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402 Cards in this Set
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hCG source
|
placental synsytiotrophoblast;
in blood 10 days after fertilization peaks 9-10weeks, falling to plateau in 20-22 weeks |
|
hCG structure
|
alpha subunit similar to LH, FSH, thyrotropin
beta subunit is specific |
|
hCG functions
|
maintain corpus luteum production of progesterone until placenta
regulate steroid synthesis in placenta and fetal adrenals stimulate testosterone production in fetal male testes |
|
excess hCG
|
twin pregnancy
hydatiform mole choriocarcinoma embryonal carcinoma |
|
low hCG
|
ectopic pregnancy
threatened abortion missed abortion |
|
human placental lactogen
|
similar to GH and prolactin
levels rise with placental growth antagonizes insulin, predisposes to gestational diabetes if low --> threatened abortion, intrauterine growth restriction |
|
progesterone source
|
6-7 weeks --> corpus luteum
7-9 weeks --> corpus luteum and placenta >9 weeks --> increasingly the placenta |
|
progesterone functions
|
early pregnancy --> induces endometrial secretory changes for blastocyst implantation
late pregnancy --> induces immune tolerance for pregnancy and prevents myometrial contractions stimulates the development of milk-producing alveolar cells |
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estrogen varieties
|
estradiol (non-pregnant)
estriol (pregnancy) estrone (menopause) |
|
estradiol
|
non-pregnant reproductive years
androgens from follicular theca cells diffuse to granulosa cells aromatase in granulosa cells converts androgens to estradiol promotes the growth of breast ducts antagonizes prolactin in breast |
|
estriol
|
main estrogen in pregnancy
DHEA-S from fetal adrenals is converted to estriol by placental sulfatase promotes the growth of breast ducts antagonizes prolactin in breast |
|
estrone
|
menopause estrogen
adrenal androstenedione is converted by peripheral adipose tissue to estrone |
|
physiologic skin changes in pregnancy
|
striae gravidarum stretch marks in genetically predisposed
spider angiomata and palmar erythema from increased vascularity Chadwik sign --> bluish vagina and cervix from increased vascularity linea nigra --> hyperpigmentation between pubis and umbilicus chloasma --> blotchy pigmentation of nose and face |
|
physiologic cardiovascular changes in pregnancy
|
arterial BP --> decreased (increase is never normal)
femoral venous pressure --> increased SVR --> decreased CO --> increases up to 50% by 20 weeks (increased HR and SV) plasma volume --> increased up to 50% by 30 weeks systolic ejection murmur is normal; diastolic murmurs are abnormal |
|
physiologic hematologic changes in pregnancy
|
RBC increases by 30% but there's dilutional effect (not anemia)
WBC increase up to 16,000 ESR increases coagulation factors VII, VIII, IX, X increase --> hypercoagulable state |
|
physiologic GI changes in pregnancy
|
decreased gastric motility --> increased stomach residual volume --> gravid uterus stomach displacement --> can predispose to aspiration pneumonia with general anesthesia
decreased colonic motility --> fluid absorption --> constipation |
|
physiologic pulmonary changes in pregnancy
|
all volumes are decreased except tidal volume which increases up to 40% --> compensated respiratory alkalosis
|
|
physiologic renal changes in pregnancy
|
kidney hypertrophy
increased ureteral diameter (more on the right) GFR and creatinine clearance increase glucose treshold decreases to 155mg/dL --> glucosuria urine protein is unchanged |
|
physiologic endocrine changes in pregnancy
|
pituitary increased by 100% --> predisposes to Sheehan from postpartum hypotension
adrenals are unchanged by cortisol increases 2-3x thyroid size increases 15%, TBG and total T3/T4 increase |
|
fetal circulation shunts
|
ductus venosus --> from umbilical vein to inferior vena cava (byoasses liver)
foramen ovale --> from right to left atrium ductus arteriosus --> from pulmonary artery to descending aorta |
|
prolactin
|
from anterior pituitary stimulates milk production
|
|
oxytocin
|
from posterior pituitary causes milk ejection in response to suckling
|
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postconception week 1
|
day 0 --> fertilization in the distal oviduct
day 3 --> entry of morula into uterine cavity day 6 --> implantation of the blastocyst onto endometrium, formation of trophoblast (placenta) and embryonic cells |
|
postconception week 2
|
bilaminar germ disk with epiblast and hypoblast
invasion of maternal sinusoids by syncytiotrophoblast beta-hCG passes to maternal blood |
|
postconception week 3
|
trilaminar germ disk
|
|
postconception weeks 4-8
|
organ formation
risk of teratogenesis |
|
paramesonephric duct
|
Mullerian duct needs no hormonal stimulation to become female internal organs
Mullerian inhibitory factor produced by Sertoli cells in males causes Mullerian duct involution |
|
mesonephric duct
|
Wolffian duct needs testosterone from Leydig cells to develop into male reproductive system
absence of testosterone in females causes Wolffian involution |
|
female external genitalia
|
needs no hormonal stimulation to form
|
|
male external genitalia
|
dihydrotestosterone produced by 5-alpha reductase from testosterone is needed for formation
|
|
genetic male with androgen receptor absence
|
Wolffian duct doesn't develop
external genitalia will not develop |
|
category A teratogen
|
controlled studies show no risk
acetaminophen, thyroxine, folic acid, magnesium sulfate |
|
category B teratogen
|
no evidence of risk in humans despite risks in animals
penicillins, cephalosporins, insulin, pepcid, reglan, paxil, prozac, benadryl, dramamine |
|
category C teratogen
|
risk cannot be ruled out, controlled studies are lacking in humans
codeine, methadone, AT, beta blockers, prilosec, heparin, protamine, robitussin, sudafed |
|
category D teratogen
|
postive evidence of risk but potential benefits may outweight the risks
aspirin, valium, tetracycline, depakote, lithium |
|
category X teratogen
|
contraindicated in pregnancy
isotretinoin, danocrine, pravachol, coumadin, cafergot |
|
infectious teratogens
|
chlamydia, gonorrhea --> neonatal eye and ear infections
rubella --> CMV --> herpes --> syphilis --> toxoplasmosis --> |
|
ionizing radiation teratogenicity
|
no risk with exposure <5 rads (diagnostic procedures)
risk proportional to doses above 20rads |
|
chemotherapy teratogenicity
|
risk in the first trimester
|
|
environmental teratogens
|
alcohol --> alcohol fetal syndrome
tobacco --> IUGR and preterm delivery cocaine --> placental abruption, IUGR, preterm delivery marijuana --> preterm delivery |
|
fetal alcohol syndrome
|
IUGR
midfacial hypoplasia developmental delay short palpebral fissures long filtrum joint anomalies cardiac defects |
|
diethylstilbestrol syndrome
|
category X teratogen
T-shpaed uterus vaginal adenosis predisposition to vaginal clear cell carcinoma cervical hood incompetent cervix preterm delivery |
|
fetal hydantoin syndrome
|
due to Dilantin, category D teratogen
IUGR craniofacial dysmorphism mental retardation microcephaly nail hypoplasia heart defects |
|
isotretinoin as teratogen
|
category X teratogen
congenital deafness microtia CNS defects congenital heart defects |
|
lithium as teratogen
|
category D teratogen
produces Ebstein's anomaly (right heart defect) |
|
streptomycin as teratogen
|
VIII nerve damage
hearing loss |
|
tetracycline as teratogen
|
category D teratogen
teeth discoloration after 4th month |
|
thalidomide as teratogen
|
category X teratogen
phocomelia limb reduction defects ear/nasal anomalies cardiac defects pyloric or duodenal stenosis |
|
trimethadione as teratogen
|
facial dysmorphism
cardiac defects IUGR mental retardation |
|
valproic acid as teratogen
|
class D teratogen
neural tube defects, spina bifida cleft lip renal defects |
|
warfarin as teratogen
|
category X teratogen
chondrodysplasia microcephaly mental retardation optic atrophy |
|
indications for genetic counseling
|
advanced maternal age >35
multiple fetal losses previous child with congenital defects or neonatal death pregnancy or fetal losses family history of birth defects or mental retardation abnormal prenatal tests (triple marker screen, sonogram) parental aneuploidy |
|
Turner syndrome
|
45X due mostly to paternal loss of X
98% abort spontaneously ultrasound shows nuchal skinfold thinkening and cystic hygroma survivors have primary amenorrhea, web neck, streak gonads, absence of secondary sex features, infertility, broad chest, neck webbing, aortic coarctation |
|
Klinefelter syndrome
|
47XXY
tall stature testicular atrophy gynecomastia azoospermia truncal obesity learning disorders and low IQ |
|
Down syndrome
|
trisomy 21
short stature mental retardation endocardial cushion defects short stature short neck typical facial appearance duodenal atresia |
|
Edward syndrome
|
trisomy 18
profound mental retardation rocker-bottom feet clenched fists 1 year survival is 40% |
|
Patau syndrome
|
trisomy 13
profound mental retardation cleft lip with palate holoprosencephaly 1 year survival is 40% |
|
vacuum curetage
|
90% of induced abortions
performed before 13 weeks prophylactic antibiotics, conscious sedation, paracervical block for pain relief dilation and curettage (D&C) complications --> endometritis, retained products of conception |
|
medical abortion
|
mifepristone (progesterone antagonist) and misoprostol (prostaglandin E1)
must be used in first 63 days of amenorrhea 85% of patients will abort within 3 days |
|
second trimester abortion methods
|
dilation & evacuation
labor induction with hypertonic solutions of prostaglandins |
|
spontaneous abortion definition
|
bleeding that occurs before 12 weeks gestation
MCC is fetal in origin |
|
etiology of spontaneous abortion
|
gross chromosomal abnormalities
mendelian defects antiphospholipid syndrome |
|
spontaneous abortion general measures
|
speculum exam to rule out vaginal or cervical lesions as cause of bleeding
molar and ectopic pregnancy should be ruled out RhoGAM administration to all Rh-negative gravidas who undergo D&C |
|
missed abortion
|
sonogram finding of nonviable pregnancy
no vaginal bleeding, uterine cramping or cervical dilation management: scheduled D&C OR conservative management awaiting completion OR misoprostol |
|
threatened abortion
|
