From Iusmicm

Contents 1 OBGYN Review 1.1 guy in gynecoloe 1.2 Early preg loss 1.3 Family Planning 1.4 Maternal Fetal Phys 1.5 prego gone wrong 1.6 labor: normal, abnormal, etc. 1.7 ? 1.8 abnormal uterine bleeding 1.9 Menopause and hormone repl 1.10 infertility 1.11 gyn cancers

OBGYN Review

• 2-3 question per hour

guy in gynecoloe

• 2-3 very easy questions
• Semmelweis: figured out would prevent disease.
• Liabiligy
  • 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: ?