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413 Cards in this Set
- Front
- Back
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What is the pubic symphysis covered by
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adipose called mons pubis or mons veneris
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Labia minora meet at anterior of vulvus, what does the bottom lamella fuse to form?
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frenulum of clitoris
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Labia minora meet at anterior of vulvus, what does the top lamella fuse to form?
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prepuce
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What lays between the clitoris and the prepuce
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Clitoris
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What is located between labia minora and hymen
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Opening of bartholin's glands
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What are the 6 openings of the vestbule
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1. vagina 2. urethra 3. Bartholin glands (2) 4. Skene glands (2)
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What do Skene glands drain and open into?
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Drain group of urethral glands and open onto vestibule on each side of urethra
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What glands secrete mucus into introitus during sexual excitment
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bartholin glands
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What is the angle and plane of vagina
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45 degrees; vertical
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Anterior wall of vagina seperated from bladder by:
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vesicovaginal septum
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Posterior vaginal wall seperated from rectum by:
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Rectovaginal septum
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Location, shape, and coverage of urterus
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Between bladder and rectum; pear shaped; covered by peritoneum; lined by endometrium
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What covered upper part of urterus and lower part of vagina; seperates it from rectum
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Pouch of douglas
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Angle of uterus
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45 degrees
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Size ofurterus in nulliparious woman
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5.5-8 cm long; 3.5-4cm wide; 2-2.5 thick
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What happes to uterus during pregnancy
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enlarges it by 2-3 cm in each area
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What parts are the urterus divided into anatomically
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Corpus = fundus (upper part between insertion of fallopian tubes); Body; Isthmus (adjacent to cervix)
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How does the uterus open into the vagina
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via external cervical os
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Adnexa =?
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Fallopian tubes + ovaries supported by mesosalpinx
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Location and size of ovaries
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larteral pelvic wall at level of ASIS ; 3 x 2 x 1 cm
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Internal genitalia are seperated by what 4 ligaments?
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1. cardinal 2. uterosacral 3. round 4. broad
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Levels of hormones (Estrogen, Progestrone, FSH, and LH) during Menstural phase
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Estrogen: begins to rise (preparing follicle); Progesterone: stimulate PG causing vasoconstriction and shedding; FSH and LH decrease
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Mentrual phase: Breast
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Cell activity in alveoli decreases; breast ducts shrink
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Postmenstrual, Preovulatory Phase: Ovary
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Ovary & maturing follicle make estrogen; follicular phase -- egg in follicle
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Postmenstrual, Preovulatory Phase: Uterus
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Proliferative phase -- urerine lining thickens
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Postmenstrual, Preovulatory: Breasts
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Increased cell activity of breast ducts
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Postmenstrual, Preovulatory: CNS Hormones
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FSH stimulates ovarian follicular growth
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Ovulation: Ovary
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Egg expelled, goes into FT by fimbriae and cilia; fertilization in outer 1/3 of tube
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Ovulation: Uterus
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End of proliferative phase; progestrone causing further thickness
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Ovulation: CNS Hormones
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Increased LH and Estrogen --> LH surge --> release of egg
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Ovulation: Symptoms
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Miteelschmerz; cervical mucus increased and elastic (spinnbarkeit)
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Secretory phase: Ovary
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Egg moved into uterus
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Secretory phase: Uterus
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After egg released follicle becomes corpus luteum; secretion progestrone HIGH
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Secretory phase: CNS hormones
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LH and FSH decrease
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Premenstural, Luteal phase Ovary:
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No implanation = degreation of CL, progestrone decreased; estrogen drops then rises as new follicle made
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Premenstural, Luteal phase: Uterus
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Menstruation starts at day 28
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Premenstrual; Luteal phase: Breast
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Alveolar breasts diffrentiate into secretory cells
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Premenstrual; Luteal phase: CNS Hormones
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Increased GnRH --> increased FSH
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4 bones of bony pelvis:
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2 innominate (illium, ischium, and pubis); sacrum and coccyx
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4 joints that dont move
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symphysis pubis, sacrococcugeal, and 2 sacroilliac
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2 hormones that used during pregnancy to soften cartilage and strengthen elasticty
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estrogen and relaxin
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What happens to pelvis during pregnancy
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protrusion of abdomen as uterus grows; pelvis tilts forward -- placing strain on back or sacroilliac
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Upper border of outlet/ false pelvis at what level:
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Ishial spine - imp landmark during pregnancy
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Lower border of outlet/ true pelvis is bounded by what 2 things?
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Public arch and ishial tuberosities
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What happens to external genitialia, clitori, labias, vagina, in adolescents
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Genitalia increases in size; clitoris becomes more erectile; labia minora more vascular; vaginal opening 1cm and secretions acidic
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What happens to vaginal secretions just before menarch
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Increase
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What is responsible for uterine enlargement during 1st trimester
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Estrogen and Progesterone
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What grows uterus after 1st trimester
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growing fetus
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After birth what happens to size of uterus?
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Size @ 20 weeks; at level of umbilicus
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By end of 1st week, size of uterus?
