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Women's Health
CM-III
| Question | Answer |
|---|---|
| Introduction to Women’s Health | |
| Skene glands | lesser vestibular glands or periurethral glands |
| Bartholin glands | secrete mucus for vaginal lubrication |
| What is all included in the vulva | labia majora and minora, clitoris, vestibule, glands |
| Connective tissue that partially covers the vaginal opening | hymen |
| Pelvic floor includes what | musculature, fascia, urogenital diaphragm, ligaments, vasculature |
| Glands for sexual lubrication | skene glands and barthololin glands |
| Pelvic inlet and outlet | from top down is inlet, bottom up is outlet |
| Junction between the different cells lines between internal and external cervix | squamr-columnar junction |
| Transformation zone of the cervix | distance the squamar-columnar junction moves during life that his ↑ predisposition for cervical cancer cells |
| 3 parts of the uterus | endometrious (sluffs), myometrium (muscle), perimetrium |
| Broad ligament | divides the pelvis anteriorly and posteriously, hold other structures to uterus |
| Round ligament | connects uterus to groin, ↑ pain in pregnancy |
| Parts of the fallopian tubes | infundibulum, ampulla, isthmus |
| Gonads | overies and oocytes :7th week gestation: mesoderm |
| Comes from mullerian ducts during development | fallopian tubes, uterus, and upper vagina: 12th week, mesoderm |
| Forms external genitalia and lower vagina | endoderm, 12 weeks |
| How do females differentiate in to females | in the absence of androgens (wolfian ducts regress) |
| Primary sex cords | become overies |
| Urogenital sinus becomes | lower vagina and external structures: labia majora/minora, clitoris |
| Congenital adrenal hyperplasia | ↑↑ androgens in females, virulization, ambiguous genitalia |
| Turner syndrome | XO |
| Failed menses at puberty DDx | imperforated hymen |
| Transverse vaginal septum | urogenital septum didn’t dissolve at fusion |
| How does agenesis of lower vagina occur | two don’e fuse at all (mullarian ducts and urogenital sinus) |
| How can we get a bicornate uterus/2uterus/2 cervix | the two mullerian ducts didn’t fuse at all |
| Possible physical internal affects of XO | ↓ ovarian follicles ᴓ gonadal sex hormones, 1 ammenoria, delayed puberty |
| External physical differences | small stature, coarctof aorta, ↓ breasts, widely spaced nipples, mulptiple pigmented nevi, renal anomalies, liver dysfx |
| Why do we need estrogen replacement for XO | osteoporosis risk! |
| If we give estrogens, what else should we give | progestions: endometrial protection from cancer/overgrowth |
| At birth what are the reproductive organs | 2 overies, 1 uterus, 1 cervix, 1 vagina |
| Birth how many oocytes | 1mil, puberty 400,000 35 100,000 |
| Menarche | first menstral cycle ~12yo |
| Hypo-pit axis | GnRH→LH and FSH |
| Gonoadogropins | leutinizing hormone, follical stimulating hormone |
| Sex hormones | estrogen, progesterone, inhibin, activin, follistatin |
| Follicular phase starts when | 1st day of mensus, ends at LH surge/ovulation. Varies but on ave 14 d |
| Fxns of estradiol | estrogen (maintains the endometrium |
| Body temp raises when | at ovulation |
| What causes ovulation | LH surge |
| What causes the LH surge | estrogen: -FB on LH as it continues to rise then hits a critical level and causes a LH surge→ovulation |
| Two phases of cycle | follicular phase: proliferative phase, leuteal phase: secretory phase |
| Nl reproductive cycle | <23or >35 days is abno |
| What does progesterone do and where does it come from | produced by corpus leutum of the follical, comes from placenta after 9-10weeks |
| What does follical become at leuteal phase | corpus leutium |
| Fxn progesterone in LP | suppresses FSH and LH from pit |
| Where does hCG come from | human chorionic gonadotropin: released from zygote, |
| Withdrawal of progesterions | results in ↑ FSH to begin new cycle |
| What causes abd cramps | prostaglandins from secretory endometrium produce contractions |
| How is the endometrioum at ovulation | maximul thickeness: ready to implant |
| What happens when ᴓ progesterone | menstration occurs |
| Secondary amenorrhea | absence of menstration for 3-6m in menstruating female |
| Irregular menstral bleeding b/w cycles | metorrhagiia |
| Excessive menstral bleeding at regular intervals | menorrhagia |
| Frequent and excessive menstral bleeding | menometorrhagia |
| Frequent menstral bleed usually regular | polymenorrhea |
| Cause of anovulation | constant stimulateion with estrogen, |
| Male pattern hair growth | hirsutism |
| Masculization of a women | virilization |
| 3androgens | DHEA, androstenedione, testosterone |
| Main production sities above | adrenal glands, overies, extraglandular |
| Causes of ↑ androgens | PCOS, hormone secreting tumors, adrenal d/o |
| Infertility | |
| Infertility definition | no pregnancy after 1 yr of unprotected intercourse that is frequent enough but not too much |
| Peak fertility for a woman | before/at age 27 (then starts to ↓) |
| How often do men contribute to infertility | 40% of the time |
| Why is incidence of infertility ↑ | advanced maternal age is ↑ |
| Some causes of infertility | environment/occupational exposures, genital tract problems, leckof successful sexual iintercourse, ↓ number of sperm in seman |
| What are the 5 exceptions to evaluate infertility if <1yr of trying | >35, male factor infertility, pervous infection, dz, or surg, DES exposure, previous infertility work-up and desiring a 2nd child |
| 6 steps to successful reproduction | nl fxn egg, adequate number of sperm, nl transport for both, viable embryo is created, transport to uterus is nl, implantation is successful |
| What should we ask about their sexual hx | frequency/success, poristion/technique, correlation w/ ovulation, previous contraceptions, douches, lubricant use (some have spermicide) |
| Most important question for infertility eval | menstrual cycles and pattern (others: previous pregs, premenstrual sxs?, time of puberty/mencarche, prior STIs) |
| PMhx ?s | abd surgeries, herbal, rx, OTC use, H/o endocrine disorders |
| SHx ?s | Too much exercise? Sleep, diet, smoking (can ↓ sperm), marijuana and cocain ↓ fertility, work, DES usuage, stress, multiple abortions |
| What would indicate prolactin problems | excessive hair growth, breast discharge, wt change |
| Chronic fatigue sxs | ↓testosterone→↓ energy and libido |
| Signs of female virilism | acne, oily skin, pigmentation, hirsutism. Thyroid enlargement, galactorrhea, abd striae, surg scars |
| What signifies healthy estrogen levels | pink, moist, rugated vaginal mucosa |
| PE | pelvic: quality/quanity of cervical mucus, look for masses mobility of cervix, tenderness, size, contue |
| GU exam for males | look for hypospadias, cryptorchidism, varicocele, hydrocele (last two effect sperm regeneration) |
| 4 ways to prove oculation | Hx, ovulation predictor kits, basal body temp, progesterone challenge |
| When do you take temp for basal body temp | right away in the morning prior to rising |
| Temp during follicular phase | <98, some might experience quick drop at ovulation (d13-14) |
| How often should intercourse be | every 36-48 hrs (to produce enough sperm) |
| When is ideal time for intercourse | 3-4days prior to temp increase-2-3days after rise |
| What is a progesterone challenge | if estrogen levels are appropriate and outflow tract is nl, after 10mg medroxy-progesterone acetate PO bid 5-10d, bleeding should occur withn 1 week ᴓ the progesterone |
| If successful what is MC cause of anovulation | PCOS |
| If ᴓ bleeding occurs what do we do next | check ovulatory hormones: LH ↑, do CT/MRI of pituitary, LH nl: do FSH, if FSH↑ means primary ovarian failure, FSH nl: hypothalamic-pit vs. outflow d/o |
| What makes a good sperm sample | 48-72 hrs from last intercourse, kept at body tem and to lab w/I 1hr of ejaculation, lab has to be experienced |
| Nl values of semen | 1.5-5ml, →7.2 pH, >20mil/mL sperm, |
| What is the motility of the sperm | > 50% with >25% forward progression, >30% nl morphonlogy |
| WBC levels in sperm | <1mil/mL |
| Length of sperm production | ~70days, so if tx done, don’t recheck count for at least 70d |
| 6 tests to check sperm/egg environment | vaginal cultures, pelvic US, endometrial Bx, laparoscopy, Hysterosalpingography (contrast), postcoital test |
| 4 diseases to be detected in vag culture | bacterial vaginosis, yeast vaginitis, gonorrhea, chlamydia, |
| Anatomical abnl | detected w/ US, fibroids, T-shaped uterus, ovarian cysts, thickening of endometrial lining? |
| When do we do endometrial Bx | 2-3d b4 menses, |
| What indicates luteal phase insufficiency | endometrium that lags behind cycle dates |
| Why do we do a laparoscopy | identify adhesions, endometriosis, structural probs |
| Hysterosalpingography | contrast die that tests patency of uterine and fallopian structures, done 3-6d post menses |
| Huhner’s test | postcoital test, 1-3d prior to ovulation, examin mucus 2-12hr post intercourse, (not common) |