sonogram finding of a viable pregnancy with vaginal bleeding but no cervical dilation
management: observation |
|
inevitable abortion
|
vaginal bleeding and uterine contractions leading to cervical dilation but no POC
management: emergency suction D&C to prevent further blood loss |
|
incomplete abortion
|
vaginal bleedingm uterine contractions, cervical dilation and some POC passes
management: emergency suction D&C to prevent further blood loss |
|
completed abortion
|
vaginal bleeding and uterine contractions with all POC passed
confirm by sonogram showing no intrauterine contents management: conservative if previous intrauterine pregnancy had been diagnosed or serial beta-hCG weekly until negative to rule out ectopic pregnancy |
|
fetal demise definition
|
in utero death of fetus after 20 weeks
antenatal demise --> occurs before labor intrapartum demise --> after onset of labor |
|
fetal demise complications
|
DIC if fetal demise >2weeks (dead fetus releases tissue thromboplastin)
prolonged grief resolution |
|
fetal demise risk factors
|
MCC is idiopathic
antiphospholipid syndrome maternal diabetes maternal trauma severe maternal isoimmunization fetal aneuploidy fetal infection |
|
fetal demise presentation and diagnosis
|
before 20 weeks --> uterine fundus less than dates
after 20 weeks --> mother reports absence of fetal movements diagnosis --> ultrasound showing no fetal cardiac activity |
|
fetal demise management
|
exclude DIC --> platelets, d-dimer, fibrinogen, PT, PTT; if present then inmediate delivery
if DIC not present --> deferred delivery or conservative management with weekly coagulation tests delivery: if <20 weeks or no autopsy --> D&E; if >20 weeks or autopsy --> prostaglandins for induction of labor |
|
ectopic pregnancy presentation
|
secondary amenorrhea
unilateral abdominal/pelvic pain vaginal bleeding unilateral adnexal tenderness cervical motion tenderness if ruptured --> signs of hypotension, abdominal guarding and rigidity |
|
ectopic pregnancy with (+)b-hCG differential diagnosis
|
if positive beta-hCG -->
threatened abortion incomplete abortion ectopic pregnancy hydatiform mole |
|
ectopic pregnancy risk factors
|
pelvic inflammatory disease
tuboplasty/ligation DES idiopathic |
|
ectopic pregnancy diagnosis
|
presumption of ectopic pregnancy --> beta-hCG > 1,500 mIU + no intrauterine pregnancy with vaginal sonogram
repeat beta-hCG & sonogram in 2-3 days if beta-hCG hasn't doubled --> ectopic pregnancy else --> IUP; exclude threatened abortion or hydatiform mole |
|
ectopic pregnancy management
|
ruptured ectopic --> emergency laparotomy to stop bleeding
unruptured ectopic --> methotrexate (if criteria met) or laparoscopy/laparotomy if methotrexate or salpingostomy --> weekly beta-hCG to confirm resolution of pregnancy Rh-negative women --> RhoGAM |
|
methotrexate criteria for ectopic pregnancy
|
pregnancy mass <3.5cm diameter
absence of fetal heart motion beta-hCG <6,000mIU no history of folic acid supplementation |
|
chorionic villus sampling
|
catheter is placed into placental tissue without entering amniotic fluid at 10-12 weeks gestation
chorionic villi are aspirated tissue is sent for karyotyping |
|
amniocentesis
|
performed after 15 weeks
needle is placed under ultrasound guidance and amniotic fluid is aspirated amniocytes are sent for karyotyping neural tube defects are screened with alphafetoprotein and acetylcholinesterase |
|
pelvic relaxation
|
uterine prolapse (grades I-IV)
cystocele rectocele enterocele urinary incontinence |
|
cystocele
|
postmenopausal woman
anterior vaginal wall protrussion urinary incontinence diagnosis --> pelvic exam |
|
rectocele
|
postmenopausal woman
posterior vaginal wall protrussion digitally assisted removal of stool diagnosis --> pelvic exam |
|
medical management of pelvic relaxation
|
used in minor relaxation
Kegel exercises --> voluntary contractions of pubococcygeus muscle estrogen replacement --> in postmenopausal women pessaries --> objects inserted into vagina to elevate pelvic structures |
|
surgical management of pelvic relaxation
|
used when medical management fails
vaginal hysterectomy with anterior and posterior colporrhaphy (vaginal repair) |
|
pharmacology of urinry incontincence
|
alpha adrenergeic --> contract urethra; ephedrine, imipramine, estrogens; phenoxibenzamine is antagonist
beta adrenergic --> relax detrusor muscle; flavoxate, progestins cholinergic --> contract detrusor muscle; bethanecol, neostigmine; anticholinergics are oxybutynin, propantheline |
|
cystometry
|
urinary catheter empties bladder then infuses saline; measures -->
residual volume --> normal 50mL sensation of fullness --> normal 200-225mL urge to void --> normal 400-500mL |
|
sensory irritative incontinence
|
involuntary detrusor contractions stimulated by irritation from infections, stones, tumor, foreign body
presentation --> loss of urine with frequency, urgency and dysuria, suprapubic tenderness diagnosis --> urinalysis and urine culture or cytoscopy; cystometry is usually unnecessary management --> antibiotics for infections; cytoscopy for stones, foreing bodies and tumors |
|
stress incontinence
|
from rises in intraabdominal pressure
presentation --> involuntary loss of urine with coughing or sneezing, no urine loss at night exam --> cystocele may be present and Q-tip test is positive (rotates >30degrees) studies --> urinalysis and culture are normal; cystometry is normal without detrusor contractions management --> Kegel or estrogen; urethropexy or tension-free vaginal tape |
|
motor urge hypertonic incontinence
|
idiopathic detrusor contractions that can't be suppressed volutarily
presentation --> loss of urine, cannot suppress urge to void, day or night tests --> urinalysis and culture are normal; residual volume is normal but there are involuntary detrussor contractions management --> anticholinergics and NSAIDs |
|
overflow hypotonic incontinence
|
hypotonic bladder does not empty until theres excess pressure;
etiology --> denervated bladder from diabetic neuropathy or multiple sclerosis, anticholinergics presentation --> urine loss day and night with no detrussor contractions; decreased pudendal nerve sensation tests --> urinalysis and culture normal or infection; markedly increased residual volume without detrussor contractions management --> self-catheterization; cholinergics, alpha blockers |
|
bypass fistula incontinence
|
presentation --> history of radical pelvic or radiation surgery, continuous urine loss day and night
diagnosis --> intravenous pyelogram shows dye leakage from urinary tract fistula management --> surgical repair |
|
vaginal discharge diagnostic tests
|
speculum exam --> looking for inflammation and characteristics of discharge
vaginal pH --> normal is <4.5; nitrazine paper turns yellow when normal or dark when high pH KOH slide --> two drops of vaginal discharge + saline + KOH are analyzed on microscope |
|
bacterial vaginosis
|
high pH replaces normal flora lacbacilli
presentation and diagnosis --> fishy odor, no itching, pH>4.5, thin grayish discharge, whiff+ on KOH, clue cells on wet mount management --> metronidazole (safe in pregnancy) or clindamycin; orally or vaginally |
|
trichomonas vaginitis
|
STD; protozoan resides in seminal fluid
presentation and diagnosis -->itching, burning, pain with intercourse, green discharge, inflammation seen, erythematous cervix, pH>4.5, trichomonads and WBCs on saline management --> oral metronidazole orally for patient and partner |
|
candida yeast vaginitis
|
presentation and diagnosis --> itching, burning, pain with intercourse, normal pH, white discharge, inflammation seen, pseudohyphae on KOH
management --> single oral dose of fluconazole or vaginal azole creams |
|
physiologic discharge
|
due to excess estrogen
presentation and diagnosis --> watery vaginal discharge, no itching, no inflammation, normal pH, absence of pathogens on wet mount management --> contraception with progestins |
|
vaginal discharge with normal pH
|
candida, physiologic discharge
|
|
vaginal discharge with high pH
|
bacterial vaginosis, trichomonas
|
|
grayish discharge
|
bacterial vaginosis
|
|
white discharge
|
candida
|
|
green discharge
|
trichomonas
|
|
watery discharge
|
physiologic discharge
|
|
differentail diagnosis of vulvar itching
|
vulvar carcinoma
STDs benign vulvar dystrophy malignant cancer all lesions should have biopsy |
|
vulvar dystrophy
|
squamous hyperplasia --> whitish, firm, cartilaginous lesions with thick kertain and epithelial proliferation on microscope; management is fluorinated corticosteroid cream
lichen sclerosis --> bluish-white papula that can coalesce into white plaques and show epithelial thinning; management is clobetasol cream |
|
premalignant vulvar lesions
|
squamous dysplasia --> white, red or pigmented multifocal lesions with epithelium atypia not reaching BM; management is surgical excision
CIS --> same presentation with more atypia but not reaching the BM; management is laser vaporization |
|
malignant vulvar lesions
|
squamous cell carcinoma --> most common; associated with HPV
melanoma --> 2nd most common; any dark or black lesion should be biopsied; prognosis related to depth of invasion Paget disease --> red vulvar lesion |
|
management of malignant vulvar lesions
|
radical vulvectomy with or without lymphadenectomy
|
|
benign vulvar lesions
|
molluscom contagiousum --> spontaneously regressing umbilicated tumors; observation, curettage, cryo
condylomata acuminata --> HPV 6 & 11 cauliflower lesions Bartholin cyst --> aspiration yields sterile fluid |
|
cervical polyps
|
presentation --> vaginal bleeding and smooth red or purple fingerlike projections from cervical canal
diagnosis --> biopsy shows mildly atypical cells management --> twisting or surgical string for the polyp; electrocautery or laser for the base |
|
nabothian cysts
|
mucus-filled cyst on cervix surface
presentation --> asymptomatic small white pimpli-likeelevation palpated or seen by colposcopy management --> none necessary but can be removed by electrocautery or cryotherapy |
|
cervicitis
|
presentation --> mucopurulent cervical discharge without pelvic tenderness or fever
diagnosis --> cervical culture shows chlamydia or gonorrhea management --> oral azythromycin single dose or doxycycline 7 days |
|
premalignant cervical lesions
|
are asymptomatic and 15% can progress to cancer in 8-10 years
