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Ob/Gyn
| Question | Answer |
|---|---|
| cells of the cervix | os=columnar epithelium further out = squamous epithelium area in the middle: transitional zone...decreases with age...less likely to get certain cancers |
| lymphatics of the pelvis | vulva and vagina = inguinal nodes internal genitalia = pelvic and abdominal nodes |
| 6 hormones that anterior pituitary produces | FSH, LH, TSH, Prolactin, GH, ACTH |
| Menstrual cycle hormones day 1-4 | estrogen levels rise progesterone stimulates endometrial prostaglandins + shedding FSH and LH decrease |
| Menstrual cycle hormones (Preovulatory phase) 5-12 | Ovary produces estrogen Egg developes in FOLLICULAR PHASE -- stimulated by FSH Uterine lining thickens in PROLIFERATIVE PHASE |
| Menstrual Cycle Ovulation Day 13 or 14 | LH and estrogen levels increase Progesterone causes thickening of uterine wall egg is expelled caused by LH SURGE |
| Mittelschmerz | Mid cycle pain may occur with ovulation |
| Menstrual cycle Secretory (premenstrual)phase Day 15-20 | LH and FSH decrease corpus luteum (old follicle) secretes progesterone |
| Menstrual Cycle Luteal Phase (pre menstrual) Day 21-28 | Increased GnRH --> Increased FSH corpus luteum degenerates and progesterone decreases (in no implantation) estrogen production drops and begins to rise as a new follicle develops Menstruation starts at approximately day 28 which begins day 1 of the new |
| Menarche age | avg: 12.4 y/o 2-21/2 years after development of sex characteristics ALWAYS AFTER PH LEVEL 5 IS REACHED! |
| Amenorrhea vs. Menorrhagia vs. Metrorhagia | no menstrual flow excessive flow bleeding from the uterus other than during the menstrual cycle |
| Gyn hx ? | age at menarche date of LMP # days in cycle regularity of cycle Flow: amount (# pads/tampons) Dysmenorrhea and characteristics Intermenstrual bleed Premenstrual symptoms Pregnancy questions |
| Contraceptive and sexual hx | type of contraception, duration, frequency current and previous sex hx, partners, genders, types (be specific with teens), dyspareunia?, bleeding? satisfaction. Pap + results, STI's, tx, sequelae? |
| GaPbcde What does, G, P, and abcde stand for? (ex: G3P1112) | G: gravida (pregnancy) P: para (births) a: # of times pregnant b: # of full term babies c: # of preterm babies d: # of abortions (spontaneous or induced) e: # of living children |
| Pelvic exam | Lithotomy position WHEN GLOVE TOUCHES SKIN, IT IS CONTAMINATED! note ext. genitalia, examine bartholin glands (posterolateral portion of labia majora), examine Skene glands (anterior area, near urethral opening), muscle tone, internal genitalia |
| What are the two common infections responsible for bartholin gland abscess? Who would you check muscle tone in? | a) usu gonococcal or staphlococcyl infections b) pts who have had kids, or have symptoms of weak tone |
| cystocele vs. rectocele vs. uterine prolapse | a) bulding of anterior wall and urinary incontinence b) buldging of posterior wall c) protrusion of cervix or uterus on straining |
| Graves speculum vs. Pedersons Speculum | a) curved, space between closed blades....BOTTOM blade is 1/4 inch longer than top (b/c posterior wall is longer than anterior) b) narrower and flatter than graves speculum (used in f. w/smaller vaginal openings) (Peds: small c short, narrow, flat b |
| ddx cervix deviates from midline | pelvic mass uterine adhesions pregnancy |
| Nabothain cysts | small, white, yellow, raised, round, on cervix |
| 3 tools to collect pap smear and indications for each: Spatula Brush Broom And next step after speculum exam is finished | a) 1st to use, only one to use with pregnant patient. For external area of cervix b) for endocervix DO NOT USE ON PREGNANT PATIENTS c) can do both, not for use on pregnant patients Next: bimanual exam, uterus/adnexa/ovaries/rectovaginal exam |
| Current screening indications Pap Mammogram Osteoporosis eval Colonoscopy or sigmoidoscopy | Pap: onset of sex or 21 (new criteria..used to be 18) Mammogram: q2yrs age 40, then yearly after 50. Earlier if risk factors: Osteoporosis: age 65 (or 60 if risk factors) Colonoscopy or sigmoidoscopy: q3-5 yrs after 50 (earlier if indicated) |
| Current immunization recommendations + lipid panel rubella mmr influenza td pneumoccal HPV HepB lipid panel | rubella: titers in childbearing age women, can only give in NOT pregnant MMR: immunize NON-pregnant Td: q10 yrs pneumococcal: q10yrs age 19-64 if indicated HPV: recommend age 10-22 (want b4 sex. active) Lipid: q5y until 65 start 20 |
| Ovarian Cancer histiology, peak incidence, avg age, s/s, dx, tx, extra info | mostly epithelial, peak incidence 70 y/o, av age 63 y/o, s/s: early: asymptomatic late: abd bloating. dx: ct c contrast. Tx: surgery c optimal debulking (leave <1cm), chemo, radiation. No good screening tests: if tvus abn tx ocp, tl, oophrectomy |
| Endometrial Cancer: histiology, avg age, types, s/s, risk factors. | Most Common Malignancy in U.S. mostly adenocarcinomas (I) worst: leiomyoscarcoma. avg age: 60 y/o. Types: estrogen (better prognosis) and non. s/s: asymptomatic or pressure, pain, abn bleedling, abn discharge. risk factors, obese htn, dm, nulliparity |
| Endometrial cancer continued. Dx and Tx. | Dx: *BIOPSY IS THE ONLY DEFINITIVE DIAGNOSIS* biopsy: either - pressure through cervix or D&C Tx: *surgery*, then radiation (to decrease reocccurance), then systemic therapy if indicated |
| Cervical Cancer: histeology, age, risk factors, screening, s/s: | Most common female malignancy worldwide. usu squamous cell (rarest=adenocarcinoma), age: 20-30 and again 50-60. risk: young age at coitarche, HPV, smoking, # partners, immunocompromised. screening: Pap could decrease risk by 74%. |
| cervical cancer continued. Dx and Tx | Dx: *PHYSICAL EXAM IS CRUCIAL...THAT'S HOW YOU STAGE* Tx: two types of primary treatment. Surgery (stage 1-2) or radiation (stage 2-4). If patient could have either tx? usu surgery young pts b/c less chance of fibrosis in vagina, bowel/bladder prob. |
| Vulvar Cancer: histeology, risks, s/s, dx, tx | Rare, risk: low SES, HTN, DM. histeology: squamous mostly followed by melanoma and BCC, s/s: bump, itching, lesion usu unifocal, >6 months. Dx: *BIOPSY*. Tx: surgery (individualize) radiation, chemotherapy. (Melanoma has poor prognosis) |
| Vaginal Cancer: histology, risk factors, s/s, dx, | very rare, but often metastatic. histology: SCC, melanoma, adenocarcinoma. Risk: low SES, HPV, immunocompromised, prior abn pap. s/s: bleeding, dysuria, discharge, pain, dyspareunia **MOST COMMON SITE: POSTERIOR WALL, UPPER 1/3**. Dx: BIOPSY |
| Vaginal cancer continued: staging and tx. | clinically staged (melanoma staged using Breslow's scale), tx: Radiation--syed implant, interstitial implant sutured to vulva, surgery, chemotherapy |
| Diagnose pregnancy and it's location (3) | 1. serum hcg levels, 2. urine hcg levels (home pregnancy tests), 3. ultrasound (esp. good if you think it may be an ectopic pregnancy) |
| Three signs of pregnancy categories: | Presumptive, Probable, Positive |
| Presumptive Signs of Pregnancy (4) | 1. linea nigra 2. chloasma "mask of pregnancy" 3. Chadwick's sign (blue cervix) 4. Hegar's sign (soft uterus isthmus) |
| Probable Signs of Pregnancy (2) | 1. globular uterus 2. Piskacek's sign (one cornua (horn) of uterus may enlarge due to implantation of the ovum). |