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Size @ 12 weeks; at level of pubic symphysis
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Why do prego women have "waddle gait"
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Relaxin and progesterone softening cartilage and ligaments
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Why does cervix have bluish color
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Increased uterine blood flow --> prelvic congestion and edema
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What does the softness and compressability of isthmus do to uterus
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exaggerated uterine antiflexion during first 3 mo of prego
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Why do vaginal secrettions have acidic pH
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increase in lactic acid production by vaginal epithelium
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Defintion of menopause
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1 year with no mensues
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Why do postmenopause women have dyspareunia
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mucosa becomes thin, pale and dry
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What ceases 1-2 yrs becore menopause
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ovulation
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What are some systemic effects of ovulation:
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increase body fat, LDL, thermoregulation
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What medications can lead to abnormal bleeding?
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oral contraceptives, hormones, and tamoxifen
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What medications can lead to vaginal discharge?
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oral contraceptives and antibiotics
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What medications can lead to premenstrual symptoms?
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analgesics and diuretics
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What medications can lead to menopausal symptoms?
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hormone therapy serum estrogen receptor modulator, soy, or other natural estrogen products, black cohosh
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What are contributing factors to infertility?
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stress, nutrition and chemical substances
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What is the difference between the presentation of endometriosis in the adolescent girl and woman?
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the adolescent girls may have pelvic pain that are cyclic and noncyclic while the womans pain is often cyclic
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What medications can lead to urinary symptoms?
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urinary tract analgesics and antispasmodics
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What is the letter association when obtaining the obstetric history?
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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; and any complications of pregnancy
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What are side effects of hormone therapy?
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breast tenderness, bloating, vaginal bleeding
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What are the side effects of serum estrogen receptor modulators?
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hot flashes and breast tenderness
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What are risk factors for cervical cancer?
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lack of regular screening, HPV infection, sex before the age of 16 and multiple sex partners, cigarette smoke, HIV infection, diets low in fruits and vegetables, obese individuals, DES exposure, long term use of oral contraceptives and low socioeconomic status
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What HPV infections are considered high risk?
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HPV 16, 18, 31, 33, and 45
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What can decrease the risk of cervical cancer?
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HPV vaccination
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By how much does cigarette smoke increase the risk of cervical cancer?
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doubles it
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Which race has a higher likelihood of developing cervical cancer?
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blacks, hispanics, native americans and american indians
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What was DES used for?
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prescribed to women at high risk of miscarriage between 1940 and 1971
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How does HIV infection increase the risk of cervical cancer?
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increased susceptibility to HPV infection
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What are risk factors for ovarian cancer?
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increase with age normally after menopause, early menarche, infertility, nulliparity, first child after 30, menopause after 50, use of fertility drugs, family history, prior endometrial, breast or colon cancer, mutations in BRCA 1 and BRCA 2, occurs more in whites, hormone replacement therapy, and high fat diet
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What in the family history will increase the risk of ovarian cancer?
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one or more first degree relatives with ovarian and or breast cancer, strong family history of colon cancer, Ashkenazi Jewish descent, and family history or breast or ovarian cancer
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What are risk factors of endometrial cancer?
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early menarche, late menopause, infertility or nulliparity, obesity, tamoxifen, estrogen replacement therapy, polycystic ovaries and granulosa theca cell tumors, high animal fat diet, diabetes, risk increases with age average age is 60, family history, breast ovarian or colon cancer history, mutation in BRCA 1 or 2, prior pelvic radiation therapy
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Why does early menarche and late menopause increase the risk of endometrial cancer?
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increases the number of years that the endometrium is exposed to estrogen
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Why can being pregnant multiple times decrease the risk of endometrial cancer?
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in pregnancy the hormonal shift is toward progesterone, leading to less exposure of estrogen to the endometrium
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Why does obesity lead to an increase in endometrial cancer?
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having more fat increases the estrogen levels
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What is tamoxifen?
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antiestrogen drugs that acts like an estrogen on the uterus
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How does prior pelvic radiation therapy increase the risk of endometrial cancer?
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radiation used to treat some other cancers can damage the DNA of cells, sometimes increasing the risk of developing a second type of cancer like endometrial cancer
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What individuals should perform genital self exams?
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anyone who is at risk for contracting a sexually transmitted infection
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What are you looking for when performing a genital self exam?
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bumps, sore or blisters on the skin
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What symptoms are associated with a sexually transmitted infection?
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pain or burning on urination, pain in pelvic area, bleeding between menstrual period or an itchy rash around the vagina
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What type of discharge may be noted with a STI?
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different from usually may be yellow and thicker and have an odor
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What should be considered as a suspicion if an infant or child as genital complaints?
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insertion of foreign object by the child or possibility of sexual abuse
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Besides the suspicions what can cause pain in genital areas of children?
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bubble bath, irritating soaps, or detergents
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When is masturbation considered healthy activity?
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if its occasional, discreet and private, not preferred over other activity or play, no physical signs or symptoms and external stimulation of genitalia only
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When should masturbation be of concern?
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frequent or compulsive, no regard for privacy, often preferred over other activity or play, produces genital discomfort, irritation or physical signs and involves penetration of the genital orifice or include bizarre practices or rituals
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What can lead to anxiety before a pelvic exam?
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child abuse or sexual assault in person life or during previous pelvic exam, lack of familiarity or worry about possible findings or their meanings
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What should you ask a patient to do before performing a pelvic exam?
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empty their bladder
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During a genital exam when is a glove considered contaminated?
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once the glove touch the patients genital area
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Once a glove is contaminated what should the physician avoid?
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touching any instruments that will not be discarded or immediately disinfected until the gloves are removed or changed
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What do some physicians do to avoid constantly changing gloves?
