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Lectures 2 Flashcards

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1
Q

Define spontaneous abortion

A

Loss of fetus in less than 20 weeks

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2
Q

Most common organisms responsible for PID

A

Gonorrhea, chlamydia

Then think of ascending infxns: so anerobes, GN/GB, GBS

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3
Q

Danazol

Indications

A

Danazol = synthetic steroid/androgen previously used in the tx of endometriosis

-largely replaced by GnRH agonists b/c of their masculinizing/virulizing effects

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4
Q

What time of the month are pts most likely to present w/ PID

A

Beginning of the cycle (like day 1 aka on first day of menstrual period)
-for some reason when the pain is the worst

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5
Q

How does obesity increase risk of endometrial hyperplasia

A

-obesity: adipose tissue contains aromatase => increased peripheral conversion of androgens to estrogens

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6
Q

Differentiate appearance of pt w/ PID 2/2 gonorrhea vs. chlamydia

A

Gonorrhea- more ill appearing, usually more tender, higher fever, thicker discharge

Chlamydia- less severe, discharge thinner/more watery

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7
Q

Prevalence of ectopic pregnancy

(a) How does it change if have previous ectopics?

A

1% overall

(a) 10% if had one previously
25% if had 2+

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8
Q

Differentiate which part of puberty estrogen and testosterone are responsible for in females

A 
Estrogen = thelarche (breast development)
Progesterone = pubarche (pubic hair)
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9
Q

Top 2 things on Ddx for postmenopausal bleeding

A

60-80% endometrial atrophy

10-15% endometrial cancer => hence all F over 45 w/ AUB get endometrial biopsy

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10
Q

Risk factors for vulvar neoplasms

A
  • smoking
  • age
  • HPV, h/o abnormal pap
  • lichen sclerosis** (thin white patches of skin)
  • immunocompromised or immunsuppressed
  • Paget’s disease (adenocarcinoma)
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11
Q

Gold standard tx for endometriosis

A

OCPs, specifically continual OCPs (no progesterone withdrawal bleed part)

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12
Q

Gold standard diagnostic test for endometriosis

A

Technically gold standard diagnostic tool is laparoscopic exploration w/ tissue biopsy
-but that’s pretty invasive so really just diagnosed clinically

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13
Q

Differentiate the two classifications of delayed puberty

A
  1. Hypergonadotropic hypogonadism = elevated FSH
    ex: Turners, Mullerian agenesis, imperforate hyman
  2. Hypogonadotropic hypogonadism = arcute nucleus not producing GnRH
    - constitutional delay
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14
Q

Location of cervical cancer

A

Squamocolumnar junction- squamous outside and columnar inside
-squamocolumnar junction receds up the endocervical canal w/ age, as it recedes that’s where you get the transitional zone where metaplasia occurs

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15
Q

Difference in UA interpretation in pregnant women

A

Pregnant women can have + leukestrase w/o UTI, but nitrates is ALWAYS abnormal
-ketonuria in pregnancy can be 2/2 dehydration

Low threshold for treating UTI in pregnancy b/c pregnant women have higher incidence of asymptomatic UTI

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16
Q

32 yo F1 p/w positive urine pregnancy test at 9 4/7 and painless vaginal bleeding w/ chills

  • T 101.5, HR 95, BP 95/60
  • cervix closed on exam
  • beta-hCG of 6500
  • no fetus in gestation sac on US

Dx?
Tx

A

Septic abortion
= infectioned POCs

Tx- surgery, need to evacuate the uterus

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17
Q

Most common sit of endometriosis

A

Bilateral Ovaries
-ovarian endometrioma = chocolate cyst

2nd most common = posterior col de sac

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18
Q

Teen w/ ovarian mass

A

Buzzword for germ cell tumor

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19
Q

List in order the normal process of puberty in girls

A

Breast development (thelarche) –> Adrenarche –> Growth spurt –> Menarche

-20% of the time adrenarche comes before thelarche

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20
Q

Difference in risk profile from estrogen/progesterone therapy from only estrogen therapy

A

E/P has increased risk of 4: VTE, stroke, coronary heart disease, breast cancer

While just estrogen: increased risk of VTE and stroke (not of coronary heart disease or breast cancer)

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21
Q

Tx for gonorrohea

A

Ceftriaxone IM x1
+ Azithromycin to tx common chlamydia coinfection

-also tx partners

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22
Q

Describe the process of a D&C for termination of pregnancy

A

Paracervical block w/ or w/o mild IV sedation

  • serial dilation of cervix
  • then curretage out intrauterine material
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23
Q

Lupron- what is it?

