Gyn

Question 1

Round ligament

Answer 1

allows anteversion of uterus

Question 2

Broad ligament

Answer 2

contains uterine vessels

Question 3

Infundibular ligament (IP)

Answer 3

contains ovarian artery, nerve, and vein

Question 4

Cardinal ligament

Answer 4

holds cervix and vagina

Question 5

Pregnancy

Answer 5

can see on US at 6 weeks
fetal pole usually seen with bHCG of 6,000
gestational sac seen with bHCG of 1,500

Question 6

Missed abortion

Answer 6

1st trimester bleeding, closed os, positive sac on US, no heart beat

Question 7

Threatened

Answer 7

1st trimester bleeding, positive heart beat

Question 8

Incomplete

Answer 8

tissue protrudes through os

Question 9

Ectopic

Answer 9

acute abdominal pain; +bHCG, negative US for sac; missed period, vaginal bleeding and hypotension
RFs: previous tubal manipulation, PID, previous ectopic
- significant shock and hemorrhage can occur -

Question 10

Endometriosis

Answer 10

symptoms: dysmenorrhea, infertility, dyspareunia; can involve rectum and cause bleeding during menses (scope shows blue mass); ovaries most common site
Tx: OCPs

Question 11

Pelvic Inflammatory Disease

Answer 11

most commonly occurs in first 1/2 of menstrual cycle
Dx: cervical motion tenderness, cervical cultures, Gram stain
Tx: ceftriaxone, doxycycline
Gonococcus - diplococci
Chlamydia - granuloma lypmphadenopathy
Complications: infertility, ectopic

Question 12

Syphilis

Answer 12

positive dark-field microscopy, chancre

Question 13

Mittelschermz

Answer 13

rupture of graafian follicle; causes pain that can be confused with appendiciits; occurs 14 days after 1st day of menses

Question 14

Vaginal cancer

Answer 14

1 primary - squamous cell CA

DES - can cause clear cell CA of vagina
Botryoides - rhabdosarcoma that occurs in young girls
XRT - used for most cancers of vagina

Question 15

Vulvar cancer

Answer 15

elderly, nulliparous, obese; usually unilateral

• tx: < 2cm (stage I) - WLE and ipsilateral inguinal node dissection; > 2cm (stage II or greater) - vulvectomy with bilateral inguinal dissection, postop XRT if close margins < 1cm
• Pagets VIN III or higher - premalignant

Question 16

Ovarian cancer

Answer 16

leading cause of gyn death; symptoms: bloating, distension, pelvic pain, pelvic pressure, change in stool habits, change in urinary habits, abnormal vaginal bleeding

• decrease risk with OCPs and b/l tubal ligation
• increase risk with nulliparity, late menopause, early menarche, perineal talc use

Question 17

Types of ovarian cancer

Answer 17

teratoma; granulosa-theca (estrogen secreting, precocious puberty); Sertoli-Leydig (androgens, masculinization); struma ovarii (thyroid tissues); choriocarcinoma (beta-HCG); mucinous; serous; papillary; clear cell type (worst prognosis)

Question 18

Staging of Ovarian cancer

Answer 18

Stage I - one or both ovaries only
Stage II - limited to pelvis
Stage III - spread throughout abdomen
Stage IV - distant mets
- most common initial site of regional spread is other ovary

Question 19

Treatment of ovarian cancer

Answer 19

total abdominal hysterectomy and bilateral oopherectomy for all stages; pelvic and para-aortic LN dissection; omentectomy; 4 quadrant washes; chemo cisplatin and paclitaxel (taxol)

Question 20

Krukenberg tumor

Answer 20

stomach CA that has metastasized to ovary; path shows signet ring cells

Question 21

Meige’s syndrome

Answer 21

pelvic ovarian fibroma that causes ascites and hydrothorax (excision of tumor cures syndrome)

Question 22

Endometrial cancer

Answer 22

most common malignant tumor in female genital tract; risk factors: nulliparity, late 1st pregnancy, obesity, tamoxifen, unopposed estrogen; vaginal bleeding in postmenopausal pt is endometrial ca until proved otherwise; uterine polyps have very low change of malignancy (0.1%); serous and papillary subtypes - worst prognosis

