Step 1 Express 2018-Reproductive

First Aid Express 2018 workbook: REPRODUCTIVE

page 1

Reproductive Questions EMBRYOLOGY 1.

Place a checkmark in the appropriate column for the embryologic origin of the the organs. (p 595)

Embryologic Derivative

Ectoderm

Mesoderm

Endoderm

Adenohypophysis Muscle Brain Wall of gut tube PNS Bone Kidneys Oligodendrocytes Spleen 2.

What symptoms might a newborn suffering from neonatal abstinence syndrome display? (p 597) ______________________________________________________________________________ ______________________________________________________________________________

3.

What two two structures structures does does the urachus connect? What two structures does the the vitelline duct connect? connect? What are the clinical consequences of either of these ducts failing to close? (p 600) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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page 2 4.

Describe the genetic signal that directs differentiation along the male pathway rather than the female (default) pathway, naming specific cell types and factors. (p 604) __________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

ANATOMY 5.

Describe the venous drainage flow from the left ovary/testicle. Describe the venous drainage flow from the right ovary/testicle. To which lymph nodes do these structures drain? (p 606) ______________________________________________________________________________ ______________________________________________________________________________

6.

On which side are varicoceles more common and why? (p 606) ___________________________ ______________________________________________________________________________

7.

Match the female reproductive system ligament to the structures it connects. (p 607) _____ A. Connects cervix to side wall of pelvis

1. Broad ligament

_____ B. Connects ovaries to lateral pelvic wall

2. Cardinal ligament

_____ C. Connects ovaries to uterine horn

3. Ovarian ligament

_____ D. Connects uterine horn to labia majora

4.

Round ligament

_____ E. Connects uterus, fallopian tubes, and

5.

Suspensory ligament of the ovary

ovaries to side wall of pelvis 8.

What pathway do sperm follow during ejaculation? (p 608) ________________________________ ______________________________________________________________________________

9.

Why aren’t gametes attacked by a man’s immune system? (p 610) _________________________ ______________________________________________________________________________

10.

Which cells in the male reproductive tract secrete inhibin? Which secrete testosterone? (p 610) ______________________________________________________________________________



page 3

PHYSIOLOGY 11.

What are the three major forms of estrogen? How do they compare in potency? (p 611) ________ ______________________________________________________________________________

12.

What are the three major sources of estrogens? (p 611) _________________________________ ______________________________________________________________________________

13.

Which estrogen is used as an indicator of fetal well-being? (p 611) _________________________

14.

List the four functions of estrogen. (p 611) ____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

15.

What are the structural causes of abnormal uterine bleeding? (p 614) ________________________ ______________________________________________________________________________ ______________________________________________________________________________

16.

Identify the hormone levels shown on the image. (p 613)


page 4 17.


Where is hCG synthesized? When is hCG first detectable in the blood? In the urine? (p 614) ______ ________________________________________________________________________

______________________________________________________________________________ 18.

In what pathologic states can hCG levels be elevated? (p 614) ____________________________ ______________________________________________________________________________

19.

What hormonal changes occur during menopause? (p 617) ______________________________ ______________________________________________________________________________

20.

What are the sequelae of menopause? (p 617) ________________________________________ ______________________________________________________________________________

21.

What are the three major forms of androgens? How do they compare in potency? (p 617) _______ ______________________________________________________________________________

22.

List the five functions of testosterone. (p 617) __ _______________________________________ ______________________________________________________________________________

PATHOLOGY 23.

Klinefelter syndrome is associated with which karyotype? What are the clinical findings? (p 620) ______________________________________________________________________________

24.

Turner syndrome is associated with which karyotype? What are the clinical findings? (p 620) ____ ______________________________________________________________________________



25.

page 5

In the chart, indicate whether the lab findings are elevated, decreased, or normal (p 621)

Diagnosis

LH

Testosterone

Defective androgen receptor Hypogonadotropic hypogonadism Hypergonadotropic hypogonadism Testosterone-secreting tumor or exogenous steroids 26.

Define the following terms and list the risk factors. (p 623) A.

Abruptio placentae __________________________________________________________ __________________________________________________________________________

B.

Placenta accreta ____________________________________________________________ __________________________________________________________________________

C.

Placenta increta _____________________________________________________________ __________________________________________________________________________

D.

Placenta percreta ___________________________________________________________ __________________________________________________________________________

E.

Placenta previa _____________________________________________________________ __________________________________________________________________________

27.

What are the most common risk factors for ectopic pregnancy? (p 624) _____________________ ______________________________________________________________________________

28.

What are the risk factors for preeclampsia/eclampsia? (p 625) ____________________________ ______________________________________________________________________________

29.

What is HELLP syndrome? (p 625) __________________________________________________ ______________________________________________________________________________



page 6 30.

