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264 Cards in this Set

  • Front
  • Back
The female homolog of the penis
Clitoris, which is a small bud of erectile tissue. It's a primary center of sexual excitement.
Location of the urethra in females?
The lower 2/3rds of the urethra lies immediately above the anterior vaginal wall and terminates in the urethral meatus at the midline of the vestibule just above the vaginal opening and below the clitoris.
These drain a group of urethral glands and open onto the vestiblule on each side of the urethra
Skene ducts
Location of vaginal opening?
Occupies the posterior portion of the vestibule.
Where do the Bartholin glands open up to?
Batholin glands are located posteriorly on each side of the vaginal orifice where they open onto the sides of the vestibule in the groove between the labia minora and hymen.
Function of Bartholin glands?
During sexual excitement they secrete mucus into the introitus for lubrication.
What makes up the pelvic floor?
Composed of muscle fibers of the levator ani (pubococcygeus, puborectalis, and iliococcygeus) and the coccygeus.
What angle is the vagina found out in respect to a vertical plane?
45 degrees posteriorly.
What separates the anterior vaginal wall from the bladder and urethra?
Vesicovaginal septum.
What separates the posterior vaginal wall from the rectum?
Rectovaginal septum.
Why are the 'pockets' formed around the cervix of clinical importance?
Because the internal pelvic organs can be palpated through their thin walls.
Some functions of the vagina?
Carries menstrual flow from the uterus, serves as the terminal portion of the birth canal and is the receptive organ for the penis during sex (oh la la).
What is the Pouch of Douglas?
A deep recess formed by the peritoneum as it covers the lower posterior wall of the uterus and upper portion of the vagina, separating it from the rectum.
Why is the Pouch of Douglas important?
It can be the site ectopic pregnancies. It's also the lowest recess connected to the abdominal space, so you can find fluid build up there.
What position is the uterus usually found in?
Usually flattened anteroposteriorly, inclined forward at a 45 degree, although it can be anteverted, anteflexed, retroverted, or retroflexed.
What does the adnexa of the uterus consist of?
The fallopian tubes and ovaries.
What supports the fallopian tubes?
A fold of the broad ligmanet called the mesosalpinx.
What part of the fallopian tubes enters the uterus?
Isthmus.
At what level are the ovaries found?
Level of the ASIS.
Hormones secreted by ovaries?
Estrogen and progesterone.
Four ligament pairs that support the internal genitalia?
The cardinal, uterosacral, round and broad ligaments.
Four bones that make up the pelvis
2 Innominates, sacrum and coccyx
During pregnancy how do circulating hormones such as relaxin and estrogen affect pelvic ligaments?
They contribute to the strengthening and elasticity of pelvic ligaments and softening of the cartilage. As a result, the pelvic joints separate slightly allowing some mobility.
What can separate during pregnancy that makes walking uncomfortable?
Symphysis pubis
In prepubertal females, what is the length of the corpus versus the cervix?
Corpus: 1/3
Cervix: 2/3
In adult nulliparous females, what is the length of the corpus versus the cervix?
Corpus: 1/2
Cervix: 1/2
In adult multiparous females, what is the length of the corpus versus the cervix?
Corpus: 2/3
Cervix: 1/3
During childhood, what genitalia grow and which remain about the same?
Most genitalia except for the clitoris grow incrementally at varying rates.
In adolescents whose hymen is intact, about how large is the vaginal opening?
1 cm
What are a few changes that occur in the vagina during puberty?
It lengthens, the epithelial layers thicken and the vaginal secretions become acidic.
On average, when does menstruation begin?
Between 11 and 14 in the United States.

Just before menarche, vaginal secretions increase.
What two hormones are responsible for uterine enlargement during the first trimester?
Progesterone and Estrogen
What is responsible for uterine enlargement after the third month?
Mechanical pressure of the growing fetus.
What are some changes that occur as the uterus enlarge?
1. The muscular walls strengthen and more elastic.
2. It becomes larger and more ovoid.
3. Rises out of the pelvis.
At what point in time does the uterus reach into the abdominal cavity?
12 weeks of gestation.
Hormones responsible for the softening of the pelvic cartilage and strengthening of the pelvic ligaments?
Relaxin
Progesterone
The previous two hormones result in separation of the pelvic joints, which allows some mobility. These can result in what type of walk?
Waddle gait
When does this separation of the pelvic joints resolve itself?
3-5 months postpartum.
During pregnancy, how do the vaginal secretions change?
They increase and have an acidic pH due to an increase in lactic acid production by the vaginal epithelium.
Range of ages menstruation can stop?
40-55 years of age
Definition of menopause?
1 year without menses.
What is the due date to House and Senate Budget Committees (HBC & SBC) for all congressional committees on their respective views and estimates?
March 15
How soon before onset of menopause does ovulation cease?
1- 2 years.
Systemic effects of menopause?
1. Increase in body fat and abdominal deposition of fat (tendency towards male pattern of body fat distribution).
2. Total cholesterol and LDL increase.
3. Thermoregulation is altered--> 'hot flashes'
GTPALC=?
G- gravity: total number of pregnancies
T- number of term pregnancies
P- number of preterm pregnancies
A- number of abortions, spontaneous or induced
L- number of living children
C- complications of pregnancy, delivery, abortion or with fetus or neonate
Stages of egg in ovarian cycle?
Primary follicle--> graafian follicel (secretes estrogen)--> ovulation and release of egg--> corpus luteum (progesterone, some estrogen)--> degenerating corpus luteum
Length of menstruation?
Days 1-5
Proliferative phase?
Days 5-14
Secretory phase?
Days 14-26
Ischemic phase?
Days 26-28
Occurs during menstrual phase: days 1 to 4- OVARY
Estrogen levels begin to rise, preparing follicle and egg for the next cycle
Occurs during menstrual phase: days 1 to 4- UTERUS
Progesterone stimulates endometrial PGs that cause vasoconstriction; this allows the upper layer to become ischemic and shed
Occurs during menstrual phase: days 1 to 4- BREAST
Cellular activity in the alveoli decreases; breast ducts shrink
Occurs during menstrual phase: days 1 to 4- CNS HORMONES
FSH and LH levels decrease
Occurs during menstrual phase: days 1 to 4- SYMPTOMS
Variable bleeding
Occurs during post-menstrual, preovulatory phase: days 5 to 12- OVARY + UTERUS
Ovary and maturing follicle produce estrogen.

