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OB/GYN 2 Flashcards

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1
Q

A 30-year-old female who is 32 weeks pregnant begins to experience tremors, heat intolerance, and irritability along with some fatigue, tachycardia, hypertension, and lower abdominal pain.

Labs reveal the following:

Hct 33%;
Hgb 12.8 g/dL;
WBC 14,600/L
am cortisol 42 g/dL (normal 5 to 20 g/dL)
Total thyroxine 13.1 g/dL (normal 5 to 12 g/dL)
Total T3 225 ng/dL (normal 70 to 205 ng/dL)
TSH 0.4 U/mL (normal 2 to 10 U/mL)

Which of the following therapies is the treatment of choice?

A. amiodarone

B. propranolol

C. propylthiouracil

D. radioactive iodine

A

The answer is C

A. Amiodarone can be a cause of hyperthyroidism and is not used for the treatment.

B. beta Blockers may alleviate symptomatology of hyperthyroidism but may cause fetal growth retardation.

C. Hyperthyroidism results in low TSH and elevated T3 and thyroxine (free T4). It may cause intrauterine growth retardation, prematurity, or transient thyrotoxicosis in the newborn. Propylthiouracil is the only drug recommended for treatment of hyperthyroidism during pregnancy and lactation. This drug does cross the placenta and, although rare, may result in excess TSH secretion and goiter in the fetus. Therefore, the smallest dose possible should be used. Very little is secreted in breast milk; adverse effects in the fetus have not been demonstrated.

D. Radioactive iodine would be harmful to the fetus.

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2
Q

The presence of which of the following distinguishes eclampsia from preeclampsia?

A. hypertension

B. proteinuria

C. seizure

D. thrombocytopenia

A

The answer is C [Ob/Gyn].

A. Preeclampsia and eclampsia both manifest with hypertension, proteinuria, and thrombocytopenia.

B. See A.

C. When seizure occurs, the patient goes from a diagnosis of preeclampsia to that of eclampsia.

D. See A.

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3
Q

define adenomyosis

indicence

A

endometrial glands and stroma within the myometrium

8-40% of all hysterecyomes

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4
Q

etiology and symptoms of adenomyosis

A

unknown etiology, common in women 35-45 and abates at menopause

dysmenorrhea and menorrhagia

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5
Q

management of adenomysosi

A

diagnosis with MRI or ultrasound

supportive treatment with nsaids, analgesics, or ovarian suppression

surgical treatment with hysterectomy or segmental resection

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6
Q

how do symptoms differ between submucosal and pedunculated fibroids

A

submucus will have menorrhagia and pressure discomfort from the mass

pedunculated will have acute pain due to infarct and dysmenorrhea

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7
Q

fibroid etiology

what determines the symptoms

A

a single myometrial cell mutation found in 20-50% of women that is estrogen dependent

symptoms are depedent on location

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8
Q

are normally dosed birth control pills usually effective for adenomyosis

A

no, they need to be continuously dosed

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9
Q

treatment of fibroids

A

expectant

ovarian suppression

anti-progestational therapy

radiologica embolization

surgery (hysterectomy or myomectomy)

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10
Q

two situations where dysmenorrhea might be caused by outflow obstruction

A

pain at or soon after menarche caused by mullerian fusion or vaginal formation problem

pain after surgical procedure due to cervical stenosis

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11
Q

blind uterine horn (hematometra)

A

trapping of blood in the uterus due to a lack of opening

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12
Q

imperforate hymen

A

a hymen that doesn;t open during development and can trap blood to cause dysmenorrhea

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13
Q

vaginal septum

A

a septum in the uterus that can cause dyspariena or dysmenorrhea

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14
Q

non-communicating uterine horn

A

a malformation of the uterus where one side is closed off from the body of the uterus

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15
Q

cause of uterine prolapse

symptoms

incidence

A

weakening of uterine support caused by congenital causes, obstettrical causes, hypoestrogenism, or increased intraabdominal plressure

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16
Q

uterine prolapse

symptoms

incidence

A

pressure or heaviness, possible bowel and bladder symptoms

common 20-30%

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17
Q

causes for pelvic relaxation leading to uterine prolapse

A

obstetrical deliveries

decreased strength of connective tissue due to age

decreased estrogen

increased abdominal pressure from obesity, chronic cough, constipation

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18
Q

treatment for uterine prolapse

A

reduce intraabdominal pressure

estrogen replacement

kegels

surgical repair

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19
Q

vagina pessaries

A

a plastic ring inserted into the vagina to help support a prolapse uterus

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20
Q

24 y/0 gravida 1 para 1 complains of 10 days of progressive symptoms: Vaginal discharge, Vaginal itching and irritation, Good general health, Recently completed antibiotics for strep throat infection

