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1

Pt presents with vaginal bleeding, a larger than expected uterus for gestational age, and high beta hCG. Karyotype reveals 46 XX. Dx?

Complete mole
Exclusively paternal DAN

2

Pt has thick white vaginal discharge daily (~1 tsp). pH = 4. Saline shows epithelial cells with scarce PMNs. Dx?

Normal
"Physiologic Leukorrhea"

3

What is at risk of injury during hysterectomy?

Ureter
Passes directly under the uterine artery

4

What complications are associated with bicornuate uterus?

Infertility
Recurrent miscarriage
Preterm labor
Preterm delivery
But pregnancies are often carried to term

5

What causes a bicornuate uterus?

Incomplete fusion of the paramesonephric ducts.

6

8 y/o presents with abdominal pain, prominent breast tissue, and started menses at 7.
Bx - fluid filled cavities with a "rosette"

Granulosa cell tumors
Sex cord-stromal cell tumors that secrete estrogen, and thus often present with signs and symptoms of hyperestrogenism causing precocious puberty in adolescents
Call-Exner bodies = fluid-filled cavities with a "rosette" appearance

7

23 y/o female presents with RUQ pain and PID is found on PE. Dx?

Fitz-Hugh-Curtis syndrome (Perihepatitis)
Seen in 25% of pts with PID.
On laproscopy - "violin-string" adhesions are present in the peritoneal cavity

8

32 y/o man presents with infertility. Small testes, gyneocomastia. Low testosterone and low LH. What would confirm the Dx?

Karyotyping
Klinefelter XXY, phenotypic male with testicular atrophy, gynecomastia, sparse body hair, infertility.
Elevated LH is secondary to testicular atrophy
Abn Leydig cell fxn -> decrease in testosterone -> no feedback at the AP -> increased LH

9

During a hysterectomy, severing of which structure would disrupt blood flow to the ipsilateral ovary?

Suspensory ligament
AKA infundibulopelvic ligaments
Contains ovarian a. and v.
Ovary receives collateral flow from the uterine a. that travel in the cardinal (transverse cervical) ligament at the base of the broad ligament

10

Premenopausal woman presents with multiple masses with dysmenorrhea. what is a commonly associated condition?

Enlargement of the mass with pregnancy
Uterine fibroids (leiomyoma) = estrogen sensitive benign tumors of smooth muscle.
Tx varies with severity. Severe = hysterectomy
Can also try leuprolide, OCP, Progestins, or GnRH RH antagonist

11

What tx helps urinary flow in a BPH pt?

Tamsulosin
alpha 1 - antagonist

12

When a female is born, which phase of the cell cycle are her oocytes arrested in until ovulation?

Prophase I

13

After ovulation, the oocyte progresses through meiosis I and is arrested in?

Metaphase II until fertilization

14

Which syx would make a physician suspicious of postpartum depression in a new mom?

Feeling of worthlessness
Serious condition resembling major depressive disorder

15

What is postpartum blues?

Fatigue, anxiousness about the infant, weeping, irritability, emotional lability

16

If a pt begins HRT for meonpause what other conditions could be improved other than the typical menopause syx?

Decreased colorectal cancer and osteoporotic fx
Seldom use HRT (estro/progest) due to serious side effects (MI, stroke, DVT, and invasive breast cancer)

17

Hypospadias is due to a defect in?

Improper fusion of Urogenital folds

18

A woman is admitted for preeclampsia. She is given a drug that is used in expectant management of preeclampsia. 2 hours later labs show she has abnormally high levels of the drug. What syx would you expect?

hyporeflexia
Magnesium toxicity = loss of DTRs, SA and AV node blockade, drowsiness, respiratory depression, cardiac arrest
Magnesium sulfate is used to prevent seizures in preeclamptic women

19

What gene products cause cancer in HPV?

