Reproductive System Flashcards
(277 cards)
1
Q
Female Tanner Staging: Stage 1
A
- Breast: Papilla elevation only
- Pubic hair: None
2
Q
Female Tanner Staging: Stage 2
A
- Breast: breast buds palpable, areola enlarge
- Pubic hair: Small amount (long, downy hair on the labia)
3
Q
Female Tanner Staging: Stage 3
A
- Breast: Elevation of areola contour, areola continues to enlarge
- Pubic hair: Hair becomes more coarse and curly with lateral extension
4
Q
Female Tanner Staging: Stage 4
A
Breast: secondary mound of areola
Pubic hair: Adult-like, extends across pubis
5
Q
Female Tanner Staging: Stage 5
A
Breast: Adult breast contour
Pubic Hair: Extends to thighs
6
Q
What is the most common etiology of dysfunctional uterine bleeding (DUB)?
A
Chronic anovulation (90%)
7
Q
Workup of DUB (2)
A
- Hormone levels, transvaginal US
- Endometrial biopsy done if endometrial strip >4mm on transvaginal US or in women >35 years old to r/o endometrial hyperplasia or carcinoma
8
Q
DUB treatment: acute severe bleeding
A
- High dose estrogens, high dose OCPs with reduction in dose as bleeding improve.
- D&C if IV estrogen fails
9
Q
DUB treatment: anovulatory cause (3)
A
- OCPs
- Progesterone: used if estrogen is CI
- GnRH agonists: Leuprolide causes temporary amenorrhea
10
Q
DUB treatment: ovulatory cause (3)
A
- OCPs
- Progesterone: orally or IUD
- GnRH agonists (leuprolide)
11
Q
DUB treatment: Surgical options (2)
A
- Hysterectomy (definitive treatment)
- Endometrial ablation
12
Q
Primary dysmenorrhea
A
Not due to pelvic pathology. Due to increased prostaglandins. Pain usually 1-2 years after onset of menarche in teenagers
13
Q
Secondary dysmenorrhea
A
Due to pelvic pathology (ex: endometriosis, adenomyosis, leiomyomas, adhesions, PID). MC seen as women age
14
Q
Dysmenorrhea: Management (3)
A
- NSAIDs. Supportive: local heat, vitamin E 2 days prior and 3 days into menses
- OCPs/Depo-provera/vaginal ring
- Laparascoopy: If medications fails (endometriosis MC in younger patients, adenomyosis in increasing age)
15
Q
What is premenstrual syndrome?
A
Cluster of physical, behavioral, mood changes with cyclical occurrence during luteal phase of menstrual cycle and at least 7 days symptom free during the follicular phase
16
Q
What is premenstrual dysphoric disorder (PMDD)?
A
Severe PMS with functional impairment
17
Q
Premenstrual syndrome: Management (5)
A
- SSRIs
- OCPs: Drosperinone-containing OCP for PMDD
- GnRH
- Refractory breast pain: Danazol, bromocriptine
- Bloating: Spironolactone, calcium carbonate, low salt diet
18
Q
Amenorrhea work-up
A
Pregnancy test, prolactin, FSH, LH, TSH
19
Q
What is primary amenorrhea?
A
Failurue of onset of menarche by age 13 years (in the absence of secondary sex characteristics) or age 15 years (with secondary sex characteristics)
20
Q
Amenorrhea: If the uterus and breasts are present, what may it signify?
A
Outflow obstruction: Transverse vaginal septum, imperforate hymen
21
Q
Amenorrhea: If the uterus is absent but the breasts are present, what may this signify? (2)
A
- Mullerian Agenesis (46 XX)
- Androgen insensitivity (46 XY)
22
Q
Amenorrhea: If the uterus is present, but the breasts are absent, what may this signify? (2)
A
- Elevated: Increased FSH, Increased LH = ovarian causes
- Premature ovarian failure (46 XX)
- Gonadal dysgensis (ex: Turner 45XO)
- Normal/Low: Decreased FSH, Decreased LH
- Hypothalamus-pituitary failure
- Puberty delay (ex: athletes, illness, anorexia)
23
Q
Amenorrhea: If the uterus and breasts are absent, what may this signify?
A
Rare. Usually caused by a defect in testosterone synthesis. Presents like a phenotypic immature girl with primary amenorrhea (will often have intrabdominal testes)
24
Q
What is secondary amenorrhea?