Rank the incidence of gynecologic tumors in the United States from most common to least common: cervical, endometrial, and ovarian. Then rank the prognosis of these tumors from worst to best. (p 625) ________________________________________________________________________

______________________________________________________________________________ 31.

A 68-year-old female patient presents with porcelain-white plaques on her vulva with a red border. What is her most likely diagnosis, and what disease could follow in later years? (p 626) ___________ ______________________________________________________________________________

32.

33.

Match these gynecologic conditions with their associated findings. (pp 622, 624-629) _____ A. Cervical carcinoma in situ

1. Too little amniotic fluid

_____ B. Choriocarcinoma

2. Too much amniotic fluid

_____ C. Dysgerminoma

3. Call-Exner bodies

_____ D. Endometriosis

4. Chocolate cysts

_____ E. Granulosa cell tumor

5. Dermoid cyst

_____ F. Krukenberg tumor

6. HPV types 16 and 18

_____ G. Mature cystic teratoma

7. Increased AFP level

_____ H. Oligohydramnios

8. Increased CA 125 level

_____ I. Ovarian cancer

9. Increased hCG level

_____ J. Polyhydramnios

10. Increased hCG and LDH levels

_____ K. Yolk sac tumor

11. Signet cells

What hormonal changes occur in polycystic ovarian syndrome? (p 627) ____________________ _____________________________________________________________________________

34.

Match these breast tumors with their associated diagnostic findings. (pp 631-632) _____ A. Ductal carcinoma in situ

1. Bilateral

_____ B. Fibroadenoma

2. Ductal atypia

_____ C. Inflammatory carcinoma

3. Eczematous patches on nipple

_____ D. Intraductal papilloma

4. Hard mass with sharp margins

_____ E. Invasive ductal carcinoma

5. Increased tenderness prior to menstruation

_____ F. Invasive lobular carcinoma

6. Nipple discharge; benign

_____ G. Paget disease of breast

7. Peau d’orange



35.

Match these testicular conditions with their associated diagnostic findings. (pp 633-634) _____ A. Acquired hydrocele

1. Androblastoma

_____ B. Choriocarcinoma

2. Associated with lack of circumcision

_____ C. Leydig cell tumor

3. Dilated epididymal duct

_____ D. Seminoma

4. Dilated vein in pampiniform plexus

_____ E. Sertoli cell tumor

5. Increased fluid around testicle

_____ F. Spermatocele

6. Increased hCG level

_____ G. Squamous cell carcinoma

7. Most common testicular tumor

_____ H. Testicular lymphoma

8. Most common testicular tumor in older men

_____ I. Varicocele

9. Reinke crystals

_____ J. Yolk sac tumor 36.

page 7

10. Schiller-Duval bodies

Why is benign prostatic hyperplasia more likely to cause urinary retention than prostatic adenocarcinoma? (p 635) _________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

37.

How are most prostate cancers diagnosed? (p 635) _____________________________________

PHARMACOLOGY 38.

Continuous leuprolide has _______________ (agonist/antagonist) properties, whereas pulsatile leuprolide has ______________ (agonist/antagonist) properties. (p 637)

39.

How does clomiphene stimulate ovulation? (p 637) _____________________________________ ______________________________________________________________________________

40.

What is the main clinical use of tamoxifen? (p 637) _____________________________________

41.

How do oral contraceptive pills prevent pregnancy? (p 638) ______________________________ ______________________________________________________________________________

42.

In which patients are oral contraceptive pills contraindicated? (p 638) _______________________ ______________________________________________________________________________


page 8


43.

What drugs are commonly used to treat BPH? (p 639) ____________________________________

44.

What toxicities are associated with sildenafil, vardenafil, and tadalafil? Which class of heart medications should these never be combined with? (p 639) ______________________________ ______________________________________________________________________________



page 9

An swers EMBRYOLOGY 1. Embryologic Derivative

Adenohypophysis

Ectoderm

Endoderm

√ √

Muscle

√

Brain

√

Wall of gut tube

√

PNS Bone

√

Kidneys

√

Oligodendrocytes

√

Spleen

2.

Mesoderm

√

Uncoordinated sucking reflexes, irritability, high-pitched crying, tremors, tachypnea, sneezing, diarrhea, and possibly seizures.

3.

The urachus connects the bladder and the yolk sac; the vitelline duct connects the yolk sac to the midgut lumen. Patent urachus leads to urine discharge from the umbilicus, and a vitelline fistula leads to meconium discharge from the umbilicus.

4.

The SRY gene on the Y chromosome produces testis-determining factor, which leads to development of testes. Within the testes, Sertoli cells produce Müllerian inhibitory factor, suppressing development of the female reproductive tracts, and Leydig cells produce androgens to direct development of the male tracts.

ANATOMY 5.

Left ovary/testicle → left gonadal vein → left renal vein → inferior vena cava. Right ovary/testicle → right gonadal vein → inferior vena cava. Para-aortic lymph nodes.



page 10 6.

Left side. In contrast to the right testicular vein which drains directly into the IVC, the testicular vein on the left first drains into the left renal vein before draining into the IVC. This leads to a greater pressure buildup in the left testicular vein relative to the right.

7.

