Gyn+OB OME Flashcards
(126 cards)
1
Q
Ultrasound and ca125 indicated to screen for cervical cancer when
Is increased surveillance adequate in these pts
A
When pt has BRCA1/2 mutation
No ppx hysterectomy oopherectomy mastectomy is superior to surveillance
2
Q
BRCA1/2 mut predisposes to what cancers
A
breast ovarian uterine
3
Q
Risk factor for vaginal and vulvar squamous cell carcinoma
A
HPV
Vag and vulv scc just like cervical csused by hpv
4
Q
Endometrial cancer is driven by ______
A
Estrogen
5
Q
64 F with maligmant ascites, which gym cancer to suspect
A
Ovarian cancer
6
Q
Biggest risk factor for ovarian cancer
A
Ovulation
7
Q
Teenage girl has huge obvious cystic teratoma by history and ultrasound, next step cystectomy or CT to better stage and characterize
A
cystectomy
age of patient and size of tumor make diagnosis clear (serous cystadenoma), no need for radiation exposure
8
Q
why is TAH + BSO required for breast and uterine carcinomas?
total abdominal hysterectomy and bilateral salpingoopherectomy
A
estrogen responsive tumors
estrogen comes from ovaries
must take ovaries out in case mets
9
Q
what % of women with infertility are found to have endometriosis
A
30%
10
Q
define preterm labor
A
v37wks
11
Q
tf
ovarian torsion often occurs seated not doing anything / at rest
A
T
often does
12
Q
tf
treat 3cm simple ovarian cyst with oral contraceptives
A
f
oral contraceptives don’t affect ovarian cysts – used ot think so but not anymore
for 3cm, just repeat US in 3 mos to check but expecting spontaneous resolution
13
Q
tubo-ovarian abscess is a complication of
A
pelvic inflammatory disease
14
Q
1st and 2nd line tx of endometriosis
far down the line definitive therapy
A
nsaids
OCPs
laparoscopy
15
Q
3cm smooth fluid-filled cyst in otherwise normal child-bearing age female, what is it likely, next step
A
Likely a functional follicular cyst (ovulating ovaries make them every month)… low risk (v10cm smooth thin-walled no septations)
Reassurance, typically regress weeks to months
16
Q
rectocele causing constipation, surgery planned for next week, how to treat constipation till surgery
A
transvaginal digital reduction of rectocele - to restore normal alignment of colon and alow expulsion
17
Q
how do kegel exercises treat vaginismus
A
contract the pelvic floor, relax the vaginal muscles so they can be gradually dilated
18
Q
Mittleschmerz pain
A
Peritoneal pain from rupture / bleed from functional ovarian cyst or follicle
19
Q
primary causative organism in bacterial vaginosis
A
gardnerella
20
Q
choose between gonorrhea and chlamydia for cause of cervicitis on test
A
choose chlamydia
more prevalent
21
Q
what kind of incontinence do neurogenic bladder and hypertonic bladder cause
A
neurogenic - overflow incontinence
hypertonic - spastic/urge incontinence
22
Q
diabetes
ms
spinal lesion
are risk factors for what kind of urinary incontinence
A
neurogenic bladder - overflow incontincence
23
Q
when to get ct scan for urothelial cancer
A
to stage – CT good at identifying mets, not primary urothelial cancer – get cystoscopy and biopsy for that
24
Q
oxybutinin moa
use
A
urinary smooth muscle antispasmotic
also anticholinergic at urinary smooth muscle
tx overactive bladder (hyptertonic, spasmotic)
25
how does fibroid surgery lead to vesico vaginal surgery
trauma from surgery, or retained stitch, etc.... can lead to epithelialized tract between two epithelia...
