From Iusmicm

Contents 1 OBGYN Review 1.1 Putting the Guy Back in Gynecology 1.2 Early Pregnancy Loss 1.3 Family Planning 1.4 Maternal Fetal Phys 1.5 Pregnancy Gone Wrong 1.6 Normal and Abnormal Labor 1.7 Embryology 1.8 Abnormal Uterine Bleeding 1.9 Menopause and Hormone Replacement Therapy 1.10 Infertility 1.11 Gynecological Cancers

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.
  • 

• 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: