womens healh Flashcards Preview

Clinical Medicine > womens healh > Flashcards

Flashcards in womens healh Deck (166):
1

when to start an infertility work up?

after 1 year

2

when to start an infertility workup before 1 year

age >35, previous infertility, previous infection/disease/surgery, DES exposure

3

definition of infertility

No pregnancy after 1 year of frequent unprotected intercourse

4

important points of hx in females in infertility workup

HPI
intercourse schedule
PMH previous pregnancies, menstrual cycle, puberty, STIS, endocrine disorders
meds
SH exercise, stress, sleep
FH DES, spontaneous abortions
ROS hair growth, breast discharge

5

what should a health vaginal canal look like?

• Presence of pink, moist, rugated vaginal mucosa as evidence of good estrogen

6

some male conditions related with infertility

• Hypospadias infertility from surgeries for this
• Cryptorchidism
• Varicocele
• Hydrocele
ED
hypogonadism

7

tests to rule out other causes of infertility

STI screen ==> R/O disease/infection
UPT==> R/O pregnancy
TSH==> Assess thyroid function
Prolactin ==> Assess pituitary function
+/- LH &FSH==>Assess ovary and feedback loop

8

what are tests rec'd for checking ovulatation?

OPK, sergum progresterone, progesterone challenge

9

if progesterone challenge doesn't work, what next?

check LH

10

if LH low...? if LH high?

if low, check FSH
if high check pituitary

11

if LH normal, if FSH high, low estrogen?

primary ovarian failure

12

if LH normal, and FSH normal..?

Hypothalamic-pituitary vs. outflow disorder

13

what percent of infertility is unexplained?

10-15%

14

• Inflammation or infection of the vaginal canal

vaginitis

15

usual etiology of candidate vaginitiis

• Candida albicans

16

types of HPV with warts

6 and 11

17

types of HPV with cervical dysplasia

types 16 and 18

18

methods that proves ovulation

regular cycles, OPKs,

19

pros of OCPs

Effective contraception
Decrease in pregnancy-related deaths
Non-contraceptive Benefits
 Better cycle control
 Decrease in iron deficiency anemia
 Maintenance or improvement in bone density
 Protection from ovarian and endometrial CA

20

cons of OCPs

No protection against STDs
Adverse effects
  risk of thromboembolism and stroke
 May elevate BP
 Estrogenic and progestin side effects
Drug interactions
Daily pill taking
Cost > $30/month

21

effects of too much estrogen

Nausea
 Breast tenderness
 Increased BP
 Melasma
 Headache

22

contraindications to ocp

Absolute Contraindications
 Hx of thromboembolic disease
 Hx of stroke or CAD
 Hx of breast cancer
 Hx of estrogen-dependent neoplasm
 Undiagnosed abnormal uterine bleeding
 Pregnancy (known or suspected)
 Heavy smokers ( ≥ 15 cigarettes/day) over the age of 35
 Hx hepatic tumors
 Active liver disease
 Migraine HA with focal neurologic symptoms
 Postpartum (during 1st 21 days as well as days 21-42 in women with additional TE risk factors)

23

RELATIVE CI

 Smoking 50 years
 Elective major surgery requiring immobilization (planned in the next 4 weeks)

24

too little estrogen

Early or mid-cycle breakthrough bleeding
 Increased spotting
 Hypomenorrhea

25

too much progesterone

Breast tenderness
 Headache
 Fatigue
 Mood changes

26

too little progesteron

late breakthrough bleeding

27

too much androgen

 Increased appetite
 Weight gain
 Acne, Oily skin
 Hirsutism
  LDL,  HDL

28

abx that can decrease dose of OCP

griseofulvin, penicillins, or
tetracyclines

29

pt ed on OCPs during abx use

An alternate or
additional form of birth control may be advisable
during concomitant use & for 7 days after

30

take extra dose if miss one or vomit?

yes, if vomit within one hour after taking dose

31

OCPs FDA approved for acne

Ortho-TriCyclen, Estrostep, Yaz

32

who should be considered for extended cycle oCP?

