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Pre-conception care always think... BMI!!! Age, Hx, Meds, FH, substance abuse, diet
During physical exam for preconception care what should you check for? Dental Caries
During labs for preconception care what should you check for? Rubella, varicells, HepB, HIV, RPR, CBC, G/C culture
Which immunizations can you NOT give if pregnant? MMR & Varicella
How much folic acid pre-pregnancy? .4-.8mg daily _4mg if hx of neural tube defects
When is 1st visit recommended? ~6-8 wks gestation
Gravida-v Para- w x y z v=# pregnancies w=# full term births x=# pre-term births (<37wks) y=# abortions (spont, induced, ectopic) z=# living children
How would you calculate estimated date of confinement (EDC=Delivery Date)? Add 7 days to LMP and subtract last month: LMP: 2/20/11 then EDD=11/27/12
Blue/purple coloration of cervix/vagina Chadwick's Sign
Palpable softening at isthmus Hegar's Sign
What MUST you do on physical exam for 1st prenatal visit? Pap smear, Chlamydia/Gonorrhea Swab
Additional labs for women @risk TB, HepC, Varicella, Trich Vaginalis, HSV, Hgb A1C
What's absolutely necessary to perform at the first prenatal visit Ultrasound to confirm pregnancy
When is the second trimester? Week 13-end of 26
When is the third trimester? Beginning of week 27
How many times should she visit in the first 28 weeks? (1st and 2nd Trimester) Every four weeks
How many times should she visit in wks 28-36 Every two weeks
The first fetal movements (if first pg usually @18-20wks) Quickening
After the first visit, what should you begin monitoring? BP Fetal Heart Tones (120-160bpm norm) Fundal height Extremities
In third trimester what should you do to see the position of the head? Leopold Maneuvers
In third trimester why check the cervical exam? For: Dilation Effacement Station Presenting Part
Station 0 of head Head is @bony ischial spines & fills the maternal scrotum
Negative Stations of head Number of cm head is above the ischial spines
Positive stations of head Number of cm head is below the ischial spines
What should you test for at every visit?? Urine for protein & sugar _Test for CBC in early 3rd trimester to assess for anemia
When should you screen for gestational diabetes? At 24-28wks _>1 abnormal value is sign after 75g 2hr oral glucose tolerance test
During initial labs you use this and then test again in the third trimester. If this tests NEGATIVE then should give Immunoglobulin at 28-30wks Rhogam _Rh Immune Globulin 300ug
When should you test for GrpB strep (swabbing both lower vagina & rectum). Btwn 35-37wks (right before delivery) _If +, need intrapartum Abx prophylaxis to decrease incidence of neonatal GBS
When can you offer aneuploidy screening? At <20wks
1st Trimester Combined Test for Aneuploidy (Down's) Performed 11-13wks w/nuchal translucency w/serum markers
1st Trimester Quad Screen for Aneuploidy (Down's), Neural Tube Defects, Trisomy 18 Maternal serum screen _Can perform @15-18wks (as late as 22wks) _AFP _hCG _uE3 _Inhibin A
In the 1st trimester, why do an obstetric ultrasound? For dating purposes, to ck for bleeding or pain, locate pregnancy location
In the 2nd trimester, why do an obstetric ultrasound? Fetal growth, anatomy survey, placenta location _@18-20wks _Level 1:Basic _Level 2:In Depth Determine future sex
In the 3rd trimester, why do an obstetric ultrasound? Fetal growth, presentation, bleeding _Biophys Profile
During the 3rd trimester do a biophysical profile to check for what? Fetal movement, tone, breathing. Amniotic Fluid Volume Results of nonstress testing
Recommended weight gain for BMI <18.5 during pregnancy (underweight) 28-40 lbs
Recommended weight gain for BMI 18.5-24.9 during pregnancy (normal weight) 25-35 lbs
Recommended weight gain for BMI 25-29.9 during pregnancy (overweight) 15-25 lbs
Recommended weight gain for BMI >30 during pregnancy (obese) 11-20 lbs
Tests for fetal well-being Fetal movement/Kick counts Non-stress Test (NST) Contraction Stress Test (CST) Biophysical profile
Antiemetics used for N/V during pregnancy Phenergan, Compazine, Reglan, Zofran, Ginger