| Clomiphene citrate | antiestrogenic drug, ↓ estrogen→↑LH and FSH→↑maturation and release of egg, may cause several mature eggs→ multiple births, 10% chance of twins at lowest dose |
| Dose of clommphene citrate | 50mg PO qd x5d’s ↑ if ovulation doesn’t happen |
| hCG IM fxn | triggers ovulation: mimics LH surge, stimulates egg release ~24-36hrs |
| progesterone tx | stops growth of endometrium and prepares for implantation, 7-10days |
| referrals | OBGYN, infertility specialist, reproductive endocrinologist, urologist, counseling, adoption agencies |
| 4 psychosocial needs of the couple | counseling, financial, adoption, miscarriage/stillbirth |
| 4 reproductive techonogies | AI, IVG, GIFT, TET |
| AI | collection of sement and in clinic w/I 20mins, washed and placed into uterus via catheter |
| MC reproductive technology | IVF: 99%, very expensive, |
| GIFT | gamete intra-fallopian transfer, both egg and sperm in uterine tube by laparoscopy, more invasive IVF, |
| TET | tubal embryo transfer, IVF of embryo per laparscopy |
| Vaginal neoplasms | |
| Epidemiology of vaginal neoplasms | rare: typically from spread from another primary site: cervical or other GYN |
| Cell types of vaginal neoplasm | squamous, adenocarcinoma, melanoma |
| S/S vaginal cancer | often asymptomatic, some may bleed b/w periods, |
| Dx/detection of vaginal cancers | palpation and by pelvic exams, make sure to look at vaginal cuff in women w/ a hysterectomy, not: usually red/ white/ or ulcerated lesions |
| Dx of vaginal cancer | pap, colposcopy, bx |
| Tx vaginal cancer | radiation, radical hysterectomy, upper vaginectomy, pelvic lymphadenctomy |
| Radical hysterectomy | uterus and cervix |
| Precancerous cells in the vagina | VAIN: vaginal intraepithelial neoplasia, I: HPV infection, watchful waiting, II: and III: carcinoma in-situ, |
| Tx VAIN II or III | ablation, laser, chemical/excision |
| CIN | cervical intraepithelial neoplasia: precursor lesions |
| Types of cervical cancer | SCC< adenocarcinoma, adenosqumous carcinoma |
| Benign cervical tumors | nabothian cysts: squamous cells cover columnar cells which continue to secrete mucoid material: benign no tx |
| Etiology and timing of polyps | unknown, develop in reproductive years, especially after 40 |
| Polyp characteristics | tear-shpaed structures appear red/puple/flesh colored, look succulent and glistening |
| Tx of polyps | twist them off, typically not painful |
| Precursor lesions for cervical cancer | HPV and CIN |
| Screening for cervical cancer | pap test |
| Goals of pap test | papanicolau: identify abnl cells from transformation zone |
| Conventional pap | cells sampled w/ a stick and applied to a clear slide |
| Liquid-based cytology | cells are suspended in liquid medium plated on slide n lab |
| Advantages for LBC | fewer unsatisfactory slides and opportunity for further eval (HPV) |
| Pap test | cells collected from SCJ and transformation zone |
| Reporting system for pap smears | Bethesda system nl: “negative for intraepithelial lesion or malignancy |
| 4 classifications of the squamous cell abnls of the Bethesda sxs | ASC-US: atypical squamous cells-undertermine significance, ASC-High grade squamous epithelial lesion, LSILs, HSILs |
| 2 reports of Bethesda of glandular cell abnl | AGC, and AIS: endocervical adenocarcinoma in situ |
| ~pap recommendations | 1st 21, 21-65 every 3 yrs if not High risk, 30-65 can go 5 yrs if not abnl, >65 can stop depending on situation |
| Ave age of DES exposure cancer | 19yo rare over 35 |
| Recommendations for pap of immunodepressed | onset of sexual activity |
| What makes dysplastic tissue visable | acidic solutions (vinegar) |
| Microscopic guided eval w/ bx and endocervical curettage | colposcopy |
| Precursor to cervical carcinoma | HPV MC 16, 18, 31-45 |
| RF’s of HPV | multiple sex parners, age 1st intercourse, smoking, immunocomprimised |
| Can HPV alone be used for cervical cancer screening | no |
| Two vaccines | Gardisil, 6, 11,, 16, 18 and Cervarix 16 and 18, 11y.o to 26 |
| When do we do colposcopy in adults | >ASC, |
| Tx for < 20yo, <HSIL and >HSIL | < repeat cytology 12m, > or equal, HSIL, colposcopy and HPV infx |
| Management of HSIL adults and <20 | A: immediate LEEP: loop electrosurgical excision procedure if ᴓ more kids… , <20: LEEP is unacceptable, colposcopic exam, conservatively aggressive |
| What is NOT done during pregnancy | endocervical curettage: can cause abortion, CIN 2 and 3 will do bx |
| LSIL | CIN I or mild dysplasia |
| HSIL | CIN II moderate dysplasia |
| CIN III | carcinoma in-situ |
| Tx for CIN II and III | ablative methods: cryo or laser, ecisional: cold knife, laser conization, LEEP (II& III exact same) |
| s/s cervical cancer | irregular/heavy vag bleeds, postcoital bleed, watery, mucoid, purulent and malodorous vaginal discharge |
| tx of cervical cancer | conization of cervix, hysterectomy, lymph node dissection, radiation therapy, chemo, brachytherapy |
| primary fallopian tube cancer | adenocarcinoma |
| where does secondary come from | ovaries, endometrium, GI tract, peritoneum, breast |
| sxs | postmenopausal bleeding, vag dc, pelvic pain, pelvic mass |
| tx | surg, chemo |
| uterine leiomyomas | uterine fibroids (MC pelvic tumors in women): benign |
| ↑ incidence | black women, at younger age w/ ↑ severity of sxs |
| 3 types of uterine leiomyomas | intramural: w/I muscular walls, subserosal: beneath uterine serosa, submucosal: just beneath endometrium |
| Bleeding patterns | heavy or prolonged (NOT intermensterual or postmenopausal) |
| Sxs | bleeding, pelvic pain/pressure, infertility |
| Dx | clinical, pelvic US, sonohysterography (saline w/ US) |
| Tx | reassurance, observation, progestion, GnRH agonist, myomectomy/hysterectomy |
| When do we worry about pregnancy problems | >3cm: tx analgesics, bed rest |
| Myomectomy | removal of fibroid tumors |
| Endometrial glands and stroma present within uterine musculature | adenomyosis |
| Sxs | bleeding and painful menstration |
| Dx | histalogical examination of a hysterectomy specimen, MRI best |
| Metrorrhagia | bleeding bw periods |
| Sxs endometrial polyps | metorrhagia, heavy, nl bimanual exam, typically benign |
| Dx | transvaginal US, sonohysterography, hysterectomy |
| Tx | polypectomy >1.5cm, multiply, trhough cervix, infertility ALLLLLL postmenopausal women |
| Endometrial hyperplasia | thick lining of uterus |
| Cause | chronic estrogen stimulation w/o progesterone (MC w/ hot flashes and forget progesterone) |
| When can this lead to | cancer, 4-10yrs |
| MC and most deadly | complex atypical hyperplasia |
| RFs | PCOS, nulliparity, late menopause, obesity, lynch syndrome, early menarche, UNOPPOSED ESTROGEN |
| Sxs | postmenopausal bleeding, abnl bleeding, abnl pap |
| Dx | bx and transvag US |
| Tx for Endometrial hyperlplasia | cyclic progestins: periodic endometrial sampling, 3/6/12months |
| Cytology | adenocarcomna, AGCs or endometrial cells, <4-5mm approaches 20mm HR |
| Tx endometrial cancer | hysterectomy, high-dose progestion, radiation/chemo in late |
| Ovarian Things | |
| Simple and unilocular cycts on the ovary | <10cm, “functional ovarian cysts” MC @ reproductive age |
| What is a follicular cyst | dominant follicle sometimes fails to ovulate and does not involute, when >3cm: follicular cysts (nl size 3-8cm but can be larger) |
| Sxs | secondary amenorrhea, abnl bleeding, pain?, palpable, tender pelvic mass, mobile |
| Dx | r/o pregnancy, US: white circle black on inside, |
| f/u | repeat pelvic in 6 weeks |
| corpus luteum cyst | CL persist when fertilization has not occurred |
| CP | delayed menses, prolonged luteal phase |
| Can a pt on OCP get CL cysts | no because ovulation does not occur |
| What ↑ chance of CL cysts | fertility drugs d/t ↑ follicles |
| Tx of CL cyst | nothing, will regress on own, recurrent tx w/ OCPs |
| Corpus hemorrhagicum | blood-filled corpus luteal cysts→severe pain and hemorrhage, reach 5-12cm, rupure in leuteal phase, |
| Tx | uncomplicated: outpt w/ analgesics, sxs go away on own, cyst reabsorb |
| US dx | thin walled w/ fibrin-strands or low-level echos (blood) |
| RF | bleeding condition: anticoagulation |
| Theca Lutein cyst | d/t overstimulation by beta-HCG, will regress when hCG levels fall |
| 3 Causes | molar pregnancy, multiple gestations, ↑FSH and LH w/ Clomid |
| US dx | bilateral ovarian enlargement w/ multiloculated cyst that can replace the ovary |
| Tx | regress spontaneously on its own |
| Ovarian germ cell tumor | Dermoid Cyst: or a mature teratoma 95% all ovarian teratomas rare for malignant transfer |
| Characteristics of dermoid cyst | tissue from all 3 embryonic layers, so will see skin, sebaceous glands, hair, bone, teeth |
| Dx of a dermoid cyst | US, XR (bone) |
| Tx of dermoid cyst | surgical excision, |
| Meigs syndrome | ovarian fibroma, ascietes, right pleural effusion |
| Endometrioma | ectopic endometrial tissue w/I ovary and will adhear to surrounding structures (peritenium, tubes, bowel) |
