OBGYN - Beckmann Notes crc

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Leiomyomata are what

Localized proliferation of smooth muscle cells surrounded by a pseudocapsule of compressed muscle fibers.

Highest prevalence of leiomyomata what age

Fifth decade
1/2 of black women
1/4 white women

Clinically apparent in 25-50% of women, but studies suggest that the prevalence may be as high as 80%

More conservative options than hysterectomy for leiomyomata

Myomectomy
Uterine curettage
Operative hysteroscopy
Uterine artery embolization

Leiomyoma, hormone responsiveness

Estrogen --> grows... esp in high estrogen conditions such as pregnancy.

Menopause thus causes cessation of umor growth, and some atrophy.

How does estrogen trigger growth of myomas

Estrogen increases progesterone receptors, which then triggers increased growth.

Leiomyomata arise from what

Single cells --> in many cases the cell is smooth muscle from the vasculature in origin.

Leiomyosarcoma, suspicion should be high in what context

Rapidy enlarging uterine mass, PMB, unusual vaginal discharge, and pelvic pain in a postmenopausal patient.

Enlarging uterine mass in a PM patient should be evaluatled with considerably more concern than the premenopausal patient.

Composition of leiomyosarcomas

More heterolgous, mixed... contains other sarcomatous tissue elements not necessarily found only in the uterus...

Most common presentation of leiomyomata

Development of progressively heavier menstrual flows that last longer than normal duration... menorrhagia (defined as blood loss >80ml)

Mech of bleeding in leiomyomata

1. Alt of normal myometrial contractile function in the small artery and arteriolar blood supply underling the endometrium.
2. Inability of overling endometrium to respond normally to hormones
3. Pressure necrosis with exposure of underlying vasculature.

Besides bleeding, another common symptom for LM

"Pelvic pressure" or the sensation of pelvic fullness... these may attaina massive size and are most easily palpable on bimanual.... lumpy bumpy or cobblestone sensation....

Large LM may lead to compression of ureters...

LM may also cause secondary dysmenorrhea. Occasionally torsion of pedunculated --> acute pain.

Labor like pain with LM

Dull intermitteint low midline cramping when a pedunculated myoma progressively prolapses through the internal os of the cervix...

How to diagnose fibroids

Endometrial sampling --> irregularities of the uterine cavity, often the diagnosis is incidental to path assessment
Abdominopelvic exam ---> can feel midline irregularly countered mobile pelvic mass --> say in date weeks
Pelvic US -> but diagnosis is clinical --> may be acoustic shadowing, areas of distorted endometrial stripe
CT/MRI for large ones
Hysteroscopy, hysterosalpingography, saline infusion US
Uterine sounding as a part of endometrial biopsy. (biopsy is good to rule out other things)
Surgery if diagnosis is unclear

Retreatment after myoma removal via hysteroscopy

20% require f/u

Medical treatment for myomata

Progestin supplementation intermittent. Decreaes the amount of menstrual flow and 2/ dysmenorrhea.

Indications for a myomectomy

Rapidly enlarging pelvic masss
Persistent bleeding
Pain or pressure
Enlargement of an asymptomatic myoma to more than 8 cm in a women who has not completed childbearing

Hysterectomy after myomectomy?

W/i 20 years, 25% will have a hysterectomy mostly for recurrence.

Actions before hysterectomy for myomata

Confirm no cervical or endometrial malig
Surgical risk from anemia
Eliminate anovulation and otehr causes of weird bleeding.

GnRH analogs for myomata?

CAn reduce fibroid size by as much as 40% to 60%, but generally limited to six months of treatment. Commonly used before a planned hysterectomy to reduce blood loss as well as difficulty of the procedure.

Danazol has been less effective.

What is involved in UAE

Bilateral uterine artery cannulation
Injection of polyvinyl alchol particles, which cause acute infarction of target myomata.

Bleeding,pressure, and pain relieved in >85% of patients.

Complications of UAE

Postembolization pain in 10-15% of patients
Delayed infection
Passage of necrotic fibroids up to 30 days after procedure.

