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APGO & World Study guide
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Unit 1: Patient Unit 2: OB MFM • Pulmonary changes: o Increases: inspiratory capacity, tidal volume, minute ventilation, total body o2 consumption o Decreases: FRC, ERC (expiratory reserve volume), RV decrease, total lung capacity o Respiratory rate does NOT increase, but respiratory alkalosis (from progesterone) comes from increases in tidal volume and inspiratory reserve volume § MAIN PONT OF RESP ALKALOSIS IS TO FACILITATE CO2 FROM FETUS, WHICH MAKES FETAL HGB MORE AVID FOR O2 o Tocolytics increase risk of pulm edema during pregnancy o CXR: prominent pulm vasculature, normal, 2/2 increased circulating blood volume • Cardiac changes: CO increases up to 33% 2/2 both increases in SV and HR; SVR decreases; most women get systolic murmur 2/2 increases in volume (diastolic murmurs are always abnormal); if a VSD, and pulm vascular resistance exceeds SVR, r—L shunt develops and cyanosis develops o Colloid pressure decreases à edema o Increase in HR (and SV à increase in CO) o Fibrinolytic activity decreases and plasminogen activity increases o DIC when fibrinogen hits normal (~200) b/c increase fibrinogen levels in pregnancy; D-‐ dimers also always present o IVC syndrome: supine, get lightheaded, dizzy, faint, b/c of insufficient shunting from the paravertebral circulation when the uterus impinges on IVC return o Normal: increased second heart sound split with inspiration, distended neck veins, low-‐ grade systolic ejection murmur • Heme: o Increases: Fibrinogen, fibrin split products, 7,8,9,10 o Decreases: protein C and S o Same: prothrombin (II), 5, 12, PT and PTT o Left shift of Hb curve o Thromboembolism risk doubles o Hgb <11 is anemia, leukocyte count can go high as well 2/2 stress • Urinary: hydronephrosis from compression by uterus and R ovarian vein à 2/2 dextrorotation of uterus R>L; residual volume in bladder is also increased b/c P decreases bladder tone o Trace glucose normal b/c increased solute filtration thru kidneys o RAAS increased à affects pts with prior HTN o Hydronephrosis is considered normal on imaging • GI: o Portal vein enlarges (live and biliary tract do NOT) from increased blood flow o GERD increases, increased transit time of food, less GB contraction o Estrogen effects: inhibition of bile acid transport à gallstones, purutitis o Constipation: enlarging bowel, reduced motility, increased H20 resorption o Gums: more edematous and bleed easily o Increased hemorrhoids o Alk phos doubles b/c of placenta production
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o Cholesterol increases o Albumin increases, but looks lower b/c of hemodiluation • Endocrine: o DHEA decreases b/c liver converts to E, serum cortisol increases o Increases insulin, reduced tissue response to insulin, hyperglycemia, maternal hypoG during fasting b/c taken by fetus o Increased bone turnover, increased PTH, no bone loss however • Thyroid: increased levels of TBG from increased estrogen à increased total t4 and t3 with stable levels of free t4/3; thyroid can increase in size in pregnancy by up to 10% • Hair: increases in anagen (growth) and decreases in telogen phases • Leucorrhea of pregnancy: heavier vaginal d/c during pregnancy that some women may mistaken for ROM • Eyes: edema in cornea (blurry vision) and decreased IOP à don’t change prescription for women b/c goes away after pregnancy • In molar pregnancy: always do CXR b/c MC site of mets of gestational trophoblastic dz • Weight gain: >30 bmi, 11-‐20 pounds; if underweight (bmi<18.5), gain 28-‐40lbs Preconception Care • Screening for blood dyscrasias: routine in AA with CBC and Hb electrophoresis • Downs screening o Sequential screen: highest detection rate for trisomy 21; quad screen plus NT and PAPP-‐A o First tri: NT, PAPP-‐A and free beta-‐hCG o Second tri: quad test (AFP, bHCG, estroil, inhibin A) • Risk of miscarriage 2/2 CVS is not related to prior miscarriages from unknown causes Antepartum • DM2 a/w: shoulder dystocia, metabolic disturbances, PED, polydyraminois, fetal macrosomnia, NOT with IUGR Intrapartum • Ketone in urine: dehydration, can be secondary to hyperemesis g. • Must confirm fetal HF and status before placing an epidural. If FHR cannot be found, apply fetal scalp electrode • Intrauterine pressure cath: info on strength and frequency of patient’s contractions o If blood comes when placing: withdraw, monitor fetus and replace if reassuring; possible sources could be placenta separation or uterine perforation • Operative-‐assisted vaginal delivery: forceps or vacuum; if pt cannot deliver infant with one or two pushes during +2 fully dilated stage • Variable decel: umbilical cord compression>>umbilical cord prolapse • Umbilical cord prolapse tx: even if reassuring heart tones and status with baby coming down, elevate the fetal head and perform a c-‐section • Prophylactic episiotomy is NOT recommended Stage Characteristics Nulligravida Multigravida First Onset of true labor to <20h <14h full cervical dilation Latent Phase 0-‐3/4 cm dilation Variable Variable Active Phase ¾ to full dilation >1cm/hr >1.2cm/hr Second Full dilation to birth 30m to 3hrs 5 to 30m Third From delivery of baby 0-‐30m 0-‐30m to delivery of placenta • Arrest of descent: mgmt. is usually C-‐section
