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Flashcards in OB/GYN III Deck (194):

How is a molar pregnancy categorized

abnormal proliferation of the placental trophoblastic cells Abnormal cells distend the uterus and secrete hCG, mimicking a normal pregnancy. There are 2 types complete (classic) and partial (incomplete)


What defines a complete mole

Empty ovum fertilized by sperm.

46XX by one sperm occurs 90% of the time
46XX or 46 XY by two sperm occurs 10%


What is the most common clinical presentation of a molar pregnancy

Abnormal uterine bleeding (most common)
Uterine size greater than expected for GA
lack of fetal heart tones
hCG greater than 100,000 and uterine cavity filled with small vessicles


What defines an incomplete mole

a normal ovum is fertilized by two sperm. The resulting karyotype is 69 XXX, XXY, or XYY

A fetus may or may not be present, but will not viable if present


What are the most common clinical presentation of an incomplete molar pregnancy

Abnormal heavy bleeding
hCG is not as elevated as it is with a complete mole

Many spontaneous abortions are the result of a partial mole


How long should a patient wait for reattempting pregnancy following a molar pregnancy

at least 1 year


Gestational Trophoblastic Tumors may become metastatic to what locations

Lung (80%)
Vagina (30%)
Liver (10%)
Brain (10%)


How is a GTT diagnosed

After evacuation of a molar pregnancy
1. increase in hCG
2. the value of hCG reaches a plateau for 3 weeks
3. metastatic disease is identified


What is used to treat non metastatic GTT

Single agent chemotherapy
1. Methotrexate
2. Actinomycin D


What drug is given with methotrexate to preserve normal cells



What is the mechanism of methotrexate

Anitmetabolite inhibits purine synthesis by blocking the dihydrofolate reductase enzyme required to process folic acid. Results in arrested synthesis of DNA, RNA and proteins


What is the mechanism of actinomycin D

Antibiotic that intercalates DNA strands


How should you monitor a patient with GTT

hCG titers should be taken weekly until normal fro 3 months, then monthly for 6 months
Contraception is preferred for 1 year


What carries a good prognosis with metastatic GTT

Rules of 4
- duration less than 4 months
- less than 40,000 hCG pretreatment
- No foreign metastasis to brain or liver
- no previous chemotherapy


What is the treatment for poor prognosis metastatic GTT


Actinomycin D
Oncovin (vincristine)


How long should treatment last for poor prognosis metastatic GTT

Three additional chemo sessions after a negative hCG titer


What are the phases of the menstrual cycle



What is polymenorrhea

menstrual cycles that last less than 21 days in duration


What is oligomenorrhea

menstrual cycles that last more than 35 days in duration


When are menstrual cycles most irregular

2 years following menarche
3 years preceding menopause

During both times anovulation is common


What is the follicular or proliferative phase

lasts from the first day of menses until ovulation, during which time follicles within the oveary grow in response to FSH and in the uterus enometrial glands proliferate under the influence of estrogen, primarily estradiol produced by the follicle

Characterized by:
Variable length (average of 14 days)
development of ovarian follicles in response to FSH
Secretion of estrogen from the ovary
Proliferation of the endometrium in response to estrogen
Low basal body temperature


What causes ovulation to occur

response to the LH surge

Characterized by:
release of the oocytes from the follicle in response to FSH induction of collagenases
Resumption of meiosis, with oocytes progressing from prophase I to metaphase II
Formation of the corpus luteum with in the follicle


What is the luteal or secretory phase

Begins with ovulation and last until menses

The corpus luteum, stimulated by LH, produces progesterone, which causes secretory changes in the endometrium necessary fro preparing the endometrium for implantation.


What characterizes the luteal phase

Fairly constant duration of 12-16 days
elevated basal temperature in response progesterone production
sustaining of the corpus lute in the ovary


Where is GnRH produced and what is the frequency of release

Produced by hypothalamic neurons from the arcuate nucleus and transported to the portal plexus to the anterior pituitary.