65% regress; 20% stay the same due to HPV 16, 18, 30s risk factors for HPV --> early age of intercourse, multiple partners, cigarette smoking, immunosuppression |
|
what is a pap smear
|
exfoliative cytology
best screening test for premalignant lesions one specimen from T-zone and one from endocervix conventional method --> samples are smeared and fixated onto slide liquid-based method --> samples are rinsed into a solution |
|
pap smear screening
|
start 3 years after onset of sexual intercourse or at age 21
discontinue at age 70 after >3 consecutive negative tests if under age 30 --> screen annually with conventional or every 2 years with liquid-based if over 30 --> screen every 2-3 years if >3 negative pap smears |
|
pap smear classification
|
negative
ASC --> atypical squamous cells; undertermined significance or cannot exclude HSIL LSIL --> low-grade squamous intraepithelial lesion; biopsy shows HPV, mild dysplasia or CIN 1 HSIL --> high-grade squamous intraepithelial lesion; biopsy shows moderate-severe dysplasia or CIN 2-3 cancer --> biopsy will show invasive cancer |
|
ASCUS pap smear
|
results from inflammatory or atrophic lesions or the initial stages of HPV infection
10-15% of ASCUS paps can have a significant premalignant lesion management --> repeat cytology in 3-6 months and HPV DNA testing (reliable patients) or colposcopy+biopsy (unreliable patients) if high risk HPV DNA test --> colposcopy+biopsy |
|
colposcopy
|
performed if there's high risk results from HPV DNA test
satisfactory or adequate --> entire T-zone is visualized and no lesions dissapear into endocervix unsatisfactory or inadequate --> entire T-zone cant be visualized colposcopy includes endocervical curettage and ectocervical biopsy |
|
cone biopsy
|
indications:
pap smear is worst than colposcopy biopsy abnormal endocervical curettage lesion in endocervical canal biopsy shows microinvasive carcinoma |
|
cervical dysplasia management according to histology
|
CIN 1 --> repeat Pap in 6-12 months OR colposcopy+Pap in 12 months OR HPV DNA in 12 months
CIN 1, 2, 3 --> ablation with cryotherapy, laser or electrofulguration CIN 1, 2, 3 --> excision by LEEP or cold-knife conization biopsy confirmed recurrent CIN 2 or 3 --> hysterectomy all ablations or excisions require repeat Pap, colposcopy, HPV DNA every 4-6 months for 2 years |
|
invasive cervical cancer presentation and diagnosis
|
postcoital vaginal bleeding, irregular vaginal bleeding, lower extremity pain and edema
cervical biopsy --> initial diagnostic test metastatic workup --> do if biopsy is positive; pelvic exam, chest x-ray, IV pyelogram, cystoscopy, sigmoidoscopy CT or MRI are not used for staging |
|
invasive cervical cancer management
|
stage Ia1 --> <=3mm, simple hysterectomy
stage Ia2 --> 3-5mm, modified radical hysterectomy stage Ib --> radical hysterectomy stages II-IV --> radio and chemo follow-up --> pap every 3months for 2 years; then every 6 months for 3 years |
|
cervical neoplasia in pregnancy
|
all abnormal pap smears should be followed by colposcopy+biopsy
no ECC is performed |
|
cervical neoplasia in pregnancy management
|
CIN --> follow with Pap+colposcopy evrery 3 months during pregnancy; treat postpartum
microinvasion --> do cone biopsy; if confirmed, then treat postpartum invasive cancer --> if diagnosis before 24 weeks then radical hysterectomy or radio; if after 24 weeks then cesarean at 32-33 weeks + definitive treatment |
|
HPV vaccine
|
quadrivalent for types 6, 11, 16, 18 (70% of cancers and 90% of warts)
uses noninfectious particles recommended to all women 8-26 with target age 11-12 do not test for HPV before vaccine continue regular Paps not recommended for pregnant, lactating or immunosuppressed |
|
mullerian anomalies
|
hypoplasia/agenesis
unicornuate uterus didelphys uterus bicornuate uterus septate uterus arcuate uterus DES uterus |
|
uterine hypoplasia/agenesis
|
may lack vagina or any part of uterus except fundus
associated with urinary tract anomalies |
|
unicornuate uterus
|
one Mullerian duct does not develop or develops incompletely
the incompletely developed half uterus lacks a cavity connecting to vagina which leads to pain during menses in teenagers may have pregnancy in the bad uterus but 90% of them rupture |
|
didelphys uterus
|
double uterus from failure of Mullerians to fuse
may have a single or two cervix or vaginas |
|
bicornuate uterus
|
most common
failure of Mullerians to fuse at the top results in two horns sharing a cervix or two bodies sharing a cervix |
|
septate uterus
|
Mullerians fused but theres no degeneration of median septum
external shape appears normal |
|
arcuate uterus
|
small midline indentation at the fundus
does not have negative effects on pregnancy |
|
DES uterus
|
daughters of mothers exposed to DES during pregnancy
may have hypoplastic uterus, T-shaped cavity and/or cervical defects |
|
leiomyoma presentation
|
most common benign uterine tumor; outgrowth of the myometrium
intramural --> most common location within the wall of the uterus submucosal --> beneath endometrium and can distort uterine cavity; can have meno/metro or menometrorrhagia subserosal --> beneath the serosa and can distort the external contour and pressure the bladder, rectum or ureters |
|
leiomyoma natural history
|
slow growth --> small, grow slowly and cause no symptoms except if they are massive
rapid growth --> estrogen receptors are increased and result in rapid growth specially during pregnancy degeneration --> the size is more than blood supply resulting in ischemic with acute pain requiring hospitalization and narcotics shrinkage --> when estrogen levels fall the leiomyoma shrinks |
|
leiomyoma diagnosis
|
pelvic exam --> enlarged asymetric, nontender uterus in absence of pregnancy
sonography --> traditional for intramural or subserosal or with saline infusion for submucosal hysteroscopy --> for submucosal myomas confirmation of diagnosis is made by histologic exam of excised tissue |
|
leiomyoma management
|
observation --> most can be managed conservatively
presurgical shrinkage --> leuprolide for 3-6 months results in 60-70% shrinkage myomectomy --> done to conserve fertility; subsequent pregnancies should be delivered by cesarean embolization --> catheter injects microspheres which cause ischemia and necrosis of myoma hysterectomy --> if patient has completed childbearing |
|
adenomyosis presentation
|
ectopic endoemtrial glands in myometrium
presents with secondary dysmenorrhea or menorrhagia, symmetrical diffuse uterine enlargement and tenderness during menses |
|
adenomyosis diagnosis
|
mostly made clinically
ultrasound or MRI shows diffusely enlarged uterus with cystic areas in myometrium confirmation is by histology |
|
ademyosis management
|
medical --> levonorgestrel intrauterine system decreases menstrual bleeding
hysterectomy --> definitive treatment |
|
differential diagnosis for enlarged non-pregnant uterus
|
leiomyoma --> asymmetric, firm, nontender
adenomyosis --> symmetric, soft, tender |
|
differential diagnosis of postmenopausal bleeding
|
endometrial carcinoma (most important), vaginal or endometrial atrophy (most common), postmenopausal hormone replacement
|
|
endometrial cancer risk factors
|
unoppossed estrogen occurs in
obesity hypertension diabetes nulliparity late manopause chronic anovulation (polycystic ovarian disease) |
|
endometrial cancer diagnosis
|
endometrial sampling
D&C if cervical stenosis is present hysteroscopy --> rules out cervical or endometrial polyps ultrasound --> endometrial lining should measure <5mm thick in postmanopause |
|
endometrial cancer management
|
if negative histology from sampling --> diagnosis is atrophy treated with estrogen/progesterone replacement
if positive histology from sampling --> adenocarcinoma is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic/para-aortic lymphadenectomy; it may also require radio and chemo postoperative |
|
endometrail hyperplasia
|
may cause bleeding; cells have no atypia; treat with progestin
|
|
ovarian cyst differential diagnosis
|
pregnancy (most common)
complex masses --> dermoid cyst benign cystic hematoma endometrioma tubo-ovarian abscess ovarian cancer |
|
ovarian cyst presentation and diagnosis
|
pelvic mass in reproductive years
negative betahCG (rules out pregnancy) sonogram shows fluid-filled ovarian simple cyst |
|
ovarian cyst management
|
follow-up exam in 6-8 weeks for resolution
alert patient of possibility of acute onset pain from torsion if >7cm or prior steroid contraception --> laparoscopy |
|
ovarian hyperthecosis pathophysiology
|
nests of active luteinized cells in ovarian stroma; peripheral estrogen is increased which leads to excess androgen production by ovaries; risk of endometrial hyperplasia and carcinoma are increased due to high estrogens
|
|
ovarian thecosis presentation
|
obesity
less severe hirsutism than PCOS virilization (clitoral enlargement, balding, deep voice, male habitus) amenorrhea or irregular/anovulatory cycles can occur in postmenapause unlike PCOS |
|
ovarian hyperthecosis management
|
oral contraception suppresses androgen production and free androgens
|
|
luteoma of pregnancy
|
non-neoplastic tumor-like mass that regresses spontaneously
asymptomatic found incidentally hormonally active and can produce maternal and fetal hirsutism and virilization |
|
theca lutein cysts
|
benign neoplasm caused by excess FSH and beta-hCG
associated with twins and molar pregnancies regresses spontaneously |
|
prepubertal pelvic mass presentation and work-up
|
presents with sudden onset of acute abdominal pain in prepubertal female
serum tumor markers for germ cell tumors: LDH --> dysgerminoma beta-hCG --> chroriocarcinoma alpha-fetoprotein --> endodermal sinus tumor |
|
prepubertal pelvic mass diagnosis and management
|
if simple cyst --> diagnose with laparoscopy
if complex mass --> diagnose with laparotomy if benign --> cystectomy+annual follow-up (pelvic exam+tumor markers) if malignant --> unilateral S&O, staging and chemo |
|
premenopausal complex mass
|
most common is dermoid cyst (benign cystic teratoma)
also endometrioma, tubo-ovarian abscess, ovarian cancer b-hCG rules out pregnancy; ultrasound rules out simple mass (ovarian cyst) manage with cystectomy or oophorectomy |
|
benign cystic teratoma
|
complex mass with calcifications on ultrasound
|
|
ovarian torsion
|
presumptive diagnosis --> abrupt unilateral pelvic pain, b-hCG-, adnexal mass on ultrasound