Uterine activity that results in progressive dilation & effacement of the cervix Labor
Thinning/shortening of cervix length. Normal is >2.5cm Effacement
Diameter of cervical os in centimeters. Complete=10cm dilation & 100% effacement Dilation
Regular intervals, gradually increasing in frequency. Increasing intensity; cervical dilation, back/ab pain, no sedational relief. True Labor
Irregular intervals & duration of contractions, intensity NOT changed, no cervical dilaiton, low ab pain, can relieve w/sedation False Labor
Pooling of amniotic fluid in vagina or direct visualization of fluid leaking through cervix may support this Membrane Rupture _Leaks amniotic fluid _Nitrazine Test: Intact pH-5-6 Ruptured pH6.5-8 *blue
Fern test would show what? Amniotic fluid status (if dry, will have fernlike pattern)
Interval btwn labor onset & full cervical dilation & effacement. First stage of labor
Begins with first regular contraction & ends at 3-4cm. Rate of dilation is slow ~.5cm/hr Latent phase in the first stage of labor
Follows the latent phase (of first stage of labor) with rate increasing to ~1cm/hr. Ends with complete dilation Active phase in the first stage of labor
Begins w/complete dilation & ends with infant delivery. Entails the "pushing" phase of birth Second stage of labor
Delivery of infant & ends with delivery of placenta Third stage of labor
Uterine contractions will increase in freq/strength in the POWER PROGRESS of labor. will lead to increased sensitivity of uterine m fibers to oxytocin. What causes initial change? Prostaglandins E2 & F2alpha
During the power phase, what is the adequate labor of uterine contractions 3-5 contractions in 10min
measures frequency and duration of contractions, but not intensity External tocodynamometry
Measures frequency, duration AND intensity of contraction via IUPC (intrauterine pressure catheter) Internal tocodynamometry
Macrosomic Infant >4500 grams _Large infants
Relation of the fetal presenting part to the right or left side of the maternal pelvis Position
Bounded by the symphysis (top), sacral promontory (posterior), & pectinate lines (lateral) Inlet part of bony pelvis
Midpoint of symphysis (top), midpoint of sacral curve (posterior), & ischial spines (lateral) Midpelvis part of bony pelvis
Inferior border of symphysis (anterior), tip of sacrum (posterior), ischial tuberosities (lateral) Outlet part of bony pelvis
Most common, best suited for childbirth Gynecoid position
Occiput posterior presentation Anthropoid
Most UNFAVORABLE position for delivery Android
Least common type of delivery Platypelloid
Passage of the widest diameter of the presenting part to a level below the plane of the pelvic inle Engagement
#2 Flexion With the head completely flexed, the fetus presents the smallest diameter of its head
#3 Descent Greatest rate of descent occurs during the latter portions of 1st stage of labor and during 2nd stage of labor
#4 Internal Rotation Rotation of presenting part from its original position (usually transverse) to anteroposterior position as it passes through the pelvis
#5 Extension Occurs once fetus descends to level of introitus; head will extend beneath maternal pubic symphysis & head delivers
#6 External Rotation (Restitution) The head rotates 45 degrees to line up with shoulders which are oblique in maternal pelvis
Uterus rises in abdomen, globular configuration, gush of blood and/or lengthening of umbilical cord Third Stage of Labor _Placental delivery
Baseline Rate of Fetal Heartrate 120-160 _>180 severe tachy _<100 severe brady
Fluctation in HR with changing amplitude in every beat Short term variability
Wavelike pattern that changes 4-6 cycles/min Long term variability of HR
Acceleration, increases 15bpm above baseline & lasts 15 seconds Periodic changes in fetal HR
Mirrors shape of contraction. Due to head compression. Physiologic. Early deceleration of HR
With respect to timing of contraction, shape & severity. Caused by cord compression Variable deceleration in HR
Caused by fetal HYPOXIA, placental insufficiency, maternal HYPOtension or hypoxia Late deceleration in HR
Short term variability with long term variability present in fetal heartrate Normal fluctuation