Released in a pulsatile manner:
Follicular phase has one pulse every 60-90 minutes
Luteal phase has one pulse ever 2-3 hours

Amplitude and frequency is modulated by feedback of estrogen and progesterone


What is the role of FSH

production of estrogen and growth of the follicle. FSH receptors exist primarily on the ovarian granulosa cell membrane


What is the role of LH

responsible for the initiation of the luteal phase (ovulation) and maintenance of the luteal phase of the menstrual cycle

LH receptors exist primarily on ovarian theca cells at all stages of the cycle and on granulosa cells after the follicle matures under the influence of FSH and estradiol


What is the 2 cell hypothesis of estrogen production

1. LH acts on the theca cells to stimulate the conversion of cholesterol to androgens
2. Androgens are transported from the theca cells to the granulosa cells
3. Under the influence of FSH, androgens are aromatized to form estrogens by the enzyme aromatase in the granulosa cells


What are the key steps in the process of oogenesis

1. primordial follicle
2. Primary follicle
3. Preantral follicle
4. Antral follicle
5. Preovulatory follicle
6. Ovulation
7. Early corpus luteum
8. Mature corpus luteum
9. Corpus Albicans


What is a primordial follicle

contains an oocyte surrounded by a single layer of granulosa cells. Each oocyte is arrested in Prophase I

A woman is born with a finite number of follicles that peaks at 20 weeks gestation. The decline is independent of the menstrual cycle and ovulation


What are the estrogen effects on the preantral follicle

1. stimulates preantral follicle growth
2. with FSH, increases FSH receptor content of the follicle
3. in the presence of FSH, stimulate mitosis of granulosa cells


What are the effects of the follicular increase of estradiol

Negative feedback on FSH
positive feed back on LH


Where is inhibin secreted from

granulosa cells in response to FSH


What are the two types of inhibin

Inhibin A: under the influence of LH suppresses FSH during the luteal phase of the cycle.

Inhibin B: directly suppresses pituitary FSH secretion in the follicular phase of the cycle


What is activin

Augments secretion of FSH and increases pituitary response to GnRH by enhancing GnRH receptor formation on the pituitary


When do estrogens peak

24-36 hours before ovulation


What is the effect of LH on the follicle

initiates luetinization and progesterone production


What effect does a preovulatory rise in progesterone have

causes a midcycle FSH surge by enhancing pituitary response to GnRH and facilitating the positive feedback action of estrogen


When does ovulation occur

10-12 hours after peak of LH
24-36 hours after peak of Estradiol


When can an oocyte become fertilized

only after it has reached metaphase II


What does the LH surge stimulate

Resumption of meiosis in the oocyte
Luteinization of the granulosa cell
Synthesis of progesterone and prostaglandin


When are peak levels of progesterone obtained

7-8 days after ovulation


What happens in the absence of pregnancy to the corpus luteum

will undergo apoptosis and cease to produce progesterone by 12-14 days after ovulation


What effect does the decrease in estrogen and progesterone have on the endometrium

leads to coiling and constriction of the spiral arteries in the endometrium


What causes menstrual cramps

the result of uterine contraction which are stimulated by prostaglandins. Therefore the cramps can be controlled with prostaglandin synthetase inhibitors (NSAIDs)


What is amenorrhea

absence of menses for 6 months or longer


What is primary amenorrhea

Absence of menses by 14 years of age ingirls without appropriate development of secondary sexual characteristics or by 16 years of age regardless of secondary sex characteristics


What are the categories of amenorrhea

Hypergonadotropic: elevated gonadotropins (typically FSH more than 20 IU/L; LH more than 40 IU/L)

Hypogonadotropic: low levels of gonadotropins (FSH and LH less than 5 IU)

Eugonadotropic: normal gonadotropin levels (FISH and LH of 5-20 IU/L)