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clinicians double or triple gloves at beginning of exam and then remove a glove when a clean hand is needed
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What position should a patient be placed in for a pelvic exam?
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lithotomy position
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How should you drape a woman for the pelvic exam?
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cover her knees and symphysis and allow yourself to see the woman's face
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How should you start the pelvic exam?
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neutral touch on her lower thigh, moving your examining hand along the thigh without breaking contact to the external genitalia
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Labial swelling, redness or tenderness may be a sign of what?
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Bartholin gland infection
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What does discoloration or tenderness of labia minor possibly indicate?
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traumatic bruising
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Length of clitoris
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2 cm
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Clitoris diameter
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0.5 cm
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Enlargement of clitoris is indication of what?
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masculinizing condition
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What is a caruncle
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Bright red polypoid growth that protrudes from urethral meatus
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When should you ask the patient questions about your findings during the pelvic exam?
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Later time- not during exam
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What is another name for the irregular edges from the hymenal remnants at the vaginal introitus
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myrtiform caruncles
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Discharge from the skene galnds indicates what?
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infection- usually gonococcal
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How do you test muscle tone of the vagina
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ask patient to squeeze the vaginal opening around your finger. then ask pt to bear down as you watch for urinary incontinence & uterine prolapse.
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What is the difference in perineal tissue between nulliparous and multiparous women?
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nulliparous- tissue thick & smooth. multiparous: tissue thin & rigid
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Advantage of using water as lubricant for speculum?
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cold speculum can be warmed by rinsing in warm water
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Proper way to hold speculum
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hold it in your hand with the index finger over the top of the proximal end of the anterior blade & other fingers around the handle. This position controls the blades as speculum is inserted into vagina
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Proper way to insert speculum
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Use fingers to separate labia minora so vaginal opening is visible. Insert speculum along path of least resistance, often slightly downward
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Normal color of cervix
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pink with color evenly distributed
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Bluish color of cervix indicates what?
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increased vascularity, which can be a sign of pregnancy
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Pale cervix indicates what?
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anemia
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A cervix pointing anteriorly indicates what?
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retroverted uterus
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A cervix pointing posteriorly indicates what?
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anteverted uterus
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A cervix in horizontal plane indicates what?
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midposition uterus
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Normal position of cervix
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midline
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A cervix deviated left or right suggests what?
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pelvic mass, uterine adhesions or pregnancy
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What is the normal cervix protrusion into vagina?
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1-3 cm
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What is cervix diameter in women who have had children
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2-3 cm
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What should the cervix look like upon speculum exam?
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Surface should be smooth. Some cervical squamo-columnar epithelium may be seen as a symmetric reddened circle around the os
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How does columnar epithelium from the cervical canal appear?
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shiny red tissue around os that may bleed easily
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What should be done next if ectropian is seen on speculum exam of cervix?
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Ectropian is not an abnormality but bc its indistinguishable from early cervical carcinoma further tests like pap smear should be done
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What do Nabothian cysts look like?
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small, white or yellow raised, round areas on the cervix
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What are Nabothian cysts?
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retention cysts of the endocervical glands. Are considered an expected finding
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You should always look for friable tissue, red patchy areas, granular areas & white patches on cervical exam bc they could indicate what 3 things?
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cervicitis, infection & carcinoma
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Difference in cervical os appearance between nulliparous and multiparous women?
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nulliparous- small & round. multiparous- horizontal slit, stellate or irregular
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Difference in appearance of vaginal wall btwn premenopausal & postmenopausal women
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pre- wall will be ruggated. post-wall smooth
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Vaginal secretions that may be expected
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thin, clear, cloudy and odorless
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Vaginal secretions unexpected
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thick, curdy or frothy, gray, green, yellow & foul odors
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Cystocele
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hernial protrusion of bladder through anterior wall of vagina
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Rectocele
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hernial protrusion of rectum through posterior vaginal wall
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Pap Smear procedure
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-1st collect sample from ectocervix with spatula. Insert longer projection of spatula into cervical os & rotate it 360 degrees. -withdraw spatula & spread specimen on glass slide. -immediately spray w/ cytologic fixative & label slide. - Next introduce brush into vagina & insert into cervical os. Rotate. Remove. Prepare endocervical slide
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What is the main advantage of using the broom instrument for pap smears
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Causes less bleeding
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How is a gonococcal culture obtained
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Sterile cotton swab into vagina & inserted into cervical os. Hold it there 10-30 sec.Withdraw swab & spread specimen in Z pattern on culture plate.
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What kind of swab is used when doing a DNA probe for Chlamydia & gonorrhea
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Dacron swab
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When doing a wet mount slide procedure the presence of trichomonads indicates what?
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T. vaginalis
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When doing a wet mount slide procedure, the presence of bacterial filled epithelial cells (clue cells) indicates what?
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bacterial vaginosis
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When doing a wet mount slide procedure with KOH a fishy odor indicates what?
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bacterial vaginosis
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Under the microscope, the presence of mycelial fragments, hyphae & budding yeasts indicate what?
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Candidiasis
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What is the best way to remove the speculum at the end of the exam?
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blades tend to close themselves. Avoid pinching cervix & vaginal walls. Maintain downward pressure of speculum to avoid trauma to urethra. Hook index finger over anterior blade & thumb on handle lever
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What should you feel when doing the bimanual exam
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Palpate vaginal wall as you insert fingers. Should be smooth, homogenous & non tender. feel for cysts, nodules, masses & growths
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Why should you be careful of your thumb placement during the bimanual exam
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Be aware of where your thumb is. Keep it from touching clitoris
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How is exam of a woman who had a hysterectomy different?