| Dx and Tx | US, histopathology, surgical removal for pain relief and prevent rupture |
| Mortality rate is highest in what GYN cancers | ovarian malignant neoplasm |
| Sxs | abd fullness/bloating, pelvic/abd pain, urinary symptoms, mass, |
| Dx is when | usually in late stages d/t no test and asymptomatic |
| Dx and Tx | US and histopathology, TAH-BSO: Total abdominal hysterectomy-bilateral salpingo-oophorectomy |
| RF for ovarian neoplasms | nullparity, white, endometriosis |
| Protection for ovarian neaplams | multiparity, breastfeeding, OCP use, tubal ligation |
| Test to monitor the cancer | CA-125 blood test (not diagnostic) and transvag US 6-12m |
| MC form ovarian cancer, RF | epithelia ovarian cancer, ovulation: causes repeated trauma and repair to ovarian epitheliam |
| Is there a precursor for EOC | no |
| MC EOC | serous cystadenocarcinoma 6th-7th decade of life |
| What may a dermoid cyst turn into | mucinous cystadenocarcinoma EOC rare tho |
| Two germ cell tumors | dysgerminoma, and immature teratoma unilateral oophorectomy on both |
| MC cause of ovarian torsion | cysts and neoplasms 94% |
| 3 things ↑ risk of ovarian torsion | ovarian cyst, neoplasm, pregnancy |
| Sxs | acute pelvic pain, N/V mass, |
| Dx and tx | U.S., Labs, lytes, surg tx to preserve fxn |
| TNM | tumor staging, T: tumor through organ or mets, N: lymph node involvement, M: distant metastasis |
| Vulvar Diseases | |
| Cardiovascular dz in women | |
| MC cause of morbidity and mortality in women | CVD |
| What is CVD | MI and stroke |
| CVD RF’s | Men>50 F>60, Fhx <50m <60 female, ↑LDL, ↓HDL, DM, HTN, physical inactivity, cigarette smoking, obesity |
| Strong predictor of mortality in women than men - ↓ HDL, DM, Smoking, ↑ systolic BP | |
| RF’s for women | preterm birth, small for gestational age, pregnancy complications: preeclampsia, gestational DM, |
| Facts about CVD in women | generally ↑ mortality w/ 1st MIs, Dx at advanced age, ↑ serious SE’s, |
| Typical MI pain | buring, heavy, sqeezing, substernal, w/activity, ST elevation, relieved by rest and nitro |
| Atypical MI pain | sharp/fleeing pan, prolonged and occur repeatedly, N/V/dyspnea, fatigue, left upper chest, abdomen back, arm, unrealated to exercise, nl EKG, not relieved by nitro |
| How often is CP atypical in women | >50% have atypical sxs of MI |
| When does incidence for CVD in women ↑ | after menopause |
| + of estrogen supplementation | ↓ LDL, lipoprotein a ↑ HDL, controls hot flashes |
| - of estrogen supplementation | thrombogenic, ↑ TGs, |
| Cardiac syndrome x | angina, abnl cardiac stress test, nl coronary angiogram, all other causes CP r/o |
| Description of cardiac syndrome x | lack of blood flow caused by microvascular dz and the enhanced pain perception |
| Two CP causes that respond to nitro | prinzmetal’s angina? And esophageal spasm |
| Do we treat CVD with estrogen due to its lipid effects | never, too many risks to the benefits |
| 5 main strategies for CVD prevention | ᴓ smoking, exercise, eat heart-healthy, healthy wt, BP, Chol, DM screening |
| How do we predict risk of a CVD event | Framingham Rsk score within 10 yrs |
| Risk levels | <10% low, intermediate 10-20% high >20% |
| When is there an automatic high risk category | M/W >70yo, DM |
| New risk calculation designed especially for women’s CHD risk | Reynolds risk score |
| What is CHD event | stroke, MI, or need of bypass or vascular surgery |
| Primary prevention | screen, use the framinham and Reynolds score to assess risks |
| Secondary prevention | once earlierst stages are recognized, treat early and aggressively; ASA/d, HTN, Dyslipid, Hyperglycemia tx, LIFESTYLE MODIFICATIONS!! |
| GXT | graded exercise test |
| Problems w/ GXT in women | less likely to achieve adequate HR response, |
| What may causes false + ST-segment depression? | estrogen replacement HRT |
| Diagnostic test for CHD in women | stress echo!! $$ but best for women, most cost-effective |
| Other test for CHD dx, limitations | thallium stress testing; breast tissue may lead to false + in women |
| Women presenting to ED w/ CP | more likely to get opiods and anzxiolytics than EKG and cardiac enzymes |
| HD is more common in | women, so maintain a high degree of suspicion |
| Women’s Health Exam | |
| Dyspareunia | pain w/ intercourse |
| DDx w/ oral/anal sex | gonorrhea of throat |
| OB ?’s | Gravidity: #pregnant and Parity: # generally >20-23 weeks gestational age |
| Why is nutrition and diet important | for menstration habits (↓ nutrition or ↑ exercise can ↓ periods and pregnancy) |
| PE | external, speculum: testing, bimanual |
| What position does the pt lay in | lithotomy (feet in stirrups, butt at edge of table) |
| External genitalia examination | mons pubis, labia, perineum/anus, labia minora, clitoris, vaginal opening |
| How do we asses sexual maturity | tanner stages |
| What do we do with the speculum prior to insertion | warm it, and use water as lube if possible, lube might interfere with tests |
| How do we insert the speculum | downward slope, closed and maybe angled, rotate to horizontal position |
| Prep for pap | obstain from anything per vagina 24hrs before pap, better if not bleeding but can still do it |
| 3 ways to obtain cervical sample | paddle, brush, broom and either do slide or liquid based cytology |
| Wet prep | use nl cotton swab, place in tube add nl saline: trichomonus, clue cells, eyast, (add KOH if needed) |
| Whiff test | smell for yeasty smell |
| Nl vaginal pH | 3.8-4.5 |
| Gonorrhea/chlamydia test | place probe in the cervical os for 10 sec, place in designated tube |
| What other way can we test for Gon/chlam | urine test, wait 1 hr after last urination, catch the first amount of urine |
| During bimanual exam what do you do with thumb | tuck it! Be mindfull of the clitoris |
| Steps to bimanual exam | two fingers, palpate and move cervix w/ two fingers, palpate uterus and two ovaries (typically can’t feel ovaries:nl |
| Adnexa | fallopian tubes and ovaries |
| Breast exam looking for what | pain, mass, discharge, |
| How do we inspect the breasts | arms at sides, above head, hands on hips, supine, leaning over |
| When start pap | 21 yo and breast exam, do every 3 yrs unless HR |
| When start mammograms | start at 40? >50 q2r |
| When stop pap and mammograms | 65-70? |
| Maternal-Fetal Physiology & Prenatal Care | |
| Ave lifespan of sperm | 300milion released, about 48hrs in the female body, sometimes longer |
| Fertilization occurs | in ampulla of fallopian tube |
| When is implantation | transport is 2-3 days and implantation 6-7d |
| Solid ball of cells formed by 16 or so blastomeres | Morula |
| Mature ovum, after fertilization in fallopian tbue | zygote |
| When morula reaches uterus, fluid-filled cavity, ready for implantation | blastocyst |
| Mitotic division of zygote gives rise to daughter cells called | blastomeres |
| Two cell types of zygote | inner: blastomeres become embryo, trophoblasts became placenta and fetal membrane |
| What cells of the trophoblast invade uterus | cytotrophoblasts, divide into chorionic villi of vasculature |
| Synctiotrophoblasts | surround chorionic villi, transport gases, nutrients, waste products and synthesize hormones |
| 2 fxns of the placenta | interface b/w mom and fetus, prevents rejection, metabolic (glycogen/cholesterol for energy and hormones, protein) and endocrine fxns (hCG, hPL(↑glucose to fetus), ILGF, progesterone, GS |
| Inner and outer layers of feltal membrane | amnion and chorion, |
| Embryonic period ends when | end of 7th week |
| Name for thing after 7th week | fetus |
| Conceptus | all tissue products of conception: embryo, fetus, fetal membranes, placenta |
| 4 weeks gestation is what in fetal age | 2 weeks, cell differentiation begins here |
| Outer layer | CNS, skin, hair |
| Middle Layer | skeleton, muscles, circulatory, kidneys, sex organs |
| Inner layer | respiratory and digestives systems |
| When are home pregnancy tests + | 4 weeks gestational age (2weeks fetal age) |
| How do we measure a fetus | w/ transvag US crown to rumb length at 6 weeks |
| When in fetus most susceptible to drugs | days 17-56 (8 weeks) |
| When are organs present | 12 weeks gestation , rates of miscarriage ↓↓↓ here |
| Development of bones and muscles, external parts | 16 weeks |
| When does nervous system start to fxn | 20 weeks, sex genitalia fully developed |
| What is first movement called | quickening, typically anywhere from 16-20weeks |
| When is a fetus “viable | 23 weeks, but MANY complications |
| When does a fetus begin resonding to movement (↑HR) | 24 weeks |
| What happens at 28 weeks | brain waves fxn lke full-term newborn, lungs continue developing |
| When are lungs viable | usually around 32-34 weeks, can give surfactant to ↑ development if needed |
| What happens at 32 weeks | a layer of fat begins to form, will gain more ½ wt b/w now and delivery |
| When do they switch to vertex position | 36 weeks, |