What are the etiologies of hypergonadotropic amenorrhea

1. turner syndrome
2. Premature ovarian failure
3. Gonadal dysgenesis
4. Gonadal agenesis
5. Resistant ovary syndrome
6. Galactosemia
7. Enzyme deficiency


What are the phenotypic characteristics of turner syndrome

Short stature
webbed neck
shield chest
increased carrying angle at the elbow


What are the etiologies of hypogonadotropic amenorrhea

1. anorexia
2. Female athlete triad
3. Kallman syndrome
4. Postpill amenorrhea
5. Medication or drugs
6. Pituitary disease
7. Stress
8. Delayed puberty


What is the female athlete triad

Syndrome of disordered eating, amenorrhea, and osteopenia or osteoporosis


What percent of body fat is generally needed to initiate menarche and maintain regularity

17% to initiate
22% to maintain


What is kallman syndrome

Deficient secretion of GnRH associated with anosmia or hyposmia.

Involves the failure of olfactory axonal and GnRH neuronal migration from the olfactory placode in the nose


How does stress lead to amenorrhea

stress leads to an increased output of corticotropin releasing hormone, which subsequently results indecreased GnRH pulsatile secretion and thus decreased secretion of FSH and LH


What are the etiologies of Eugonadotropic amenorrhea

1. Disorders of Androgen excess (PCOS)
2. Disorders of the outflow tract or uterus
a. Mullerian agenesis
b. Mullerian anomalies
c. androgen insensitivity syndrome (AIS)
d. Asherman Syndrome


What is the triad assocated with PCOS

1. Menstrual irregularity signifying oligo or anovulations
2. Appearance of multiple small ovarian cysts on ultrasound "string of pearls"
3. Clinical or laboratory evidence of hyperandrogenism

loss of 5-10% body weight may help patients reestablish ovulatory cycles.


When and how may an imperforate hymen present

generally not until 6-12 months after menarche. The vagina maybe distended with more than 1 Liter of old blood


What is the problem with Androgen insensitivity syndrome

The defect is in the androgen receptor and can not respond to the androgen. The individual is phenotypically female and is usually raised female

Testosterone levels will be in the male range, but they will not have any pubic or axillary hair. Normal breast development because the testosterone is converted to estrogen

Gonadectomy is required to prevent gonadoblastoma


What should be suspected if a female patient presents with bilateral inguinal hernia



What is asherman syndrome

Intrauterine scarring usually a result of viorous curettage during a hypoestrogenic state or in the presence of an intrauterine infection.

Adhesions can develop


What is the goal of hormone replacement for the treatment in patients with hypergonadotropic amenorrhea

prevent bone loss, vasomotor symptoms, urogenital atrophy, and cardiovascular disease due to lack of estrogen


When is it safe to consider an estrogen only treatment

in women without a uterus

Progesterone is needed as it is protective of the uterus


What is the mechanism behind using OCP for the treatment of PCOS

Progestin component suppresses endogenously elevate LH levels, thereby decreasing androgen overproduction

Estrogen component of the pill increases the sex hormone binding globulin levels thereby decreasing the amounts of free estrogens and androgens


What is the rotterdam criteria

It is the criteria established in 2003 that is used to diagnose PCOS. It requires 2 of the following 3:

a. Menstrual irregularities
b. Hyperandrogenism
c. Polycystic ovaries


What are the results of irregular ovulations

lack of adequate progesterone and experience chronic estrogen exposure to the endometrium. Increases risk for endometrial hyperplasia and endometrial cancer


What is the Ferriman-Gallwey score

It is a score used for diagnosing hirsutism.

