OBGYN - Review

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=OBGYN Review=
=OBGYN Review=
-
*2-3 question per hour
+
*2-3 question per hour
 +
==Putting the Guy Back in Gynecology==
 +
*2-3 very easy questions
 +
*Semmelweis: figured out hand washing would prevent disease.
 +
*Liability:
 +
**Failure to dx breast ca is number 1 lawsuit (lots of docs involved)
 +
**Bad baby is #2 lawsuit
-
==guy in gynecoloe==
+
==Early Pregnancy Loss==
-
*2-3 very easy questions
+
*1 scenario with 3-4 related quesetions
-
*Semmelweis: figured out would prevent disease.
+
*Pregnancy test is the first test one runs for any Gyn complaint in a fertile woman.
-
*Liability
+
*Know the definitions of the abortions:
-
**Failure to dx breast ca is number 1 lawsuit
+
**Abortion is '''any loss before 20 weeks gestation'''
-
**bad baby is #2 lawsuit
+
*For '''Threatened Abortions''', 25% bleed in second trimester.
 +
*"Septic abortion" is any sort of abortion (regardless of type) that includes maternal infection.
-
==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''
-
*70% of spontaneous abortions are because of ch abnormalities.
 
-
**Trisomies are mosst common
 
 +
*Tx of abortions:
 +
**Threatened abortions should be given "expectant management", pelvic rest, and reassurance.
 +
**Inevitable abortions and Incomplete abortions should be treated with '''dilation / curettage, methergine, and anti-Rh (Rhogam).'''
 +
***Recall that methergine constricts blood vessels ''and'' induces smooth muscle contraction so it can be used to decrease bleeding and to induce labor (as in an incomplete abortion).
-
*Tx:
 
-
**threatened: expectant management, pelvic rest, reassurance
 
-
**inevitable / in complete: d&c, methergine, anti rh
 
 +
*98% of all ectopic pregnancies are in the fallopian tubes.
-
*98% of all ectopics are in the fallopian tubes
 
 +
*Etiology of ectopic pregnancies is not important for the exam.
-
*etiology: not important
 
-
 
+
*Early pregnancy loss example questions:
-
*dx preg sample:
+
==Family Planning==
==Family Planning==
-
*3 basic questions
+
*3 basic questions
-
*85% chance of getting pregnant with absolutely no protection
+
 
-
*Know the contraindications to CHC
+
 
-
**dvt, prolonged immobility
+
*There is an 85% chance of getting pregnant with regular intercourse and absolutely no protection.
-
**smoking over the age of 35
+
 
 +
 
 +
*Know the contraindications to CHC (combined hormone contraception):
 +
**DVT (deep vein thrombosis), prolonged immobility
 +
**Smoking over the age of 35
**Hypercoagulatory state (like Leiden mutation)
**Hypercoagulatory state (like Leiden mutation)
-
**poorly controlled HTN
+
**Poorly controlled HTN
-
*IUD, IUC, IUS
+
*IUD, IUC, IUS:
**Know the indicators, contraindications:
**Know the indicators, contraindications:
-
**Contra:
+
**Contraindications for IUD:
-
***preg
+
***Pregnancy
-
***unexplained vag bleeding
+
***Unexplained vaginal bleeding
-
***infection (uterine)
+
***Uterine infection
-
***uterine fibroid / septum
+
***Pelvic tuberculosis
-
***pelvic tb
+
***Uterine architecture abnormalities (fibroids, septum)
-
**indicators:
+
**Indicators for IUD:
***
***
*contraception sample?
*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.
+
 
 +
*'''Cervical cancer is not an hereditary disease but a lifestyle disease (HPV).'''
 +
*'''IUD is an inappropriate form of birth control when the pt has an history of STI because IUDs induce  peritonitis and endometriitis upon infection.'''
==Maternal Fetal Phys==
==Maternal Fetal Phys==
-
*3 questions, case presenation; gi, heme, and pulm phys
+
*3 questions / case presenations focused on GI, Heme, and Pulmonary physiology
-
*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
+
*GI:
-
**compenstated respiratory ?
+
**In the first trimester, '''progesterone causes nause / vomitting by slowing smooth muscle.'''
-
**relative hypervent to blow off co2
+
**Average weight gain over the course of pregnancy is 20 pounds.
-
**po2 is elevated (106-108)
+
**It is not uncommon for mom to lose weight before gaining weight.
-
*Questions
+
*Heme:
-
**
+
**Physiologic anemia occurs in mom because '''plasma is increased by 50% but RBC count is only increased by 30%''' (more fluid increased compared to RBC increase).
 +
**Hb in pregnancy is often around 11.5 mg / dL (whereas normal is 12.0-16.0).
-
==prego gone wrong==
 
-
*2 cases, focus on case management; 1 case on dx
 
-
*preelampsia, previa, and ?
 
 +
*Respiratory:
 +
**In pregnancy, it is normal to be in a state of '''respiratory alkalosis with metabolic compensation'''.
 +
Fill this out a bit.
 +
**Relative hyperventilation occurs in pregnancy so as to blow off CO2.
 +
**pO2 is elevated in pregnancy (106-108, compared to normal 70-100).
-
*definitions are important
 
-
**chornic htn is before 20 and after 12 wpp
 
-
**preeclampsia: no bp issues until 20 weeks, then 300 mg proteinuria.
 
