Gynecology Flashcards
(112 cards)
1
Q
Gonorrhea treatment
A
Ceftriaxone 500 mg IM
- 1 gram if weight > 120 kg
2
Q
Chlamydia treatment
A
Doxycycline 100 mg bid * 7 days
- Azithromycin 1 gram once if pregnant
3
Q
Cervical cancer screening with hiv
A
Start earlier: within 1 year of sexual activity or hiv diagnosis, no later than 21
Screen more often: cytology x 3 or co-testing q3 to start
4
Q
Treatment for lymphogranuloma venereum
A
Doxycycline 100 mg bid x 21 days
5
Q
Syphillis treatment
A
Primary, secondary, early tertiary: Penicillin 2.4 million units IM
Late tertiary: 2.4 x 3
Neurosyphillis: inpatient iv penicillin
6
Q
Treatment for granuloma inguinale (Klebsiella granulomatis)
A
Doxycycline 100 mg BID x 14 days
Azithromycin 1 gram every week x 3 weeks or until painless red bump or ulcer gone
7
Q
PID treatment
A
Ceftriaxone 1 gram iv qd + doxycycline 100 mg bid + metronidazole 500 mg bid until 24 hours clinically improvement > 14 days total
8
Q
When to redose cefazolin
A
4 hours from preop dose
1500 mL blood loss
9
Q
Antibiotics before uterine evacuation
A
Doxycline 200 mg once
10
Q
Ultrasound diagnosis of pregnancy failure
A
Crown-rump length 7+ mm without heartbeat
Mean sac diameter 25+ mm and no embryo
Absence of embryo with heartbeat 2 weeks after gestational sac without yolk sac
Absence of embryo with heartbeat 11 days after gestational sac with yolk sac
11
Q
Do you pretreat before endometrial ablation?
A
Yes to thin endometrium to level that necrosis can be achieved
- all ablation trials other than Novasure did pre-treatment with danazol or Gn-RH agonist or suction aspiration
12
Q
Mechanism of mifepristone
A
Selective progesterone receptor modulator
- Acts as antiprogestin by binding to progesterone receptor with greater affinity than progesterone itself
13
Q
Mechanism of misoprostol
A
Prostaglandin E1 analogue
14
Q
Dose of mifepristone
A
200 mg orally
15
Q
Length of ureter
A
30 cm
16
Q
Path of ureter
A
Renal pelvis > psoas muscle > crosses bifurcation of common iliac vessels > medial leaf of broad ligament > crosses under uterine artery > curves into bladder through tunnel of wertheim
17
Q
Length from bladder to do uretero-neocystotomy vs uretero-uretero anastomosis
A
5 cm
18
Q
Cheney incision
A
2 cm above pubic symphysis > excise rectus tendon 1-2 cm off pubis
- can damage inferior epigastrics
19
Q
Absorption of catgut
A
Plain: 7 days
Chromic catgut: 14 days
20
Q
Absorption of Vicryl
A
Loses 50% tensile strengths in 21 days
- 6-10 weeks to dissolve
21
Q
Absorption of PDS or Maxon
A
Loses 50% strength in 60 days
22
Q
Definition of post-op fever
A
Temp > 101.5F
Two or more temperatures 100.4F or higher 4 hours apart
23
Q
Two non-absorbable sutures
A
Silk, nylon
24
Q
Baden-Walker staging system
A
Stage 1: Cervix to ischial spines
2: Cervix between spines and intriotus
3: Cervix below introitus
4: Procidentia (uterus below intriotus)
25
At time of hysterectomy, how do you manage the vaginal apex?