Greater than 8 is an abnormal score


If a patient experience an rapid onset of hirsutism, what is the most likely etiology

Drug induced or Androgen secreting tumor

Suspect a tumor with levels of testosterone greater than 200 ng/dL

PCOS will likely have a more gradual onset of hirsutism


What defines polycystic ovaries by ultrasound criteria

12 or more antral follicles between 2 and 9 mm in size and peripheral in location in at least one ovary


What is the pathophysiology of LH in PCOS

increased LH pulse frequency and amplitude stimulated by GnRH
LH stimulates production of androgens from the theca cells in the ovary leading to hyperandrogenism


What is the pathophysiology of Insulin resistance in PCOS

With PCOS insulin resistance is present regardless of obesity
Insulin has been shown to increase production of androgens in women with PCOS
a. IGF-I receptor binding
b. Decreases production of sex hormone binding globulin produced by the liver. Increases free metabolically active testosterone


What are the health consequences of PCOS

Metabolic syndrome
Cardiovascular disease
Endometrial Hyperplasia


What is the cause of cushings syndrome

Excess cortisol from ACTH

Diagnosed by 24 hour urine collection of free cortisol with the level greater than 100 on two determinations


What is ancanthosis nigricans

Raised, velvety, hyper pigmentation of skin, typically seen on the axilla, neck and intertriginous areas
Marker of insulin resistance
Will go away as insulin resistance improves


How can an insulin and glucose be used to determine insulin sensitivity

Glucose/Insulin Ratio

Ratio less than 4.5 in obese adult women
Ratio less than 7 in adolescents

suggested to diagnose insulin resistance


What is the underlying condition in PCOS and how can it be medically treated

Insulin resistance



What is lanugo hair

soft, short hair covering the fetus that is shed in late gestation and during the neonatal period


What is vellus hair

soft, fine, unpigmented hair that covers apparently hairless areas of the body


What is terminal hair

longer, coarse, pigmented hair that may grow in response to sex hormones or may be sex hormone independent


What is hypertrichosis

excessive growth of androgen independent hair in nonsexual areas such as forearms and legs


What is hirsutism

the presence of terminal hair in androgen dependent sites where hair does not normally grow in women.


What is virilization

hirsutism associated with other signs of hyperandrogenism, such as increased muscle mass, clitormegaly, temporal balding, voice deepening and increased libido


What is the normal level of testosterone in women

less than 70 ng/dL


What are the percentages of free testosterone in women, women with hirsutism and men

women: 1%
hirsutism: 2%
men: 2-3%


Is it possible to have hirsutism with normal testosterone levels


The active testosterone is unbound. With a decreased level of SHBG there is an increased level of free or unbound testosterone


What effect does cirrhosis have on SHBG

Increases the plasma levels therefore decreasing free testosterone


What factors may lead to the development of hirsutism

1. Increased concentration of serum androgens, especially free testosterone
2. Decreased levels of SHBG, resulting in increased bioavailable androgen
3. Increased activity of 5a-reductase


What is NCAH

Nonclassic Adrenal Hyperplasia

This is a less severe form of congenital adrenal hyperplasia that is diagnosed in the newborn and is associated with amigos genitalia and salt wasting


What drug exposure may cause hirsutism without virilization



What is the goal of treatment of hirsutism

The major goal is arresting the virilization process, not removing the hair. Once terminal hair has been established, withdrawal of androgens does not affect the established hair pattern


What is the benefit of using Combination hormonal contraceptive for the treatment of hirsutism

Both estrogen and progestin in the hormonal contraceptives cause a decrease in goadotropin secretion with a consequent decrease in ovarian androgen production
a. Estrogen also stimulate an increase in SHBG, causing increased binding of testosterone and decreased free testosterone levels
b. Progestin also may displace active androgens at the hair follicle and may inhibit 5a-reductase activity


What are some androgen receptor blockers that may be used for hirsutism

Spironolactone (5a-reductase inhibitor properties)
Flutamide (nonsteroidal antiandrogen)
Cyproterone acetate