E6 - p53
E7 - Rb
Allows loss of control of the cell cycle despite DNA damage.
p53, Rb = tumor suppresors
hypophosphorylated Rb inhibits G1 to S progression

20

Pt presents with a adnexal mass during a routine pap smear.
Bx - nests of transitional cells with coffee bean-shaped nuclei among fibrous stroma
Dx?

Brenner tumors
Benign ovarian tumor that resembles bladder transitional epithelium.
Least common ovarian tumor.

21

In spermiogenesis, meiosis has been completed and cells are just undergoing their final morphologic changes and maturation. What's the karyotype of these cells?

Spermatids = 23, 1N
23 chromosomes and haploid
Become secondary spermatocytes after meisosis 2 is completed

22

What golgi defect can occur in spermiogenesis?

globozoospermia (sperm with round heads)
Golgi is not transformed into the acrosome causing infertility. Correction of the transformation allows for spermiogenesis

23

What lab changes can be seen as a complication of preeclampsia

Increased D-dimers
HTN + edema + proteinuria
DIC is major complication as well as acute fatty liver, acute tubular necrosis, and HELLP syndrome

24

What is HELLP syndrome?

Hemolysis
Elevated Liver enzymes
Low Platelet count

25

If a pt is unable to get an erection during REM sleep, what is the problem and what is the treatment?

Pathological ED
Tx - sildenafil
Inhibits cGMP phosphodiesterase to increase cGMP -> smooth muscle relaxation in the corpus cavernosum

26

63 y/o female presents with weight gain x 2 months. on PE build up of mucinous fluid in the intra-abdominal cavity. Dx?

Pseudomyxoma peritonei
Filling of the intra-abdominal cavity upon rupture of a mucinous ovarian tumor (mucinous cystadenocarcinoma)

27

Which hormone causes the prenatal differentiation of the external genitalia in males?

Dihydrotestosterone
Made from testosterone by enzyme 5 alpha reductase.
3x more potent than testosterone
Prenatal - development of male external genitalia
Later in life - secondary sexual characteristics

28

Which type of tumor presents with vaginal bleeding and is estrogen-sensitive ovarian cells resembling endometrial tissue. Dx?

Endometrioid tumor

29

What increases the risk of cryptorchidism?

Prematurity
Cryptorchidism causes an increased risk of germ cell tumors and infertility
Risk of testicular cancer persists even if the cryptorchidism is surgically corrected

30

Ligation of the right cardinal (transverse cervical) ligament would compromise which vessel?

Right uterine a. and v.

31

A woman at 24 weeks gestation presents with vaginal bleeding. U/S shows a gestational sac and intrauterine fetal heartbeat. What is likely to be in her history?

Prior cesarean delivery
Placenta previa manifests as painless vaginal bleeding after 20 weeks gestation.
RFs = cesarean, increased number of pregnancies, twins, history of D&C for elective abortion

32

Male presents with a testicular mass that doesn't tranilluminate, high alpha fetoprotein
On resection - large well demarcated mass, mucinous, and yellow. Dx and demographic?

Yolk sac tumor
Tumor of childhood
derived from malignant endodermal cells that secrete AF{
Syx - testicular swelling and pain
schiller-Duvall bodies - resemble glomeruli and are pathognomonic for sac tumors

33

male presents with a testicular mass that is large, well demacated, and gray/white in appearance. Histology - large cells in lobules with watery cytoplasm "fried egg" appearance. Dx and demographic

Seminomas
40-50 y/o
Never in infancy

34

What does the genital tubercle develop into?

Males - glans penis (DHT)
Female - clitoris

35

Describe the genetic components of the seminepherous tubule of the basal layer vs. the apical layer

2N (spermatogonia, supported by Sertoli cells) and N

36

20 y/o female presents with LLQ pain x 1 day. LMP was 2 weeks, B-hCG is negative. U/s reveals no masses or abnormalaties. Dx?