A
Absence of menses for 3 months in a patient with previously normal menstruation (or 9 months in a patient who was previously oligomenorrheic)
25
Secondary amenorrhea: hypothalamus dysfunction etiologies (5)
1. Hypothalamus disorder
2. Anorexia (or weight loss 10% below IBW)
3. Exercise
4. Stress nutritional deficiencies
5. Systemic disease (ex: Celiac)
26
Secondary amenorrhea: Hypothalamus dysfunction diagnosis
Normal/low FSH and LH; low estradiol, normal prolactin
27
Secondary amenorrhea: hypothalamus dysfunction treatment
Stimulate gonadotropin secretion: ***clomiphene***, menotropin (pergonal)
28
Secondary amenorrhea: Pituitary dysfunction diagnosis
Decreased FSH, LH, Increased prolactin. MRI of pituitary sella
29
Secondary amenorrhea: pituitary dysfunction treatment
Transsphenoidal surgery (tumor removal)
30
Secondary amenorrhea: ovarian disorder clinical manifestations
**sx of estrogen deficiency** (similar to menopause): hot flashes, sleep & mood disturbances, vaginal dryness, dyspareunia, dry/thin skin
31
Secondary amenorrhea: lab levels for ovarian abnormalities
1. Increased FSH
2. Increased LH
3. Decreased estradiol
32
Secondary amenorrhea: lab values for pituitary or hypothalamus causes
1. Normal/Decreased FSH, LH
33
With the progesterone challenge test, if there is withdrawal bleeding, what does this signify?
**_Ovarian_** (patient is anovulatory or oligoovulatory) and there is enough estrogen present
34
With the progesterone challenge test, if there is no withdrawal bleeding, what does this signify?
1. **hypoestrogenic** ex. HP failure OR
2. **Uterine** (ex: Asherman's or uterine outflow tract [imperforate hymen])
35
What is Asherman's syndrome?
Acquired endometrial scarring usually secondary to postpartum hemorrhage, s/p D&C or endometrial infection
36
Secondary amenorrhea: Uterine disorder diagnosis (2)
1. Pelvic US: absence of normal uterine stripe.
2. Hysteroscopy: to diagnose and treat
37
Secondary amenorrhea: uterine disorder treatment
Estrogen treatment: to stimulate endometrial regeneration of denuded area
38
What is adenomyosis?
Islands of endometrial tissue within myometrium
39
Adenomyosis: clinical manifestations (2)
1. Menorrhagia (progressively worsens)
2. Dysmenorrhea, +/- infertility
40
Adenomyosis: Physical examination
***Tender*** symmetrically (uniformly) enlarged "***boggy uterus***"\*, "globular" enlargement
41
Adenomyosis: Diagnosis (2)
1. Diagnosis of exclusion of secondary amenorrhea. MRI
2. Post-TAH examination of uterus: definitive dx
42
Adenomyosis: Treatment (2)
1. ***Total abdominal hysterectomy (TAH)***: only effective therapy
2. Conservative tx: to preserve fertility, analgesics, low dose OCPs
43
What is a leiomyoma?
Benign uterus _smooth muscle tumor_. MC benign gynecological lesion
44
Different types of leiomyomas
Intramural, submucosal, subserosal, parasitic
45
Which population is at the highest risk of having leiomyomas?
African-Americans
46
Leiomyoma: diagnosis
Pelvic US: shadowing. Also used to observe for growth
47
For the majority of patients, what the treatment of leiomyomas?
Observation
48
Medical management of leiomyomas (2)
1. Progestins (ex: medroxyprogesterone)
2. Leuprolide: Most effective medical tx
49
Surgical management of leiomyomas (3)
1. **_Myomectomy_**: used especially to preserve fertility
2. Endometrial ablation, artery embolization. May affect fertility
3. **_Hysterectomy_**: Definitive tx\*\*\*. ***MC cause for hysterectomy***
50
MC organisms in endometritis (4)
GABHS, S. aureus, anaerobes, polymicrobial (vaginal flora)
51
With endometritis, in patients who have given birth via C-section, what is the antibiotic treatment that is given to prevent endometritis?
1st generation cephalosporin x 1 dose during c-section (cefazolin)
52
Endometritis: Diagnosis
Clinical: pts with fever, abdominal pain, and uterine tenderness esp. with C-section or postabortal
53
Endometritis: Management (2)
1. Infection with C-section: Clindamycin + Gentamicin
2. Infection with vaginal delivery or chorioamnionitis: Ampicillin + Gentamicin
54
MC sites of endometriosis
**_Ovaries_**\*, posterior cul-de-sac, broad & uterosacral ligaments, rectosigmoid colon, bladder & distal ureter
55
Endometriosis: Risk factors (3)
1. Nulliparity
2. Family history
3. Early menarche
56
Classic triad of endometriosis (3)
1. Cyclic premenstrual pelvic pain +/- low back pain
2. Dysmenorrhea
3. Dysparenunia; dyschezia (painful defecation). Pre-post menstrual spotting
57
What is the most common cause of infertility in women?