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o Nulli: no change in 2 hrs (add another if epidural in place) o Multi: no change in 1 hr (add another hour if epi in place) o MC from cephlopelvic disproportion esp if “prominent ischial spines” • Bloody show: results as cervix beings thinning/effacement • Start pushing once 2nd stage of labor begins • MCC overestimation of amt of descent (station): molding and caput succedaneum (edema of fetal scalp caused by pressure on head from cervix) • Signs that placenta is coming: 1) cord lengthening, 2) gush of blood, 3) uterus becomes more firm and globular (shrinks) • C-‐section indications: uterine rupture, cord prolapse, hemorrhage from placenta previa or abruption Immediate Care of Newborn • Mg use during PEC: check baby for respiratory distress after birth • Large babies: gestational DM; small babies: DM1; both at risk for hypoG • DM babies: hypoG, polycythemia, hyperbili, hypoCa, respiratory distress • Chorio baby: fetal tachy in response to maternal fever, lethargic, pale baby with high temp at birth • Naloxone to infant could put them at life-‐threatening withdrawal • HIV mother: AZT immediately, test for HIV at 24h, do NOT breastfeed Postpartum • Sheehan’s: anterior pit – loss of THS, ACTH, gonadotropins • Endometritis: higher in c-‐section births, prolonged labor, prolonged rupture of membranes, internal fetal monitoring, mult vag exams • Endometritis: MCC postpartum fever • Postpartum depression: w/in 2-‐6mos delivery, >2 weeks o 2 weeks: postpartum blues • Breastfeeding decreases the risk of ovarian CA Lactation • Pain and cracking during b-‐feeding: from malposition of baby • Prolactin stimulates milk production, E & P inhibit lactation, oxytocin stimulates ejection o Nipple stimulation: milk ejection from release of oxytocin • Mastitis tx: Abs and continue b-‐feeding • Candidiasis: from baby’s oral cavity, pink and shiny nipples with peeling at the periphery • Signs baby is getting sufficient milk: 3-‐4 stools in 24h, 6 wet diapers in 24h, sounds of swallowing and weight gain Postpartum Infection • Fever differential: endometritis, cystitis, mastitis, thrombophlebitis (rare) o Thrombo is a dx of exclusion; mgmt. is with anticoag and antibiotics • C-‐section erythematous site: drainage always to evaluate for fascia dehiscence and heal from bottom up • Can also get nec-‐fascitis from c-‐dif which requires debridement and AB’s; characterized by loss of sensation and necrotic tissue Uworld • Uterine atony: o Risk factors: overdistension (multiple gestation, polyhydraminos, macrosomnia), uterine fatigue (prolonged labor) o 80% of PPH within 24h
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o Mgmt: oxytocin infusion, fundal massage, IV access, infusion if BP<90 systole à if oxytocin doesn’t control à carboprost, ergot alkaloid à pack uterus with gauze, foley, sengstaken-‐blakemore tube, bakri postpartum balloon Endometritis: o MCC post-‐partum fever 2nd and 3rd day o RFs: prolonged rupture of membranes (>24h), prolonged labor (>12h), c-‐section, fetal scalp electrodes used o Sx: fever, tender nipples, tender uterus, foul-‐smelling lochia o Mgmt: Broad-‐spec Abs (clinda and genta) to cover polymicrobial infection § PID would be ceftriaxone (gonorrhea) and azithromycin (chlamydia) BPP scoring: o Used in high-‐risk preg, decreased FM, after a nonreactive nonstress test and still nonreactive after vibroacoustic stimulation (b/c common cause of abnormal NST is sleeping baby) o 5 parameters assessed by US: § NST (reactive) § Fetal tone (flexion or extension of extremity) § Fetal mvmt (2 in 30m) § Fetal breathing (20 sec in 30 minutes) § Fluid volume (single pocket greater than 2cm in vertical axis) o 8-‐10 is normal, 2 or less is severe fetal asphyxia § if 8 and dec fluid, delivery § 4 or less, delivery if >26w old o Contraction stress test: used in setting of equivocal NST or BPP test o NST: normal if in 20 min at least 2 accelerations at least 15 bpm increase for at least 15 seconds Screening tests: o For all: cervical cytology, rhesus type and AB, H&H, MCV, rubella immunity, varicella immunity, urine culture, syphilis testing, hepBAg, chlamydia testing (not gon, only if RF), HIV, influenza vaccine during any flu season, offer CF and Down’s genetic tests Breech: o Majority correct by 37th week, no correction before then § Attempt ECV beyond 37th week w/o contraindications: placental abnormalities, hyperextended fetal head, fetopelvic disproportion SAB mgmt o Inevitable or incomplete: hospitalize, give IV fluids, prevent DIC, extensive hemorrhage, sepsis, RhoGAM administration o Inevitable: suction curettage o Missed and after 16th week: induction of labor § IUFD (>20w): induction of labor esp to prevent DIC, coag consumption represented by decreasing fibrinogen, platelet levels, and increasing PT/PTT o Complete: serial bHCG testing to ensure nothing remains in uterus DM during pregnancy o Goals:
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§ T3 and T4 total are increased b/c increase in thyroid binding globulin Increased AFP: from inaccurate dating, NTD (then do amniotic fluid analysis to also find increased aceylcholinesterase), abd wall defects (gastrochisis, omphalocele) o Decreased AFP: downs and Edward syndrome o Downs: low AFP, increased bHCG, low estriol, elevated inhibin A o Edwards: low AFP, very low bHCG, low estriol, normal inhibin A Post-‐partum low grade fever: o Blood clots still coming, small leukocytosis o VERY common in first 24 h PP and mgmn is REASSURANCE o Lochia rubra à lochia serosa à lochia alba Fetal heart tones: o Tx in recurrent variable decel’s (non-‐reassuring in general tx): improve oxygenation by administering O2 to mom and changing maternal position à then amnioinfusion (AROM and infusion of saline into amniotic cavity) o Variable decel: <30 second; intermittent (<50% of uterine contractions) vs recurrent; etiology: cord compression, cord prolapse, oligo PEC: o Severe features: thrombocytopenia, renal insufficiency (>=1.1 Cr or doubling Cr), impaired liver function, neuro sx, pulm edema, very high BP (>=160 OR >=110) o Hypertensive emergency (>=160 OR >=110) tx: hydralazine IV or labetalol IV False labor: o Last 4-‐8w of pregnancy o Contraction are in lower abd and irregular w/o increase in intensity, relieved by sedation, no cervical changes o True contraction: increase in intensity, shortening intervals btwn regular contractions GBS prophylaxis when unknown status: o Del <37w, PPROM (<37w) o Membrane ruptured for >/=18 hours o BGS bacteriuria during current pregnancy o Prior hx of delivery of infant with GBS sepsis Renal colic/flank pain evaluation: US to see renal stones o Don’t do CT or IV pyelogram in pregnancy IUGR: o Symmetric: insult from fetus, begin <28w usually o Asymmetric: insult from mom, normal length but decreased girth § HTN, hypoxemia, smoking, vascular dz, PEC § Better Px than symmetric HELLP syndrome mgmt.: DELIVERY IMMEDIATELY (labor induction or c-‐section) CVS: aspiration from CV of placenta during 10-‐12w; offers earlier dx, can do FISH, ; do in women >35 after US (for instance, if US shows nuchal translucency) o Amnio: 16-‐18w o Risks of CVS: limb reduction, fetal death; increased when done before 9-‐10w gestational age bHCG: alpha unit common among TSH, LH, FSH; promotes male sex differentiation, stimulates maternal thyroid, peaks at 6-‐8w gestational age (a/w nausea?) Progesterone: inhibits uterine contractions during pregnancy; preps endometrium for implantations of fertilized ovum Estrogen: induces prolactin production during pregnancy Acreta: 2/3 need hysterectomy to stop bleeding; previa: 25% risk for accreta after c-‐section
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When to do hysterosalpingogram for infertility workup: when ovulation you know if not an issue, and past hx of PID à fallopian tubes, endometriosis, DES, congenital things • No breastfeeding tx: ice packs and tight-‐fitting bra • Previa: painless bleeding in 3rd tri; US to dx; tx: if mom and fetus stable à scheduled c-‐section; do NOT induce labor b/c could make bleeding worse; if massive bleeding or unstable à ER c-‐ section • Appendicitis dx: US offers least amt of rads < xray < CT • CTS: increased in pregnancy 2/2 estrogen-‐mediated depolymerization of ground substance à edema in tissues à CTS (carpal tunnel syndrome) • Intrahepatic cholestasis of pregnancy: mgmt. for baby is early delivery once fetal lung maturity is established 2/2 risk for demise and meconium-‐stained amnio fluid • Placenta previa and prior c-‐sections: increased risk for placenta acreta • PEC increased risk for placental abruption (b/c of association btwn HTN and abruption) o If bleeding controlled during abruption, can proceed with vaginal and augmentation of labor if necessary o Similarly in PEC pt who just had seizures, but is now stabilized, can also do induction of labor • Isoimmunization: recommends testing at 28w for ABs if Rh(-‐) à if at risk, give rhoGAM at 28w and at time of delivery • Bacteruria screening: 12-‐16w • Luteoma of pregnancy: benign solid lesions on both ovaries, from bHCG, Sx include hirsutism and virilization • Post pregnancy low-‐grade fever: common after pregnancy along w/moderate leukocytosis; also normal is lochia rubra • Grave’s dz: IgG crosses placenta and can cause toxicosis in baby à goiter, tachypnea, tachycardia, cardiomegaly, restlessness, diarrhea, poor weight gain • Cervical incompentence dx: gold std is transvaginal US • Fetal demise: IUFD after 20w gestation; should perform autopsy to determine cause • Chorio: maternal tachy (>100), fetal tachy (>160), uterine tenderness, leukocytosis; a/w PPROM • Vasa previa: mother’s vitals remain stable while babies decrease from tachy to brady to sinusoidal pattern. Can occur during AROM; fetus exsanguinates à immediate c-‐section • All pregnant women should be offered vaccines: flu and TDaP for transplacental immunization • Good for UTI in pregnancy: nitrofurantoin, amoxicillin, first gen ceph à no fluoroquinolones, no Bactrim Unit 3: GYN Contraception & Sterilization • Depo-‐Provera: can cause unpredictable bleeding that resolves usually in 2-‐3 months; after one year of use, 50% have amenorrhea • Plan B: levonorgestrel, not an abortifacient, not terotogenic effects, can give it and start OCPs immediately • Contraindications to combined estrogen pills: thromboembolic dz hx (DVT), lactating women (decreases protein in milk), women over 35 who smoke, or women who get severe nausea on pill • OCPs decrease ovarian and endo CA, but may inc b-‐CA risk if high dose and used for extended time period; slightly higher risk of CIN • Tubal ligation: slight decrease in ovarian CA • IUD lower risk of endometrial CA b/c of progestin release