Follicular phase--> egg develops within follicle

Proliferative phase--> uterine lining thickens
Occurs during post-menstrual, preovulatory phase: days 5 to 12- BREAST
Parenchymal and proliferation (increased cellular activity) of breast ducts occurs
Occurs during post-menstrual, preovulatory phase: days 5 to 12- CNS HORMONES
Secreted FSH stimulates ovarian follicular growth
Occurs during ovulation-- days 13 or 14
Egg is expelled from follicle into abdominal cavity and drawn into the uterine tubes. This signifies the end of the proliferative phase. Progesterone causes further thickening of the uterine wall.

LH and estrogen levels increase rapidly; LH surge stimulates release of egg
Symtoms during ovulation
Mittelschmerz can occur with ovulation.
Cervical mucus is increased and is stringy and elastic (spinnbarkeit)
Occurs during the secretory phase- days 15-20
Egg/ovum moved by cilia into the uterus. After the egg is released, the follicle becomes a corpus luteum, which secretes progesterone. Levels of progesterone increases and predominates.
What happens to FSH and LH levels during the secretory phase?
Both decrease. Progesterone secreted by CL and dominates.
Occurs during the menstrual, luteal phase- days 21 to 28- OVARY
If implantation doesn't occur, CL degenerates. This causes progesterone levels to drop and then to slowly increase again as a new follicle develops.
Occurs during the menstrual, luteal phase- days 21 to 28- UTERUS
A woman's period begins around day 28, which begins day 1 of the menstrual cycle.
Occurs during the menstrual, luteal phase- days 21 to 28-BREAST
Alveolar breast cells differentiate into secretory cells.
Occurs during the menstrual, luteal phase- days 21 to 28- CNS Hormones
Increased levels of GnRH cause increased secretion of FSH
Symtoms that occur during the menstrual, luteal phase- days 21 to 28
Vascular engorgement and water retention occur.
What is considered a short menstrual cycle?
Less than 19-21 days
What is considered a lengthened period between periods?
More than 37 days
Prolonged menses= how many days?
More than 7 days
RIsk factors for cervical cancer?
1. Pap smear history- lack of regular screening for cervical cancer
2. High risk HPVs: 16, 18, 31, 33 and 45
3. Sex before 16, along with multiple partners (increases risk of HPV infection)
4. Cigarette smoking doubles risk
5. HIV infection
6. Diets low in fruits and veggies; overweight women more likely to develop this cancer.
7. Being black, hispanic or Native American (higher rates of invasive cancer)
8. DES exposure from moms (1940-1971)
9. Some say use longer than 5 years increases risk
10. Low socioeconomic status
RIsk factors for cervical cancer?
1. Pap smear history- lack of regular screening for cervical cancer
2. High risk HPVs: 16, 18, 31, 33 and 45
3. Sex before 16, along with multiple partners (increases risk of HPV infection)
4. Cigarette smoking doubles risk
5. HIV infection
6. Diets low in fruits and veggies; overweight women more likely to develop this cancer.
7. Being black, hispanic or Native American (higher rates of invasive cancer)
8. DES exposure from moms (1940-1971)
9. Some say use longer than 5 years increases risk
10. Low socioeconomic status
Risk factors for ovarian cancer?
1. Age-- most develop after menopause; half are found in women older than 63
2. Menarche before 12, infertility, nulliparity or first child after 30, menopause after age 50.
3. Use of fertility drugs may increase the risk, especially if pregnancy not achieved
4. Family history with one or more first degree relatives who've has ovarian and or breast cancer, strong family history of colon cancers, or having Ashkenazi jewish decent.
5. Personal history of any type of cancer
6. Inherited mutation of BRCA1 or BRCA2 gene
7. Being white (occurs 50% more frequently)
8. Using hormone therapy replacement
9. High-fat diet
10. Potentially the use of talcum products in hygiene sprays or in sanitary napkins
Risk factors for endometrial cancer?
1. Increased number of years that the endometrium is exposed to estrogen (so menarche before 12 years of age)
2. Late menopause (after 50), again increases number of years exposed to estrogen
3. Total length of menstruation span-- early menarche is less of a risk factor for women who also have early menopause.
4.Infertility or nulliparity-- this is because during pregnancy the hormonal balance shifts toward more progesterone. Therefore, having many pregnancies reduces endometrial cancer risk and women who have not been pregnant have a higher risk
5. Being obese. Fat tissue increases a woman's estrogen levels. Increases risk 2-5 times.
6. Tamoxifen- an ANTIESTROGEN drug that acts like estrogen in the uterus. :(
7. Estrogen replacement therapy- estrogen alone without progestin