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Exam essentially no different. Same exam steps and sequence with minor variations as to what you are assessing (i.e. no uterus)
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Are pap smears recommended after hysterectomies?
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No, as long as hysterectomy was done for noncancer reasons & there was no evidence of malignancy
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If the uterus is anteverted or anteflexed where will your abdoninal hand feel the fundus
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level of pubis
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if the uterus is midline where will your abdominal hand feel the fundus
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fundus wont be palpable
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uterus deviated left or right is a possible indication of what?
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pelvic mass, adhesion or pregnancy
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Normal size and shape of uterus
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pear shaped. 5.5 - 8 cm
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Larger than expected uterus can indicate what?
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pregnancy or tumor
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Mobility of uterus
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uterus should be mobile in the AP plane. fixed uterus indicates adhesions
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What should ovaries feel like on palpation?
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firm, smooth & ovoid
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Normal ovary size
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3x2x1 cm
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What can you assume if you are unable to feel anything in the adnexal areas
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no abnormality present
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How far into the pelvis does a rectovaginal exam allow you to reach?
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almost 2.5 cm (1 inch)
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How is mittelschmerz associated with adnexal tenderness?
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Mittelschmerz may present with adnexal tenderness on the side of ovulation that month, but will still lead to a negative pelvic exam.
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What causes an extremely tight anal sphincter?
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anxiety about exam, scarring, spasticity caused by fissures, lesions, or inflammation
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What causes a lax anal sphincter?
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neurological deficit
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What causes an absent anal sphincter?
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improper repair of third-degree perineal laceration after childbirth or trauma
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When would you be able to feel the uterus in a rectovaginal exam?
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Retroflexed uterus allows you to occassionally feel the uterine fundus, may be able to feel uterine body.
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When does the labia majora completely cover the clitoris and labia minora?
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36 weeks gestation
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What does the newborn genitalia reflect?
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influence of maternal hormones
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How do the newborn's external genitalia appear?
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This answer was not on the spreadsheet SO LOOK ER UP
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When do these features disappear?
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few weeks after birth
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Is apparent clitoromegaly 'normal' in very premature newborns?
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yes! only 1/5000 have an endocrine problem- look for other virilizing features to distinguish
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What does a truly enlarged clitoris indicate?
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CAH
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What is the diameter of the central opening of the hymen?
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0.5 cm
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Are you supposed to stretch the hymen if not opened?
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No! An imperforate hymen may cause hydrocolpos in the child and hematocolpos in adolescents.
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How could the external genitalia appear after a breech delivery?
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swollen and bruised for many days after delivery
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What does a white, mucoid vaginal discharge indicate up to 4 weeks after birth?
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expected finding- seen from passive hormonal transfer from mother (still normal even with blood)
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How would you separate thin but difficult to separate adhesions between the labia minora that occur during the first few months or years of life?
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gentle teasing or estrogen cream
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What does discharge from irritation from diapers or powder look like?
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mucoid
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When is an internal vaginal examination warranted on a child?
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Only when there's a specific problem (bleeding, discharge, trauma, or suspected sexual abuse)- otherwise inspection & palpation
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Are the Skene's and Bartholin's glands palpable?
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No! If palpable, they are enlarged. Most likely a gonococcal infection.
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What are causes of vaginal discharge?
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UTI, foul odor (most likely a foreign body in pre-K children, especially w 2nd infection, also could be trichonomal, gonococcal, or monilial infections.
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What does swelling of vulvar tissues especially if accompanied by a foul-smelling discharge indicate in a child?
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usually sexual abuse (especially if smooth tissues, bike seats cause injury of more fixed structures)
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What position is best to exam for sexual abuse?
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knee-chest position (better view of perineum & abuse usually has more posterior injuries)
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What are the causes of vaginal bleeding in a child?
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usually unintentional injury, also from other genital lesions, vaginitis, foreign body, trauma, tumors, endocrine changes, estrogen ingestion, precocious puberty, hormone-producing ovarian tumor
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How is the physical exam often in sexual abuse?
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normal
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What are some medical complaints and findings that indicate sexual abuse?
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evidence of general abuse, neglect, trauma, scarring, unusual changes in color, STDs, anorectal or GU problems (itching, pain, bleeding, etc.)
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What are some behavioral manifestations of sexual abuse?
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problems with school, dramatic weight changes, depression, sleep problems, personality changes, aggression, avoidence of people or certain places
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What are some concerning sexual behaviors that indicate abuse?
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????
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When would a rectal exam for GU purposes be indicated?
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to feel for the presence or absence of the uterus or presence of foreign body in the vagina
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Is bleeding or transient mild rectal prolapse a pathological finding after this exam?
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no! it's normal
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When should a sexually active adolescent first see a gyno?
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within 3 years of sexual intercourse (need Pap & STD eval.)
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When should females who are not sexually active first see a gyno?
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by 21 y/o
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When is urine-based STD testing useful?
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for sexually active female who are not due for their annual Pap smear
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What is the size of a pediatric speculum?
