

CIN1- repeat in 6- 12 months
HPV DNA testing

CIN1 or C1N3- cryotherapy
cold knife conization, or LEEP

6

cervical cancer

3rd most common

RF: early sex, too man sex partner, HPV, smoking
16, 18, 31, 33

squamous cell

s/sx: post-coital bleeding

exam: cervix if friable

dx: pap and bx

tx TAH
Stage 3/ 4 chemo and rad tx

7

cytocele/ retocele/ uterine prolapse

common after menopause

-cystocele- prolapse of bladder into ant wall of vagina

-retocel- herniation of rectum into post wall

uterine prolapse- prolapse vaginal canal

sx: vaginal fullness or pressure, feeling of incomplete voiding/ defecation

tx: topical estrogen therapy ( cystocele)
-pessary
-kegel exercises
-surgcial repair

8

mastitis

- occurs inf breastfeeding women
- caused by nipple trauma
- s. aureus

sx: unlit, erytheamt, tenderness
-fever/ child

tx: dicloxacilin, cefalexin, erythro
- continue breast feeding on affected side

9

breast abscess

farther along mastitis
-localized mass
-f/c

management: I and D
IV abx- vancomycin
stop breastfeeding
pump and dump

10

fibrocystic breast

- sxs: painful cystic billet breast pain, size of cyst fluctuate during menstrual cycle

exam; bilat cysts that vary in size
sonogram- fluid filled cysts

tx: conservation, reduce caffeine, increase vitamin e, tamoxifen, or bromocritpin

11

fibroadenoma

-AA, 20 years of puberty
-painless and unlit
-mobile

s/s: painless uniat lump

dx: sonogram- smooth, uniform, solid, FNA ( no fluid)
-watched,
large- surgery

12

breast cancer

most common cause in women, 2nd MC cause of cancer

RF: BRCA 1 and 2
-prolonged use of unopposed estrogen
-early menarche, late menopause, late first pregnancy, nulliparty, over 40
- high fat diet
-obesity
-hyperplasia with fibrocystic breast

mammogram screening:
If average risk:
start at 40
40-40--> every 1-2 years
> 50-- every year

Genetic RF: 25-35
not accurate
consider MRI

tumor types 80% infiltrating ductal
- painless, stony hard unlit mass
-infiltrating lobular- 10%
-inflammatory- 2%
-Paget's dz- 1% ( rash on her breast and tried anti-fungal cream)

sx: painless mass in URQ, nipple d/x, erosion.

dx: 90% seen on exam
u/s
mammogram
FNA
open bx

surgery: 1 cm

hormone therapy-HR positive( tamoxifen and AI)

Zometa to dec fx

13

menopause

mean age 51
-low estrogen

changes: cessation of sense, hot flashes, dec vaginal lubrication, depression, mood swings

late changes: CAD

- everything dries up and falls down

FHS> 30 diagnostic

tx: HRT-contervial
used for hot flashes and dryness

CI: liver dz, thrombosis, CA of breast or endometrial

alternative tx:
hot flashes- depo vera, SSRI, yoga, acupuncture

osteopsosi: calc with vitamin d

vaginal dryness

14

vaginitis

candida:
RF: HIV, DM, abx
s/sx: thick white
10% KOH pseudonyme
tx: diflucan po or single dose or azole cream

bacterial vaginosis
-smells bad, d/c worse after menses, scant/ sticky, clue cells,
flagyl 500 mg bid X 7 days
-think about cost

trichomonas - sexual awtiviy, copious d/c, green/ yellow frothy ( strawberry cervix), protozoa, flagyl 2 g po X 1 dose

flagyl- avoid ETOH and sun

15

chlamydia

most common of STI

RF: sex

16

gonorrhea

- vaginal itching or penile itching

-cervical motion tenderness
-dissementiated infection
-cause of septic arthritis ( wrist, elbows, knee, ankles)
-macular papular leions on hands and feet


tx: zithromax X 1 dose
or ceftrixome

tx partners

17

HPV

most common STI in women

- subtype 6 and 11 are being
16, 18, 31, 33- cause cervical cancer

-cauliflower -like warts on external genitalia, anus, cervical

dx: HPV DNA testing, clinical on PAP
tx: small lesions
-podophyllin, imiquimod
large lesions: cryotherapy or surgery

