OBGYN Flashcards
(82 cards)
1
Q
indication for endometrial biopsy
A
> 4mm endometrial stripe on TV-US
2
Q
indications for D+C
A
- molar pregnancies
- termination 4-12 wks gestation
- may be used post-miscarriage to ensure empty
3
Q
medical abortion meds / timeline
A
MIFEPRISTONE + MISOPROSTOL - safe up to 9 wks
- mifepristone given first (progestin antagonist)
- misoprostol 24-72 after (prostaglandin analog –> contract)
METHOTREXATE + MISOPROSTOL - safe up to 7 wks
- methotrexate, misoprostol 3-7 days after
- methotrexate is folic acid antagonist
4
Q
follicular phase
A
Days 1-14 Follicular (Proliferative) Phase
ESTROGEN PREDOMINATES
-pulsatile GnRH from hypothalamus –> inc FSH and LH from pituitary to stimulate ovaries
Ovaries
- inc FSH causes FOLLICLE AND EGG MATURATION
- inc LH STIMULATES maturing follicle to MAKE ESTROGEN
Endometrium
-ESTROGEN CAUSES THICKENING (PROLIFERATIVE)
- ESTROGEN CAUSES NEGATIVE FEEDBACK IN HPO system (hypothalamus-pituitary-ovarian)
- inc levels of estrogen inhibit hypothalamic GnRH release as well as pituitary release of LH and FSH so no new follicles mature
5
Q
menstruation
A
First days of Follicular phase
- if egg not fertilized, the corpus luteum soon deteriorates
- FALL OF PROGESTERONE AND ESTROGEN
- endometrium no longer supported –> sloughs
- negative feedback on GnRH subsides causing inc pulsatile GnRH secretion –> inc FSH and LH wich starts follicle maturation process over
6
Q
ovulation
A
Days 12-14 (part of follicular phase)
- inc estrogen being released from mature follicle switches from NEGATIVE –> POSITIVE FEEDBACK on GnRH causing mutual INC ESTROGEN, FSH, LH
- sudden LH SURGE CAUSES OVULATION
7
Q
luteal phase
A
Days 14-28 (aka Secretory Phase)
PROGESTERONE PREDOMINATES
-LH surge also causes ruptured follicle to become the CORPUS LUTEUM –> SECRETES PROGESTERONE and estrogen to maintain endometrial lining
If pregnancy occurs:
- blastocyst keeps the corpus luteum functional (secreting estrogen and progesterone, which keeps endometrium from sloughing)
- if no implantation, corpus luteum degenerates, leading to steep decreases in estrogen and progesterone –> leads to menstruation
8
Q
GnRH pulses
A
> 1 per hour favors LH secretion
less frequent pulses favor FSH secretion
9
Q
abnormal (dysfunctional) uterine bleeding
A
ABNORMAL FREQ/INTENSITY OF MENSES DUE TO NONORGANIC CAUSES (dx of exclusion)
Etiologies: CHRONIC ANOVULATION (90%) -due to disruption of HPA -esp w/ EXTREMES OF AGE -UNOPPOSED ESTROGEN - w/out ovulation there is no progesterone = unopposed estrogen --> endometrial overgrowth w/ IRREGULAR, UNPREDICTABLE SHEDDING
OVULATORY (10%)
-REGULAR CYCLICAL SHEDDING
+ovulation with prolonged progesterone secretion (due to low estrogen levels) –> inc blood loss from endometrial vessel dilation and prostaglandins
- dx-
- DIAGNOSIS OF EXCLUSION - r/o reproductive, systemic, iatrogenic causes (no evid of organic cause and negative pelvic exam)
- W/U: hormone levels, TV US, endometrial bx if stripe >4mm or women >35y to rule out hyperplasia or CA
- tx-
- ACUTE SEVERE BLEEDING –> HIGH DOSE IV ESTROGENS OR HIGH DOSE OCP (reduce as bleeding improves)
- ANNOVULATORY –> OCP 1ST LINE
- regulates cycle, thins endometrial lining and reduces flow)
- progesterone if estrogen c/i; GnRH agonists cause tempory amenorrhea
- OVULATORY –> OCP, progesterone (orally or IUD), GnRH agonists
- SURGERY - if no response (hysterectomy definitive), ablation
10
Q
dysmenorrhea
A
PAINFUL MENSTRUATION, affects normal activities
PRIMARY - NOT DUE TO PELVIC PATHOLOGY
-INC PROSTAGLANDINS –> painful uterine muscle wall activity
SECONDARY - DUE TO PELVIC PATHOLOGY
-endometriosis, adenomyosis, leiomyomas, adhesions, PID
- tx-
- NSAIDS 1ST LINE (inhibits prostaglandin-mediated uterine activity) - best to start before onset of sx
- local heat, vit E started 2 days prior
- OVULATION SUPPRESSION: OCP
- Laparoscopy (r/o secondary causes)
11
Q
PMS
A
- cluster of physical, behavioral and mood changes w/ cyclical occurance in LUTEAL PHASE
- sx in 75-85% patients, significant disruption in 5-10%
- sx-
- physical, emotional, behavioral
- dx-
- SX INITIATE DURING LUTEAL PHASE (1-2 WKS BEFORE MENSES), RELIEVED W/IN 2-3 DAYS OF THE ONSET, PLUS AT LEAST 7 SX FREE DAYS DURING FOLLICULAR PHASE
- tx-
- lifestyle: stress reduce, caffiene reduce, NSAIDs, vit B6, E