8. PCOD and some ovarian tumors like granulosa thecal cell tumors that cause an increase in estrogen relative to progestin.
9. Diet high in animal fat
10. Type 1 and 2 diabetes
11. Age-- 95% of endometrial cancers occur in women older than 40 years or older. Avg age of diagnosis= 60 years of age
12. Family history of endometrial cancer, ovarian or colorectal cancer
13. Personal history of cancer; mutations in BRCA1/2
14. Prior pelvic radiation for previous cancers
Women may have occasional vaginal discharge. What might be signs this is may be due to an STI?
If it's yellow and thicker and has an odor.
When evaluating masturbation in children, what aspects would require further assessment?
1. If it's frequent and compulsive.
2. There's no regard for privacy.
3. Preferred over other activities or play.
4. Produces genital discomfort, irritation or physical signs.
5. Involves penetration of the genital orifices; includes bizarre practices or rituals.
What aspects of masturbation are considered healthy in growing children?
1. Occasional
2. discreet, private
3. not preferred over other activity or play
4. no physical signs or symptoms
5. external stimulation of genitalia
During the pelvic examination, what position should the table be facing in regards to the door?
The patient and table should be facing away from the door, so that way if a door is opened or someone walks in the patient is not exposed.
Why are assistants or chaperones often required during examination?
Because it's policy and protects both the examiner and patient.
Is bimanual examination of the pelvic region uncomfortable for women with full bladders?
Yep. Not only that, but it makes it harder to palpate the pelvic organs.
When you are about to begin the examination what should you do?
Tell the patient you are about to begin, then start with a neutral touch on her lower thigh, moving your examining hand along the thigh without breaking contact, to the external genitalia.
Patient should be in what position during examination?
Dorsal lithotomy.
Signs indicative of a Bartholin gland abcess in the labia majora?
Labial swelling, redness, or tenderness unilaterally.
What would suggest infections or inflammation of the labia majora?
Excoriation, rashes, lesions
If signs of Bartholin gland abscess or inflammation of the labia majora are present what should you ask the patient?
Whether she's been scratching down there.
Ulcers or vesicles of the labia minora may be signs of what?
STDs.
Average size of clitoris and enlargement suggests what?
2 cm or less in length, .5 cm diameter. Enlargement may be a sign of a masculinizing condition.
If you find signs of inflammation of the urethral opening (potentially secondary to UTIs or insertion of foreign objects) when should you ask questions about this?
At a later time, not during the pelvic examination when the woman feels most vulnerable.
Another name for hymenal remnants?
Myrtiform carnucles
Discharge from the Skene glands or urethra usually indicates what?
An infection, most commonly, but not necessarily, gonococcal.
Already asked before, but what are signs of Bartholin gland abscess?
The gland will be painful, hot to touch and fluctuant.
Organism responsible for Bartholin gland abscess?
Gonococcal or staphylococcal in origin
What would a non-tender mass of the Bartholin gland suggest?
A Bartholin cyst, which is the result of chronic inflammation of the gland.
When examining muscle tone, bulging of the anterior wall and urinary incontinence indicate the presence of what?
A cystocele.
When examining muscle tone, bulging of the posterior wall indicates?
A rectocele.
What marks uterine prolapse?
Protrusion of the cervix or uterus on straining.
Feel of the tissue of the perineum in nulliparous women versus multiparous women?
The tissue will feel thick and smooth in the nulli, while it will be thinner and rigid in multi women. In either case, it shouldn't be tender.
Concerns about using gel lubricants when collecting a pap smear?
That the gel will contaminate or obscure analysis and interpretation of findings.
SInce there is concern about using gel lubricants during a pap smear, what should be done?
Just use water as lubrication. If you do use gel, though, a thin layer on the external surface of the blades only will help avoid contamination of the specimen.
How should the speculum be held when using it?
Hold it in your hand with the index finger over the top of the proximal end of the anterior blade and the other fingers around the handle. This position controls the blades as the speculum is inserted.
Steps taken to insert the speculum into vagina?
Insert a finger of your other hand just inside the vaginal introitus and apply pressure downward.