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• Patch is less effective in heavier women (obese) Abortion • 17-‐OH progesterone is only for prior Hx of preterm labor (20w to 37w) • Recurrent miscarriage is 2 or more consecutive losses or 3 more losses <20w • Antiphospholipid syndrome tx: aspirin and heparin in order to get pregnant • Medical abortion is a/w more blood loss than surgical o Manual vacuum: <8 weeks o d/c <16w and dilation & evacuation >16w o Intact fetus for autopsy: must do medical abortion à induction with intravaginal PGs o Medical abortion with heavy bleeding tx: D/C Vulvar & Vaginal Disease • Lichen sclerosis: chronic inflmm skin changes in post-‐meno and pre-‐menarche pts; sx: vulvar pruritis that is extreme, burning pain and introital dyspareunia; skin changes: polygonal ivory papules (white patches confused with thrush), hypopigmentation, erosions and fissures from scratching, introital stenosis, phimoisis (absorption of clitoris), and labia minora are resorbed; tx: hi potency topical steroids; 5% SCC • Lichen planus: in FA, involves skin, scalp, nails, oral mucus membranes and vulva; vulva gets itchy, burning, bleeds, dyspareunia; skin shows lacy reticular pattern with or without scaring and erosions; tx: topical steroids • Vulvar vestibulitis: tenderness, erythema, painful intercourse, pain wearing tight pants, pain during tampon insertion • Lichen simplex chronicus: rubbing and itching that leads to loss of protective barrier à lichenified, rubor, with or without edema; tx: corticosteroids topical • Pelvic organ prolapse 1st line: Pessary STIs and UTIs • Can have b/l tubo-‐ovarian abscesses with more aggressive PID 2/2 polymicrobial cause • Hospitalize for PID if: high fever, n/v such that cannot tolerate oral meds o Cefotetan or cefoxitin PLUS doxy o Or clindamycin PLUS gentamicin o Outpatient: ceftriaxone, cefoxitin or third-‐gen ceph PLUS doxy with or w/o metronidazole Pelvic Relaxation and Urinary Incontinence • Urge test: bladder contractions while filling o Mainstay of urge tx: anti-‐chol à oxy • Stress: 2/2 urethral hypermobility (straining Q-‐tip angle >30 degrees) and/or intrinsic sphincter deficiency (ISD); or both!; tx: urethropexy o Tx: kegels • Urethral bulking procedure: for intrinsic sphincter def (ISD that causes stress incontinence) but little to no mobility of urethra (drain pipe urethra) • Vaginal prolapse surgery: colpocleisis (also for uterine prolapse) • Pessary: first-‐line, noninvasive tx for POP (can also use pessary for incontinence) Breast • Best prolactin levels are when patient is fasting • If FNA bloody and mass shrinks à excisional biopsy of mass is necessary o If FNA clear and mass shrinks à reexamine in 2 months to make sure cyst hasn’t recurred o If FNA negative à exicisional biopsy b/c high rate of false negatives w/FNA • If no breast-‐feeding desired: ice packs and tight bra • Mastitis: MCC s. aureus, so first-‐line tx is dicloxacillin; erythromycin if penicillin allergy
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Endometriosis • Older women with endo Hx, who has complex ovarian cyst needs work-‐up in case it’s ovarian CA à EXPLORATORY SURGERY • Definitive tx: hysterectomy with BSO b/c 60% who don’t get BSO need to go for re-‐operation • Danazol is NOT first-‐line b/c it causes weight gain, increased body hair/acne and adverse blood lipid levels – decrease LDL and increase HDL o OCPs first-‐line b/c of decrease in estrogen o OCPs induce a decidual reaction in the functioning endometrium à OCPs can also be given continuously to prevent secondary dysmenorrhea o Can also give DMPA (osteoporosis though) or implants • Hemorrhagic cyst: in older women, aSx, mass-‐like, repeat US b/c will likely resolve so no radical workup is required • Trying to get pregnant: clomiphene citrate (similar to PCOS and trying to get pregnant) • Gross: clear white lesions, small dark red or mulberry or brown or powder burn lesions, dark brown chocolate, dark red or blue domes that are 15-‐20cm in size at largest • Histo: endo glands, stroma, epithelium, hemosiderin-‐laden macs Chronic Pelvic Pain • Chronic pelvic pain in teen dx: dx laproscopy • Rx: o GnRH: down-‐regulates axis o Danazol: suppresses mid-‐cycle LH and FSH surges o OCPs: assume pseudopregnancy state • Women with PID can develop chronic pelvic pain o Salpingectomy if persistent pain and there is some type of mass • Ilioinguinal N: pain worse with thigh adduction (obturator injury would be that she can’t adduct), numbness over the right inguinal area and right medial thigh à groin, symphysis, labium, upper inner thigh • Iliohypogastric N: groin and skin overlying the pubis Gynecological Problems • LSIL à colpo (unless pregnant, teen, or post-‐meno) [20% of LSIL on pap have HSIL on colpo-‐ directed biopsy] • After above scenario, colpo shows HSIL (CINIII) & ECC is negative à LEEP to send tissue to path to fully evaluate dysplasia; if invasive cervical CA Ia2 though IIaà radical hysterectomy • ACOG on mammos: annual starting at 50, and at least q2y from 40-‐50yo • LSIL, colpo then showed CIN-‐I, ECC was negative à f/u pap in 6 and 12 mos. Or HPV testing at 12 mos o Excisional or ablative procedures are not indicated for LSIL o Cold knife/LEEP if: positive ECC, HSIL too large for LEEP, can’t see on colpo • Can do hysteroscopy in office or OR • New breast mass in 42-‐yo who drinks a lot of caffeine, mass is mobile, no LAD, rubbery: FNA!!!!!!!!!!! • Adnexal mass felt on PE: transvag US is best way to being workup Dysmenorrhea (book – ch32) • dysmenorrhea and infertility: chronic PID or endometriosis UWORLD • Urinary incontinence: o Stress § Pelvic floor muscle weakness