Mittelschmerz
Sudden onset abdominal pain in the middle of her menstrual cycle and all findings are inconsistent with pregnancy.

37

Amnio reveals Low AFP, unconjugated estriol, and B-hCG. Dx?

Trisomy 18
Edwards syndrome

38

Amnio reveals Low AFP, unconjugated estriol, but high B-hCG. Dx?

Trisomy 21
Also high inhibin A

39

Amnio reveals low B-hCG all other findings are WNL. Dx?

Trisomy 13

40

24 y/o Male pt has a nontender R testicle nodule and enlarged paraaortic lymph nodes. Dx?

Seminoma
Most common testicular cancer in 15-35 y/o
paraaortic lymphatic spread

41

A post partum pt presents with a right ovarian v. thrombosis is at risk of the thrombus reaching which vessel?

IVC
Puerperium ovarian v. thrombosis due to stasis + hypercoagulability + endothelial damage all associated with pregnancy.
Fever + flank pain
Most thrombus are R sided and can extend to IVC
L ovarian v. can extend to the Left renal v.

42

21 y/o female presents with facial flushing, HA, n/v, and abdominal cramps after consuming alcohol. What is she being treated for and what is the drug?

Trichomonas vaginitis
Metronidazole causes disulfiram-like effects (abd cramps, n/v, HA) when combined with alcohol due to acetaldehyde accumulation

43

A pt is likely receiving pulsatile GnRH infusion as a treatment for?

Infertility
Pulsatile GnRH stimulates FSH and LH.

44

When would continuous GnRH infusion be used?

suppress FSH and LH to suppress gonadal function
Could also use a long acting analog

45

What pathologic finding is expected in a PCOS pt?

Enlarged ovaries
PCOS is caused by elevated LH, androgen production, and insulin resistance
Obesity, irregular menses, hirsutism, enlarged ovaries and increased risk of DM and endometrial hyperplasia

46

How do you treat the infertility associated with PCOS?

Estrogen receptor modulation
Clomiphene = estrogen receptor modulator that decreases negative feedback inhibition on the hypothalamus by circulating estrogen, thereby increasing gonadotropin production

47

A woman is being evaluated for infertility. She has pain with deep intercourse
PE - retroverted uterus, posterior vaginal fornix is tender on palpation. The condition likely involves?

Ectopic endometrial tissue
Endometriosis - presence of endometrial glands and stroma outside the uterus. May be asymptomatic or present with dysmenorrhea, dyspareunia, and/or infertility

48

MOA of combined hormonal OCP's?

Inhibit ovulation by decreasing FSH and LH synthesis inthe AP
Progestin - pregnancy prevention (prevents the LH spike required for ovulation)
Estrogen - improved bleeding profile

49

Histology - ducts distended by pleomorphic cells with prominent central necrosis that do not penetrate the basement membrane. Dx?

Ductal carcinoma in situ
Precursor to invasive ductal carcinoma
Microcalcifications on mammography

50

LH stimulates theca interna cells of the ovarian follicle to produce?

Androgens

51

FSH stimulates the ovarian follicle's granulosa cells to convert androgens to?

Estradiol
Converted by aromatase

52

CA-125 is a marker for?

Epithelial ovarian cancer is the most common ovarian malignancy and is typically diagnosed in postmenopausal women.
Pathology - anaplasia of epithelial cells with invasion into the ovarian stroma, along with multiple papillary formations with cellular atypia
CA-125 is produced by epithelial ovarian tumors and can be used as a serum marker for this condition
Presents with abd distension, constipation, a mass, ascites, and decreased appetite

53

A pt presents with skin dimpling suggestive of breast cancer. She has a mass in the RUQ of her breast. Where has the mass infiltrated to?

Suspensory ligament
Invasive breast carcinoma
Presents as an irregularly shaped adherent breast mass most commonly in the upper outer quadrant
Malignant infiltration of suspensory ligaments of the breast causes dimpling of the skin

54

Which of the following endometrial processes leads to menstruation?