Lamaze, relaxation techniques Psychoprophylaxis
Sedatives (Vistaril), Narcotics (Demerol, Stadol, Nubain), Dissociative Drugs (Ketamine) Systemic Drugs during labor
Paracervical block, pudendal block, epidual Labor Pain Relief
Perineal laceration involving only skin & vagina 1st degree perineal laceration
Perineal laceration involving skin, vagina & deeper perineal tissues 2nd degree perineal laceration
Perineal laceration involving external anal sphincter & skin, vagina & depper perianal tissues 3rd degree perineal laceration
Perineal laceration involving rectal mucosa, external anal sphincter,skin, vagina & depper perianal tissues 4th degree perineal laceration
9-13 points on Bishop score High likelihood of successful induction of labor
0-4 points on Bishop score High likelihood of failure with induction of labor
Stripping membranes, amniotomy, PGE gel, oxytocin, Cytotec Induction of labor
Complications of oxytocin 1)Uterine Hyperstimulation: >5 contractions every 10 minutes 2)Fetal distress/intolerance to labor: LATE decelerations of fetal HR 3)Water intoxication: caused by antidiuretic properties of oxytocin
Period following delivery of baby & placenta to about 6 weeks postpartum. Puerperium _Anatomy resolves: uterus involutes, cervix loses marked vascularity/glandular hypertrophy/hyperplasia, ovarian function(lactating influenced by prolactin. While lactating, no ovulation). Vaginal vault will decrease in size.
How long hospitalize after birth? Natural: 1-2days C-Section: 2-4days
Autoab's attack ECM & basement. Affects all levels of skin. 22% genetic. _Trauma: Kobner's phenom (possible) _Contact dermatitis Lichen Sclerosus _POST Menopause _Pruritis _Dysuria, Dyspareunia(painful sex)
Itchy "cellophane paper" waxy/hyperkeratotic WHITE plaques. See purpura, erosion, fissures. (NOT seen where there is keratin, hair or mucous membranes) Lichen Sclerosus _Menopausal women _On vestibule, vagina, rectal mucosa
Left untreated this disease which causes cellophane waxy white plaques may cause squamous cell carcinoma. Lichen Sclerosis _At risk of old or HYPERkeratotic lesions _May be HYPOthyroid
Labs for dx of Lichen Sclerosus (itchy cellophane paper waxy keratin plaques) Vulvar Punch Biospy
Tx of of Lichen Sclerosus (itchy cellophane paper waxy keratin plaques) TOPICAL Ultrapotent Steroid OINTMENT _Temovate!!
Cysts form here as result of obstruction caused by trauma or inflammation. Abscess forms from infected cyst or primary gland infection (polymicrobial or STI) Bartholin Cyst (in labia minora) _Acute, painful UNILATERAL labial swell _Painful sex, pain when sitting/walking _Tender, fluctuating mass that's red/swollen w/cellulitis. _May see FEVER associated w/infection
Tx of Bartholin cyst Incision/drainage with Word Catheter _Culture the pus _Empirically give Keflex or Doxy _Sitz baths 2-3dd after I&D _NO SEX till remove catheter
Neoplastic cells in squamous epithelium. Vulvar Intraepithelial Neoplasia (VIN) _Only VIN 2/3 are true precursors to vulvar cancer
Associated with HPV 16 & 18. Usual type. See in young women. Risk: smoking, immunosuppresion, many sex partners Vulvar Intraepithelial Neoplasia Usual(VINu) Dx: Vulva Colposcopy (acetic acid, lesions will change color from gray to white or red to black) _Typically NO sx _Often associated with cervical intraepithelial neoplasia, therefore MUST perform colposcopy
When should you biopsy a VIN (vulvar intraepithelial lesion) If has pigment
Treatment of VINu (vulvar intraepithelial lesion-usual) with medication All are OFF-LABEL; none really guarantee cure -5FU (Efudex) -Interferon (Intron-A) -Imiquimod (Aldara)
Standard of care tx of VINu Surgical Tx: CO2 laser vaporization (destroys entire epithelium) Local wide excision Vulvectomy Post-Tx Rate: 30-50%
NOT associated with HPV. Differentiated, effects older women >70, involves LOWER 1/3 of epithelium ONLY VINd (vulvar intraepithelial lesion-differentiated) _Associated w/sqaumous cell hyperplasia (Lichen's...) _Prevention: Tx of underlying condition _Tx: Surgery
Post-treatment of VIN Colposcopy vulvar inspection at 6mos, 12mos and then annually.