UAE and childbirth

Do not mix!!

Newest approach for leiomyomata

MRI guided focused US which raise temp in myomas by 70 deg cel. Coagulative necrosis. Minimal pain, appears to improve quality of life...

Myoma size that starts to impede with labor, and complications

>3 cm

Preterm labor, placental abruption, pelvic pain, cesarean delivery... Myomas can grow a lot during pregnancy, and can cause pain due to red or carneous degeneration as they outgrow their blood supply.

When should myomectomy be used in pregnancy

Only when myoma is pedunculated with a clear stalk

Patients typically pretreated wth B-adrenergic tocolytics

Vag birth after this is controversial, sig risk of uterine rupture.

Risk factors for pelvic support defects

Genetic predisposition
Parity
Menopause
Advancing age
Pelvic surgery
Connective tissue d/o
Elevation of intraabdominal pressure --> obesity, or chronic constipation, or heavy lifting
Atrophic changes due to loss of estrogen

When the cervix descends beyond the vulva, what is this called

Procidentia

Procidentia

Cervix descending beyond the vulva

What type of prolapse is most common?

Multiple forms together

Q-tip test, what is considered positive

Angle >30 degrees --> positive test

Prolapse may be so severe as to cause what

Hydronephrosis or hydroureter, due to insertion of hte urter into the trigone, thus kinking the trigone

What may mimic a cystourethrocele (pelvic support defect)?

Urethral diverticulum
Skene gland abscess

Rectocele may be confused with what

Enterocele

Nonsurgical alternative to pelvic prolapse

PElvic floor exercises
Pessaries
Symptom-directed mgmt

Women at high risk for prolapse complications and who no longer desire sexual intercourse

Colpocleisis --> complete obliteration of the vaginal lumen.

Prolapsed but no incontinence, what should be discussed at the time of surgery

Some women may develop incontinence AFTER the surgery...

Extensive bladder dissection during surgery may increase risk of what

Urge incontinence

What happens in stress incontinence

Normal phys allows increased ab pressure to be transmitted along entire urethra. In patients with stress incontinence, pressure is only on bladder and its neck, thus it descends

How to eval urinary incontinence

PE --> pelvic
Direct obs of urine loss
Measurement of postvoid residual
Urine culture
U/A
Urodynamic testing
Cystourethroscopy (in prep for surgery)

Urodynamic testing, single channel

Patient voids, and the volume is recorded. Urinary cath is then placed and the post void residual is recorded. Bladder filled in retrograde fashion. PAtient is asked to note when she first feels fullness/diesre to void, and when she can no longer hold urine
First - 100-150 cc
Second - 250 cc
Third - 500-600 cc

Urodynamic testing, multichanel

Transducer to measure intraabdominal pressure.. allows assesment of entire pelvic floor. Uninhibited bladder contraction can be clearly documented.

Success rates of pelvic floor strenghthening exercises

85% or so.

Behavioral training with biofeedback may help in what

Urge incontinence

Drug classes that help with urinary continence

Anticholinergic
TCAs
Musculotropic drugs

What explains 20% asymptomatic bacteriuria in PM women

Estrogen deficiency causes a decrease in urethral resistance to infection, which contributes to ascending contamination.

Staph saprophyticus

Usually just causes lower UTIs

Organisms assoc with structural abnormalities of urinary tract, indwelling catheters, renal calculi

Proteus
Pseudomonas
Klebsiella
Enterococcus
GBS, fungal stuff in people with indwelling catheters.

When is a culture used in the mgmt of UTI

Lower - usually when treatment fails
Upper - at time of diagnosis

Problem with Dipstick tests

False negatives are common, so if symptoms are there, a urine culture or U/A should be performed.

Duration of therapy for UTIs

As low as three days is effective, of BActrim, Trimethoprim, Cipro, Levo, and Gati

Mgmt of recurrent UTIs

Assess for risk factors:
- frequent sex
- long term spermicide
- diaphragm use
- new sex partner
- young age at first uti
- maternal history of uti

Who should be treated for asymptomatic bacteriuria

All pregnant women
Urologic procedures
Catheter acquired bacteriuria persistent for 48 hours.