PMS, HA, anemia, endometriosis

33

pt ed of OCPs

Directions for Use
 Adherenc, star,,,,,t missed pills
 Other Topics
 Identify backup method (provide a few condoms)
 OCs will not protect against STDs
 Discuss the transient nature of most OC side effects in new users, especially spotting and
bleeding
 Discuss noncontraceptive benefits of OCs
 Five possible warnings of serious trouble

34

spotting on OCPs could be a sign of what?

nonadherence

35

how soon should you take oral EC agents?

within 72 hours

36

OTC emergency contraception

plan b one step for all ages, my way and next choice for >17

37

T or F: EC can disrupt a fertilize egg after implantation

F

38

what is yuzpe method for emergency contraceptoin

take multiple doses of normal OCP +antiemetic

39

based on ACOG guidelines, EC should be offered after how many hours?

120

40

pros and cons of patch

pros: easy, high adherence, cons: breast tenderness, increased risk of clots

41

pros and cons of vaginal ring

pros: convenient, effective, reversible cons: FB sensation, coital problems, expulsion, irritation/infection

42

mechanism of patch, ring, depo shot birth control pill

anovulatory

43

pros/cons of depo

pros: bleeding absent, non daily, affordable, immediately effective cons: office visit every 90 days, decreased bone density, weight gain, fatigue

44

pros and cons of subnormal implant

pros: can leave in for 3 years
cons:may be felt under skin

45

pros and cons of iUd

pros: effective, easy, no hormones
cons: r/o PID, req office visit for insertion/removal

46

when is IUD insertion done?

• Usually done during menses- open os, not pg

47

IUD insertion procedure

clean cervix, get uterine depth, insert with tube, trim tail

48

how long are iUDs good for?

3-10 years

49

• Mechanical barrier between cervix and vaginal canal
• Circular ring fitted for each individual

diaphragm

50

how often does male contribute to infertility?

20% of the time

51

pmS sx suggest ovulation T or F

T

52

best drug to induce ovulation (increases FSH and LH by tricking body into thinking low estrogen)

clomiphene citrate (clomid or serophene)

53

what is primary sx of vaginitis?

change or increase in discharge

54

thick white discharge, intense pruritis of vagina and vulva and no odor makes you think of what?

candidiasis

55

tests for all with discharge

pH, wet prep (could combine with koh)

56

vaginal hygiene patient education

wipe front to back, wear cotton underwear, avoid baths or foreign bodies (esp during vaginitis), avoid douching and perfumed stuff

57

normal vaginal flora

staph, strep, lactobacillus

58

etiology of bacterial vaginosis

gardnerella vaginalis, mobiluncus spp., mycoplasma spp., bacteroides

59

RFs of bacterial vaginosis

multiple partners, douching, vaginal irritants, smoking

60

non irritating, thin/gray-white/yellow discharge with foul odor makes you think of?

bacterial vaginosis

61

what are the 4 damsel criteria for bacterial vaginosis? must have 3.

abnormal discharge (color with foul odor), abnormal or high pH, positive whiff test, clue cells on wet prep

62

profuse frothy discharge + odor and pruritus makes you think of? +/- petechia on cervix

trichomonas

63

pH over 4 indicates? 4.5? 5?

4: candidiais
4.5 BV
5 trichomonas

64

T or F: viral shedding is possible with hPV even if not warts visible

t

65

tx of HPV warts

difficult, cryotherapy, electrocautery/currettage, laser, surgery, chemical

66

risk factors for spontaneous abortions

• Known: Age (AMA- advanced maternal age, > 35 years), Previous SAb, Smoking, BMI 25kg/m2
• Potential: Alcohol (>3 drinks/weeks), NSAIDS, Caffeine (100F

67

MC cause of spontaneous abortion

abnormal chromosomes

68

Vaginal bleeding through a closed cervical os

threatened abortion

69

T or F: threatened abortion means the fetus will not survive

F

70

signs of a threatened abortion

• Vaginal bleeding
• Pelvic pain/cramping
• Cervical os: Open or closed- should stay closed during pregnancy
• Products of conception: Passed or retained-

71

• A spontaneous abortion in which the entire contents of the uterus are expelled

complete abortion

72

common time of complete abortions

73

signs and sx of septic abortion

signs of infection
•Fever, chills
• Tachycardia
• Vaginal discharge- usually purulent
• Peritonitis- diffuse abdominal pain
• Septicemia
signs of abortion
• Vaginal bleeding
• Pelvic tenderness
• Cervical os open- how infection got in
• Uterus tender and boggy

74

how do you evaluate history of a spontaneous abortion?