Most common symptom of vulvar cancer Pruritis _Usually asymptomatic, therefore INSPECT THE VULVA
Varies in appearance from large, exophytic, cauliflowerlike lesion to small ulcerative lesion with lesion to small ulcerative lesion with surrounding hyperkeratosis Squamous cell carcinoma in vulva
Raised lesion w/ULCERATED center & rolled borders Basal Cell carcinoma in vulva
Seen @labia minora & clitoris. Raised DARK pigment lesion Malignant Melanoma on vulvar cancer
Tx of vulvar cancer Surgical removal with inguinal node dissection (radiate if lymph involved)
HPV must be present in order to develop this neoplasm. May have NO history of cervical cancer/neoplasms. Vaginal Intraepithelial Neoplasia (VaIN) _In UPPER 1/3 of vagina _Usually preceded by sqaumous carcinoma of vulva or cervix _At risk if have hx of CIN III
Benign Viral proliferation of VaIN VaIN 1 (Vaginal Intraepithelial Neoplasm-1) _Observation with cytology/HPV/Colposcopy every 6months
Intermediate risk of proliferation of VaIN VaIN 2 (Vaginal Intraepithelial Neoplasm-2) _Surgery +/- chemo
True precursor to vaginal cancer VaIN 3 (Vaginal Intraepithelial Neoplasm-3) _Surgery +/- chemo
Detection of VaIN (Vaginal Intraepithelial Neoplasm) Pap Smear (cytology) Colposcopy
When would you perform a vaginectomy when dealing with VaIN (Vaginal Intraepithelial Neoplasm) Suspect invasion, >40, cytology & colposcopy differ & if extended sampling is needed. _Will remove UPPER 1/3 of vagina (90%success) -SE: shorter vagina, blood loss, skin graft, poor sexual functioning
Used to destroy dysplastic cells to 1.5mm depth but unable to assess lesions extending into vault or lesions within surgical scar from TAH & operator dependent Laser Vaporization
Topical chemo used for VaIN tx _ONLY use if other tx NOT available! 5FU (50-85% success). Causes vaginal epithelium to slough. _ONLY used if other tx options NOT feasible!
Most common reason for vaginal cancer Metastasis from endometrium, ovary or cervix _ONLY when PRIMARY site is from vagina can you call it vaginal cancer _<20% dx under 50 _Squamous Cells MOST common
Most common cell type in vaginal cancer Squamous cell
Milky discharge, vaginal odor & post-sex bleeding are signs of this Vaginal cancer _Since so rare, no standard tx _Combo: vaginectomy & radiation
MOST common type of ovarian cyst. NON-malignant. Will regress after 1-2 menstrual cycles. Follicular Cyst _Mature follicle won't rupture OR _Non-dom follicles will not die in presence of Graafian
NON-resorption of blood from the cavity of the corpus luteum (>3cm) called this. Will resolve after 1-2 menstrual cycles Corpus Luteum Cyst
This cyst, seen with INC chorionic gonadotropin levels is typically seen bilaterally. Fluid is clear, straw-colored. _Hydatidiform Mole _Choriocarcinoma _Clomid Therapy for infertility Theca Lutein Cyst _Will regress if tx underlying disorder
Half of all benign neoplasms are this. Come from germ cells & found along migration pathway of germ cells-->glands. Mature Teratoma _Will see well-differentiated tissue from any of 3 germ layers (ectoderm, mesoderm, endoderm) _Cyst lined with keratined squamous epithelium w/abundant sebaceious & apocrine glands _USUALLY ectodermal origin: hair, teeth
This cyst doesn't typically have sx unless secondary to torsion or rupture. Have urinary frequency/urgency. See back pain. Will feel a pelvic mass on bimanual exam. Mature Teratoma _Will see well-differentiated tissue from any of 3 germ layers (ectoderm, mesoderm, endoderm) _Cyst lined with keratined squamous epithelium w/abundant sebaceious & apocrine glands _USUALLY ectodermal origin: hair, teeth