management --> untwist ovary; if revitalization then cystectomy; if necrosis then oophorectomy |
|
ovarian cancer presentation
|
postmenopausal adnexal mass
|
|
ovarian cancer risk factors
|
BRCA1 gene
positive family history high number of lifetime ovulations perineal talc powder protective factors --> oral contraceptives, chronic anovulation, brest feeding, short reproductive life |
|
ovarian cancer diagnosis
|
screening --> bimanual pelvic examination (large, solid, irregular, fixed)
tumor markers --> CEA, CA-125, LDH, AFP, hCG, testosterone abdominal pelvic CT or pelvic ultrasound barium enema to rule out diverticulosis IV pyelogram for urinary tract lesions |
|
types of ovarian tumors
|
epithelial --> older women; ovarian cancers (serous, mucinous, Brenner, endometrioid, clear cell)
germ cell --> younger women; dysgerminoma, endodermal, teratoma, choriocarcinoma stromal --> granulosa-theca cells, Sertoli-Leydig cell metastatic --> from other primary sites (endometrium, GI, breast, krukenberg) |
|
serous ovarian carcinoma
|
postmenopausal woman, pelvic mass, high CEA or CA-125
|
|
choriocarcinoma
|
postmenopausal woman, pelvic mass, high hCG
|
|
Sertoli-Leydig tumor
|
postmenopausal pelvic mass, masculinization, high testosterone
|
|
endometrial carcinoma metastatic to ovaries
|
postmenopausal woman with bilateral pelvic masses
postmenopausal bleeding enlarged uterus |
|
CEA or CA-125
|
serous ovarian cancer
|
|
hCG as tumor marker
|
choriocarcinoma (ovarian germ cell tumor)
|
|
testosterone as tumor marker
|
Sertoli-Leydig cell ovarian stromal tumor
|
|
LDH as tumor marker
|
dysgerminoma
|
|
AFP as tumor marker
|
endodermal sinus germ cell tumor (ovary)
|
|
ovarian cancer management
|
laparotomy or laparoscopy with unilateral salpingo oophorectomy with histology during surgery
if benign --> USO is enough or TAH+BSO if malignant --> TAH+BSO, omentectomy and bowel ressection if necessary + postop chemo |
|
benign gestational neoplasia types
|
hydatiform mole
complete --> empty egg, paternal X, 46XX, fetus absent, grape-like vesicles incomplete --> normal egg, maternal and paternal X, 69XXY, fetus nonviable |
|
malignant gestational neoplasia types
|
nonmetastatic --> uterus only, 100%cure
good prognosis --> metastasis to pelvis or lung, 95% cure, single agent chemo poor prognosis --> metastasis to brain or liver, 65% cure, combo chemo |
|
gestational trophoblastic neoplasia presentation
|
bleeding prior to 16 weeks
passage of vesicles hypertension proteinuria no fetal heart tones hyperthyroidism fundus larger than dates |
|
gestational trophoblastic neoplasia diagnosis
|
snowstorm ultrasound shows homogenous intrauterine echoes without sac or fetus
|
|
gestational trophoblastic neoplasia management
|
1) baseline beta-hCG
2) chest x-ray to rule out lung metastasis 3) suction D&C 4) oral contraceptives during follow-up if benign --> weekly b-hCG until negative for 3 consecutive weeks, then monthly until negative for 12 months if b-hCG does not lower --> brain, thorax, abdominal and pelvic CTs for metastasis if good prognosis metastatic --> single agent chemo + 1 year follow-up if poor prognosis metastatic --> multiple chemo + weekly b-hCG then monthly then every three months (5 years) |
|
cercivitis
|
presentation --> mucopurulent cervical discharge, without pelvic tenderness or fever
diagnosis --> nucleic acid amplification tests of cervical discharge or urine; normal WBCs and ESR management --> single oral dose of cefixime and azithromycin |
|
acute salpingo-oophoritis presentation and diagnosis
|
bilateral lower abdominal/pelvic pain
mucopurulent cervical discharge cervical motion tenderness high WBCs and ESR |
|
acute salpingo-oophoritis management
|
certain diagnosis and no evidence of systemic infection or absecess --> ofloxacin+metronidazole 14 days
uncertain diagnosis, nulligravida, evidence of abscess or fever --> inpatient, IV cefoxitin or cefotetan + IV doxy |
|
lower abdominal-pelvic pain differential diagnosis
|
acute salpingo-oophoritis
adnexal torsion ectopic pregnancy appendicitis endometriosis diverticulitis Crohn ulcerative colitis |
|
tubo-ovarian abscess presentation
|
sepsis (tachycardia, hypotension, high fever)
severe lower abodominal-pelvic pain peritoneal guarding and rigidity nausea, vomit adnexal masses may be palpated |
|
tubo-ovarian abscess diagnosis
|
positive cervical cultures for chlamydia or gonorrhea
positive blood cultures for gram- pus on culdocentesis high WBCs and ESR sonogram or CT show bilateral complex masses |
|
differential diagnosis of sepsis+lower abdominal-pelvic pain
|
tubo-ovarian abscess
septic abortion diverticular abscess appendiceal abscess adnexal torsion |
|
tubo-ovarian abscess management
|
IV clindamycin and gentamicin
if no change in 72 hours or abscess rupture --> laparotomy and consider TAH+BSO |
|
chronic PID
|
chronic bilateral abdominal/pelvic pain
no cervical discharge cervical motion tenderness negative cultures normal WBCs and ESR sonography may show bilateral cystic pelvic masses diagnosis --> laparoscopic visualization of pelvic adhesions management --> lysis of tubal adhesions or if unremitting TAH+BSO |
|
primary dysmenorrhea Vs. secondary dysmenorrhea
|
primary --> teenagers, absence of pelvic pathology
secondary --> mature women, presence of pelvic pathology (endometriosis, adenomyosis) |
|
primary dysmenorrhea
|
recurrent lower abdominal pain during menstrual periods in a teenager with absence of pelvic pathology
due to excess prostaglandin F2 treat with NSAIDs (first line) or oral contraception (2nd line) |
|
endometriosis presentation and diagnosis
|
pelvic-abdominal pain
dyspareunia painful bowel movements infertility exam --> cul-de-sac adhesions, uterosacral ligament nodularities, enlarged adnexa lab --> normal WBCs and ESR, CA-125 may be elevated diagnosis --> laparoscopy |
|
endometriosis management
|
medical --> leuprolide (DOC), medroxyprogesterone, testosterone derivative
surgical --> laparoscopic lysis of tubal adhesions, cystectomies, laser vaporization or TAH+BSO |
|
chancroid
|
painful ulcer with ragged edges due to Haemophilus ducreyi
confirm diagnosis with culture treat with single dose azithromycin, single dose IM ceftriaxone or erythromycin 7 days |
|
lymphogranuloma venereum
|
due to chlamydia trachomatis
painless vesiculopustular vaginal eruption that spontaneously heals can have perirectal adenopathy, absecesses and fistulas within weeks diagnosis --> postitive culture from pus aspirated from lymph node management --> doxycylcline or erythromycin for 3 weeks |
|
granuloma inguinale
|
due to calymmatobacterium granulomatis
painless ulcer with granulation tissue and no lymphadenopathy diagnosis --> microscopicexam shows donovan bodies management --> doxycycline or TMP-SMX 3 weeks |
|
condyloma acuminatum
|
HPV 6, 11
generally asymptomatic but clinical lesions in 30% pedunculated, soft papule turns into cauliflower lesion management --> small lesions are treated topically with podophyllin, trichloroacetic acid; larger lesions with cryo, laser or surgical excision |
|
mucopurulent discharge
|
chlamydia trachomatis (cervical), gonorrhea (cervical and vulvovaginal)
|
|
STDs with ulcers
|
chancroid (painful, ragged)
granuloma inguinale genital herpes (painful, smooth) lymphogranuloma venerreum syphilis |
|
STDs without ulcers
|
chlamydia
HPV gonorrhea HBV HIV |
|
ragged soft edge inflamed painful vaginal ulcer
|
chancroid
|
|
groove sign
|
lymphogranuloma venereum
|
|
beefy red painless vaginal ulcer
|
granuloma inguinale
|
|
rolled, hard edges, painless vaginal ulcer
|
syphilis
|
|
smooth edge inflamed painful vaginal ulcer
|
herpes
|
|
gonorrhea
|
vulvovaginal and cervical mucopurulent discharge
if cervicitis or PID --> pelvic pain, cervical motion tenderness, etc… if disseminated --> petechial skin lesions, septic arthritis management --> single dose cefixime + single dose azithromycin |
|
estrogen-mediated effects of oral contraception
|
fluid retention
accelerated cholelithiasis increased hepatic proteins healthy lipid profile changes |
|
progestin-mediated effects of oral contraception
|
mood changes and depression
androgenic --> weight gain, acne unhealthy lipid profile changes |
|
absolute contraindications of oral contraception
|
pregnancy
acute liver disease history of vascular disease (DVT, CVA, SLE) hormonally-dependant breast cancer smoker >35y/o uncontrolled hypertension migraines with aura diabetes known thrombophilia |
|
relative contraindications of oral contraceptives
|
migraines
depression diabetes chronic hypertension hyperlipidemia |
|
premanarchal vaginal bleeding differential diagnosis
|
ingestion of estrogens
foreign body (MCC) cancer of vagina or cervix pituitary or adrenal tumor ovarian tumor sexual abuse idiopathic precocious puberty |
|
premenarchal vaginal bleeding diagnosis
|
pelvic exam under sedation for foreign bodies, sexual abuse or tumors
CT or MRI of pituitary, abdomen and pelvis for tumors |
|
abnormal vaginal bleeding diagnosis and management
|
1) rule out pregnancy or complications of pregnancy --> incomplete abortion, threatened abortion, ectopic pregnancy, mole
diagnosis --> b-hCG + sonogram 2) rule out anatomic lesions --> vaginal lacerations, cervical polyps, cervicitis, leiomyomas, uterine hyperplasia, adenomyosis diagnosis --> pelvic exam, saline sonogram, endometrial sampling, hysteroscopy 3) rule out dysfunctional uterine bleeding --> anovulation (hypothyroidism, hyperprolactinemia) diagnosis --> history of irregular unpredictable menstrual bleeding without cramps; clear thin watery cervical mucus; no midcycle temperature rise; endometrial biopsy shows proliferative endometrium |
|
primary amenorrhea diagnosis
|
absence of menses at age 14 without 2dary sexual characteristics or
absence of menses at age 16 with secondary sexual characteristics |
|
primary amenorrhea, breasts+, uterus-
|
Mullerian agenesis --> 46XX, create a vagina
androgen insensitivity --> 46XY but looks female, absent pubic hair, high testosterone; give estrogen, create vagina and remove testes |
|
primary amenorrhea, breasts-, uterus+
|
gonadal dysgenesis --> Turner, high FSH, no follicles, streak ovaries
HP axis failure --> low FSH, normal ovaries, diagnose with brain scan Kallman --> +anosmia |
|
secondary amenorrhea diagnosis
|
absence of menses for 3 months if previously regular
absence of menses for 6 months if previously irregular |
|
first step in evaluation of secondary amenorrhea