- SSRIs
- OCPs (DROSPERINONE-CONTAINING OCPs for PMDD)
12
Q
amenorrhea
A
W/U: pregnancy test, serum prolactin, FSH, LH, TSH
PRIMARY - FAILURE OF MENARCHE ONSET by 15yo (w/ 2ry char) or 13yo (w/ absence of 2ry char)
- Breast + Uterus: OUTFLOW OBSTX –> transverse vaginal septum, imperforate hymen
- Breasts no Uterus: MULLERIAN AGENESIS, ANDROGEN INSENSITIVITY
- Uterus no Breasts: ELEVATED FSH/LH = OVARIAN CAUSES; NORMAL/LOW FSH/LH = HPA AXIS FAILURE
SECONDARY - ABSENCE OF MENSES FOR >3 MO IN PT W/ PREVIOUSLY NORMAL MENSTRUATION
-PREGNANCY MC
- HYPOTHALAMUS DYSFX
- disruption of normal pulsatile hypothalamic secretions of GnRH that lead to dec FSH/LH (anorexia, exercise, stress, nutritional, systemic disease)
- dx- NORMAL/LOW FSH + LH, low estrodial, norm prolactin
- tx- CLOMIPHENE (stim gonadotropin secretion)
- PITUITARY DYSFX
- ex. prolactin-secreting pituitary adenoma
- dx- DEC FSH + LH, INC PROLACTIN (inhibits GnRH)
- tx- surgery
- OVARIAN DISORDERS
- PCOS, PREMATURE OVARIAN FAILURE, follicular failure or resistance to LH or FSH, TURNER’S SYNDROME
- dx- INC FSH + LH, DEC ESTRADIOL –> OVARIAN ABNORMALITIES
- PROGESTERONE CHALLENGE TEST (pos w/drawl bleeding –> ovarian)
- UTERINE DISORDER
- SCARRING OF UTERINE CAVITY (ASHERMAN’S SYNDROME = ACQUIRED ENDO SCAR)
- dx- pelvic US, absence of normal endo stripe
- tx- estrogen tx to stimulate endometrial regeneration
13
Q
menopause
A
CESSSATION >1 YEAR DUE TO LOSS OF OVARIAN FX
-premature before 40yo (mc in DM, smokers, vegetarians, malnourished)
-sx- ESTROGEN DEFICIENCY CHANGES
-dx- FSH ASSAY MOST SENSITIVE INITIAL TEST
(INC SERUM FSH >30)…x3
-INC SERUM FSH, LH, DEC ESTROGEN (due to depletion of ovarian follicles)
-Estrone is primary estrogen after menopause
-loss of estrogen’s protection –> inc osteoporosis, inc cardiovascular risks, inc lipids
- tx-
- ESTROGEN ONLY - most effective, inc risk endometrial cancer (unopposed) so GOOD FOR PT W/OUT UTERUS
- risk of THROMBOEMBOLISM
- ESTROGEN + PROGESTERONE - pt w/ uterus
14
Q
leiomyoma (uterine fibroids) fibromyoma
A
LEIOMYOMA: BENIGN UTERUS SMOOTH MUSCLE TUMOR
- GROWTH RELATED TO ESTROGEN PRODUCTION
- 5X MC AFRICAN AMER, ESP >35
- sx-
- BLEEDING MC PRESENTATION
- pressure/pain related to size, bladder sx
- LARGE, IRREGULAR, HARD MASS DURING BI-MANUAL
- dx-
- PELVIC US
- tx-
- OBSERVATION, tx determined by sx, desire for fertility
- LEUPROLIDE (GnRH inhibition –> dec estrogen = dec endometrial growth) shrinks uterus 50% but will return
- SX - MYOMECTOMY (PRESERVE FERTILITY) OR HYSTERECTOMY DEFINITIVE; ablation
15
Q
adenomyosis
A
ISLANDS OF ENDOMETRIAL TISSUE W/IN MYOMETRIUM
-mc later in repro years
- sx-
- MENORRHAGIA, DYSMENORRHEA, +/- infertility
- TENDER, SYMMETRICALLY, BOGGY UTERUS
- dx-
- exclusion of 2ry amenorrhea, MRI
- definitive: post-total abdominal hysterectomy examination
- tx-
- TOTAL ABDOMINAL HYSTERECTOMY - ONLY EFFECTIVE
- conservative/fertility: analgesics, low dose OCPs
16
Q
endometritis
A
INFECTION OF UTERINE ENDOMETRIUM
- chorioamnionitis (fetal membrane infx)
- RF: POSTPARTUM OR POSTABORTAL INFX (C-SECTION BIGGEST RF), prolonged rupture of membranes >24h, vag delivery, D+C
- dx-
- FEVER, TACHY, ABD PAIN AND UTERINE TENDERNESS AFTER C-SECTION, 2-3 days post-abortal
- tx-
- POST-C-SECTION or VAG DELIVERY –> CLINDA + GENT (may add amp for group B strep coverage)
- PROPHYLAXIS W/ 1ST GEN CEPHALOSPORIN X 1 DOSE DURING C-SECTION
17
Q
endometriosis
A
ECTOPIC ENDOMETRIAL TISSUE
- OVARIES MC SITE, posterior cul de sac
- RF: NULLIPARITY, ONSET <35y
- sx-
- TRIAD: CYCLIC PREMENSTRUAL PELVIC PAIN, DYSMENORRHEA, DYSPAREUNIA, DYSCHEZIA
- Infertility >25% cause of female
- dx-
- LAPROSCOPY W/ BIOPSY DEFINITIVE
- ENDOMETRIOMA “CHOCOLATE CYST”
- tx-
- OVULATION SUPPRESSION VIA OCPs
- progesterone, leuprolide, danazol
- sx-
- CONSERVATIVE LAPAROSCOPY W/ ABLATION
- TAH-BSO
18
Q
endometrial hyperplasia
A
ENDOMETRIAL GLAND PROLIFERATION –> precursor to endometrial cancer, MC POST-MENOPAUSE
-HYPERPLASIA DUE TO CONTINUOUS INC UNOPPOSED ESTROGEN –> chronic anovulation, PCOS, perimenopause, obesity (androgen converts to estrogen in fat)
- sx-
- POST-MENOPAUSAL BLEEDING
- dx-
- TV-US, ENDO STRIPE >4MM
- ENDO BX DEFINITIVE
- tx-
- w/out atypica –> PROGESTIN, repeat bx in 3-6 mo
- w/ atypica –> TAH +/-BSO
19
Q
endometrial cancer
A
MC GYNECOLOGIC MALIGNANCY IN US!