Endometriosis
58
Endometriosis: Diagnosis (2)
1. **_Laparoscopy_** with biopsy: **definitive diagnosis**\*
2. Endometrioma (endometriosis involving the ovaries large enough to be considered a tumor, usually filled with old blood appearing chocolate colored [chocolate cyst])
59
Endometriosis: Medical management (4)
1. Premenstrual pain: **Combined OCPs + NSAIDs**
2. Progesterone tx
3. Leuprolide (GnRH analog)
4. Danazol (testosterone)
60
Endometriosis: Surgical management (2)
1. Conservative laparoscopy with ablation (used if fertility is desired)
2. TAH-BSO (if no desire to conceive)
61
Endometrial hyperplasia: clinical manifestations
Menorrhagia, metrorrhagia, postmenopausal bleeding, +/- vaginal discharge
62
Endometrial hyperplasia: Diagnosis (2)
1. Transvaginal US (TVUS): \>4 mm\* (screening test)
2. Endometrial biopsy: ***definitive diagnosis***\*\*
63
When is an endometrial biopsy used with endometrial hyperplasia? (
1. Women \>35 years old
2. Increased endometrial strip seen on TVUS
3. Unopposed estrogen tx
4. Tamoxifen
5. Atypical glandular cells on Pap smear or persistent bleeding despite endometrial stripe \<4mm
64
Endometrial hyperplasia without atypia: Treatment (2)
1. Progestin tx (PO or IUD-Mirena)
2. Repeat endometrial biopsy in 3-6 months
65
Endometrial hyperplasia with atypia: Treatment (2)
1. ***Hysterectomy***
2. Progestin tx if not surgical candidate or pt wishes to preserve fertility
66
What is the MC gynecological CA in the US?
Endometrial cancer
67
Endometrial Cancer: With the endometrial biopsy, what is the most common subtype of endometrial cancer?
Adenocarcinoma (\>80%)
68
Endometrial cancer: Treatment (2)
1. Stage I: Hysterectomy +/- psot op radiation treatment
2. Stage II: TAH-BSO + lymph node excision + post-op radiation treatment
69
What is the most effective treatment for menopausal symptoms?
Estrogen only
70
Risks of estrogen only HRT (2)
1. Thromboembolism
2. Increased risk of endometrial cancer (often used in patients with no uterus)
71
What coud vaginal bleeding + abdominal pain + amenorrhea signify?
Threatened abortion (MC), ectopic, nonviable pregnancy
72
Pelvic organ prolapse: Grades
Grade I: descent into upper 2/3 of vagina
Grade II: cervix approaches introitus
Grade III: Outside introitus
Grade IV: entire uterus outside the vagina - complete prolapse
73
Pelvic organ prolapse: Prophylactic treatment
***kegel exercises***, weight control
74
Pelvic organ prolapse: nonsurgical treatment (2)
1. Pessaries
2. Estrogen treatment
75
Pelvic organ prolapse: surgical treatment (2)
1. Hysterectomy
2. Uterosacral or sacrospinus ligament fixation
76
Pharmacologic treatment for stress incontinence
1. Alpha agonists: Midodrine, pseudoephedrine
2. Estrogen: Cream or estradiol-impregnated vaginal ring
77
Pharmacologic treatment for urge incontinence (3)
1. Anticholinergics (1st line meds): Tolterodine, propantheline, oxybutynin
2. TCAs: Imipramine
3. Mirabegron: Beta-3 agonist
78
Pharmacologic treatment for overflow incontinence (2)
1. Cholinergics: bethanacol
2. Alpha-1 blockers: Tamsulosin (for BPH)
79
Functional ovarian cysts: Treatment (2)
1. Supportive: Most cysts \<6-8 cm are functional and usually spontaneously resolve. Rest. NSAIDs, repeat pelvic US in 6 weeks.
2. OCPs
80
Functional ovarian cysts: complications (2)
1. Ovarian torsion
2. Bleeding
81
What is the second most common type of gynecological cancer that also has the highest mortality of all gyn cancers?
Ovarian cancer
82
Ovarian cancer: Risk factors (5)
1. +FH
2. increased number of ovulatory cycles (infertility, nulliparity, \>50 yo)
3. BRCA1 & BRCA2
4. Peutz Jehgers
5. Turner's syndrome
83
Ovarian cancer: PE (3)
1. Abdominal or ovarian mass, ascites\*
2. Sister Mary Joseph's node: METS to umbilical lymph nodes
3. Constipation
84
Ovarian cancer: Diagnosis (2)
1. Biopsy: 90% are epithelial tumors (seen esp. postmenopausal). Germ cell tumors in pts \<30 years
2. Transvaginal US useful screening in high risk patietns. Mammography to look for primary in breast
85
Ovarian cancer: Management (3)
1. Early stage: TAH-BSO + selective lymphadenectomy
2. Surgery: Serum Ca-125 levels are used to monitor treatment progress\*
3. Chemotherapy: Paclitaxel + Cisplastin or carboplatin
86
What is the MC type of benign ovarian neoplasm?