Incorporate uterosacral ligaments into vaginal cuff
26
Surgical management options of vaginal vault prolapse
Plication of uterosacral ligaments
Sacrospinous ligament suspension
Sacrocolpopexy
Colpocleisis
27
Difference between LeForte and complete colpocleisis
Uterus remains in place with LeForte
| - preop endometrial sampling and cervical cancer screening
28
Treatment of enterocele
Plication of uterosacral ligaments in the midline
| Obliteration of the cul-de-sac
29
Evaluation of urinary incontinence
- history, bladder diary
- prolapse exam
- cough test
- neurological exam
- post-void residual (abnormal > 150 mL)
- q-tip test for urethral hyper mobility (goes with sui)
- urinalysis and culture
30
Components of office cystometry
First sensation
First desire to void
Bladder capacity
31
Medical therapy for urge incontinence
Beta-3 adrenoreceptor agonist (Mirabegron 50 mg qd)
Anti-muscarinics (oxybutynin 2.5 mg qd, tolterodine)
If refractory, intravesicular Botox or sacral neuro modulation
32
Repair of rectovaginal fistula
Excise the fistulous tract
Close in non-overlapping layers with Vicryl
Post-operative stool softeners and Sitz baths
33
Repair of Vesico-vaginal fistula
Excision of tract
Bladder submucosal layer
Bladder muscularis layer
Vaginal mucosal closure
34
Normal hCG rise
35+% rise over 2 days
35
Contraindications to methotrexate for ectopic pregnancy
Ruptured ectopic (hemoperitoneum)
Hemodynamically unstable
Immunosuppression, renal, liver, blood disease
Relative: hCG > 5000 iu/ml, fetal cardiac activity, > 4 cm
36
Two dose methotrexate regimen
50 mg/m2 BSA on days 1 & 4
| - repeat dose if day 7 not 15% decrease from day 4
37
Single dose methotrexate regimen
50 mg/m2 BSA
| - Repeat dose if <15% decrease from day 4 to 7
38
Steps of appendectomy
Dissect the meso-appendix
Ligate appendiceal vessels (off SMA)
Clamp and cut base of appendix
Purse-string stump and invert
39
Breast cancer risk with BRCA
BRCA-1 and 2: 45-85% breast cancer risk
40
Ovarian cancer risk with BRCA
BRCA-1: 40%
| BRCA-2: 10-25%
41
FIGO GTN staging
```
Age
Duration from antecedent pregnancy
Type of prior pregnancy
Pre-treatment hCG
Largest tumor size
Site of metastases
Number of metastases
History of failed chemotherapy
```
42
Karyotype of partial mole
69 xxx or 69 xxy
| Fetus may be present
43
Karyotype of complete mole
46 xx or 46 xy (all paternal)
44
Embryologic origins of vagina
Upper 1/3: Müllerian ducts
| Lower 2/3: Urogenital sinus
45
How does HPV cause cervical cancer?
High risk HPV strains produce E6 and E7 proteins > destruction of tumor suppressors p53 and RB > abnormal cell cycle progression
46
Pathological features of CIN
Koilocytic change, nuclear atypica, increased mitotic activity, disordered cellular maturation
47
HPV strains in 9-valent vaccine
Wart causing: HPV types 6, 11
| Cancer causing: HPV types 16, 18, 31, 33, 45, 52, 58
48
Pathological feature and treatment of chronic endometritis
Plasma cells
| Doxycycline 100 mg BID 14 days
49
Incidence of cancer in fibroids
1/250 (FDA), 1/10,000 (AQHR)
50
Histologic features of leimyosarcoma
Necrosis, mitotic activity, cellular atypia
51
Hormonal findings of PCOS
LH: FSH > 2
- LH acts on theca cells to induce androgen production > hirsutism
- Androgen converted to estrone in adipose tissue > decreased FSH
52
Brenner tumor
Benign surface epithelial ovarian tumor
- Used to be transitional cell or bladder tumor
- path: coffee bean nuclei (also seen in granulosa cell)
53
How often are dermoids bilateral?