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1 to 1.5 cm wide (can use a small adult speculum for sexually active)
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What are healthy activities of sexual play in adolescents? (sorry I don't know how to ask this, check out box 18-6)
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discreet, private; mutual consent; no power balance; no threats or violence; infrequent; age-appropriate language & sexual knowledge; does not result in injury; basic, rudimentary sexal activity
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What types of activities need further assessment? (same box as above)
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no regard for privacy; one adolescent does not freely consent; power imbalance; actual or implied threats of violence; frequent & compulsive; language beyond age-appropriate level of sexual knowledge; causes injury; explicit, graphic, and detailed sexual history; attempted or actual penetration of genitalia
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What is the Naegele rule to calculate EDC?
|
add 1 year to the first day of LMP, subtract 3 months, and add 7 days
|
|
|
What's the average duration of pregnancy?
|
40 weeks or 280 days (3 trimesters, each slightly more than 13 weeks)
|
|
|
How do you measure fundal height and what does it tell us?
|
measure in supine position from symphysis pubis to superior fundus uterus (baby bump); provides an estimate for length of pregnancy, fetal growth, and gestational age
|
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|
What is Piskacek sign?
|
deviation of uterus to one side and an irregularity in its contour at implantation sight; OCCURS WEEKS 8-10 of pregnancy
|
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|
When is the measurement of fundal height most accurate?
|
Between 20 and 32 weeks gestation (height in cm should be equal to gestational age in weeks)
|
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|
What is the expected increase in height per week?
|
1 cm
|
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|
What does a uterine size variation of greater than 2 cm indicate?
|
Need for US
|
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|
Less than 1 cm?
|
possible IUGR
|
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|
What factors affect fudal height measurement?
|
obesity, amount of amniotic fluid, myomata, multiple gestation, fetal size, and position of uterus
|
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|
Check out p. 573 for lengths/widths in early pregnancy.
|
In general, length equal to week + 2, width half the upper range of length
|
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When does the cervix, vagina, and vulva acquire their bluish color from increased vascularity during pregnancy?
|
2nd month (also have increased vaginal secretions due to increased vascularity as well)
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What is the diameter considered to be full or complete dilation of the cervix?
|
10 cm
|
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|
When can the fetal heart be detected by Doppler?
|
10-12 weeks
|
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When is the uterus palpable above the pubic symphysis?
|
week 12
|
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|
When is ballottement of fetus possible by abdominal and vaginal examination?
|
week 16 (halfway between symphysis and umbilicus)
|
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When can the fetal heartbeat be auscultated with a fetoscope?
|
week 20 (lower border of umbilicus)
|
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|
When is the fetus palpable?
|
week 24-26 (uterus changes from globular to avoid shape)
|
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|
What signs make a strong case for pregnancy?
|
internal ballottement (16 weeks), palpation of fetal parts, and increased hCG in serum or urine
|
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|
What is Goodell's sign? When does it occur?
|
softening of the cervix- 4-6 weeks
|
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|
What is Hegar's sign? When?
|
softening of the uterine isthmus- 6-8 weeks
|
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|
What is McDonald's sign? When?
|
fundus flexes easily on the cervix- 7-8 weeks
|
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|
What is Braun von Fernwald's sign? When?
|
fullness and softening of the fundus near the site of implantation- 7-8 weeks
|
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|
What is Piskacek's sign? When?
|
palpable lateral bulge or soft prominence of one uterine cornu- 7-8 weeks
|
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|
What is Chadwick's sign? When?
|
bluish color of the cervix- 8-12 weeks
|
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|
What is effacement?
|
Thinning of the cervix that results when myometrial activity pulls the cervix upward, allowing the cervix to become part of the lower uterine segment during prelabor or early labor. (Cervix is reduced in length).
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What does shortening of cervix (less than 29 mm) indicate?
|
Risk for preterm delivery (always measure effacement in cm & check by US)
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When does effacement occur in a primipara?
|
before cervical dilation
|
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When does effacement occur in a multipara?
|
with dilation
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|
What are two markers of fetal well-being?
|
fetal heart rate & fetal movement; for fetal HR, count for 1 min and compare to mother's, note quality, rhythm, & PMI
|
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|
When is fetal movement felt by mothers?
|
between 16 and 20 weeks (maternal assessment can be used!)
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|
What should the mother do if there is a decrease or cessation of fetal movement?
|
notify HCP immediately
|
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|
What is the Cardiff count-to-10 method?
|
When the woman counts 10 movements, noting the length of time for them to occur. Should be between 10 times in 1 hour to 10 times in 12 hours. Fewer than 12 times in 10 hours= notify HCP
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When should the mother be concerned if no monitoring technique is used?
|
if the occurrence is three or fewer FMs in 2 hours for 2 consecutive days while the woman is at rest in the left lateral decubitus position
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When should the woman start recording FM with no risks of uteroplacental insufficiency?
|
34 to 36 weeks of gestation
|
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|
With risk factors?
|
28 weeks
|
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|
When do you perform the Leopold maneuver? What is the mother's position?
|
latter half of third trimester of pregnancy; mom supine with head slightly elevated & knees flexed
|
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|
What is the first maneuver?
|
hand on fundus to identify fetal part; head= soft, round, moveable; butt= softer, less moveable
|
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|
What is the second maneuver?
|
use palmar surface of one hand to locate back of fetus (feels convex) & other hand to feel irregularites (hands & feet)
|
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|
What is the third maneuver?