Dermoid cystic teratomas
87
Benign ovarian neoplasms: treatment
Surgery
88
PCOS: Labs
Increased testosterone, increased DHEA-S (Intermediate of testosterone); Increased LH: FSH ratio 3:1
89
Anti-adrogenic agents for hirustism in PCOS
**_Spironolactone\*_**, leuoprolide, finasteride
90
Pap smear results: Negative for intraepithelial lesion or malignancy (no neoplasia)- No HPV management (4)
Follow routine PAP screening
1. Every 2 years starting age 21 until 29 y
2. Every 3 years ≥30y (if h/o 3 negative cytologies previously)
3. Yearly if HIV, in-uteruo DES exposure, increased risk factors
4. D/C age 65-70 y (if last 3 PAP's were normal)
91
Pap smear results: Negative for intraepithelial lesion or malignancy (no neoplasia): Greater than 25 yo and HPV management (2)
Two options:
1. cytology and HPV testing in 12 months OR
2. Genotype for HPV 16, 18
92
ASC-US: Management if greater than 25 (2)
Two possible options
1. **_Do HPV testing\*_**: HPV negative --\> repeat PAP and HPV cotesting in 3 years; HPV positive --\>colposcopy with biopsy
2. Repeat PAP in 1 y. If negative, resume PAP screening. Colposcopy if positive
93
ASC-US or LSIL Management if 21-24yo
_Repeat PAP in one year_ or HPV testing
94
ASC-US Management if \<21 yo
Repeat PAP in one year
95
ASC-H Management
***Colposcopy*** allows for visualization of cervix using magnification after applying dilute acetic acid for accentuation of lesions
96
LSIL (inlcudes CIN I): Management for 25-29yo
Colposcopy with biopsy
97
LSIL (includes CIN I): Management for ≥ 30yo (2)
1. HPV negative --\> repeat cytology in 1 year
2. HPV positive --\> colposcopy with biopsy
98
HSIL (Includes CIN II, CIN III, and carcinoma in situ) Management
Colposcopy in all ages
99
Pap smear: Glandular cell abnormalities management (2)
1. Colposcopy for all glandular cells abnormalities
2. Glandular abnormalities may be indicative of endometrial hyperplasia
100
LSIL (CIN I) : Managment (3)
1. Observation: 75% resolve by immune system within one year. May be an option if \<20 y
2. Excision: LEEP procedure or cold knife cervical conization
3. +/- Ablation
101
HSIL (CIN 2, CIN 3, and carcinoma-in-situ) Management (2)
1. Excision: LEEP, cold knife cervical conization
2. Ablation: Cryocautery, laser cautery, electrocautery
102
2 types of cervical carcinomas
Squamous (90%) and adenocarcinoma (10%)
Clear cell carcinoma linked to DES
103
Cervical carcinoma: Stage 0 (carcinoma in situ) treatment (3)
1. Exicision (LEEP, cold knife cervical conization); preferred
2. Ablation tx (cryotherapy or laser)
3. TAH-BSO
104
Cervical carcinoma: Stage Ia1 (microinvasion)
Surgery: Conization, TAH-BSO, XRT
105
Cervical carcinoma: Other Stage I, IIA
TAH-BSO; XRT + chemo tx (cisplatin)
106
Cervical carcinoma: Stage IIb-IVa (locally advanced) management
XRT + Chemo (Cisplatin +/- 5FU)
107
Cervical carcinoma: Stage IVb or recurrent (distant METS)
Palliative XRT, chemo (surgery is not likely to be curative)
108
What is cervical insufficiency (incompetent cervix)?
Premature cervical dilation especially in 2nd trimester
109
Cervical insufficiency: PE
Painless dilation and effacement of cervix
110
Cervical insufficiency: Management (2)
1. Bed rest, weekly injection of 17 α-hydroxyprogesterone (increases progesterone)
2. Cerclage (suturing of cervical os)
111
What is the most common subtype of vulvar cancer?
90% squamous
112
Vulvar cancer: clinical manifestations (2)
1. Pruritus MC presentation (70%), vaginal itching, irritation
2. Asymptomatic (20%). Post-coital bleeding, vaginal discharge
113
Vulvar cancer: diagnosis
Red/white ulcerative, crusted lesions. Biopsy
114
Vulvar CA: Treatment (4)
Surgical excision, XRT, chemo (ex: 5-FU), laser treatment
115
Vulvovaginal atrophy: management (3)
1. Vaginal estrogens
2. Ospemifene: SERM (estrogen agonist in vagina; antagonist in breast, uterus)
3. Vaginal moisturizers (won't help with atrophy)
116
What is the MC cause of vaginitis?