• LMP (last menstrual period): Confirm pregnancy, Dating
• Signs of spontaneous abortion
• Signs of sepsis
• Consider Differential Diagnosis
− Physiologic – due to implantation
− Ectopic pregnancy
− Cervical, vaginal or uterine pathology

75

definition of recurrent pregnancy loss

• 3 or more losses before 20 weeks (0.4-1% of pregnancies)

76

what Must you rule out in any woman of reproductive age with abdominal/pelvic pain or irregular bleeding

ectopic pregnancy

77

where are most ectopic pregnancies?

fallopian tubes

78

what are risk factors for ectopic pregnancies?

1. Pelvic infections: Douching, multiple partners
2. Previous ectopic pregnancy
3. Age >35
4. In vitro, infertility treatments
5. History of abdominal or pelvic surgeries
6. IUD in place
7. Exposures to DES

79

signs of ectopic pregnancy

severe abdominal pain, abornaml uterine bleeding, amenorrhea, pregnancy sx, dizziness, signs of sepsis..

80

how to make dx of HSV

serology or PCR best b/c can detect asx or clinical

81

must take PO antivirals for herpes within how many hors of onset?

24-72

82

tx for chlamydia and gonorrhea

AZT po 1 gm x1 or doxy 100 mg x 7 days (or ceftriaxone 250 mg IM + AT po 1 gm x1 for gonorrhea)

83

MC sx of chlamydai and gonorrhea

discharge from cervix (mucopurulent in chlamydia or watery and profuse milky/mucopurulent with gonorrhea), fever, pelvic pain

84

signs of primary s yphilis

pain hard indurated ulcer

85

complications of PID

tubal occlusion, infertility, ectopic pregnancy risk

86

sx of PID

low abdominal pain MC, dyspareunia, vaginal discharge +/- odor, N/V, F/C, dysuria, irregular bleeding

87

what sign is pathopneugmonic for PID?

cervical motion tenderness

88

gene related to ovarian malignancies

CA-125

89

cancers associated with CA-125

ovarian, endometrial, breast, colon

90

important points to discuss with pt and partner before conception

Risks of maternal health/development
Genetic testing options (cystic fibrosis, hereditary)
Family history

91

what are 3 main mechanisms that cause sx of pregnancy?

1. Hormonal changes
2. Maternal structural changes
3. Unknown

92

gi changes in pg

reflux, hemorrhoids, constipation, decreased gallbladder function, N/V

93

pulm changes in pregnancy

increased o2 demands, increased rest drive, can hyperventilate, sob

94

CV changes

increased CO, could compress vena cava when laying, roll on side

95

optical weight gain in pg for normal BMI and rate

25-35 lbs, about 3-5

96

gravida

# of pg

97

para

# of completed pregnanites

98

what does the 4 parts of para stand for?

term, preterm, abortion induced or missed, living

99

important parts of initial visit hisotry

• Personal and demographic information
• Past OB history: Miscarriages, deliveries, OB complications- preterm labor, mode of delivery, birth weight
• Personal and family medical history- HTN, DM, pre-eclampsia, Preterm labor/delivery
• Past surgical history
• Genetic history
• Menstrual and gynecological history
• Current pregnancy history
• Psychosocial information- Single mom, partner info, supportive SO/family, drug use, homeless

100

chadwicks sign

increased vasculature of the cervix in first trimester, causes blue coloring, normal

101

parts of physical for pg initial visit

• Baseline BP, weight- Over/under weight
• Complete physical
• Focus on CV, Respiratory, pelvic, neurology
• Pelvic Exam

102

safe abx in pg

• Amoxicillin
• Ampicillin
• Clindamycin
• Erythromycin
• Penicillin
• Cephalosporins

103

avoid these abx in p if

• Tetracyclines
• Nitrofurantoin (not best in 1st trimester and term) though people use it a lot
• Sulfonamides
• Fluoroquinolones

104

at what age is fetus most susceptible to drugs and disease?

days 17-56

105

when is is important to start counting fetal kick counts and gestational diabetes glucose tolerance test?