| Why do we get GERD, constipation, hemorrhoids | smooth muscle relaxation to prevent contractions, slows everything else down, and ↑ abd pressure for hemorrhoids |
| Why hyperemesis graviderum? Complications? | d/t hormones and unknown mechanisms, ketoneuria, electrolytes, |
| Tx for N/V | fluids if needed, ginger, B6, Zofran and unasom but try to refrain from meds |
| What happens in mom d/t ↑↑ O2 demands | hyperventilation, so low PCO2, but compensated by kidneys, ↑ respiratory drive and tidal vol |
| Cautions w/ dyspnea in pregnancy | common, but don’t forget PE, ↑ hormones and pressure of baby on IVC |
| What happens to mom’s heart | ↑ cardiac ouput, ↑ SV, HR, blood vol postpartum d/t fluid changes |
| Term used for uterus compressing on IVC while laying on back | supine hypotensive syndrome |
| What happens hematologically | anemia d/t ↑ plasma vol >↑ RBCs, also Na+ and H20 retention, often need iron supplementation 30-60mg/ vitamin, also: hypercoagulability state: note DVT/PE |
| Renal changes | ↑ urine output d/t fluctuating fluid levels, ↑ urinary stasis d/t sml muscle relaxation, so ↑ risk UTI and pyelonephritis, ↑ urgency d/t pressure, ↑ renal plasma flow |
| MS changes | ↑ wt 25-35 pounds, ↑ lumbardosis→pain, changes to pelvis and pubic symphasis, and SI joints, joint laxity, leg cramps |
| Skin changes | hyperemia of mucous membranes,→ epistaxis, gum bleeding, pigmentation, vascular distention, striae |
| Hyperemia | blood vessels move closer to outside tissue |
| Breast change s | growth and development, lactation d/t progesterone, oxytocin, prolactin, cholostrom production |
| Colostrum | first milk produced by mom high in nutrients and antibodies |
| Metabolic changes in mom | ↑ insulin resistance, ↑ protein demands |
| EDD | estimated delivery date, LMP + 7d -3m |
| Gestational age | age from 1st day LMP |
| G Ptpal | Gravida, Para: term, preterm, abortion, living |
| Size of uterus 6, 8, 10, 12,14, 16, 20 >20 | 6: pear, 8: tennis ball 10: softball 12: grape fruit 14: cantaloupe, 16 ½ b/w pubic sympahsis and umbilicus, 20 umbilicus >20 grows1 cm/ week |
| Chadwick’s sign | bluish discoloration of the cervix, vagina, and labia caused by the hormone estrogen which results in venous congestion. It can be observed as early as 6-8 weeks after conception[1], and its presence is an early sign of pregnancy |
| Two probs w/ Rh factor | hemolytic anemia of newborn, erythroblastosis fetalis |
| Tx for Rh + baby and Rh – mommy | Rhogam anti-D immune globulin at 28 weeks and postpartum or any special trauma or puncture of uterus |
| MC trisomy and tests for it | Down syndrome Trisomy 21: 9-13 weeks, Nuchal translucency (fat), PAPP-A, 15-18: AFP, inhibin A, chorionic vlillous smples <15 >15 amniocentesis |
| At risk individuals for cystic fibrosis | Ashkenazi jewish, northern Europeans, |
| When do we do transvag US at first visit | when don’t know LMP, less accurate the older the fetus |
| Increased diet calories | 100-300 kCal/day |
| Common sxs of pregnancy | N/V heartburn, constipation, urinary frequency, round ligament pain, backache |
| What analgesics are no good | NSAIDS!!! |
| Appointments | q4weeks until 28-32 then q 2 weeks until 36 weeks, weekly until delivery |
| When do we hear fetal heart beats | between 9-12 weeks |
| Fundal height | pubic symphysis to fundus, correlates w/ date pregnancy |
| Causes of size/dates: fundal ht 3 cm > gestational age | macrosomia: big baby, polyhydramnios: excessive amniotic fluid risk for delivery complications |
| Size < dates <3cm of dates | intrauterine growth restriction: many causes, karyotypic, hx FGR, placental abnl, maternal medical d/o ↓ BF |
| When is universal screening for gestational DM | 24-28 weeks, 1 hr oral glucose tolerance test? 50gm >130 post hr |
| Complications of DM in pregnancy | preeclampsia, polyhydramnios, fetal macrosomnia, birth trauma |
| Common vaginal infection and when do we test | week 35-37 group B hemolytic strep: can cause preterm labor, rupture membranes, GBS pneumonia in baby, tx w/ IV penicillin intrapartum |
| Blood tests | anemia at 24-28 weeks, and recheck Rh: give rhogam at 28 if needed |
| Down syndrome tests | 11-13 nuchal translucency, 15-18 quadruple test, neural tube defects |
| Quickening detection | 17-20 weeks 10kicks over 2hrs is nl↓ fetal movement → hypoxia |
| Non stress test | 26-28 weeks, cardiotocgraphic method for fetal hypoxia, 2 or more accelerations in a 20 min period is reactive , > 15 bpm, for >15sec reactive? Odds very good live next 7d |
| 5 comps needed for biophysical profile | reactive NST, 1 episode fetal breathing movements lasting 30s, 3 limb movements,, 1 extremety extension + open/close hand, max vertical AF pocket > 2cm each given 2 pts |
| AFI | amniotic fluid index, bestpredictor of uteroplacental sufficiency |
| Oligohydramnios or polyhydramnios | to high, too low |
| Pt ed at each visit | advice for healthy pregnancy, what toexpect b4 next visit, testing next visit, warning signs @ appropriate gestational age early: pelvic pain, cramping Later: early contractions |
| 1st trimester education | flu vaccine, ᴓ smoking, drugs, alcohol, domestic violence, seat belt use, childbirth class |
| 2nd trimester education | when to call: vag bleeding, leakage of fluid, contractions, signs preterm labor, ↓ fetal activity |
| 3rd trimester education | contractions every 5 minfor at least 1 hr, rupture of membranes |
| Can we recommend for circumcision | no at discretion of parents |
| 1st breastfeeding | 2-4 hrs of delivery, do it every 1-3 hrs to start |
| Postterm pregnancy | >42 weeks, usually induce >41 to prevent perinatal mortality |
| Trimester lengths | 1st: 1-12 weeks 2nd 13-end 27weeks, 3rd: 28 to labor |
| Pregnancy Loss and Ectopic Preganncy | |
| Pregnancy that ends spontaneously before the fetus reaches a viable gestational age | spontaneous abortion: expulsion or extraction of embryo or fetus weighing < 500gm |
| What is nl bleeding in pregnancy | ~20% has bleeding, for ½ day is nl, |
| When are 80% of abortions | first 12 weeks |
| When does spontaneous abortion risk ↓ | once a fetal heartbeat is found on US, ↓ by 50% |
| Known risk for spontaneous abortion | age, previous SAb, smoking, BMI <18.5/ or >25/m2 |
| Potential risks | alcohol, NSAIDS, caffeine, Fever >100F |
| MC cause of spontaneious | chromosomal abnormalities 50% |
| When do most SAs occur | before 8 weeks 2/3, |
| Most common chromosoman abnormalities | trisomies (16MC), monosomy X, polyploidies, Other |
| Common causes of SAs | Chromosomal abnl, congenital anomalies, teratogens, trauma, host factors, acute maternal infxs, hypercoagulable states, abnl immune sxs |
| Common teratogens | DM w/ poor glycemic control, isotretinoin, physical stress: fever, mercury |
| s/s | vaginal bleeding, pelvic pain/cramping, uterus: appropriate size, consistency, tenderness |
| Threatened abortion | vaginal bleeding through a closed cervical os, pregnancy may still be viable: usually painless, |
| Tx of TA | serum hcg, detect fetal heartbeat |
| How do we know that fetus is nl with hCG | doubles in 48 hrs in no, if hCG ↑ less than doubles, then problem w/ pregnancy |
| Expectant management | <13 weeks, stable no evidence of infection, aka watchful waiting, tx w/ NSAIDS |
| Surgical management | D&E, dilation and evacuation (suction) |
| Inevitable abortion | SA is imminent, bleeding, pelvic cramping, cervical os open, gestational contents +/- be visable, |
| Tx for IA | Expectant management |
| Complete abortion | entire contents of uterus is expelled, Common <12 weeks, minimal bleeding, mild cramping cervical os closed, uterus is small and contracted |
| Tx for CA | confirm passing of products of conception, expectant management |
| Incomplete abortion | abortion w/ retained products, common >12 weeks, heavy bleeding, cervical os open, severe pain, retain products, uterus not well contracted |
| Tx for IA | surgical management |
| Missed abortion | retention of a failed intrauterine pregnancy, ᴓ pregnancy sxs, mild bleeding, os is closed, ᴓ products visable, small for gestational age |
| Tx for MA | surgical management can lead to septic abortion |
| Septic abortion | SA complicated by uterine infx: common S. aureus, gram – bacilli, |
| Risks for septic abortion | invasive procedures (illegal abortion), foreign bodies, incomplete/illegal abortion |
| Sxs for septic abortion | s/s of abortion: uterus tender and boggy, fever, chills, tachy, discharge, peritonitis, septicemia |
| Sepsis signs | Body temperature < 36 °C (96.8 °F) or > 38 °C (100.4 °F) (hypothermia or fever). Heart rate > 90 beats per minute. Respiratory rate > 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg (4.3 kPa) (tachypnea or hypocapnia due to hyperventila |
| Tx for Septic abortion | stabilize pt, blood and endometrial cultures, broad spectrum abx: clinda, gentamicin +/- |
| How do we evaluate SAs | LMP: confirm pregnancy, dating, S/S of SA and signs of sepsis, look for source of bleeding, characteristics of uterise, abd, hcg, TV US, RH incompatibility |
| Ddx | physiologic, ectopic, cervical/vaginal/uterine pathology, |