 +
*Questions
-
*eclampsia:
+
==Pregnancy Gone Wrong==
-
**tx: stabilize mom (before delivering).
+
*3 cases; 2 focus on management, 1 focuses on diagnosis
-
**magn sulfate, abcs, hypertensions in the severe malignant range (could stroke out)
+
*Pre-elampsia, placenta previa, and placental abruption
-
**once stable: vag, induce, c/s
+
-
*placental abruption
+
*Definitions important to pregnancy gone wrong:
-
**separte from the uterus
+
**Chornic htn is before 20 weeks gestation and after 12 weeks post-partum.
-
**abnd pain, non-reassuring heart rate, u/s is bad a dx of abruption
+
**'''Pre-eclampsia: BP issues occurring after 20 weeks gestation concurrent with 300 mg proteinuria.'''
-
**trauma increases suspicion
+
-
**causes: cocaine, smoking, fibroids,
+
-
*placenta previa
+
*Eclampsia:
-
**even partial is indicator for c/s
+
**Definition of Eclampsia:
-
**low=lying
+
***'''having one or more generalized convulsions and / or coma in the setting of preeclampsia'''
-
**vaso previa: major vessel between baby and os
+
***'''in the absence of other neurologic conditions'''
-
**tx: conservative management, monitor
+
**Treatment for eclampsia:
-
**tx: with bad heart tones or bleeding after 34 weeks, deliver the baby
+
***'''Stabilize mom (before delivering)''', ABCs
 +
***Rx: magnesium sulfate,  
 +
***Rx: hypertensions in the severe malignant range (could stroke out)
 +
***'''Deliver baby once stable''' (vag, induce, c/s, depending on condition of mom / baby)
-
==labor: normal, abnormal, etc.==
 
-
*3 questions: placenta acreda, pelvimetry,
 
 +
*Placental abruption:
 +
**Placental abruption is a separation of the placenta from the uterine wall.
 +
**Placental abruption presents with '''abdominal pain and non-reassuring fetal heart rate'''.
 +
**Placental abruption is '''poorly diagnosed with ultrasound.'''
 +
**'''A history of trauma should always increase one's suspicion of placental abruption.'''
 +
**Other causes of placental abruption include cocaine, smoking, fibroids.
-
*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
 
 +
*Placenta previa
 +
**Placenta previa is the attachment of the placenta near or over the cervical os.
 +
***Placenta previa's described as "low" indicates the placenta has attached low in the uterus, near the os.
 +
***Vaso previa is when major placental vessels lie between the fetus and the os.
 +
**Treatement for Placenta Previa:
 +
***Conservative management, monitor mother and baby.
 +
***With bad heart tones or bleeding '''after 34 weeks, deliver the baby'''.
 +
**'''Even a partial placental previa is an indicator for c-section.'''
-
*fetal monitor
+
==Normal and Abnormal Labor==
-
**120-160 normal
+
*3 questions; focused on placenta accreta, pelvimetry
-
**variability, should go up and down
+
-
**accelerations are good
+
-
**some decels are normal
+
-
**hr during contractions
+
-
*decels:
+
*Pelvimetry:
-
**early: with contractions (dip with contraction), vagal (head compression)
+
**'''The Diagonal Conjugate is an indirect measurement of the Obstetric (True) Conjugate.'''
-
**late: after peak contraction, fetal hypoxia (poor fetal reserve)
+
**The diagonal conjugate should be 11.5 cm or greater.
-
**early and late are smooth curves, usually.
+
**The obstetric conjugate is 1.5-2 cm less than the diagonal conjugate.
-
***delivery qucikly if not near to vag delivery
+
**Good conjugates are: diagonal (>11.5), obstetric (>9.5)
-
**variable: sharp v, any time; cord compression (usually not worrisome unless deep or many)
+
**The average fetal head is about 10 cm in diameter.
 +
**Proper pelvimetry exam includes:
 +
***Palpation of the ischeal spines.
 +
***Determination of the '''pelvic wall shape: convergent or divergent'''.
 +
***Determination of the '''bituberous diameter: 6-8cm is ideal'''
 +
***Determination of the '''pubic arch angle: >=90 degrees'''
 +
**If all metrics are adequate, assume a vaginal delivery without difficulty.
 +
**Even if the diagonal is slightly small (slightly <11.5), try a vaginal delivery.
 +
**Ischeal spines are not usually contraindicators of vag delivery.
-
*c-section:
+
*Fetal monitoring:
-
**uterine rupture, prior c/s, placenta previa
+
**Baseline heart rate should be 120-160 beats per minute.
-
**accreta:
+
**'''Variability of the heart rate should be seen!'''
-
***nitty box layer borked, placenta can't attach, may grow into womb and even into the bladder.
+
**Accelerations are good!
-
***occurs after vaginal rupture
+
**'''Some decels are normal: "early" decelerations during contractions.'''
-
***if prev c/s, pre
+
-
*chance of pp with 1 c/s chance is 24%
+
-
*question:
+
*More on decelerations:
-
**
+
**Early and late decelerations generally present as smooth curves.
 +
**Early decelerations occur with uterine contractions (dip with contraction) and represent vagal (head) compression.
 +
**Late decelerations '''peak after the contraction has begun''' and '''indicate fetal hypoxia (poor fetal reserve)'''
 +
***For late decelerations, '''delivery qucikly if not near to vag delivery'''.
 +
**Variable decelerations are '''sharp changes that can occur any time''' and represent '''cord compression'''.
 +
***Variable decelerations are '''not usually worrisome unless deep (very low heart rate) or long in duration'''.
-
==?==
 