26
when to get urodynamics
eval urinary incontinence when not sure stress vs urgency
27
overflow incontinence aka aka
hypotonic aka neurogenic bladder
28
when to use foley vs bethanecol or doxasosin for neurogenic bladder
foley for acute relief of hydronephrosis
bethanecol or doxasosin for long term treatment
29
When to perform external cephalic version of fetus
When baby is breech after 37 weeks (before 37 weeks the fetus is likely to spontaneously cephalize)
30
TF
| Mom with PPROM and fever and tachy fhm needs betamethasone
F
Abx - broad spectrum pip/tazo or amp/gent/metro
And deliver asap... don't wait to deliver with evidence of chorioamnionitis
31
TF
| Abx for PROM even if no signs of infection yet
T
| Not laboring yet, may take time, ppx against infectiom
32
When to use cerclage
First trimester presence or historynof cervical incompetence
aka way before labor, mist be removed before cervical changes in labor or else damage
33
TF
| One sac, two placentas is possible
```
F
These are possibe:
One sac one placenta
Two sacs two placentas
Two sacs one placenta
```
34
What kind of twinning risks cord entanglement
One sac one placenta
35
What kind of twinning risks twin-twin transfusion
Two sacs one placenta
36
What kind of twinning risks malpresentation and premature birh
Two sacs two placentas
37
Types of twinning according to time of separation
Earlier separation, less shared
```
Separate eggs - dizy dichor diamn
Day 0-3 - monozy dichor diamn
Day 4-8 - monozy monochor diamn
Day 9-12 - monozy monochor monoamn
Day 12+ - conjoined mono mono mono
```
38
Each additional gestation pushes the EDD up about...
4 weeks (from mono edd 40 wks)
39
Quadruplets cooking in there, edd?
28 weeks
Each additional gestation pushes the EDD up about 4 weeks
40
Major cause of DIC in delivery
Placental embolization
41
How does amnionic fluid embolism present differently from placental embolism
Amnionic fluid PE w dyspnea amd hypoxia then maybe DIC
Pacental embolism DIC
42
Blood vessels to edge of delivered placenta implies...
And how to treat...
Retained parts of placenta
If PPH - D&C, then uterine artery ligation, then total abdominal hysterectomy ad needed
43
Retained placenta has long term complication of this cancer
Choriocarcinoma
44
How to follow up a DandC of a retained placenta
Serial bHCG's for about a year to make sure no choriocarcinoma developes
45
Algorithm for workup of decreased fetal movement
Doppler for fetal heart tones (alive)
NST
NST w vibrioacoustic stim
BPP
CST or repeat BPP 24h if BPP 3-7 and preterm
Deliver if BPP 2 or less or CST abnorm or BPP 3-7 and term
Only go to next one if you get an abnormal... if normal.. can repeat at follow-up to acknowledge mom's feelings
46
Act on BPP score
8-10 reassure and repeat weekly to check again
3-7 consider delivery if term, if preterm consider steroids and try to keep cooking a bit longer and do CST or repeat BPP IN 24hrs to help decide whether to deliver
0-2 deliver or else baby is going to die
47
In which does fetus decompensate faster, placenta previa or vasa previa?
Vasaprevia
48
What Rh antibody titer would cause you not to give rhogam because Mom already has anti-Rh abs
1:8 or greater
49
Painless genital ulcer
Think...
Dx by...
Painless genital ulcer
Think syphilis
Dx by dark field microscopy
50
Dx heamophilis ducrei in painful genital ulcer
Culture
51
Diffuse intracranial calcifications
Hydrocephalus
Chorioretinitis
Think what congenital infection
Toxoplasma
52
Saddle nose
Saber shins
Snuffles/rhinitis
Think what congenital infection
Syphilis
53
Periventricar calcifications
IUGR
Microcephaly
Think what congenital infection
CMV
54
Labs typically obtained at first prenatal visit
```
Type and screen
CBC
HIV
HBV HBsAg
Pap
Rubella
Syphillis
Gonorrhea/Chlamydia
Urine culture
```
2 blood stuffs, 4 virus stuffs, 3 bacterial stuffs
55
Labs typically obtained at first prenatal visit
2 blood stuffs, 4 virus stuffs, 3 bacterial stuffs
Type and screen
CBC
HIV
HBV HBsAg
Pap
Rubella
Syphillis
Gonorrhea/Chlamydia
Urine culture
56
TF
Routinely screen folate levels in preggys
TF
Routinely give folate supplementation to preggys
F - only screen if megaloblastoc anemia
T - always supplement regardless of level
57