Ask patient to breathe slowly and try to get her to consciously relax the muscles of the buttocks. When you feel relaxation use the fingers to separate the labia MINORA very widely so that the hymenal opening becomes clearly visible. Then slowly insert the speculum along the path of least resistance, (usually slightly downward, avoiding trauma to the urethra and vaginal walls). Regardless of what position you prefer to insert the speculum, avoid the clitoris, catching pubic hair or pinching labial skin.
A bluish color of the cervix may indicate what?
Increased vascularity due to pregnancy!
When would reddened areas of the cervix be considered unexpected findings?
When the borders are irregular or patchy.
A pale cervix is a sign of what?
Anemia.
A cervix pointing anteriorly indicates what type of uterus?
A retroverted uterus.
(most women are retroverted, retroflexed)
A cervix pointing posteriorly indicates what type of uterus?
An anteverted uterus. (Harder to get pregnant this way)
A cervis in the horizontal position indicates?
A uterus in modposition.
If there was a pelvic mass, uterine adhesions or pregnancy how would these affect the cervix?
You might see deviation to the right or left.
How far can the cervix protrude into the vagina to still be considered 'WNL'?
1-3 cm
If the cervix projects greater than 3 cm into the vagina, what might this suggest?
A pelvic or uterine mass.
Size of a cervix of a woman of childbearing age?
2-3 cm
Enlarged cervix sign of?
Cervical infection
What do Nabothian cysts on the cervix look like? What are they and are they expected?
Small, white or yellow, raised, round. These are retention cysts of the endocervical glands and are considered an expected finding.
What happens if a Nabothian cyst is infected?
It becomes swollen with fluid and distorts the shape of the cervix, giving it an irregular appearance.
Normal discharge versus discharge secondary to bacterial or fungal infections
Normal discharges are usually odorless, may be creamy or clear, thick or thin or stringy and is heavier midcycle or immediately before menstruation.

Discharge of a bacterial or fungal infection will probably have an odor and can be white to yellow, green or gray.
Shape of a nulliparous os?
Small, round or oval
abeyance
Suspended action
"let's hold that problem in abeyance for a while"
What tools are being used now in conjunction with, or instead of, just the conventional spatula?
Brushes and brooms.
Which type of cells does the cylindric-type brush collect?
Endocervical cells. (Use a spatula first to collect the ectocervical cells)
What cells does a spatula collect?
Ectocervical cells.
What does the broom-type device collect?
Ectocervical and endocervical cells at the same time.
Why are broom-type devices somewhat better?
Reported to cause less blood spotting.
How is a gonococcal culture specimen obtained?
Immediately after the pap smear is obtained, introduce a sterile cotton swab into the vagina and insert it inot the cervical os. Hold it there for 10-30 seconds, withdraw and spread the specimen in a large Z pattern over the culture medium, rotating the swab at the same time.
Vaginal discharge may be a sign of what kind of infection?
Bacterial vaginosis, candidiasis or Trichomonas vaginalis.
Once a wet mount is prepared of the discharge and examination is done under microscope, what would suggest infection with trichomonas vaginalis?
Presence of trichomonads.
What suggests bacterial vaginosis infection?
The presence of bacteria-filled epithelial cells (clue cells).
On a separate glass slide, you place some of that vaginal discharge specimen and apply KOH. You smell a 'fishy odor'... What does this suggest?
Again, bacterial vaginosis.
So if there is no fishy odor, what can the use of KOH actually help with?
It dissolves epithelial cells and debris and facilitates visualization of the mycelia of a fungus. This would allow you to see mycelial fragment, hyphae and budding yeast cells, which indicate candidiasis.
Normal vaginal secretions are usually?
Thin, clear or cloudy and odorless.
Secretions indicative of infection are often....?
Profuse, thick, curdy or frothy, gray, green or yellow and can smell foul.
Should women continue to have pap smears following a hysterectomy?
If hysterectomy was done for noncancerous reason, with the cervix removed, no evidence of malignancy and no history of abnormal cancerous cell growth then pap smears screening for cervical cancer can be discontinued. Annual pelvic examinations should be continued, though.
What two fingers are used for bimanual examination?
Index and Middle fingers
Be careful of what when examining with fingers?
Make sure to not let the thumb limit your exam and to not let the thumb touch the clitoris since it can cause discomfort.
Consistency of the cervix in a nonpregnant woman?
Firm like the tip of a nose.
Consistency of the cervix during pregnancy?
Softer than during nonpreg. state.
How do you examine the patient for cervical motion tenderness?
Grasping the cervix between the fingers and moving it from side to side. Observe the patient's expression for pain. It should move 1 to 2 cm in each direction with pain.
What does painful cervical movement suggest?
Acute PID, pelvic inflammatory process or ruptured tubal pregnancy.
Most common position of the uterus?
Anteflexed or anteverted.
If the uterus is anteflexed or anterverted (the position of most uteri) what will you feel between your inserted fingers the palm of the hand on the suprapubic area?
The fundus of the utuerus.
If the uterus is retroflexed or retroverted what technique should be used to palpate uterus?
By putting the fingers in the posterior fornix and pushing the uterus up so it can be felt more easily.
Uterus should usually be midline. What does it suggest of it's deviated?
Possible adhesions, pelvic masses, or pregnancy.
What is mittelschmerz?
Lower abdominal pain associated with ovulation. It can be accompanied by a degree of tenderness on the side in which ovulation took place that month and even by similarly unilateral and usually mild adnexal tenderness.

