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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....


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

Cisplatin side effects

Renal damage
Neural toxicity

Well hydrate patients!

Paclitaxel side effects

Bone marrow depression

Bleomycin side effects

Pulm fibrosis

Rubicin side effects


Vincristine side effects

Peripheral neuropathy

Sertoli-Leydig cell tumors make up how many ovarian tumors


Histologically they resemble fetal testes, must be differentiated from adrenal tumors which can also produce androgens.

Tumors with excessive estrogen production

Theca cell tumors.

Excessive estrogen production due to theca cell tumors or granulosas may manifest how

Pseudoprecocious puberty
Postmenopausal bleeding
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


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


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


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
Serum progesterone in the luteal phase --> one of the best >10

Way to test ovarian reserve

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

Tubal disease - top
Ovulatory problems - top
Cervical factors

Top causes of male infertility

Unexplained and varicocele - top
Testicular failure

Conditions that warrant earlier medical intervrention, history of

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


Low motility


Poor morphology

Intracystoplasmic sperm injection



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

Weight loss
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

hMG injections


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)
Visual changes
Breast tenderness.

How many cycles of Clomid


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


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
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
Tubal scarring

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