-
*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'''
 
 +
*Cesarean Sections:
 +
**C/s increases the risk of uterine rupture upon subsequent pregnancies.
 +
**C/s increases the risk of placenta previa.
 +
**'''C/s increases the risk of placenta previa converting to accreta (when the placenta--and maybe even fetus--invade the myometrium).'''
 +
***This risk increases with each subsequent c/s: '''0 (5%), 1 (24%), 2 (48%), 3 (67%), etc.'''
 +
***'''In accreta, the nitty box layer is dsyfunctional''' such that the placenta can't attach and may grow into the myometrium and even into the bladder.
 +
***Accreta is also seen after uterine rupture.
-
*teratology:
+
*question:
-
**all or nothing is the first 2 weeks: cleavage, implantation
+
-
**75% of pregnancies are aborted
+
 +
==Embryology==
 +
*3 questions; 1 focuses on the type of anomaly, 1 on incidence of congenital anomalies
-
*questions:
 
-
**B
 
-
==abnormal uterine bleeding==
+
*Definitions:
-
*cut your grass
+
**Malformations are abnormalities that result from ''intrinsically abnormal development processes that have been wrong from the beginning.''
-
*3 questions, AUB
+
**Disruptions are abnormalities that interferes with previously normal development.
-
*know the chart of the uterine / ovarian cycle
+
***'''Disruptions include teratogens and ''amniotic bands''.'''
-
**before ovulation: follicular ovarian (estrogen) cycle, proliferative uterine cycle
+
**Deformations are abnormaliteis of form or shape because of mechanical disturbance.
-
**after ovulation: corpus luteum (progesterone) ovarian cycle (luteal phase), secretorial endometrial phase
+
***Deformities include oligohydraminos (low amniotic fluid levels) which results in a smushed face (like wearing a pair of lady's hose over one's head).
 +
**Dysplasias are abnormal cellular formations.
 +
***Dysplasias include renal issues due to obstruction of flow.
-
*dysfunctionl uterine bleeding:
+
*Single minor anomalies are very common: '''14% of live births have a minor anomaly.'''
-
**anovulation is the cause
+
*Single major anomalies are not uncommon: '''3% of live births have a major anomaly.'''
-
**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
+
*Teratology:
-
**menorrhagia: heavy, prolonged
+
**The first two weeks of gestation is the "all or nothing" stage in which teratogen exposure results in fetal abortion (nothing).
-
**metorrhagia: light, irregulart
+
***In this all or nothing period, the '''teratogen is interfering with implantation and cleavage'''.
-
**menotomorrhagia; heavy, irregular
+
*75% of all pregnancies are aborted.
-
*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:
+
*questions:
-
**cause: polyp, cerv cancer, IUD, infection
+
-
**ovulation
+
-
**VWD: with bleeding gums
+
-
*anovulatory cuases: POD
+
 +
==Abnormal Uterine Bleeding==
 +
*3 questions, AUB
-
*etiology:
 
-
**hormonal: anovulation
 
-
**anatomical: coagulopathies
 
 +
*Know the uterine / ovarian cycle!
 +
**Leading up to ovulation is the follicular phase (estrogen dominated) of the ovarian cycle and the proliferative phase of the uterine cycle.
 +
**Post-ovulation is the luteal phase (progesterone dominated) of the ovarian cycle and the secretory phase of the uterine phase.
 +
**http://upload.wikimedia.org/wikipedia/commons/c/cd/MenstrualCycle2.png
-
*questions:
 
-
**atrophic vaginitis
 
-
==Menopause and hormone repl==
+
*Abnormal uterine bleeding:
-
*3 questions: 1 clinical scenariso, sx w/ menopause, menopause workup
+
**Anovulation is the most common cause of abnormal uterine bleeding.
-
*FSH is increased when menopausal
+
**When a woman doesn't ovulate, there is no corpus luteum and therefore no progesterone.
 +
**Recall that progesterone causes the endometrium to become secretory.
 +
**Without ovulation / progesterone, the endometrium just keeps proliferating.
 +
**Initially, there will be a lack of bleeding as the endometrium doesn't get the progesterone signal drop that causes menses.
 +
**Once the excessively-proliferating endometrium outgrows its blood supply, it will bleed--heavily.
 +
 
 +
 
 +
*Terminology:
 +
**Menorrhagia means ''heavy, prolonged bleeding''.
 +
**Metorrhagia means '''light, irregular bleeding'''.
 +
**Menotorrhagia means '''heavy, irregular bleeding'''.
 +
**Amenorrhea is defined as absent bleeding '''for 3 or more cycles'''.
 +
**Eumeorrhea has a cycle of 21-35 days.
 +
**Oligomenorrhea is an interval over 35 days.
 +
**Polymenorrhea is an interval less than 24 days.
 +
**Intermenstrual bleeding is bleeding between regular menses.
 +
**Prementstrual spotting refers to light bleeding just before menses begins.
 +
**Post-coital spotting refers to bleeding ''within 24 hours of vaginal intercourse''.
 +
 