Dx of Mature Teratoma _Will see well-differentiated tissue from any of 3 germ layers (ectoderm, mesoderm, endoderm) _Cyst lined with keratined squamous epithelium w/abundant sebaceious & apocrine glands _USUALLY ectodermal origin: hair, teeth Transvaginal ultrasound (unilateral, COMPLEX cyst) CEA, CA-125, AFP, bHCG (all should be within normal)
Tx of Mature Teratoma _Will see well-differentiated tissue from any of 3 germ layers (ectoderm, mesoderm, endoderm) _Cyst lined with keratined squamous epithelium w/abundant sebaceious & apocrine glands _USUALLY ectodermal origin: hair, teeth Lapartomy/Laparoscopy Ovarian cystectomy/oophorectomy _10% chance of recurrence
Highest incidence among women 65-74 Ovarian Cancer _2nd most common gyno cancer
Incessant Ovulation Theory of Ovarian cancer Repeated ovarian epithelial trauma by follicle rupture & subsequent epithelial repair causes genetic change within surface epithelium
Gonadotropin Theory of Ovarian cancer Persistent stimulation of ovaries by gonadotropin coupled w/local effects of endogenous hormones. INC surface epithelial proliferation & subsequent mitotic activity.
Reduce risk for ovarian cancer Multiparity Breastfeeding Long-Term OCC use Bilateral Tubal Ligation Low Fat Diet
Serous epithelial neoplasm in OVARIAN cancer From fallopian tube _MOST common type!!!
Mucinous epithelial neoplasm in OVARIAN cancer From cervix
Clear cell epithelial neoplasm in OVARIAN cancer From mesonephros _<1% _Rarely reach size of serious/mucinous neoplasms _Bio AGGRESSIVE _HYPERCalcemia & HYPERpyrexia
Neoplasm from germ cells, 20-30yo, grow rapidly, favor lymphatics & contain mix of tumor types. Typically unilateral. Germ Cell Neoplasms in Ovarian Cancer _Produce helpful tumor markers
Dysgerminoma, endodermal sinus tumor, immature teratoma, embryonal carcinoma & choriocarcinoma Subtypes of Germ Cell Neoplasms in Ovarian Cancer
MOST common type of germ cell neoplasm Dygerminoma _Unilateral _<30
Bilateral germ cell tumor with MOST RAPID growth. Makes AFP Endodermal Sinus Tumor
2nd most common type of germ cell neoplasm seen typically under 20. Makes AFP Immature Teratoma
Uncommon germ cell tumor with rapid growth & EXTENSIVE SPREAD. Makes AFP AND HCG Embryonal Carcinoma
Germ cell neoplasm seen with precocious puberty, uterine bleeding or amenorrhea. VERY RARE. 20's Choriocarcinoma
MOST common type of sex-cord stromal tumor. Causes HYPERestrogenism (precocious puberty, post menopause bleeding). In 50s. Granulosa Cell _Sex-Cord Stromal Tumors
Rare sex-cord stromal tumor that causes HYPERandrogenism. See in 30-40. Sertoli-Stromal cell _Sex-Cord Stromal Tumor
No sx until advanced, Nausea, dyspepsia, changed bowel habits, ab distension, pelvic pressure, abnormal vaginal bleeding, wt loss Ovarian Cancer _Ascites, Inguinal Lymphadenopathy, Pelvic mass
When would you order CA-125? Suspect EPITHELIAL ovarian cancer >65U/mL
When would you order hCG, AFP, LDH Suspect GERM cell tumor
Only 2 germ cell tumors to for sure show hCG Choriocarcinoma Embryonal Carcinoma
Only 2 germ cell tumors to definitely NOT show AFP Choriocarcinoma Dysgerminoma
Tx of Ovarian Cancer Consult gyno oncologist Surgical Staging Chemo
Uncontrolled androgens/metab will INC testosterone, androsterendione, DHEA-S. Will see INSULIN-RESISTANCE & HYPERinsulinemia because insulin changes FSH/LH effects on ovarian function. Will DEC synthesis of SHBG & IGF1. Will see DEC Adiponectin. Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS
Under INC levels of insulin androstenedione what happens to androgens? Androgens converted to testosterone instead of estrogen. This will INC SHGB but because of already high insulin levels, production will be decreased, causing INC in free testosterone.