Thats it!!

Diabetes risk for recurrent UTIs

Type 1, in PM women..

Changes of menopause, what is it called

Climacteric

How many oocytes are ovulated during reproductive years

400

What serves as the triggering method to induce ovulation

LH surge

Why does FSH begin to rise many years before the advnce of actual menopause

As reproductive age grinds on, remaining oocytes become increasingly resistant to FSH

FSH in menopause

>30 mIU/mL

FSH in prime reproduct years - 6-10
Perimenopause - 14-24
Childhood - <4

Age boundaries of menopause

44-55, average age 51

What is premature ovarian failure

Menopause <40 yo

Postmenopausal ovary, what is going on

Theca cell islands produce androgens in response to LH.... Postmenopausal testosterone concentrations are higher by 2/3 in women with intact ovariies

What estrogen is considered extragonadal

Estrone. Concentration is related directly to body weight, because androstenedione is converted to estrone in fatty tissue.

Obese vs thin menopausal tradeoff

Obese - higher risk of endometrial cancer
Thin - higher rate of hot flashes

What is considered perimenopause

Late 30s early 40s, when the concentration of FSH begins to increase from normal cyclic ranges (6-10) to perimenopausl 14-24.... During this period, women begin to experience ssx of decreasing estrogen levels.

What is the first physical sign of decreasing ovarian function

Hot flush, a sx of vasomotor instability

Hot flushes differential diagnosis

Menopause
Thyroid disease
Epilepsy
Infection
Hodgkin lymphoma
Alcohol/use of certaind rugs.

How long does a hot flush typically last

3 minutes, from hotness to coldness.

What plays a significant role in hot flushes

Declining estradiol from ovarian follicles

NAtural history of hot flushes

Resolution within 2-3 years, but some may last as long as 10.

Bone density decline in perimenopausal vs postmenopausal

0.5% vs 1-2% per year

Loss is more in trabecular vs cortical bone.

How much calcium and Vitamin D

1500mg calcium daily
10ug-15ug VIt D

Lipid profile in menopause

HDL decreases
LDL increases
Total cholesterol increases

Chromosomal aberrations behind premature menopause

Partial deletion of long arm of one X chrom --> premature ovarian failure.... thus Turner syndrome.

What is Savage Syndrome

aka Gonadotropin resistant Ovary Syndrome. Adequate number of ovarian follicles yet these follicles are resistant to FSH and LH. Exogenous estrogen helps... because estrogen stimulates FSH receptors in ovarian follicles.

Problems with chemotherapy

Premature ovarian failure, esp with alkylating agents

Hysterectomy with ovarian preservation.... menopause effects

Go into menopause 3-5 years earlier than other people.

Why might people not like taking progestins

Affective symptoms
Weight gain

WHI revealed what cancer effects of HRT

Increased risk of MI, stroke, VTE, and breast cancer
Decreased risk of colorectal cancer and hip fractures

HRT for menopause

Only short term, early on, and only for relief of hot flushes and other symptoms.

Definite CI to HRT

Undiagnosed abnormal genital bleeding
Known or suspected estrogen-dependent neoplasia, except in appropriately selected patients
ACtive DVT, PE, or history
Active stroke or MI
Liver dysfunction or disease
Known or suspected pregnancy
HSN to HRT

Problems with Dong quai or red clover

Interaction with drugs, esp by potentiating the effects of warfarin.

Non estrogen treatment of hot flushes

SSRIs (venlafazine, paroxetine, and fluoxetine)
Gabapentin
Cetirizine
Progesterone (off label!)

PAtient has history of weird vaginal bleeding, you want to start HRT. What hsould be documented

Normal endometrium by tissue diagosis
Pelvic US with an endometrial strip of <4mm

AGe of premature ovarian failure

<35 yo

How much calcium for PM woman per day

1200mg

Colles fracture

Fracture of the distal radius in the forearm with dorsal (posterior) displacement of the wrist and hand.