| Positive Signs of Pregnancy (3) | 1. 12 week doppler for FHR (18 weeks w/fetoscope) 2. Quickening: fetal movement (15-17 weeks multiparous pt, 18-20 weeks primagravida). 3. visualize fetus via US or xray |
| functions of oxytocin and prolactin in pregnancy | Oxytocin: from post pituitary - causes uterine contractions and milk letdown. Prolactin: from anterior pituitary - stimulates milk production |
| HcG | human chorionic gonadotropin. Produced by placenta to maintain pregnancy. Beta subunits of Hcg is measured in serum pregnancy tests. Begins to rise 8 days after ovulation. Peaks at 60-90 days. hcg maintains corpus luteum and progesterone production. |
| hcg levels: positive, date of expected menses, in normal pregnancy how often does hcg double? what is the maximum level? when does the max occur? What does it fall to after that? | + = >25mIU/L 100mIU/l is reached at date of expected menses Urine pregnancy detects >25 (*HOME PREGNANCY TESTS HAVE HIGH FALSE NEGATIVE RATE). Norm preg: hcg levels double q2.2 days. Max = 100,000 at 9 weeks, then drops to 10,000-20,000 for duration |
| serum pregnancy test vs. urine pregnancy test | most accurate, can detect levels as low as 5. Urine pregnancy test: detects levels 25-50 CANNOT GIVE QUANTITATIVE LEVELS. Use first morning sample! |
| Elevated hcg could mean... (3) | Downs syndrome, or hydatidiform mole, or choriocarcinoma |
| Low hcg levels could mean...(2) | ectopic pregnancy, or impending spontaneous abortion |
| Maternal adaptations to pregnancy - hematologic | blood volume increase by 45%, protects against blood loss during delivery. Hemoglobin and hematocrit drop + slighly smaller increase in RBCs = PHYSIOLOGIC ANEMIA OF PREGNANCY. |
| Cardiac changes to pregnancy: CO, BP, P, complications of venous compression | CO: increase, BP: decrease in mid pregnancy, then rises, P: increases 10-15bpm Systolic murmur present in 90% (probably b/c of h20 increase). Gravida uterus compresses IVC -> supine fall in BP (nausea, dizziness, syncope), hemorrhoids and thrombosis |
| Respiratory changes to pregnancy: O2 consumption, tidal volume, TLC, hyperventailation | Ox consumption increases, tidal volume increases due to progesterone, TLC decreases, hyperventilation causes respiratory alkalosis (decrease C02 and increase pH). |
| Endocrine changes in pregnancy: insulin Weight changes: + recommended amounts | insulin response in augmented in early pregnancy, later insulin resistance. See hyperglycemia, hyperinsulinemia, hypertriglyceridemia and reduced tissue response to insulin. Weight gain: recommended 25-35 lbs. in woman of normal weight before pregnancy. |
| Abdominal changes: diastasis recti | separation of the rectus muscle at the midline of the abdomen. Occurs in later trimesters. |
| Vaginal changes during pregnancy + uterus | secretions: more profuse, thick, and white. pH: more acidic b/c lactobacillus acidophillus acts on glycogen in vaginal epithelium. This may help prevent vaginal infections. Uterus: Hegar's, increase fibrous and elastic tissue adds to strength (5 ltr |
| When does uterus become an "abdominal organ"? | 12th week it moves out of the pelvis. Stretching of supportive ligaments causes pain |
| Braxton-Hicks contractions | painless start 1st trimester, sporadic and unpredictable, increase frequency at end of pregnancy, aka FALSE LABOR |
| Cervix | bloody show: At onset of labor, thick mucous plug in cervix is expelled (not the same as water breaking). "Beading" "ferning" mucous presentation on slide. |
| EDC | expected date of confinement. measure with modified negal's rule or pregnancy wheel |
| modified negal's rule | date LMP - 3 months + 7 days. |
| Date of PIH | after 24 weeks, htn not previous seen is pregnancy induced htn, if it's seen before 24 weeks, it's chronic hypertension |
| 1st trimester weight loss should not exceed..... | 5 lbs. extreme vomiting/nausea = hyperemesis gravida |
| Fundal Height: when do you start to measure, #'s | start at 20 weeks, should be +,- 2 of gestation weeks (ex 22 weeks, should be 20-24 cm) |
| FHR: early and near term | early: 160 (find midline of lower abdomen until 12-14 weeks), near term: 120-140 (find w/fetal position). |
| t/f vaginal infections more common in pregnancy? | True |
| pathological edema, knee reflexes and PIH | common in pretibial area, hands, and face, knee reflexes >2+ after 24 weeks |
| When do you begin leopold manuevers? | 28 weeks |
| Leopold 1 | which part is in FUNDUS? |
| Leopold 2 | Which side is BACK and FRONT? |
| Leopold 3 | Which part in in PELVIC INLET? |
| Leopold 4 | Is HEAD FLEXED? (if hand on back moves down further than the other, the head is flexed) |
| The best birth control method is... | ...one that is MEDICALLY APPROPRIATE and used CONSISTANTLY and CORRECTLY by pt. happy with method |
| Ineffective BC methods (3) | post coital urination, post coital douching, different sex positions |
| Perfect use rate vs. Typical use rate | Perfect: no errors, Typical: #s based on the avg person who doesn't always use it correctly or consistently. |
| Quote patients typical user rate, T/F? | True |
| 3 cancers celibate women are more at risk for | breast, cervical, endometrial CAs |
| How long is EC effective if patient is not already pregnant? | Up to 5 days |
| Can EC be substituted with monophasic BCP? | Yes, pt. needs to take 4 low dose otcs then 4 more 12 hrs later, more side effects |
| Rhythm method | Day before ovulation LH surge, get 1-2 degree increase in temp (take temp firtst thing in morning while still in bed) |
| 3 methods used in periodic abstinence | calendar, basal body temp, mucous thinning (BBT: post ovulatory temp rise .5-1 degree F x 3 days) (mucous thins abstain for 4 days) |
| What about ovulation time for irregular cycles? | Longest cycle -18 days, shortest cycle -11 - calendar method |
| Diaphragm, fitting, how long before intercourse, how long after, max time in | must be fitted, put in w/spermicide up to 6 hrs before, must leave in minimum 6 hrs after, may be left up to 24 hrs |
| OCP - Combination CA protection | ovarian and endometrial CAs (reg: 30 mg estrogen, low: 25 mg. estrogen) |
| 3 ways hormonal contraception works | 1. inhibits ovulation. 2. thickens cervical mucous. 3. alters endometrial lining |
| early pill danger signs: ACHES | A: abdominal pain (sever) C: chest pain- SOB, tachy H: headeache (severe) E: eye problems, blurred vision S: severe leg cramps (may be clots) |
| Risk factors for pulmonary embolism/DVT | hypercoagulability states: malignancy. Blood dyscrasias, factor V leiden, pregnancy, estrogen use (risk proportional to dose), venous stasis, nephrotic syndrome, surgery, trauma |
| Progestin only pill: how long, for who, compliance, side effects | "minipill" x 28 days, ok HTN, smokers, breast feeders. Strict dosing or may fail if late or missed, side effects: irregular menses, spotting |
| Depo Provera (+pts 3) | dose q 11-13wks, s/e spotting, amenorrhea, weight gain, depression excerbated. Post depo amenorrhea (up to 12-18 months). Consider for pts w/ dysmenorrhea, endometriosis, hx of poor complaince |
| surgical sterilization | mandated 2 informed consents, 30 days apart, laproscopic same day surgery, high percentage of patients regret this choice |
| IUD | safe, effective, up to 10 yrs, one type is copper check for allergy |
| nonoxynol-9 spermicide | CDC does not recommend b/c possible increased risk of HIV and STI spread b/c it may irriate cervix/vagina |