prevention gardais vaccine
girls and boys 9-26
16, 18,

18

pelvic inflame dz

- bacteria starts in uterus and works its way up bilat

pathogens: chlamydia- dos common, gonorrhea,

RF: age 20, prior PID, prior douche


sx: bilat pelvic pain, back pain down the legs

exam: mucopurlent cervical d/c
-cervical motion tenderness


dx: cervcial cx
-elevatd WBC
-sonogram

d/d: ectopic, appendicitis, pyelonephritis

tx: inpatient- pelvic access, fever above 102, pregnancy, unreliable pt

outpatient: ceftriazone IM single dose +doxcycyline po X 14 days

19

contraception

NPF- tracking a women menstrual cycle,
avoid sex 48 hours before and after this time
- check Basal body temp and monitor cervical mucous
failure rate: 25%

barrier methods "
condoms- protects gains STI, diaphragm ( bladder irritation), cervical cap
, spermicides

advantage: low SE profile, low cost

hormonal method
estrogen and progesterone - 3 weeks and 1 week off ( get periods

monphasic- dose is stay

-advantage- in monogamous relationship

OrthoEva- path changed once a week X 3 weeks
failure rate 1%

Nuva Ring-
leave in for 3 weeks and then come out for menses

- estrogen suppress FSH so follicle won't mature
- no ovulation
-mucous is thicker


benefits: dec endometrial can, ovarian cyst, dysmneoorhea, fiber breast

CI: pregnancy, H/o: dat, breast/ endometrial cancer, melanoma, abn liver function tests

20

progesterone only

-taken daily
- take same time every day
- good breastfeeding
- women > 40

Depo Provea- IM every 3 months
- return of ovulation up to 18 months
( good for teenagers)
SE: weight gain, mood changes,
only use for 2 years
calcium loss

SQ Rods: left 3-5 years
cannot take oral
ovulation start promptly after removal

SE: scarring

- MOA: ovulation interrupted

CI: breast ca and liver tumors

21

IUD

replace every 5-10 years
-wire in winning of future
-multi-parous women
- smokers > 35 y/o
CI: pregnancy, uterine bleeding, acute gyn infection,

complications: uterine perforation,

22

sterilization

tubal is most common
vasectomy is reliable

23

infertility

not able to conceive w/in 12 months of unprotected sex
primary- no prior pregnancy
secondary- after previous pregnancy

causes: an-ovulation- most common
-tubal dz
-male factor
-unexplained


an ovulation
- PCOS, high prolactin, hypothalamic-pit dysfunction, hypothyroidism

dx: menstrual diary, literal phase day 21

management: bromocriptine to dx hyperpolactinemia, climid to stimulate ovulation, metformin to increase ovulation and pregnancy

24

infertility- tubal dz

-cause: scarring/ adhesions
PID, endometriosis, h/x rupture appendix

dx: hysterosalpinogram
lapro

management: surgery/ lysis of adhesions

25

infertility-male factors

abnormal semen analysis

cause: increase scrotal temp, smoking, excessive ETOH, varicocele

dx: semen analysis

tx: tx etiology
-IUI
doner insemination

26

General approach to infertility

-phase 1-
-detailed h/o and type of coitus, ovulation tracking, semen analysis, TSH, prolatic, LH

Phase 2:
-hystersalpinogram
-lapro
-IVF if no cause

27

fetus/ infant nomenclature

abortion: 42 weeks

twins counts as 1 pregnancy

28

presumption manifestations of prengnay

amenorrhea
n/v
quickening ( fetal movement)
nulliparas 18-20 weeks
multipara: 14-16 weeks

urinary frequency, nocturia, infection

signs; chadwicks signs- bluish discoloration of vagina and cervix

skin change: melasma/ chloasma ( dark patches on face)
-linea nigra

probable manifestation
- positive pregnancy test
- hagar' sign -softenging b/w fundus and cervica

uterine growth-
12 weeks-symphisi pubis
20 weeks - at umbilicus
after 20 weeks- 1 cm

positive manifestations
fetal heart tones
-u/s examination of fetus

labs:
cholesterol increase > 200

BUN/ cr decrease

29

prenatal labs

abc, blood type, vdrly, hep b, rubella,

every visit- check maternal weight, BP, fundal height, fetal size , urine dipstick for protein,glucose, ketones