What are some structural causes of abnormal bleeding

endometrial polyps
endometrial or uterine cancer


What is dysfunctional uterine bleeding (DUB)

abnormal bleeding that can be excessive or prolonged, or unpredictable, reflects a disturbance in normal ovulatory function. It is a manifestation of abnormal hormonal stimulation of the endometrium


What is metrorrhagia

bleeding at irregular intervals


What is menometrorrhagia

excessive bleeding at irregular intervals


What is menorrhagia

excessive or prolonged bleeding at regular intervals. Generally not associated with DUB because of the regular cycles


What causes the irregularity associated with DUB

unopposed estrogen stimulation that allows the endometrium to slough off in isolated locations at various times


What is the etiology of DUB

2. Immaturity of the hypothalamic pituitary ovarian axis
3 Dysfunction of the hypothalamic pituitary ovarian axis
4. Abnormalities of the normal feedback signals


What is estrogen withdrawal bleeding

Bleeding that may occur at MIDCYCLE when estrogen levels decline briefly just before ovulation


What are some organic causes of abnormal uterine bleeding

1. polyps
2. uterine fibroids
3. endometritis
4. endometrial hyperplasia
5. pregnancy
6. blood dyscrasia


What increased risk does DUB carry

Increases risk of endometrial hyperplasia and cancer


30% of adolescents who present with severe blood loss will generally have what pathology

associated coagulapathy such as Von Willebrand Disease in which platelets are dysfunctional


What type of sonography is more sensitive in detecting endometrial polyps



What are the orally administer progestins administered to control bleeding

1. Medroxyprogesterone acetate 10mg daily for 10-12 days
2. Norethindrone acetate 5 mg daily for 10-12 days
3. Oral Micronized progesterone 200 mg daily for 10-12 days


How soon should a response be noted when utilizing OCP for control of bleeding

with in 24 hours of therapy initiation. If no response has occured by this time, another treatment for the DUB should be initiated


Can estrogen be used to stop DUB bleeding


Rapidly stops bleeding with in 12-24 hours of treatment

It is effective when bleeding has been prolonged or is secondary to progesterone breakthrough bleeding


What is the mechanism of high dose estrogen to control bleeding

initiation of clotting at the capillary level


What role do NSAIDs have with DUB

limiting menstrual blood loss in women who ovulate, and they reduce excess blood loss by as much as 50%


What is the success rate of endometrial ablation

50% of women will achieve amenorrhea
90% will see a significant reduction


What are some common names for uterine leiomyomas



What are leiomyomas

porliferative well circumscribed, pseudoencapsulated, benign tumors composed of smooth muscle and fibrous connective tissue. Primarily located in the uterus but may be found in areas outside the uterus


What is the most common uterine mass


present in 20-40% of women over the age of 35


How are leiomyomas classified

according to location

1. Intramural leiomyomas: most common variety. Occurs within the myometrium of the uterus as isolated, ecapsulated nodules of varying size
2. Submucous leiomyomas: located beneath the endometrium and can grow into the uterine cavity
3. Subserosal leiomyomas: located just beneath the serosal surface and how out toward the peritoneal cavity and causing distortion of the peritoneal surface


How are leiomyosarcomas diagnosed

based on a mitotic count of 10 mitotic figures per 10 high power fields


What are the associated symptoms of leiomyomas

1. Abnormal Uterine Bleeding
2. Pain
3. Pressure (GU and GI problems)
4. Reproductive disorders
5. Pregnancy related disorders


What should be done initially for treatment of leiomyomas

Expectant management.

Bimanual exam every 3-6 months to determine uterine size and rate of tumor growth

NSAIDs on a regular schedule to limit blood loss


What are the indications for surgery for leiomyomas

When symptoms fail to respond to conservative management.