| Physiology of vaginal fluids | estrogen -> lactobacilli -> acidic. Mostly alkaline until puberty. H202 and lactic acid offer some protection against STIs |
| Most common microbe found in vagina | Lactobacillus acidophilus |
| other microbes found in vagina | streptococcus agalactiae, escheria coli, ureaplasma urelyticum, mycoplasma hominis, garnerella vaginalis, candida albicans, and bacteriodes fragilis |
| 3 things that may alter normal vaginal flora | Douching, sexual intercourse w/semen (raises pH up to 7.2 for 6-8 hrs), and foreign body (tampon, object) |
| Vaginitis | inflammation of vagina. s/s discharge, odor, irritation, and/or itching |
| 3 most common vaginal infections | Bacterial Vaginosis, Trichomoniasis, and Candidiasis |
| Whiff test | 10%KOH w/discharge -> amine odor (fishy smell). Seen in BV or Trich |
| Wet Mound | take sample from posterior fornix + 2 ml saline. BV: look for clue cells, Trich: look for trichomonads, Candida: look for pseudophyphae |
| BV + bacteria involved (3) | 40-50% cases vaginitis. GARDINELLA VAGINALIS, genital mycoplasms (hominus, urelyticum) and anaerobes (bacetriodes, mobiluncus sp.) |
| s/s BV | frothy white-gray discharge, +whiff test, no erythema, 1/2 pts may be asymptomatic |
| d/x BV (3 of 4) | homogenous white-gray adherent discharge, pH >4.5, +whiff, clue cells |
| tx BV (2) | Metronidazole or Clindamycin |
| vulvovaginal candidaisis | 2nd most common cause vaginitis, C. albicans (or c. glabrata). yeast overgrowth, common - many conditions increase risk |
| s/s candidiasis | vaginal itching/burning + or - dysuria. Odorless white cheesy discharge sticks to walls, erythema, swelling, Satellite Lesions |
| dx candidiasis | budding yeast, pseudohyphae, - whiff, pH<4.7 |
| tx candidiasis | butoconazole, nystatin, fluconazole |
| Trichomoniasis | caused by protozoan, infects vagina, glands, and urethra, almost always sexually transmitted |
| s/s: Trich | green-yellow frothy discharge, musty odor, dyspareunia, irrituation, dysuria |
| d/x: Trich | strawberry cervix (petechiae), motile protozoa on wet prep, pH elevated (5-6.5) |
| tx Trich + pregnancy problems | Metronidazole, tx partner at same time. Pregnancy: preme, low birth weight, increased risk HIV transmission |
| Atrophic Vaginitis | inflammation from low estrogen, most commonly seen in post-menopausal, s/s *watery discharge*, dysuria, vulvar itching, burning, bleeding, spotting, dyspareunia, pale epithelium, pH>5.5, Pap: immature basal cells Tx: topical estrogen |
| Most common bacterial STI in U.S. | Chlamydia, affects columnar epithelium of endocervis, urethra, endometrium, fallopian tubes, and rectum. If untreated can -> PID |
| s/s chlamydia | mostly asymptomatic, can be mucopurulent cervicitis, yellow discharge, friable cervix (bleeds easily), urethritis may be present |
| dx chlamydia | NAAT (nucleic acid amplification test). |
| Tx chlamydia | azithromycin, doxycycline, tx. all sexual partners x60 days prior to diagnosis |
| tx chlamydia in pregnancy | *Erythromycin or Amoxicillin, can cause preterm labor, chorioaminionitis, postpardum endometritis if untreated |
| Gonorrhea | Neisseria gonorrhoeae, gram - diplococcus, affects columnar epithelium (like chlamydia), also can be in pharynx |
| s/s gonorrhea | frequently asymptomatic, 3-5 days post exposure, same visual finidngs as chlamydia, differnt color discharge, pharyngitis c/ edema and erythema may be present |
| dx gonorrhea | gram stain, cuture on Thayer-Martin or Trhansgrow media, DNA hybridization, also NAAT. Screening is necessary in high risk women to control infection (since if often presents as asymptomatic) |
| tx gonorrhea | lower genital tract: cefixime or ceftriaxone. also treat for chlamydia, untreated can -> PID, TOA (tuboovarian abscess), ectopic pregnancy,and infertility |
| gonorrhea and pregnancy | same as chlamydia + neonatal conjuctivitis (ophthalmia neonatorum) PREVENT with ERYTHROMYCIN OINTMENT at birth |
| Syphillis | spirochete treponema pallidum. chancre followed by fever, ha, malaise, pharyngitis, anorexia, generalize lymphadenopathy, and diffuse symmetic maculopapular rash palms and soles can coalesce to form CONDYLOMA LATA. then late stage: organ damage, GUMMA |
| dx syphilis | darkfield microscope, VDRL and RPR...only looks for autoantibodies NOT SPECIFIC for syphillis. can also get + from TB, MALARIA, PNEUMONOCOCCAL PNEUMONIA, MULTIPLE MYELOMA, etc in VDRL. If VDRL + need FTA-ABS or MHA-TP trep tests. Report to NYS 48 hrs |
| tx syphilis | PCN, Benzathine PEN G, Doxycycline or erythromycin. If pregnant tx woman with erythromycin, but also treat baby with PCN. |
| Most prevalent STI in US | HSV. DNA virus, contagious, regular condom use decreases transmission, pregnancy: infant -> microcephaly, MR, seizures, and microphthalmos |
| s/s HSV | tingling, itching, burning prodrome. Clear vesicles, rupture and form shallow painful ulcers with red border, may coalesce and become secondarily infected. may get dysuria from urine passing over lesions |
| dx HSV | H&P, can confirm with viral culture, PCR. Serology test is VERY sensitive and specific for HSV 1 (coldsores) and HSV 2 (70% of infections). even in asymptomatic pts |
| tx HSV | supportative, sitz bath + drying, antivirals (-clovir), can use in smaller doses for suppressive therapy once daily, educate on use of condoms, and counseling |
| HPV (warts) | Condyloma Acuminata (veneral warts), types 6 and 11. risk factors: smoking, ocp, multiple partners, early coitarche age. |
| s/s HPV (warts) | painless bumps, pruritis, discharge, cauliflower or plaquelike the same color as skin or red or hyperpigmented |
| dx HPV (warts) | clinically, may biopsy to confirm, acetowhitening with colposcopy may help visualize lesions |
| tx HPV (warts) | Pt applied: podoflox, imiquimod. Also, cryotherapy, surgical excision (has highest success rate and lowest reoccurance rate), CO2 laser tx, podophyllum resin, and interferon alpha 2a and 2b |
| Most common causes PID | Chlamydia trachomatis, Neisseria gonorrhoeae, and genital mycoplasms. Definition of PID: ascending spread of microorganisms from vagina and endocervix to endometrium. Problem: chlamydial cervicitis highest rates teens and young adults-usu.asymptomatic |
| s/s PID | low abdominal pain, abn discharge, fever, chills, also possible bleeding, dysuria, N/V. PE: NEED 3 tenderness (ABDOMINAL, ADNEXAL, CERVICAL MOTION) and mucopurulent cervicitis ("chandelier sign" want to jump off table and hit chandelier) or another sign |
| should you do a laproscopy in PID? | yes, if you need to differentiate it from other conditions (such as appendicitis) |
| Hospitalize pts with PID if (11) | 1. severe infections or can't take oral abx (vomiting), 2. possible surgical emergencies, 3. pregnant, 4. already failed oral outpatient tx, TOA, adolescent, WBC off, (>20,000 or <4000), IUD users, complaince problems, immunocompromised |
| Tx PID Inpatient | A: Cefoxitin, Cefotetan, Doxycycline. B: Clindamycin, Gentamicin, doxycycline |
| Tx PID Outpatient | A: Ofloxicin, Levofloxacin, c or s Metronidazole B: ceftriaxone, cefoxitin, probenecid, doxycycline c or s metronidazole |
| prevent PID (4) | Rapid dx and tx STI once, routine screening, use sensitive and specific diagnostic tests (ex PCR), idenfify and tx partners to prevent reinfection |