DDx

A

vaginitis

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21
Q

what is the most common GYN problem in women from 15-45

symptoms

A

cervicitis/vaginitis/vulvovaginitis

vaginal discharge; vaginal or vulvar irritation; odor esp with bacterial vaginosis

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22
Q

big three causes of vaginitis

A

monilia (candida albicans)

trichomonaisis

bacterial vaginosis (gardnerella vaginalis)

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23
Q

three things associated with monilia causing vaginitis

A

hormonal changes, ABx, immune status in frequent infections

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24
Q

which of the vaginitis big three is sexually transmitted

A

trichomonaisis

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25
why does gardnerella vaginalis cause bacterial vaginosis
unknown, but the bacteria is associated with sexual activity
26
diagnosis of vaginitis
wet mount on two slides one with saline to look for flagellated trichomonads or clue cells (bacterial vaginosis) one with potassium hydroxide to look for budding yeast
27
health care issues with the big three vaginitis causes
frequent monilia: immunosuppression trichomonaiasis: other STDs bacterial vaginosis: increased risk of premature labor, increased risk of PID with clap, increased risk of post GYN surgery infection
28
treatment of the big three vaginitis
oral or topical fungicides for monilia oral or topical metronidazole for trichomoniasis and bacterial vaginosis topical clindamycin for bacterial vaginosis
29
what are the advantages of barrier contraception three types
they are very effective with the right population and they may provide protection against STI diaphram, cervical cap, condoms
30
methods of intrauterine contraception
IUD (Copper, mirena, Skyla, Liletta) endometrial ablation
31
advantages of endometrial ablation
it will make conception much less likely and can reduce dysmenorrhea or endometrial pain to managable levels
32
types of tubal contraception
surgical inflammatory occulsion
33
three types of surgical sterilization for women
postpartum "mini-laparotomy" tubal laparoscopic coagulation or application of occlusive clips/rings hysteroscopic
34
describe the process of laparoscopic tubal sterlization what are the advantages
coagulation, cutting, or binding the fallopian tube no incisions, very effective, can be reversed, IVF still effective
35
four types of emergency contraception
progestin only (plan B) Yuzpe method IUD insertion withine 5 days Progesterone receptor blockers
36
what drug is in Plan B when are the best given what is the method of action what is the main side effect
levonorgestrel pills best results within 72 hours blocks ovulation nausea
37
how many couples will experience infertility in their lives how many women
8-14% 25%
38
strategy for dealing with infertility
discover the causes correct the issue if possible bypass if possible provide support
39
causes of infertility along with percent incidence
egg/ovulation (25%) sperm problems (30%) tubal/pelvic (30%) unusual problems (5%) Unexplaned (10%)
40
what are the three most common causes of infertility
egg or ovulation sperm tubal or pelvic
41
what is the source of many idiopathic cases of infertility and treatment failure
infertility due to female age
42
30 yr old patient attempting to get pregnany comes to the clinic to seek infertility treatment after 1 month of unprotected sex. how should be cancelled what if she were 35+ 40+
less than 35 should try 1 year of unprotected sex before attempting infertility treatment without obvious issues 6 months immediately
43
three factors that would warrant infertility evaluation at any time
amenorrhea known tubal Hx male infertilty Hx
44
the essential work up for infertility (HEST)
health, eggs, sperm, tubes
45
issues to look for in the health portion of the HEST workup
pelvic exam look for infection (HIV, HepB/C) changes to immune status (rubella, hepatitis) TSH Genetic screening
46
egg/ovulation test for HEST workup
FSH and estradiol (E2) testing on cycle day 2 or 3 serum progesterone
47
when checking FSH and estradiol for HEST workup, what should the values be what about serum progesterone
FSH \<10 E2 \<80 SP \>9 if taken 7-10 days after LH surge
48
when evaluating a semen analysis for infertility what are three things to look at what should happen if the results are abnormal
concentration, motility, volume repeat at 4-8 weeks
49
what is a normal semen concentration what is considered mild oligospermia severe very severe
+20million 10-19 million 5-9 million \<5million
50
what percent of sperm in semen are normally motile what is considered mild asthenospermia severe very severe