A-2, B-5, C-3, D-4, E-1.

8.

Remember SEVEN-UP: Seminiferous tubules

→

Epididymis

→

Vas deferens

→

E jaculatory ducts

(Nothing) → Urethra → Penis.

→

9. 10.

Adjacent Sertoli cells form tight junctions that serve as a blood-testis barrier. Sertoli cells. Leydig cells.

PHYSIOLOGY 11.

Estradiol is more potent than estrone, which is more potent than estriol.

12.

Ovary (estradiol), placenta (estriol), and adipose tissue (aromatization).

13.

Estriol is used as a marker of fetal well-being.

14.

Development of genitalia and breast/female fat distribution, growth of follicle/endometrial proliferation, upregulation of estrogen/luteinizing hormone/progesterone receptors and feedback inhibition of FSH/LH, and increased transport of proteins.

15.

Structural causes (PALM) including Polyp, Adenomyosis, L eiomyoma, or Malignancy/hyperplasia, and non-structural causes (COEIN) inclduing Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Not yet classified. Remember PALM-COEIN.



page 11

16.

17.

In syncytiotrophoblasts of the placenta; 1 week (blood); 2 weeks (urine).

18.

hCG levels can be elevated in hydatidiform moles and choriocarcinoma.

19.

Decreased estrogen and increased FSH, LH, and GnRH levels.

20.

Remember: HAVOCS: Hot flashes, A trophy of Vagina, Osteoporosis, and Coronary artery disease, Sleep disturbances.

21.

Dihydrotestosterone is more potent than testosterone, which is more potent than androstenedione.

22.

Differentiation of the internal genitalia (except prostate), growth spurts, deeping of the voice, closing of the epipyseal plate, and libido.

PATHOLOGY 23.

47,XXY; testicular atrophy, eunuchoid body shape, tall stature, long extremities, and gynecomastia.

24.

45,XO; short stature, ovarian dysgenesis, webbing of neck, preductal coarctation of the aorta, and primary amenorrhea.



page 12 25. Diagnosis

LH

Defective androgen receptor Hypogonadotropic hypogonadism Hypergonadotropic hypogonadism Testosterone-secreting tumor or exogenous steroids 26.

A.

Testosterone

↑ ↓

↑ ↓

↑

↓

↓

↑

Abruptio placenta: premature separation of placenta from uterine wall. Risk factors include trauma, smoking, hypertension, and cocaine abuse.

B.

Placenta accreta: defective decidual layer leads to abnormal attachment to myometrium without penetrating it, and separation after delivery. Risk factors include prior C-section or uterine surgery involving myometrium, inflammation, placenta previa, advanced maternal age, and multiparity.

C.

Placenta increta: placenta penetrates into the myometrium. Risk factors same as for placenta accreta.

D.

Placenta percreta: placenta penetrates myometrium into surrounding uterine serosa. Risk factors same as for placenta accreta and increta.

E.

Placenta previa: placenta attaches to lower uterine segment. Risk factors include multiparity and prior C-section.

27.

Prior ectopic pregnancy, history of infertility, salpingitis (pelvic inflammatory disease), ruptured appendix, prior tubal surgery, smoking and advanced maternal age.

28.

Preexisting hypertension, diabetes, chronic renal disease, and autoimmune disorders.

29.

HELLP: Hemolysis, Elevated L iver enzymes, L ow Platelets.

30.

For incidence: endometrial > ovarian > cervical. For prognosis: ovarian > endometrial > cervical.

31.

Lichen sclerosus; non-HPV vulvar carcinoma.

32.

A-6, B-9, C-10, D-4, E-3, F-11, G-5, H-1, I-8, J-2, K-7.

33.

↑ LH:FSH, ↑ testosterone, ↑ estrogen .

34.

A-2, B-5, C-7, D-6, E-4, F-1, G-3.



page 13

35.

A-5, B-6, C-9, D-7, E-1, F-3, G-2, H-8, I-4, J-10.

36.

In BPH the periurethral lobes enlarge to compress the urethra. Prostatic adenocarcinoma occurs most commonly in the posterior lobe of the prostate, and the tumor would need to grow quite large before it impinged on the urethra eno ugh to cause urinary retention.

37.

Increased PSA and subsequent needle core biopsy.

PHARMACOLOGY 38.

Antagonist; agonist.

39.

By preventing normal feedback inhibition and increasing LH and FSH release from the pituitary.

40.

To treat and prevent recurrence of estrogen receptor–positive breast cancer.

41.

OCPs prevent the estrogen surge, which in turn prevents the LH surge, and thus ovulation.

42.

Smokers >35 years old, patients with a history of thromboembolism and stroke, and those with a history of migraines, breast cancer, or liver disease.

43.

Finasteride, tamsulosin, and tadalafil.

44.

Headache, flushing, dyspepsia, impaired blue-green color vision, and severe hypotension. They should never be taken with nitrates, as this combination can exacerbate hypotension even further.


Step 1 Express 2018-Reproductive

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