Osteoporotic fracture, what next

Treatment with bisphosphonates

Most common reason why women will stop HRT

VAginal bleeding - irregular bleeding occurs within the first six months.

When who are amenorrheic for a time are often disturbed by the resumption of any vaginal bleeding/spotting and find it intolerable.

Raloxifene effects on hot flahses

SERM that will actually make these symptoms worse.

How does estrogen raise HDL

Inhibits hepatic lipase which converts HDL2 to HDL3

Incidence of multiple gestations inthe US

3%

1/90 twinning, slightly higher in blacks than in whites.

Incidence is increasing with age and the use of assisted reproductive techniques. Weirdly enough this includes monozygotic twins

Incidence of monozygotic twinning in pregnancy

1/250. Rates are higher in families with twins.

Diamnionic / Dichorionic, when is the split

Within 3 days of fertilization. Each fetus surrounded by own amnion and chorion

Types of monozygotic twins

Diamnionic/Dichorionic
Monochor/diamnion
Mono/mono

Division day for monoamnio/dichorio

4-8 days post fertilization... Chorion has already started developing, whereas the amnion has not....

Monoamnion/monochorion

Division b/w 9-12 days.

1% of monozygotic twins....

Division on day 14 past fertilization

Conjoined,a nything 12 days past fertilization.

Division days with results

0-3 - di/di
3-8 - diamnionic/monochor
9-12 - mono/mono
>12 - conjoined

Conjoined twins, where conjoined, how often, and mortality rate

Chest or abdomen most commonly
1/70000 deliveries
Mortality rate of >50%

Multifetal vs singleton pregnancies.... morbidity

3-4x that of a singleton pregnancy, mostly from preterm labor.

Average age of delivery of twins

37 weeks
Triplets - 33 weeks
Quadruplets - 29 weeks
With each additional fetus, GA at delivery is decreased by approx 4 weeks.

Hydramnios is particularly a risk in what types of multifetal gestations

Monochorionic

Morbidities of multifetal gestation

Preterm - biggest
IUGR
Hydramnios - 10%
Preeclampsia
Congenital anomalies
PPH
Abruptio placenta
Umbilical cord accidents

Cord abnormalities in twins

Single umbilical artery in 3-4% of twins, compared to 0.5-1% of singletons.

Twin-twin transfusionsyndrome

Seen in monochorionic

Donor twin - impaired growth, anemia, hypovolemia, and other problems incl oligohydramnios

Recipient twin - Hypervolemia, HTN, polycythemia, CHF as a result of this preferential transfusion

Percent of twins with IGUR, and admission to NICU

IUGR - 14-25%
PICU - 25%

Risk of CP gets higher as well

When should twins be suspected

When uterine size is large for calculated gestational age. >4 cm or more ...

>4 cm beyond gestational age in fundal size

Inaccurate dates
Multiple gestation
Hydramnios
GEstational trophoblastic disease
Pelvic tumor

What percent of twins diagnosed in first trimester result in delivery of viable twins

50%... other 50% result in single fetus because of intrauterine demise and ultimate resorption of one embryo/fetus --> vanishing twin syndrome.

When can chorionicity be deterined

100% certainty as early as 9-10 weeks of gestational age.

Management of twin gestation, what should be done in midtrimester

Cervical exams to detect early effacement and dilation q1-2 weeks.
Transvag U/S for cervical legnth

When are daily fetal kick counts useful

30-32 weeks

US for multifetal pregnancies

Serial US beginning at 16-18 weeks GA q4 weeks.

What is discordant growth in multifetal gestation

15-25% reduction in estimated fetal weight of the smallest fetus vs the largest. Perform U/S more frequently in this case.

TWin presentation during delivery

40% vertex vertex (aka cephalic cephalic)
40% A: vertex, B: anything else --> eexternal cephalic version using US, or breech extraction (aka internal podalic version)
20% first twin is in breech, C-section....