30

screening tests

1st visit- dating sonogram -discuss screening tests

10-13 weeks-nuchal translucency

15-18 weeks- alpha-fetal protein/ quadruple screen

18-22 weeks- anatomical sonogram

24-28 weeks: glucose challenge test

28 weeks- Rhogam if woman is RH negative

32 weeks- repeat abc, VDRL, chlamydia, gonorrhea, Grp B strep

31

trisomy 21

1st trimester- PAPP-A- low
free beta hCG- high

2nd trimester-
AFP -low
inhibin A

nuchal translucency screenin test

10- 13 weeks

10-13 weeks- CVS, not risky
15-20 - amniocentesis

32

weight gain/ nutrition

20-35 pounds

- intake 300 kc/per day

-avoid ETOH, smoking, drugs, unpasteurized foot, deli meat, farm salmon

33

stages of labor

stage 1- onset of labor to full dilated ( 10 cm )

second stage: fully dilated to birth of infant

3rd stage; - delivery of infant to delivery of placenta



34

causes of slowed labor

pelvic floors- inadequate pelvis, failure to descent,
contraction factors ( tx picot )

aides:
episiotomy- incision to widen vulvar orifice

forceps
vacuum- suction cup on stop of baby's head
- do first before C-seciton

induction of labor:
considered when prolgoned pregnancy
- DM, pre-eclmapia

CI: cephalospelic dispropriotn, placenta previa, uterine scar, traverse lie



35

inducing labor

meds: early- prostaglandin gel, given vaginally to ripen the service

some dilation and effacement- Piton - causes uterine contraction, given IV

36

antepartum testing

NST- non-stress test
- reactive test
- 2 acceleration in 20 minutes, up 15 beast from baseline- positive test is GOOD


Contraction stress test:
given pitocin and watch monitor
-if late decellerations- BAD

vibroacoustin stiumuatlion:
auditory source to wake up the baby
-

biophysical profile- watch sonogram for 20 minutes

- check breathing, gross body movements, fetal tone, amniotic fluid index

37

monitor during labor

120-160 normal fetal HR
- if consistent decceleration- could be fetal distress

external fetal monitor
internal fetal monitor- dilated and ruptured


if non-reassuring FHR
- stop piton, scalp PH

38

induced abortion

medical ( up to 7-9 weeks)

suction curetage

39

spontaneous abortion

-pregnancy ends befor 20 weeks gestation

more than 80% of abortions

RF: parity, increase with material/ paternal age

60% -caused by chromosomal abn
endocrine, infection, ETOH, caffeine

40

clarifications of spontaneous abortion

all except for missed have vaginal bleeding

threatned- women w/ vaginal bleeding and pregnant,

inevitable- POC have not passed

incomplete vaginal bleeding, partial pass of POC

habitual abortion 2-3 ore more abortions
check genetic, endocrine labs

41

incompetent cervix

-cervical weakness causing passive, painless cervical dilation

results in 1st or 2nd trimester abortion or pre-term labor

management:
cerclage- cervical suture in 1st trimester to provide support to weak cervix

42

ectopic pregnancy

-embryo is somewhere besides uterine cavity
most common in tube

cause: salpingitis ( PID)

sxs: pain, vaginal bleeding, amenorrhea
( women with positive pregnancy test now having slight vaginal bleeding with pain)

unruptured- more pain
ruptured- pain better, hypotension, tachycardia

lab: B-HCG or serum positive
sonogram: absence of IU gestational sac

tx: methotrexate
- serum b-hcg
stable, compliant
has to comply

surgical: salpingostomy,

43

gestational trophoblastic dz

hydatiform mole- grape like vesicle on sonogram, no egg/ fetus

presentaiotn: positive pregnancy test, vag bleeding, pre-ecamplisa , hyperemesis

studies: b-hcg titer higher than gestation age

sonogram: sack of grapes on snows town pattern

44

pre-term labor

20-36 weeks

triad- preterm pregnancy, uterine contractions ( 3 in 20 minutes), dilation/ effacement