28 weeks

106

at what point do you give rhogam?

28 weks

107

which gestational age?
• Appearance of a tadpole
• Measured in crown-rump length by ultrasound because legs are not well developed yet
• Cardiac motion can be detected by US
• Fetus is most susceptible to drugs, disease and other factors that interfere with normal growth between days 17-56- prenatal vitamins, stop drug/alcohol/smoking

6 wks

108

which gestational age?
● Presents for initial prenatal H&P (see previous slides)
Common symptoms:
● Nausea and Vomiting
● Heartburn
● Constipation
● Urinary Frequency
● Fatigue
● Backache

8-10 wks

109

which gestational age?
• The embryo has multiplied to more than 250 cells by day 6.
• Specialization of cells:
• Outer layer- Nervous System, Skin and Hair
• Inner layer- Respiratory and Digestive Systems
• Middle layer- Skeleton, Muscles, Circulatory System, Kidneys, and Sex Organs
• Home pregnancy tests are now positive- Some are sensitive up to 6 days after a missed period
• Serum pregnancy test is most accurate

4 weeks gestation

110

which gestational age?
• Pt generally feeling better in 2nd trimester, feel stronger flutters/fetal movement
• Fundus at umbilicus
• Fetal Anatomy Screen (FAS) US completed for anomalies
• Weight – 140 gm (5 oz) size of a banana
• Nervous system starts to function
• Fetus can hear
• Sex genitalia fully developed
• Patient should be able to feel fetal movement- second time mother might feel as soon as 13 weeks
• Lips developing—can see clef palate?

20 weeks

111

which gestational age?• Development of bones and muscles
• External parts: face and ears
• Most organs developed and functioning

16 weeks

112

which gestational age?
• Crown rump length (CRL) 38mm (1.5 in)
• Weight – 14 grams (1/2 oz)
• Organs now present- Maturation occurs in 2nd and 3rd trimesters
• Most critical development has occurred
• Rates of miscarriage drops after this week.
• By end of week placenta has taken over
• Mom typically feels better at this point

12 weeks

113

which gestational age?
• Weight – ½ kg (1 lb)
• Fetus responds to sounds by movement or increase in heart rate
• Bone marrow begins to make blood cells
• Lower airways develop (begins producing surfactant)
• Fat stores begin
• If fetus not moving can provoke to get movements
• Fundal height is 24 cm
• Begin assessing for preterm labor (PTL) sx
• Can start to obtain testing for PTL
• Can give betamethasone for lung development prn
• Can give terbutaline prn PTL contractions
• Pt should be feeling fetus by now

24 weeks

114

which gestational age?
• Weight – 2.5--3 kg ( 6.5 lbs)
• Brain developing rapidly
• Lungs nearly developed
• Vertex position (97%)
• Early term labor, considered full term at 37 weeks
• Group B strep culture obtained
• Cervical exams begin
• Assessing dilation, effacement, station, consistency
• If fetus not vertex, may undergo external cephalic version (ECV)
• Weekly appts begin

36 weeks

115

which gestational age?
• Weight – 1.8 kg (4 lbs)
• Layer of fat forming
• Fetus will gain more than half its weight between now and delivery
• Pregnancy sx may return
• Blood volume has increased 40-50% since beginning of pg
• Continuing assess PTL risks
• Pt may begin feeling Braxton-Hicks contractions, known as tightening and releasing discomfort without pain (practice ctx, not changes cervix)
• Begin assessment of fetal position (Leopold's Maneuvers)

32 weeks

116

which gestational age?
• Weight – 1 kg ( 2 lbs 4 oz)
• Brain wave patterns appear like full-term newborn
• Lungs continue developing--Viability rates increased
• Start measuring fetal movements (fetal kick counts) daily
• Screen for gestational diabetes (GDM) with 1hr glucose tolerance test. Confirm with 3hr
• If RH negative, recheck antibody screen and give Rhogam 300mcg injection
• Recheck hemoglobin
• Give Tdap at >27 weeks
• Begin follow ups every 2 weeks