Infertility, anovulation, obesity, acne, hirsutism, male-pattern baldness, acanthosis nigricans, metabolic syndrome, sleep apnea Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS
What must you rule out before you dx female with Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS HYPERprolactinemia CAH Cushings --After rule out, THEN must have 2 of 3: oligomenorrhea, HYPERandrogenism, polycystic ovaries
What would you expect to find on ultrasound of Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS >12 follicles in each ovary (2-9mm) String of Pearls appearance Ovaries >10ml
What lab would be a good indicator of Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS LH: FSH will =3:1
Tx for Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS Weight Loss (INC SHGB, dec testosterone) Metformin (only if have HYPERinsulin) Combined Oral Contraceptives Fertility consult Provera (protects endometrium) Lifestyle modification
Risks associated with Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS Endometrial Hyperplasia/Carcinoma Type2 DM HTN High Cholest Cardio Dz Stroke
Bartholin glands are located where? At 4 and 8 o'clock position of labia minora
Most common cause of vaginal cancer Metastasis
Stratified squamous epithelium in cervix Exocervix
squamo-columnar junction & metaplastic squamous epithelium in cervix Transformation zone of cervix
Single layer mucin-producing columnar cells in cervix Endocervical canal
HPV will infect which level first before remaining latent, then activated by immune deficiency Basal Layer _mature basal cells containing HPV will migrate from basement membrane to surface
High risk type of HPV HPV 16 & 18
Low risk type of HPV HPV 6 & 11
Will long-term COCs put you at risk for HPV? Yes, COCs are a risk factor for HPV infection
When should you begin screening for HPV Begin at 21
When should you begin performing PAPs? NEVER before 21
When should you stop screening for cervical cancer? Between 65-70 if last 3 consecutive PAPs were normal & no abnormal PAP in the last 10 yrs and no HSIL in last 20yrs
When should you stop screening for cervical cancer after hysterectomy? If hysterectomy was for BENIGN reasons, can stop screening
How often should you screen for cervical cancer? Every 2 yrs
When should you do Cytology + HPV DNA? In Women >30 _If DNA is neg, repeat every 3yrs until 45
BEST screening test for cervical cancer HPV DNA
Receive results with negative HPV DNA. What does this say about the cytology? NORMAL cytology
Receive results with positive HPV DNA. What should you do? Refer for colposcopy
Causes of atypical cells of undetermined significance, NOT HPV: Chlamydia Trach HSV Vulvovaginal Atrophy
See low-grade squamous intraepithelial lesion(HYPERchromatic w/INC cytoplasm) What should you assume? That there's HPV DNA _Refer for Colposcopy!!
Large cell with INC cytoplasm. Hyperchromatic nuclei Low-grade squamous intraepithelial lesion
Large cell with DEC cytoplasm. Hyperchromatic nuclei High-grade squamous intraepithelial lesion _Assume +HPV and refer for colposcopy
What should you do for cytology that may suggest intraepithelial lesions in adolescents? Repeat cytology in 12 months. Remember do NOT give PAP till 21!! _2 positive results, refer for colposcopy
Why should you differentiate between transient & persistent HPV infection (+HPV but NEG cytology). Repeat in 12 mos. Persistently +HPV puts at risk for devo of cervical intraepithelial neoplasia
Woman with endometrial cells on PAP & menopausal. Next step? Transvaginal US +/- endometrial biopsy
What does it mean to see endometrial cells on PAP? Functioning endometrium Benign endometrium w/stromal breakdown Hormone alteration & endometrial cancer
Cervical lesion in LOWER 1/3 of epithelial lining CIN 1 (Cervical Intraepithelial Neoplasm) _Typically regress in 1yr
Cervical lesion in LOWER 2/3 of epithelial lining CIN 2 (Cervical Intraepithelial Neoplasm) _half regress, a quarter progress
Cervical lesion with >2/3 of epithelial lining CIN 3 (Cervical Intraepithelial Neoplasm)
Biopsy confirmed CIN1 (lower 1/3 epithelium) EXPECTANT management _Repeat cytology/HPV test in 12 months _If still abnormal, refer for colposcopy _Lasts >1 yr, can excise
Biopsy confirmed CIN2/3 (involves lower 2/3 epithelium) Tx!! _Cryotherapy or LEEP _REMOVE transformation zone (this only removes the cells, NOT the HPV virus!)