| Recommendations post surgical evacuation | pelvic rest x2 weeks, ᴓ sex, avoid pregnancy x 6m, call if changes: |
| Reasons to call after an abortion | heavy bleeding, vag discharge, fever |
| Classifications for recurrent pregnancy loss | 3 or more before 20 weeks |
| Causes for recurrent pregnancy loss | uterine anomalies, chromosomal, endocrine, immunologic, hematologic |
| Common early causes of PL | chromosome, endocrine |
| Later causes of PL | anatomical, immunologic, |
| Cause of Intrauterine growth restriction | High altitudes, Multiple pregnancy (twins, triplets, etc.), Placenta problems, Preeclampsia or eclampsia |
| Maternal causes of IUGR | Alcohol abuse, Clotting disorders, Drug addiction, High blood pressure or heart disease, Kidney disease, Poor nutrition, Smoking |
| Elective abortion | termination of pregnancy before fetal viability, |
| Therapeutic abortion | termination before fetal viability for purpose of safeguarding mother’s health |
| ACOG exceptions to abortion | therapeutic abortion, and when pregnancy is from rape or incest |
| Medical abortion | <9w meds: mifepristone, methotrexate, misoprostol, surg if not successful |
| Ectopic pregnancy | implantation anywhere outside of the uterus |
| When must we rule this out | in any women of reproductive age with abd/pelvic pain or irregular bleeding |
| Leading COD in mom in 1st trimmest | hemorrhage from ectopic pregnancy |
| Ectopic pregnancy risks | PID, previous ectopic, >35yo, h/o abd or pelvic surgeries, IUD (during pregnancy), DES |
| S/s of ectopic pregnancy | abd pain, abnl uterilne bleeding, amenorrhea, preg sxs, dizziness, SHOCK |
| PE of EP | abd tenderness, peritoneal signs, adnexal tenderness, CMT, adnexal mass, uterus is nl size |
| Adnexal tenderness | pain from ovary and fallopian tube |
| Tests for EP | TVUS, pregnancy tests: follow hCG: discriminatory zone, CBC: infx and hemorrhage |
| Discriminatory zone | hCG >1500-2000 IU/L TVS to see where fetus is, follow pregnancy if can’t visualize, if ↑↑ ectopic is dx, ↓↓ follow to 0, <1500 IU/L follow hCG to 0 if ↓, slow rise: abnl pregnancy |
| Tx | expexectant management, risk of rupture/ severe hemorrhage, medical therapy: methotrexate, surgical management (preferred) |
| Complications of Pregnancy | |
| Abnormal location of the placenta over/close to cervical os | placenta previa |
| When is placental previa usually dx | 16-20weeks, bleeding around 29-30 weeks, |
| Dx of placental previa | US, frequently seen on 2nd trimester US |
| Tx of placental previa | expectant management (depending on mom), scheduled C section, serial USs, |
| Premature separation of the normally implanted placenta from the uterine wall | placental abruption |
| Risks for placental abruption | maternal HTN, distention of uterus, tumor or anomaly, previous, cocain, alcohol, cigaretts?, trauma |
| Dx for placental abruption | vag bleed, uterus painful to touch, tense, uterine contractions, painful, US to r/o placenta previa |
| Maternal complications | hypovolemia, hemorrhage, DIC, multisystem organ failure, death |
| Fetal complications | IUGR, hypoxemia, preterm, death |
| Tx for placental abrubption | hemodynamic stabilization, delivery (>34 weeks) expectant if <34, |
| Types of HTN issues in pregnancy | gestiational hypetension, preeclampsia, eclampsia, HEELP |
| s/s of HTN | visual changes, HA, RUQ pain, LOC or sz’s N/V jaundice, SOB |
| labs of HTN | CBC, UA, 24 hr collection (creatnine level) LFTs uric acid level, LDH, blood smear |
| tx for HTN | labetalol, nifedipine, sz prophalaxis: magnesium sulfate, monitor baby, c-section if needed |
| Gestational HTN | HTN developing after 20th week of pregnancy |
| Preeclampsia | HTN induced by pregnancy with proteinuria (140/OR90) AND >300mg proteinuria in 24 hr specimine or spot prot;cret <0.2 |
| Severe preeclampsia | 160/110, or >5grams in 24 hr and severe HTN signs |
| RFs for preeclampsia | nulliparity, >40yo, multiples, h/o, chronic HTN, chronic renal dz, large BMI, DM, |
| Tx for preeclampsia | biweekly BPs, periodic 24 hr creatning measurement, 2/week NST, weekly,US for fetal growth Q3-4 weeks, weekly labsmonitor for end organ damage, deliver 40 weeks |
| How do we prevent eclampsia | prevent sz’s with magnesium, calcium gluconate at bedside, lower BP w/ labetalol |
| Sequelae for mom and baby | mom: pulm edema, cerebral hemorrhage, hepatic failure, renal failure, death, baby: utero-placental insufficiency growth restriction oligohydraminos, preterm, death |
| What is eclampsia | preeclampsis + sz’s: 60-90s no respiratory effort, happens before and after birth |
| Tx for eclampsia | ABCs, Mg, and anti sz meds, |
| HEELP | Hemolysis, elevated, liver enzymes, low platelet coun: hemolytic anemia, |
| Oral Contraceptives | |
| Two ways to prevent contraception | prevent sperm to meet w/ ovum w/ barriers, and preventing ovulation, 2) prevent implantation into the uterus |
| Most popular method of reversible contraception in the U.S. | oral contraceptives |
| Effectiveness | 99.7 in first year with perfect use 93% with ave use |
| Types of OCPs | combination: estrogen and progestin, have monophasic-four phasic (no advantages), progestion only pills |
| ↓ and ↑of progestin only | ↓ STRICT adherence, less effective, irregular bleeding, ↑ for breastfeeding and estrogen CI or ↓ tolerated |
| Adhearance for progestin only | taking EVERY day within 3 hours of each dose! |
| MOA of estrogen | ↓ FSH, prevents development of follicle, potentiates progestin LH surge suppression, stabilizes endometrial lining |
| MOA of progestin | ↓ LH surge, prevents ovulation, thickening/impermeability of cervical mucus, atrophy of endometrium |
| *Advantages of combinations OCPs | effective, ↓ pregnancy-related dealths, (non-BC +s) better cycle control, ↓ iron def anemia, ↑ bone density, protection from ovarian/endometrial CA |
| *Disadvantages of OCPS | no STD protection, AE’s: ↑ risk VTE, stroke, BP, Se’s of estrogen, Dis, daily, >30$/m |
| Estrogen SE’s both ↓ and ↑ | ↓: mid-cycle breakthrough bleeding, ↑ spotting, hypomenorrhea, ↑: nausea, breast tenderness, melisma, HA, ↑ BP |
| Progestin SE’s ↓ and ↑ | ↓: late breakthrough bleeding, ↑ breast tenderness, HA, fatigue, mood changes |
| Androgen SE’s ↓ and ↑ | ↑: increased appetitie, wt gain, acne, oily skin, hirsutism, ↑ LDL, ↓ HDL |
| Two drugs with ↑↑ progestin and androgen hormone levels | levonorgestrel, and norgestrel |
| ↑↑ estrogen | ethynodil diacetate |
| Note about YAZ (drosperinone) | tx PMDD, but ↑ Na+ and H20 excretion→↑↑↑clots, and ↑ K+ |
| Note about SE’s | may be transient, usually d/c after 3m |
| When do we avoid low dose OCs | BMI >27.3 or wt 165 lbs, ↓ effectiveness in heavier pts? |
| Miss a dose | skip it, outweights getting too much, take another if pt vomits w/I an hour |
| DI’s w/ anticoags | can ↑ and ↓ levels |
| What drugs do OCPs ↑ dose | TCAs, BBs, CS, Theophylines, cyclosporine, selegline, benzos |
| What drugs can ↑ OCPs dose | atorvastatin |
| What can ↓ OCP dose | Abx ( penicillins, tetracyclines, griseofulvin), AEDs, HIV PIs, St John’s wort |
| CI for OCP use | any CAD risk MI, vascular issues, DM with issues, clotting d/os, Migrane w/ focal aura, heavy smokers (>15 cigs/day >35yo), uncontrolled HTN >160/90 |
| Caution for OCP use | RF’s for CVD, ↑ lipids, HTN hx, migrane w/o aura >35, postpartum <21days and not breastfeeding, light smokers, <15 cigs >35yo, hx breast CA, drugs that induce CYP 45-, gallbladder dz |
| 5 things to consider before OCP use | Age, smoking status, concomitant dz or conditions, precaustions, Dis |
| OCP for young, healthy pt | monophasic w/ IM estrogen: Ortho-cyclen, Sprintec |
| Acne | Ortho-Tricyclen, estrostep, Yax only |
| ↓ estrogen exposure | alesse, lessina |
| Breastfeeding or don’t want/can’t have estrogen | Micronor, Nor QD |
| PMS HA anemia, endometriosis | extended cycle, Seasonale |
| When do we start OCPs | Quick start, or Sunday start |
| 5 possible warning signs of serious trouble | ACHES abd pain, (gallpladder, liver, blood clot, pancreatitis) CP (PE/MI), HAs (severe)(CVA, HTN, migraine), eye problem, (CVA, HTN, temporary vascular prob severe leg pain (DVT) |
| Yearly PE | breast, BP pelvic, pap |
| Emergency contraception | ↑ dose of combined estrogen and progestin |
| 4 types of ECs | Plan B, Plan B one-step, Ella, Yuzpe method |
| Plan B | levonorgestrel, OTC >18yo, Rx <18 one dose right away, 2nd 12 horus later |
| Plan B one-step | OTC anyone < or equal 17 yo, two right away |
| Ella | ulpristal, blocks progesterone receptors, inhibits ovulation, and prevent implatantion |
| Yuzpe method | ↑↑ OCPs: Ovral 2 tabs, Nordette, levelen, 4 tabs, Levlit: 5 tabs |
| AEs | N/V use antiemetic w/ yuxpe method, others not bad, irregular bleeding 1 week before expected time |
| Effectiveness of ECs | 12-24hours best |
| Pregnancy Nutrition | |
| Folic Acid | take up to 1m before pregnancy ↓ NTD risk 50-70% dose: 1000ug/ 1mg |
| LBW effects | is taken for 66% perinatal mortality |