Bacterial vaginosis
117
MC organisms for bacterial vaginosis
Gardnerella vaginalis, anaerobes
118
Bacterial vaginosis: Vaginal discharge
Thin, homogenous, watery grey-white "fish rotten" smell
119
Bacterial vaginosis: urinary pH
\>5
120
Bacterial vaginosis: Microscopic (2)
1. **_Clue cells_**\*
2. Few WBCs, few lactobacilli
121
Bacterial vaginosis: Management (2)
1. Metronidazole (Flagyl) x 7 days
2. Clindamycin
122
Trichomoniasis: vaginal discharge (3)
1. Copious malodorous discharge
2. _Frothy yellow green discharge_\*
3. Strawberry cervix\* (cervical petechiae)
123
Trichomoniasis: pH
\>5
124
Trichomoniasis: Microscopic (2)
1. Mobile protozoa (wet mount)
2. WBCs
125
Trichomoniasis: Management (2)
1. Metronidazole (Flagyl): Oral preferred
2. Tinidazole
126
Trichomoniasis: Prevention (2)
1. Spermicidal agents
2. MUST TREAT PARTNER
127
Candida vulvovaginitis: vaginal discharge
Thick curd-like/cottage cheese discharge
128
Candida vulvovaginitis: urinary pH
Normal
129
Candida vulvovaginitis: Microscopic
Hyphae, yeast on KOH prep
130
Candida vulvovaginitis: Management (2)
1. Fluconazole
2. Intravaginal antifungals: Clotrimazole, nystatin, butoconazole, miconazole
131
Cytolytic vaginitis: Pathophysiology
Overgrowth of lactobacilli
132
Cytolytic vaginitis: vaginal discharge
Nonodorous discharge white to opaque
133
Cytolytic vaginitis: Urinary pH
Normal
134
Cytolytic vaginitis: Management (2)
1. Discontinue tampon usage (to decrease vaginal acidity)
2. Sodium bicarbonate (sitz bath or douche)
135
What is the MC cause of cervicitis?
Chlamydia
136
Chlamydia: Diagnosis (2)
1. LCR test most spp/sensitive
2. Cultures, DNA probe
137
Chlamydia: Treatment (2)
1. Azithromycin OR doxycycline
2. Treat for gonorrhea
138
Chlamydia: second line treatment (2)
1. Erythromycin, ofloxacin, levofloxacin
2. Cultures, DNA probe
139
Chlamydia: Prevention
Avoid sexual intercourse 7d after treatment
140
Chlamydia: Complications
PID, infertility, ectopic pregnancy, premature labor
141
Gonorrhea: Diagnosis
Culture, DNA
142
Gonorrhea: Management (3)
1. Ceftriaxone IM
2. Cefixime
3. Treat for chlamydia
143
Gonorrhea: Complications (2)
1. PID, infertility, ectopic pregnancy
2. Reactive arthritis
144
Chancroid: Clinical manifestations (3)
1. Genital ulcer: soft, shallow, painful\*
2. +small vesicles or papules
3. PAINFUL inguinal LAD
145
Chancroid: Management (4)
1. **Azithromycin**
2. Ceftriaxone IM
3. Erythromycin
4. Ciprofloxacin
146
PID: Outpatient treatment
Doxycycline + ceftriaxone (cover gonorrhea & Chlamydia) OR clindamycin + gentamicin
147
PID: Inpatient treatment
Doxycycline + 2nd generation cephalosporin (ex: Cefoxitin or Cefotetan)
148
Toxic shock syndrome: Diagnosis
CBC, cultures, clinical. Isolation of organism is NOT required
149
Toxic shock syndrome: Management (3)
1. Hospital admission, supportive measures
2. Anti-staphylococcus abx x 1-2 weeks: Clindamycin + Oxacillin or Nafcillin
3. If MRSA: Clindamycin + Vancomycin (or Linezolid)
150
151
Management of cystitis in pregnancy
1. ***amoxicillin***\*, augmentin, cephalexin, ***macrobid***, cefpoxidime, fosfomycin
2. Sulfisoxazole
152
SERM (tamoxifen) is an agonist in what systems?
Bone, endometrium, liver, and coagulation system
153
Ectopic pregnancy: Physical examination
Cervical motion tenderness, adnexal mass
154
Indications for methotrexate in ectopic pregnancy
Hemodynamically stable patients, early gestation \<4 cm, beta-HCG \<5,000
155
Shoulder dystocia: nonmanipulative treatment
McRoberts maneuver
156
Shoulder dystocia: manipulative treatment
Woods "Corkscrew" maneuver; C section
157
What is a hydatidiform mole?
Neoplasm due to abnormal placental development with trophoblastic tissue proliferation arising from gestational tissue (not maternal) origing
158
What is a complete molar pregnancy?
Egg with no DNA fertilized by 1 or 2 sperm. 46XX all paternal chromosomes. Associated with a higher risk of malignant potential (choriocarcinoma development)
159
Gestational Trophoblastic Disease (Molar pregnancy): Clinical manifestations (4)
1. ***Painless vaginal bleeding***
2. Uterine size/date discrepancies
3. Hyperemesis gravidarum
4. Choriocarcinoma
160
With choriocarcinoma, where is the most common METS location?
Lungs
161
Gestational Trophoblastic Disease (Molar Pregnancy): Diagnosis (2)
1. Beta-HCG: Markedly elevated (\>100,000)
2. Ultrasound: "Snowstorm" or "cluster of grapes" appearance
162
Gestational Trophoblastic Disease (Molar Pregnancy): Treatment (2)
1. Uterine suction curettage ASAP
2. METS: chemotherapy (ex: **Methotrexate\***) destroys trophoblastic tissue
163
When is gestational DM usually diagnosed?