+40% 20-39% 10-19% \<10%
51
in the case of mild oligiospermia or asthenospermia, what action can be taken what about a severe issue
fertility without treatment is possible but intrauterine insemination (IUI) may help fertility without treatment is very unlikely, IVF is the only option
52
two ways to evaluate fallopian tubes on a HEST workup
hysterosalpingogram laparoscopy
53
what other test might be considered for infertility treatment in the presense of oligomenorrhea or amenorrhea what bout oligospermia
serum prolactin chromosomal analysis
54
what are fertility drugs used for two types
to cause or enhance ovulation gonadotropins, clomiphene
55
T/F fertility drugs are "fertility enhancers" what conditions are not treatable with fertility drugs
false sperm, tubal, uterine issues
56
what is in a gonadotropin fertility drug what are the risks of treatment
FSH with or w/o LH hyperstimulation, multiple births
57
what is the action of clomphene citrate what are the possible side effects
inhibits estrogen, induces the release of FSH and LH functional ovarian cysts; decrease cervical mucus; decreased endometrial growth; hot flashes
58
what is the general strategy for the use of clomid
use as much as necessary but as little as possible expect rapid response (1st 3-4 months) no effect in continuing beyond 6 months
59
treatment options for idiopathic infertility
IVF egg donation surrogate IVF
60
what is the ultimate goal of infertility treatment
prenancy, adoption, or acceptance of life without children
61
two types of epithelial carcinoma categorized as breast cancer one special category
intermediate type ducts (ductal carcinoma) terminal lobular ducts (lobular carcinoma) carcinoma in-situ
62
how is carcinoma in situ usually diagnosed
mammography
63
describe ductal CIS
a localized carcinoma with penetration of the basement membrane with 1-3% having + axillary nodes
64
describe lobular CIS
localized carcinoma that is not truly malignany but increase the risk of later malignancy by 20%
65
how are breast cancers identified by their hormone receptor
estrogen positive or negative HER-2 positive or negative basal ("triple negative")
66
describe the relationship between breast cancer and age before what age is breast cancer less likely what is the mean age at diagnosis what is the time from origin to dianosis
risk increases with age 40 unless genetically predisposed 60-61 2-8 years
67
what is the male risk of breast cancer
1/150 that of women with similar risk factors and treatment
68
rectocele vs cystocele
rectocele is posterior vaginal wall weakness cystocele is anterior vaginal wall weakness
69
Whiff test for vaginosis
KOH on a vaginal secretion slide will produce a fishy smell with gardnerella vaginalis
70
how will clue cells look like on a microscope slide
epithelial cells with granular bacterial inclusions
71
T/F IUD can be used to treat menorrhagia
true
72
complication common with fallope ring for laparoscopic sterlization
can cause cramping 12 hts post op
73
primary infertility
a couple (particularly the woman) has never been pregnant together
74
what is an effective treatment for HER-2 sensitive breast cancer
monoclonal antibodies against the receptors
75
why are triple negative breast cancer the ones with the worse prognosis
because they are not receptive to anti-estrogen/progesterone/HER-2 drugs
76
T/F estrogen causes breast cancer reasoning?
false, it opens the door to allow for breast cancer to form women without esstrogen have a low risk, men with estrogen do, early menses + late menopause increases risk
77
T/F oral contraceptives increase breast cancer risk
probably slightly
78
what is the effect of postmenopausal HRT on breast cancer
estrogen + progestin increases risk, estrogen alone does not
79
T/F delayed childbearing decreases risk of breast cancer
false, pregnancy after 35 increases risk by 1.5x
80
what is the genetic paradox in breast cancer
first degree relative with breast cancer increases risk by 3-4x BUT 85% of patients have no family Hx
81
what percent of breast cancer is associated with BRCA1-2
5-10%
82
cancers associated with BRCA1
breast cancer ovarian cancer pancreatic cancer fallopian tube
83
cancer associated with BRCA2
breast cancer ovarian cancer pancreatic cancer prostate
84
environmental factors associated with breast cancer
high rate in developed nations related to fat intake ETOH slightly increases risk
85
how is breast cancer usually discoved
90% are found as a painless lump in the breast
86
three less common presentations of breast cancer
nipple erosion or discharge (pagets) skin dimpling (retraction) inflammatory breast cancer
87