A

Lupron = GnRH agonist

For hormone-responsive cancers and estrogen-dependent conditions (ex: endometriosis or uterine fibroids)

-can be given pre-op before myomectomy to decrease burden

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24
Q

Inpatient tx for PID

A

Cefotetan (cephamycin = type of cephalosporin) IV q12
+ Doxy IV q12

Treat until afebrile or clinically improved for 24 hrs, then switch to PO and monitor

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25
Ddx of first trimester vaginal bleeding
spontaneous abortion ectopic pregnancy vaginal/cervical lesions or lacerations extrusion of molar pregnancy
26
Risk factors for ectopic pregnancy
Fallopian tube scarring/damage - h/o ectopic - chlamydial infection Smoking ART (assistive reproductive therapy): IVF
27
Most common subtype of vulvar neoplasm
90% of vulvar neoplasms are squamous cell carcinomas (can be progression from VIN) - 5% melanoma - 5% other: Bartholin's, Pagets (red and scaly)
28
Explain the mechanism of hypogonadotropic hypogonadism
Delayed puberty b/c arcuate nucleus doesn't produce GnRH
29
Describe what it means for a pap smear to show a high-grade squamous intraepithelial lesions
cells on the pap smear suggest an abnormality that will be present from 2/3 to full thickness of the transitional zone
30
Ddx for acute abdominal pain in 25 yo sexually active female
1. 1. 1. R/o ectopic pregnancy - PID - Appendicitis - Torsion - Ovarian Cyst - Kidney stone
31
Clear cell adenocarcinoma
Buzzword for DES exposure DES exposure in utero increased risk for ovarian clear cell carcinoma
32
Name 4 medication options to tx endometriosis
Want to cause deciduation of the endometrial lining 1. OCPs = gold standard 2. Progesterone- minipills, depot, IUP 3. GnRH agonists (basically induce menopause so use transiently) 4. Danazol- synthetic androgen to suppress FSH/LH release
33
Describe how endometriosis causes (a) Pain (b) Infertility
(a) Ectopic endometrial stroma/glands cause inflammation that build into adhesions and scarring (b) Adhesions and occlusions => infertility
34
Checking progesterone on what day of the menstrual cycle would help confirm ovluation
Day 21
35
Name 2 etiologies of GnRH independent precocious puberty
GnRH independent precocious puberty = puberty not due to early activation of HPA axis, instead due to some form of peripheral estrogen production 1. McCune Albright syndrome = ovaries producing estrogen w/o stimulation 2. Granulosa cell tumor
36
Buzzword: uterosacral nodularity
Endometriosis
37
Physical exam findings of ectopic pregnancy
-Abdominal or adnexal tenderness if ruptured- acute abdomen w/ rebound/guarding -uterus small for gestational size (aka normal sized)
38
Etiology of GnRH dependent precocious puberty
GnRH dependent precocious puberty = early activation of the HPA axis -most often idiopathic
39
Clinical presentation of ectopic pregnancy
Main features = vaginal bleeding + abdominal pain
40
Outpatient tx for PID
Ceftriaxone IM x1 + Doxy PO BID x14 days then RTC in 3 days for f/u -need broad spectrum b/c of polymicrobial nature of PID infections 2/2 ascending vaginal infxn
41
What blood test is essential in every pt w/ any type of abortion
Type and screen! | Prevent autoimmunization if Rh- mother
42
First steps of management for woman of reproductive age who p/w vaginal bleeding
- beta-hCG - if pregnant => vaginal ultrasound to determine location of pregnancy (ectopic of IUP) - pelvic exam etc
43
56 yo nulligravid post-menopausal F p/w intermittent vaginal bleeding Next step in workup
Transvaginal ultrasound to look at endometrial stripe- if under 4-5mm that's thin and believe bleeding is 2/2 atrophy If endometrial stripe isn't thin => do endometrial biopsy
44
Contraindications to medical MTX tx for first semester abortion
