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198 terms

OB/GYN PANCE Review

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Amenorrhea
No menses
Primary Amenorrhea
The absence of spontaneous menstruation by age 16
Secondary Amenorrhea
Absence of menses for >6 months
Androgen insensitivity
Breast without pubic hair
Cause of secondary amenorrhea
1. Pregnancy is the most common
2. Drug users
3. Stress
4. Excessive exercise
Asherman's Syndrome (intrauterine adhesion) or PCOS
Secondary amenorrhea with normal estrogen
Galactorrhea
Prolactinemia
Progesterone challenge
determines if estrogen levels are sufficient
Amenorrhea treatment
Treat underlying cause
Dysmenorrhea
Painful menstuation
Primary dysmenorrheal
1. Excessive Prostaglandin E2 (causes smooth muscle contraction)
Sx's of dysmenorrhea
1. Cramping radiating to back or thighs
2. Beginning before or at onset of menses
3. Lasting for 1-3 days
Adenomyosis
Implantation of endometrial tissue in the myometrium
Large and "boggy" uterus
Adenomyosis
Diagnosis of dysmenorrhea
H/P
Dysmenorrhea treatment
1. NSAIDS
2. Oral contraceptives
3. Heat
4. Exercise
Prementrual Syndrome (PMS) Symptoms
1. Start during LUTEAL phase (1-2 weeks BEFORE menses)
2. Monthly symptom-free period during FOLLICULAR phase (day 1 of menses of obulation)
3. Mood alteration
4. Psychological affects
PMS treatment
Symptomatic
1. Diuretics (spironolactone) for fluid retention
2. NSAIDs
3. SSRIs
Menopause (climacteric)
1. Final menses
2. Lasts 3-5 years
Premature menopause
Before age 40
Estrone
Post-menopausal estrogen
Menopause Complications
1. Poor vaginal lubrication
2. Bone loss
3. Cardiovascular protection declines (estrogen-related)
4. Sleep changes
5. Endometrial cancer (unopposed Estrogen)
Diagnosis of menopause
FSH of greater than 3. mIU/mL
Menopause Treatment
1. Lifestyle modifications
2. HRT - increases risk of: cardiovascular disease, breast cancer, cognitive changes
3. Ca++, Vit-D, Bisphosphonates, Calcitonin (slow Ca++ from bones)
Dysfunctional uterine bleeding (DUB)
Abnormal bleeding with an unremarkable physical examination in a very young or perimenopausal woman
DUB treatment
Oral contracetpives, but not in women who:
1. Smoke
2. HTN
3. DM
4. Hx of vascular disease
5. Hx of breast cancer
6. Hx of liver disease
7. Hx of focal headaches
Leiomymata
Uterine fibroids - fibroids depend on estrogen
Women with fibroids have what increase of endometrial cancer
4x
Most common presenting symptom of Leiomyomata
Bleeding
Treatment for Leiomyomata
GnRH or MIFEPRISTONE
1. Reduce tumor size
2. Restore fertility
Most common gynocologic malignancy
Endometrial cancer
75% of endometrial cancer pts
Postmenopausal women
Endometrial cancer may be estrogen-dependent
in younger pts
Estrogen-independent endometrial cancer
in older, postmenopausal pt
Adenocarcinoma
Most common type of estrogen-independent endometrial cancer
Risk factors for endometrial cancer
1. Obesity
2. Nulliparity
3. Infertility
4. Late Menopause
5. DM
6. HTN
7. White Race
Oral contraceptives have what effect on endometrial cancer
a PROTECTIVE effect
Cardinal symptom of endometrial cancer
Inappropriate uterine bleeding
Endometrial biopsy has an accuracy rate of what in diagnosing endometrial cancer
90-95%
Endometial cancer treatment
1. Total hysterectomy with bilateral salpingo-oophorectomy
2. Radiotherapy (if indicated)
Endometrioses most common in who
Nulliparous women in their late 20's or 30's
Endometriosis commonly causes
Infertility
Endometriosis presents with
1. Dysmenorrhea
2. Intermittent spotting
3. Pelvic pain
Endometriosis treatment
1. Symptomatic - NSAIDs (discomfort), combination oral contraceptives or progestins
2. Danazol or GnRH agonist with surgery improves fertility
Adenomyosis
Extension of endometrial glands into the uterine musculature
Not related to endometriosis
Classic Adenomyosis
Middle-aged, parous with severe secondary dysmenorrheal and menorrhagia and a symmetrically enlarged uterus