24-28 weeks of gestation
164
Gestational DM: Pathophysiology
Caused by placental release of human placental lactogen (HPL), which antagonizes insulin
165
Gestational DM: Diagnosis (3)
1. Screening: 50g oral glucose challenge test (nonfasting) @ 24-28 weeks gestation. **If \>140**mg/dL in one hour --\> proceed to 3 hour oral GTT
2. 3 hour 100g oral GT: ***Gold standard***\*
3. Glucosuria
166
When is a 3 hour oral GTT considered to be positive?
1 hour \>180
2 hour \>155
3 hour \>140
167
Gestational DM: Treatment (3)
1. **_Insulin_**: Tx of choice! (does not cross the placenta)
2. Glyburide: higher risk of eclampsia
3. Early delivery @ 38 weeks
168
With gestational DM, what is the fasting glucose goal?
\<95
169
Gestational DM: Insulin requirements (2)
1. NPH/regular insulin: 2/3 in the AM and 1/3 in the PM
2. 0.8 IU/kg 1st trimester; 1.0 IU/kg in 2nd trimester; 1.2 IU/kg in 3rd trimester
170
RH alloimmunization: Clinical manifestations
- If subsequent newborn is Rh positive: **hemolytic anemia, jaundice, kernicterus, hepatosplenomegaly**
- **_Fetal hydrops_**, congestive heart failure in the newborn
171
What is fetal hydrops?
Fluid accumulation in 2 spaces: Pericardial effusion, ascites, pleural effusion, SQ edema
172
When is RhoGAM given in the mother?
At 28 weeks gestation and also within 72 hours of delivery of the Rh positive fetus
173
Treatment of erythroblastosis fetalis in the newborn (in Rh alloimmunization)
Moderate to severe anemia treated with Ag negative RBCs through ultrasound-guided umbilical vein transfusion
174
Premature rupture of membranes (PROM): Risk factors (4)
1. STDs
2. Smoking
3. Prior pre-term delivery
4. Multiple gestations
175
PROM: Diagnosis (3)
1. Nitrazine test: amniotic fluid pH\>7.1
2. Fern test: amniontic fluid: fern pattern
3. Sterile speculum exam: look for infection
176
PROM: Management (2)
1. Await for spontaneous labor or induction of labor (with oxytocin or prostaglandin gel)
2. Monitor for infection (***infection MC complication of PROM***)
177
If the cervical dilation is ≥3 cm and the effacement is 80%, what is the diagnosis?
Premature labor (PTL)
178
If the cervical dilation is 2-3 cm and the effacement is \<80%, what is the diagnosis?
Premature labor likely
179
If the cervical dilation is ≤2 cm and the effacement is \<80%, what is the diagnosis?
PTL unlikely
180
Premature labor: diagnosis (3)
1. Tocolytics: Given for 48 hours to delay delivery so steroids can take full effect on the fetus
2. Antenatal corticosteroids
3. Antibiotics: GBS prophylaxis if needed (penicillin G)
181
Tocolytics given in premature labor (4)
1. Beta2 agonist: Terbutaline, ritodrine
2. Magnesium sulfate
3. Nifedipine: not given concurrently with Mg
4. Indomethacin
182
S/E of terbutaline
pulmonary edema
183
1st-line anti-emetics given in hyperemesis gravidarum
Pyridoxine (vitamin B6) +/- doxylamine
184
Threatened abortion: Definition (2)
1. Pregnancy may be viable (progress) or abortion may follow
2. MC cause of 1st trimester bleeding
185
Threatened abortion: Products of conception
No POC expelled from the uterus
186
Threatened abortion: Cervical os
Closed
187
Threatened abortion: Clinical manifestation (3)
1. Bloody vaginal discharge (Spotting--\>profuse)
2. +/- contraction of uterus
3. Uterus size compatible with dates
188
Threatened abortion: management (3)
1. Supportive
2. Serial beta-HCG to see if doubling
3. No sex or douching
189
Inevitable abortion: definition
Pregnancy not salvageable
190
Inevitable abortion: Products of conception
No POC expelled
191
Inevitable abortion: Cervical os (2)
1. Progressive cervix dilation (\>3 cm, effaced)
2. +/- Rupture of membranes
192
Inevitable abortion: Clinical manifestation (3)
1. Moderate bleeding \>7 days
2. Moderate-severe uterus cramping
3. Uterus size compatitble with dates
193
Inevitable abortion: Management (2)
1. D&E 2nd trimester, suction curettage in 1st
2. RhoGAM if indicated
194
Incomplete abortion: Definition
Pregnancy not salvageable
195
Incomplete abortion: Products of Conception
Some POC expelled, some retained
196
Incomplete abortion: Cervical os
Dilated
197
Incomplete abortion: Clinical manifestation (3)
1. Heavy bleeding
2. Mod-severe cramping
3. Retained tissue. Boggy uterus
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Incomplete abortion: Management (3)
1. D&C in 1st, D&E after 1st
2. Pitocin
3. RhoGAM if indicated
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Complete abortion: Definition
Pregnancy not salvageable
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Complete abortion: Products of conception
All POC expelled from uterus
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Complete abortion: Cervical os
Usually closed
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Complete abortion: Clinical manifestation (2)
1. Pain, cramps, and bleeding usually subsides
2. Pre-pregnancy size of uterus