Onset is usually sudden and remission is spontaneous.
Shape of uterus likened to which fruit?
Pear!
uterus larger than expected sign of?
Pregnancy or tumor.
If uterus not mobile in the anteroposterior plane, this could indicate?
Fixed uterus sign of: Adhesions.
When palpating a healthy ovary, what should the patient feel?
Slight tenderness. Marked tenderness, enlargement and nodularity are unexpected.
Why are the adnexa difficult to palpate?
Because of their location and position and the presence of excess adipose tissue. If you can't feel anything then you can assume there are no abnormalities present.
When observing sphincter tone, an extremely tight sphincter may suggest what?
Anxiety, scarring or spasticity due to fissures, lesions or inflammation.
A lax sphincter suggests?
Neurologic deficit.
Absent sphincter suggests?
Improper repair of 3rd degree perineal laceration after childbirth or trauma.
When would it be easiest to feel the uterus and fundus of the uterus when doing a rectovaginal exam?
If the uterus fundus was retroflexed.
When examining an infant's external genitalia, which position should the legs be in?
Infant's legs are held in frog position.
How do the labia majora look like prior to 36 weeks gestation?

How do they look by full term?
Labia majora are widely separated and the clitoris is prominent up to 36 weeks.

Full term, majora completely cover the labia minora and clitoris.
When a newborn girl is born, and the mother sees that the child's labia majora and minora are swollen and the hymen is slightly protruding what would you tell her?
That these are transient changes that simply reflect the mother's own hormones and will disappear in a few weeks.
Remember that all really premature female infants seem to have clitoromegaly.
Only one as 5000 babies will have endocrine problems (adrenal hyperplasia).
Average size of central opening of they hymen?
.5 cm
An imperforate hymen can lead to what in a child? In adolescents?
Child- hydrocolpos
Adolescent- hematocolpos
A baby girl is brought into the physician's office because of white, mucoid vaginal discharge. The mother said it's occasionally mixed with blood. The kid is no older than 4 weeks old.
You would tell the parent that this finding is the result of passive hormonal transfer from the mom to the child. It's temporary and an expected finding.
Vaginal discharges in infants and young children that are mucoid in appearance are caused by?
Irritation from their diaper or powder.
When examining children, is an external examination adequate enough or do you need to do an internal one too?
External is enough. Only preform internal if there is bleeding, discharge, trauma or suspected sexual abuse.
What is anterior labial traction?
A technique used to visualize the interior of the vagina and the hymenal opening in prepubertal girls.
Are Bartholin and skene glands palpable in children?
No, if they are enlargement exists. It can indicate an infection, which is most often gonococcal.
If a girl has an imperforate hymen and you ask her to cough, what would you expect?
The imperforate hymen will bugle. A hymen with an opening will not.
Causes of genital bleeding in children:
1. genital lesions
2. vaginitis
3. foreign body
4. trauma
5. tumors
6. endocrine changes
7. estrogen ingestion
8. precocious puberty
9. hormone-producing ovarian tumor
When performing the rectal examination on a child, what is one method of getting them to relax their muscles?
Having the child 'pant like a puppy'.
For women who are not sexually active, when should the first pelvic examination take place?
21 years of age
What methods of screening for STDs do adolescents tend to prefer?
First-void urine specimens and self-collected vaginal swab specimens.