Excessive bleeding
Rapid growth
Repetitive pregnancy loss
Enlarged Uterine size


What are the types of surgical procedures available for leiomyomas

1. Myomectomy
a. Abdominal myomectomy
b. Hysteroscopic resection
c. Laparoscopic myomectomy
d. MRI guided focused Ultrasound
e. Laproscopic myolysis or cryomyolysis
2. Hysterectomy
3. Uterine Artery Embolization (UAE)


What is endometriosis

the presence of functioning endometrial glands and stroma outside their usual location within the uterine cavity


Where does endometriosis occur

It is primarily a pelvic disease with implants in or adhesions of the ovaries, fallopian tubes, uterosacral ligaments, rectosigmoid, bladder, and appendix

Less common it can be located outside the pelvis suggesting a metastatic disease


What are the causes of endometriosis

1. Retrograde menstrual flow
2. Hematogenous or lymphatic spread
3. Metaplasia of the coelomic epithelium
4. Genetic and immunologic influences


What causes the pain associated with endometriosis

1. Irritation or direct ivasion of pelvic floor nerves by infiltrating implants
2. Effects of active bleeding from implants
3. may result from growth factors, cytokines, prostaglandins, and histamines in endometriotic tissue and peritoneal fluid of women with endometriosis


How is fertility effected with endometriosis

Moderate to sever endometriosis is thought to cause infertility by causing adhesions and scarring of the ovaries and fallopian tubes


What are the signs and symptoms of endometriosis

1. dysmenorrhea
2. pain with ovulation
3. chronic pelvic pain
4. dyspareunia
5. infertility
6. GI and GU disturbances
a. 1/3 will urinary tract involvement
b. up to 1/3 will have bowel involvement


What is dyschezia

pain with defication


How is endometriosis diagnosed

the only way to diagnose the condition is by visualization at surgery or by biopsy of implants


What is a marker for endometriosis


Not specific


What pathologies will elevate CA-125

Ovarian Ca


What will a typical pelvic exam demonstrate on a patient with endometriosis

1. Nodularity and tenderness of the uterosacral ligaments
2. Endometriomas
3. Uterus is often in a fixed retroverted position
4. Usually normal pelvic examination for minimal endometriosis


What are endometriomas

ovarian cysts filled with old blood from endometriosis, forming "chocolate cysts". Palpated as adnexal masses often fixed to the lateral pelvic walls or to the posterior cull-de-sac


What is the appearance of endometriosis

brown or black pigmentation known as powder burn lesions

Lesions that are clear vesicular, white opacified, glandular excrescences, polypoid or red hemorrhagic vesicles are consider to be "atypical" lesions. May be more metabollically active

White scarring of pelvic peritoneum suggests old burned-out endometriosis


What is the basis of medical therapy for the treatment of endometriosis

hormonal suppression of menses


What are the medical options available for the treatment of endometriosis

1. OCP
2. GnRH agonist
3. Danazol
4. Aromatase inhibitors


What is the mechanism of OCP

creates a pseduopregnancy state associated with amenorrhea


What is the mechanism for GnRH agonist

Chemical alteration of the amino acids at positions 6 and 10 produce synthetic derivatives of GnRH that resist cleavage by endopeptidases but retain a high affinity for the pituitary GnRH receptor.

The effect is down regulation and desensitization of the pituitary with resulting lack of ovarian estrogen production


What are the side effects associated with GnRH agonist

1. menopausal symptoms
2. Bone loss with prolonged use


What is the mechanism of danazol

adrogenic testosterone derivative that suppresses FSH and LH as well as ovarian estrogen and progesterone production


What are the adverse effects of danazol

weight gain
decreased breast size


What is the mechanism for aromatase inhibitors

Aromatase enzyme converts androgen precursors suchas androstenedione and testosterone to estrone and estradiol.

Inhibitors such as letrozole and anastrazole will inhibit the production of estrogen within the endometriotic lesion. They will increase FSH and LH by blocking estrogens negative feedback on the pituitary.