Destroys tissue @transformation zone in cervical neoplasm by NO2. Ablative Therapy _Disadvantage: Cannot do histo on tissues _NO invasion, PG, HIV
After effects of Ablative Therapy Vasomotor response during procedure Cramp Profuse, bad smelling WATER discharge Infection/Bleeding (<5%) Cervical Stenosis (<5%)
What determines success rate in ablative therapy? SIZE of lesion (not the grade). Lesions at 3 and 9 oclock have INC blood supply therefore may RESIST the cooling temp.
High electrical current density-->rapid heating of tissue for cervical dysplasia. Tissue IS ABLE TO SEND to Histo. Loop Electrosurgical Excision Procedure _Has replaced Laser surgery!
Precursor to cervical cancer. Has endocervical gland involvement which is lined w/atypical columnar epithelial cells. Adenocarcinoma in situ _Hard to manage since may be in canal & may have skip lesions
Why might you have delayed dx of Adenocarcinoma in situ Cytology better at seeing SQUAMOUS than Glandular disease (which is adenocarcinoma) _MUST perform Endocervical Curettage during colposcopy
A large area of tissue around cervix is excised for exam Cold Knife Colonization
Gardasil protects against which type of HPV 6, 11, 16, 18 (Quadrivent)
Cevarix protects against which type of HPV 16 & 18 (Bivalent)
This type of cervical cancer is DECREASING. Is microinvasive/invasive Cervical Squamous Cell Cancer
This type of cervical cancer is INCREASING Cervical Adenocarcinoma _Endocervical, Endometroid, Clear Cell, Adenoid Cystic
HPV 16 typically causes this type of cervical cancer Squamous cell (50-60% of the time) =16SS
HPV 18 typically causes this type of cervical cancer Adenocarcinoma (40-60% of time)...ON the rise _=18A
Columnar cells with ELONGATED nuclei that are large, hyperchromatic. See MITOSIS & APOPTOTIC bodies Cervical Cancer
Typically no sx but may see vaginal bleeding (MOST common), after sex bleed, pelvic pain that unilaterally radiates (sign of advanced dz), and vaginal discharge Cervical Cancer
If patient with cervical cancer has pelvic pain that's unilateral with radiation to hip thigh, thoughts? Late Stage Cervical Cancer
Arise from smooth m cells in uterine walls. Made of collagen, smooth m, elastin surrounded by pseudocapsule. MORE common in black women (age 50) Uterine Fibroids
Does estrogen cause myomas (uterine fibroids)? Estrogen does NOT cause myomas, but does encourage their growth. Have higher amt of receptors and estrogen may cause INC ECM growth.
Lies just beneath endometrium Submucosal uterine fibroids
Lies just at serosal surface of uterus Subserosal uterine fibroids
Lies within the uterine wall Intramural uterine fibroids
50 y/o black woman with abnormal uterine bleeding, pain w/contraction, pelvic pressure, infertile & spontaneous abortions uterine fibroids
Saline-Infused sonohystgram & hysteroscopy can help show this uterine fibroids
GnRH agonist that decrease fibroid size. Improves anemia before surgery, allows minimal invasive. Do NOT use >6mos!! Depot Lupron
For patients w/prolonged, heavy menses with NO submucosal fibroids Steroidal therapy OR Lysteda (oral antifibrinolytic): use ONLY during menstrual cycle
Preserves fertility/uterus and can be performed on ALL types of uterine fibroids. Myomectomy
When can you perform an abdominal or minilaparotomic myomectomy? Contraindic for laproscopy (cardiopulm dz or fibroids too big) Prior pelvic/ab radation severe hip dz DEC BMM, renal, liver fcn
Preserves fertility/uterus. ONLY performed on SUBMUCOSAL fibroids Hysteroscopy _Use heated loop to resect _May cause fluid overload & HYPOnatremia
Minimally invasive for fibroids but no future kids! MUST continue a contraceptive too. Only use if NO distorsion (remove fibroids first) Endometrial Ablation _Destroys endometrium
Preserves uterus but NOT fertility to tx fibroids. Embolize uterine a to cut off blood supply to fibroid Uterine a Embolization _NO future kids!! _No numerous/large fibroids!