| Teen pregnancy assosciated conditions in pregnancy | LBW, IUGR, prematurity, infant death, mom death, PIH, anemia, ↓ nutrition, psych? |
| Risks of smoking | 25% LBW, IUGR, premature, post-delivery acute respiratory, asthma, SIDS |
| FAS | fetal alcohol syndrome >8drinks/day →3-5% infants but still known to have “fetal alcohol effects” |
| What is risky behavior | >7 dinks/week, or >3 in one occasion, recoomend no alcohol |
| 2 SHx concerns | safe place for baby? Have at least one person reliable for you and baby |
| Weight gain recommendations for pregnancy | underweight (<18.5) 30-40lbs, nl (18.5-24.9) 25-35, overweight (25-29.9) 15-25lbs, obese (>30) 11-20lbs |
| Should pts diet while pregnant | no. 30 min/day exercise/walking, |
| Cause of GDM | ↑ HcG and HCS (HPL) or human placental lactogen: ↑↑↑↑ anti-insulin and lipolytic, hepatic glucose leves are 30% higher despite insulin levesl |
| Dx GDM | >200 random or >126 fasting requires OGTT 75gm 2 hr 1: >180 2hr >153 |
| Repeat when | 6-12 week pp to r/o T2DM, do every 3 years after that |
| ↑ calorie intake w/ pregnancy | 100-300kcal/day more |
| Daily Ca+ folic acid, and Fe intake for pregnancy | Ca+: 100-1200mg, Folic acid: min 400ug-1mg, may need up to 4mg, iron: 27mg/day, RDA female is 18mg/day |
| 8 herbal remidies of concern | Echinacea, black cohosh, garlic and willow barks, ginko, licorice, ginseng, blue cohosh, pennyroyal |
| Minimal tx for morning sickness | small meals, dry foods, high protein foods, avoid high fat/spicy foods ginger may help?? |
| Hyperemesis gravida | <2% pregnancies, sever N/V, tx: pyridoxine (b6), doxylamine, sever: IV hydration or TPN |
| How do we avoid mercury intake | ᴓ shark, swordfish, tuna, (do use chunk light tuna) other fist >12 oz |
| Good fish choices | shrimp, canned tuna, salmon, Pollock, catfish, crab, tilapia (CHECK W/DNR) |
| Major bacteria in food to cause miscarriage | listerosis, |
| Where is listerosis founds | unpasteurized milk, soft cheeses, no hot dogs, deli meats, uncooked meats, poultry, shellfish |
| Sxs of listeriosis | fevers, chills, muscle aches, back pain, some no sxs at all. Tx w/ abx if suspect |
| Conspumtion of non food items: | pica, clay ice, laundry starch? |
| Menopause and Osteoporosis | |
| Menopausal transition | begins when menstrual cycle length is varied and serum FSH ↑ ends w/ final menstral period |
| What part of the menstrual cycle changes | follicular, luteal never really changes |
| Stage 2 or early menopause transition | when cycle length changes >7days from nl cycle (length of bleeding, short b/w periods, lenth between periods) |
| Stage 1 or late menopause transistion | >2skipped cycles w/amenorrhea >60days, |
| What starts to occur in stage 1 | hot flashes, sxs of hormone changes of FSH and estradiol |
| Menopause definition | >12m of amenorrhea immediately following last menstrural period |
| What can happened up until those 12 months | could still get pregnant! |
| What is occurring at menopause | no more estrogen from ovaries, no more maturation of the follicles, so no period |
| Ave age of menopause | 51 |
| Perimenopause | from when periods change till death, both transitional and actual menopause put together |
| Postmenopause | time after 12m from LMP |
| Stage +1 postmenopause | up to 5 years past menopause, ↑↑↑↑↑ bone loss |
| Stage + 2 postmenopuase | >5yr till death |
| Risk for early menopause | FH, Hispanic, smokers, ᴓ kids or have shorter cycle length |
| Menopause hormones | ↓ follicular number, ↓ estrogen (fluctuates), ↑ FSH, ↓ progesterone |
| Hormonal definition of menopause | FSH > 30mlU/ml |
| Pre and postmenopausal estradiol levels | pre: 30-400, post: 0-30pg/ml |
| What are menopausal sxs | d/t ↓ estrogen, hot flashes, vag dryness, genital tract atrophy, sleep disturbance, mood changes, skin, hair, nail changes |
| Bleeding changes | very heavy w/ clots, longer than nl, more often the every 3 weeks, after intercourse or b/w periods “anything can happen” |
| Hot flash characteristics | heat radiating from within, 2-4mins, red hot, sweath, then cold, d/t freezing can occur anywhere from 1-2/hour or day and MC sxs of menopause (ovarian failure of estrogen) |
| Atrophic vaginitis | epithelium thins, itching, burning, pale w/ lack of rugae, thinning to see vellels and petechial hemorrhages, ↑ risk of infection |
| Sxs of endometrial atrophy | postmenopausal spotting |
| Reasons for sex dysfx | atrophy, dryness, ↓ elasticity, length, width, pudendal neuropathy (clit and vulva), psych factors on body image |
| 3 main physical malformations w/ GU tract | cystocele, rectocele, uterine prolapse |
| Urinary tract sxs/issues | dysuria and frequency w/ cystocele, ↑ infx, urinary retention, stress incontinence ᴓ support urethrovesical jxn |
| Sxs cystocele | obstructive sxs, ↑UTIs, dx: take of top art of speculum, bear down, buldge will show in the introitis |
| Sxs of rectocele | same as above but w/ stool and bottom part of speculum removed |
| Sxs of uterine prolapse | B/B sxs both and typically managed by OBGYN or urology |
| Pessary | metal structure inserted holds up the tissues that support the uterus |
| When do menopausal sxs occur | vasomotor (hotflashes) earlier, UG (uterine prolapse later |
| Cause of mood changes in menopause | ↓ estrogen, sleep changes, stage of life psych stuff |
| What happens to skin, hair and nails | ↓ skin thickness, less elastic, hair loss, thin brittle nails, ↑ free testosterone: ↑ facial hair |
| Other possible changes | breast tenderness, menstrual Has worsing, bone density ↓ |
| Is FSH a steady decline | no it “sputters” usually don’t check until late or months of ammenorreagh |
| Ddx of menopausal signs | hypothyroidism, pregnancy, so do a UPT and TSH |
| When is an evaluation needed for menopause | postmenopausal bleeding and premature ovarian failure |
| Postmenopausal bleeding is what | cancer until proven otherwise, TV US, and endometrial Bx |
| Tx for bleeding | low dose HRT or intermittent progesterone |
| Premature ovarian failure | menopause <40yo, d/t: smoking, chemo, hysterectomy, low body weight |
| Menopause tx | HRT: estrogen oral or topical, lowest dose for shortest amount of time, lifestyle modifications: FANS, pharm: CAM |
| Tx for hot flashes | try to stay cool, fans, exercise, avoid alcohol, nicotine, caffeine, should meditae, relax, stress ↓ |
| Medicational tx for hot flashes | SSRI’s and SNRIs, Gabapentin, OTCs: plat soy estrogen, black cohosh, dong quanoi, evenng primrose, red clover ginseng, wild yam, vit E |
| What do we not use w/ bleeding | black cohosh |
| Tx for GU sxs and sleep issues | moisturizers, lube, sex: will ↑ blood flow, local estrogen: ring, sleep: Lunesta |
| Osteoporosis | ↓ bone mass with ↑ risk fracture |
| Fragility fracture | shouldn’t have occurred with the MOI that happened: fall of distance < person’s height |
| Estrogen def in women | primary OP type 1, ↑osteoclastic bone resorption, MC frx vertebrae, hip, distal radias (T11-L1) and T6-T9 |
| >75 yo, poo calcium absorption | Primary osteoporosis type II |
| MC fracture locations for Type II | hip and pelvis, gradual ↓ osteoblastic, and no ↑ osteoclastic |
| Bone is lost d/t other diseases | secondary osteoporosis |
| Bone mneral density is below nl | osteopenia: precursor to OP, Dectection is crucizl |
| 10yr PM, | 50% ofwhite women have osteopenia or osteoporosis |
| How many ppl of geriatric pop recover from hip frx | ~40% |
| Peak bone mass | age 30 |
| w/o estrogen | ↑ bone demineralization, ↑ resorption, ↓ formation (blastic) |
| perimenopausal transition reaction | resorption gradually > rate of formation |
| menopause | rapid acceleration in bone loss after first decade |
| non- modfiableRFs for OP | age, gender, race (white or Asian), Fhx: hip frx of parent |
| MC fracture sits | hip, back, forearm, humerous |
| Labs | CBC, serum Ca+, phos, lytes, creatnn, LFTs, vit D |
| Radiology | XR will show change in bone density of 30% loss |
| Thoracic vertebrae become wedge shaped and cause a curve in the spine | Dowager’s hump |
| Hight loss | up to 3 inches, more → investigate this |
| Screening recommendations | all over 65, or < 65 w/ 1 or more: smokes, h/o frx after menopause, BMI <21 or >27, hip frx of parents |
| How do we measure risk of fracture | FRAX fracture risk assessment model: estimates 10 year prob of hip frx or other osteoporotic frx for untreated pts b/w 40-90 |
| How do we screen | DEXA: dual-energy XR absorptiometry, or quant CT but ↑↑ radiation exposure |
| Where do they measure | hip, lumbar spine, wrist |
| How often | low risk 2-3 years, high risk yearly |
| Dexa scan interpretation | T score nl > -1 standard deviation osteopenia -1 to -2 SD osteoporosis < -2.5 or > -2.5+ fragility frx |
| Ca++ intake | 1200-1500mg/day but too much can cause kidney stones, |
| Vit D recommendation | 400-800 Iu/d (up to 2000) |
| Labor and Delivery | |
| Shortning and thinning of cervix | effacement |
| Dilation of the cervix | as it effaces, it dialates up to 10cm |
| When is post term | after 42 weeks |
| When do 85% go into labor | 37-42 weeks, go through with nl labor and delivery |