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Complete abortion: Management
RhoGAM if indicated
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Missed abortion: Definition
Embryo not viable but retained in uterus
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Missed abortion: Products of conception
No POC expelled
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Missed abortion: Cervical os
Closed
207
Missed abortion: Clinical manifestation (2)
1. Loss of pregnancy sx
2. +/- brown discharge
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Missed abortion: Management (2)
1. D&C if 1st trimester, D&E OR
2. Misoprostol
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Septic abortion: Definition
Retained POC becomes infected --\>infection of uterus and organs
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Septic abortion: Products of conception
Some POC retained
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Septic abortion: Cervical os (2)
1. Closed
2. Cervical motion tenderness
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Septic abortion: Clinical manifestation (3)
1. ***Foul, brownish discharge, fevers, chills***
2. Uterine tenderness
3. Spotting --\> heavy bleed
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Septic abortion: Management (3)
1. D&E to remove POC +
2. Broad spectrum abx
3. +/- Hysterectomy if refractory
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Placenta Previa: Definition
Abnormal placental implantation on or close to cervical os
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Placenta Previa: Clinical manifestations (2)
1. 3rd trimester bleeding - sudden onset of PAINLESS bleeding (bright red)
2. No abdominal pain; uterine soft and nontender
216
Placenta Previa: Fetal heart rate
Normal
217
Placenta Previa: Diagnosis
Pelvic US
218
Placenta Previa: Management (3)
1. Hospitalization
2. Stabilize fetus (tocolytics, amniocentesis)
3. Delivery when stable
219
When is a C-section done in placental previa?
If it is complete
220
Placenta Previa: Risk factors
Multiparity, increasing age
221
Abruptio placenta: Definition
Premature separation of placenta from the uterine wall
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Abruptio placenta: Clinical manifestations (3)
1. 3rd trimester bleeding - continuous and often **_dark red_**
2. **_Severe abdominal pain_**\* (painful uterine contractions), **_rigid uterus_**\*
3. +/- back, abdominal pain, shock sx
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Abruptio placenta: Fetal HR
Fetal **bradycardia** (fetal distress!!)
224
Abruptio placenta: Diagnosis (2)
1. Pelvic US
2. Do not perform a pelvic exam
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Abruptio placenta: Management (2)
1. Hospitalization
2. Immediate delivery: may lead to DIC
226
Abruptio placenta: Risk factors (6)
1. **_Maternal HTN MC cause_**
2. Smoking, etoh, cocaine
3. Folate deficiency
4. High parity
5. Increased age
6. chorioamnitis
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Vasa previa: Definition
Fetal vessels traverse the fetal membranes over the cervical os
228
Vasa previa: Clinical manifestations
Rupture of membranes ⇒ PAINLESS vaginal bleed
229
Vasa previa: Fetal HR
Fetal bradycardia (fetal distress!!)
230
Vasa previa: Diagnosis
Pelvic US
231
Vasa previa: Management
Immediate C-section
232
Preeclampsia: Definition
HTN + Proteinuria\* +/- edema after **20 weeks gestation**
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Preeclampsia: Diagnosis (mild)
1. BP ≥ 140/90 on 2 separate occasions @ least 6 hours apart
2. Proteinuria ≥300mg/24 hr (or \>1+ on dipstick)
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Preeclampsia: Diagnosis: Severe
1. BP ≥160/110
2. Proteinuria: ≥5g/24h (or \>3+ on dipstick)
3. Oliguira (\<500 ml/24h)
4. Thrombocytopenia, +/-DIC
5. HELLP syndrome
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Preeclampsia: Management (Mild)
1. Delivery is the only cure (performed at 34-36 weeks)
2. Steroids to mature lungs 26-30w
3. Supportive: daily weights, BP and dipstick weekly, bed rest
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Preeclampsia: Management (severe)
1. Delivery is the only cure (Performed at 34-36 weeks)
2. Hospitalization: low salt, Mg sulfate
3. BP meds: started if BP ≥180/110
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BP meds used in pregnancy
Hydralazine\*, labetalol, nifedipine
238
Eclampsia: Definition
Seizures or coma\* in patients who meet preeclampsia criteria
239
Eclampsia: Clinical manifestations (2)
1. Abrupt tonic clonic seizures\*\*
2. +/- HA, visual changes, cardiorespiratory arrest
240
Eclampsia: Diagnosis (2)
1. Same as preeclampsia + seizures
2. Hyperreflexia
241
Eclampsia: Management (4)
1. ABCDs 1st
2. Mg sulfate: for seizures (Lorazepam 2nd line)
3. Delivery of fetus: once pt is stabilized
4. BP meds: Hydralazine\*, labetalol
242
What is DOC for chronic HTN in pregnancy?