|
b-hCG to rule out pregnancy
|
|
etiology of secondary amenorrhea
|
anovulation --> PCOS, hypothyroidism, pituitary adenoma, hyperprolactinemia, antipsychotics, antidepressants
hypoestrogenic --> absence of functional ovarian folliclles, HP insufficiency outflow tract obstruction |
|
secondary amenorrhea work-up
|
1) b-hCG; if negative -->
2) TSH (primary hypothyroidism causes high TRH and hyperprolactinemia); if negative --> 3) prolactin (antipsychotics or pituitary tumor); do MRI tu rule out adenoma; if negative --> 4) progesterone challenge test; if positive then anovulation; if negative then inadequate estrogen --> 5) estrogen-progesterone challenge test; if positive --> inadequeate estrogen; if high FSH then ovarian failure; if low FSH then HP insufficiency if negative --> outflow tract obstruction or endometrial scarring; order hysterosalpingogram |
|
idiopathic/constitutional precocious puberty
|
too much gonadotropins
all puberty changes are seen 6y/o girl normal MRI treat with leuprolide to avoid premature closure of epiphysis |
|
McCune-Albright syndrome
|
autonomous aromatase activation with excess estrogen
complete precocious puberty 6 y/o café au lait spots multiple cystic bone lesions management --> aromatase enzyme inhibitor |
|
granulosa cell tumor
|
precocious complete puberty
6 y/o girl pelvic mass management --> surgery |
|
premenstrual syndrome (PMS) diagnosis
|
based on diary of symptoms throughout 3 menstrual cycles; must meet all criteria -->
recurrent in at least 3 consecutive cycles absent in preovulatory phase present in the 2 postovulatory weeks intereferes with normal functioning resolves with onset of menses |
|
premenstrual syndrome management
|
yaz (drospirenone/estradiol)(low-dose combo OCP, 4-day hormone free)
drospirinon (DRSP)(spironolactone analogue with antimineralocortocoid effects) SSRIs (for emotional symptoms) alprazolam (for emotional symptoms) GnRH agonists |
|
hirsutism due to adrenal tumor
|
rapid onset virilization
abdominal/flank mass on CT or MRI markedly elevated DHEAS remove surgically |
|
hirsutism definition
|
excessive male-pattern hair growth with or without virilization (clitorimegaly, baldness, deep voice, increased muscle)
|
|
hirsutism due to Sertoli-Leydig tumor
|
rapid onset virilization
adnexal pelvic mass on exam and ultrasound markedly elevated testosterone remove surgically |
|
hirsutism due to congenital adrenal hyperplasia
|
21-hydroxylase deficiency
gradual onset hirsutism without virilization normal exam markedly increased 17OH progesterone treat with corticosteroid replacement |
|
hirsutism work-up
|
sudden onset --> testosterone and DHEAS levels, pelvic exam, abdominal CT or MRI, pelvic ultrasound
gradual onset --> serum 17OH progesterone levels, testosterone, pelvic ultrasound (PCOS) |
|
differential diagnosis of hirsutism
|
21-hydroxylase deficiency
stromal ovarian tumor PCOS idiopathic (MCC) adrenal tumor |
|
idiopathic hirsutism
|
due to 5-alpha reductase overactivity
gradual onset hirsutism normal DHEAS, 17-OH progesterone and testosterone treat with spironolactone or eflornithine |
|
polycystic ovarian syndrome presentation
|
irregular menstrual bleeding (from anovulation/unopposed estrogen; gonadotropins arent pulsatile)
hirsutism (increased LH stimulates androgens which also decrease SHBG) obesity infertility ovarian enlargement with multiple cysts |
|
polycystic ovarian syndrome diagnosis
|
suspected with --> irregular menstrual bleeding, obesity, hirsutism, infertility
confirmed with --> LH/FSH ratio 3:1 (normal is 1.5:1) |
|
polycystic ovarian syndrome management
|
OCPs (normalize bleeding and suppress LH)
spironolactone (suppresses 5-alpha reductase) if pregnancy is desired --> clomiphene |
|
semen analysis for infertility
|
normal values:
volume >2ml pH 7.2-7.8 sperm density >20million/ml motility >50% morphology >50% normal if sperm density is low --> intrauterine insemination if severely abnormal --> intracytoplasmic sperm injection or in-vitro fertilization |
|
causes of infertility
|
primary hypothyroidism
hyperprolactinemia PCOS pituitary adenoma antipsychotics PH insufficiency ovarian insufficiency semen abnormalities PID |
|
infertility work-up
|
1) initial step is semen analysis
2) rule out anovulation with history, progesterone levels, endometrial biopsy and temperature chart 3) if semen is normal and anovulation is ruled out --> hysterosalpingogram if positive --> attempt laparoscopic correction OR in-vitro fertilization if negative --> unexplained infertility; spontaneous pregnancy occurs in 60% at 3 years OR treat with clomiphene+intrauterine insemination |
|
premature ovarian failure
|
hot flashes and sweats
>30 y/o high FSH |
|
menopause presentation and diagnosis
|
presentation --> amenorrhea, hot flashes, cardiovascular disease, osteoporosis
diagnosis --> 3 months of amenorrhea with elevation of gonadotropins |
|
osteoporosis presentation and diagnosis
|
vertebral crush fractures, hip and wrist fractures
diagnosis --> dual-energy x-ray absoprtiometry (DEXA scan) |
|
osteoporosis management
|
lifestyle changes --> Ca+ and vitamin D, weight-bearing exercise, stop cigarettes and alcohol
medications --> biphosphonates and/or SERMs (raloxifene) |
|
risks of hormone replacement therapy
|
estrogen+progestin --> breast cancer, heart disease, stroke
estrogen alone --> risk of stroke; no change in risk of breast cancer or heart disease both groups --> DVT |
|
benefits of hormone replacement therapy
|
improves -->
vaginal dryness hot flashes vasomotor symptoms osteoporois |
|
indications of hormone replacement therapy
|
only indication is vasomotor symptoms
if only need to treat osteoporosis consider SERMs |
|
cystic breast mass diagnosis and management
|
diagnosis --> cyst aspiration and fine-needle aspiration with pathology exam
management --> preaspiration mammography then aspiration; if benign, no further work-up |
|
fibrocystic breast change presentation
|
bilateral breast enlargement which fluctuates with menstrual periods (cyclic mentrual mastalgia)
may have palpable painful nodules |
|
fibrocystic breast change diagnosis and management
|
aspiration and complete drainage
mass dissapears and fluid is clear --> discard fluid; reexamine in 4-6 weeks mass dissapears and fluid is bloody --> send for cytologic exam; reexamine in 4-6 weeks mass persists after aspiration --> wait 2 weeks after aspiration then mammography + excisional biopsy |
|
fibroadenoma presentation
|
most common in adolescents and young women
discrete, smoothly contoured, rubbery, nontender, movable mass |
|
fibroadenoma diagnosis and management
|
diagnose with ultrasound or fine needle aspiration showing a solid mass that does not collapse after aspiration
treat conservatively or elective excisional biopsy |
|
mammographic calcifications
|
nonpalpable; most are benign but 15-20% are early cancer; requires steoretactic needle localization and biopsy under mammographic guidance; treatment depends on histology
|
|
indications of excisional biopsy of the breast
|
cellular bloody cyst on fluid aspiration
failure of a suspicious mass to dissapear completely upon aspiration bloody nipple discharge with or without palpable mass skin edema and erythema and needle biopsy cannot be performed |
|
bloody nipple discharge
|
requires excisional needle biopsy
usually results from intraductal papilloma management based on histology |
|
breast cancer management
|
determine prognostic factors
stages I and II do breast-conserving therapy with wide excision + axillary node dissection or sentinel node biopsy + radiotherapy |
|
breast cancer prognostic factors
|
lymph node status --> most important; inversely proportional to survival
tumor size --> correlates with lymph node involvment but 15% of small tumors have positive node involvement receptor status --> estrogen and progesterone receptor status is needed before surgical therapy; it's prognostic and predictive factor DNA ploidy --> determines diploid or aneuploidy (worse); it's unclear wether this is an independent risk factor |
|
infiltrating ductal carcinoma
|
80% of breast cancers
starts as atypical ductal hyperplasia --> ductal carcinoma in situ --> invasive mas is stony hard and increases in size |
|
infiltrating lobular carcinoma
|
10% of breast cancers
better prognosis than infiltrating ductal carcinoma |
|
inflammatory breast cancer
|
uncommon
rapid growth with early metastasis skin is erythematous, swollen, warm, edematous and orange |
|
paget disease
|
uncommon
lesion is pruritic, red and scaly, located in nipple and areola nipple may become inverted discharge may occur |
|
breast cancer risk factors
|
BRCA 1 or 2 gene mutation (RR 15)
ductal or lobular carcinoma in situ (RR 15) atypical hyperplasia (RR 4) breast irradiation age < 20 (RR 3) positive family history (RR 3) |
|
sentinel node biopsy
|
first lymph node to which cancer cells are likely to spread from primary tumor
dye is injected into tumor which flows into the sentinel node biopsy is performed to determine stage and if removal of nodes is necessary |
|
adjuvant treatment for node positive breast cancer
|
premenopausal, ER or PR positive --> chemo +- ovarian ablation +- tamoxifen
premnopausal, ER and PR negative --> chemo postmenopausal, ER or PR positive --> tamoxifen + chemo postmnopausal, ER and PR negative --> chemo elderly --> tamoxifen or chemo |
|
diagnosis of pregnancy
|
presumptive --> amenorrhea, breast tenderness, nausea, vomiting, hyperpigmentation, skin striae
probable --> increased uterine size, postitive beta-hCG positive --> hearing fetal heart tones, sonographic visualization of fetus, perception of fetal movements |
|
pregnancy dating
|
conceptual dating --> 266 days or 38 weeks
menstrual dating assuming 28 day cycle --> 280 days or 40 weeks calculate due date --> LMP - 3 months + 7 days +- 1 week |
|
first trimester events and complications
|
from conception to 13 menstrual weeks
nausea, vomiting, breast tenderness, frequent urination spotting and bleeding in 20% (50% of which will continue normally) average weght gain is 5-8 pounds complications --> spontaneous abortion |
|
second trimester events and complications
|
from 13-26 menstrual weeks
round ligament pain Braxton-Hicks contractions are painless quickening (maternal awareness of fetal movements) starting at 16 weeks average weight gain is 1 pound/week after 20 weeks complications --> incompetent cervix, premature membrane rupture, premature labor |