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Dx: history and PE showing prlvic floor weakness such as uterine prolapse and/or cystocele; UA, cystometry and post-‐void are normal Also increased urethral mobility – dx by cotton-‐swab that shows >30 degree angle when there is an increase in abd pressure Tx: Kegel exercises, pessaries, estrogen replacement • Surgery: Burch or sling or urethropexy
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o Urge: § Causes: detrusor instability, bladder irritation from neoplasm, interstitial cystitis § Sx: more urinary freq than stress b/c they have the urge to go when detrusor is contracting § Tx: oxybutynin o Overflow: § Tx: bethanechol and alpha-‐blockers Vaginismus: o Involuntary contraction of perineal muscles o Cause: psychological o Tx: relation, kegels (to relex muscles), insert dilators/fingers Atrophic vaginitis: o Vag dryness, pruritis, dyspareunia, dysuria, urinary frequency, negative urine dip o Tx: lubricants, low-‐dose vag estrogen cream Interstitial cystitis (painful bladder syndrome) o Chronic condition of bladder of unknown etiology – disruption of GAG layer that coats bladder epi o Triad: urge and frequency with chronic pelvic pain that is made worse by intercourse, bladder filling, exercise, spicy foods; also get nocturia o Pain improves with voiding; bimannual exam: anterior pain o Cystoscopy: submucosal petechiae or ulcerations o Dx: bladder distension w/h20 or K sensitivity testing o Versus cystocele: herniation of bladder making an vaginal wall herniate; similar sx of freq, urge but usually aSx o Tx: dimethyl sulfoxide, NSAIds, antihistamines, TCAs, pentosan polysulfate (a GAG) POF dx: increased FSH and >/= 3 months of amenorrhea in women <40yo; FSH higher than LH b/c FSH takes longer to clear from blood EMB: if >35 with recurrent anovulation, <35 with RF for endo CA (prolonged estrogen exposure, obesity, DM2) and irregular bleeding, excessive bleeding unresponsive to Rx therapy ; if normal à PELVIC US HypoT a/w galactorrhea: TRH stimulates prolactin secretion Candida: pseudohyphae; tx with oral fluconazole; can also use topical nystatin; oral nystatin is used for candida of mouth (thrush) and of esophagus (esophagitis) Amsel critieria for BV: 1) thin, gray-‐white d/c 2) pH >4.5 3) whiff test of fishiness when KOH added 4) Clue cells on wet mount (vag epi cells on coccobacilli) Up to 90% of periods within first year will be anovulatory à causes irregular and longer periods Precocious puberty: before age 8 in girls with the development of secondary sexual characteristics; tx: GnRH agonist
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Unit 4: REI Puberty • Thelarche à adrenarche à growth spurt à menarche o Breasts around 10yo, menarche is 12.7yo; earlier for fatter, less active girls
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Body weight 85-‐101 needed for menses to occur; need sleep, weight and optic sunlight exposure • Rokitansky-‐Kuster-‐Hauser Syndrome: agenesis of vaginal and uterine components, normal ovaries so therefore normal secondary sexual characteristics • Kallmans: suspect when no development of secondary sexual characteristics (2/2 no GnRH from arcuate nucleus of hypothal) à tx: pulsatile GnRH • Normal menarche: between 9 and 17, normal esp if normal secondary sex characteristics • Mullerian agenesis: absence of uterus and cervix (blind pouch vagina); normal ovaries so therefore normal secondary sexual characteritistics; do RENAL US b/c renal anomalies occur 25-‐30% of time in females with mullerian agenesis Amenorrhea • Asherman’s can cause amenorrhea • Do prolactin before LH and FSH in work-‐up of amenorrhea; prolactinoma is the MC pit tumor causing amenorrhea • OCP cessation: may lead to amenorrhea if prior to pill, pt had irregular menses (i.e. oligo-‐ ovulatory cycles) Hirsutism and virilization • Late onset 21-‐hydroxylase deficiency: measure 17-‐OH-‐progesterone • Sertoli-‐leydig cell tumor: 20-‐40yo, acne, hirsutism, amenorrhea, clitoral hypertrophy, deepened voice, adnexal mass • Causes of virilization: PCOS, hypoT, androgen producing tumors (ovary, adrenal gland, pituitary), anabolic steroid use • Spironolactone: aldosterone antagonist Normal and AUB • Medroxyprogesterone acetate mechanism: converts endometrium from proliferative (done by estrogen) to secretory; progestins inhibits further endo growth, convert to secretory, then withdrawal mimics the involution of CL à endo sloughing • Endo Polyp: do not observe is >1.5cm à tx is polypectomy via hysteroscopy • OCPs contraindicated in SMOKING >35 YO!!!!!!!!!!!!! Dysmenorrhea • Mechanism in OCPs for painful periods: progestin in OCPS causes endo atrophy à less PGs from endometrium are produced therefore • Screening: chlam and gon for all sexually active pts 40yo, do EMB to r/o CA • Osteoporosis: best to rate if also know risk factors o Prior fracture, family Hx, race, dmentia, hx of falls, poor nutrition, smoking, low BMI, estrogen def, alcoholism, insufficient physical activity • Estrogen endogenous: from circulating androgens that are converted to E by aromatization Menopause • Contraindication to meno tx: vaginal bleeding à must first do EMB or pelvic US with endometrial stripe <4mm • Bone fracture alone is evidence enough to begin tx for osteoporosis with bisphosphonates after a DEXA scan