- MC POSTMENOPAUSAL, 50-60Y PEAK
- ESTROGEN-DEPENDENT –> RF: INC ESTRO EXPOSURE (nulliparity, chonic anovulation, PCOS, obesity, ERT, late menopause, tamoxifen)
-COMBO OCP PROTECTIVE AGAINST BOTH OVARIAN AND ENDOMETRIAL CA
- sx-
- POSTMENOPAUSAL / ABNORMAL BLEEDING
- dx-
- ENDO BX –> ADENOCARCINOMA MC
- US –> STRIPE >4MM
- tx-
- Stage I: HYSTERECTOMY (TAH-BSO) +/- radiation
- Stage II, III: TAH-BSO + lymph node excision +/- radiation
- Stage IV: systemic chemo
20
Q
postmenopausal bleeding
A
etiologies:
- MC BENIGN: vaginal/endometrial atrophy, cervical polyps, submucosal fibroids, 10% ENDO CA
- dx-
- any post-meno bleeding not on HRT should raise suspicion for endo ca, hyperplasia or leiomyosarcoma
- TV-US –> <4mm, repeat in 4 mo, if continues –> bx
21
Q
pelvic organ prolapse
A
RF: weakness of pelvic support structures, MC after childbirth, inc pelvic floor pressure (multiple vag births, obesity, heavy lifting)
CYSTOCELE: POSTERIOR BLADDER HERNIATING INTO ANTERIOR VAGINA
ENTEROCELE: POUCH OF DOUGLAS (SMALL BOWEL) INTO UPPER VAGINA
RECTOCELE: DISTAL SIGMOID COLON/RECTUM INTO POSTERIOR DISTAL VAGINA
- sx-
- PELVIC OR VAG FULLNESS, HEAVINESS “FALLING OUT” SENSATION
- low back pain, vag bleed, purulent discharge, urinary sx
- BULGING MASS ESP W/ INC ABD PRESSURE / VALSALVA
- tx-
- PROPHYLACTIC –> KEGALS, wt control
- pessaries, estrogen tx (improves atrophy)
- surgical: hysterectomy; uterosacral or sacrospinous ligament fixation
22
Q
functional ovarian cysts
A
FOLLICULAR CYSTS - when follicles fail to rupture and continue to grow
CORPUS LUTEAL CYSTS - fail to degenerate after ovulation
- sx-
- most asymptomatic until rupture, undergo torsion or become hemorrhagit –> UNILATERAL RLQ OR LLQ PAIN
- dx-
- PELVIC US
- tx-
- SUPPORTIVE: most <8cm are functional and usually spontaneously resolve –> rest, NSAIDs, repeat US in 6 wks
- OCPs prevent but don’t treat existing ones
- if >8cm or postmenopause –> +/-laparoscopy/laparotomy
23
Q
ovarian cancer
A
2ND MC GYNECOLOGIC CANCER
- HIGHEST MORTALITY OF ALL GYNECOLOGIC CA
- RF: FAM HX, INC NUMBER OVULATORY CYCLES, BRCA1/2, peutz-jehgers, turner’s syndrome
- sx-
- rarely sx until late in disease (extensive mets)
- presents usually 40-60s
- abd fullness/distention, back/abd pain, urinary freq
- irregular menses, menorrhagia, postmeno bleed, constipation
- palpable abdominal or ovarian mass (solid, fixed) ASCITES
- SISTER MARY JOSEPH’S NODE = METS UMBILICAL
- dx-
- BIOPSY –> 90% EPITHELIAL, germ cell in pt <30y
- TV-US useful screen in high-risk patients, mammography to look at 1ry in breast
- tx-
- Early: TAH-BSO + selective lymphadenectomy
- Sx: tumor debulking; SERUM CA-125 USED TO MONITOR TX PROGRESS
- Chemo
24
Q
dermoid cystic teratomas
A
mc benign ovarian neoplasms
-remove due to potential risk of torsion or malig transform
25
PCOS
Triad: AMENORRHEA, OBESITY, HIRSUTISM (androgen excess)
- PCOS due to insulin resistance; 10% of pop
- assoc w/ abnormal fx of HPO-axis --> inc insulin and inc LH-driven in ovarian androgen production
- sx-
- MENSTRUAL IRREGULARITY
- INC ANDROGEN --> HIRSUTISM, acne, male pattern bald
- INSULIN RESISTANCE --> DM2, OBESITY
- BILAT ENLARGED, SMOOTH, MOBILE OVARIES, ACANTHOSIS NIGRICANS
- dx-
- exclude: thyroid, pituitary adenoma (prolactin), ovarian tumors, cushing's (dexa suppress test)
- labs: INC TT, LH:FSH RATIO >3:1 (normal 1.5:1)
- GnRH agonist stimulation test --> rise in serum hydroxyprogesterone
- lipid panel, GTT
- PELVIC US --> STRING OF PEARLS, ENLARGED OVARIES W/ PERIPH CYSTS
- tx-
- COMBO OCP --> NORMALIZE BLEEDING AND SUPPRESS ANDROGEN
- SPIRONOLACTONE (BLOCKS TT RECEPTORS)
- Infertility --> Clomiphene, metformin
- complications:
- chronic anovulation --> inc risk infertility and endometrial hyperplasia or cancer
26
pap smear cervical cytology
ASC-US - atypical squamous of undetermined significance
- if >25yo can do HPV test (negative, repeat PAP/HPV in 3 years; if positive --> colposcopy w/ bx)
- or no HPV test and repeat PAP in 1y (also for <21yo)
ASC-H - atypical squamous cells, can't exclude HSIL
- higher chance of ca than ASCUS
- COLPOSCOPY
LSIL - low grade squamous intraepithelial lesion
- mc seen w/ TRANSIENT HPV INFECTION
- 50% regress in 2y, may progress to ca in 7y
- 25-29yo --> COLPOSCOPY W/ BX
- >30y --> TEST HPV (neg, repeat in 1y)
HSIL - high grade squamous intraepithelial lesion
- include CIN II, CIN III, + CARCINOMA IN SITU
- COLPO W/ BX FOR ALL AGES
27
cervical biopsy histology results
- MC ASSOC W/ HPV (CIN = cervical intraepithelial neoplasia) is precursor to cervical ca
- TRANSFORMATION ZONE (SQUAMOCOLUMNAR JX) OF CERVIX IS HIGHEST RISK FOR MALIG
LSIL
- changes seen w/ HPV
- CIN I = MILD DYSPLASIA
- OBSERVE (75% resolve 1 y) or EXCISION VIA LEEP OR COLD KNIFE CONE
HSIL