|
third trimester events and complications
|
26-40 menstrual weeks
lower back and leg pain urinary frequency Braxton-Hicks contractions lightening bloody show average weight gain is 1 pound/week after 20 weeks complications --> premature membrane rupture, premature labor, preeclampsia, urinary tract infection, anemia, gestational diabetes |
|
1st trimester lab tests: CBC
|
normal hemoglobin --> 10-12g/dL due to dilutional effect
MCV --> low hemoglobin and MCV (<80) suggests iron defficiency; low hemoglobin and high MCV (>100) suggests folate defficiency thrombocytopenia --> idiopathic thrombocytopenic purpura or pregnancy induced thrombocytopenia leukocytosis up to 16,000/mm3 is normal; leukopenia suggests immune suppression or leukemia |
|
1st trimester lab tests: rubella IgG
|
absence of antibodies has fetal risks; vaccine is contraindicated in pregnancy but recommended after delivery
|
|
1st trimester lab tests: hepatitis B
|
HbsAb --> successful vaccination
HbsAg --> previous or present infection; only routine hepatitis test on prenatal lab panel HbeAg --> highly infectious state |
|
1st trimester lab tests: type, Rh and antibody screen
|
blood type and Rh --> direct Coombs test; if Rh negative risk for anti-D isoimmunization
|
|
1st trimester lab tests: STDs
|
cervical cultures --> chlamydia and gonorrhea
syphilis --> VDRL; if positive --> MHA-TP or FTA-ABS hepatitis B --> HbsAg HIV (requires consent) --> screen with ELISA; if positive --> western blot |
|
1st trimester lab tests: urine
|
urinalysis --> suggests renal disease, diabetes, infection
urine culture --> to screen for asymptomatic bacteriuria (8% of pregnant women) |
|
1st trimester lab tests: TB
|
PPD --> done in high-risk populations, not routinely
if positive PPD --> chest x-ray if chest x-ray negative --> INH + B6 9 months if chest x-ray positive --> sputum culture and triple therapy until cultures return |
|
1st trimester lab tests: cervical pap smear
|
to identify cervical dysplasia or malignancy
|
|
routine 1st trimester lab tests
|
complete CBC
rubella IgG cervical culture (chlamydia, gonorrhea) HbsAg VDRL HIV urinalysis urine culture cervical pap smear |
|
2nd trimester lab tests: MS-AFP
|
elective prenatal test; (only 20% sensitivity for trisomy 21)
detects neural tube defects, ventral wall defects, twin pregnancy, placental bleeding, fetal renal disease, teratoma if >2.5 MoM --> ultrasound to confirm gestational age if error --> re-do MS-AFP if correct --> amniocentesis for AF-AFP and AF acetylcholinesterase (NTD) if <0.85 MoM --> ultrasound to confirm gestational age if error --> re-do MS-AFP if correct --> amniocentesis for karyotype (trisomy 21) |
|
triple marker screen
|
window is 15-20 weeks
MS-AFP, hCG and estriol trisomy 21 --> low MS-AFP and estriol with high hCG; perform amniocentesis for karyotype trisomy 18 --> all markers are decreased; perform amniocentesis for karyotype quadruple marker screen --> inhibin A; increases sensitivity for Down to 80% |
|
gestational diabetes testing
|
1-h 50g oral glucose tolerance test --> screening test to all pregnant women between 24-28weeks
if >140mg/dL at 1 hour --> 3-h 100g oral glucose tolerance confirmatory test after overnight fast if fasting blood glucose >125mg/dL --> diabetes mellitus; no further testing required else --> FBS: <95mg/dL 1h: <180mg/dL 2h: <155mg/dL 3h: <140mg/dL if one abnormal value --> impaired glucose tolerance if two abnormal values --> gestational diabetes |
|
third trimester lab tests: CBC
|
should be performed between 24-28weeks in all pregnancies checking for iron defficiency anemia and pregnancy induced thrombocytopenia
|
|
third trimester lab tests: atypical antibody screen
|
indirect Coombs test at 28 weeks for all Rh negative women
if no isoimmunization (no anti-D antibodies) --> RhoGAM else --> RhoGAM is futile |
|
third trimester lab tests
|
1h oral glucose tolerance test between 24-28weeks
CBC atypical antibody screen + RhoGAM |
|
late pregnancy bleeding differential diagnosis
|
cervical causes --> erosion, polyps, carcinoma
vaginal causes --> varicosities, lacerations placental causes --> abruptio placenta, placenta previa, vasa previa |
|
late pregnancy bleeding work-up
|
CBC
DIC work-up (platelets, PT, PTT, fibrinogen, D-dimer) type and cross-match sonogram for placental location never perform digital or speculum exam until sonogram rules out placenta previa |
|
abruptio placenta presentation
|
late trimester painful bleeding (external or retroplacental hematoma)
normal placental implantation DIC |
|
abruptio placenta diagnosis
|
painful late trimester bleeding with a normal fundal or lateral wall placental implantation (upper 2/3 uterus)
|
|
abruptio placenta risk factors
|
previous abruption
hypertension maternal trauma cocaine premature membrane rupture |
|
abruptio placenta management
|
if maternal or fetal jeopardy --> emergency cesarean
if bleeding is controlled and >36 weeks --> induce vaginal delivery with amniotomy if mother and fetus are stable and remote from from term with subsiding signs --> conservative in-hospital observation |
|
abruptio placenta complications
|
hemorrahgic shock with acute tubular necrosis and DIC
|
|
placenta previa presentation and diagnosis
|
late trimester painless bleeding
ultrasound shows placental implantation over the lower segment |
|
placenta previa risk factors
|
previous placenta previa
multiple gestation multiparity advanced maternal age |
|
placenta previa management
|
if maternal or fetal jeopardy --> emergency cesarean delivery
if mother and fetus are stable --> conservative in-hospital observation with blood transfusions if placental edge >2cm from internal cervical os --> vaginal delivery if 36weeks and lung maturity confirmed by amniocentesis --> scheduled cesarean delivery |
|
placenta previa complications
|
if placenta is implanted over previous uterine scar --> intractable bleeding requiring cesarean hysterectomy
if too much blood loss and hypotension ---> Sheehan or acute tubular necrosis |
|
placenta accreta/increta/percreta
|
accreta (MC) --> villi invade deeper layers of endometrium but not myometrium
increta --> villi invade the myometrium but not serosa or bladder percreta --> villi invade the serosa or bladder |
|
vasa previa
|
presentation --> rupture of membranes, painless vaginal bleeding and fetal bradycardia
diagnosis --> suspected when sonogram has previously revealed a vessel crossing the membranes over internal cervical os risk factors --> velamentous insertion of umbilical cord, accessory placental lobes, multiple gestation management --> immediate cesarean |
|
uterine rupture
|
presentation --> vaginal bleeding, loss of electronic fetal heart rate signal, abdominal pain, loss of station of fetal head
diagnosis --> surgical exploration of the uterus to identify the tear risk factors --> classic (vertical) uterine incision, myomectomy, excessive oxytocin stimulation management --> surgical immediate delivery with uterine repair or hysterectomy |
|
GBS neonatal sepsis
|
presentation --> newborn sepsis within hours of birth with bilateral pneumonia (50%) mortality
prevention --> IV penicillin G if --> positive GBS urine culture or previous baby with GBS sepsis positive vaginal culture at 36-37weeks risk factors: preterm gestation, membranes ruptured>18h, maternal fever |
|
congenital toxoplasmosis
|
can only occur during the parasitemia of a primary infection
40% of pregnant women are toxoplasmosis IgG seropositive fetal infection --> IUGR, fetal hydrops, microcephaly, itracranial calcifications neonatal findings --> chorioretinitis, seizures, hepatosplenomegaly prevention --> avoid infected cat feces, raw goat milk, undercooked meat |
|
varicella infection
|
neonatal findings --> zigzag skin lesions, micropthalmia, chorioretinitis, extremity hypoplasia
prevention --> varicella zoster immune globulin within 96h of exposure or live-attenuated vacciine to non-pregnant with no IgG treatment --> acyclovir if maternal varicella pneumonia, encephalitis or immunocompromised |
|
congenital rubella
|
presentation --> congenital deafness, congenital cataracts, congenital heart disease
prevention --> all pregnant women should be screened for ruberlla IgG; if negative then vaccination after delivery |
|
cytomegalovirus infection
|
fetal manifestations --> hydrops, IUGR, microcephaly, periventricular cerebral calcifications
neonatal findings --> sensorineural deafness; if symptomatic: petechiae, meningoencephalitis, jaundice treatment --> ganciclovir |
|
HIV in pregnancy
|
triple therapy recommended including ZDV
cesarean should be offered at 38 weeks breast feeding should be avoided |
|
syphilis
|
fetal --> hydrops, macerated skin, anemia, thrombocytopenia, hepatosplenomegaly
neonatal ---> Hutchinson teeth, mullberry molars, saber shins, saddle nose, VIII nerve deafness |
|
obstetric complications
|
cervical insufficiency
multiple gestations isoimmunization preterm labor premature rupture of membranes postterm pregnancy |
|
hypertensive complications
|
gestational hypertension
mild preeclampsia severe preeclampsia eclampsia chronic hypertension HELLP syndrome |
|
medical complications in pregnancy
|
cardiac disease
thyroid disease epilepsy diabetes anemia liver disease UTIs thrombophilias thromboembolism |
|
cervical insufficiency
|
painless cervical dilation at 18-22 weeks with possible delivery of previable baby
diagnosis --> ultrasound management --> elective cerclage or emergency cerclage if theres sonographic evidence and after ruling out labor and chorioamnionitis |
|
multiple gestations
|
Di-Di twins --> 2 zygotes; two placentas seen
mono-di twins --> one zygote; one placenta, two sacs mono-mono twins --> one zygote; one placenta, one sac presentation --> hyperemesis gravidarum due to high beta-hCG, uterus larger than dates, high AFP diagnosis --> more than one fetus on sonogram management --> iron and folate, monitor blood pressure, vaginal delivery if both cephalic, else cesarean |
|
determination of fetal risk in isoimmunization
|
present if:
atypical antibodies detected with indirect Coombs test antibodies are associated with hemolytic disease of newborn titer more than 1:8 father of baby is antigen positive else --> no risk if ATT <1:8 management is conservative; repeat titer monthly |
|
determine degree of fetal anemia in isoimmunization
|
