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98 terms

OBGYN - APGO Notes crc

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2 cm subserosal fibroid in a pregnant woman at 17 GA, further eval?
No further eval. Although fibroids may demonstrate red or carneous degeneration with rapid growth, this is uncommon for smaller fibroids. Uncommonly, fibroids can be located below the fetus --> C-section. If the fibroid were causing symptoms such as pain or is in a concerning position, it would be good to follow its growt
Single highest risk for bad outcomes with breast carcinoma
Axillary node mets --> led to use of postsurgical adjuvant therapy in these patients.
Endometrial how is it categorized
Grade: 1 --> 3 based on well to poorly differentiated
Clear cell carcinoma of the endometrium....
Diethylstilbestrol...

Tumor origins thoought to be mesonephric duct remnants.
Clear cell carcinoma stains with what
Periodic acid-Schiff staining-positive for glycogen.

Typically appear in older women and are very aggressive.
Mixed Mullerian endometrial cancer has what
Combination of heterologous elemetns, with tissues of different sources, e.g. cartilage.
Cyclophosphamide side effects
Hemorrhagic cystitis
Alopecia
Cisplatin side effects
Renal damage
Neural toxicity

Well hydrate patients!
Paclitaxel side effects
Allergies
Bone marrow depression
Bleomycin side effects
Pulm fibrosis
Rubicin side effects
Cardiotoxicity
Vincristine side effects
Peripheral neuropathy
Sertoli-Leydig cell tumors make up how many ovarian tumors
1%...

Histologically they resemble fetal testes, must be differentiated from adrenal tumors which can also produce androgens.
Tumors with excessive estrogen production
Granulosa
Theca cell tumors.
Excessive estrogen production due to theca cell tumors or granulosas may manifest how
Pseudoprecocious puberty
Postmenopausal bleeding
Menorrhagia
Endometrial cancer - 15% of patients!!

Tumors are quite friable, so may present with sx caused by tumor rupture and intraperitoneal bleeding.
Gonadoblastomas contain what
Frequently contain calcifications, are present in women with ambiguous genitalia usually.
What are the high risk HPV
HPV 16, 18, 31
HPV types assoc with benign condyloma
6,11
Most common ovarian neoplasm of young women in their teens and early twenties
Germ cell origin
Sarcoma botryroides, what is this
Tumor seen in children, malignancy asoc with Mullerian structures such as the vagina and the uterus, including cervix.
Ovarian malignant epithelial tumor>
Papillary serous cystadenocarcinoma
Ovarian serous carcinoma, what percent are bilateral
1/3 or so
Histo appearance of lichen sclerosus
Loss of rete pegs within the dermis, chronic inflammatory infiltrate below the dermis, etc. etc.
Why is lichen sclerosus important
People do have more cancers, but it isn't a precancer. Rather, it must be differentiated from vulvar squamous cancer.
First line therapy for lichen sclerosus
Ultrapotent steroids: clobetasol, halobetasol, diflorasone.

Topical estrogens only if labial adhesions are present.
US findings indicative of exlap in a PM patient with ovarian mass
Internal ovarian papillary vegetations
Size >10 cm
Presence of ascites
Possible ovarian torsion
Solid ovarian lesions
Younger woman with ovarian mass, how to follow?
Follow past one menstrual cycle to determine if it is a follicular cyst, since a follicular cyst should regress after onset of the next menstrual period... IF regression does not occur, then surgery is appropriate.
Large enterocele prolapse, first step in mgmt
Pessary fitting, least invasive...

Sacrospinous ligametn suspension would also be appropriate, but faurther downt he line.
Transvaginal tape used for what
Urinary incontinence
Anticholinergic used for urge incontinence
Oxybutynin
Colpocleisis, anesthesia requirements
Can be performed under local
Normal post void residual
50-60 cc

>300 in overflow incontinence
Defects of what fascia are fixed in the repair of central and lateral cystoceles
Pubocervical fascia --> reattaching it to a sidewall
What defect is fixed in the repair of rectoceles
Rectovaginal fascia
UTerine prolapse, how to fix
Vaginal hysterectomy
Vaginal vault prolapse, how to fix
Supporting vaginal cuff to uterosacral ligaments, sacrospinous ligament or sacrocolpopexy.
GSI picture but without urethral hypermobility?
10% of GSI --> intrinsic sphincteric deficiency.
Best 5 year success rates for patients with GSI due to hypermobility
Retropubic urethropexies
Sling procedures

Much more than: needle suspensions and anterior repairs
GSI due to intrinsic sphincteric deficiency treatment
URethral bulking procedures.
Uninhibited contraction of bladder with forced filling
Urge incontinence
AVerage length of twin gestation
35-37 weeks
Nadir of twin gestational mortality
ARound 37-38 weeks....
Why is advancing maternal age associated with increased in dizygotic twins
Increasing FSH, harder to folliculate follicles --> release of multiple eggs.
What is superfecundation
Fertilization of two or more ova from the same cycle by sperm from separate acts of sexual intercourse.
Di di identical twins due to division when (what stage of development)
Prior to the morula state
Which twin in TTT gets hydrops
Either one can develop hydrops fetalis.
Untreated TTT mortality rate
70-100%
Longstanding risks of TTT
Neurologic sequelae
What has been shown to reduce risk of preterm delivering in multiple gestation
Adequate weight gain in first 20-24 weeks of pregnancy... at least 24 lbs by 24 weeks.
Cerclage for twin pregnancies
Not effective
TWin infant death rate vs singleton
5x higher!!!!