|
use thumb and third finger of dominant hand to grasp the presenting part of the symphysis pubis; head= firm & moveable; butt= softer
|
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|
What is the fourth manuever? (do if you can't feel third)
|
Turn & face the woman's feet and use two hands to outline the fetal head. If the head is presenting and is deep into the pelvis, only a small portion can be felt.
|
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|
What does palpation of the cephalic prominence (the part of the fetus that prevents descent of the examiner's hand) on the same side as the small parts suggest?
|
the head is flexed and the vertex is presenting (optimal position)
|
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|
What does palpation of the cephalic prominence on the same side as the back suggest?
|
the fetus is extended
|
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|
What do you include when you record abdominal palpation?
|
the presenting part (vertex or breech), the lie (the relationship of the long axis of the fetus to mom, i.e. longitudinal, transverse), and the attitude of the fetal head (ie. flexed or extended)----> all confirmed via US
|
|
|
How can you tell if there's twins?
|
two fetal heart beats or on abdominal palpation with detection of 2nd pair of fetal parts; confirmed by US
|
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|
Besides fetal well-being, what else can fetal heart rate tell us?
|
fetal position
|
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|
What position is the fetus is FHR is above the umbilicus?
|
breech
|
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What position is the baby if FHR is below the umbilicus?
|
vertex
|
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|
What is the station?
|
the relationship of the presenting part of the ischial spines of the mother's pelvis
|
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|
How is this recorded?
|
plus (+) or (-) in cm for distance from ischial spines; +1 indicates presenting part is 1 cm BELOW the ischial spines while -1 is 1cm ABOVE the ischial spines (on cervical exam record 1. dilation, 2. cervical length, 3. station)
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|
What are Braxton Hicks contractions?
|
uterine contractions that begin as early as 3 months gestation
|
|
|
When do they need evaluation?
|
with regular occurrence of more than 4 to 6 uterine contractions per hour before 37 weeks of gestation
|
|
|
How do you assess uterine contractions?
|
through abdominal palpation or use of electronic monitoring equipment (i.e. placement of intrauterine pressure catheter)
|
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|
What is considered a "mild" contraction?
|
slightly tense fundus that is easy to indent with fingertips
|
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|
What is considered a "moderate" contraction?
|
firm fundus that is difficult to indent with fingertips
|
|
|
What is considered a "strong" fundus?
|
rigid or hard, boardlike fundus or one that does NOT indent with fingertips
|
|
|
How do you measure the duration of contractions?
|
in seconds, beginning until relaxation occurs
|
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|
How do you measure frequency?
|
from the beginning of one contraction to the beginning of the next; assess for regularity (i.e. every 5 min, or at irregular or sporadic intervals)
|
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|
How do you determine the position of the fetal head?
|
insert your fingers anteriorly into the posterior aspect of the vagina and then move your fingers upward over the fetal head as you turn them, locating the sagittal suture with the posterior and anterior fontannels at either end
|
|
|
How do you determine the position of the fontanelles?
|
examine the anterior aspect of the sagittal suture and then using a circular motion pass alongside the head until the other fontanel is felt and differentiated
|
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|
When does the uterus become more anteflexed? What does this cause?
|
Becomes more anteflexed during the first 3 months from softening of the isthmus (Hegar's sign!) Fundus can press on the urinary bladder, causing urinary frequency.
|
|
|
What causes varicosities during pregnancy in both the vulva and rectal areas?
|
pressure from the pregnant uterus and possibly hereditary factors
|
|
|
What positional changes are made in an older individual who has orthopnea for a pelvic exam?
|
elevate chest & head
|
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|
What are changes in an elderly woman's anatomy?
|
labia flat & smaller (due to loss of subcutaneous fat), skin drier & shinier, pubic hair gray & sparse, smaller clitoris
|
|
|
What changes would be seen in the urinary meatus?
|
may appear as an irregular opening or slit; may be located more posteriorly, very near or within the vaginal intraoitus as a result of relaxed perineal musculature
|
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|
Changes in the vagina?
|
narrower and shorter, absence of rugation, vaginal intraoitus may be smaller and may only admit one finger, may gape in multiparous women with vaginal walls rolling toward the opening
|
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|
Changes in the cervix?
|
may seem less mobile, protrudes less far into the vaginal canal; the os may be smaller but should still be palpable
|
|
|
Changes in uterus?
|
diminishes in size and may not be palpable
|
|
|
Should ovaries be palpable in an elderly woman?
|
they are RARELY palpable because of atrophy; if they are, suspicious for a tumor---> must do US!
|
|
|
What do you look for since the pelvic musculature relaxes?
|
stress incontinence and proplapase of the vaginal walls or uterus (pt. may also have somewhat diminished sphincter tone)
|
|
|
What inflammatory condition is an older woman susceptible to?
|
atrophic vaginitis
|
|
|
What is the knee chest position?
|
Woman lies on her side with both knees bent, with her top leg brought closer to her chest. May have bottom leg straightened while other leg still bent towards chest. MAKE SURE TO ANGLE THE SPECULUM TOWARD THE SMALL OF THE PT.'S BACK! Position does not require stirrups.
|
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|
What is the diamond-shaped position?
|
Woman lies on her back with knees bent so that both legs are spread flat and her heels meet at the foot of the table. SPECULUM MUST BE INSERTED WITH HANDLE UP. Position does not require stirrups. May be used in children.
|
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|
What is the obstetric stirrups position?