- usualy from persistent HPV infx, often P-16 pos
- CIN II + CIN III (MOD - SEV), FULL THICKNESS --> IN SITU
- EXCISION (LEEP OR COLD KNIFE CONE) or ABLATION (CRYOCAUTERY, LASER CAUTERY OR ELECTROCAUTERY)
28
cervical cancer
- HPV ASSOC W/ 99.7% ESP 16, 18 (70%), 31, 33, 45
- 3rd mc gyn cancer
- 45y ave age diagnosis, local mets
- RF: smoking, CIN, DES exposure (diethylstilbestrol was synthetic estrogen used in OCP), immunosuppressed
- takes 2-10 yrs for ca to penetrate basement membrane
- sx-
- POST COITAL BLEEDING/SPOTTING MC, metrorrhagia, pelvic pain +/- watery discharge
- dx-
- COLPO W/ BX
29
Gardasil
-Rec: given at 11 up to 26y
- Gardasil Quad: 6, 11, 16, 18
- Gardasil 9: same + 31, 33, 45, 52, 58
-Schedule:
-<15y, receive 2 doses at least 6 mo apart
->15y, receive 3 doses over minimum of 6 mo (0, 2, 6mo)
minimal is 0, 1, 4mo
-c/i if immunosuppressed, pregnant or lactating
30
ACOG screen guidelines
- initiate: 21
- discontinue: 65
- age 21-29 --> pap every 3y
- can consider primary HPV testing q3y for >25y
- age >30 --> pap + HPV (co-testing) q5y preferred
- pap every 3y
- can consider primary HPV testing q3y for >25y
31
cervical insufficiency (incomplete cervix)
- inability to maintain pregnancy 2ry to PREMATURE CERVICAL DILATION (ESP IN 2ND TRI)
- RF: prev cervical trauma or procedure, uterus defects, DES exposure in utero, multiple gestations
- sx-
- bleeding, vag discharge, esp in 2nd tri
- PAINLESS DILATION + EFFACEMENT OF CERVIX
-tx-
-CERCLAGE AND BED REST
+/- weekly injection of 17 a-hydroxyprogesterone in some women w/ preterm birth hx
32
Bartholin cyst/abscess
- bartholin duct obstx --> retained secretions --> gland enlargement
- may be infectious
- sx-
- INFECTED: TENDER, unilateral vulvar mass, edema/inflam
- NON-INFECTED: NONTENDER, unilateral at duct location
- dx-
- CBC, cultures
- tx-
- infected --> I+D w/ antibiotics
- non-infected --> no intervention needed if asymptomatic
33
vaginal cancer
- rare (usually 2ry to another cancer)
- peak 60-65y, SQUAMOUS CELL 95%, CLEAR CELL IF DES EXPOSURE IN UTERO
-asymptomatic, changes in period, abnormal bleed/discharge
- tx-
- radiation
34
vulvar cancer
- 90% SAUAMOUS (RISK INCLUDES HPV 16, 18, 31)
- peak at 50y, linked to DES exposure
- sx-
- PRURITUS MC, asmyptomatic, post-coital bleeding
- dx-
- RED/WHITE ULCERATIVE, CRUSTED LESIONS --> BX
- tx-
- surgical excision, radiation tx, chemo
35
vaginitis
INFECTIOUS: BACTERIAL VAGINOSIS, TRICHOMONIASIS, CANDIDA, CYTOLYTIC
ATROPHIC: postmenopausal, allergic rx
36
vulvovaginal atrophy
-seen w/ dec estrogen states (post-meno)
- sx-
- vaginal dryness, dyspareunia, vaginal inflammation, infx, recurrent UTIs w/ inc pH (loss of lactobacilli which normally converts glucose to lactic acid)
- tx-
- VAGINAL ESTROGENS
- Ospemifene
37
mastitis + breast abscess
Mastitis
- INFECTION: MOSTLY IN LACTATING WOMEN 2ry nipple trauma (esp PRIMAGRAVIDA); S. AUREUS MC
- UNILATERAL pain w/ tenderness, warmth, swelling, discharge
- CONGESTIVE: BILATERAL breast enlargement 2-3d postpartum
- may have low-grade fever and axillary lymphadenopathy
- tx-
- Infx --> SUPPORTIVE (warm compress, breast pump) + ANTI-STAPH ABX (MAY CONTINUE TO FEED)
- Congestive:
- if doesn't want to breastfeed --> ice, tight bras, analgesic
- if breastfeeding --> manually empty after baby is done eating, local heat, analgesics
-Abscess: I+D, discontinue breastfeeding from affected
38
fibrocystic breast disorder
- MC breast disorder, esp 30-50y
- FLUID-FILLED BREAST CYST DUE TO EXAGGERATED RESPONSE TO HORMONES (esp 30-50y)
- sx-
- multiple, mobile, well-demarcated lumps in breast
- TENDER, OFTEN BILATERAL
- usually no axillary involvement or nipple discharge
- BREAST CYSTS MAY INC OR DEC IN SIZE W/ MENSTRUAL HORMONE CHANGES
- dx-
- US, FNA reveals STRAW-COLORED FLUID, NO BLOOD
- tx-
- most spontaneously, +FNA removal of fluid if sx
39
fibroadenoma of the breast
- mc in late teens, early 20s
- made of glandular + fibrous tissue (collagen in swirls)
- sx-
- smooth, nontender, freely mobile, rubbery lump in breast
- gradually grows over time, DOESN'T WAX + WANE W/ MENSTRUATION
- may enlarge in pregnancy, no axillary involvement
- tx-
- observation - most reabsorb w/ time +/-excision
40
breast cancer
malig primarily of the milk ducts or lobules
- RF: BRCA 1+2, AGE >65Y, INC NUMBER MENSTRUAL CYCLES, INC ESTROGEN, 1st degree relative, obesity, etoh
- 75% have no RF
Types:
- DUCTAL: INFILTRATIVE CARCINOMA MC (75%) DCIS
- assoc w/ lymphatic mets esp axillary
-LOBULAR: infiltrative lobular carcinoma in situ (may not progress but assoc w/ inc risk of invasive breast ca)
- sx-
- BREAST MASS, PAINLESS, HARD, FIXED LUMP
- MC UPPER OUTER QUADRANT (65%) areola 18%
- UNILATERAL NIPPLE DISCHARGE +/-BLOODY, purulent or green