| Tubo-Ovarian Abscess (TOA) | involves tubes, ovaries, other pelvic organs, can be serious/lethal complication of PID. Rupture TOA can cause PERITONITIS which if not quicky dx and tx can be lethal. s/s TOA: tender, inflammatory adnexal mass. dx: US, CT, MRI, drain w/US |
| dx cont'd + Tx TOA | laoroscopy may be necessary to distinguish from other pathologies (ex infection/torsion of adnexa, appendicitis), irrigate and drain w/ laproscopy or laparotomy. Tx. also wtih BROAD SPECTRUM ABX. to cover gonorrhea, ecoli, b. flagilis, etc. cervix cultur |
| Tx TOA contd medically | IV: Clindamycin or Metronidazole + an aminoglycoside or Aztreonam, after clinical improvement: po doxycycline, amoxicillin/clauvanic acid, or metronidazole for at least 1 wk after IV abx. |
| Tx TOA contd surgically | aspiration under US guidance, I and D of abscess or salpingectomy to preserve ovaries, total abdominal hysterectomy or oophoretomy may be necessary in refractary cases. |
| complications PID (4) | Infertility, Ectopic Pregnancy (14x more likely for tubal factor infertility, adhesions) 6x more likely ectopic, Endometriosis 10x more likely, Chronic pelvic pain |
| HIV | lenti RNA virus, related to SIV in chimps, has gp 120 and 41 (stem), and protein p24 (core antigen). gp120 attracts Cd4 on Thelper cell |
| dx HIV via HIV antibody testing (most comonly used to diagnose infection in ADULTS) | ELISA (sensitive and specific SCREENING TEST), Western Blot (confirms elisa), |
| Dx HIV infants (<18 months | PCR, look sfor viral DNA and amplifies in blood |
| Evaluate disease progression by watching these two things | CD4 count (norm 750-1000), viral load (want low as possible b/c it's # of particles/ml blood) |
| Drug resistance testing (2) | Phenotype (ability fo HIV virus to grow w/meds (petri dish)), Genotype testing (tells which meds patient's strain of HIV should be sentitve to by evaluating patient's mutations). |
| 72% AIDS cases in women | are in childbearing age 30-49, comonly minority women, mostly through heterosexual contact, other STI's increased rate of transmission, as did anal intercourse |
| Clinical Manifestations of AIDS (3) | Amenia, Wasting Syndrome, Menstrual Changes (premature menopause puts pts at risk for CAD and osteoporosis just like non HIV women) (for opportunitstic infections, like candidaisis, tx orally right away b/c of immonocompromised state) |
| Name an AIDS indicator disease | Invasive cervical cancer caused by HPV b/c risk of HPV/cervical dysplasia increase with increasing immunocompromised |
| Are other genital cancers more frequent in HIV patients? | NO! Just more aggressive! |
| Pregnancy and HIV | AZT reduced transmission of HIV from mom to infant by 66%. given to women, and at delivery, and to infant x 6 weeks. First dose to infant, must be before 12 hrs of age wtih dosing q8hrs for 6 weeks, PCR birth, 2-4 wks, 4-6 mo, 18mo to see if seroconvert |
| What increases risk of maternal to infant transmission of HIV (5) | Mom cd4 count, mom viral load, prolonged ruptured membranes, vaginal delivery, breastfeeding |
| Prenatal care, initial visit labs (8) | pap, cbc w/diff (check for anemia), VDRL/RPR, HepBsAG, Rubella, Type/RH, UA/C&S (utis are often asymptomatic in pregnancy and can cuase premature labor) |
| Calculate gestational age (4) | Pregnancy wheel, and Clinical Signs (size of uterus, quickening, ultrasound) |
| Clinical Pelvimetry, when and what 3 things do you look for? | ~36 weeks, diagnona conjugate, promonence of spines, transverse outlet diameter |
| 4 shapes of pelvises determined from clinical pelvimetry | Gynecoid (IDEAL), Platypoid, Anthropoid, Android. Max widest cirumference is 12cm |
| How often should fetus move? what to do 1st if they don't? later? | 3x hr, first lay down, if none go to ER |
| When do you do Leopolds? | 34-36 wks |
| Routine tests 16-20 wks (3), 24-28 (3), 36-38 (5), 40+ (2 (sub4)) | 16-20: sonogram, triple screen, amnio (over 35) 24-28: GCT (>135 is abn), 3hr GTT PRN, give Rhogam if Rh-, 36-38: Group Bstrep CBC, VDRL, HSV, Gc/Chl (hi risk pop), 40+: NST 2xwk, Biophysical profile (AFI, fetal breathing, mvmt, tone (ifluid low=no tone) |
| Most common cause of fetal sepsis | Group B. Strept |
| Freq of visits 28, 34-36, birth | q4wks until 28, then q2wks until 36, then weekly until birth. These are ACoG standarrds, do more often if high risk or if doing certain screenings |
| False vs. True Labor | Irregular intevals vs Reg, intensity unchanged vs. shortens, no cervical dilation vs. dilates, lower abd discomfort vs. back and entire abd discomfort, relieved by sedation vs. no relief with sedation |
| 3 things we record on the pelvic exam of patient in labor | Dilation (cm), Effacement (%, 100=paper thin), Station (-5,0 -ischial spines, +5) |
| Reference baby's occiput | triangle shaped = posterior fontanelle, anterior fontanelle = diamond shaped. R/L Occiput Ant/Transverse/Post. OT and OP are larger diameters |
| Stages of Labor + Friedman's Curve | First: 0-4 latent 4-10 active Second: 10-delivery Third: delivery-placenta delivery Fourth: post pardum, check vaginal bleed, uterus firm. Min time in this stage: 1hr, max 6 wks. Friedman's curve for staging. x: time y: cervical dilation |
| Avg latent phase, active phase, dilation, second stage of nulliparous and multiparous women | Nulli: 20 hrs latent, 12 hrs active, dilation 1.2cm/hr, second stage 2.4 hrs. Multiparous: 14 hrs latent, 2 hrs active, dilation 1.5 cm/hr, second stage 0.5 hrs |
| *Indications for Episiotomy (3) | Facilitate Delivery, Inevitable Tear, Forceps/ Vacuum/Breech delivery |
| FHR norm | 120-160bpm!!!! |
| FHR Tracing systematic review | Uterine activity (frequency, duration, strength only measured w/IUPC (montevideo units), Baseline Hr, Variability (Long term vs short (only internal scalp electrode call tell us this), Accelerations (want 10-20 seconds, wants reactive |
| fetal tracing systemic review cont'd | want reactive acclerations (2 or more increase in 15 bpm for at least 15 seconds). EACH LITTLE BOX = 20 sec, EACH BIG = 1 min. Decelerations (3 types) |
| 3 types of fetal tracing decelerations | 1) early: uniform, norm, nadir (Lowest Point of Deceleration) within 18 seconds of contraction peak, Late: uniform, nadir lag time >18 sec from contraction peak CAUSE OF LATE: UTERINE/PLACENTAL INSUFFICIENCY. Variable: U, C, W shape CAUSE CORD COMPRES |
| ways to treat possible fetal problems seen on tracing | 1) Mom on L side with 100% O2 through NREbreather. |
| Definition: High risk pregnancy | increased risk of morbidity/mortality to neonate (1st 28 days), fetus or mom |
| What is the cut off date between spontaneous abortion and fetal death? | 20 weeks |
| what is the leading cause of perinatal death? | Premature birth |
| Maternal Diabetes | Difficult birth, need for C/s, Preeclampsia, increased fluids (poly hydraminos), infection, placenta hormones are anti insulin -> increased risk of diabetic ketoacidosis |
| Maternal Diabetes causes what 4 things in the fetus? | Macrosomia**MAIN PROBLEM** (whcih may cause birth trauma), Stillbirth (to reduce risk, deliver between 38-40wks), Congenital Anomalies, and/or Prematurity |
| Maternal Diabetes can cause what 4 things in the neonate? | hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia |
| tx Diabetes | If pt is insulin depended, only glyburide doesn't cross placenta, must be taken off all others and put on insulin |
| HTN (+s/s preeclampsia (4)) | 75% caused by preeclampsia. s/s bp>140/90, proteinuria, edema, hyperreflexia. Only PIH if seen after 20 wks. Eclampsia= seizure plus preeclampsia |
