OBGYN - Review
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**Failure to dx breast ca is number 1 lawsuit | **Failure to dx breast ca is number 1 lawsuit | ||
**bad baby is #2 lawsuit | **bad baby is #2 lawsuit |
Revision as of 23:44, 14 December 2011
Contents |
OBGYN Review
- 2-3 question per hour
guy in gynecoloe
- 2-3 very easy questions
- Semmelweis: figured out would prevent disease.
- Liability
- Failure to dx breast ca is number 1 lawsuit
- bad baby is #2 lawsuit
Early preg loss
- 1 scenario with 3-4 related quesetions
- Pregnancy test is first.
- know the definitions of the abortions
- Abort is any loss before 20 weeks gestation
- threatened, 25% bleed in second trimester
- septic is "any of the above" with maternal infection
- 70% of spontaneous abortions are because of ch abnormalities.
- Trisomies are mosst common
- Tx:
- threatened: expectant management, pelvic rest, reassurance
- inevitable / in complete: d&c, methergine, anti rh
- 98% of all ectopics are in the fallopian tubes
- etiology: not important
- dx preg sample:
Family Planning
- 3 basic questions
- 85% cahnce of getting pregnant with absolutely no protection
- Know the contraindications to CHC
- dvt, prolonged immobility
- smoking over the age of 35
- Hypercoag state like leiden
- poorly controlled HTN
- IUD, IUC, IUS
- Know the indicators, contraindications:
- Contra:
- preg
- unexplained vag bleeding
- infection (uterine)
- uterine fibroid / septum
- pelvic tb
- indicators:
- contraception sample?
- cervical cancer is not an hereditary disease but a lifestyle disease (HPV)
- IUD is the least appropriate because it causes peritonitis and endometriitis upon infection.
Maternal Fetal Phys
- 3 questions, case presenation; gi, heme, and pulm phys
- first trimester: progesterone causes n/v by slowing smooth muscle
- average weight gain is 20 pounds
- not uncommon to lose weight first
- physiologic anemia
- plasma up by 50%
- rbc up by 30%
- more fluid compared to rbc (both increased)
- hb is around 11.5
- normal preg state
- compenstated respiratory ?
- relative hypervent to blow off co2
- po2 is elevated (106-108)
- Questions
prego gone wrong
- 2 cases, focus on case management; 1 case on dx
- preelampsia, previa, and ?
- definitions are important
- chornic htn is before 20 and after 12 wpp
- preeclampsia: no bp issues until 20 weeks, then 300 mg proteinuria.
- eclampsia:
- tx: stabilize mom (before delivering).
- magn sulfate, abcs, hypertensions in the severe malignant range (could stroke out)
- once stable: vag, induce, c/s
- placental abruption
- separte from the uterus
- abnd pain, non-reassuring heart rate, u/s is bad a dx of abruption
- trauma increases suspicion
- causes: cocaine, smoking, fibroids,
- placenta previa
- even partial is indicator for c/s
- low=lying
- vaso previa: major vessel between baby and os
- tx: conservative management, monitor
- tx: with bad heart tones or bleeding after 34 weeks, deliver the baby
labor: normal, abnormal, etc.
- 3 questions: placenta acreda, pelvimetry,
- diag cong: indirect measurement of the obstetric conjugate.
- should be 11.5 cm
- obst is diag - 1.5/2 cm (9.5-10)
- fetal head is about 10 cm
- palpate the ischeal spines; convergent or deconvergent walls
- bituberous diameter: 6-8cm is ideal
- Pubic arch: 90 degrees
- if all are adequate, assume delivery without difficulty
- even if diagonal is slightly small, still try vaginal
- ischeal spines are not usually contraindicators of vag delivery
- fetal monitor
- 120-160 normal
- variability, should go up and down
- accelerations are good
- some decels are normal
- hr during contractions
- decels:
- early: with contractions (dip with contraction), vagal (head compression)
- late: after peak contraction, fetal hypoxia (poor fetal reserve)
- early and late are smooth curves, usually.
- delivery qucikly if not near to vag delivery
- variable: sharp v, any time; cord compression (usually not worrisome unless deep or many)
- c-section:
- uterine rupture, prior c/s, placenta previa
- accreta:
- nitty box layer borked, placenta can't attach, may grow into womb and even into the bladder.
- occurs after vaginal rupture
- if prev c/s, pre
- chance of pp with 1 c/s chance is 24%
- question:
?