|
Woman lies on her back near the foot of the table with her legs supported under the KNEE by obstetric stirrups. The speculum can be inserted with the handle down.
|
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|
What is the M-shaped position?
|
Woman lies on her back, knees bent and apart, feet resting on the examination table close to her buttocks. SPECULUM MUST BE INSERTED WITH HANDLE UP. Does not require use of stirrups.
|
|
|
What is the V-shaped position?
|
Woman lies on her back with her straightened legs spread out wide to either side of the table. SPECULUM MUST BE INSERTED WITH THE HANDLE UP. May or may not require stirrups (depending on if you want to do a variation of the position with one leg in the stirrup).
|
|
|
What position does the visual or hearing impaired usually want to assume?
|
foot-stirrup position
|
|
|
What can you do to make them feel a little more comfortable?
|
ask the patient if she would like to examine the speculum (or other instruments to be use) & let them familiarize themselves with a three-dimensional model if available
|
|
|
How can you additionally help someone who is hearing impaired?
|
Elevate the head of the table so that she can see the clinician and/or interpreter
|
|
|
What is the big clue for detecting an ectopic pregnancy? (important because they usually rupture before they are diagnosed because symptoms may be mild)
|
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, particularly on one side. (Rigidity and rebound may come on early or late).
|
|
|
So, what should you do if a woman presents with vague abdominal complaints?
|
Check out sexual contact and menstrual hx., do a pelvic exam, and do not disregard mild tenderness that might be evoked. Consider radiologic evaluation and try to anticipate an ER or a rupture.
|
|
|
What is a collection of physical, psychological, and mood symptoms related to the menses?
|
PMS
|
|
|
What causes PMS?
|
Hormones
|
|
|
When does PMS begin?
|
Late 20s gets worse with age
|
|
|
Symptoms of PMS?
|
Breast swelling, tenderness, acne, bloating, weight gain, food cravings, headaches, arthralgias, mood swings, crying depression
|
|
|
When do PMS symptoms begin?
|
5-7 days before menses
|
|
|
What period of time classifies "infertility"?
|
1 year of unprotected sex and no baby
|
|
|
What are female contributions to infertility?
|
Abnormal vagina, cervix, uterus, tubes, ovaries
|
|
|
What are the male contributions to infertility?
|
Insufficient, nonmotile, immature sperm; ductal obsruction of sperm; transport factors
|
|
|
What are the contributions from both genders to infertility?
|
stress, nutrition, chemicals, chromosome issues, iseases, sex problems, hematologic/immunologic disorders
|
|
|
What is the condition where endometrial tissue grows outside the uterus?
|
Endometriosis
|
|
|
What causes endometriosis?
|
rhetrograde reflux of menstrual tissue from the tubes during menstruation
|
|
|
Symptoms of endometriosis?
|
pelvic pain, dysmenorrhea, heavy/long flow
|
|
|
What is seen on exam of suspected endometriosis?
|
Tender nodules palpable along uterosacral ligaments. Confirm via laproscopy
|
|
|
What lesions does HPV cause?
|
Condylomata acuminatam
|
|
|
How does HPV infect someone?
|
invades basal layer of epidermis => penetrates through skin => causes mucosal microabrasions
|
|
|
How long can the latent phase of HPV last?
|
month to several years (asymptomatic)
|
|
|
What happens after latency?
|
Viral DNA, capsids, and particles are produced; host cells become infected and skin leasons appear
|
|
|
What does HPV look like?
|
Well its gross, but flesh-colored, whitish pink to reddish brown, discrete, soft growths on labia, vestibule or perianal area. occur in singles/clusters and enlarge to form cauliflower-like masses
|
|
|
What is a viral infection of the skin/mucous membranes?
|
Molluscum contagiosum
|
|
|
Is Molluscum sexually transmitted?
|
In adults - yes; in children - no
|
|
|
What causes Molluscum?
|
Poxvirus, virus enters skin through small breaks of hair follicles
|
|
|
How is Molluscum transmitted?
|
Direct person-to-person contact; contact with contaminated objects; sex
|
|
|
What is Molluscum's incubation period?
|
2-7 weeks
|
|
|
What does Molluscum look like?
|
White or flesh colored, dome-shaped papules that are round or oval. Central umbilication where a thick creamy core can be expressed.
|
|
|
How long does Molluscum last?
|
several months to several years
|
|
|
What is a key sign of primary syphillis?
|
Chancre - lasts 3-6 weeks
|
|
|
What causes syphillis?
|
treponema pallidum
|
|
|
When does the first syphillis lesion occur?
|
2 weeks after exposure
|
|
|
What does a chancre look like?
|
Firm, round, small, painless, ulcer. INdurated boarders with a clear base. scrapings will show spirochetes
|
|
|
What is condyloma latum?
|
Lesions of secondary syphillis
|
|
|
When does condylomata latum appear?
|
6-12 weeks after infection
|
|
|
What do condylomata latum look like?
|
flat, round or oval papules covered by a gray exudate
|
|
|
When does the most transmission of HSV occur?
|
When individuals shed the virus in the absence of symptoms
|
|
|
What are common symptoms of HSV-2?
|
painful lesions in genital area, burning/pain when urinating
|
|
|
What does a HSV breakout look like?
|
Superficial vesicles in the genital area; internal or external; may be eroded.
|
|
|
What is different about initial vs recurrent HSV infection?
|
Initial = extensive; recurrent = localized
|
|
|
What causes inflammation of bartholin gland?