| tx mild preeclampsia (3) | Rest in lateral position, Evaluate organs (liver, kidney, blood, fetus), allow to get to term or spontaneous labor/inducibility |
| Tx. severe preeclampsia (4) | hydrate, control BP, magnesium sulfate, deliver. BP >160-180/105-110, hepatonecrosis or thrombocytopenia, renal failure/oligouria, pulmonary edema, fetal concerns (intrauterine growth retardation IUGR), severe proteinuria |
| HELLP | Hemolysis, elevated liver function tests, low platelets |
| what chronic htn drugs to avoid: | ACE inhibitors, or diuretics. SIDE NOTE: CAN GIVE MOM CORTICOSTEROIDS TO TRY TO INCREASE FETAL LUNG FUNCTION IN CASE NEED TO DELIVER BABY EARLY |
| Hemolytic disease | Rh issues, fetus: anemia->hydrops->death. tx. RhoGAM. Amniocentesis: Delta OD450 (to measure bilirubin level, byproductof erythrolysis). can tx. with intrauterine fetal transfusion if needed |
| Hypothyroidism | dx: elevated TSH tx: T4 supplement safe b/c it does not cross placenta |
| Hyperthyroidism | dx: free Tv, tx: surgery, PTU (propothyroid uracil)--only ive a little b/c it does cross--fetal goiter, fetal hypothyroidism. CANNOT DO RADIOACTIVE THYROID TEST |
| Heart Disease | tx: meds digitalis, beta blockers, quinidine OK, labor: minimize valsalva, use epidural, use forceps, SBEW prophylaxis if they have an artifical heart valve |
| Respiratory Disease | always tx mom. Pneumonia: tx: PCN, erythromycin. Asthma: theophylline, terbutalime, steroids ok. Keep pO2 >60-70 Keep O2 SAT >90-95% |
| Acute renal disease | asymptomatic UTI, tx b/c 25% could get pyelonephritis. Dx: GOLD STANDARD: Urine culture C&S. If they have a UTI, ALWAYS do a Test of Cure to make sure you got it. |
| Liver Disease (4) | Hep B, Preeclampsia, Cholestasis ***Pruritis*** increase alk phos only, acute fatty liver (rare) |
| Most common blood problem in pregnancy: | Anemia (Iron def: supplement 65 mg qd. folate def: supplment 1mg qd). Folate lessens risks of birth defects. Alll women shoud be on 0.4 mg daily even if not pregnant |
| Third trimester bleeding | Abruption or Placenta Previa |
| Cardinal Rule: 30 week bleeding | NEVER DO A PELVIC! You could rupture , if she has a placenta previa. Do an US!! |
| Habitual Abortion | 3 or more spontaneous abortions |
| Thrombocytophilia associated iwth what 3 things | recurrent miscarriage, sever preeclampsia, fetal growth restriction |
| For every extra fetus, how long should you subtract off teh due date? | 3 weeks! |
| Fetal Growth Restriction can be one of to categories: | Symmetric or Asymmetric (better prognosis) |
| Incompetent cervix | start to painlessly dilate 13-26 wks, etiology: trauma, cone bx, LEEP. Clerage: McDonald or Shirodkar, if cervis is small enough you can sitch it back up and try to keep pregnancy going. |
| Amnionitis: | dx: fever, fetal tachy, tender uterus, leukocytosis. Tx: delivery, broad spectrum abx. |
| Most common cause of preterm labor | Preterm rupture of membranes |
| Fetal Assessment (7 things) | US, Amniocentesis, Fetal Blood sampling, Non Stress Test, Contraction Stress Test, Biophysical profile, Fetal Mmvt Survelliance by Pt. |
| FHR Monitoring | Bseline rate, baseline variability, accelerations, decelerations (early: head compression, normal. Late: uteroplacental insufficiency. variable: cord compression). |
| Benign Disorders of Vulva (3) | Epidermal Inclusion Cyst, Bartholins Cysts, LIchen Sclerosis |
| Epidermal Inclusion Cysts (Sebaceous Cysts) | **Most common cystic lesion of the vulva** Bleow epidermis, occulusion of sebaceous gland. Mobile, non-tender, no tx. unless infection, then I&D usually sufficient, can excise but commonly reoccur |
| Bartholin's cyst (in post-menopausal women, malignancy must be ruled out via escision/histologic evaluation) | chronic cystic dialationa and occulsion of main Bartholin duct, may be caused by chronic inflammatory reactions or trauma from alcerations. Tx. if symptomatic, MARSUPIALIZATION w/word catheter therapy. local anesthetics, office procedure, excise |
| Lichen Scherlosis | skin thin, elastic, tissue paper appearance. post menopausal women s/s intense pruritis., dyspareunia, burning pain,a nd introital stenosis. ext genitalia can invert, Tx: topical steroids (clobetasol) and emollients. |
| Benign Disorders of the Vagina (1) | Inclusion Cyst of Vagina |
| Inclusion cyst of vagina | common lesion, due to lacerations, usu. small and asymptomatic |
| Benign disorderes of the uterus (1) | Leiomyomas |
| Most common reason for gynecological surgeries: | Leiomyomas. mass derived from smooth muscle cells in myometrium. More common AfricanA women, increase risk w/estrogen increase (estrongen and fat). |
| Locations for Leiomyomas (4) | Subserosal (feel distortion of comfort, re: how small), Intramural , Subcmucousal (under endometrium, responbile for any intrauterine bleeding). Lastly, pedunculated stalk, torsion and ischemic necrosis may occur. |
| s/s leiomyomas: | most asymptomatic, abn uterine bleeding, pelvic pressure, pain is RARE, unless torsion is present, pressure symptoms (freq, GI bloating). |
| dx leiomyomas: | PE, US, Radiographs (to show caliications), MRI, medically |
| Menorrhagia assocated w/leiomyoscarcoma: manage this pt | can be tx: w/hormonal therapy PROGESTIN ONLY!, or GnRH agonist (blocks ovarian steroid production by suppressing LH, FSH), surgical: conservative surgery based on his symtpoms. HYSTERECTOMY IS THE DEFINITIVE PROCEDURE |
| Most common reason for hysterectomy | Fibroids |
| Diseases in the ovary (functional: 3 neoplastic: 2-3) | corpus luteum cysts, theca lutien cysts, follicule cyst, dermoid cyst, PCOS, adnexal mass |
| Corpus Luteum Cysts: | thin, walled, usu goes away 1-2 months. "tx: ocp 2-3 months to try to decrease symptoms |
| Theca Lutein cysts | during pregnancy, gonadotropin stimulation (Hydatidiform mole or chroicocarcinoma, usu bilateral. Regress when gonadotropin levels fall. Tx: obesrvation, surery if complications (torsion, hemorrhage) |
| Most common cysts of the ovary? | Follicular cysts |
| Follicle cysts: | follicle failts to rupture with ovulation, ssx: non eot patient with rupture, menstrual changes. Dx: bimanual exam, US Tx: observe, OC to suppress gonadotropic, cystectomy if needed. |
| Most common ovarian neoplasm? | Benign Cystic Teratoma (Dermoid Cyst) |
| Benign cystic teratoma (dermoid cysts) | us unilateral, dx: US, tx: ystectomy with preservation of ovarian tissue. Cx: chemical peritonitis if it's ruptured. |
| PCOS | common cause of ovarian androgen excess and hirsuitism. s/s: hirsutisims, menstural irregularieites, and infertility....also acne, obesity, virillism (male-like fetures), dysfunctiona bleeding. AKA STEIN LEVENTHAL SYNDROME. No midcyclic LH surge. |
| PCOS continued | estrogens produce androgens, which are converted to estrogens, normal follicule development is disrupted. dx: hx, US, biopsy (if irregular bleeding). eval glucose, htn, cad, (increase risks). Anovulation induced if pt. wants pregnancy. |
| Benign Disorders of the Cervix (2) | Nabothians Cysts, Cervical polyps |
| Nabothian's cysts: | mucous retention cysts, squamous cell epitehlium covers mucousa secreting columnar epithelium. |
| Cervical polyps: | proliferation of columnar cells in endocervix. "Beef, red, stalk" single or multiple. May cause coital bleeding or menorrhagia, may be removed by cautery or by twisting. 1% could be malignant, send it to the lab. |