Still, pelvic exams are the best.
How large should the hymenal opening be by the time menarche starts?
About 1 cm wide.
A pregnant patient comes in for a pelvic exam. You note that the cervix, vagina, and vulva have just become blue in color. Why is this happening and when does it indicate?
The color change begins in the second month of pregnancy and is due increased vascularity.
What pelvic type is more common in white women? Black women?
Which has equal occurence?
White women-- android type
Black women-- anthropoid type.
Equal occurrence- gynecoid
Rarest= platypelloid
In pregnant women, when should the bony pelvis be measured?
During the third trimester to ensure accuracy.
The following are early signs of pregnancy:
The following are early signs of pregnancy:
Goodell Sign
Softening of the cervix
4-6 wks gestation
Hegar Sign
Softening of the uterine isthmus
6 to 8 weeks
McDonald Sign
Fundus flexes easily on the cervix
7 to 8 weeks
Braun von Fernwald Sign
Fullness and softening of the fundus near the site of implantation
7 to 8 weeks
Piskacek Sign
Palpable lateral bulge or soft prominence of one uterine cornu
7-8 weeks
Chadwick Sign
Bluish color of the cervix, vagina and vulva
8 to 12 weeks
Shape of brim of gynecoid type?
Usual mode of delivery?
Round
Vaginal, spontaneous, occiput anterior position
Shape of brim of android type?
Usual mode of delivery?
Heart Shaped
Cesarean-- vaginal delivery difficult with forceps
Shape of brim of anthropoid?
Usual mode of delivery?
Oval shaped
Vaginal, occiput posterior or occiput anterior position
Shape of brim of platypelloid (only 3% of women!)?
Usual mode of delivery?
Flat shaped
Vaginal, spontaneous
What is the most important clinical measurement for estimating the AP diameter of the pelvic inlet?
Diagonal conjugate.
When would you find that the pelvic inlet AP diameter was shortened?
When the pelvis is abnormal.
Is the midplane (transverse/interspinous diameter) measurable?
Nope. The interspinous diameter is estimated between the interspinous processes.
How is the outlet measured?
From the inferior border of one ischial tuberosity to the other.
Changes in fundal height with pregnancy:
Changes in fundal height with pregnancy:
Weeks 10-12:
Uterus within pelvis, fetal heart beat detectable
Week 12:
Uterus palpable just above the pubic symphysis
Week 16:
Uterus palpable halfway between symphysis and umbilicus; ballottement of fetus is possible by abdominal and vaginal examination
Week 20:
Uterine fundus at lower border of umbilicus, fetal heartbeat can be auscultated with fetoscope.
Weeks 24-26:
Uterus changes from globular to avoid shape; fetus palpable
Week 28:
Uterus approximately halfway between umbilicus and xiphoid; fetus easily palpable
Week 34:
Uterine fundus just below xiphoid
Week 40:
Fundal heigh drops as fetus begins to engage in pelvis
What measurement of the cervix is considered full/complete dilation in pregnancy?
10 cm
What is effacement of the cervix?
Refers to thinning of the cervix that results when myometrial activity pulls the cervix upward, allowing the cervix to becomepart of the lower uterine segment during prelaboror early labor. This reduces the cervix in length.
What does shortening of the cervix during pregnancy suggest the mom is at risk for?
Early delivery.
When does effacement usually occur?
Precedes dilation of the cervix in the primipara mother.

Occurs with dilation in the multipara mother.
What are stations?
Station describes the relationship of the presenting part of the ischial spines of the mother's pelvis to the descent of the presenting part of the infant.
With what fontanelle do you determine the position of the fetal head and body?
Anterior fontanelle. The position of the fontanelle is determined by examining the anterior aspect of the sagittal suture and then using a circular motion to pass alongside the head until the other fontanelle is felt and differentiated.
WHo is the knee-chest position best for?
Women who feel most comfortable and balanced lying on their side.
Best position for women with visual or hearing impairment?
A foot-stirrup position.
A 28 year old female comes to your office complaining of edema, weight gain, headache, irritability, nervousness, dysphoria and lack of coordination. She mentions that these happen to occur about 5 to 7 days before her period and stop when her period begins. What would you tell her is her diagnosis?
Premenstrual syndrome. It usually begins in a woman's late 20's and increases as menopause approaches.
A couple has been trying to conceive for over 1 year. They now come to your office seeking advice about figuring out what the problem is. What factors would you need to consider in females? In males? What are some factors that can effect both of them?
The inability to conceive over a period of 1 year of unprotected regular intercourse defines infertility.

Contributing factors:
Females: Abnormalities of the vagina, cervix, uterus, fallopian tubes and ovaries.

Males: Insufficient, nonmotile or immature sperm, ductal obstruction of sperm, and transport related factors.

Factors affecting both men and women: Stress, nutrition, chemical substances, chromosomal abnormalities, certain diseases processes, sexual and relationship problems, and immunologic response.
A young woman comes to you crying because she's had pelvic pain along with heavy and sometimes prolonged menstrual flow. On bimanual examination, tender nodules are palpable along the uterosacral ligaments. What do you suspect is the problem. How would you confirm your suspicions?
Endometriosis.

You would confirm this by laproscopy.
What is the difference in presentation of endometriosis between adolescents and older adults?
Adolescents may have pelvic pain that us cyclic and noncyclic.

The pain in older women is most often cyclic.

Don't let noncyclic pelvic pain in an adolescent make you rule out the possibility of endometriosis!
A sexually active woman comes into your office complaining of flesh-colored and whitish-pink discrete growths growing on her labia, within her vestibule and even reaching back to the perianal region. She's worried she has caught something. What's she got?
Genital/veneral warts! (Condyloma acuminatum). They are due to HPV infection. They can occur singly or in clusters and can enlarge to form cauliflower-like masses.
What disease is caused by a poxvirus?
Molluscum Contagiosum.

This is a usually benign skin infection that can be transmitted by sexual contact. The incubation period is from 2 to 7 weeks.

The lesions are white or flesh-colored, dome-shaped papules that are round or oval.

The surface has a characteristic central umbilicaition from which a thick creamy core can be expressed.

The lesion can last from several months to several years. Microscopic examination will reveal typical molluscum bodies within the epithelial cell.
What is a sign of primary syphilis?
Syphilitic chancres are firm, painless ulcers. Most chancres in women develop internally and often go undetected.
Signs of secondary syphilis?
Condyloma latum, which are the name of lesions of secondary syphilis appear about 6 to 12 weeks after infection.