- SKIN: ASYMMETRIC REDNESS, dimpling (cooper's ligament), nipple inversion
- PAGET'S DISEASE OF NIP: CHRONIC EXZEMATOUS, ITCHY, SCALING RASH ON NIPPLES AND AREOLA
- INFLAMMATORY BREAST CA: RED, SWOLLEN, WARM, ITCHY BREAST
- dx-
- MAMMOGRAM: MICROCALCIFICATIONS AND SPICULATED
- ULTRASOUND: rec initial modality to eval breast masses in women <40y
- BIOPSY: fine needle, large needle core, open/excision
41
breast cancer stage/treat
Stage: based on T (size), N (nodes), M (metastasis)
- Stage 0: precancerous, DCIS or LCIS
- Stage I-III: w/in breast/regional lymph nodes
- Stage IV: metastatic bc
- tx-
- lumpectomy, mastectomy, removal of regional LN
-Adjunctive:
RADIATION THERAPY
-after lumpectomy
CHEMO
-used in stage II-IV and inoperable disease, esp ER neg dz
NEOADJUVANT ENDOCRINE TX
- ANTI-ESTROGEN (TAMOXIFEN): useful w/ ESTRO POS (blocks estrogen receptor)
- AROMATASE INHIBITORS (LETROZOLE, ANASTROZOLE): useful postmeno ER-pos patients (reduces production of estrogen)
- MONOCLONAL AB TX (TRASTUZUMAB): useful w/ HER2 POS (human epidermal growth factor receptor)
42
breast cancer screening
MAMMOGRAM - detects as early as 2 yrs before palpated
- ACS screen: annually age 45-54y, and q2y age >55
- ACOG: annually >/=40
- USPSTF: baseline mammogram q2y 50-74y; every 2y at age 40 if increase risk factors
CLINICAL BREAST EXAM: at least q3y in 20-39y (annually after 40y)
BREAST SELF EXAMINATION: monthly >20y of age IMMEDIATELY AFTER MENSTRUATION OR ON DAYS 5-7 OF MENSTRUAL CYCLE (less fluid retention)
Prevention in High-Risk pt:
TAMOXIFEN OR RALOXIFENE CAN BE USED IN POSTMENO OR WOMEN >35Y W/ HIGH RISK
-treatment usually for 5 yrs
-increased risk of DVT or endometrial cancer
43
pelvic inflammatory disease
-usually mixed, MC GONORRHOEAE + CHLAMYDIA
- sx-
- pelvic/lower abdominal pain, dysuria, dyspareunia, vag discharge, nausea, vomiting
- dx-
- ABDOMINAL TENDERNESS (+REBOUND IF SEVERE), CERVICAL MOTION TENDERNESS, ADNEXAL TENDERNESS
- pelvic ultrasound
- laparoscopy
- tx-
- out-pt: DOXY (14d) + CEFTRIAXONE IM +/- flagyl
- in-pt: IV DOXY + 2ND GEN CEPH (CEFOXITIN OR CEFOTETAN) or clinda + genta
- complications:
- FITZ-HUGH CURTIS SYNDROME: hepatic scarring and peritoneal involvement RUQ PAIN
44
toxic shock syndrome
- exotoxins made by STAPH AUREUS
- seen in tampons, diaphragm or sponge, esp >24h
- sx-
- HIGH FEVER, tachy, n/v/d, pharyngitis
- DIFFUSE, ERYTHEMATOUS MACULAR RASH (looks like sunburn, includes palms and soles), desquamation;
severe: ulcerations, petechiae, vesicles, bullae
- HYPOTENSION
- dx-
- CBC, CULTURES, CLINICAL (isolation not required)
- tx-
- hospital admission, supportive measures (fluid replace), clinda + vanc
45
bacterial vaginosis
- decreased lactobacilli (maintains pH) --> overgrowth of normal flora GARDNERELLA VAGINALIS, ANAEROBES
- MC CAUSE VAGINITIS
- sx-
- ODOR, itching, asymptomatic, discharge
- THIN, WATERY, GREY-WHITE, ROTTEN FISH SMELL
- pH > 5
- dx-
- WHIFF TEST = FISH W/ KOH PREP
- CLUE CELLS
- tx-
- METRONIDAZOLE X 7d OR CLINDA
- don't need to tx partner
- complications: PROM, preterm labor, chorioamnionitis
46
trichomoniasis
- PEAR SHAPED FLAGELLATED PROTOZOA
- sexually transmitted
- FROTHY YELLOW-GREEN DISCHARGE
- STRAWBERRY CERVIX (CERVICAL PETECHIAE)
- pH >5
- tx-
- METRONIDAZOLE (2G X 1 DOSE) - PO PREFERRED
- MUST TREAT PARTNER
- spermicides reduce transmission
-perinatal complications, inc HIV transmission
47
combo OCP
-prevent ovulation by inhibiting mid-cycle LH surge, thickens cervical mucosa, thins endometrium
- improves dysmenorrhea, controls menstrual cycle
- protects vs. osteoporosis, ovarian cysts, ovarian cancer and endometrium cancer
- NOT FOR SMOKERS >35Y
- INC GALLSTONES, FLUID RETENTION, THROMBOEMOLISM
48
progestin only "mini pill"
- SAFE DURING LACTATION
- no estrogen side effects (ha, htn, nausea)
- dec ovarian and endometrial cancer
- less PID
- menstrual irregularities
- slightly less effective than combo OCPs
49
long-acting progestins
```
Depo provera (inject)
-last 3 months
```
Implanon (rod)
- lasts 3 years
- SE: OSTEOPOROSIS
50
ortho evra
transdermal patch
-applied q 3wks --> 1 wk off
51
NuvaRing
- 3 weeks on, 1 week off
| - remove during intercourse, replace w/in 3 hours
52
uncomplicated pregnancy
Uterus changes:
- LADIN'S SIGN: uterus softening after 6 wks
- HEGAR'S SIGN: uterine isthmus softening after 6-8 wks
- PISKACEK'S SIGN: palpable lateral bulge or softening of uterine cornus 7-8 wks
Cervix changes:
- GOODELL'S SIGN: cervical softening due to inc vascularization (about 4-5wks)
- CHADWICK'S SIGN: bluish color of cervix and vulva at 8-12 wks
Fetal heart tones --> 10-12 wks (120-160 bpm)
Pelvic US --> detects fetus 5-6 wks
Fetal movement --> 16-20 wks
53
fundal height
12 wks --> above pubic symphysis
16 wks --> midway btw pubis and umbilicus