| Endometriosis: | endometrial glands outside uterus, typical pt, 30s nulliparous, infertile |
| Theories 3 | Retrgrade menstruation theory (it floats out of tubes), Mullerian Metaplasia GTheory (transformation of peritoneal mesothelium inot endometrium due to some stimulus). Lymphatic spread theory: taken up by lymphatics |
| respond to estrogen? | yes, be careful b/c of the increase cancer risks. on ovaries, is chocolate colored (hemolyzed blood), Adhesions are often present, can be staged. |
| *Common Triad of Endometriosis* | Dysmenorrhea, Dyspareunia, Dyschezia. NO CLEAR CORRELATION BTWN EXTENT OF DISEASE AND SEVERITY OF PAIN. |
| what is an uncommon symptom of endometriosis? | Menorrhagia!!! |
| s/s endometriosis: | nodules may be found, lg. tender, noncystic mass, tender fixed adnexal mass may be noted on the bimanual exam. Uterus may be fixed and retroverted, PE may be normal. D/x: H&P, Laproscopy is the definitive diagnosis. |
| tx: endometriosis | surgical: take it out. If you want kids, laparoscopic or abdominal surgery to only destoy implants and remove adhesions. Preoperatie Therapy with GnRH agonists 3-6 months prior to surgery increases success of surgery. Medical: Danazol (inhibits GnRH) |
| more medical tx. endometriosis | OCP and progesterone are used to tx pelvic pain from endometriosis by drecreasing size of implants. Medroxyprogesterone acetate oral or IM given for us to 6 months. GnRH agonists suppress ovarian estrogen production, |
| Adenomyosis: | extension of uterine gland and stroma into uterine musculature |
| s/s Adenomyosis: | Dysmehnorrhea, Menorrhagia. |
| tx: Adenomyosis: | nsaids, oc hormone patches, hysterectomy |
| Pap Specificity and Sensitivity | Specificity: HIGH Sensitivity: LOW (get some false +) |
| What HPV types are high risk for developing cervical cancer? How is this first caught? | types 16 and 18, by Pap smears |
| Transition Zone of cervix | where the majority of the cancers are found b/c there is a lot of regeneration here. In a yonger person columnar epithelium -> squamous epithelium is larger. As we start to age TZ migrates inward, so by age late 30s-> menopause have less visible TZ. |
| Important things with Pap Exam | Timing: mid cycle, 3 months since last one, nothing in vagina 48-72 hrs before, spray fixture ASAP |
| Frequency of Screening | New standard: Age 21 or first sexual experience, whenever is you. |
| Reporting system | Bethesda Classificiation System: Aequacy, Descriptive Changes |
| Benign cellular changes: | infection, reactive (fought off old infection, but not yet completely healed. |
| cell abnormalities | ASCUS, LGSIL, HGSIL (all sqaumous cell). Pap is very insensitive for Trich, but extremely specific for it, so if Trich is positive, need to start tx. immediately. |
| Other diagnostic procedures after Pap | Conization of cervix, endomtrial biopsy |
| tx:abn pap | ascus: usu repeat lgsil, dna testing repreat, immedate colpe. hgsil colposcopy needs to be done imediately. |
| Definition Chronic Penvic Pain | non menstrual pain >6 months duration. Dx of exclusion |
| Visceral pain | diffuse aching. Triggered by stretch, inflammation, ischemia. |
| Investigate | abdomen, pelvic, back PE, labs? cbc, esr, cutlture of vaginal d/c, hcg to r/o ectopic pregnancy, urine to r/o infection. US, TVUS. **LAPROSCOPY IS THE ULTIMATE METHOD TO DX ETIOLOGY OF CPP** **CPP IS MOST COMMON INDICATION FOR LAPROSCOPY |
| Endometroisis | Size of lesion does NOT correlate with pain |
| Chronic PID | adhesions around tubes, ovaries, etc. |
| Ovarian cysts, | pain from rapid distension |
| Uterine pain | adenomyosis (rem: this is the one when u get menorrhagia) |
| Leiomyomas | Do NOT cause pain unless degenerating, undergoing torsion or pressing in nerves |
| Pelvic Congestion Syndrom | varicosities of pelvic veins and congested organs cause premenstrual pain worse with fatigue, standing, intercourse. Tx: vasoconstrictors, hormones (progestins, GnRH agoniss, emobolotherapy, v. ligationg, hysterectomy. |
| GU s/s cystitis | urgency, frequency, dysuria, penvic pain |
| other causes (dx not made in ~1/3 cases even after laproscopy | nerve, musculoskeletal, PSYCHOLOGICAL |
| Medical management CPP | try OCP, tr y GnRH-agonists for pain related to cycle or ovarian pathology (cysts), NSAID, Antidepressants (increase NE, serotonin). Only surgical if pathology discovered |
| Oligiomenorrhea | menstrual flow at intervals >35 days |
| Abn bleeding before menarche | newborn withdrawl bleeding, trauma, assault, 50% involve lesions of the GU tract. Pelvic exam should be performed |
| By age 18-21 hypothalamic-pituitary axis has matured, therefore what is NOT the most likely cause of abn bleeding in this age group? | ANOVULATION is not the most likely cuase of abn bleeding in this age group |
| what is the most likley cuase of abn bleeding in childbearing yrs? | Pregnancy and pregnancy related conditions (ectopic, abruptio placeta, spontaneous abortion, etc) |
| *Evaluating abn bleeding in childbearing yrs | r/o pregnancy 1st, then look at coagulopathy, pelvic lesions, malignancy, thryoid, dysfunctional uterine bleeding. Older pts be sure to r/o cancers, esp endometrial. Post menopausal bleeding is CA until proven otherwise! |
| Severe bleeding | Stabilize with high dose of estrogen, if successful follow with low dose. If estrogen fails, D&C to control bleeding |
| mild bleeding | OCP may be used, D&C, ablation, or hysterectomy may be needed if bleedign does not stop |
| Dysfunctional Uterine Bleeding (DUB) | abn uterine bleeding in women between menarache and menopause. Not attributed to ther cause. Dx. of exclusion |
| most common cause of DUB in adolescents? | anovulatory bleeding primary caused by hypothalamic-pituitary axis problem |
| most common cause of DUB in Perimenopausal women | Decline in estrogen |
| Tx younger pts with DUB | cyclic progestins if bodie's estrogens can balance, OCP, shorter cycle, then bleed, repeat 3-6 months to try to establish normal cycle |
| If medical therapies fail | move to d/x tests, US etc. Hysterectomy or endometrial abliation if all therapies fail. |
| Primary amenorrhea | no spontaneous uterine bleeding by age of 16 w/normal secondary sex characteristic, or 14 if pts shows signs of abn sexual characteristics |
| Secondary amenorrhea | absence of menstrual period for 6 months in a woman who had periods previously |
| Hyperandrogenism causing amenorrhea | excess testosterone by adrenal tumors |
| Turner Syndrome (Gonadal Dysgenesis) | 45XO, primary amenorrhea, abn gential development, webbed neck, increase carrying angle, no breast development, streak ovaries, infertility, amenorrhea |
| Pseudohermaphroditism | has internal organs of one sex with external physical characteristics of the opposite sex |
| Male pseudohermaphroditism | enzyme deficit in testesterone synthesis. Presents as sexually premature phenotypic girl with male genotype 45 XY, ext genitalia is female, no uterus, intraabdominal tests, tx as infertile hypogonadal woman |
| female psuedohermaphroditism | genetic and gonadal female XX with partial masculinization. Ambigous genitalia, normal internal genitalia. |
| * Most common cause of amenorrhea | Pregnancy |
| Girls with permanent hypogonadism (turner's syndrome...also see shield chest) | Tx w/estrogen replacement therapy |