Currently only indicated for Breast cancer and this treatment option is considered investigational


What is the treatment choice for adhesions associated with endmetriosis



What is the physiology of splanchnic pain

occurs when an irritable stimulus is appreciated in a specific organ secondary to tension, peritoneal irritation or inflammation, hypoxia or necrosis of viscera, or production of prostanoids


What is the physiology of referred pain

Occurs when autonomic impulses arise from a diseased visceral organ, eliciting an irritable response within the spinal cord. pain is sensed in the dermatomes corresponding to cells receiving those impulses


When is laparoscopy indicated for pelvic pain

cases that are unresponsive to medical therapy or when an organic cause of the pain is suspected


What should be included as differential for ACUTE pelvic pain

Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
GI disorders
Urologic causes


what is mittleschmerz

pain the lower abdomen noticed at or near the time of ovulation. May be associated with a ruptured ovarian cyst


What should be included as differential for CHRONIC pelvic pain

Pelvic Adhesions
Mullerian anomalies


What is the success rate of laporascopic separation of adhesions

75% report improvement in pain that is sustained at least 6-12 months


What is adenomyosis

a condition characterized by the presence of ectopic foci of endometrium within the myometrium, may also cause chronic pelvic pain and dysmenorrhea


What are the locations of ectopic pregnancies

1. Tubal (99%) and most common sight is the ampulla
2. Ovarian
3. Abdominal
4. Cervical
5. Heterotropic


What is a heterotropic ectopic pregnancy

both intrauterine and ectopic pregnancy occurring simultaneously


What is the prevalence of ectopic pregnancy



What are the signs and symptoms of an ectopic pregnancy

Vaginal bleeding
Abdominal pain
Other symptoms related to hypotension
Pregnancy status


How does smoking effect ectopic pregnancy

smoking causes tubal ciliary dysfunction


What approach is needed to diagnose an ectopic pregnancy

1. Transvaginal ultrasound to rule out an intrauterine pregnancy
2. hCG
3. D&C
4. Serial hCG if below discriminatory zone
5. Laparoscopy
6. Serum progesterone levels: Levels less than 5 ng/mL are considered nonviable


What is the discriminatory zone

the quantitative hCG level above which all viable intrauterine pregnancies are visible by ultra sound. Generally this is 2000 IU/mL


What are the surgical approaches available for treatment of an ectopic pregnancy

1. Salpingectomy
2. Linear Salpingotomy
3. Operative laparoscopy
4. Laparotomy
5. Cornual resection


What are the medical approaches available for treatment of an ectopic pregnancy


folic acid antagonist that interferes with DNA synthesis


how is infertility defined

no conception after 1 year of unprotected intercourse.


what is fecundability

monthly probability of pregnancy. Which is rough 20% among fertile couples. The cumulative probability of pregnancy after 1 year reaches 85%


How can hypothyroidism induce oligo/anovulation.

increased thyrotropin-releasing hormone (TRH) secretion stimulates prolactin secretion

High levels of prolactin cause thalamic dysfunction and lack of progesterone, leading to miscarriage


What is the treatment for ovulatory dysfunction

1. Correcting the underlying problem
2. clomiphene citrate: Most commonly prescribed fertility drug and is indicated for the treatment of anovulation


What is the mechanism of clomiphen citrate

estrogen antagonist and works best in women with functioning hypothalamic pituitary ovarian axis

It triggers endogenous release of FSH, which then stimulates follicular development


How is a decreased ovarian reserve diagnosed

1. Elevated menstrual cycle day 3 FSH is a marker for decreased number and quality of oocyte.


What is the definition of ovarian failure

FSH greater than 40 mIU/mL associated with amenorrhea.