 +
 
 +
*Intermenstrual cycle bleeding (bleeding between menses):
 +
**Causes of intermenstrual bleeding include mechanical issues or ovulation.
 +
***'''polyps, cervical cancer, IUD issues, and infection.'''
 +
***'''drop in estrogen just before ovulation'''
 +
 
 +
 
 +
*Menorrhagia (regular, heavy):
 +
**Causes of menorrhagia include anatomical issues and coagulation issues.
 +
***'''fibrionids, polyps'''
 +
***'''vWf deficiency'''
 +
 
 +
 
 +
*Menotorrhagia (irregular, heavy):
 +
**Causes of menotorrhagia are ''anovulatory''
 +
**PCOS, thyroid deficiency
 +
 
 +
 
 +
*Etiology of abnormal uterine bleeding includes:
 +
**Hormonal: anovulation
 +
**Anatomical: coagulopathies
 +
 
 +
 
 +
*questions:
 +
**atrophic vaginitis
 +
 
 +
==Menopause and Hormone Replacement Therapy==
 +
*3 questions; 1 clinical scenario, 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.
**No end organ means no estrogen to feed back on hypothal to inhibit fsh release.
-
*checking estrogen doesn't help
+
*Checking estrogen doesn't help
-
*declining fertility in menopause is not absolute
+
*'''Declining fertility in menopause is not absolute.'''
-
**can't still get pregnant (52!)
+
**One can still get pregnant after the onset of menopause.
 +
**Be sure to talk to menopause pts about birth control.
 +
*Contraindications to estrogen replacement therapy include:
 +
**Undiagnosised abnormal genital bleeding
 +
**Cctive thrombosis
 +
**Pregnancy
 +
**'''Endometrial cancer and breast cancer'''
-
*contraindications to estrogen replacement:
 
-
**undiagnosised abn genital bleeding
 
-
**active thrombosis
 
-
**pregnancie
 
-
**?cancer?
+
*Evaluation of the post-menopausal pt:
-
*
+
**Determine the menopausal stage.
 +
**Determine the diagnsis
 +
**Do a mammogram
 +
**'''Be sure to rule out pregnancy!'''
-
endometrial cancer and breast cancer are contraindications
 
 +
*S&S of Menopause
 +
**Loss of concentration
 +
**Loss of libido
 +
**Decreased vaginal lubrication
 +
**Depression
-
*eavl of post menopausal:
+
**blue slide: don't worry about it
-
**menopausal stage, diagnoses, mamogram,
+
-
**rule out pregnancy
+
-
**blue slide: don't worry about it
+
-
*questions
+
*questions
**endometrial cancer suspicion
**endometrial cancer suspicion
**all the rest are not contraindications
**all the rest are not contraindications
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***others are: decrease libido, decreased vag lubrication, depression
***others are: decrease libido, decreased vag lubrication, depression
 +
==Infertility==
 +
*3 questions that center on evaluation and diagnositics for infertility
 +
 +
*The definition of infertility is '''1 year of regular coitus without conception'''.
 +
*Infertility can be the result of a single factor or several factors.
 +
**Therefore, we work up from easiest / most-likely / cheapest / least invasive.
 +
*A careful history and physical exam is important for narrowing the tests to be ordered
 +
 +
 +
*Normal fertility requirements
 +
**Regular ovulation
 +
**Patent fillopian tubes
 +
**Receptive endometrium, with hormone cascasde
 +
**Cervical mucus in a favorable state
 +
**Spermatogenesis
 +
**Erectile and ejaculatory competence
 +
 +
 +
*Anovulation associated with ovarian failure:
 +
**Most of the details of ovarian failure are in excess.
 +
**Turner syndrome is one cause of ovarian failure.
 +
***'''Turner syndrome is characterized by primary amenorrhea, ovarian streaks, no secondary sexual characteristics (because of primary gonadal failure).'''
 +
**Primary gonadotropic deficiency is another cause of ovarian failure.
 +
***No GnRH / LH / FSH;
 +
***Hypogonadic
 +
***'''Anosmia'''
 +
 +
 +
*Functional chronic anovulation:
 +
**Commonly seen in athletes, anorexics, high stress situations, and physical-appearance-success coupling.
 +
**Stress suppresses gonadotropic release at hypothalamus.
 +
***This response to stress is good for a state of famine (don't make more eaters when there's little eating to be done).
 +
**Part of the problem in functional chronic anovulation is that '''a certain amount of body fat needed to maintain LH / FSH levels''' and these women lack that fat threshold.
-
==infertility==
 