Apoptosis
Occurs following progesterone withdrawal

55

Urinary incontinence occurs during pregnancy due to?

Increased abdominal pressure
Stress incontinence
Also pregnancy hormones relax the pelvic floor muscles (levator ani, cocygeus) Kegel's can help

56

A woman is HIV + that she contracted during her birth from her mom. She has had sex with one partner and uses condoms consistantly. She has an abn Pap smear. What is the likely RF for this?

Immunosuppresion
HPV is the strongest risk factor for cervical dysplasia and invasive cervical carcinoma. HIV coinfection allows HPV infection to persist and enhance expression of HPV oncogenes increasing the risk of cervical dysplasia/cancer

57

A 26 y/o female presents with lower abdominal discomfort and a right adnexal mass
Histology - mature and immature cells. Dx?

Teratomas
Most common subtype of germ cell tumor.
Ovarian teratomas occur most frequently in females 10-30. They are divided into mature (cell lines of >1 germ layer, commonly including hair teeth and skin) and immature types.

58

A woman has had 2 abn Pap smears. Cerbical bx reveals high-grade cervical intrepithelial neoplasia. What would be seen on histology?

Expansion of immature basal cells to the epithelial surface

59

Pt has a defect in Sertoli cell fxn. What would be seen in blood hormone levels?

WNL - Testosterone, LH
Increased - FSH
Decreased - Inhibin
Sertoli cells produce inhibin in response to FSH. Inhibin suppresses FSH from the pituitary.
Sertoli also facilitates spermatogenesis.
So in total, decreased inhibin, increased FSH, and impaired fertility

60

Signs of Klinefelter

47 XXY
Tall stature, small firm testes, azoospermia, gynecomastia
Mild intellectual disability is seen in some pts
Primary testicular failure + enuchoid body habitu + mild intellecutal disability

61

Which BPH tx improves the pts urinary syx and will also decrease the size of the prostate?

5-alph reductase inhibitors
Finastride, dutasteride
Block conversion of testosterone to DHT in the prostate. Reduces protate volume and relieve bladder outlet obstruction.
NOTE - tamulosin, terzosin (alpha 1 antagonists) relax smooth muscle to impove obstructive syx, but cannot reduce the size of the prostate

62

A pt with ED says that he is still able to get nocturnal erections. dx?

Psycogenic ED
anxiety, sexual partner dissatisfaction, marital problems, emotional stress
10% of ED

63

Why dont the urethral folds fully fuse in females?

To form labia minora
Urethral fold = urogential folds
Failure to fuse in males = hypospadias

64

What blood hormone levels would be expected in a klinefelter pt?

Primary hypogonadism:
Low - testosterone, inhibin (hyalinized seminiferous tubules = low inhibin)
High - FSH, LH
Also elevated estradiol causes gynecomastia

65

Pt is unable to urinate or be cath'd following a pelvic fx. Where is the fx?

Injury to the posterior urethra (above bulb of penis, membranous portion most susceptable) = pelvic fx
anterior urethra (within bulb and corpus spongiosum) = straddle injuries
Inability to void with a full bladder sensation, high-riding boggy prostate and blood at the urethral meatus = urethral injury
Foley placement is contraindicated in urethral injuries

66

Where are the bladder and prostate in relation to each other?

Bladder - anterior
Prostate - posterior
Just like females

67

Through which structure will prostate cancer drain into in order to metastasize to the bone?

Prostatic venous plexus
Hematogenous seeding is seen in bone metastasis
Cancers of the pelvis spread to the lumbosacral spine via the vertebral venous plexus which includes the prostatic venous plexus.
Lymphatic spread to bone is very rare

68

A kid is born with apical displacement of the tricuspid valve leaflets, decreased RV volume, and atrialization of the right ventricle. Dx and what caused this?