- fetal cardiac activity (usually fetal heart beat seen around 6 weeks) - beta-hCG over 5,000 - impaired renal fxn (MTX is renally cleared) - elevated LFTs (MTX is directly hepatotoxic) - HD unstable (b/c they're ruptured => need surgery)
45
Surgical tx options for ectopic pregnancy
Salpingectomy vs. salpingostomy ``` Salpingectomy = removal of fallopian tube Salpingostomy = surgical unblocking of fallopian tube (remove pregnancy w/o removing the tube)- preserves fertility ```
46
What is Ashermna syndrome?
Intrauterine adhesions + symptoms (infertility, amenorrhea) -syndrome 2/2 scar tissue development in the uterine cavity Infertility if scarring prevents normal implantation Amenorrhea/AUB when scarring prevents normal endometrial growth/shed
47
3 theories of the mechanism of endometriosis
1. Retrograde menstrual flow (most likely) 2. Vascular/lymphatic dissemination 3. Coelomic metaplasia (from pleuripotent/undifferentiated cells in the peritoneum)
48
Name some RF for endometrial hyperplasia/carcinoma
- unopposed estrogen exposure: nulliparity, early menarche, late menopause - age - obesity: adipose tissue contains aromatase => increased peripheral conversion of androgens to estrogens - Tamoxifen - granulosa cell tumor of the ovary (secretes estrogen)
49
Overview of tx for ovarian cancer
Surgery, then chemotherapy: surgical b/c almost always diagnosed so late (stage III) so already have peritoneal disease -often intraperitoneal chemo
50
Which method of ovarian stimulation is more likely to result in multiple gestations
Clomiphene citrate (SERM); 10% risk GnRH: 25% risk of multiple gestations
51
16 yo G1P1 p/w severe lower abdominal pain, F/C/N/V, rebound tenderness - purulent vaginal d/c - b/l adnexal fullness - + GC, -RPR, WBC 17.6 w/ left shift Dx
PID Major criteria = abdominal/adnexal pain + Minor criteria = white count, fever
52
Explain how giving GnRH can suppress ovulation
FSH/LH respond to pulsatile GnRH, not continuous => if you give continuous GnRH it'll suppress FSH/LH release
53
Mechanism of tx in endometriosis
Want to cause deciduation of the endometrial lining => use OCPs, progesterone, GnRH agonist (but only transiently b/c induces menopause)
54
Describe the staging of cervical cancer
Need to have a way to stage it worldwide (aka also in undeveloped countries) => cervical cancer is staged clinically -staged w/ palpation: feel for parametrial involvement, CXR for pulm involvement -in developed countries use CT/MRI to further characterize, but overall its clinical (physical exam) staging
55
Name 3 etiologies of hypergonadotropic hypogonadism
Hypergonadotropic hypogonadism = elevated FSH but no response => delayed pubrety 1. Turners (XO) 2. Mullerian agenesis 3. Imperforate hyman
56
Hormone replacement therapy | a) 4 disadvantages (increased risk of... (b) Decreases risk of 2 things
HRT (referring to both estrogen and progesterone) (a) Increased risk of 1. breast cancer (only w/ both E/P) 2. stroke 3. VTE 4. coronary artery disease (only w/ both E/P, not E alone) (b) Decreased risk of 1. colon cancer 2. fractures
57
Rate of progression of the dif types of endometrial hyperplasias to cancer
quarter, dime, nickel, penny 25% complex w/ atypia => cancer 10% simple w/ atypia => cancer 5% complex w/o atypia => cancer 1% simple w/o atypia => cancer
58
Differentiate the two classifications of precocious puberty
GnRH dependent (high LH) vs. GnRH independent (LH doesn't increase w/ GnRH administration)
59
Mechanism of visualization in colposcopy
Acetic acid- use dilute acetic acid to make atypical cells turn white
60
How to equate the cytology and histology findings in cervical cancer
1/3 of the epithelium involved: LSIL, CIN I 2/3 of the epithelium involved: HSIL, CIN II and III
61
Concept of how to treat TOA