-
*3 questions that center on evaluation and diagnositics for infertility
 
-
*def: 1 year reg coitus w/o conception
+
*Polycystic ovarian disease:
-
*infertility: single factor or several factors
+
**'''POCD is the most common cause of anovulation.'''
-
*don't do every test, work it up
+
**POCD '''presents as hirsuitism, high BMI, oligo- / a-menorrhea, and insulin resistance.'''
-
*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:
+
*Workup for the anavulating patient:
-
**details are in excess
+
**Chemistries: FSH, LH, prolactin
-
**turner syndomre: primary amenorrhea, ovarian streaks, no secondary sexual characteristics (because of primary gonadal failure)
+
***Recall that prolactinemia / prolactinomas can cause anovulation
-
*Primary gonadotropic deficiency: no lh / fsh; hypogonadic; anosmia (can't smell);
+
**Imaging:
-
*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;
+
***CT of the sela tercica to identify a prolacitnoma
-
*polycystic ovarian disease: most common cause of anovulatory; hirsuitism, high bmi; oligo / amenorrhea; insulin resistance;
+
***U/S of ovaries to be sure they exist and do not have cysts
 +
==Gynecological Cancers==
 +
*3 questions; 1 on risk factors of endometrial cancer, 1 on diagnosis, 1 on appropriate tx for pelvic mass
-
*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==
+
*Endometrial cancer
-
*1 questions on risk factors of endometr, 1 on dx, 1 on appropriate tx for pelvic mass
+
**Risk factors: age, null-gravis, unopposed hormone replacement, obesity, hypertension, and diabetes.
 +
**Presentation of endometrial cancer includes '''abnormal bledding, post-menopausal bleeding, pre-menopausal bleeding'''.
-
*endo cancer: risk sinclude age, an null-gravis, unopposed hormone replacement
 
-
**presentation: abnormal bleeding, post-menopausal (or pre_
 
-
**factors: obesity, hypertension, diabetes
 
-
*uterine cancer:
+
*Uterine cancer:
-
**prego test first
+
**For all gynecological problems, consider a pregnancy test as the first diagnostic.
-
**office biopsy (pipelle), 98% sensitivity
+
**Upon suspecting uterine cancer, '''take a biopsy'''.
-
**histeroscopy is gold standard
+
***Biopsy is via pipelle.
-
***can show cancer lesion for direct biopsy
+
***Biopsies have a 98% sensitivity for uterine cancer.
-
**in known cancer, fluid may push cancer into peritoneal cavity (contraindication)
+
**For diagnosing uterine cancer, '''histeroscopy is the gold standard.'''
-
*u/s: endo should be less than 6 mm, over is indicator for biopsy
+
***Hysteroscopy can reveal cancer lesion for direct biopsy.
 +
***Hysteroscopy should not be used for known uterine cancer cases as the fluid used can push malignant cells to new locations
 +
**Suspicion of a uterine cancer can also indicate an U/S.
 +
***The endometrium in non-malignant cases should be less than 6mm thick.
 +
***Endometrium over 6mm is an indication for biopsy.
-
*endo cancer epi:
+
*Cervical Cancer Epidemiology:
-
**paps catch most: 60% in stage 1
+
**Cervical cancer screening:
-
**mintorities and undersreved have higher risk
+
***Screening is now recommended to begin at 21 yo--not based on time of first coitus.
-
**multiparity, early pairty, early ccoitus increase
+
***Pap smears should be done every 1-2 years until 70yo or until a ''total'' hysterectomy is performed.
-
**HPV: 16, 18, 31, 33
+
***'''Pap smears catch most cervical cancer cases: 60% are caught in stage 1.'''
-
*screening:
+
**Cervical cancer risk factors: minorities / underserved, multiparity, early parity, early coitus
-
**21 yo, not based on time of first coitus
+
**HPV strains 16, 18, 31, 33 are associated with cervical cancer.
-
**some young cases resolve on their own (hpv) b/c of high turn over (whereas older poeple have lower turnover)
+
**Some cases of HPV infection (especially in the young, with their highly proliferative cervical epithelium) resolve spontaneously.
-
**paps every 1-2 years; until 70 or ''total'' hysterectomy
+
-
*no stats
+
*no stats
-
*adnexal mass:
+
*Adnexal masses:
-
**asymptomatic is good, cystic means benign, young 15-45 is good, may resolve
+
**Good prognostic indicators of adnexal masses: being asymptomatic, cystic nature (fluid filled, means it is benign), being young (15-45 yo)
-
**bad: solid, painful, persistent, complex, ascities, omental caking, lymphadenopathy
+
**Bad prognostic indicators of adnexal masses: having associated pain, solid / complex nature, ascites, omental caking quality, lymphadenopathy
-
**ddx:
+
**The differential diagnosis for an adnexal mass should include:
-
***do pelvic exam
+
**Adnexal mass workup:
-
***do ca125 as triage for gyn onc as backup
+
***Pelvic exam
-
***u/s > ct for dx
+
***CA 125 as triage, be ready to call in gyncological oncology as backup
-
**tx: operate on large, mass with ascites in a 60 yo
+
***Imaging
 +
****U/S is superior to CT
 +
**Adnexal mass Treatment:
 +
***Operate on large masses.
 +
***Operate on masses with many bad indicators (old age, ascites, etc.)
-
*questions:
+
*questions:
-
**c; ovarian cancer: ?
+

Revision as of 20:24, 15 December 2011

Contents

OBGYN Review

*2-3 question per hour

Putting the Guy Back in Gynecology

*2-3 very easy questions
  • Semmelweis: figured out hand washing would prevent disease.
  • Liability:
    • Failure to dx breast ca is number 1 lawsuit (lots of docs involved)
    • Bad baby is #2 lawsuit

Early Pregnancy Loss

*1 scenario with 3-4 related quesetions
  • Pregnancy test is the first test one runs for any Gyn complaint in a fertile woman.
  • Know the definitions of the abortions:
    • Abortion is any loss before 20 weeks gestation
  • For Threatened Abortions, 25% bleed in second trimester.
  • "Septic abortion" is any sort of abortion (regardless of type) that includes maternal infection.