10%
| - 1% malignancy rate
54
Tumor marker for dysgerminoma
LDH
55
Tumor marker for endodermal sinus tumor or yolk sac tumor (germ cell tumors)
AFP
| Schiller duval bodies on histology
56
Pathologic finding of yolk sac or endodermal sinus tumors
Schiller-Duval bodies
| Elevated AFP
57
Meigs syndrome
Pleural effusions, ascites, and fibroma (benign sex cord stromal tumor)
58
Risk of choriocarcinoma after molar pregnancy
Complete mole: 16%
| Partial mole: 4%
59
Lifetime risk of ovarian cancer
1. 6% or 1 in 60
| - 5% with positive family history
60
Non-cancer differential for adnexal mass
Non-gyn: Diverticular abscess, appendiceal abscess, nerve sheath tumor, pelvic kidney, retroperitoneal sarcoma
Gyn: TOA, hydrosalpinx,teratoma, endometrioma, fibroid, paratubal cyst, serous or mucinous cystadenoma, Mullerian anomalies
61
Work up of ambiguous genitalia
Blood pressure, pelvic exam, testosterone, 17-OHP
62
Work up for primary amenorrhea
Physical vs ultrasound
- Uterus present: FSH/LH, AMH, Karyotype
- Uterus absent: Karyotype, testosterone levels
63
Differential for primary amenorrhea
Uterus present: Functional, Turners syndrome, primary ovarian insufficiency, Kallman’s
Uterus absent: AIS, 5-alpha reductase deficiency, Mullerian agenesis
64
A-C of 3rd degree laceration
```
A: <50% external sphincter
B: 50-100% external sphincter
C: Internal and external sphincter
- overlap repair only possible for class c
```
65
1st degree perineal laceration
Vaginal mucosa only
66
Peroneal nerves injuries
Lateral tibial compression > foot drop
| - controls muscles that lift ankle and toes upward
67
Sciatic nerve injuries
External rotation of hip with knee extension (candy cane stirrups) > weakness of knee flexion and foot dorsiflexion
68
Femoral nerve injuries
Retractors along psoas in thin patients > sensory deficit of anterior/medial thigh, weakness of hip flexion and knee extension
69
Virchow’s triad
Hypercoagulable state
Venous stasis
Endothelial damage/vessel wall injury
70
Ovarian tumors with elevated hCG
Dysgerminoma, choriocarcinoma
71
CA-125: CEA ratio for ovarian cancer
CA-125/CEA > 25
- 91% sensitive
- 100% specific for ovarian cancer
72
Diagnostic criteria for PID
Lower genital tract inflammation (discharge, cervical friability, tenderness)
Temperature (101F), elevated ESR/CRP, positive NAAT/culture, abnormal discharge (WBCs on microscopy)
Necessary: uterine, adnexal or cervical motion tenderness
73
Point A
Medial parametria (where uterine artery and ureter cross)
- 2 cm superior to lateral vaginal fornix
- 2 cm lateral to cervix
74
Point B
```
Lateral parametria (to obturator nodes)
- 5 cm from midline at level of point A
```
75
Impact of 1 unit of FFP or cryopreciptate
Increase in 50 mg/dl fibrinogen
76
Options for positive CIN 2/3 margins
Co-testing and ECC at 4-6 months
- repeat excision acceptable
- simple hysterectomy acceptable if required-excision not feasible
77
Absolute risk of persistent/recurrent HSIL
17%
| - related to hpv persistence (doubles risk)
78
Surveillance for AIS after negative margins
Co-testing, ECC every 6 months for 3 years
| Annually until hysterectomy
79
Anal wink nerves
S2-S4
80
Timing of anticoagulation after regional anesthesia
4 hours for LMWH, 1 hour for heparin
81
Recurrence of AIS by margin status
2.5% with negative margins
| 20% with positive margins
82
How does estrogen increase VTE risk?
Increases hepatic production of coagulation factors (factor VII, X, fibrinogen)
83
Differential diagnosis of vulvar ulcer
```
Infection
- Herpes
- Syphillis
- Chancroid
- Granuloma inguinale (Klebsiella)
- Lymphogranuloma venereum
- Molluscum contagiosum
Cancer
Behçet’s disease
Stevens Johnson syndrome
```
84
How does Lugol’s iodine work?
Stains glycogen dark
| - dysplastic cells have high cell turnover and low glycogen stores > light compared to normal tissue
85
Ovarian cancer risk reduction with rrBSO
80-90%
- rrBSO reduces breast cancer risk in BRCA-2 patients
- Prophylactic mastectomy reduces breast cancer risk by 90%
- Tamoxifen reduces breast cancer risk by 60%
86
Histology of lichen sclerosus
Absence of rete pegs
87
Age at which to biopsy with Bartholins abscess
40 years
88
Length and purpose of Word catheter
4 weeks to create a fistula tract from gland to skin
89
Delay in starting hormonal conception after emergency contraception
Levonorgestrel 1.5 mg: No need to delay
| Ulipristal 30 mg: Delay OCPs for 5 days
90
How does the harmonic scalpel work?