They are flat, round or oval papules covered by a gray exudate.
A sexually active woman had unprotected sex a few weeks ago and now has small red vesicles that are itchy and painful. What did this poor soul catch?
Herpes! It is sexually transmitted, and the initial infection is often extensive. Recurrent infections are usually confined to a small localized patch on the vulva, perineum, vagina or cervix.

The can be found externally and internally and can result in erosions with exudates.
What organism is usually responsible for infection of Bartholin glands?

Difference between acute and chronic infection symptoms?
Gonococcal infections. The infection can be acute or chronic.

Acute infection produces a hot, red, tender, fluctuant swelling that can drain pus.

Chronic inflammation results in a nontender cyst on the labium.
What's a cystocele?
A hernial protrusion of the urinary bladder through the anterior wall of the vagina, sometimes even exiting the introitus!

The bulging can be seen and felt as the woman bears down.

Severe degrees of cystocele are accompanied by urinary stress incontinence.
What's a rectocele/proctocele?
Hernial protrusion of part of the rectum through the posterior wall of the vagina.

Bulging can be seen and felt as the woman bears down.
What medication taken by mothers has been associated with an increased incidence of vaginal carcinoma?
DES.
Findings include vaginal discharge, lesions and masses. There may be a history of spotting, pain and change in urinary habits.
What does cancer of the vulva look like?
It can appear as an ulcerated or raised red lesion.
Another poor soul comes in complaining of something coming out of her urethral meatus. She mentions that it hasn't caused any symptoms, but that it's a little unsightly. What's she got?
Urethral caruncle. These are bright red polypoid growths that protrude from the urethral meatus. They don't usually cause symptoms.
In adolescent females who present with a 'strawberry cervix', what is the cause?
Petechial hemorrhages.
Findings in physiologic vaginitis
Increase in discharge that is clear or mucoid with a pH < 4.5

On a wet mount you'd see up to 3-5 WBCs.
Findings in Bacterial vaginosis (Gardnerella vaginalis)
No foul odor, itching or edema.
Foul smelling discharge, complains of 'fishy odor'

Thin, white or gray discharge. pH <4.5

+ KOH whiff test
+ clue cells
Findings in Candida vulvovaginitis (candida albicans)
Pruritic discharge, itching of labia, itching may extend to thighs

White curdy discharge, pH 4-5
Cervix might be red and erythema of perineum and thighs may be present

On a KOH prep, you'd see mycelia, budding, branching yeast, pseudohyphae (characteristic of yeast)
Findings in Trichomoniasis (Trichomonas vaginalis)
Watery discharge, foul odor, dysuria and dyspareunia with severe infection.

Will find profuse, frothy greenish discharge, pH 5-6.6.

Red friable cervix with petechiae ('strawberry' cervix)

Wet mount, round or pear-shaped protozoa. Motile or 'gyrating' flagella
Findings in Gonorrhea (Neiseria gonorrhea)
Partner will probably have the STI too. Often asymptomatic or may have symptoms of PID.

Purulent discharge from cervix.
Skene/Bartholin inflammation.
Cervix and vulva may be inflamed as well.
Findings in chlamydia (chlamydia trachomatis)
Partner with non-gonococcal urethritis. often asymptomatic, may complain of spotting after intercourse or urethritis.

May or may not have purulent discharge, cervix may or may not be friable/red.
Findings in Atrophic vaginitis
Dyspareunia, vaginal dryness, peri-menopausal or post-menopausal.

Pale, thin vaginal mucosa, pH<4.5

On wet mount you'd see folded, clumped, epithelial cells.
Findings in Allergic vaginitis
May occur after a new bubble bath, soap, douche or other hygiene products are used.

There can be a foul smell, erythema. pH<4.5

WBCs on wet mount
Findings in Foreign body
Red, swollen vulva, vaginal discharge, history of use of tampon, condom or diaphragm.

Blood or foul-smelling discharge present.

WBCs on wet mount.
What are the most common causes of cervical lacerations?
Trauma, most often from childbirth. Lacerations can produce lateral, transverse, bilateral transverse or stellate scarring.
Infected nabothian cysts present how?
As enlarged fluid-filled cysts that distort the shape of the cervix. Can occur singly or in multiples.
Looks bright, red, soft and fragile. It often arises from the endocervical canal.
Cervical polyps
A woman comes in for her pap smear for the first time a long time. On examination you find a hard, granular surface at and near the cervical os. The lesion seems to have evolved to form an extensive irregular cauliflower growth that bleeds easily. What's her diagnosis?
Cervical carcinoma. Early lesions are indistinguishable from ectropion.