When to screen for gestational diabetes with ogtt
At or after 24 weeks
| GDM gets a 2nd-3rd trimester screen
58
When to stop pap screening if all prior paps have been normal
Age 65
59
```
Primary amenorrhea and anosmia think
Pathophys
Anatomy
Karyotype
Tx
```
Kallman syndrome
Pituitary GnRH deficiency
Normal anatomy (uterus, vagina, ovaries, etc)
46XX normal karyotype
Estrogen and Progesterone supplementation
60
47XXX phenotype
Normal phenotype, may never be diagnosed
61
47XXY
Syndrome
Phenotype
Klinefelter syndrome
| Tall lanky male phenotype with small testes
62
Leuprolide is a ___ analog
GnRH analogue
63
TF
| Oophorectomy for Kallman's
F
Just supplement axis with E and P or maybe from the top woth GnRH
(Kallman's is GnRH insufficiency in setting of normal everything else)
Leaving ovaries in is not a cancer risk like leaving undescended testes in
64
When is gonadectomy performed for testicular feminization
After completion of puberty
(Testosterone that cannot be converted into active 5-DHT will be converted into estrogen instead and female secondary sex traits will develop -- just amenorrhea because no upper vagine uterus or tubes because mullerian inhibiting factor killed those back as a fetus)
65
How does testicular feminization commonly present
Pathophys
Amenorrhea
Testosterone that cannot be converted into active 5-DHT will be converted into estrogen instead and female secondary sex traits will develop -- just amenorrhea because no upper vagine uterus or tubes because mullerian inhibiting factor killed those back as a fetus
66
why tah+BSO for endometrial cancer in PMP woman
because endometrial carcinoma is an estrogen-responsive tumor and there may be mets even if remove uterus, so remove ovaries (a potential source of estrogen even though post-menopausal)
67
what is the staging process for endometrial cancer in a postmenopausal woman
CT
| completed via paraaortic lymph node dissection and peritoneal wash during TAH+BSO
68
TF
| radical hysterectomy includes resection of omentum
T
69
stages of endometrial cancer and corresponding general tx guidelines
stage I: contained by myometrium - TAH+BSO
stage II: subserosal? TAH+BSO and radiation
stage III: local mets - TAH+BSO and chemo/radiation
stage IV: A - beyond uterus bowel bladder, B - distant -- chemo +/- radiation/debulking
70
which female hormone is protective against endometrial cancer
PROgesterone is Protective against endometrial cancer
71
when do ovaries pathologically overproduce estrogen enough to increase risk of endometrial cancer
granulosa-theca tumor
| POCS (anovulation so less progesterone, more estrogen)
72
define menometorrhagia
```
menorrhagia (heavy)
plus metrorrhagia (irregular)
```
prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal. It is thus a combination of menorrhagia (heavy) and metrorrhagia (irregular)
73
otherwise healthy woman with menometorrhagia and endometrial hyperplasia without atypia on biopsy, tx? hysterectomy? OCP?
cyclical progestin
reserve hysterectomy for atypia... too much risk to surgery for just hyperplasia
OCP prevents hyperplasia, but too late when hyperplasia already present
74
indication for endometrial ablation
- for endometrial hyperplasia?
- for endometrial atypia?
only in women with uterine bleeding before menopause who are done having kids but in whom the biopsy ins normal
- not for endometrial hyperplasia - can burn in developing cancer such that cancer is hidden on future biopsies
- not for atypia for same reason and also just do hysterectomy for atypia (or cyclical progestin if premenopausal and wants more kids... I think...)
75
TF
| tamoxifen is a treatment for uterine cancer
F
| it causes uterine cancer
76
Irregular periods leading to amenorrhea and positive bleeding with progestin test think...
related pathophys
PCOS
Oligo-anovulation... no luteal/progesterone phase, just estrogen endometrium buildup without differentiation and scheduled sloughing so only sloughs less frequently when outgrows blood supply
77
chemo regimen for endometrial cancer
pac splat dox
| paclitaxel doxorubicin cisplatin
78
cyclophosphamide doxorubicin 5-fu in setting of OBGYN treats...
breast cancer
79
Adriamycin bleomycin vinblastine and dacarbazine a the chemo regimen for...