28 weeks

117

what is leopold maneuver?

feeling for what position baby is in

118

method to determine IUGR

doppler velocimetry

119

typical signs of ectopic pregnancy

abdominal pain and vaginal bleeding

120

risks for placenta previa

• Prior C/S or hx of uterine curettage
• ? Damage to myometrium or endometrium
• Cocaine
• Advanced maternal age
• Tobacco
• Increasing parity
• Hx previous previa- Recurrence rate is 6-12x in subsequent pregnancies

121

what does a painless bleed in 2nd/3rd trimester indicate?

placenta previa

122

2nd/3rd trimester painful bleeding indicates?

placental abruption

123

risk factors for placental abruption

Risk Factors
• Hypertensive disorders- Pre-eclampsia
• Maternal trauma- MVA, assaults, falls, nosocomial infections
• Substance abuse- Tobacco (90% increased risk), Cocaine, Alcohol do a tox screen
• Rupture of Membranes (ROM)
− Prolonged (>24 hours)
− Over distention of the uterus with acute decompression from loss of amniotic fluid
− PROM/PPROM
• Retroplacental fibromyoma or uterine anomaly- placenta implanted on uterine fibroids, septum
• Previous abruption
• Multiparity, multiple gestations
• Previous C-section
• Thrombophilia
• Short umbilical cord
• Maternal age (extremes of age): 35 yrs

124

clinical presentation of placental abruptoin

• Vaginal bleeding- Concealed, could present just with cramping/pelvic pain but no bleeding
• US to assess placental location- Not all US detect abruptions, often a clinical diagnosis
• Painful contractions
• Uterus tender to palpation- tetanic (hard uterus)

125

MC medical disorder in pregnancy

HTN

126

dx of preecamplsia

• Proteinuria > 0.3 g protein in a 24-hour urine specimen
• In the absence of proteinuria, increased BP accompanied by
1. Symptoms of headache (different from normal HA), blurred vision, abdominal pain
2. Abnormal laboratory tests: Low platelet counts, abnormal liver enzymes

127

• Gestational BP elevation after 20 weeks of gestation in a woman with previously normal BP

preecmpalsia-eclampsia

128

leading cause of iUGR in pg

chronic HTN

129

drugs to give to treat acute HTN in pregnancy

hydralaizine (arterial vasodilator), beta blocker (only labetalol), nifedipine (calcium antagonist), sodium nitropruside,

130

greatest risk for post part HTN

antenatal preeclamspsia

131

elampsia

preeclampsia + seizures

132

what do each of these mean?
White Scheme- DM Classification KNOW!
A1
A2
B
C
D
F
R
H
T

White Scheme- DM Classification KNOW!
A1 - GDM not requiring insulin- majority of pregnancies
A2 - GDM requiring insulin
B - Onset > age 20 years or duration 20 years
F - Nephropathy
R - Proliferative retinopathy or vitreous hemorrhage
H - atherosclerotic heart disease clinically evident
T - Renal transplant

133

indications for c/s in diabetics

EFW >4500g or DM with prolonged second stage or arrest of descent with EFW >4000g

134

etiologies of post part hemorrhage

atony, retained placental fragments, coagulopathy, lacerations of vagina or cervix, uterine rupture or inversion

135

T or F: you should not breastfeed if you re hIV + even if undetectable viral loads

T, excpe tin 3rd world (r/o malnutrition greater than HIV transmission)

136

CI to vacuum extractor

• Fetal prematurity (

137

indications for C/S

• Failure to dilate
• Failure to descend
• Malpresentation ~11%
• Non-reassuring FHR ~10%
• Previous uterine scar ~30%
• Maternal request • Abnormal placentation-
• Placenta previa, vasa previa, placenta accreta
• Maternal infection- HSV or HIV
• Multiple gestation • Fetal bleeding diathesis
• Mechanical obstruction to vaginal birth previous obstruction with labor
• Large leiomyoma or condyloma acuminata, severely displaced pelvic fracture, macrosomia, fetal anomalies such as severe hydrocephalus