Follicular phase, when does it end

First day of LH surge

Ovulation occurs when

Within 30-36 hours of LH surge

Duration of what phase remains relatively constant

Luteal phase

Estrogen deficiency, what gonadotropin is secreted more than otherse

FSH

Menarche, how many oocytes

300-500k

Late follicular phase, what happens

Peak estradiol oconcetratiosn from the dominant follicle reverse and instead have a postivie feedback effect on the pituitary which stimulates the mdicycle surge of LH that is necessary for ovulation.

Endometrial phases of the ovulatory cycle

Proliferative and the Secretory phase

What is day one of the menstrual cycle

First day of menstrual bleeding

Normal blood loss during menstruation

20-60ml of dark red blood and desquamated dneometrial tissues

What leads to cessation of menstruation

Rising estrogen levels in the early follicular phase --> induces endometrial healingand leads to cessation off menstruation

First chemical to rise after end of luteal phase

FSH, to recruit next cohort of follicles.

What becomes the dominant follicle

The follicle with the most granulosa cells thus the most FSH receptors. The other follicles undergo atresia

LH surge

Begins 34-36 hours prior to ovulation, with peak LH secretion 10-12 hours prior.

Oocyte arrests in what phase

Meiosis of primary follicle completes after LH surge. The oocyte then arrests in metaphase of meiosis II until fertilization

What is luteinization

Coversion of follicle to producing progesterone post ovulation. Progesterone has negative feedback on pituitary secretion of FSH and LH, and thus both hormones are suppressed in the luteal phase.

Corpus luteum also produces estradiol at the same time asprogesterone, but less than progesterone.

Lifespan of corpus luteum if conception does not occur

9-11 days post ovulation

hCG does what early on

Sustains the corpus luteum for antoehr 6-7 weeks. After which, the placenta produces the progesterone.

Size of corpus luteum

2.5 cm in diameter

What initiates desquamation of the endometrial

Progesterne withdrawal.

Cervical mucus changes

Estrogen - Large quantities of thin clearwatery mucus - Spinnbarkeit

Progesterone - thicker, decreased mcuus --> mucus plug.

Basal body temperature, when

In the morning.

When is Adrenarche, approximately

6-8 yo. Involves the increased production of androgens, occurring in the adrenals.

Obesity and pubertal onset

Mild to moderate obesity results in earlier puberty, whereas thinness results in later puberty. Much of the ethnic differences can be attributed to that

Abnormalities of puberty

Precocious
Primary amenorrhea
Delayed sexual maturation
Incomplete sexual maturation

Initial eval for pubertal problems

FSH and LH, which can help distinguish a hypothalamic pituitary problem from a gonadal problem

Precocious puberty

Puberty before age 6 in black girls,and 7 in white girls.

Idiopathic precocious puberty, what happens

Arcuate nucleus of the hypothalamus is triggered early. This also results in short stature in adulthood 2/2 premature closure of the epiphyseal plates.

How many tanner stages

5

What is McCune-Albright syndrome

aka Polyostotic fibrous dysplasia.

Multiple bone fractures
Cafe-au-lait spots
Precocious pubrety, which can be the first sign.

Thought to arise from defect in the cellular regulation with a mutation in the alpha subunit of the G protein which stimulates cAMP formation, which causes tissues to function autonomously. E.g. ovary produces estrogen without need for FSH.

Classic CAH

21 hydroxylase deficiency, presents with ambiguous genitalia, salt wasting.

Late onset CAH

Tedne to present in adolescence, in this disorder, cortisol and aldosterone is not produced as much as androgens. This results in precocious adrenarche. Appears somewhat like PCOS

Pathognomonic finding in 21 hydroxylase deficiency

Elevated 17 hydroxyprogesterone level. You can also measure renin to determine mineralocorticoid deficiency.

Goals of treatment for precocious puberty

Arrest and diminishment of sexual maturation until normal pubertal age
Maximize adult height.

Therapy for GnRH dependent precocious puberty

GnRH agonist

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