- 3 questions, 1 focuses on the type of anomaly, 1 on incidence of congenital anomalies,
- malformation: intrinsically abnormal dev process (begin)
- dysruption: end organ starts normal but then encounters teratorgen that interferes
- because it is so early, amniotic bands can be considered a disruption
- deformatioN: abnormal form or shape
- oligohydraminos: hose over head
- many secondary to low fluid
- dysplasia: abnormal cellular formation
- renal dysplais with obstruction
- single minor anomalies are common: 14%
- 3% of inftants have a major anomaly
- teratology:
- all or nothing is the first 2 weeks: cleavage, implantation
- 75% of pregnancies are aborted
- questions:
- B
abnormal uterine bleeding
- cut your grass
- 3 questions, AUB
- know the chart of the uterine / ovarian cycle
- before ovulation: follicular ovarian (estrogen) cycle, proliferative uterine cycle
- after ovulation: corpus luteum (progesterone) ovarian cycle (luteal phase), secretorial endometrial phase
- dysfunctionl uterine bleeding:
- anovulation is the cause
- when you don't ovulate, no corpus luteum
- progesterone turns endomet to secretory
- without ovulation, entire endometirum (cycle dominated by estrogen) keeps prolifearting; outgrows the blood supply; build more and more wihtout bleeding; then heavy bleeding / spotting
- amenorrhea
- terminology
- menorrhagia: heavy, prolonged
- metorrhagia: light, irregulart
- menotomorrhagia; heavy, irregular
- amenorr: abscent for 3 cycle
- oligo: interval is > 35 days (21-35 norm, 28)
- polymen: interval is < 24
- intermenstrual is between reg periods
- spotting: before reg cycle
- ?: bleeding after intercourse
- intermenstrual cycle:
- cause: polyp, cerv cancer, IUD, infection
- ovulation
- VWD: with bleeding gums
- anovulatory cuases: POD
- etiology:
- hormonal: anovulation
- anatomical: coagulopathies
- questions:
- atrophic vaginitis
Menopause and hormone repl
- 3 questions: 1 clinical scenariso, sx w/ menopause, menopause workup
- FSH is increased when menopausal
- No end organ means no estrogen to feed back on hypothal to inhibit fsh release.
- checking estrogen doesn't help
- declining fertility in menopause is not absolute
- can't still get pregnant (52!)
- contraindications to estrogen replacement:
- undiagnosised abn genital bleeding
- active thrombosis
- pregnancie
- ?cancer?
endometrial cancer and breast cancer are contraindications
- eavl of post menopausal:
- menopausal stage, diagnoses, mamogram,
- rule out pregnancy
- blue slide: don't worry about it
- questions
- endometrial cancer suspicion
- all the rest are not contraindications
- loss of concentration is a s/e of menopause
- others are: decrease libido, decreased vag lubrication, depression
infertility
- 3 questions that center on evaluation and diagnositics for infertility
- def: 1 year reg coitus w/o conception
- infertility: single factor or several factors
- don't do every test, work it up
- careful history and pe is important to narrow tests
- normal fertility:
- reg ovulation
- patent fillopian tubes
- receptive endometrium, with hormone cascasde
- cervical mucus (favorable state)
- Male:
- spermatogenesis
- erectile and ejaculatory competence
- anovulation associated with ovarian failure:
- details are in excess
- turner syndomre: primary amenorrhea, ovarian streaks, no secondary sexual characteristics (because of primary gonadal failure)
- Primary gonadotropic deficiency: no lh / fsh; hypogonadic; anosmia (can't smell);
- functional chronic anovulation: athletes, anorexics; stress suppresses gonadotropic release at hypothal; good for famine; certain amount of body fat needed to maintain lh / fsh levels;
- polycystic ovarian disease: most common cause of anovulatory; hirsuitism, high bmi; oligo / amenorrhea; insulin resistance;
- anovulation workup:
- fsh, lh, prolactin (prolactinemia can cause amenorrhea)
- ct of sela tercica for prolacitnoma
- ovaries via pelvic u/s: present?, multiple follicles? (pod)
gyn cancers
- 1 questions on risk factors of endometr, 1 on dx, 1 on appropriate tx for pelvic mass
- endo cancer: risk sinclude age, an null-gravis, unopposed hormone replacement
- presentation: abnormal bleeding, post-menopausal (or pre_
- factors: obesity, hypertension, diabetes
- uterine cancer:
- prego test first
- office biopsy (pipelle), 98% sensitivity
- histeroscopy is gold standard
- can show cancer lesion for direct biopsy
- in known cancer, fluid may push cancer into peritoneal cavity (contraindication)
- u/s: endo should be less than 6 mm, over is indicator for biopsy
- endo cancer epi:
- paps catch most: 60% in stage 1
- mintorities and undersreved have higher risk
- multiparity, early pairty, early ccoitus increase
- HPV: 16, 18, 31, 33
- screening:
- 21 yo, not based on time of first coitus
- some young cases resolve on their own (hpv) b/c of high turn over (whereas older poeple have lower turnover)
- paps every 1-2 years; until 70 or total hysterectomy
- no stats
- adnexal mass:
- asymptomatic is good, cystic means benign, young 15-45 is good, may resolve
- bad: solid, painful, persistent, complex, ascities, omental caking, lymphadenopathy
- ddx:
- do pelvic exam
- do ca125 as triage for gyn onc as backup
- u/s > ct for dx
- tx: operate on large, mass with ascites in a 60 yo
- questions:
- c; ovarian cancer: ?