20 wks --> at umbilicus
38 wks --> 2-3 cm below the xiphoid process
54
routine lab tests at first prenatal visit
blood type, Rh, CBC, UA (glucose + protein), random glucose, HBsAg, HIV, syphilis, rubella titer, screening for sickle cell and CF, pap smear
55
1st trimester: maternal blood screen tests
Down syndrome:
- Free B-hCG - abnormally high or low may be indicative of abnormalities
- PAPP-A: usually low w/ down synd
- Nuchal translucency: US at 10-13 wks, inc thickness abn
+/- chorionic villus sampling (risk of spont abortion)
56
2nd trimester: screening/tests (13-27)
Triple Screen at 15-20 wks: a-fetoprotein, B-hCG, estradiol
- Down Synd: low a-FP, high B-hCG, low Estradiol
- Open neural tube defects: high a-FB
- Trisomy 18 (stillborn or die in 1 yr): all low
Gestational Diabetes Screen: 24-28 wks
+/- amniocentesis
57
3rd trimester: screening/tests (28-birth)
Gestational Diabetes Screen: 24-28 wks
Repeat Rh titers
-RhoGAM AT 28 WKS AND W/IN 72 HRS AFTER BIRTH
Group B Strep at 32-37 wks
Hemoglobin + Hematocrit at 35 wks
Biophysical profile: look at fetal breathing, fetal tones, amniotic fluid, NST and gross fetal movements (2 pts ea)
NON STRESS TESTING: baseline hr is 120-160
- REACTIVE: FETAL WELLBEING >/= 2 accelerations in 20 minutes, inc fetal hr >/= 15 bpm from baseline lasting >/= 15 sec
- Non-reactive: no fetal hr accelerations (maybe sleeping, immature or compromised fetus)
CONTRACTION STRESS TEST: measures fetal response to stress at times of uterus contraction
- NEGATIVE: FETAL WELLBEING - no late decelerations in the presence of 3 contractions in 10 minutes
- Positive: repetitive late decelerations in presence of 3 contractions in 10 minutes --> worrisome, prompt delivery
58
ectopic pregnancy
-FALLOPIAN TUBE MC (ESP AMPULLA)
- sx-
- Triad: UNILATERAL PELVIC/ABD PAIN, VAG BLEEDING, AMENORRHEA
- CERVICAL MOTION TENDERNESS, ADNEXAL MASS
- dx-
- SERIAL QUANTITATIVE B-HCG (fails to double 24-48h)
- TVUS - absence of gest sac w/ B-hCG levels >2000
- tx-
- UNRUPTURED: METHOTREXATE
- RUPTURED: LAPAROSCOPIC SALPINGOSTOMY
59
spontaneous abortion
- termination BEFORE 20 WKS
- FETAL CHROM ABNORMAL MC (50%), infx, uterine defects, endocrine, malnutrition, immunologic, trauma, smoking, drugs
Threatened
- MAY BE VIABLE
- MC CAUSE OF 1ST TRI BLEEDING
- SUPPORTIVE CARE, REST
Inevitable
- PROGRESSIVE CERVIX DILATION +/- RUPTURE MEMB
- D+E IN 2ND TRI
Incomplete
- SOME POC EXPELLED (SOME RETAINED)
- DILATED CERVIX
- D+E IN 2ND TRI, PITOCIN
Complete
-ALL POC EXPELLED
Missed
- FETAL DEMISE BUT STILL RETAINED IN UTERUS
- NO POC EXPELLED
- D+E (2ND TRI), D+C (1ST TRI)
Septic
- RETAINED POC BECOMES INFECTED --> INFX OF UTERUS; SOME POC RETAINED
- CERVICAL MOTION TENDERNESS
- FOUL BROWN DISCHARGE, FEVER, CHILLS
- D+E, BROAD SPECTRUM ABX
60
D+C vs. D+E
Dilation + Curettage (including suction curettage)
-used 4-12 weeks gestation
Dilation + Evacuation
-used >12 weeks gestation
61
transitional (gestational) HTN
- HTN w/ NO PROTEINURIA AFTER 20 WKS
- RESOLVES 12 WKS POST-PARTUM
-tx-
+/- hydralazine or labetalol
62
preeclampsia
-HTN W/ PROTEINURIA +/- EDEMA AFTER 20 WKS
+/- earlier with multiples or molar pregnancy
- sx-
- ha, visual sx, fetal growth restriction, edema (bc proteinuria)
- dx-
- Mild: BP >140/90, PROTEINURIA >300mg/24h (>1+)
- BP at 2 separate occasions at least 6h apart and no >1 wk
-Severe: BP >160/110, PROTEINURIA >5000mg/24h, THROMBOCYTOPENIA, +/-DIC, HELLP SYNDROME (hemolytic anemia, elevated liver enzymes, low platelets)
- tx-
- Mild: DELIVER AT >/= 37 WKS, conservative <34 wks (BP and dipstick weekly, bedrest), STEROIDS TO MATURE LUNGS
- Severe: PROMPT DELIVERY ONLY CURE
- HOSPITALIZATION + MAGNESIUM SULFATE (prevent eclampsia/seizures)
- HYDRALAZINE, LABETALOL
63
eclampsia
SEIZURES OR COMA in pt who meet preeclampsia criteria
- sx-
- SAME AS PREECLAMPSIA PLUS:
- ABRUPT TONIC-CLONIC SEIZURES 1-2 MIN --> POSTICTAL STATE
- HYPERREFLEXIA
-tx-
-ABCD'S
-MAGNESIUM SULFATE FOR SEIZURES (LORAZEPAM 2ND LINE)
-DELIVERY OF FETUS ONCE PT STABILIZED
HYDRALAZINE, LABETALOL
64
chronic/preexisting HTN
- HTN BEFORE 20 WKS GESTATION or before pregnancy
- persists >6 wks post-partum
- dx-
- Mild: BP >140/90, NO PROTEINURIA
- Moderate: >150/100
- Severe: >160/110
- tx-
- Mild: monitor q2-4 wks, weekly 34-36 wks, deliver at 37
- weekly NST during 3rd tri, serial BP and urnie protein
- Mod/Severe: meds if BP >150/100 (METHYLDOPA TX OF CHOICE, LABETALOL)
- AVOID ACEI AND DIURETICS
65
placenta previa
ABNORMAL PLACENTA PLACEMENT ON OR CLOSE TO CERVICAL OS
- partial: covering part of cervix
- complete: total coverage of cervical os
- marginal: w/in 2-3 cm of cervical os
- sx-
- 3RD TRI BLEEDING, PAINLESS, UTERUS NON-TENDER
- no fetal distress
- dx-
- PELVIC ULTRASOUND - NO PELVIC EXAM!