what type of breast cancer is the most aggresive but uncommon
inflammatory breast cancer
88
clinical factors to keep in mind when assessing a breast lump
most are benign (90% \<20, 60-70\>40) is the mass solid vs cystic mobile vs fixed dimpling or nipple erosion
89
DDx for a breast mass
benign cyst (fibrocystic disease or cystic duct) fibroadenoma (benign) cancer fat necrosis lipoma epidermal cyst
90
three types of breast mass biopsy
open (excisional) fine needle core needle
91
compare and contrast open, fine needle, and core needle biopsies for breast masses
open is the most reliable fine needle is the least invasive but has a higher false negative rate and needs US or Xray guidance core needle has fewer false negatives
92
two step principle as it applies to breast cancer
make diagnosis with biopsy first, then treat
93
how is a cysy managed clincially when should it be biopsied
outpatient aspiration if its the first cyst, it is still present after aspriation, or the fluid aspirated is cloudy
94
when is fine needle biopsy the only reasonable method for breast cancerq
when assessing masses that are too small to palpate
95
are self breast exams positively correlated to survival are they still useful
no useful in a diligent patient using good protocol during cycle day 6-10
96
is there a benefit for performing an annual breast exam important notes for the exam
yes, but a hurried or incomplete exam is useless palpation supine with arm behind head, extra attention in the upper out quadrant, palpate axilla
97
in what age group does mammography increase survival is it safe what is the most common finding
50-70 yes there is fairly low radiation with modern equipment microcalcification
98
what is the only method of breast cancer screening that is capable of finding non-palpable breast cancer
mammography
99
is there a value for mammography in ages below 40? 40-50 70+
no because the breast is more dense maybe no proven value after 70
100
T/F screening is strong correlated with breast cancer survival
false, there is only a small increase in survival, a lot what we are picking out are not aggressively malignant similar to prostate cancer
101
what is the trade off from mammography
reduce mortality by 8 per 100,000 increase false positives by 122 per 100,000
102
breast cancer treatments
surgery radiation chemo endocrine modulation immune modulation
103
when is MRI mammography useful
high risk patients (BRCA1, 2, FHx)
104
what is the goal of primary breast cancer treatment intial recurrence after that
surgical or medical therapy for a cure still hope with endocrine, chemo, occasional surgical follow up eventually palliative care
105
TNM
Tumor: size, Node: lymph node involvement, Metastasis: presence of distant metastasis
106
general prognostic factors for breast cancer
best age is 40-70 preexisting conditions can limit treatment staging receptor status and genetic profile
107
breast cancer prognosis divided by receptor status
good: estrogen and progesterone receptors neutral: HER-2 poor: tipple negative, HER-2 without monoclonal antibodies
108
primary surgical treatment for breast cancer
conservative (lumpectomy) mastetctomy axillary nodes
109
compare and contrast lumpectomy vs mastetcomy
similar survival studies with post op radiation lumpectomy is under utilized, but not everyone is a candidate (small breast and large tumor size)
110
adjunctive therapy associated with breast cancer what is the goal types is chemo needed?
improve long term survival endocrine modulation for estrogen sensitive patients (anti-estrogen and aromatase inhibitors) chemo is not necessary for early stage cancer
111
immunologic therapy associated with breast cancer
trastuzumab for HER-2 sensitive cancer trastuzumab emtansine is a chemo drug bonded to trastuzumab
112
types of breast reconstructuve surgery
saline implants trans-rectus abdominis muscle flap
113
what is the long term survivability of lung cancer two big take aways to maximize survival
old standard is 5 years most studies are showing 10 years early diagnosis is crucial and long term surveillance is needed
114
factors that increase risk for ovarian cancer
age genetics (familial, BRCA1-2, ashkenazi) high fat diet PCOS
115
factors that lower ovarian cancer risk
pregnancy (-15% per pregnancy) oral contraceptives (-50%)
116
three ovarian cancer origins
epithelial (90%) germ cell origin stromal/sex cord
117
types of epithelial ovarian cancer
serous cystadenocarcinoma mucinous cystadenocarcinoma
118
types of germ cell ovarian cancer
dysgerminoma choriocarcinoma embryonal cell carcinoma
119
stromal/sex cord ovarian cancer
granulosa cell tumor
120
what is the usual presentation of ovarian cancer screening tests conclusion?