Ebstein's anomaly
Lithium exposure
Mom probably has bipolar

69

What the rectus abdominous muscle is reflected back by horizontal transection, what is at risk for damage?

Inferior epigastric a.
Enters the muscle at the arcuate line.

70

Which hormone suppresses lactation during pregnancy?

Progesterone
Secreted by the corpus luteum and later by the placenta

71

Other than trisomy 21, what is another way to get Down's syndrome?

Robertsonian translocation, 46 XX, t(14;21)
Mosaicism

72

Rubella infection in first trimester could mean what for mom and baby?

Mom - polyarthralgia
Baby - deaf

73

Pt is presenting with a ruptured ectopic pregnancy (despite tubal ligation). What would be seen on DandC?

Dilated, coiled endometrial glands and edematous stroma

74

A pt with a fam hx of BRCA is presenting with a R sided ovarian mass and elevated CA-125. What would have been protective for her?

Oral contraceptive use
Multiparity, breastfeeding
Tubal ligation, salpingo-oophorectomy
RFS - nulliparity, endometriosis, Postmenopausal
Think the more ovulations they've had the greater the cancer risk

75

CA-125 is indicative of?

Epithelial ovarian cancer (EOC)
Advanced dz, increased mortality
CA-125 is neither sensitive or specific

76

Male is born without Sertoli cells. What is his phenotype?

Both male and female internal genitalia but male external genitalia
Leydig cells will produce testosterone -> develop male internal (mesonephric, Wolffian)
Lack of sertoli = no mullerian-inhibiting factor = female internal genetalia still occurs

77

Adnexal mass bx reveals anaplasia of epithelial cells with invasion into the stroma and multiple papillary formations with cellular atypia. Dx and what is likely to be elevated?

Epithelial ovarian cancer
CA-125
Postmenopausal women
Can have psammoma bodies

78

B hCG will be detectable in the serum how many days post fertilization?

8 days
Secreted by synctiotrophoblasts after implantation
Urine at 14 days

79

Pt taking valproic acid would have high risk of what if she became preggo?

NTD's (myelomeningocele)
Also phenytoin, methotrexate

80

Pt is dx'd with cervical neoplasia. What is the greatest RF?

Lack of barrier contraception
HPV 16, 18, 31 = Increased risk of SCC of the cervix
HPV 6, 11 = condylomata acuminata

81

Pt presents with distention and syx of fullness. Bilateral adnexa fullness and pelvic U/S reveals solid and cystic components and gastric thickening. Dx>

Krukenberg tumor
Gastric tumor that metastasized to the ovary
presents - unintentional weight loss, epigastrc pain, adnexal mass
Bx = mucin producing cells with apically displaced nuclei (signet ring)

82

After ovulation oocytes are halted in?

Metaphase of meiosis II

83

Prior to ovulation oocytes are halted in?

Prophase I

84

A pt with infertility due to PCOS is given a single injection of hCG. What is this meant to mimic?

LH surge
Pt is first treated with menotropin which acts like FSH to trigger formation of a dominant ovarian follicle. Then stimulate ovulation with hCG administration which mimics LH surge

85

29 y/o male presents with a painless scrotal mass. He has increased T4/T3
U/S - hypoechoic mass within R testicle. Dx and what else is elevated?

Testicular germ cell tumor
Elevated hCG (similar structure to TSH, causing his increased T3/T4)
Causes paraneoplastic hyperthyroidism

86

26 y/o female (g1,p1) is presenting with new facial hair and deep voice. LMP 5 months ago. Pelvic exam reveals clitomegaly and a large adnexal mass. U/S confirms a large ovarian cyst. Dx?

Sertoli-Leydig tumor
Arise from sex cord stroma and secrete testosterone
Suspect in female with large ovarian cyst + virilization
Bx - tubular structures lined by round sertoli cells and surrounded by fibrous stroma

87

Which hormone increases right after ovulation?