- tx-
- hospitalization for stabilization
- TOCOLYTICS: MAG SULFATE - inhibits labor preterm
- AMNIOCENTESIS - to see fetal lung maturity (steroids btw 24-34 wks)
- delivery when stable (vaginal if partial/marginal)
66
abruptio placentae
PREMATURE SEPARATION OF PLACENTA FROM UTERINE WALL after 20 wks
- sx-
- 3RD TRI BLEEDING (CONTINUOUS, DARK RED), SEVERE ABDOMINAL PAIN, CONTRACTIONS, RIGID UTERUS
- FETAL BRADYCARDIA/DISTRESS
- dx-
- PELVIC ULTRASOUND - NO PELVIC EXAM!
- tx-
- hospitalization
- IMMEDIATE DELIVERY (C-SECTION PREFERRED)
- MAY LEAD TO DIC
*MATERNAL HTN MC CAUSE (smoking, etoh, cocaine, folate deficiency, high parity, increased age, trauma, chorioamnionitis)
67
vasa previa
FETAL VESSELS TRAVERSE THE FETAL MEMBRANES OVER THE CERVICAL OS
- sx-
- rupture of membranes PAINLESS VAGINAL BLEEDING
- FETAL DISTRESS / BRADYCARDIA
- dx-
- PELVIC ULTRASOUND
- tx-
- IMMEDIATE C-SECTION
68
gestational diabetes
RF: family or prior hx of gestational diabetes, spontaneous abortion, hx of infant >4000g at birth, multiple gestations, obesity, >25y, AA, Hisp, Asian/Pacific, Native
-caused by placental release of GH, corticotropin-releasing hormone and human placental lactogen (HPL) which antagonizes insulin
- dx-
- screen w/ 50G ORAL GLUCOSE CHALLENGE TEST AT 24-28 WKS --> IF >140 AFTER 1 HR --> 3HR GTT
```
-CONFIRMATORY (GOLD STD): 3 HR 100G GTT
In am after overnight fast, positive if:
-fasting >95
-1 hr >180
-2 hr >155
-3 hr >140
```
- tx-
- daily fingersticks overnight and after each meal, diet and exercise
- INSULIN TX OF CHOICE (DOESN'T CROSS PLACENTA)
- glyburide doesn't cross placenta (higher risk eclampsia), metformin also safe
- LABOR/INDUCTION AT 35 WKS IF UNCONTROLLED / MACROSOMIA
*50% chance of devo Dm after pregnancy, >50% chnce of recurrence w/ subsequent pregnancies
69
postpartum blues
onset: 2-4 wks postpartum
- resolves w/in 10 days
- mild insomnia, anhedonia, fatigue, depressed mood, irritable, NO THOUGHTS OF HARM TO BABY
70
postpartum depression
onset: 2 WKS - 2 MONTHS POSTPARTUM
- duration 3-14 months
- irritability, sleep and mood disturbances, eating changes, anxiety
- MAY HAVE THOUGHTS OF HARMING BABY
71
gestational trophoblastic disease (molar pregnancy)
Abnormal placental trophoblastic tissue, 4 types:
- molar pregnancy (benign)
- invasive mole
- choriocarcinoma
- placental site trophoblastic tumor
-Abnormal pregnancy in which a nonviable fertilized egg implants --> abnormal placenta devo
HYDATIDIFORM MOLE: NEOPLASM DUE TO ABNORMAL PLACENTAL DEVO W/ TROPHOBLASTIC TISSUE PROLIFERATION ARISING FROM GESTATIONAL TISSUE
-MC TYPE, 80% BENIGN
- COMPLETE MOLAR PREGNANCY: egg w/ no DNA fertilized by 1 or 2 sperm (46XX all paternal chromes) assoc w/ higher risk of malignant devo
- PARTIAL MOLAR PREGNANCY: egg fertilized by 2 sperm (or 1 that duplicates its chromes), there may be devo of fetus but never viable; RF: EXTREMES OF MATERNAL AGE
- sx-
- PAINLESS VAG BLEEDING, +/- begin at 6wks - 4/5mo
- UTERINE SIZE / DATE DISCREPANCIES (larger than expected)
- HYPEREMESIS GRAVIDARUM (inc hormones)
- CHORIOCARCINOMA - mets to lungs mc, lower genital tract
- dx-
- B-hCG MARKEDLY ELEVATED (>100,000), LOW A-FETO
- US: "SNOWSTORM" OR "CLUSTER OF GRAPES" APPEARANCE, absence of fetal parts and heart sounds; cluster of grapes = enlarged cystic chorionic villi
- tx-
- SURGICAL EVACUATION: SUCTION CURETTAGE MAINSTAY ASAP, follow pt until B-hCG falls to undetectable, avoid preg for 1 yr after
- METS: CHEMO (METHOTREXATE) DESTROYS TROHPH TISSUE AND/OR HYSTERECTOMY
72
RH alloimmunization
Maternal AB that bind to fetal RBCs --> neonate hemolytic disease
- occurs if Rh neg mom carries Rh pos fetus w/ exposure to fetal blood mixing (causes maternal immunization --> maternal anti-Rh IgG antibodies)
- if next time, mom carries a Rh pos fetus, the AB may cross the placenta and attack the fetal RBCs (hemolysis)
Preventative:
- 300 mg RhoGAM (Rh immunoglobulin - pooled anti-D IgG vinds to fetal RBCs to prevent maternal mixing)
- Given if Rh neg, Ab-neg in 3 indications:
1. 28 weeks gestation
2. w/in 72 h of delivery of Rh pos baby or
3. after any potential mixing of blood
73
morning sickness + hyperemesis gravidarum
Morning sickness: N/V up to 16 wks
HEG: SEVERE, EXCESSIVE FORM assoc w/ WL, electrolyte imbalance, develops during 1st/2nd tri (longer than 16wks)
-acidosis (from starvation) and alkalosis (from vomiting)
- RF: primagravida, pervious hyperemesis in past pregnancy, multiple gestations, molar pregnancy
- Pathophys: vomiting center oversensitivity to pregnancy hormones
- tx-
- fluids, electrolytes, vitamins, high protein foods, small/freq meals, avoid spicy/fatty; TPN if severe