If these findings are before the age of 40, it is considered premature ovarian failure


What is the treatment for decreased ovarian reserve

1. Donor oocytes
2. Adoption


What are the common causes of tubal disease

Pelvic inflammatory disease
tubal ligation


How is tubal disease diagnosed

1. HSG: hysterosalpingography - fluoroscopic view of the uterine cavity
2. Laproscopy


What is the treatment for tubal disease

1. IVF
2. Surgery
a. Tubal reanastomosis
b. Lysis of peritubal adhesions


What are the WHO standards for a semen fertility sample

1. Volume: 1.5 - 5.0mL
2. Concentration greater than 20 million sperm/mL
3. Total sperm greater than 40 million per ejaculate
4. Percent motility greater than 50%
5. Progression greater than 2
6. Morphology more than 30% normal
7. WBC less than 1 million/mL


what is azoospermia

absence of sperm in the ejaculate


What karyotype is associate with azoospermia

kleinfelter syndrome


what is CBAVD

congenital bilateral agenesis of the vas deferens

2/3 with CBAVD will have Cystic Fibrosis.


When is a woman's most fertile days

up to 4 days prior to ovulation and the day of ovulation


What are the assisted reproductive technology options

1. IVF (in vitro fertilization)
2. ICSI (intracytoplasmic sperm injection)
3. PGD (preimplantation genetic diagnosis)
4. GIFT (famete intrafallopian transfer)
5. ZIFT (zygote intrafallopian transfer)


What is RPL

Recurrent pregnancy loss


What defines recurrent pregnancy loss

two to three or more CONSECUTIVE spontaneous abortions of clinically recognized pregnancies prior to 15 weeks gestation


What is the incidence of RPL



What are the etiology of miscarriages in the general reproductive population

Advanced age
Chromosome anomaly
Congenital anomaly
Structural anomalies of the uterus
Hormonal conditions


What is the etiology of RPL

50% is idiopathic
Genetic/parental chromosomal abnormality
Antiphospholipid syndrome
Anatomic cause
Endocrinologic factors


What is a robertsonian translocation

occurs when genetic information is exchanged between two acrocentric chromosomes.


What are acrocentric chromosomes

13, 14, 15, 21, 22

unique because their centromeres are near the end of the chromosome and their short arms encode redundant genes


How is APS (Antiphospholipid Syndrome) diagnosed

1 of the 2 clinical criteria
a. Thrombosis
b. Pregnancy morbidity

1 of the 2 laboratory criteria
a. Anticardiolipin antibodies, IgM or IgG in medium or high titers
b. Lupus anticoagulant antibodies


What do the muellarian ducts develop into

fallopian tubes and fuse to form the uterus, cervix and upper third of the vagina


What are the common muellarian anomalies associated with RPL

Uterine septum
Unicornuate uterus
Bicornuate uterus
Uterin didelphys


What is a uterine septum

results when fusion of the paired mullerian duct has occurred normally but the medial septum between the ducts has not been completely resorbed. Most common uterine abnormality diagnosed with RPL


What is a unicornuate uterus

occurs when one of the paired mullerian ducts fails to develop. A uterus with a limited cavity results


What is a bicornuate uterus

arises due to the incomplete fusion of the mulllerian ducts resulting in two separate uterine cavities joined at a common cervix


What is a uterine didelphys

the result of complete failure of the mullerian ducts to fuse, but normal differentiation of each duct system. The final out come is two separate uteri and cervices, with each uterine horn a smaller than normal uterus


How are uterine abnormalities diagnosed

1. HSG hysterosalpinogography
2. Ultrasound
3. Saline sonohysterography
4. MRI
5. Hysteroscopy


At what point will DM become a significant risk for inducing RPL

A1C above 8%. Well controlled diabetes has little effect on RPL


What is the treatment for APS

heparin injections and low dose aspirin throughout pregnancy

The benefit is in its prevention of placental microthrombi and possible treatment of inflammation


What is a metroplasty

a surgical procedure to unify the cavities and reconstruct the uterus and can be performed when pregnacy outcomes have been particularly poor despite excellent and aggressive prenatal care in previous pregnancies

Can be done for bicornuate uterus and uterine didelphys


What is the treatment option for a unicornuate uterus