Hodgkin's lymphoma
| ABVD
80
most common cause of postmenopausal bleeding
most concerning cause of postmenopausal bleeding
vaginal atrophy
endometrial carcinoma
81
# define hyperemesis gravidarum
BMP disturbance
1st 2 staps
severe nausea and vomiting leading to dehydration
hypokalemic hypochloremic metabolic acidosis
IVF and K
beta quant (quant beta hCG) to confirm cause (pregnancy, mole)
pelvic US
82
most dangerous cause of hyperemesis gravidarum
gestational trophoblastic disease i.e. hydatidiform moleor choriocarcinoma
83
How do you treat choriocarcinoma of the uterus?
low risk: methotrexate
| high risk: EMA/CO (etoposide, methotrexate, and dactinomycin, cyclophosphamide and vincristine (Oncovin))
84
what distinguishes hyperemesis gravidarum from normal morning sickness
and what causes them
degree of metabolic and vital sign derangement
vomiting likely caused by elevated b-HCG
85
snowstorm on US and no fetal parts suggests what kind of molar pregnancy
complete mole
86
when to perform suction curettage vs dilation and curettage for mole/abortion
suction curettage for early gestation moles and abortions
dilation and curettage for second trimester
87
what is the role of CT scan in molar pregnancy
staging CHORIOCARCINOMA to inform surgical decision / therapy if this cancer arises AFTER the molar pregnancy is removed
88
what is the role of MTX in molar pregnancy
a treatment for CHORIOCARCINOMA if it arises AFTER the molar pregnancy is removed
89
incomplete mole is caused by how many sperm and how many eggs
2 sperm
1 egg
(Dispermy)
90
what type of molar pregnancy is caused by dispermy
incomplete mole
| 2 sperm, 1 egg
91
TF
| karyotype of molar pregnancy is necessary to guide management
F
| not necessary, but often obtained
92
how does dispermy occur
rarely, when two sperm enter egg at exactly the same time
93
how do incomplete moles present vs complete moles
just the same for the most part
-B-HCG too elevated for dates +/- hyperemesis gravidarum, size/date discrepancy, US shows snowstorm
but some fetal parts in snowstorm in incomplete mole
94
what is the cause of a complete mole
| how many sperm, how many eggs
dyfunctional oocyte
| 1 sperm meets 1 dysfunctional egg (absent nucleus), sperm doubles own genetic content, can grow but non-viable
95
absence of barr bories is associated mostly with
Turner syndrome 46XO
96
maternal nondisjunction is associated mostly with
downs trisomy 21
97
high b-HCG with molar pregnancy makes high risk for ___ after removal
high risk of choriocarcinoma
98
```
molar pregnancy with bHCG 150,000 now 3,600 8weeks s/p suciton curettage
lost to follow-up in interim
no symptoms
no period
not compliant with OCPs
```
what is the risk to worry about
next step
next next step
management if risk becomes reality
risk for choriocarcinoma s/p gestational trophoblastic disease
repeat bHCG in a week, it has downtrended, make sure of this with 1 week repeat bHCG
repeat US if 1 week not downtrending
CT, suction curettage vs ex-lap, chemo
99
choriocarcinoma diagnosed, manage
CT, suction curettage vs ex-lap, chemo
100
choriocarcinoma with mets but no mass effect after normal pregnancy spontaneously aborted, treat
methotrexate, actinomycin D (standard)
| + cyclophosphamide (after pregnancy, elevated bHCG, or brain mets)
101
standard chemo for choriocarcinoma
| additional agent and indications
standard methotrexate and actinomycin D
| add cyclophosphamide if follows a normal pregnancy, bHCG elevated, or brain mets
102
indications for cyclophosphamide in chemo for choriocarcinoma
if follows a normal pregnancy, bHCG elevated, or brain mets
103
what is a positive GnRH stimulation test and what does it tell you in the setting of precocious puberty, e.g. tanner stage II axillary hair pubic hair and breast development with bone age 2 years ahead of stated age. Next step after positive GnRH stim test in this patient, differential, treatment, why treat
positive if exogenous GnRH elevates LH
tells you its a central issue
get MRI
- pituitary adenoma - resect
- "constitutional" if negative -- aka idiopathic but maybe caused by diet or urban environement factor that stimulates axis early -- continuous leuprolide (GnRH agonist) to stifle axis
treat to stave off early menarche which will compromise growth spurt
104
cause of "constitutional" precocious puberty
idiopathic but maybe caused by diet or urban environement factora that stimulates hormonal axis early
105
when to get abdominal ultrasound in workup of precocious puberty
what have your ruled out already