138

% of breast cancer that is hereditary

5-10%

139

RFs for breast cancer

12.8% by age 90
• Menarche before age 12 higher # of cycles in life=higher risk
• First live birth after age 30
• Nulliparity
• Menopause after age 55
• Atypical hyperplasia or LCIS dx by breast biopsy
• Postmenopausal obesity
• HRT
• Alcohol use (>2 drinks/day)
• Previous therapeutic radiation to chest or upper body
• Family history of breast cancer

140

T or F: you are at an increased risk of prostate, pancreatic and colon, uterine and melanoma with + BRCA

T

141

when to suspect a hereditary cancer

in >2 close relatives, dx

142

red flags for hereditary cancer

• Breast cancer before 50
• Ovarian cancer at any age b/c 25% chance hereditary
• Male breast cancer at any age- 13% of positive BRCA
• Multiple primary cancers
• Ashkenazi Jewish ancestry
• Relatives of a BRCA mutation carrier
• Triple negative breast cancers (ER-/PR-/Her2-)

143

2 genetic testing methods

sequencing (determine code) and MLPA or Q-PCR to find whole deletions or duplications

144

T or F: you can reach detection rate in 100%

F

145

if genetic test done 5 years ago, no need to get it again

false, tests and fm hx can change

146

T or F: Family history is the most effective screening tool for assessing cancer risk

T

147

causes of uterine displacement

• Childbirth
• Heavy physical labor
• Connective tissue labor- Marfans-absence of strong support
• Family tendency
• Age plus gravity

148

tx of uterine prolapse

nothing, pessary or surgery (hysterectomy)

149

sx of cystocele

• Pressure
• Feeling something bulging “feels like egg in vagina when I’m showering”
• Urinary incontinence, retention
• Frequent UTIs

150

non surgical options for cystocele

pessaries, kegels, double voiding, surgery

151

history clues to rectocele

• Pressure
• Feeling something bulging
• Stool incontinence- incomplete emptying, odor
• “when I am running little balls of poop come out” or “can’t seem to wipe away all the stool”

152

causes of vaginal fistulas

• Childbirth injuries: lacerations, necrosis
• Previous surgery- urologic procedures
• Crohn’s disease- most common cause of rectovaginal fistulae

153

FSH > what indicates post menopause?

>30

154

GU problems in menopause

atrophy of estrogen dependent tissues: atrophic vaginitis/dryness, itching, burning, more susceptible to UTIs, endometrial atrophy and spotting, cystocele, etc dysuria and frequency

155

menoapuse

• 12 months of amenorrhea immediately following last menstrual period- clinical diagnosis

156

when to consider premature ovarian failure

• 1% of women who undergo menopause 30 IU/L
• Causes infertility and perimenopausal/menopausal symptoms

157

lifestyle modifications for hot flashes

keep cool, exercise, medication, relaxation, stress reduction, avoid spicy food, caffeine, alcohol, and nicotine

158

most common fx sites in osteoporosis?

Vertebrae, hip, and distal radius

159

diff btwn primary and secondary osteoporosis

secondary d/t other dz

160

diff between type I and II primary osteoporisis

type I d/t increased osteoclastic bone resorption, type II d/t decreased osteoblastic activity

161

conditions involved in secondary osteoporosis

• Malignancies
• Corticosteroid use
• GI disorders- poor absorption
• Endocrine disorders- thyroid problems • Disuse from prolonged immobilization- MS
• Medications such as heparin or AEDs
• Alcohol use

162

osteopenia

bone density below normal, if catch here can prevent osteoporosis

163

RFs for osteoporosis

• Alcoholism
• Smoking
• Small, thin body build
• Weight 25 • Sedentary lifestyle
• Low calcium and vitamin D
• Corticosteroid use
• Prolonged immobilization
and age, causion or asian, female gender, family hx

164

dowager's thump

thoracic kyphosis

165

screening rec'd for bone screen

postmenopausal >65, postmenopausal

166

interpretation of T score -1 to -2.5 SD

osteopenia