| Hormonal mechanisms in labor | ↑ prostaglandings from myometrium, ↑ oxytocin, ↑ estrogen, ↑ inhibitory mechanisms: progesterone |
| What is lightning | “baby drops” into the pelvis, may cause ↑ urination, easier to breath, feels like the baby is “lighter” |
| What is bloody show | as effacement and dilation occurs, cervix secretes a bloody mucus, typically right before or around delivery |
| What are adequate contractions preparing for labor | 3-5/10mins that are strong enough to take breath away/can’t speak |
| What would significant bleeding mean | placental problem |
| Two maternal vital signs we focus on | BP and temp |
| Eval for labor | identify complications in the past; DM, GBS, confirm gestational age, contraction hx, SROM, physical exam, fetal status, IV access, Labs |
| What labs would we order | CBC; infx and hgb, UA: infx and protein; preeclampsia, blood type |
| Leopold’s maneuver | four palpations through abdominal wall 1: what occupies fundus 2: identify small parts, 3: identify descent/presenting part, 4: identify cephalic prominence |
| What 3 things are we evaluating with plaption of uterus | Lie: longitudinal, transverse, oblique, Presentation: breech or cephalic/vertex Position: Right occiput anterior etc |
| How do we determne position | the occiput fontenal and then to the left or right, not turned? Then just “occiput anterior” |
| Assessment for the digital vaginal exam | effacement, dilation, position, consistency of cervix, fetal station |
| How do we document those three important parts | as just numbers dilation/effacement/station 5cm/50%/-3 |
| What defines stages of labor | dilation of cervix Stage 1: latent phase <3-4cm, active phase 3-10cm, stage 2: delivery-complete |
| Measurement of fetal station | -5cm- + 2 |
| What is the term when reach 0 station and where is this | when head reaches the level of ischial spines, now called engaged; rare to stop delivery now |
| Third stage of labor | delivery of placenta |
| 4th stage of labor | 2 hours postpartum |
| Where does stage 1 latent phase occur | most moms prefer to be at home, wait until 5mins apart, or powerful; can’t speak do things to be comfortable, warm bath, ambulation |
| Tips/things to do during active stage | frequent urination, fetal/maternal vital signs, pain management, iv access, pelvic exams, |
| How often are pelvic exams done | they are sterile, rare to do speculum exam; 1-4 hrs |
| Types of pain management | epidural block; intrathecal tube, continusous, blocks motor, slower effects, but constant, spinal anthestetic; injection, usually works faster, but wears off quicker too and may have ↑ perineal sensitivity (tear/suture), pudendal block, local anesthetic |
| How do we monitor contractions | external tocodynameter, intrauterine pressure catheter (IUPC) |
| Amniotomy | artificial rupture of membranes; use tiny hook |
| With fluid expulsion, what do we look for | meconium; nl but must observe baby better, blood, infection |
| Risks of AROM | infection, umbilical cord prolapse (head decends with cord in front of it) |
| Usual max of 2nd stage for nullip | 2-3 hours or until exhaustion |
| What is a trick to ↓ 2nd stage | delayed pushing; especially for nulliparity pt’s, start pushing when pt feels the urge to push |
| Alteration of fetal cranial bones as fetal head adjusts to bony pelvis | molding |
| Surgical incision through perineum to enlarge vagina and assist childbirth | episiotomy, don’t typically do this any more, if you do, do a medial/lateral incision, inferior; leads to tear to anus |
| NSVD | normal spontaneous vaginal deliver; head, anterior shoulder, posterior shoulder, body, clamp the umbilical cord, |
| How do we incuce placental dilvery | oxytocin |
| Signs of placental separation | uterus rises in abdomen, gush of blood, umbilical cord lenthens |
| What all needs to be in the placenta | two umbilical artieries, one vein, cotyledons, 2 intact membranes |
| Why do we give oxytocin | induce placental delivery, and induce uterine contractions, prevent uterine atony |
| When is the greatest risk of postpartum hemorrhage | 1 hrafter, inspect vag canal for lacs, repair if necessary |
| % of birth C/S | 30% |
| Risk of C/s | ↑ fetal and maternal mortality, longer recovery period, ↑ risk future pregnancies |
| Indications for c/s | failure to progress, ↓ fetal status, fetal malpresentation to vagina, maternal infxn, multiple gestations, fetal bleeding, mechanic obstruction |
| TOLAC and VBAC | Trial of labor after cesarean delivery, vaginal birth after c/s |
| Postpartum care | vitals, bleeding, uterus contracted, hemorrhage, infection, analgesia; apap ice |
| Lochia | changing of vaginal bleeding from red→brown→white discharge, |
| When can we insert IUD postpartum | 10 weeks, most moms start having sex before 6 week f/u, progestins OCP works best |
| Does breastfeeding prevent pregnancy | it may ↓ ovulation, but no guarantee, need to do alterior BC method |
| When do we start and how long breastfeed | immediate or 2-4 hrs post birth, for 4-6m. |
| When does mild come | usually 24-48hrs, collustrum present first: high in nutrients and abs for baby |
| Proper latch | most of areola and nippole in mouth, lips flared outward, no dimpling, |
| Breastfeeding adnvantages for mom | ↓ breast cancer, wt loss, attachment/bond, |
| Breastfeeding advantages for baby | immunity, ↓ allergies, ↓ DM, obesity, GI illness, ↓ hypercholestremia HTN |
| Postpartum blues | days to week postpartum |
| Postpartum depression | 1m delivery, not bodning, obsessional thoughts about harming self or baby |
| Uterus size at 2 and 6 weeks | 2: back in pelvis 6: nl size |
| When does ovulation occur | 4-5 weeks postpartum mean 10 weeks |
| Newborn baby care rating | apgar 1 & 5 mins Appearance, pulse, grimace, activity, color |
| 2 MC causes of preterm delivery | preterm labor, PPTROM |
| Define preterm labor | persistent uterine contractions with documented cervical change or cervical effacement < 37 weeks: assocated w/ ↑ infant mortality |
| Management for preterm delivery | < 32weeks, glucocorticoids: surfactant stimulation for lung development, tocolytics x 24-48 hours, labor/delivery?, >34weeks: labor and delivery |
| PPROM | preterm premature rupture of membranes |
| What do we need to do with PPROM | make sure it is actually amniotic fluid! Could be urine! Test with amnisure, or fetal fibronectin |
| Same management as preterm labor | 90% go into labor w/I 24 hours |
| Meds used for PROM | indomethacin for ductus areteriosis, Mg+ for eclampsia |
| When do we induce | labor does not start spontaneiously ~41-42 weeks, labor starts, but doesn’t progress |
| How do we know if an induction will work | Bishop score 0-3 45% will fail to deliver with nullip (8%), 4-6 10% (4%), 7-10 1.5% (1%) |
| 5 parts to the bishop score | dilation, effacement, station, consistency, position of baby head |
| Tx for an unfavorable cervix (bishop 5-6) | cervical ripening prior to induction, intravaginal prostaglandins |
| Favorable cervix tx | oxytocin, w or w/o amniotomy |
| Do we do elective inductions | no, but can do weekly striping of the membrane from the uterus |
| Failure to progress | no dilation, or descent of the fetus |
| Protracted labor | slow cervical change (1st stage), slowed descent of fetus (2nd stage) |
| Arrested labor | 1st: cervical change stops, 2nd: decent stops |
| 3 causes for failure to progress | power inadequate, passenger abnormality (position), passage abnormality (can’t get past pelvic bones) |
| 2 common causes for ↓ power | exhaustion, anesthesia |
| Abnl passenger | >4000-4500gm, fetal lie, presentation to cervix, position |
| Indications for C/S for 1st stage and 2nd stage | 1: ↓ fetal status, passenger abnl, passage inadequate, continued protraction despite oxytocin (2hrs), 2nd: nonreassuring fetal status, failure w/ conservative management |
| Shoulder dystocia and tx | ant should becomes impacted behind symphysis pubis, obsetetric Emergency!! “turtle sign” |
| Complications of shoulder dystocia | fracture clavicle or humerus, brachial plexus injury, hypoxic brain injury, dealth, mom: hemorrhage, 4th degree lacs |
| Tx of shoulder dystocia | stop pushing, ensure patient position (McRoberts maneuver), draining a bladder |
| 5 things to monitor for electronic fetal monitoring | contractions, baseline FHR, variability, accelerations, decelerations |
| Baseline, tach, and brady fetal HR | Base: 120-160 Tachy: >160 x 10 min, (maternal fever) brady <120 bpm x 10ming, (congenital heart block, severe fetal compromise) |
| Most reliable indicator of fetal status | variablility of HR: moderate is best: 6-25bpm, minimal <5, marked >25 |
| Causes for ↓ variability | fetal hypoxia, academia, drugs (maternal narcs), fetal tach, fetal CNS/cardiac anomalies, ↑ uterine contractions, prematurity, fetal sleep |
| Accerlerations | FHR above baseline >15bpm x 15-20s, nl and is a good sign |
| Early Decelerations | early (compared to contraction) or mirror contractions, may be d/t pressure on fetal head, nl |