pelvic mass with ascites pelvic exams, CA-125 assays, ultrasound there is no cost effective protocol
121
what types of patient would warrant vaginal ultrasounds and CA-125 assays every 6 months
BRCA1-2 positive patients with a first degree relative who had premenopausal ovarian cancer
122
what is the most common germ cell ovarian cancer
dysgerminoma
123
what type of ovarian cancer can secrete steroid hormones
granulosa cell tumors
124
treatment for ovarian cancer
surgery to cure stage 1-2, or debulk stage 3-4 for better chemo chemo
125
when is conservative treatment of ovarian cancer warranted
young people with no children or those with stage one disease with low malignany potential
126
sources of morbidity associated with ovarian cancer
intra-abdominal spread obstruction or malabsorption in the GI tract distant mets (liver, lung, bone)
127
why isn't US used to screen for ovarian cancer
increased survival by 50% but lead to many false positives
128
ovarian cancer stagin
stage one: tumor only in ovaries stage II: tumor limited to pelvis stage III: tumor limited to abdomen Stage IV: distant mets
129
what is prognosis of ovarian cancer dependent on
stage, age, health, tumor type, tumor grade
130
what is the main cuase of cervical cancer two synergistic factors
HPV smoking and immunosuppression
131
HPV types 6, 11, 42, 43 are low risk for HPV but are asociated with what
condlyomata and CIN I
132
HPV 16, 18, 33, 35, 45 are high risk and are associated with what
CIN II, III, cervical cancer
133
prevention of cervical cancer
HPV vaccine pap smear to detect cervical intraepithelial neoplasia
134
gardasil is most effective when potential benefit
girls and boys 11-12, reccomended 9-26 prevent 70% of cervical cancer 90% genital warts
135
differentiate between CIN and CIS
CIN = cervical intrepithelial neoplasia, can be mild, moderate, or severe dysplasia CIS = carcinoma in situ
136
screening protocol for cervical cancer
begin 3 years after sexual activity or 21-25 q3yrs as long as results have been normal q5yrs after 50 stop at 65 (or 70) with 5 normal paps
137
bethesda system to classify pap smears
normal: negative for CIN, CIS, cancer atypical squamous cells, undetermined or cannot exclude (ASC) low grade squamous intraepithelial lesion (LGSIL) high grade squamous intraepthelial lesion (HGSIL)
138
prognosis of intraepithelial lesions
50% will regress to normal 25% will persist 25% will progress to invasive cancer
139
evaluating abnormal pap smears (ASC-US, LGSIL, HGSIL)
ASC-US: treat any vaginal infections and repeat in 3-6 months for any others colposcopy with directed biopsy
140
treatment of CIN
loop electrosurgical excision procedure (LEEP) cervical cryotherapy cold knife cone biopsy
141
morbidity associated with cervical cancer
local spread and destruction of ureters, bladder, rectum lymphatic spread rare distant metastasis
142
treatment of invasive cervical cancer
radiacl hysterectomy with lymph node dissection radiation therapy chemo (adjunctive)
143
factors the increase risk of endometrial cancer decrease risk
estrogen exposure, genetic factors oral contraceptives, progestin use
144
three types of endometrial hyperplasia
hyperplasia without atypia hyperplasia with atypia carcinoma in situ
145
what is the prognosis of endometrial hyperplasia w/o atypia with atypia carcinoma in situ
80% regress, 1% progress to cancer considered premalignant, 8-29% progress to CA considered the same as CA
146
advantages/disadvantages of radiation treatment in cervical cancer
advantage: able to use direct appliation of radiation disadvantage: can damage the vaginal tissue so is reserved for older women
147
what is the most common symptom of endometrial cancer
abnormal uterine bleeding or postmenopausal bleeding
148
postmenopausal bleeding DDx
postcoital (cervical polyp or carcinoma) ovulatory abnormal (endometrial hyperplasia/carcinoma)
149
evaluation of post menopausal bleeding
TV US to measure endometrial thickness, biospy if \<3mm endometrial biopsy \>3mm dilation and curettage in the case of cervical stenosis
150
treatment of endomettrial cancer
radiation therapy adjuct to surgery or primary surgery (TAH, BSO) progestin, tamoxifen chemotherapy
151
primary radiation therapy for endometrial cancer
implants in the endometrium or vagina lymph nodes irradiation for mets
152
when would leiomyosarcoma be high on the DDx how are they treated
when there is a rapidly growing uterine mass or suspected fibroid excision
153
other types of GYN cancer vulvar vaginal
vulvar: squamous carcinoma, malignant melanoma vaginal: clear cell adenocarcinoma (DES) esxposure

Clinical Medicine (11 decks)

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