- PYRIDOXINE (VIT B6) +/- DOXYLAMINE 1ST LINE
- promethazine, dimenhydrinate
74
cardinal movements of labor
Engagement: fetal presenting part enters pelvic inlet
Flexion: flexion of the head to allow the smallest diameter to present to pelvis (tucks chin)
Descent: passage of the head into the pelvis (lightening)
Internal Rotation: fetal vertex moves from occiput transverse position to a position where the sagittal suture is parallel to the anteroposterior diameter of the pelvis
Extension: vertex extends as it passes beneath the pubic symphysis
Externa rotation: fetus externally rotates after the head is delivered so that the shoulder can be delivered
75
stages of labor
Stage I: onset of labor (true regular contractions) to full dilation of cervix (10 cm)
- Latent phase: cervix effacement w/ gradual dilation
- Active phase: rapid cervical dilation (begins at 3-4 cm)
Stage II: time from full cervical dilation until delivery
- Passive phase: complete cervical dilation to active maternal expulsive efforts
- Active phase: from active maternal efforts to delivery
Stage III: postpartum until delivery of placenta (0-30 min, average 5 min)
-3 Signs of placental separation:
1. gush of blood
2. lengthening of umbilical cord
3. anterior-cephalad movement of the uterine fundus (becomes globular and firmer) after placenta detaches
Placental expulsion: due to downward pressure of retroplacental hematoma, uterine contractions
76
apgar score
- usually done at 1 and 5 min after birth, repeat at 10 min if abnormal
- score 1-10: >/= 7 normal, 4-6 fairly low, = 3 critical low
```
Appearance (skin color changes)
Pulse
Grimace (reflex irritability)
Activity (muscle tone)
Respiration
```
77
postpartum (puerperium)
6 wk period after delivery
- Uterus: at level of umbilicus after delivery, shrinks after 2 days, descends into pelvic cavity after 2 weeks, normal size at about 6 wks
- Lochia serosa: pink/brown vag bleeding, esp days 4-10 (from decidual tissue), resolves 3-4 wks
- Breasts/menstruation: breast milk in postpartum days 3-5 bluish-white. if lactating, mothers may remain anovulatory during that time (otherwise menses may return 6-8 wks postpartum)
78
postpartum hemorrhage
- bleeding >500ml if vaginal, >1000ml if c-section
- early: 24 hrs post partum, delayed >24 hrs up to 8 wks
- UTERINE ATONY MC CAUSE (unable to contract to stop bleeding), uterine rupture, congestion, bleeding disorder, DIC
- RF: rapid, prolonged labor, overdistended uterus, c-sect
- sx-
- hypovolemic shock: hypoTN, tachy, pale, dec cap refill
- SOFT, BOGGY UTERUS w/ dilated cervix
- work up-
- CBC for H+H, US
- tx-
- BIMANUAL UTERINE MASSAGE
- UTEROTONIC AGENTS: OXYTOCIN IV, METHLERGONOVINE; prostaglandin analogs (carboprost, tromethamine, misoprostol) to enhance contractions
79
PROM
premature rupture of membranes
-RF: STDs, smoking, prior preterm delivery, multiple gestations
- dx-
- STERILE SPECULUM EXAM - VISUAL INSPECTION --> POOLING OF SECRETIONS
- NITRAZINE PAPER TEST --> BLUE IF PH > 6.5 (amniotic fluid pH 7-7.3, vaginal pH 3.8-4.2)
- FERN TEST --> AMNIOTIC FLUID FERN PATTERN
- ultrasound
- tx-
- wait for spontaneous labor, monitor for infection
80
PPROM
```
premature labor (preterm labor)
-Labor: regular uterine contractions (>4-6/hr) with progressive cervical changes before 37 weeks
```
- dx-
- cervical dilation >3cm, >80% effacement
- NITRAZINE PAPER TEST, FERN TEST
- PRESENCE OF FETAL FIBRONECTIN btw 20-34 weeks strongly suggests preterm labor
- L:S ration <2:1 = fetal lung immaturity
- tx-
- ANTENATAL STEROIDS (BETAMETHASONE) FOR LUNGS
- TOCOLYTICS TO SUPPRESS CONTRACTIONS (INDOMETHACIN, NIFEDIPINE, MAG SULFATE)
- abx prophylaxis (group b strep)
81
dystocia
abnormal labor progression
- 3 categories:
- Power: contraction
- Passenger: presentation or size of fetus (shoulder dystocia)
- Passage: uterus or soft tissue abnormalities
- TX SHOULDER DYSTOCIA:
- NONMANIPULATIVE 1ST LINE: MCROBERT'S MANEUVER (inc pelvic opening w/ hip hyperflexion)
- MANIPULATIVE: WOODS "CORKSCREW" MANEUVER 180 shoulder rotation
82
induction of labor
- Ind: vaginal delivery when prolonged labor may lead to complications
- C/I: situations where risk of induction of vag delivery greater than c-section (prior uterine rupture, prior c-section, active herpes, umbilical cord prolapse, placenta previa, transverse fetal lie)
- tx-
- EARLY INDUCTION --> PROSTAGLANDIN GEL ON CERVIX (CERVIDIL), balloon catheter or laminaria
- LATER INDUCTION --> when cervix is dilated <1cm w/ some effacement --> IV OXYTOCIN (PITOCIN)
- AMNIOTOMY (artificial rupture of membranes w/ hook)