TOA = tubovarian abscess Want to start w/ aggressive broad spectrum IV abx (cefotetan or cefoxitin + doxy) -but may be hard for abx to penetrate TOA (b/c no blood supply and capsulated) => may need to surgically drain the abscess if abx don't work
62
Differentiate the two classification systems used for cervical cancer
1. Cytology- this is what you see on pap smears - LSIL and HSIL 2. Histology- seen when you take biopsy of colposcopy - CIN I, II, III
63
Why does uterine atony cause bleeding post-partum?
Uterine atony = lack of uterine tone Uterine tone is needed for contractions to clamp down on the spiral arteries- so much vasculature, need to clamp down to stop the bleeding
64
Briefly describe the IVF process
1. ovarian stimulation 2. oocyte retrieval, done transvaginally 3. fertilization of egg w/ sperm in petri dish (hence the in vitro) 4. insertion of fertilized egg into uterus
65
Age at which you stop needing pap smears?
After 65 you can stop (and never restart!) if never had CIN II or worse
66
beta-hCG (a) When does it peak? (b) Peak level (c) Level at term
beta-hCG (pregnancy hormone) rule of 10s (a) Peaks at abotu 100,000 (b) At 10 weeks of gestation (c) About 10,000 at time of term fetus
67
Causes of spontaneous abortion
1st T most common i is spontaneous abortion 2nd T: maternal infection/anatomic abnormality, teratogen exposure, uterine malformation, trauma -thyroid disease -diabetes 2/2 poor vascularization -antiphospholipid syndrome
68
Relationship btwn BMI and risk of osteoporosis
Low BMI have higher risk of osteoporosis- less body weight = less pressure being put on bones
69
Medical management of first trimester spontaneous abortion
Prostaglandings such as Misoprostol (cytotec) to | -contract uterus and open the cervix to expel POCs
70
Describe the details of administering a medical abortion
1-3 tablets of RU-486 (Mifepristone = progesterone antagonist to stop growth of pregnancy) given Then 6-72 hrs later insert 4 tablets of misopristol (prostaglandin analogue to induce uteirne cramping and POC crampign) transvaginally -pregnancy passes w/in 4-6 hrs of misopristol Then F/u apt for US or beta-hCG to confirm completion
71
Possible consequences of untreated PID
- infertility 2/2 tubal scarring - TOA - chronic pain/adhesions
72
Most common location for ectopic pregnancy
95+% are in the fallopian tubes | -majority of which are located in the ampulla
73
Discriminatory zone of b-hCG and its relevance
Discriminatory zone 1500-2000 -level above which imaging scan should be able to se gestational sac w/in the uterus So if b-hCG is >2000 and you don't see gestational sac = high suspicion for ectopic, but if b-hCG is 1,000 and no gestation sac it's still pregnancy of unknown location
74
Indication for continuous GnRH therapy
Continuous GnRH can be given to suppress ovulation in girls w/ precocious puberty
75
Leading cause of maternal death in the first trimester
Ectopic pregnancy
76
Buzzword: violin strings
Fitzhugh-Curtis = perihepatitis = adhesions from liver edge to anterior abdominal wall -inflammation of liver capsule to adjacent periotneal surfaces
77
Buzzword: cervical motion tenderness
Buzzword for PID
78
Diagnostic criteria for PID
Need 1 major and 1 minor criteria (at least) Major criteria: 1 of 2 1. Cervical motion tenderness 2. Adnexal/uterine tenderness Minor - fever - WBC - elevated CRP/ESR
79
Fitz-Hugh-Curtis syndrome
= Perihepatitis = inflammation of the liver capsule and adjacent periotoneal surfaces - increased risk in PID - adhesions from liver edge to anterior abdominal wall
80
'Chocolate cyst'
Chocolate cyst = ovarian endometrioma
81
Purpose of HPV testing in pt w/ diagnosis of HSIL
In LSIL and HSIL pt is assumed to be HPV+ -especially if age 21-29: most likely that the patient is + if she's sexually active, and high probability of clearing it on her own

OB/GYN (10 decks)

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