  • 70% of spontaneous abortions are because of ch abnormalities.
    • Trisomies are mosst common


  • Tx of abortions:
    • Threatened abortions should be given "expectant management", pelvic rest, and reassurance.
    • Inevitable abortions and Incomplete abortions should be treated with dilation / curettage, methergine, and anti-Rh (Rhogam).
      • Recall that methergine constricts blood vessels and induces smooth muscle contraction so it can be used to decrease bleeding and to induce labor (as in an incomplete abortion).


  • 98% of all ectopic pregnancies are in the fallopian tubes.


  • Etiology of ectopic pregnancies is not important for the exam. 


*Early pregnancy loss example questions:

Family Planning

*3 basic questions


  • There is an 85% chance of getting pregnant with regular intercourse and absolutely no protection.


  • Know the contraindications to CHC (combined hormone contraception):
    • DVT (deep vein thrombosis), prolonged immobility
    • Smoking over the age of 35
    • Hypercoagulatory state (like Leiden mutation)
    • Poorly controlled HTN


  • IUD, IUC, IUS:
    • Know the indicators, contraindications:
    • Contraindications for IUD:
      • Pregnancy
      • Unexplained vaginal bleeding
      • Uterine infection
      • Pelvic tuberculosis
      • Uterine architecture abnormalities (fibroids, septum)
    • Indicators for IUD:


  • contraception sample?


  • Cervical cancer is not an hereditary disease but a lifestyle disease (HPV).
  • IUD is an inappropriate form of birth control when the pt has an history of STI because IUDs induce peritonitis and endometriitis upon infection.

Maternal Fetal Phys

*3 questions / case presenations focused on GI, Heme, and Pulmonary physiology


  • GI:
    • In the first trimester, progesterone causes nause / vomitting by slowing smooth muscle.
    • Average weight gain over the course of pregnancy is 20 pounds.
    • It is not uncommon for mom to lose weight before gaining weight.


  • Heme:
    • Physiologic anemia occurs in mom because plasma is increased by 50% but RBC count is only increased by 30% (more fluid increased compared to RBC increase).
    • Hb in pregnancy is often around 11.5 mg / dL (whereas normal is 12.0-16.0).


  • Respiratory:
    • In pregnancy, it is normal to be in a state of respiratory alkalosis with metabolic compensation. 
Fill this out a bit.
    • Relative hyperventilation occurs in pregnancy so as to blow off CO2.
    • pO2 is elevated in pregnancy (106-108, compared to normal 70-100). 


*Questions

Pregnancy Gone Wrong

*3 cases; 2 focus on management, 1 focuses on diagnosis
*Pre-elampsia, placenta previa, and placental abruption


  • Definitions important to pregnancy gone wrong:
    • Chornic htn is before 20 weeks gestation and after 12 weeks post-partum.
    • Pre-eclampsia: BP issues occurring after 20 weeks gestation concurrent with 300 mg proteinuria.


  • Eclampsia:
    • Definition of Eclampsia:
      • having one or more generalized convulsions and / or coma in the setting of preeclampsia
      • in the absence of other neurologic conditions
    • Treatment for eclampsia:
      • Stabilize mom (before delivering), ABCs
      • Rx: magnesium sulfate,
      • Rx: hypertensions in the severe malignant range (could stroke out)
      • Deliver baby once stable (vag, induce, c/s, depending on condition of mom / baby)


  • Placental abruption:
    • Placental abruption is a separation of the placenta from the uterine wall.
    • Placental abruption presents with abdominal pain and non-reassuring fetal heart rate.
    • Placental abruption is poorly diagnosed with ultrasound.
    • A history of trauma should always increase one's suspicion of placental abruption.
    • Other causes of placental abruption include cocaine, smoking, fibroids.


  • Placenta previa
    • Placenta previa is the attachment of the placenta near or over the cervical os.
      • Placenta previa's described as "low" indicates the placenta has attached low in the uterus, near the os.
      • Vaso previa is when major placental vessels lie between the fetus and the os.
    • Treatement for Placenta Previa:
      • Conservative management, monitor mother and baby.
      • With bad heart tones or bleeding after 34 weeks, deliver the baby.
    • Even a partial placental previa is an indicator for c-section.