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MCC of women stopping HRT: vaginal bleeding which happens during initiation of HRT in first 6 months • Estrogen: best way to stop hot flashes (use for littlest amt of time); also increases HDL while lowering LDL Infertility • Primary if inability to conceive for one year w/o contraception • Hysterosalpingogram: evaluate for tubal dz from PID à after one salpingitis episode, 15% pts experience infertility • Evaluate PCOS first with testosterone test; then can do LH/FSH ratio, which will be increased • Imipramine: causes hyperprolactinemia • hypoT also causes infertility à increased prolactin à no ovulation; confirm with serum TSH and free t4 • exercise-‐induced hypothalamic amenorrhea: normal FSH and LOW estrogen; if change in daily habits doesn’t cure, can use exogenous gonadotropins (FSH and LH) • ovarian reserve: determine with clomiphene challenge test • Males are the issue in 35% of cases à semen analysis if everything is normal o Tests before: pelvic exam, weight/BMI, cycle length and regularity, thyroid function tests, prolactin levels PMS & PMDD • PMS: exercise helps, vita A, E and B6 also help • PMS and PMDD: occur during luteal phase (not follicular) • Tx: OCPs are beneficial as well as SSRIs • PMS is a/w family Hx, lack of B6, calcium and magnesium, as well as other mental illnesses UWORLD • Ovarian torsion: o RFs: ovarian mass (>/= 5cm, reproductive age, pregnancy, infertility tx) o Sx: sudden onset pelvic pain (right more common than left b/c of ligament length), adnexal mass, n/v (don’t usually get with ovarian cyst rupture), possible low-‐grade fever esp if necrosis, vaginal bleeding NOT common o Dx: color Doppler US o Tx: laparoscopy w/detorsion, possible SO-‐ectomy if necrosis or malignancy o Pathophys: twisting of suspensory ligament of the ovary (has vessels in it) aka infundibulopelvic ligament, and also the utero-‐ovarian ligament • Rupture ovarian cyst: o Sudden onset lower pain following sex or strenuous activity; sometimes light bleeding; no n/v usually o Cullen’s sign: periumbilical ecchymoses 2/2 significant intraperitoneal bleeding from rupture o Dx: pelvic US – showing ovarian mass with moderate amt of free fluid • Mittelschmerz: recurrent mild, unilateral midcycle pain from normal follicular enlargement prior to ovulation, pain lasts hours to days, US normal (not needed) • Ectopic: amenorrhea, cramp ab pain, vag bleeding, +bHCG, no intraU preg o Dx: transvaginal US b/c transabdominal cannot see gestational sac at bHCG <6500 but transvag can see one (or not see one) as low as 1500. • Elevated prolactin: causes anovulation and galactorrhea • Turner’s: cause of anovulation, low FSH, low inhibin (marker of ovary function), normal GH levels (even though short), low estrogen (ovarian dysgenesis) • Aromatase deficiency:
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o XX, normal internal genitalia, but ambiguous external genitalia o Later get polycystic ovaries, hi levels of testosterone, hi FSH and LH, no estrogen o Cause of primary amenorrhea, sexual infantilism, clitoromegaly • McCune Albright triad: café au lait spots, polyostotic fibrous dysplasia, autonomous endocrine hyperfunction, most commonly precocious puberty, o Menses before breast and pubic hair • Precocious puberty: early breast, menarche, dx of exclusion b/c work-‐up is normal; tx: GnRH agonist; from a premature secretion of GnRH in a pulsatile manner • CAH: usually leads to precocious adrenarche • Kallman’s syndrome: hypogonadotrpic hypogonadism with anosmia, low FH, FSH, delayed puberty • MIF: in XY (from the Y, or the testes), prohibits uterus, f-‐tubes and upper vagina formation • Androgen insensitivity syndrome: defect/absence of androgen-‐receptors, blind pouch vagina, MIF so no female sex organs, breasts b/c test is converted to estrogen, but no axillary or pubic hair b/c these are dependent on testosterone • POF: <40 yo, increased FSH, LH and decreased estrogen, a/w addisons, DM1, pernicious anemia, Hashimoto’s, only option for future pregnancy is IVF with donor oocyte • In anovulation, FSH and LH levels are normal (just don’t get progesterone release, and don’t get sloughing of endometrium b/c that is caused by P-‐withdrawal); so if person not getting periods, and progresterone withdrawal causes period, it must be 2/2 anovulation and NOT a physical barrier • Primary amenorrhea from Turner’s: FIRST TEST IS measure FSH to see if its central OR peripheral à if high, it’s peripheral (like Turner’s)à karyotyping; if central à pit MRI Unit 5: Neoplasia Gestational Torphoblastic Dz: • Molar incidence: higher in Asians, women <20yo or >40yo, less consumption of beta carotene and folic acid, increased in women with 2 or more miscarriages, prior molar pregnancy (20X more common, and 100X more common if 2 prior moles); no association with obesity, fetal aneuploidy • Snowstorm is the result of: multiple hydropic villi; also find multiple internal echoes • Can get tachy and HTN in molar pregnancy • bHCG >1mil is dx for molar • Mole also a/w elevated bHCG and uterus size greater than gestational dates o Whenever there is a discrepancy btwn dates and uterine size, dx: PELVIC US – excludes multiple gestations, uterine abnormalities, moles • Molar mgmt.: SUCTION CURETTAGE, follow with serial bHCG, only chemo is noncompliant or GTD that persists • Molar types: o Partial: fetal parts maybe, triploidy (69XXX, 69XXY, 69XYY; egg fertilized by 2 sperm of sperm that reduplicates), show marked villi swelling, lower bHCG than complete, older pts, longer gestations, often dx as missed or incomplete abortions o Complete: no fetal parts, diploid (sperm fertilizes an empty egg, 1 sperm that duplicates is 46XX in 90% or 2 sperm that make 46XY in 10%); show trophoblastic proliferation w/hydropic degeneration; present usually with larger uterus, PEC, greater likelihood of post-‐molar GTD (choriocarcinoma) • Further mgmt.: serial bHCG to ensure regression after evacuation, NO pregnancy for 6 months after negative bHCG levels • Chorio dx: DO NOT BIOPSY as in the std with other malignancies, b/c very vascular and cld track; dx by QUANTITATIVE bHCG in a woman with recent term, miscarriage, termination or mole is sufficient to make dx of choriocarcinoma
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Vulvar Neoplasms: • Lichen sclerosis: carries risk of SCC; responds to steroid use o Mgmt. of SCC on vulva: RADICAL VULVECTOMY AND GROIN NODE DISSECTION; only microinvasive SCC can be tx with wide local excision • Vulvar CA: SCC accounts for 90%, melanoma is 5% • Paget’s dz of vulva: an in situ carcinoma; looks like: white, lacey, plaque-‐like lesions poorly demarcated erythema (not a mass), hyperkeratosis areas • VIN from HPV: dark spots, multicentric, sometimes itchy, maybe past Hx of HPV o Mgmt.: local superficial wide excision; likelihood of recurrence is high however; not a full out CA, so don’t do radical surgeries o If widespread can also do CO2 laser ablation • Bartholin’s neoplasm: in region, firm, nontender, somewhat fixed; typically adenocarcinoma, more common post-‐menopausal women (cysts are not very common in post-‐meno women) • Condyloma tx: trichloroacetic acid, imiquimod cream • Cervical dysplasia tx: cryotherapy Cervical Dz and Neoplasia: • Biggest RF for development: HPC and condyloma o Others: early-‐onset sexual activity, mult partners, previous STDs, immunosuppression, smoking, low SES, lack of regular Pap smears; 6 and 11 a/w warts while 16 and 18 a/w with high-‐grade dysplasia and cervical cancer • Pap recommendations o ASCUS positive à either HPV testing or repeat pap (cytology) in 1 year § If HPV negative à routine screening (next pap in 3 years) § If HPV positive or repeat cytology 1 year later shows ASCUS or higher à colposcopy § HOWEVER: if 21-‐24 and HPV positive, then do repeat cytology in 1 year, and follow with colpo only if ASC-‐H (H means cannot r/o high grade sq intraepi) • Screening: o Starts at 21 o 21-‐29 pap q3y o 30-‐65 pap and HPV q5 or pap q3 o stop after >/=65yo if no hx of mod/severe dysplasia or cancer and 3 negative paps in a row or 2 negative co-‐tests within past 10 years, with most recent performed within past 5y o immune compromised: start screening at onset of sex, every 6 mos for 2 times then q1y o 21-‐24: § AUCUS or LSIL à repeat pap in 1y § If in 1 y: ASC-‐H, AGC, HSIL à colpo § If in 1 y: ASCUS or LSIL or negative à repeat in 1 year à if ASCUS again (three times ASCUS so far), à colpo; or negative pap times 2 after first ASCUS à routine screening • Leukoplakia on cervix: white plaque; shld be biopsied • Cervix most concerning: atypical vessels, mosaisicm (new bl vessels on sides), punctations (new vessels on their ends) • Case: HSIL, colpo shows acetowhite lesion with punctations and unsuccessful visualization of entire lesion à ECC is negative (high amt of false negatives though)à cervical conization o Conization is done after ECC to obtain path specimen and r/o cancer (cryo would destroy specimen); done with cold knife cone or LEEP o Indications for conization with knife or LEEP:
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Unsuccessful colpo inc ability to see entire transformation zone Positive ECC Pap smear indicating adenocarcinoma in situ Cervical biops that cant r/o invasive CA Discrepancy btwn pap smears and biopsy results: i.e. HSIL on pap and three negative biops on colpo Uterine Leiomyomas • Sx MC a/w fibroids: menorrhagia; 2/2 1) inc in uterine cavity size means greater SA for endometrium; 2) congestion in myo/endometrium resulting in hypermenorrhea • Dx: pelvic US o Pelvic US has higher sensitivity than CT for uterine and ovarian pathology • Estrogen makes fibroids grow o Tx: GnRH agonist for medical therapy (relieves pain and excess bleeding) • If suspected fibroids and menstrual abnormalities, do ENDOMETRIAL SAMPLING to r/o endo hyperplasia or CA • Adenomyosis: “boggy” uterus, menorrhagia + dysmenorrhea • Fibroid compromise fertility: tx = myomectomy (like in our patient) o If do not desire fertility: uterine A embolization or hysterectomy • Sx: dysmenorrhea, menorrhagia, urinary frequency, constipation (compression effects), back pain Endometrial Carcinoma • Top 5 CA in women: breast, lung, colon, uterine, ovarian • Top 5 gyn CA: uterine, ovarian, cervical, vulva, vaginal • RFs for endometrial CA: late meno, early menarche, nulli, obesity, Tamoxifen, DM (a/w obesity) • D/C: when pt has Sx of CA (bleeding) and endo sample (what you do first) reveals atypical cells • Routine eval shld include CXR b/c lungs is the MC site of mets • Surgical Tx: TAH, BSO, b/l pelvic and para-‐aortic LN-‐ectomy • A theca-‐lutein cyst is seen in presence of molar pregnancy and often b/l • Pt on Tamoxifen: no screening or intervention for monitoring of endometrium ONLY if symptomatic Ovarian Neoplasms • Functional ovarian cyst: adnexal mass that is +/-‐ symptomatic • Endometrioma: endometriosis isolated to the ovary • After optimal debulking, common practice is chemo with combo of taxane and platinum adjunct • Dermoid tumors: solid and cystic components, teeth/hair/sweat glands/cartilage/bone/fat Unit 6: Sexuality Unit 7: Violence Comprehensive Exams UWORLD NOTES • If fetal anomaly is incompatible with life and she goes into PTL, just allow for spont delivery; i.e. b/l renal agenesis • If known gonorrhea negative at visit, then can just treat for chlamydia – with single dose azithromycin 1g • CDC on chlamydia: annual test for sexually active women 25 if they have RFs such as new or multiple sex partners