Methyldopa
243
Ladin's sign
Uterus softening after 6 weeks
244
Hegar's sign
Uterine isthmus softening after 6-8 weeks gestation
245
Piscacek's sign
Palpable lateral bulge or softening of uterus cornus 7-8 weeks gestation
246
Goodell's sign
Cervix softening 4-5 weeks gestation
247
Chadwick's sign
Cervix and vulva bluish color 8-12 weeks
248
When is fetal heart tones first heard and what is the normal rate?
10-12 weeks. Normal is 120-160 bpm
249
When does a pelvic US detect a fetus?
5-6 weeks
250
When is quickening (fetal movement) first noticed?
16-20 weeks
251
When is triple screening (alpha-fetoprotein, beta-HCG, estradiol) first measured?
15-20 weeks
252
Down syndrome: Alpha-fetoprotein, beta-HCG, and estradiol levels
1. Alpha-fetoprotein: Low
2. Beta-HCG: High
3. Estradiol: Low
253
Open neural tube defects (ex: spina bifida): Alpha-fetoprotein, beta-HCG, and estradiol levels
1. Alpha-fetoprotein: High
2. Beta-HCG: N/A
3. Estradiol: N/A
254
Trisomy 18: Alpha-fetoprotein, beta-HCG, and estradiol levels
1. Alpha-fetoprotein: Low
2. Beta-HCG: Low
3. Estradiol: Low
255
When is GBS screening done?
35-37 weeks
256
APGAR score: Appearance (skin color changes)
0=Blue all over
1=Acrocyanosis (body pink but blue extremities)
2= Pink baby (no cyanosis)
257
APGAR score: Pulse
0=0
1=\<100
2=≥100
258
APGAR score: Grimace
0=No response to stimulation
1=Grimaces feebly
2=Cry or pull away
259
APGAR score: Activity
0=None
1=Some flexion
2=Flexes arm and legs resist extension
260
APGAR score: Respiration
0=Absent
1=Weak, irregular
2=Strong cry
261
Post-partum hemorrhage: etiologies (2)
1. Uterine atony: MC cause
2. Others: uterine rupture, congestion, bleeding d/o, DIC
262
Post-partum hemorrhage: Risk factors (3)
1. rapid or prolonged labor
2. Overdistended uterus
3. C-section
263
Post-partum hemorrhage: Management (2)
1. Uterotonic agents: Oxytocin IV, misoprostol
2. Bimanual massage. Treat the underlying cause.
264
Fibrocystic breast disorder: Clinical manifestations (2)
1. Usually multiple, mobile, well demarcated areas in breast tissue. Often ***_tender_***\*, bilateral. Often no axillary involvement nor nipple discharge.
2. Breast cysts may increase or decrease in size with menstrual hormonal changes
265
Fibrocystic breast disorder: Diagnosis (3)
1. US
2. Biopsy shows **_straw-colored fluid (no blood)_**
3. +/- Seen on mammogram
266
Fibrocystic breast disorder: Management
Most spontaneously resolve. Can do FNA of fluid if symptomatic
267
Fibroadenoma of the breast: Clinical manifestations (3)
1. Smooth, well-circumscribed, mobile rubbery lump with no axillary involvement or nipple discharge
2. Gradually grows over time and does not usually wax and wane with menstruation\*
3. May enlarge in pregnancy
268
Fibroadenoma of the breast: Management
Most small tumors resorb with time. +/- excision (not usually done)
269
Breast CA: Types (3)
1. Ductal carcinoma
2. Lobular carcinoma
3. Medullary, mucinoid, tubular, papillary, metastatic, mammary Paget's disease
270
Breast CA: Ductal carcinoma (2)
1. ***Infiltrative ductal carcinoma MC*** (75%). Associated with lymphatic METS especially axillary
2. Ductal carcinoma in situ (DCIS). Does not penetrate the basement membrane.
271
Breast CA: Lobular carcinoma (2)
1. Infiltrative lobular carcinoma
2. Lobular carcinoma in situ (may not progress but associated with risk of invasive BRCA in either breast)
272
Breast CA: Clinical manifestations (2)
1. Breast mass that is usually painless, hard, fixed (non-mobile) lump\*
2. Unilateral nipple discharge (may be bloody)
273
Which medication is useful for breast CA tumors that are ER (estrogen receptor) positive?
Anti-estrogen (Tamoxifen)
274
Which medication is useful for postmenopausal ER positive breast CA patients?
Aromatase inhibitors (ex: Letrozole, Anastrozole, Exemestane)
275
Which medication is useful for HER2 positivity in breast CA patients?
Monoclonal Ab treatment (Trastuzumab [Herceptin], Lapatinib)
276
Which medications can be used in postmenopausal women or women \>35 years old with a high risk of breast CA?
Tamoxifen or Raloxifene (SERM). Treatment is usually for 5 years. Tamoxifen is preferred. Aromatase inhibitors are an alternative.
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