Normal and Abnormal Labor

*3 questions; focused on placenta accreta, pelvimetry


  • Pelvimetry:
    • The Diagonal Conjugate is an indirect measurement of the Obstetric (True) Conjugate.
    • The diagonal conjugate should be 11.5 cm or greater.
    • The obstetric conjugate is 1.5-2 cm less than the diagonal conjugate.
    • Good conjugates are: diagonal (>11.5), obstetric (>9.5)
    • The average fetal head is about 10 cm in diameter.
    • Proper pelvimetry exam includes:
      • Palpation of the ischeal spines.
      • Determination of the pelvic wall shape: convergent or divergent.
      • Determination of the bituberous diameter: 6-8cm is ideal
      • Determination of the pubic arch angle: >=90 degrees
    • If all metrics are adequate, assume a vaginal delivery without difficulty.
    • Even if the diagonal is slightly small (slightly <11.5), try a vaginal delivery.
    • Ischeal spines are not usually contraindicators of vag delivery.


  • Fetal monitoring:
    • Baseline heart rate should be 120-160 beats per minute.
    • Variability of the heart rate should be seen!
    • Accelerations are good!
    • Some decels are normal: "early" decelerations during contractions.


  • More on decelerations:
    • Early and late decelerations generally present as smooth curves.
    • Early decelerations occur with uterine contractions (dip with contraction) and represent vagal (head) compression.
    • Late decelerations peak after the contraction has begun and indicate fetal hypoxia (poor fetal reserve)
      • For late decelerations, delivery qucikly if not near to vag delivery.
    • Variable decelerations are sharp changes that can occur any time and represent cord compression.
      • Variable decelerations are not usually worrisome unless deep (very low heart rate) or long in duration.


  • Cesarean Sections:
    • C/s increases the risk of uterine rupture upon subsequent pregnancies.
    • C/s increases the risk of placenta previa.
    • C/s increases the risk of placenta previa converting to accreta (when the placenta--and maybe even fetus--invade the myometrium).
      • This risk increases with each subsequent c/s: 0 (5%), 1 (24%), 2 (48%), 3 (67%), etc.
      • In accreta, the nitty box layer is dsyfunctional such that the placenta can't attach and may grow into the myometrium and even into the bladder.
      • Accreta is also seen after uterine rupture. 
*question:

Embryology

*3 questions; 1 focuses on the type of anomaly, 1 on incidence of congenital anomalies


  • Definitions:
    • Malformations are abnormalities that result from intrinsically abnormal development processes that have been wrong from the beginning.
    • Disruptions are abnormalities that interferes with previously normal development.
      • Disruptions include teratogens and amniotic bands.
    • Deformations are abnormaliteis of form or shape because of mechanical disturbance.
      • Deformities include oligohydraminos (low amniotic fluid levels) which results in a smushed face (like wearing a pair of lady's hose over one's head).
    • Dysplasias are abnormal cellular formations.
      • Dysplasias include renal issues due to obstruction of flow.


  • Single minor anomalies are very common: 14% of live births have a minor anomaly.
  • Single major anomalies are not uncommon: 3% of live births have a major anomaly.


  • Teratology:
    • The first two weeks of gestation is the "all or nothing" stage in which teratogen exposure results in fetal abortion (nothing).
      • In this all or nothing period, the teratogen is interfering with implantation and cleavage.
  • 75% of all pregnancies are aborted. 


*questions:

Abnormal Uterine Bleeding

*3 questions, AUB


  • Know the uterine / ovarian cycle!
    • Leading up to ovulation is the follicular phase (estrogen dominated) of the ovarian cycle and the proliferative phase of the uterine cycle.
    • Post-ovulation is the luteal phase (progesterone dominated) of the ovarian cycle and the secretory phase of the uterine phase.
    • MenstrualCycle2.png


  • Abnormal uterine bleeding:
    • Anovulation is the most common cause of abnormal uterine bleeding.
    • When a woman doesn't ovulate, there is no corpus luteum and therefore no progesterone.
    • Recall that progesterone causes the endometrium to become secretory.
    • Without ovulation / progesterone, the endometrium just keeps proliferating.
    • Initially, there will be a lack of bleeding as the endometrium doesn't get the progesterone signal drop that causes menses.
    • Once the excessively-proliferating endometrium outgrows its blood supply, it will bleed--heavily.


  • Terminology:
    • Menorrhagia means heavy, prolonged bleeding.
    • Metorrhagia means light, irregular bleeding.
    • Menotorrhagia means heavy, irregular bleeding.
    • Amenorrhea is defined as absent bleeding for 3 or more cycles.
    • Eumeorrhea has a cycle of 21-35 days.
    • Oligomenorrhea is an interval over 35 days.
    • Polymenorrhea is an interval less than 24 days.
    • Intermenstrual bleeding is bleeding between regular menses.
    • Prementstrual spotting refers to light bleeding just before menses begins.
    • Post-coital spotting refers to bleeding within 24 hours of vaginal intercourse.


  • Intermenstrual cycle bleeding (bleeding between menses):
    • Causes of intermenstrual bleeding include mechanical issues or ovulation.
      • polyps, cervical cancer, IUD issues, and infection.
      • drop in estrogen just before ovulation


  • Menorrhagia (regular, heavy):
    • Causes of menorrhagia include anatomical issues and coagulation issues.
      • fibrionids, polyps
      • vWf deficiency


  • Menotorrhagia (irregular, heavy):
    • Causes of menotorrhagia are anovulatory
    • PCOS, thyroid deficiency


  • Etiology of abnormal uterine bleeding includes:
    • Hormonal: anovulation
    • Anatomical: coagulopathies 


*questions:
**atrophic vaginitis

Menopause and Hormone Replacement Therapy

*3 questions; 1 clinical scenario, 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.
    • One can still get pregnant after the onset of menopause.
    • Be sure to talk to menopause pts about birth control.