Question 23

Staging and Treatment Endometrial Cancer

Answer 23

Stage I - Endometrium; TAHBSO or XRT
Stage II - Cervix; TAHBSO or XRT
Stage III - Vagina, peritoneum, ovary; TAHBSO and XRT
Stage IV - bladder and rectum; TAHBSO and XRT

Question 24

Cervical cancer

Answer 24

goes to obturator nodes 1st; assoc with HPV 16, 18; squamous cell CA most common

Question 25

Staging of Cervical Cancer

Answer 25

Stage I - cervix; TAH Stage II - upper 2/3 of vagina; IIa TAH; IIB XRT Stage III - pelvis, side wall, lower 1/3 of vagina, hydronephrosis; XRT Stage IV - bladder and rectum; XRT - microscopic disease without basement membrane invasion - cone biopsy (conization)

Question 26

Treatment of cervical cancer

Answer 26

* microscopic disease without basement membrane invasion: cone biopsy (conization) * stage I and IIa: total abdominal hysterectomy (TAH) * stages IIb to IV: XRT

Question 27

Ovarian cysts postmenopausal patient

Answer 27

* if septated, has increase vascular flow on Doppler, has solid components, or has papillary projections --> oophorectomy with intraoperative frozen sections; TAH if ovarian cancer * if none of above are present, follow with ultrasound for 1 year --> if persists or gets larger --> oophorectomy with intraoperative frozen sections; TAH if ovarian cancer

Question 28

Ovarian cysts premenopausal patient

Answer 28

* if septated, has increase vascular flow on doppler, has solid components, or has papillary projections --> oopherectomy with intraoperative frozen sections (algorithm very complicated after this, weighing how aggressive the cancer is compared with desire for future pregnancy) * if none of above are present, can follow with US; surgery if suspicious findings appear

Question 29

Incidental ovarian mass at time of laparotomy for another procedure (postmenopausal patient)

Answer 29

*oopherectomy, frozen section, TAH, BSO if ovarian cancer at time of initial surgery

Question 30

Incidental ovarian mass at time of laparotomy for another procedure (premenopausal patient)

Answer 30

*much more complicated; likely will need partial oophorectomy and frozen section; if cancer removal of tube and ovary (need to have gyn look at this); then determine whether patient wants children, if not go with TAH (usually at second procedure)

Question 31

Abnormal uterine bleeding < 40 y old

Answer 31

anovulation; tx medroxyprogesterone; if leiomyomas tx with GnRH

Question 32

Abnormal uterine bleeding > 40 y old

Answer 32

cancer or menopause; need biopsy

Question 33

contraindications to estrogen therapy

Answer 33

endometrial cancer, active thromboembolic disease, undiagnosed vaginal bleeding, breast cancer

Question 34

Uterine endometrial polyp

Answer 34

can present as progressively heavier menses

Question 35

Uterine fibroids (leiomyomas)

Answer 35

under hormonal influence; recurrent abortions, infertility, and bleeding

Question 36

most common vaginal tumor

Answer 36

invasion from surrounding or distant structure

Question 37

appendicitis with pregnancy

Answer 37

increase risk of premature labor and fetal mortality

Question 38

hydatidiform mole

Answer 38

malignancy risk with partial mole; complete mole is of paternal origin; tx: chemo (methotrexate)

Question 39

Toxic shock syndrome

Answer 39

fever, erythema, diffuse desquamation, nausea, vomiting; associated with highly absorbent tampons

Question 40

Ovarian torsion

Answer 40

tx: remove torsion and check for viability

Question 41

adnexal torsion with vascular necrosis

Answer 41

tx: adnexectomy

Question 42

ruptured tuboovarian abscess

Answer 42

tx: drainage

Question 43

ovarian vein thrombosis

Answer 43

dx: CT scan; tx: heparin

Question 44

Postpartum pelvic thrombophlebitis

Answer 44

tx: heparina and antibiotics