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Hypovolemia in patient with worsening vitals who was just in MVA: uterine rupture>>placental abruption; more likely to exsanguinate with rupture o Uterine rupture: distended abd with irregular contour N/V: torsion>>cyst rupture Gestational DM tx: 1st line: diet and exercise; 2nd-‐line: insulin Mittelschmerz: think of “middle” meaning midcycle pain 2/2 normal follicular enlargement that occurs prior to ovulation à unilateral, mild pain, lasts a few hrs PPROM: best med to prolong labor onset is antibiotics! Which prolongs for 5-‐7 days, longer than tocolytics and steroids In persistent chronic pelvic pain 2/2 PID: take the chronically inflamed fallopian tube, leave the ovary and take down adhesions Breastfeeding protects against ovarian CA (along with OCPs) PID tx inpatient/outpatient: o Cefotetan or cefoxitin PLUS doxy or clinda PLUS genta (b/c clinda doesn’t do GNs) o Ceftriaxone, cefoxitin or ceph PLUS doxy with or without metronidazole Terb = beta agonist to relax uterus and stop contractions; don’t use >48h; can cause tachycardia, hypotension, anxiety, chest tightening and pain Post-‐term pregnancy a/w placental sulfatase deficiency, fetal adrenal hypoplasia, anencephaly, extrauterine pregnancy If one twin dies, must r/o coagulopathy by measuring maternal fibrinogen levels Cervical cerclage: place in second trimester PPROM at 36w tx: augment labor b/c benefits of delivery outweigh risks of expectant management, namely chorioamnionitis 1st: vag mucosa 2nd: vag fascia and perineum 3rd degree lac: partial or complete rectal sphincter transection 4th: ext anal sphincter, internal anal sphincter, or rectal mucosa o Do medial-‐lateral epi to avoid ext anal sphincter Tocolysis o Terb and ritodrine are contraindicated in DM o Mg sulfate is contraindicated in MG Lowest pregnancy rates: Depo-‐Provera, IUD, Implanon LSIL à colpo next Amnioinfusion decreases repetitive, variable decels Management of lupus during pregnancy: steroids RF for uterine atony: chorio (think of vasodilation), twins, prolonged labor, multiparity, precipitous labor, hydraminos, macrosomnia, general anesthesia, tocin in labor Prolonged latent phase: >20 in nulli and >14 in multi Primary amenorrhea eval: look for uterus on US à if present do FSH, if absent do karyotype; if FSH is increased, do karyotype; if FSH is decreased, do cranial MRI Variables decel: prolapse of cord, nuchal cord, low amniotic fluid levels; recurrent if >/=50% of contractions, progressively lower nadir and longer duration with each subsequent contraction o 1st-‐line mgmt.: improve fetal O2 by changing maternal position and adding suppl O2 o 2nd-‐line mgmt.: amnioinfusion – AROM and saline injection into cavity Placental abruption: can be no bleeding b/c concealed in 20% of cases, and US doesn’t see it either – US is just to r/o previa; uterus also becomes hypertonic during abruption (just as if it would during third-‐stage of pregnancy) FGR estimates: abdominal circumference on US is the most reliable predictor for weight
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Androgen-‐insensitivity syndrome tx: gonads removed after puberty is complete b/c of breast and height à extra testosterone is turned into estrogen responsible for breast development; after gonad removal, estrogen therapy ensues w/o progesterone b/c there is no uterus o MIF they have b/c XY and it is produced by tests à responsible for prohibiting formation of uterus, FT and upper vagina (blind-‐pouch vagina) 5-‐alpha-‐reductase deficiency: XY, don’t have DHT b/c can’t convert it; female external genitalia but virilize at puberty both above ^^ are XY and phenotypically female In IUFD with threatened DIC, tx: induce labor; if DIC, transfuse o Abruption is the MCC of coagulopathy during pregnancy PID and pregnant: inpt tx PTL: intermittent pain (no pain btwn contractions) – distinguish from other etiologies causes constant pain Bleeding in a hemodynamically teen tx (AUB acutely): hi-‐dose estrogen HPV vac: girls 9 -‐26; boys 9 – 21 US for renal stones YES! Paps in immunocompromised, SLE, organ transplant recipients: start them at onset of sexual intercourse, do q6months just twice, then annually thereafter. Increases risk for PTL: multifetal gestation, polyhydraminos, uterine issues i.e. bicornate uterus (uterine distension), abruption of placenta (decidual hem), chorio, maternal/fetal stress, idiopathic Bloody show is a/w cervical dilation during pregnancy – if not cervical dilating, then its NOT bloody show If vaginal bleeding and pregnant, dx: transvaginal US to r/o previa
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