amniocentesis bilirubin --> indirectly indicates fetal hemolysis; plotted on Liley graph; severe anemia if zone III
PUBS --> directly measures fetal hematocrit; severe anemia if <25% ultrasound doppler -->measures peak flow velocity of fetal blood through middle cerebral artery; higher velocity, more anemia |
|
criteria for intervention in isoimmunization
|
severe fetal anemia is diagnosed when Liley Is in zone 3 or PUBS shows fetal hematocrit <25%
perform intrauterine intravascular transfusion if <34 weeks delivery if >34 weeks |
|
management of isoimmunization
|
1) determine fetal risk
2) determine degree of anemia 3) intervene if severe anemia |
|
prevention of isoimmunization
|
RhoGAM routinely:
1) to Rh negative mothers at 28 weeks 2) within 72h of chorionic villus sampling, amniocentesis or D&C 3) within 72h of delivery of an Rh positive infant |
|
preterm labor diagnosis
|
pregnancy 20-36 weeks
>= 3 contractions in 30 min cervix >=2cm or changing all three should be positive for diagnosis |
|
preterm labor presentation
|
lower abdominal pain or pressure
lower back pain increased vaginal discharge bloody show |
|
preterm contractions
|
pregnancy 20-36 weeks
>=3 contractions in 30 minutes dilated <2cm and no change |
|
tocolytic contraindications
|
obstetric --> abruptio placenta, ruptured membranes, chorioamnionitis
fetal --> lethal anomaly, fetal demise maternal --> eclampsia, severe preeclampsia, advanced cervical dilation |
|
tocolytic agents
|
may prolong pregnancy but for no more than 72h to administrate maternal IM betamethasone for lung maturation and transport mother to a facility with neonatal intesive care
magnesium sulfate terbutaline nifedipine indomethacin |
|
magnesium sulfate for tocolysis
|
competitive inhibitor of calcium
side effects --> muscle weakness, respiratory depression, pulmonary edema contraindications --> renal insufficiency and myasthenia gravis treat overdose with IV calcium gluconate |
|
terbutaline for tocolysis
|
depends on myometrial beta2 receptor activity
side effects --> hypertension, tachycardia, hyperglycemia, hypokalemia contraindications --> cardiac disease, diabetes, uncontrolled hyperthyroidism |
|
calcium channel blockers for tocolysis
|
side effects --> tachycardia, hypotension, myocardial depression
contraindications --> hypotension |
|
indomethacin for tocolysis
|
decreases prostaglandin production
side effects --> oligohydramnios, PDA closure in utero contraindications --> gestational age >32 weeks |
|
preterm labor management
|
confirm labor with specific criteria
rule out contraindications for tocolysis IV hydration with IV fluids magnesium sulfate 5g IV for 20 minutes then 2g/h cervical and urine cultures for GBS prophylaxis maternal IM betamethasone if <34 weeks |
|
preterm labor prevention
|
women with history of previous preterm delivery should receive IM 17alpha-OH progesterone starting at 20 weeks
|
|
premature rupture of membranes presentation
|
sudden gush of copious vaginal fluid
clear fluid flowing out of vagina oligohydramnios seen in ultrasound |
|
premature rupture of membranes diagnosis
|
sterile speculum exam showing:
1) posterior fornix pooling of amniotic fluid 2) nitrazine positive fluid turns pH-sensitive paper blue 3) fern positive pattern when fluid is allowed to dry on glass slide |
|
chorioamnionitis diagnosis
|
need all criteria:
maternal fever and uterine tenderness in the presence of PROM in the absence of a URI or UTI |
|
PROM management
|
if uterine contractions are present --> tocolysis is contraindicated
if chorioamnionitis is present --> cervical cultures, IV antibiotics and prompt delivery if infection is absent and <24 weeks --> induce labor or manage with bed rest if 24-33 weeks --> bed rest, IM betamethasone, cervical cultures, 7-day prophylactic ampicillin+erythromycin if >34 weeks --> initiate prompt delivery with oxytocin or prostaglandins or cesarean |
|
postterm pregnancy
|
>40 weeks from conception or >42 mentrual weeks
can predispose to macrosomia (viable placenta) or dysmaturity syndrome (decaying placenta) if sure date and favorable cervix --> induce labor with oxytocin and artificial rupture of membranes else --> conservative |
|
gestational hypertension
|
pregnancy >20weeks
nonsustained BP >140/90 without proteinuria conservative management and preeclampsia should ruled out |
|
mild preeclampsia
|
pregnancy >20weeks
sustained hypertension >140/90 with proteinuria 1-2+ or >300mg on 24h urine hemoconcentration if stable and <36w --> conservative management and no antihypertensive or MgSO4 if >36w --> induce labor with dilute oxytocin and IV MgSO4 to prevent eclamptic seizures |
|
severe preeclampsia
|
preganancy >20weeks
sustained hypertension >160/110 + >300mg proteinuria sustained hypertension >140/90 + 3-4+ or >5g proteinuria sustained hypertension >140/90 with headache, epigastric pain, visual changes, DIC, elevated liver enzymes or pulmonary edema if maternal or fetal jeopardy --> IV MgSO4, hydralazine/labetalol and prompt delivery if no maternal or fetal jeopardy and 26-34 weeks --> conservative if BP can be lowered, IV MgSO4 and IM betamethasone |
|
eclampsia
|
unexplained grand mal tonic clonic seizures + hypertension + proteinuria
first step in management --> protect mother's airway and tongue MgSO4 aggressive prompt delivery lower diastolic BP with IV hydralazine or labetalol |
|
chronic hypertension
|
BP >140/90 with onset before 20 weeks
superimposed preeclampsia --> worsening BP, worsening proteinuria or maternal jeopardy |
|
antihypertensive drugs in pregnancy
|
if mild to moderate HTN --> may discontinue medications if theres normal decrease in BP
if severe hypertension --> methyldopa ACEIs and diuretics are contraindicated in pregnancy BP target is diastolic between 90-100 |
|
chronic hypertension management
|
if uncomplicated --> conservative; discontinuation of antihypertensives, serial sonograms, serial BP and urinalysis
if superimposed preeclampsia --> MgSO4, hydralazine/labetalol and prompt delivery |
|
HELLP syndrome
|
complication of preeclampsia
hemolysis + elevated liver enzymes + thrombocytopenia manage with prompt delivery |
|
antepartum maternal overt diabetes measures
|
Hemoglobin A1c on first visit and each trimester
early pregancy baseline 24h urine protein to assess renal status assess retinal status with fundoscopy home blood glucose monitoring |
|
antepartum fetal assesment in overt diabetes
|
triple marker screen at 16-18 weeks for NTDs
targetted ultrasound at 18-20 weeks if glycosylated hemoglobin is high --> fetal echo at 22-24 weeks monthly sonogram for macrosomy or IUGR no increased risk of anomalies in gestational DM because anomalies are in first trimester |
|
intrapartum management of overt DM
|
lung maturity is often delayed
target delivery date is 40 weeks amniocentesis for lecithin/sphingomyelin ration of 2.5 in the presence of phosphatidyl glycerol assures lung maturity cesarean is considered if macrosomia |
|
postpartum management of overt DM
|
watch for uterine atony related to overdistended uterus which causes postpartum hemorrhage
falling levels of hPL decreases insulin resistance so turn off insulin infussion |
|
neonatal complications of overt DM
|
hypoglycemia due to hyperinsulinism
hypocalcemia due to failure of parathyroids polycythemia due to high erythropoietin from relative hypoxia hyperbilirubinemia respiratory distress syndrome due to low surfactant |
|
iron deficiency anemia
|
general malaise, palpitations, andkle edema
hemoglobin <10g, MCV <80, RDW >15% FeSO4 325mg po tid prevent with elemental iron 30mg/day |
|
folate deficiency anemia
|
malaise, palpitations, ankle edema
hemoglobin <10g, MCV >100, RDW >15% fetal effects --> low birth-weight, NTDs treatment --> folate 1mg po/day prevent --> folate 0.4mg po/day; 4mg if risk of NTDs |
|
sickle cell anemia
|
screening --> peripheral test to detect hemoglobin S
final diagnosis --> hemoglobin electrophoresis to differentiate between SA trait and SS disease complications --> spontaneous abortions, IUGR, fetal deaths, preterm delivery treatment --> avoid hypoxia, folate supplements, monitor fetal well being |
|
intrahepatic cholestasis of pregnancy
|
intractable pruritus on the palms and soles, worst at night, without rash
diagnosis --> markedly increased serum bile acids, mild bilirubin elevation treatment --> gold standard is ursodeoxycholic acid; may also use cholestyramine and antihistamines in mild cases |
|
acute fatty liver
|
nonspecific --> nausea, vomit, anorexia, epigastric pain
hypertension, proteinuria, edema can mimic preeclampsia but hypoglycemia and high serum ammonia are specific can also have acute renal failure, pancreatitis, hepatic encephalopathy, coma moderate elevation of liver enzymes, hyperbilirubinemia and DIC prompt delivery is indicated |
|
asymptomatic bacteriuria
|
no urgency, frequency or burning
no fever positive urine culture with >100K CFU single antibiotic treatment |
|
acute cystitis
|
urgency, frequency, burning
no fever positive urine culture with >100K CFU antibiotic monotherapy |
|
acute pyelonephritis
|
urgency, frequency, burning
systemic signs --> fever with chills, anorexia, nausea, vomit, flank pain positive urine culture with >100K CFU hospital admission, hydration, IV antibiotics and tocolysis if needed |
|
thrombophilia etiology and pregnancy complications
|
factor V Leiden
prothrombin mutations hyperhomocysteinemia antithrombin III deficiency protein C/S deficiency antiphospholipid syndrome complications --> first trimester miscarriages, stillbirths, placental abruption, preeclampsia, pulmonary embolus (MC COD in pregnant women) |
|
thrombophilia diagnosis
|
all pregnant women with blood clot should be tested for:
factor V Leiden and prothrombin gene mutations hyperhomocysteinemia antithrombin III, protein C, protein S deficiency antiphospholipid syndrome recommended testing if: familiy history of thrombosis, pulmonary embolism, thrombophilias or pregnancy complications |
|
thrombophilia treatment
|
subcutaneous heparin +- aspirin
low-molecular weight is better than unfractionated monitor blood levels for anticoagulation effect warfarin postpartum 6-8 weeks |
|
superficial thrombophlebitis
|
localized pain and sensitivity, erythema, tenderness, swelling
diagnosis of exclusion after ruling out DVT with doppler or venography manage with bed rest, local heat and NSAIDs |
|
deep venous thrombosis
|
pain and increased skin sensitivity, calf pain