Labs for adenomyosis
1. Pelvic ultrasonography
2. Endometrial biopsy will rule out endometrial cancer
Adenomyosis treatment
1. D/C
2. GnRH agaonist or Mifepristone
Pelvic Organ Prolapse Grade 0
No decent
Pelvic Organ Prolapse Grade 1
Descent between normal position and ISCHIAL SPINES
Pelvic Organ Prolapse Grade 2
Descent between ISCHIAL SPINES and HYMEN
Pelvic Organ Prolapse Grade 3
Descent WITHIN HYMEN
Pelvic Organ Prolapse Grade 4
Descent THROUGH HYMEN
Prolapse Treatment
1. Weight reduction
2. Smoking cessation
3. Pelvic muscle exercises
Ovarian Cysts Labs
Ultrasonography
Ovarian cysts treatment
1. Persistent cysts warrant further investigation
2. Cysts in postmenopausal women are presumed to be MALIGNANT until proven otherwise
PCOS is the most common cause of
Adrogen excess and Hirsutism
PCOS underlying issue
Hypothalamic pituitary dysfunction and INSULIN RESISTANCE
PCOS pts present with
hirsutism, truncal obesity, infertility, intractable acne
PCOS ultrasound will show
"string of pearls" appearance in ovaries
PCOS treatment
1. Weight reduction
2. Oral contraceptives (hirsutism)
3. Clomiphene citrate (infertility)
Risks for ovarian cancer
1. Older
2. Nulliparous
3. White
What may be protective against ovarian cancer
Long-term oral contraceptive use
% of ovarian cancer cases are sparodic
90%
Ovarian cancer labs
1. BRCA1 (5% of cases)
2. for treatment progress CA-125
3. Association with P53 tumor suppressor gene
4. Ultrasound helpful
Cervical dysplasia and neoplasia types 6 and 11 are linked to
Condylomata acuminate
Cervical dysplasia and neoplasia are most commonly in women
In their 20's
Carcinomai in situ (CIS)
ages 25-35
Cervical cancer
> 40 years old (47 average)
39 years old in lower socioeconomic status groups
Abnormal pap smear procedure
1. Biopsy is mandatory
2. Colposcopy with biopsy is the most appropriate technique
Cervical dysplasia and neoplasia treatment
1. Mild lesions may resolve spontaneoulsy
2. Gardasil
Gardasil
1. All girls aged 11-12
2. 3 injections over 6 months
3. Available to all women 9-26 years old
The rarest of gynocologic neoplasms
Neoplasm of the vulva and vagina
Most Vulvar malignancies are
Squamous cell carcinomas in postmenopausal women
Most vaginal intraepithelial neoplasms occur
in the upper 1/3 of the vagina
The most common presenting problems for neoplasms of the vulva and vagina
Postmenopausal bleeding and bloody discharge
Labs for neoplasms of the vulva and vagina
Staining with toluidine blue
Treatment for neoplasms of the vulva and vagina
1. Local excision
2. Topical 5-fluoruoracil (anit-neoplastic)
Benign breast disorders - mastitis is most often caused by
Staphaureus
Persistent, noncyclic breast pain may suggest
Underlying cancer
Fibroadenomas
Typically are ROUND, FIRM, smooth, discrete, MOBILE, and NONTENDER
When should a fibroadenomatous be biopsied
When pt is <25 years old
Treatment for Mastitis
Cephalosporin + hot compress
BRCA1 and BRCA2
Genes associated with breast neoplasms (5-10%)
Risk factors for breast neoplasms
1. Nulliparity
2. Early menarche
3. Late menopause
4. Long-term estrogen
5. Delayed childbearing
Ductal carcinomas
Account for 80-85% of breast cancers
-The remainder are LOBULAR carcinomas
Paget's disease
DUCTAL carcinoma; eczematous lesion of the nipple
Presentation of breast neoplasms
1. "SNIF" lesion: Single, NONTENDER, Immobile, Firm
% of breast neoplasms that occur in the upper outer quadrant
45%
% of breast neoplasms that occur under the nipple and areola
25%
Treatment for breast neoplasms
1. Lumpectomy + RADIATION
2. Tamoxifen in POSTMENOPAUSAL women
Traditional methods of contraception
Abstinence from just before the time of ovulation until 2-3 days thereafter
1. Calendar method
2. Basal body temperature
3. Cervical mucous
Effectiveness of combining the calendar and basal body temp methods
Results in only 5 pregnancies per 100 couple per year
Failure rate of calendar methods of contraception
35% Failure rate