RF: infection, Group B strep, cocaine, heavy cig smoking

sx: contraction, vag bleeding

labs: fetal fibronectiven testing
positive
negative lower risk

cervical length - if 2 cm at 20 weeks

if both abn 50/50 go into labor

management:
observe for 30-60 minutes and hydrate her

then abx to tx subclinical infection

bethamethsaone to help w/ fetal lungs
tocolytics- increase labor

45

premature rupture of membranes

- most common dx leading to NICU admission

Risks:
vaginal/ cervical infection
-cervical incompetence
- multiple pregnancy
- cig smoking

sxs: gush of fluid from vagina
- every time she cough or strains--> feels a squirt

signs: sterile speculum exam, pooling, nitrazine paper, ferning test, visual leakage

treatment:
34 weeks for lung mature- bethamethsone
> 35 weeks - induce
under 34- immature lungs - keep baby in mom, check NST, CBC, bed rest until she is 35 weeks then deliver

46

maternal RH isoimmuniation

mom produces ab again foreign red blood cells antigen in maternal circulation

- risk is present only if mom is RH negative and dad id RH + and baby is RH +

tx: Rhogam
- 28 weeks protective
-

47

multiple gestation

-more severe s/sx of pregnancy
- high risk

complications:
spontaneous abortion
- pre-eclampsia
-increas of death for fetus,
-cord prolapse
- incr risk for placenta separation

48

gestational diabetes

DM during pregnancy

RF: AA, hispanic, indian

correlation with pre-eclampsia, traumatic birth

fetal risK : macrosomia, prematurity, still birth,
delayed fetal lung maturity


24-28 week- GCT
- non fasting 50 g glucose load
-check maternal glucose after 1 hour
- if > 140 mg/ dl move to GTT

GTT- fasting testing
take blood and then given 100 gm oral glucose at 1, 2, and 3 hours
- 2 abn values

fasting: 95

don't use h A1c during DM

A1: diet controlled
A2: insulin

tx: diet and exercise
finger stick X qid
keep BS

49

HTN in pregnant

chronic HTN-
HTN before 20 weeks before gestation

140/ 90- 179/109
- no end organ damage

check monthly sonogram- to make sure baby growing
-stat weekly NST and biophysical profile

serial BP and urine protein
medication 150/100
methoadopa

50

preeclampsia/ eclampsia

- proteinuria, edema, HTN

eclampsia- above pause seizures

after 20 weeks and moslty near term

- can occur up to 2 weeks post part
No incr risk for HTHn later in life

** most common risk factor is nulliparity
multiple gestation
DM
chronic HTN

complications: ecclmpia
, renal failure, HELP, DIC

prevention: 1 gm calcium daily

mild and severe classification

mild tx: BP high,
proteinuria, and no other sx -->

tx: deliver baby
before 37 weeks--: bed rest and check BP and urine dips
- if not reliable--> admit them and deliver at 37 weeks


severe: BP higher 160-180/ 100, ++ proteinuria, and have sxs ( HA, blurred vision, RUQ pain, elevated creatinine)

tx: hospitalize , ICU
given betamethasome
over 34 weeks --> induced
not stable--> immediate C-section
mag sulfate- to dec seizures
hydralazien and labetolol

51

placental abruption

placenta becomes detached from side of uterine

most common cause of 3rd trimester bleeding

RF: HTH, cocaine, cig smoking, trauma

external form: blood drains through the cervix
- more common, less serious

concealed- hemorrhage is confined
- less common, more serious

sx: abd pain ( searing)
fetal distress

labs/test: clinical, sonogram, H/H, PT/PTT

tx:
if large and fetal distress- emergency C-seciton

if small- watchful waiting

complications: fetal demise, maternal hemorrhage, maternal DIC and death

52

placenta previa

placenta over the cervical os

- may be partial or complete

RF: advanced mat age, multiple gestation, previous previa, scarred endometrium

sx: painless, bright red bleeding
may have contractions
( no prenatal care, easily seen on sonogram)

signs: sonogram , no vaginal exam

tx: if little spotting- bed rest

if full gush of blood- delivered C-section

complications: embolism, prematurity, hypoxia

53

post part hemorrhage

uterine atony
- uterus continues to contact after baby born

RF: later is short or long or infection

findings: soft uterus
tx: piton and uterine manage

Genital laceration
- suture it

Retained placenta-
see on the placenta missing or go in do manual exploration

54

endometritis

infection in the endometrium

ruptured membrane > 24 hours

2-3 days post part

fever , uterine tenderness


labs: elevated WBC
UA

tx: clindamycin and gentamicin