Early cancer changes detected by pap smear, not by physical examination.
What's ectropion?
Columnar epithelium from the cervical canal appearing as shiny red tissue around the os that may bleed easily. It's not an abnormality, but because it is distinguishable from early cervical carcinoma, further diagnostic studies have to be done.
What causes uterine prolapse? What does it often occur with?
Weakening of the supporting structures of the pelvic floor, often occurring concurrently with cystocele and rectocele.
What's the progression of uterine prolapse?
The uterus becomes progressively retroverted and descends into the vaginal canal.
First degree uterine prolapse?
Second degree uterine prolapse?
Third degree uterine prolapse?
1st- Cervix remains within the vagina
2nd- Cervix is at the introitus
3rd- The cervix and vagina drop outside the introitus. :O
Common causes of midcycle spotting
Midcycle estradiol fluctuation associated with ovulation
Common causes of delayed menstruation
Anovulation or threatened abortion with excessive bleeding
Common causes of frequent bleeding
Chronic PID, endometriosis, DUB, anovulation
Common causes of profuse bleeding
endometrial polyps, DUB, adenomyosis, submucous bleeding leiomyomas, IUD
Common causes of intermenstrual or irregular bleeding
endometrial polyps, DUB, uterine or cervical cancer, oral contraceptives
Common causes of postmenopausal bleeding
Endometrial hyperplasia, estrogen therapy, endometrial cancer
What are myomas?
Myomas include leiomyomas and fibroids.

They are benign uterine tumors that are firm, irregular nodules in the contour of the uterus.

They cause the uterus to become enlarged.
A postmenopausal woman shows up at your doorstep complaining of vaginal bleeding. What is this CC most likely a red flag for?
Endometrial cancer. Nearly all of them are found in the lining of the uterus. Most known risk factors are linked to the balance between estrogen and progesterone in the body.
What medication increases a woman's risk of endometrial cancer?
Women taking tamoxifen are at increased risk.
Ovarian cysts versus tumors
Can occur unilaterally or bilaterally. Cysts tend to be smooth and at times compressible whereas tumors feel more solid and nodular.

Neither is tender.
What can a ruptured ovarian cyst produce symptoms similar to?
Those of a ruptured tubal pregnancy.
An enlarged ovary should raise what suspicion?
That it may be ovarian cancer.
If a woman comes in who is older than 40 years of age with persistent and unexplained vague GI symptoms such as generalized abdominal discomfort and pain, gas or indigestion and a feeling of fullness even after eating a light meal you should suspect what?
Ovarian cancer!
Signs of a ruptured tubal pregnancy?
Pelvic tenderness with tenderness and rigidity of the lower abdomen.

Motion of the cervix produces pain. A tender, unilateral adnexal mass may indicate the site of pregnancy.

Tachycardia and shock reflect the hemorrhage into the peritoneal cavity and cardiovascular collapse.

THIS IS A SURGICAL EMERGENCY!
What is a big clue that indicates an ectopic pregnancy?
A sudden, dramatic change from mild, even vague abdominal pain that is there but not particularly distressing to a sudden onset of severe abdominal tenderness in the hypogastric area, especially on the involved side.
Organisms commonly responsible for PID?
Gonorrhea or chlamydial infection.

PID can be acute or chronic. Adhesions can develop and chronically, infertility could develop.
Acute PID versus Chronic PID
Acute- very tender, bilateral adnexal areas, the patient guards and cannot tolerate bimanual examination.

Chronic- bilateral, tender, irregular and fairly fixed adnexal areas.
Patient has inflammation and infection of the fallopian tubes. You suspect she also has PID. There is tenderness in the lower quadrants bilaterally on examination. Diagnosis?
Salpingitis
What findings would suggest ambiguous genitalia in infant females?
Partially fused labia, suggesting the presence of a scrotum.

A urinary meatus that is not located behind the clitoris, which could suggest the presence of a penis.
What is hydrocolpos?
Vaginal secretions that can collect behind an imperforate hymen. It can be manifested by a small midline lower abdominal mass or a small cystic mass between the labia.

It can resolve on its own or may require surgery.
Vulvovaginitis symptoms and causes
Symtoms- vaginal discharge accompanied by warm, red and swollen vulvular tissues.

Causes- sexual abuse, trichomonal, gonococcal infection; secondary infection from a foreign body and non specific infection from bubble baths, diaper irritation, urethritis and injury.
What is PROM?
Premature rupture of membranes. It's a spontaneous rupture that carries a high risk of perinatal and materal morbidity and mortality,
Causes of PROM?
Not known for sure, but infection and hydraminos implicated.

Some doctors consider the rupture of membranes before the onset of labor in a term pregnancy to be premature rupture if labor doesn't begin in 12 hours.
Symptoms of PROM?
Passage of fluid from the vagina. Test this fluid with pH paper because amniotic fluid has a pH of about 7.15 and will turn Nitrazine paper blue-green.

Amniotic fluid placed on a slide and air-dried will have a 'fern' pattern.
Prolapse of the umbilical cord associated with what changes in fetal heart rate?
The presence of variable decelerations in fetal heart rate. Can result in death.
Causes of bleeding in pregnancy?
Early on- unknown causes that are of little consequence to potentially life-threatening situations like ectopic pregnancies.

Later on- Cervical changes (benign) to abruptio placentae (bad!)
What contributes to vulvular varicosities?
Pressure from the pregnant uterus, hereditary factors.

Involve both the vulva and rectal area.
Main cause of atrophic vaginitis?
Lack of estrogen!

The vagina mucosa is dry and pale, although it can become reddened and develop petechiae and superficial erosions. The accompanying vaginal discharge may be white, grey yellow, green or blood-tinged.

It can be thick or watery and it's rarely profuse.