CP - 5-6x higher
US marker for dizygotic twins
Two separate placentas --> anterior and posterior.
Preterm birth twins, triplets, quadruplets
Twins - 50%
Triplet - 90%
Quadruplet - 100%
Ultrasound markers of dizygotic twins
Dividingmembrane thickness >2mm
Twin peak --> lambda sign
Different fetal genders
Two separate placentas.
Good easy test for ovulation
Midluteal progesterone, above ten is good.
Tests of ovulation
Symptoms --> painm ,ovulatory mucus (spinnbarkeit),
Ovulation predictor kits --> LH surge
US
Serum progesterone in the luteal phase --> one of the best >10
Way to test ovarian reserve
FSH/E2
Ultrasound for follicles
Normal semen values
Volume 1.5-5.5 ml
Count >20 mil/ml
Motility >50%
Morphology >14% normal forms

So-called "strict criteria" for sperm morphology - Thaddeus kruger. WHO >30%.
Top causes of female infertility
Unexplained
Tubal disease - top
Ovulatory problems - top
Endometriosis
Cervical factors
Top causes of male infertility
Unexplained and varicocele - top
Testicular failure
Conditions that warrant earlier medical intervrention, history of
STDs
Ruptured appendix
Ruptured ovarian cyst or pelvic surgery
Male reproductive organ disease or surgery
AMA or prolonged history of infertility
Level III care for infertility
Duration > 36 months
Female partener >35 yo
ART is under consideration
Mgmt of complicated anovulation, endometriosis, etc.
Congenital bilateral absence of the vas deferens
Cystic fibrosis
Y chrom microdeletions
Germ cell arrest
Asthenospermia
Low motility
Teratospermia
Poor morphology
Intracystoplasmic sperm injection
ICSI
Mittelschmertz
Pain with ovulation
Ultrasound test for ovulation
Follicle disappearance
Cheapest way to tell ovulation
Basal body temperature
WHO classification of anovulation
I --> hypothalamic failure
II --> abnormal hormones, with normal FSH --> PCOS
III --> ovarian failure (high FSH) --> premature ovarian failure or ovarian destruction
Causes of hypothalamic failure for anovulation
Anorexia
Weight loss
Stress
FSH deficiency
Kallman syndrome
Pituitary hypothalamus tumors
Thyroid diesase
FSH for ovarian reserve
Cycle day 3 FSH with E2:
Normal <10
Borderine 10-15
High >15

Estradiol level can suppress FSH
Clomiphene citrate challange test
CD3 FSH/E2 with repeat of FSH at CD 10 after Clomiphene

Normal - 43%^
Abnormal - 9%. Test of ovarian reserve.
Proximal tubal occlusion
If unilateral --> consider spasm. If bilateral, probably not.
How to induce ovulation
Clomid
hMG injections
Clomid
Antiestrogen, competes with estrogen at hypothalamus and tricks body into thinking that the estrogen is low. Requires nromal hypothalamus and ovaries.
Side effects of clomid
Hot flashes (anti estrogen)
Bloating
Nausea
Headache
Visual changes
Breast tenderness.
How many cycles of Clomid
3-6.
Side effects of gonadotropin shots
May lead to ovarian hyperstimulation syndrome (OHSS) --> can be very sick, or high order multple pregnancies.

Stronger than clomid.
Normal follicle size before ovulation
20-25 mm, about an inch.
Menotropins risk of multiple gestation
25% vs 5% for Clomid
What TWO criteria can be used to gauge success with IVF
Age
+ FSH
Success rate for IVF
<35 - 37.3%
41-42 - 11%
How do oral contraceptives relieve primary dysmenorrhea
Creates endometrial atrophy..
Endometriosis under a microscope
Endometrial glands/stroma with hemosiderin-laden macrophages
PE of adenomyosis
Enlarged, soft, boggy uterus with no masses palpable. History of progressively worsening severe menstrual pain.
Adenomyosis relieve for women who do not desire hysterectomy
Endometrial ablation
Insertion of a levonorgestrel-containing intrauterine device.
Endometrial biopsy recommendations for women with weird bleeding
Even with solid diagnosis of fibroids, e.g., every woman over age 40 with irregular bleeding needs an endometrial biopsy to rule out carcinoma
What confirms the diagnosis of fibroids
Well circumscribed, non encapsulated myometrium
Acute uncomplicated cystitis causes
E coli - 80-85% of causes
OThers:
S. saprophyticus
K. pneumoniae
Proteus mirabilis
Citrobacter and enterococc occas
PID + high fever
Inpatient management. Needs aggressive therapy in effort to prevent scarring of her fallopian tubes and possible future infertility.

Also consider for N/V, nulliparous patients, etc.
HBV screening looks for what
Outer shell of the Dane particle of the virus - HBsAg.
Parenteral antibiotics forPID
Two regimens:
Cefotetan or Cefoxitin + Doxy
Clinda + Gentamicin
Outpatient for PID
Ceftriaxone, Cefoxitin, or other third generation cephalosporin (such as ceftizoxime or cefotoxime) + Doxy with or without metronidazole
Initial HSV infection
Viral like symptoms preceding the appearance of vesicular genital lesions. W/ primary infection,dysuria --> retention, may require catehter drainage.
Chancre of syphilis, who will progress
25% of untreated will develop secondary
Unrecognized salpingitis
Chronic pelvic pain
Hydrosalpnix
Tubal scarring
Ectopic