diagnosis --> duplex Doppler (above knee) or venography (below knee); perform thrombophilia work-up treatment --> IV heparin |
|
pulmonary embolus
|
chest pain, dyspnea, tachypnea, normal x-ray, low pO2 on ABG, tachycardia
diagnosis --> initially spiral CT if CT negative and high risk symptomatic patient --> pulmonary angiography perform thrombophilia work-up management --> IV heparin |
|
IUGR definition and etiology
|
estimated fetal weight <5-10th percentile for gestational age
or birth weight <2,500grams fetal causes --> aneuploidy, TORCH, structural anomalies --> symmetrical placental causes --> infarction, abruption, twin-twin transfusion --> asymmetric maternal causes --> hypertension, small vessel disease, malnutrition, tobacco, alcohol, drugs |
|
symmetrical IUGR
|
all ultrasound parameters are smaller than expected
workup --> detailed sonogram, karyotype, screen for fetal infections |
|
asymmetrical IUGR
|
head sparing but abdomen small
serial sonograms, non-stress tests, amniotic fluid index (decreased), biophysical profile, umbilical artery Doppler |
|
macrosomia definition and risk factors
|
estimated fetal weight >90-95th percentile for gestational age
or birth weight >4,000-4,500 grams risk factors --> gestational or overt diabetes, prolonged gestation, obesity, weight gain |
|
macrosomia complications and management
|
maternal --> operative vaginal delivery, perineal lacerations, postpartum hemorrhage, emergency C-section
fetal --> shoulder dystocia, birth injury, asphyxia neonatal --> intensive care admission, hypoglycemia, Erb palsy manage with C-section |
|
nonstress tests
|
reactive NST:
>=2 accelerations in 20 min; >10 or 15 beats/min for >10 or 15 seconds interpretation --> reassuring of fetal well-being repeat weekly or biweekly non-reactive NST: no accelerations or did not meet criteria interpretation --> sleeping fetus, immature, sedated perform vibroacoustic stimulation test if still not reactive --> biophysical profile |
|
amniotic fluid index
|
<5cm --> oligohydramnios
5-8cm --> borderline 9-25cm --> normal >25cm --> polyhydramnios |
|
biophysical profile
|
NST, amniotic fluid volume, fetal gross body movements, fetal extremity tone and fetal breathing movements
8-10 --> highly reassuring; repeat weekly or as indicated 4-6 --> worriesome; delivery if >36weeks or repeat in 12-24 hours 0-2 --> fetal hypoxia; prompt delivery regardless of age |
|
contraction stress test
|
negative CST:
no late decelerations in the presence of 3 contractions in 10min reassuring of fetal well being repeat CST weekly positive CST: repetitive late decelerations in the presence of 3 contractions in 10min worriesome, especially in nonreactive NST prompt delivery |
|
contraction stress test indications and contraindications
|
indication --> BPP 4-6
contraindications --> should not stimulate contractions if: previous classical uterine incision previous myomectomy placenta previa incompetent cervix preterm membrane rupture preterm labor |
|
umbilical artery Doppler
|
absent or reversed diastolic flow is predicitive of poor perinatal outcome only in IUGR fetuses
|
|
types of pelvis
|
gynecoid, android, anthropoid, platypelloid
|
|
fetal lie
|
longitudinal --> fetus and mother in same vertical axis
transverse --> fetus at right angles to mother oblique --> fetus at 45 degree angle to mother |
|
fetal presentation
|
cephalic --> head first; most common
frank breech --> thighs flexed, legs extended complete breech --> thighs and legs are flexed footling breech --> thighs and legs are extended compound --> more than one anatomic part is presenting shoulder --> shoulder first |
|
fetal position
|
occiput anterior or posterior --> flexed head on cephalic presentation
sacrum anterior or posterior --> breech presentation mentum anterior or posterior --> extended head on face presentation |
|
definition of labor
|
effacement and dilation of the cervix with uterine contractions at least every 5min lasting 30s; resulting in delivery of fetus and expulsion of placenta
|
|
physiology of labor
|
increasing frequency of contractions
formation of gap junctions between uterine myometrial cells increasing levels of oxytocin and prostaglandins multiplications of specific receptors upper uterine segment --> contractile, mostly smooth muscle, thickens lower uterine segment --> passively thins out, mostly collagen fibers |
|
cervical effacement and dilation
|
0% effacement --> cervix is 2cmX2cm; oxytocin and prostaglandins break dissulfide likanges of collagen fibers
dilation --> complete dilation is 10cm as lower uterus is thinned and pulled up by upper uterus |
|
movements of labor
|
1) engagement --> presenting part moves below pelvic inlet
2) descent --> presenting part moves through curve of birth canal 3) flexion --> fetal chin on thorax 4) internal rotation --> fetal head from transverse to antero-posterior in mid pelvis 5) extension --> fetal chin moves away from thorax 6) external rotation --> fetal head rotates after passing pelvic outlet 7) expulsion --> delivery of fetal shoulders and body |
|
stages of labor
|
stage 1 latent phase --> regular uterine contractions-acceleration of cervical dilation; <14-20 hours
stage 1 active phase --> acceleration-10cm dilation; >1.2-1.5cm/hour stage 2 descent --> 10cm dilation-delivery; 1-2 hours stage 3 expulsion --> delivery of baby-delivery of placenta; <30min stage 4 --> 2h observation period |
|
management of labor
|
preadmission --> not admitted until cervical dilation is 3cm unless ROM; presentation is confirmed
admission --> IV access first stage --> assess fetal heart rate and perform serial vaginal exams checking dilation and descent stages 2 and 3 --> pushing efforts; episiotomy might be performed; IV oxytocin after delivery of placenta |
|
prolonged latent phase
|
pregnant with regular uterine contractions
cervix dilated 2cm no cervical change in 14 or 20 hours management --> rest and sedation |
|
prolonged active phase
|
pregnant with regular uterine contractions
cervix dilated >3cm cervical dilation <1.2 or 1.5cm management: normal contractions --> 2-3min, 45-60sesc, 50mmHg if hypotonic --> IV oxytocin if hypertonic --> morphine if adequate --> emergency cesarean |
|
active phase arrest
|
pregnant with regular uterine contractions
cervix dilated >3cm cervical dilation not changed for >2h management: normal contractions --> 2-3min, 45-60sesc, 50mmHg if hypotonic --> IV oxytocin if hypertonic --> morphine if adequate --> emergency cesarean |
|
stage 2 arrest
|
pregnant with regular uterine contractions
10cm dilation at +1 station no descent change in 3h management: IV oxytocin enhanced coaching if adequate and head not engaged --> emergency cesarean if adequate and head engaged --> obstetric forceps or vacuum extractor |
|
prolonged third stage
|
failure to deliver plaenta within 30 minutes in spite of oxytocin
suspect placenta acreta, increta or percreta may require manual placental removal or hysterectomy |
|
prolapsed umbilical cord
|
pregnnt with regular uterine contractions
amniotomy at -2 station severe variable decelerations management --> don't hold the cord or push back into uterus; place patient in knee-chest position; elevate presenting part and perform immediate cesarean delivery |
|
shoulder dystocia
|
second stage of labor
head has delivered no further delivery of body management --> suprapubic pressure; maternal thigh flexion; internal rotation of fetal shoulder |
|
obstetric lacerations
|
first degree --> vaginal mucosa
second degree --> vagina and muscles of perineal body third degreee --> vagina, perineal muscles, anal sphincter fourth degree --> vagina, perineal muscles, anal sphincter and rectal mucosa |
|
obstetric anesthesia physiology
|
stage 1 --> T10-T12
stage 2 --> S2-S4 pregnancy predisposes to hypoxia medications can pass the placenta to fetus give antacids prophylactically uterus should be laterally displaced |
|
IV anesthetics
|
narcotics and sedatives
active phase neonate may need naloxone antidote |
|
paracervical block
|
bilateral transvaginal injection to block Frankenhauser ganglion
active phase transitory fetal bradycardia |
|
pudendal block
|
bilteral transvaginal injection to block pudendal nerve at ischial spine
stage 2 |
|
epidural block
|
injection into epidural space to block lumbosacral roots
stages 1 and 2 side effects --> hypotension (treat with IV fluids and ephedrine); spinal headache |
|
spinal block
|
injection into subarachnoid space to block lumbosacral roots
stage 2 side effects --> hypotension |
|
types of decelerations
|
early --> with contractions
variable --> before or with contractions late --> after contractions (non reassuring) |
|
reassuring FHR tracings
|
baseline rate 110-160/min
accelerations no decelerations variability is present |
|
nonreassuring FHR tracings
|
baseline rate is tachycardia or bradycardia
accelerations absent repetitive variable decelerations repetitive late decelerations variability is absent |
|
intrauterine resuscitation
|
decrease uterine contractions --> turn off oxytocin or administer 0.25 terbutaline
500mL bolus of normal saline 8-10L O2 by facemask amniofusion lateral position vaginal exam to rule out prolapsed umbilical cord scalp stimulation |
|
fetal pH assessment
|
normal fetal pH is 7.2 or more
fetal scalp blood pH postpartum umbilical arter blood pH |
|
management of nonreassuring fetal monitoring tracings
|
intrauterine resuscitation
if no normalization --> prompt delivery |
|
forceps or vaccum extractor indications
|
prolonged second stage (MC indication)
nonreassuring FHM tracings to avoid maternal pushing breech presentation |
|
indications for cesarean
|
cephalopelvic disproportion
nonreassuring tracings presentations other than cephalic |
|
uterine atony
|
risks --> rapid labor, chorioamnionitis, MgSO4, halothane, overdistended uterus
soft uterus palpable over the umbilicus treat with uterine massage and oxytocin, methylergonovine or carboprost |
|
lacerations
|
risks --> uncontrolled vaginal delivery, operative vaginal delivery
identifiable lacerations in the presence of a contracted uterus treat with surgical repair |
|
retained placenta
|
missing placental cotyledons in the presence of contracted uterus
treat with manual removal or uterine curetagge by sonogram |
|
uterine inversion
|
bleeding mass in the vagina and failure to palpate uterus
treat by lifting uterus back to its position and giving oxytocin |