what are you looking for now
after negative GnRH stim test rules out central lesion (pituitary mass vs "constitutional" issue)
looking for peripheral lesion -- ovarian or adrenal gland tumors
106
```
CAH with female masculinization
what will be elevated in urine
what is functional hormone is overproduced
what hormone is upregulated in blood
how to treat and reasoning
```
17-OH-progesterone elevated in urine
androgens overproduced
ACTH upregulated to try to get cortisol going
give prednisone (adrenalcorticoid) to suppress ACTH which is driving androgen production
107
T/F
| prednisone and fludrocortisone for CAH with female masculinization or precocious puberty, why
F
prednisone only - suppress ACTH which is driving androgen production
prednisone + fludrocortisone for renal failure (AI, TB, Neisseria) with hypotension and electrolyte abnormalities, to support sugar and salt... not for precocious puberty
108
TF
| bilateral adrenalectomy for CAH
F
would force hormone dependence when can be treated by prednisone to suppress the upregulated ACTH driving androgen production
109
why is ACTH elevated in CAH
no cortiosol negatively inhibitin
| all the 17-OH-progesterone shunted into androgen production by 21-hydrozylase deficiency
110
risk factors, lab abnorms, radiologic findings in dysfunctional uterine bleeding
1st line treatment
2nd line addition
none -- no risk factors, lab abnorms, radiologic findings in dysfunctional uterine bleeding, diagnosis of exclusion
OCPs
NSAIDS - vague prostaglandin effect on uterus reduces bleeding
111
TF
| get coags for irregular periods that do not provoke anemia
F
not likely to be a bleeding/clotting disorder, those look more like menorrhagia (heavy but regular), not metorrhagia (irregular)
-give OCPs and add NSAID if necessary
112
when to get coags for uterine bleeding
if bleeding and can't stop it
| if menorrhagia suspicious of acquired bleeding disorder
113
how to NSAIDS treat uterine bleeding
a mysterious prostaglandin effect
114
when to give leuprolide for fibroids
| routine?
to shrink Large fibroids prior to myomectomy
| not routine, not necessary if fibroids small
115
how is endometriosis most commonly definitively diagnosed
ex-lap
| typically clinically suspected but not usually evident on imaging and unconfirmed till ex-lap
116
classic physical exam finding in adenomyosis
next step
smooth, symmetric, enlarged uterus with soft consistency on bimanual exam
rule out cancer with a biopsy, though exam reassuring
117
leiomyosarcoma
| common presentation and diagnosis
presents like fibroids and commonly diagnosed surgically while treating fibroids or if MRI distinguishes irregular invading borders on a fibroid-like mass
118
painful irregular heavy periods in 14yo, otherwise healthy normal doing well, most likely cause, pathogenesis
next step
if hemodynamically stable
if anemic
ddx if persists, next steps
anovulaiton - just common at extremes of menarche / menopause, FSH and LH getting their levels figured out (but no need to draw levels)
reassurance with follow-up if hemodynamically stable
coags if symptomatic anemia looking for von willebrand and hemophilia
consider endometrial pathology eg fibroids or cancer if persists -- imaging, endometrial biopsy
119
DES exposure increases risk of
endometrial cancer
120
chemical risk factor
| 2 common presentations of endometrial cancer
DES exposure
obese woman with heavy periods
post-menopausal bleeding
121
fibroids are ___-responsive and get better with ____ ____ and ____
estrogen-responsive
| better with OCPs, pregnancy, menopause
122
how to check if advanced maternal age mom has ovarian reserve to ovulate
check inhibin-B level -- decreases with age
123
38yo w enlarged uterus that has a prominent smooth posterior mass on bimanual exam
```
likely dx?
next step(s)?
```
likely fibroids
(smooth... not symmetric)
pelvic ultrasound to decrease supsicion of cancer, followed by biopsy if ultrasound equivocal or if pt age ^45
124
when to get endometrial biopsy for large uterus with assymetric smooth mass on bimanual exam
after ultrasound if ultrasound equivocal for fibroid vs cancer
or in any woman ^45yo... cancer risk high
125
bimanual exam in endometriosis
normal typically
126
TF
CT with IV contrast is good for GYN pathology
general use indications
F
not usually for GYN - uterus bladder ovaries etc small and tight down there in pelvis, and radiation to these organs not great for young patients
maybe used for staging cancer once found
much better for abdominal pathology