| Secondary amenorrhea- most common cause | *Pregnancy. Also, PCOS, obesity, hypothyroidism, cushing's disease (inc adrenalin), Asherman's syndrome (uterine adhesions) |
| Progestational challenge | progesterone givena nd withdrawal bleeding (indicates presence of estrogen). If no bleeding, low, estogen levels or problem with outflow tract. |
| Dysmenorrhea | affects 50% women, |
| Primary dysmenorrhea | no readily identifiable cause, age 17-22 usu. Usually during ovulatory cycles within 6-12 months of menarche. Prostaglandins relaeased, tx: NSAIDS, OCP, topical heat, low fat meat decrease diet, if no response consider secondary with work up |
| Secondary dysmenorrhea | underlying cause, usu 30-40 y/o usu associated with dyspareunia, infertility of abn uterine bleeding. endometriosis, fibroids/adenomyosis, PID, pelvic congestion |
| workup secondary dysmenorrhea | cervic cx to r/o STI, WBc to r/o infection hcg to r/o pregnancy, US to evaluate IUP or ectopic, pelvic mass, hysterosalpinogram to r/o endometrial polyps, fibroids, Laparoscopy to determine pathology. Tx: nsaid, OCP |
| PMS | luteal phase, 80% experience it, severe=Premenstrual dysphoric disorder PMDD. Tx: vitamin (ca/mg), mild diuretic (spironolactone), anti anxiety meds (Buspirone), SSRI antidepressants (prozac) in luteal phase, GnRH agonist (Lupron), NSAIDS |
| 95% ectopic pregnancies occur where? most often in which part? | fallopian tube, ampulla |
| Does IVF increase risk? | yes |
| What is heterotopic tube | both in tube and in uterus |
| Most common cause of maternal mortality in 1st trimester? | ectopic pregnancy |
| increased incidence of ectopic pregnancies is related to what? | increased incidence of PID, and increase # tubal surgeries in a conservative leave slighlty damaged tubes in place. Previous ectopic pregnancy increases risk, so does G3, African america/hispanic, IUD usage |
| Problems with ectopic pregnancy | tube may rupture causing intraperitoneal hemorrhage |
| option if ectopic is natural (3) | 1. rupture, 2. reabsorb b/c of inadequate blood supply 3. aborted into the peritoneal cavity |
| Classic triad of symptoms in ectopic pregnancy | 1. amenorrhea, 2. abdominal pain, 3. bleeding |
| acute ruptured ectopic pregnancy | dizzy, hemorrhage, sever abd pain, ipsilaterla shoulder pain if blood irritates the phrenic nerve, LOC, shock, rebound tenderness/guarding, cervical motion tenderness |
| D/x ectopic pregnancy | urine pregnancy test (HCG) AND ultrasound showing it's not in the uterus. |
| which antibody does serum pregnancy test looks for of hcg? | b subunit |
| d/x ectopic pregnancy | hemaglobin/hematocrit, urine or serum test for hcg, TVUS |
| Progesterone levels for intrauterine preg, ectopic, non-viable preg | >25, <15, <5 |
| Culdocentesis inserts into where? | pouch of douglass through posterior vaginal wall |
| ddx ectopic pregnancy (7) | threatened or incomplete abortion, ruptured corpus luteum cyst, acute PID, adnexal torsion, acute appendicitis, pyelonephritis, pancreatitis |
| surgical tx if hemodynamically stable and ustable | stable: laparoscopy. if unstable: laparotomy to access bleeding site (also appropriate if patient has adhesions) |
| indications for salpingectomy | only if tube is severely damaged and les than 6 cm of functional tube remains |
| If the pregnancy is implanted in the ampullary portion what else can you do? | partial salpingectomy and reapproximate tube later |
| salpingotomy vs. salpingostomy | incision that gets closed, opening that is allowed to heal by itself. USE SERIAL HCG TO SEE IF ANY HORMONE PRODUCING CELLS REMAIN |
| Medical managment of ectopic pregnancy | Methotrexate: folic acid antagonists used for hemodynamically stable patients |
| What percentage of couples reproductive age experience infertilitiy? | 15% |
| at what age does the risk of miscarriage, chromosomal abnormalities increase and pregnancy decrease | ~age 37 |
| A fertile couple trying to get pregnancy with appropriate timing what percentage of a success rate? | 20% per month |
| The most common causes of infertility (6) | male factor, ovulation disorders, peritoneal issues, tubal issues, cervical issues, uterine issues |
| Most common cause of female infertility? | ovulation disorders. If she experiences PMS it is due to progesterone and means that she ovulated. |
| Dx. infertility workup (6) | semen analysis, test ovulation, tubal status Hsg, Post-coital test (mid cycle, have sex, look at sperm under microscope), Day 3 FSH/estradiol (low means she has a good reserve), Laparoscopy (+/- therapeutic) |
| 3 ways to treat infertility: | intrauterine insemination, ovulation induction, IVF |
| meds for ovulation induction: | clomapine citrate or tomoxafine to increase her FSH levels to stimulate ovary. In women with PCOS tx with metformine b/c it's an insulin sensitizer and many women wtih PCOS are insulin resistant |
| IVF embryonic transfer is done with a full bladder, T/F? | True, unique! |
| what is PGD? | blastomere biopsy, could technically allow u to chose sex of baby, not done b/c of ethical concerns, no medical reason to have a boy or a girl |
| Domestic Violence | pattern of abusive behavior existing within a home |
| Abuse | force or threat of forrce to maintain power or control in a relationship |
| What 7 categories can abuse fit? | physical, mental/emotional, verbal, sexual, financial, isolation, destruction of personal property |
| What three steps are in the cycle of violence theory? | Tension Building, Violence, and Honeymoon |
| how may homes have some form of domestic violence, how many women are seen in the Er with some form of domestic violence related cc? | 1 out of every two homes, 25-33% are in ER for domestic violence related injuries and/or issues |
| Domestic Violence risk is decreased in teenagers. T/F | False, it increases |
| Domestic violence risk is increased in pregnancy. T/f | True |
| Why doesn't survivor disclose or leave? | FEAR, also love, finances (power and control), hope children (self-sacrificing), self-esteem, awareness, shame, childhood, guilt |
| Pregnancy and DV: are they twice as likey to miscarry? are babies 4x more likely to have low birth weight? are babies 40x more likely to die in the first year? | yes, yes, yes |
| What are two of the most dangerous times for a female in a domestic violence relationship? | while exiting, while pregnant |
| 2 theories of physiology of puberty | 1) critical BMI sets it off or 2) aging neural tissue triggers it |
| what are the two secondary sexual characteristics we monitor? | breast development, pubic hair |
| how to we rank breast development? | Tanner staging. |
| stage 1 | preadolescent |
| stage2 | breat bud stage |
| stage3 | breast and areola enlarge |
| stage4 | areola and nipple forms secondary mound |
| stage5 | mature, only nipple protrudes, areola becomes flush with breast contour again |
| what is SMR? what is adrenarche? | sexual maturity rating. pubic hair development |
| how many stages for pubic hair development, when does axillary hair start? | 5 stages, axillary hair starts approximately 2 yrs after onset of pubic hair |
| age, first visible sign, sex interests for early adolescence | age 8-13 avg 11.2, first visible breast buds begins with smr 1-2 (b2 and/or ph2), sex interest usually exceeds activity |
| Menarche, age, always after XX is reached? | usu 21/2 hrs after beginning of puberty, average age is 12.4, ALWAYS AFTER PH 5 IS REACHED |