Basal body temperature method of contraception
Slight drop in temperature occurs 24-36 hours after ovulation
Symptothermal method of contraception
The MOST RELIABLE periodic abstinence method
1. Combines the cervical mucous and basal body temperature methods
Cervical mucous method of contraception
Fertile mucus resemble egg white
MOST EFFECTIVE REVERSIBLE means of contraception
COC's
Failure rates of Oral hormonal contraceptives
1% (theoretical)
4-6% (actual)
Minipills
1. Progestin only (are HALF as effective as COC
Disadvtages of oral hormonal contraceptives
1. Increased risk of thromoboembolic diseas and abnormal lipids
2. Possible increased risk of breast cancer and HTN, cholelithiasis
DEPOT formulation inhibits
Anterior pituitary function
DEPOT failure rate
0.3%
After discontinuation of DEPOT fertility rates return to normal
within 18 months
Transdermal patch is applied
Once a month
Trans dermal patch is not effective
In women who weight >200 lbs
Infertility
Failure to conceive after 1 year of unprotected intercourse
First step in testing infertility
Semen analysis should precede any other testing
Expected Date of Confinement (EDC) - Nagele's Rule
LMP - 3 months + 1 week
1st trimester testing can detect what 5 of Trisomy 21 and other genetic disorders
82-87%
1. Low PAPP-A
2. High free beta-hCG
3. Nuchal translucency
Chadwick's sign
Bluish discoloration of vagina and cervix
Sign of pregnancy
Chorionic villus sampling is performed when
10-13 weeks
1. Option of a 1st trimester termination if a major malformation is detected
2. Risk of spontaneous abortion after CVS is slightly higher than that after amniocentesis
During the 2nd trimester abnormally high levels of AFP
Indicate increased risk for neural tube defects
Amniocentesis is performed
At 15-18 weeks
Nonstress Test (NST)
1. 2 accelerations of fetal heart rate in 20 minutes
2. 3rd trimester test
Contractions will have what effect on blood flow to the placenta
Decrease blood flow to the pelacenta
Decelerations
A decline in fetal heart rate of 15 bpm, or lasting more than 15 seconds, or a slow return to baseline
Ectopic Pregnancy 95% occur
In the fallopian tube
Most common cause of ectopic pregnancy
Occlusions to the tube secondary to adhesions
Ectopic pregnancy presentation
1. Unilateral adnexal pain
2. Amenorrhea or spotting
3. Tenderness or mass on pelvic exam
Ectopic pregnancy labs
1. Serial increases of hCG are LESS THAN EXPECTED (normally 2x/48hrs)
2. Transvaginal ultrasound
Ectopic pregnancy treatment
Methotrexate
Spontaneous abortion
Loss of pregnancy BEFORE 20 weeks
Spontaneous abortion occurs in what % of clinically recognized pregnancies
15-20%
80% of spontaneous abortions occur during
The 1st trimester
Missed spontaneous abortion
Cervix1. is CLOSED
2. No bleeding
3. No products of conception
Fetal demise has occurred WITHOUT symptoms
Threatened abortion
Cervix is CLOSED
Inevitable abortion
Cervix is OPEN, NO PRODUCTS of conception
Incomplete abortion
Cervix is OPEN, SOME products of conception
Complete abortion
Cervix is OPEN, PRODUCTS of conception
% of complete hydatidiform moles progress to malignancy
20%
Partial hydatidiform moles have
Have a fetus present
Gestational trophoblastic disease (GTD) labs
1. Persistently ELEVATED levels of hCG
2. Ultrasound - "grape-like vesicles" or "snowstorm"
Gestational trophoblastic disease (GTD) treatment
1. Suction curettage
2. Monitor with serial hCG
3. Contraception for 6-12 months
With Multiple gestation symptoms of pregnancy
Are more severe
Prenatal visits should occur more frequently
2/3 of twins are
Dizygotic (fraternal; formed by fertilization of 2 ova)
Gestational diabetes increase lifetime risk of DM
to 50%
Gestational diabetes effects what races
Non-white
Gestational diabetes labs
1. Screening high-risk women at 1st prenatal visit
2. Repeat screening at 24-28 weeks
3. Screening: Non-fasting glucose challenge with serum glucose 1 hour later
If non-fasting glucose challenge is >103