Presence of endometrial glands & stroma outside endometrial cavity & uterine muscles. Usually in pelvis. Endometriosis _Premenstrual pelvic pain, infertility, painful periods/sex, INC CA-125
MOST common dx for hospitalizing women 15-44 Endometriosis _INC risk of ovarian cancer _Premenstrual pelvic pain, infertility, painful periods/sex, INC CA-125
Retrograde menstruation, deficient cellular immunity (INC risk of AI disorders) & hereditary play risk in this dx Endometriosis _Premenstrual pelvic pain, infertility, painful periods/sex, INC CA-125
Premenstrual pelvic pain, infertility, painful periods/sex, INC CA-125 Endometriosis
Why is their premenstrual pelvic pain in endometriosis? Lesion grows w/estrogen & progesterone but their expansion is stopped by surrounding fibrosis-->pressure & inflammation leading to pain which will subside after menses.
Tender at posterior cul-de-sac. Fixed or retroverted uterus. Adnexal masses or tenderness Endometriosis _Premenstrual pelvic pain, infertility, painful period/sex, INC CA-125
Dx of endometriosis Laparscopy: Red petichial lesions on peritoneal surface. Surrounding peritoneum is thick & scarred. Ovaries show lesions or chocolate cysts. See adhesions.
Red petichial lesions on peritoneal surface. Surrounding peritoneum is thick & scarred. Ovaries show lesions or chocolate cysts. See adhesions. Endometriosis _Chocolate Cysts & red petichia on peritoneum
Tx of mild endometriosis NSAIDS
Tx of mod-severe endometriosis Goal: STOP endometrial tissue stimulation -OCPs -Progestins -Deopot Lupron _Laparscopy w/fulguration _hysterectomy w/bilat salping-oophorectomy
MOST common pelvic genital cancer Endometrial Cancer _Early menarche, late menopause, OBESITY!!!
Huge cause for endometrial cancer OBESITY!!
Cause of endometrial cancer INC estrogen levels which stimulates proliferation of endometrium. Unopposed will cause endometrial hyperplasia & atypia.
Cancer which arises due to UNOPPOSED endog/exog estrogen. Has FAVORABLE prognosis bc well-differentiated tumor Type 1 Endometrial Cancer
Arises independently of estrogen & seen with endometrial atrophy. Poorly differentiated therefore poor prognosis. Type 2 Endometrial Cancer
MOST common type of endometrial cancer Adenocarcinoma
Endometrial cancer NOT associated with HYPERestrogen state. Poor prognosis Serous Carcinoma or Clear Cell (High grade, aggressive with deep invasion)
Most common stage of endometrial cancer found Stage 1 Endometrial Cancer
Abnormal vaginal bleeding, ab cramping, back pain, weight loss, painful sex. Screen if have hereditary nonpolyposis colon cancer syndrome (HNPCC) Endometrial Cancer
Pap smear with endometrial cells may show this endometrial cancer
May cause endometrial cancer Tamoxifen
Tx of endometrial cancer Hysterectomy with bilateral salpingoophorectomy w/pelvic & periaortic lymphadenectomy Radiation (if surgery contraindications) Chemo (RARE, only if advanced dz)
32 yo female presents for her WWE visit and you see she had (-) cytology but (+) HPV DNA on last years Pap. This year cytology remains negative but HPV DNA is still (+). What do you recommend? Refer for Colposcopy with 2 positive HPV tests
When should you offer a colposcopy? With 2 consecutive year HPV + results.
Created by: glittershined



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