Progesterone

88

Pt is presenting with a thin blood tinged discharge from the right nipple. What would be seen on histology?

Papillary cells with fibrovascular core
Intraductal papilloma - proliferation of papillary cells in a cyst wall
Most common cause of bloody nipple discharge and presents without masses or skin changes
Bloody discharge is caused by twisting of the vascular stalk of the papilloma in the duct

89

15 y/o female presents with primary amenorrhea and fully developed secondary sexual characteristics. Pelvic exam - shortened vaginal canal with a rudimentary uterus. Dx?

Mullerian aplasia (Mayer-Rokitansky-Kuster-Hauser syndrome)
No upper vagina, variable uterine development. 46 XX females with normal ovaries and secondary characteristics

90

In pregnancy termination a pt is given mifepristone and misoprosotol. What is the MOA of each?

Mifepristone - progesterone antagonist
Misoprostol - protoglandin E1 agonist
Used to terminate 1st trimester pregnancies
Progesterone blockade -> necrosis of the uterine decidua

91

Breast bx - Cellular or myxoid stroma that encircles and sometimes compresses epithelium-lined glandual and cystic spaces

Fibroadenoma

92

Infant is born 46 XX with ambiguous genitalia and clitomegaly with elevated serum testosterone and androstenedione. Mother had facial hair and voice deepening during pregnancy. Infant is deficient in?

Placental Aromatase deficiency
Converts androgens into estrogens (estrone, estradiol) in the ovaries, testes, placenta, and other peripheral tissues.
Normal internal genitalia with ambiguous or male external
At puberty - amenorrhea, osteoporosis, tall stature
Men with arotomase deficiency have tall stature, osteoperosis, but no genital anomalies

93

Male infant is born is bilaterally descended testicles with an enlarged, fluctuant left hemi-scrotum that transilluminates. Where is his swelling?

Tunica vaginalis
Communicating hydrocele = serous fluid accumulates within the tunica vaginals due to a patent processus vaginalis.

94

Why do women develop gallstones during pregnancy?

Estrogen causes cholesterol hypersecretion
Progesterone causes gallbladder hypomotility
Also women that use oral contraceptives

95

Elevated LH
Excess androgen
Insulin resistance

PCOS
Obesity, menstrual irregularities, hirsutism, enlarged ovaries, increased risk of DM and endometrial hyperplasia
Tx - estrogen receptor modulation (clomiphene), decreases negative inhibition on the hypothalamus by circulating estrogen

96

Pt has an ovarian mass that is yellow and firm
Bx - small cuboidal cells in sheets with gland like structures containing acidophilic material arranged in a microfollicular pattern around a pink, eosinophilic center. Dx and what is it secreting?

Granulosa cell tumor
Post menopausal
Sex - cord stromal tumor of the ovary that secretes estrogen and can cause endometrial hyperplasia
Call-Exner bodies = cells arranged in a microfollicular or rosette pattern
Tumor is yellow due to lipid content of the theca cells

97

Woman is being evaluated for infertility. Pain on deep vaginal penetration.
Moderate to severe lower abdominal pain on menstruation
pelvic exam - normal sized retroverted uterus. Posterior vaginal fornix is very tender to palpation.
Dx and condition involves?

Endometriosis
Ectopic endometrial tissue

98

Pt has twins, one male and one femal. What type of pacentation is present?

Dichorionic
Diamnionic

99

During labor the myometrial cells express connexin-43 and the oxytocin receptor to increase formation of?

Gap junctions
Facilitate communication and coordination between cells and play an important role in labor. Connexins assimilate into gap junctions

100

Male infant has an undescended testical that is palpated medial to the right mid-inguinal point. During his procedure the testis will be pulled through which opening?

External oblique muscle aponeurosis
Teste is lodged in the inguinal canal and needs to be pulled through the superficial inguinal ring, an opening in the external oblique muscle aponeurosis