  • Contraindications to estrogen replacement therapy include:
    • Undiagnosised abnormal genital bleeding
    • Cctive thrombosis
    • Pregnancy
    • Endometrial cancer and breast cancer


  • Evaluation of the post-menopausal pt:
    • Determine the menopausal stage.
    • Determine the diagnsis
    • Do a mammogram
    • Be sure to rule out pregnancy!


  • S&S of Menopause
    • Loss of concentration
    • Loss of libido
    • Decreased vaginal lubrication
    • Depression 


**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
  • The definition of infertility is 1 year of regular coitus without conception.
  • Infertility can be the result of a single factor or several factors.
    • Therefore, we work up from easiest / most-likely / cheapest / least invasive.
  • A careful history and physical exam is important for narrowing the tests to be ordered


  • Normal fertility requirements
    • Regular ovulation
    • Patent fillopian tubes
    • Receptive endometrium, with hormone cascasde
    • Cervical mucus in a favorable state
    • Spermatogenesis
    • Erectile and ejaculatory competence


  • Anovulation associated with ovarian failure:
    • Most of the details of ovarian failure are in excess.
    • Turner syndrome is one cause of ovarian failure.
      • Turner syndrome is characterized by primary amenorrhea, ovarian streaks, no secondary sexual characteristics (because of primary gonadal failure).
    • Primary gonadotropic deficiency is another cause of ovarian failure.
      • No GnRH / LH / FSH;
      • Hypogonadic
      • Anosmia


  • Functional chronic anovulation:
    • Commonly seen in athletes, anorexics, high stress situations, and physical-appearance-success coupling.
    • Stress suppresses gonadotropic release at hypothalamus.
      • This response to stress is good for a state of famine (don't make more eaters when there's little eating to be done).
    • Part of the problem in functional chronic anovulation is that a certain amount of body fat needed to maintain LH / FSH levels and these women lack that fat threshold.


  • Polycystic ovarian disease:
    • POCD is the most common cause of anovulation.
    • POCD presents as hirsuitism, high BMI, oligo- / a-menorrhea, and insulin resistance.


  • Workup for the anavulating patient:
    • Chemistries: FSH, LH, prolactin
      • Recall that prolactinemia / prolactinomas can cause anovulation
    • Imaging:
      • CT of the sela tercica to identify a prolacitnoma
      • U/S of ovaries to be sure they exist and do not have cysts

Gynecological Cancers

*3 questions; 1 on risk factors of endometrial cancer, 1 on diagnosis, 1 on appropriate tx for pelvic mass


  • Endometrial cancer
    • Risk factors: age, null-gravis, unopposed hormone replacement, obesity, hypertension, and diabetes.
    • Presentation of endometrial cancer includes abnormal bledding, post-menopausal bleeding, pre-menopausal bleeding.


  • Uterine cancer:
    • For all gynecological problems, consider a pregnancy test as the first diagnostic.
    • Upon suspecting uterine cancer, take a biopsy.
      • Biopsy is via pipelle.
      • Biopsies have a 98% sensitivity for uterine cancer.
    • For diagnosing uterine cancer, histeroscopy is the gold standard.
      • Hysteroscopy can reveal cancer lesion for direct biopsy.
      • Hysteroscopy should not be used for known uterine cancer cases as the fluid used can push malignant cells to new locations
    • Suspicion of a uterine cancer can also indicate an U/S.
      • The endometrium in non-malignant cases should be less than 6mm thick.
      • Endometrium over 6mm is an indication for biopsy.


  • Cervical Cancer Epidemiology:
    • Cervical cancer screening:
      • Screening is now recommended to begin at 21 yo--not based on time of first coitus.
      • Pap smears should be done every 1-2 years until 70yo or until a total hysterectomy is performed.
      • Pap smears catch most cervical cancer cases: 60% are caught in stage 1.
    • Cervical cancer risk factors: minorities / underserved, multiparity, early parity, early coitus
    • HPV strains 16, 18, 31, 33 are associated with cervical cancer.
    • Some cases of HPV infection (especially in the young, with their highly proliferative cervical epithelium) resolve spontaneously. 


*no stats


  • Adnexal masses:
    • Good prognostic indicators of adnexal masses: being asymptomatic, cystic nature (fluid filled, means it is benign), being young (15-45 yo)
    • Bad prognostic indicators of adnexal masses: having associated pain, solid / complex nature, ascites, omental caking quality, lymphadenopathy 
**The differential diagnosis for an adnexal mass should include:
    • Adnexal mass workup:
      • Pelvic exam
      • CA 125 as triage, be ready to call in gyncological oncology as backup
      • Imaging
        • U/S is superior to CT
    • Adnexal mass Treatment:
      • Operate on large masses.
      • Operate on masses with many bad indicators (old age, ascites, etc.) 


*questions:
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