| Variable decelerations, tx | slowing before/durng/after contractions, rapid fall in FHR <100 pbm for 30s, umbilical cord compression, tx: maternal postion change, |
| Late decelerations | slowing of FHR at end of contraction, ominous, dstress, signs of fetal hypoxia and academia |
| Cat I and III | I: nl FHR, observe 110-160 HR, mod baseline, FHR accelerations III: recurrent late declerations, mild variability, brady, sinusoidal pattern, deliver within 30mins |
| Cat II | 70% deliveries, and no criteria, doesn’t fit the others. |
| Tx for nonreassuring stress | d/x oxytocin, maternal O2, tx HOTN w/ IV fluids/pressur, change maternal position, operative vag deliver, C/S |
| What does the breast all consist of | skin and fat mostly, fibroglandular tissue, nipple and areola |
| What is fibroglandular tissue | connective tissue that makes up lobules and ducts, significant ↓ after menopause d/t ↓ hormone stimulation |
| What are the margins of the breast | infraclavicular to inframammary fold, from the sternum to the lat dorsi or axilla |
| What is the breast loosely attached to | a thin membrane called the pectoralis fascia, thin but separates breast from chest wall |
| What is the lymphatic drainage of the breast? | 97% axillary, 3% inframammary rarely supraclavicular |
| What extra landmarks can be seen on the breast and around it | extra nipples, and breast tissue anywhere along the margins of the breast |
| 5 things to examine on PE | overall shape/symmetry, lumps/bumps, discharge, skin changes with hands over head, leaning forward, etc, check lymph nodes |
| 5 skin changes | dimpling, retraction of nipple, erythema, crusting of the nipple, peau d’ orange (inflammatory breast CA) |
| Diagnostic tests for lumps of the breast | mammagram (>30) <30 US d/t dense breast tissue, |
| Possible findings of the radiologic imaging tests and tx | cystic: aspirate or observe, solid: require biopsy, nl tissue: bx based on clinical findings or monitor |
| Screening recommendations for breast CA | >40 yearly mammagram. If ↓↓↓↓↓↓ risk can maybe do e/o year, if ↑↑↑↑↑ Risk? Start 10 years earlier |
| If suspicious on a screening mammogram then what | a diagnostic mammogram, magnifies the view and changes the tissue orientation |
| Use of US | primary Dx in pts <30 or adjuvant in regular patients |
| What do we do w/ abnl mamms or US | f/u w/ bx either stereotactic or wire-localized excisional bx |
| When do we do MRI | ↑↑↑ risk pt’s previous CA, dense breasts, FHx, evaluate other breast |
| Benign histalogical findings | fibrofatty tissue and fibrocystic change, fibroadenoma, simple cysts, phyllodes tumors |
| Examples of fibrocystic chage | fibrosis, cysts, hyperplasia, metaplasia, adenosis |
| Cystosarcoma, can be low-grade malignant | phyllodes tumors |
| What is a precursor to invasive carcinoma | atypical hyperplasia |
| What % of women who get breast cancer have a Fhx | only 15% |
| Risk of breast cancer increases with what | age! |
| RF’s for breast CA | Early menarche/late menopause/nulliparity/1st birth after 30, FHx, atypical hyperplasia, LCIS, BRCA1&2, h/o colon, uterus, ovarian CA, HRT, radiation |
| Removing a piece of suspicious mass for dx only | incisional bx |
| Excising a mass completely for dx with clear margins | excisional bx |
| If comes back cancerous then what is the term | lumpectomy |
| Lumpectomy | reserved for the term for cancers, excision of mass an nl surrounding tissue “partial mastectomy” |
| Tx post lumpectomy | radiation to ↓ risk of recurrence (usually day surgery back to work in 1 day or 2) |
| Mastectomy | excision of breast tissue,pectoralis fascia, overlying skin (nipple and areolar) |
| Modified radical mastectomy (MRM) | includes axillary lymph nodes |
| Sentinel lymph node bx | great technique, inject dye into lesion, watch where the dye goes, remove those lymph nodes plus a few more, typically for staging |
| What happens if we remove all the lymph nodes in 1 arm | very debilitating, ↑↑↑ lymphedema in the arm, usually do 1,2,3 arms |
| Cancer classification | TMN T: size N: nodes (1-4) M: distal metastasis |
| When is chemo recommended | >2cm or >1cm premenopausal, |
| Chemo drugs | AC (Adriamycin/cyclophosphamide) 4 cycles, |
| When in taxol added, SE’s | lymph nodes or poor prognostic tumor (bone pain, muscle pain, neuopathies) SUCKS |
| When do we use Herceptin | adjuvant therapy w/ Her2 positive (control cell growh, typically fast growing cells, attacks those!) IV 1/week for 1 year |
| AEHT | tamoxifen: competitive inhibitor of estrogen receptors, stops cancer cells from getting the estrogen |
| AE’s of tamoxifen | uterine CA, thrombotic events, hot flahes, wt gain |
| When do oncotype Dx | if ER + or Her2 -, otherwise if ER – and Her2+ automatically in HR and tx aggressively |
| Radiation indication | all undergoing lumpectomy, or tumors >4cm, chest wall involvement, >4 axillary lymph nodes |
| Stage 0 (dcis tx) | AEHT? |
| Stage I | premonopauseal: chemo + tamoxifin, post: arimidex (aromatase inhibitor) |
| Stage II | AC chemo + taxol + HT |
| Stage III | AC chemo + taxol + HT + radiation to chest wall and lymph nodes |
| Stage IV | HT + radiation to mets, (palliative tx) |
| Factors that ↑ breast CA genetics | bilateral dz, multiple primary CAs, multifocal (4 tumors in 1 breast), same CA in >2 relatives |
| 2 MC breast CA syndromes | BRCA 1 (Chromosome 17) and BRCA 2(men only have breast CA with 2)) (Chrom 13) |
| 4/5 BRCA1 related ca | ovarian, breast, prostate CA, fallopian tube, Colon?? |
| 5/6BRCA2 CA | breast, ovarian, pancreatic, prostate, melanoma, colon?? |
| Genetic counseling indications | breast/ovarian CA before 50, male, bilateral, breast & ovarian, strong Fhx |
| How do you determine how old the child is | Tanner stages, I, II, III, IV, V |
| Gonadal dysgenesis | any inherited developmental disorder of reproductive system: loss of primordial germ cells and developing of gonads: streak ovaries |
| Primary ammenorreah d/t ovaries | no ovaries: no estrogen: ↑↑ FSH, LH |
| The absence of spontaneous menstruation by age 16 following no development of secondary sex characteristics by age 13 | |
| What can present as 1 amenorrhea? | secondary early on: PCOS |
| MC etiologies of 1 amenorrhea? | chromosomal abnormalities, hypothalamic hypogonadism, Mullerian agenesis (no sex organs), Transverse vaginal septum or imperforated hymen, pituitary dz |
| Thelarche | breast development 8-13yo |
| Pubarche | pubic hair 8.5-13.5yo |
| Adult hight reached by | 15.5yo |
| Cryptomenorrhea | accumulation of menstrual debris behind the transverse vaginal septum |
| Secondary amenorrhea | absence of menses for 6m or longer in woman w/ oligomenorrhea: 12 m |
| MC cause of secondary amenorrhea | pregnancy |
| Nl estrogen patients, MC cause of 2 amen | Asherman’s syndrome or PCOS |
| Oligomenorrhea | irregular menses |
| Common causes of abnl uterine bleeding | preg, anovulation, benign uterine pathology (fibroids, polyps) |
| Risks of anovulation | though there is a dysfunction of ovarian estrogens, other androgens are present and converted to estrogens: ↑ uterine hyperplasia and d/t no progesterone (from CL during luteal phase) risk of endometrial cancer |
| MC cause of menorrhagia in premonopausal women | leiomyomas, polyps, adenomyosis |
| MC pelvic tumors in women | fibroids (submucosal, intramural, subserosal) |
| MC uterine cancer | adenocarcinoma of the endometriam (rarely before age 35) |
| What is cancer until proven otherwise | bleeding in post menopausal women |
| What thickness of the endometriam ↑ cancer | >20mm |
| RFs for uterine pathology | Tamoxifen use, Lynch syndrome nulliparity, late menopause, HTN, gallbladder disease, DM |
| Protective effect for uterine cancer | OCPs |
| Where do sarcomas come from | stroma of the endometrium and myometrium dx: hysterectomy |
| Ddx for extra bleeding | coagulopathy: factor deficiencies, vonWillebrand dz, platelet abnl, chronic renal failure, liver dz |
| s/s of uterine infection and cause | fever, uterine tenderness, foul lochia, and leukocytosis, come from procedures |
| how can medications cause abnl uterine bleeding | OCPs: low dose that doesn’t keep the estrogen suppressed: breakthrough bleeding, and progestin only can cause abnl bleeding |
| does OCP break through bleeding ↓ efficacy | no |
| progestin only contraceptives causing bleeding | Depo-provera, mirena IUD, implanon, progestin-only pills, continued use often results in amenorreah |
| how does liver dz affect hormones | affects estrogen metabolisms and synthesis, lead to anovulation and bleeding diathesis |
| chornic renal dz does what | hypothalamic-pituitary-gonadal and platelet dysfxn |
| benign condition where the central columnar epithelium protrudes out through the external os of the cervix: wide SCJ | cervical ectropion |
| postcoital bleeding ddx | cervicitis nonspecific inflammatory changes or ulcerative STI |
| ectopc endometriosis can be found where | on the cervix: bleeding |
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becker15