Ultrasonic energy > protein denaturization
91
Ultrasound findings of molar pregnancy
Complete mole: Theca lutein cysts, vesicular pattern
| Partial mole: Cystic changes in placenta, non viable fetus
92
Immunochemistry of complete vs partial mole
P57: Maternally expressed > negative in complete mole (46 paternal genes)
93
HCG follow up after molar pregnancy and HCG normalization
Monthly HCG for 6 months (ACOG)
| -1 year if GTN
94
FIGO/WHO criteria for post-molar GTN
Plateauing HCG (+/- 10%) for 4 values over 3 weeks
Rising HCG (10+%) for 3 values over 2 weeks
Persistent HCG for 6 months
Histologic diagnosis of choriocarcinoma or invasive mole
Clinical or radiologic evidence of metastases
95
Initial HCG monitoring after evacuation of molar pregnancy
Weekly HCG monitoring
96
Hemostatic agents that will work in DIC
```
Thrombin+gelatin (eg Floseal)
- converts fibrinogen to fibrin
- matrix for clot formation
Fibrin sealant (eg Tissel)
- combines thrombin with fibrinogen
```
97
Topical hemostatic agents that require functional coagulation cascade (ie not in DIC)
Oxidized regenerated cellulose
- activates extrinsic coagulation cascade
Collagen
- activates extrinsic coagulation cascade
Gelatin matrix
- matrix for clot formation
98
Options for vaginal vault support
Abdominal sacrocoplexy
Sacrospinous ligament suspension
Obliterative procedures
99
Space-filling pesssaries
Donut
Gelhorn
Cube
Opposite is support pessary (eg ring with support)
100
Hyponatremia management after hysteroscopy
Typically isotonic or hypertonic hyponatremia
| - correct with diuresis and IV administration of hypertonic saline 3%
101
Electrolyte poor hysteroscopic solution
```
Glycine 1.5%
Sorbitol 3%
Mannitol 5%
- Stop at 1000 mL
- Used with monopolar
```
102
Renal anomalies with congenital uterine anomalies
20-30% on time
| On same side as uterine anomalies
103
STI prophylaxis after sexual assault
```
Ceftriaxone 500 mg IM
Azithromycin 1 gram single dose
Metronidazole 2 gram single dose
Offer Hep B and HPV vaccine
HIV risk assessment
```
104
Progesterone treatment options for endometriosis
Norethindrone acetate 5 mg daily (max 15 mg)
- also used as add-back on GnRH agonist
Depo provera q12 weeks
Levonorgestrel IUD
105
Max length of GnRH agonist therapy
12 months
| - add back norethindrone 5 mg or provera 2.5 mg at 6 months
106
Anterior abdominal wall layers
```
Skin
Subcutaneous tissue
Camper’s and Scarpa’s fascia
External oblique
Transversus abdominis
Internal oblique
Rectus abdominis
Transversalis fascia
Extra peritoneal fat
Peritoneum
```
107
Bladder cystotomy repair
Running of mucosa
Interrupted of muscularis
Running of serosa
- 3-0 Vicryl
108
Oral GnRH antagonist for fibroids
Elagolix
- 300 mg BID
- Add-back: 1 mg estradiol and 0.5 mg norethindrone
- up to 2 years
109
TXA dosing
IV: 1 gram
Oral: 1.3 g TID for up to 5 days during menstruation
110
Ultrasound findings of endometrioma
Homogenous (ground glass) echos in a cystic mass
- Ultrasound 80% sensitive
- MRI 90% sensitive
111
Ultrasound findings of dermoid
```
Hyperechoic nodule with acoustic shadowing
Fluid-fluid level
Calcification
Absence of Doppler flow
- US 98-100% specificity
```
112
Splenectomy technique
Anterior
- Gastrocolic and gastroepiploic artery and vein
- short gastric
- splenocolic and splenophrenic ligaments
- splenic artery
- splenic vein
Posterior (clockwise starting at 9 o’clock)
- gastrosplenic ligament, short gastrics
- splenophrenic ligament
- splenocolic ligament
- splenorenal ligament
- splenic artery and vein