Then conduct a 3-hour glucose tolerance test
HgbA1c for gestational diabetes
Is NOT recommended
For a diagnosis of gestational diabetes to be made
>/= 2 abnormal labs
Gestational diabetes treatment
1. Diet & Exercise
2. Insulin: fasting >105, or postprandial >120
Preterm
Delivery before 37 weeks
Preterm Labor
Regular uterine contractions (>4-6/hour) between 20-36 weeks
Treatment for preterm labor
Tocolytics: Mag sulfate, Terbutaline
Premature rupture of membranes (PROM) AVOID what
Digital Exam should be AVOIDED unless delivery is imminent
PROM treatment after 37 weeks
Induction with Oxytocin (Pitocin)
PROM treatment 20-36 weeks
1. Admit to hospital
2. If <34 weeks, steroids (betamethasone) for fetal lung development
3. NST and BPP daily
Chronic HTN in pregnancy presents
<20 weeks
Pregnancy induced HTN presents
>20 weeks
Pregnancy induced HTN is caused by
Vasospasm or arteriole constriction
Pregnancy HTN treatment
Severe cases - medications
1. Methyldopa
2. Labetalol (alternative)
Preeclampsia
Hypertension + edema + proteinuria
Most common risk for preeclampsia
Nulliparity
HELLP
Hemolysis, Elevated Liver enzymes, Low Platelets
Eclampsia
Preeclampsia + Seizures
Preeclampsia/Eclampsia treatment
1. After 37 weeks - Induction
2. Mag Sulfate to decrease chance of seizures
3. Severe - prompt delivery regardles of gestational age
Rh incompatibility
If mother is Rh- and baby is Rh+, than mother may develop antibodies against the infant's blood
Rh immunoglobulin (Rho-Gam)
1. Administered routinely at 28-29 weeks to ALL Rh- mothers
2. Helps prevent development of antibodies in 99% of cases
If the baby is Rh+, after delivery
The mother receives Rho-Gam again to protect future pregnancies
Coomb's test
Hemolysis, RBC antibodies
Rh incompatibility treatment
Rho-Gam to Rh- mother at 28 weeks AND within 72 hours of delivering Rh+ baby
Abruptio Placentae
Premature separation of a normally implanted Placentae
Most common cause of 3rd trimester bleeding
Abruptio Placentae
Diagnosis of abruptio placentea is
Always clinical
Treatment for abruptio placentea
C-section
Placenta Previa
When the placenta partially or completely covers the cervical os
Placenta previa what is contraindicated
Digital Exam
Hallmark of placenta previa
Painless vaginal bleeding
Placenta previa lab
ultrasound
Placenta Previa Treatment
C-section
Routine vaginal delivery 0 station
At the ischial spines
Routine vaginal delivery (-) stations
above the ischial spines
Routine vaginal delivery (+) stations
Below the ischial spines
1st Stage of Labor
Ends at Full dilataion
2nd Stage of Labor
Ends with delivery of the baby
3rd Stage of Labor
Ends with delivery of the placenta
Accelerations
Increase of 15 bpm for 15 seconds (reassuring)
Early Decelerations denote
Fetal head compression (benign)
Late decelerations
occur during the second half of the contraction (worrisome)
Treatment of nonreassuring heart rate
1. Stop Oxytocin
2. Change meternal position
APGAR
Activity
Pulse
Grimace
Appearance
Respiration
(0-2 pts each)
Dystocia
Abnormal delivery
1. cervix fails to dilate
2. fetus fails to descend
Common causes of Dystocia
abnormalities with the Pelvis - Powers - Passenger
The rate of successful VBAC is lowest
When dystocia was the indicator for previous c-section
C-section increase risk of
Thromboembolism
Early induction: Prostaglandin gel
to "ripen" the cervix
Amniotomy
Artificially rupturing the membranes with a small hook
Later indcution
Oxytocin (Pitocin)
Endometritis most commonly occurs
after c-section
Endometritis presents
1. 2-3 days postpartum
2. Fever + uterine Tenderness + left Shift
Endometritis Treatment
1. Clindamycin + gentamicin gel
2. 1 dose of abx at time of cord clamping reduces incidence
Puerperium
6 wk period after delivery; "postpartum"
Normal Lochia
bleeding after delivery; can last for 4-5 weeks
Menses resumes in non-breastfeeding women
6-8 weeks postpartum
1st postpartum visit should be
at 6 weeks
Lactating mother may have
Atrophic vaginitis