| ages, smr, sexual interest in middle adolescence | 14-16, smr 3-5, sex drive surges, experimentation, questions of sexual orientation (also height growth peaks) |
| age, smr, sex interest of late adolescence | 17-20, smr 5, sexual experimentation increases |
| t/f menses is often irregular for the first year, anovulatory possible for 1st year, however can get pregnant before menarche? | True |
| Precocious puberty | developing sex characteristics before age 8. Do a thorough endocrine evaluation |
| central causes of precocious puberty | increase fsh and lh |
| peripheral causes of precocious puberty | increase in sex steroids |
| 5 indications for pediatric pelvic exam | delayed menarche, secondary amenorrhea, unusual vag discharge, abn bleeding, dysmenorrhea unresponsive for 1st line therapy |
| T/F almost half of all std infections occur btwn ages 15 and 24.4 | True |
| at what age should you offer the HPV vaccine? | 11-12 |
| When do you NOT need consent of parents? | emergency situations, emancipated minors, pregnancy related care, provision of bc, sexual assault, hiv, abortion, reportable contagious diseases, drug or etoh abuse/treatment, mental health tx. |
| T/F chlamydia is NOT reportable in NYS | FALSE, must report |
| Definiton of sexual assault | Any sexual act performed by one person on another without that person's consent |
| T/F date rape is more common among teens and college students | TRUE, 9-10 college females knew their attacker |
| 3 basic types of rape episodes | power rape (50% considered PREMEDIATED), anger (more impulsive and episodic), Sadistic |
| Rape Trauma syndrome. what are the two phases? | Acute, and Post acute phases or post traumatic stress disorder |
| physicl and psychological concerns of acute phase? | injury, trauma, infection, shock disorientted, sleep/eating distubances, pt. may have a very controlled and calm response |
| physical/psychological concerns of PTSD phase? | infection, pregnancy, trauma/scars, nightmares, can't dissociate, wants to escape, difficulty with sex, flashbacks |
| What is the hidden agenda, and when does it occur? | during PTSD phase, it occurs when the pt comes in expressing certain concerns they'll attribute to something else when it may be related to the trauma they survived |
| you should ask long winded and brief direct questions to a survivor? T/F | FALSE, use open ended and allow for brief answers |
| Generally, how long do you have from the time of an assault for the physical and evidence exam to be legally valid? how long do you have in NYS? | generally within 3 days, NYS 96 hrs....DOES NOT mean you cannot do the exam after, just means it's less legally valid. The exam is ALWAYS medically valid |
| should you use a traumagram? | YES |
| explain the "chain of evidence" | legal concept for integrity of the specimen. EVERYONE who comes in contact with any specimens must sign for it, broken chain compromises survivor's legal case |
| when should you use a wood's lamp? | to look for semen |
| name some things you'll order labs for? | pregnancy, hiv, c&g, syphillis (VDRL) and HepB, ABO blood typing, slides/wet mount, blood/urine screening if indicated, sterile swap for kit, patient's saliva, anything under nails |
| what labs are followed up? | HIV, syphillis, Hep B at 1-2 wks, 6 wks, 3 months, 6 months after |
| can the survivor give the police a statement and then decide later whether or not to press charges? | yes he/she has up to 5 days |
| How long after you collect the test must it be submitted? | within 30 days |
| definition of menopause | 1 year without menses |
| premature menopause occurs before what age? | 40 y/o |
| how long before final menstruation does perimenopause begin? | 2-4 yrs |
| menstrual flow is often heavier and more frequent in perimenopause. T/F | True, suprises many patients. Estrogen levels are fluctuating |
| What 5 things are reduced estrogen levels associated wtih? | hot flashes, interrupted sleep, urinary symptoms, atrophic vaginitis, loss of bone density |
| 40-60% of women have hot flashes within two year of cessation of menses. T/F | True |
| What percentage of women have hot flashes for more than 5 yrs post menopause? | 30-50% |
| Tx hotflashes includes (6) | lifestyle changes, estrogen (most effective, but highest risk), progestins ("got my period back"), methyldopa (anti HTN centrally acting, safe in pregnancy), Clonidine (anti HTN, CNS acting as well), SSRIs, Gabapentine (neurontin, antiseizure) & bio agent |
| Is hot flashes a disease? | No, it's a disturbing lifestyle event |
| side effects of anti HTNs indicated to tx hot flashes | dry mouth, fatigue, dizziness, depression |
| SSRIs work to do two things | decrease SEVERITY and INCIDENCE of hot flashes, usu need less dose than that needed for depression |
| effects of menopause on the lower urinary tract (3) | atrophic changes, stress incontinence AND urge incontinence, dysuria + increase urgency and frequency |
| effects of menopause on vagina | decrease elasticity, appears pale and dry, **increase pH-> increase bacterial vaginitis |
| tx atrophic vaginitis | topical estrogen |
| Is topical estrogen safe to use? | YES, not taken everyday and so litle of it is absobed systemically it can be used on patients whom systemic estrogen would be contraindicated |
| what age does bone density start to decrease? | 40 |
| T/F amenorrhea from ANY cause decreases bone density | TRUE |
| 5 preventative measures for osteoporosis | weight bearing exercise (swimming is NOT effective), calcium (1500mg qd+800vitD), stop smoking, stop excessive etoh intake, counsel pt if amenorrhea is due to low body weight or strenous exercise |
| Screening requirement for osteoporosis | all >65y/o, >60 if they have risk factors |
| So, is osteoporosis an early sign of menopause? | NO! |
| 3 tx for osteoporosis AND goal of therapy | goal: prevent fractures: estrogen (decreases bone absorption), calcitonin (decreases rate of bone turnover THINK Calci-BONE-IN), biphosphates (fosomax) decreases osteoclastic activity |
| unopposed estrogen (without progestin) increases risk for what cancer? so which patients could it be used on? | endometrial, patients who've had hysterectomy |
| addition of progestins can cause what? what's the difference between cyclic and continuous progestins? | can cause symptoms consistant with 2nd 1/2 menstrual cycle. Cyclic: 12days/month -> cyclic bleeding, 10 days withdrawl bleed. Continuous: smaller daily dose, unpredicatble light bleeding for ~6 months. |
| Relative Contraindications to Estrogen Therapy | leiomyoma, endometriosis, cholelithiasis, migraines, pregnancy-related or OCP related thrombosis, liver disease (b/c estrogen can stimulate liver) |
| ABSOLUTE CONTRAINDICATIONS to estrogen therapy | undiagnosed vaginal bleeding (could be endometrial CA), hx Breast CA, hx Endometrial CA, Active Venous Thrombosis, Malignant Melanoma |
| What did the women's health initiative show re: estrogen replacement therapy? | increase risk in both heart disease and breast cancer on women even with combination therapy. Risk is small, but present. Option, if symtoms are SEVERE, may consider tx with estrogen for a short amount of time (1-2 yrs). obtain informed consent |
| What should you do before prescribing HRT? | med hx, PE + breats exam, Pap, mammogram |
| Bottom line of combination therapy HRT (3) | tx symptoms effectively, increase risk Breast CA, increase risk for heart disease |
Created by:
mcdemarc