|
Neisseria gonorrhea (acute or chronic)
|
|
|
What does a bartholin gland inflammation look like?
|
Hot, red, tender, fluctuatn swelling of the bartholin gland that may drain pus. Chronic = nontender cyst on the labium
|
|
|
What are the types of vaginal carcinoma?
|
squamous cell, adenocarcinoma, melanoma, sarcoma
|
|
|
Where does squamous cell carcinoma originate?
|
epithelial lining (may be caused by HPV), takes many years to form
|
|
|
Where does adenocarcinoma originate?
|
Glandular tissue
|
|
|
Where does malignant melanoma originate?
|
Pigment producing melanocytes - affects lower/outer portion of vagina
|
|
|
Where does a sarcoma originate?
|
Deep within the wall of the vagina, NOT on surface
|
|
|
What are the symptoms of vaginal cancer?
|
Abnormal bleeding, painful urination, painful sex, pain in pelvic, back, leg areas, edema in legs, mom took DES during pregnancy
|
|
|
How do you diagnose vaginal cancer?
|
Vaginal discharge, lesions, masses. Tumors are various sizes. Dx based on biopsy
|
|
|
What are precancerious vaginal changes called?
|
Vaginal intraepithelial neoplasia (VAIN)
|
|
|
Where does adenocarcinoma of the vulva originate?
|
Bartholin glands or vulvar sweat glands - small % of cases
|
|
|
What is the most common vulvar cancer?
|
Squamous cell carcinoma
|
|
|
Women with melanoma on other parts of their body have an increased risk of melanoma where?
|
Vulva - 2-4% of vulvar cx
|
|
|
Where is basal cell carcinoma of the vulva found?
|
in sun-exposed areas - it is rare
|
|
|
What are the symptoms of vulvar cancer?
|
Growth on vulva; sticks around for longer than a month; bleeds; changes in appearance; itches, hurts, burns; painful urination
|
|
|
Where is squamous cell carcinoma of the vulva usually found?
|
On the labia - ulcerated or raised
|
|
|
Where is adenocarcinoma of the vulva usually found?
|
Sides of vaginal opening
|
|
|
Where is melanoma of the vulva usually found?
|
On clitoris or labia minora
|
|
|
Vulvar cancer diagnosis based on?
|
biopsy
|
|
|
What vaginal infection gives you strawberry cervix?
|
Trichomoniasis = petechial hemorrhages
|
|
|
What vaginal infection is indicated by clue cells?
|
Bacterial vaginosis
|
|
|
What vaginal infection is indicated by budding, branching hyphae?
|
Candidia
|
|
|
What vaginal infection has clear or mucoid discharge?
|
Physiologic vaginitis (3-5 WBCs & epithelial cells)
|
|
|
What vaginal infection has homogenous thin, white or gray discharge w/ pH > 4.5?
|
Bacterial vaginosis (Gardenerella vaginalis)
|
|
|
What vaginal infection has white, curdy discharge?
|
Candidia vulvovaginitis (albicans). Itching is really bad, do a KOH prep to look for fungus
|
|
|
What vaginal infection has profuse, frothy, greenish discharge?
|
Trichomoniasis = the organism looks pear-shaped and will gyrate on wet mount
|
|
|
What vaginal infection has purulent discharge with gland inflammation and inflamed cervix/vulva?
|
Partner is usually infected with Gonorrhea (Neisseria gonorrhea) in addition to patient. Do a gram stain, culture, DNA probe
|
|
|
What vaginal infection has purulent discharge and a red/friable cervix?
|
Chlamydia = partner will have urethritis and may be asymptomatic; order a DNA probe
|
|
|
What vaginal condition has pale, thin vaginal mucosa with a pH > 4.5?
|
Atrophic vaginitis = vagina will be dry. Occurs around or after menopause. On a wet mount there will be folded, clumped epithelial cells
|
|
|
What vaginal condition is foul smelling, red, altered pH?
|
Allergic vaginitis = bubble baths, soap, douche, hygiene products. You will see WBCs on wet mount
|
|
|
What vaginal condition gives rise to bloody or foul-smelling discharge?
|
A foreign body, usually tampon, condom, diaphragm that inflames the vulva. WBCs seen on wet mount
|
|
|
What vaginal infection has fishy smelling discharge?
|
Bacterial vaginosis (Gardenerella vaginalis) = do KOH whiff test and look for clue cells on a wet mount
|
|
|
What does cervical carcinoma typically originate from?
|
A dysplastic or premalignant lesion present at the active squamocolumnar jxn. Usually from HPV infection
|
|
|
How long does it take for a cervical carcinoma to transform?
|
Several years
|
|
|
What are the symptoms of cervical carcinoma?
|
Unexpected vaginal bleeding, spotting. Usually asymptomatic though
|
|
|
What is discovered upon PE of cervical carcinoma?
|
Granular surface at or near cervical os. Lesion can be califlower that bleeds easy. Ulcerations.
|
|
|
Cervical carcinoma early lesions look like what?
|
Ectropion
|
|
|
Why does uterine prolapse occur?
|
The supporting structures of the pelvic floor atrophy. Uterus becomes retroverted and decends into vaginal canal.
|
|
|
What is first degree prolapse?
|
The cervix remains within the vagina
|
|
|
What is second degree prolapse?
|
The cervix is at the introitus
|
|
|
What is third degree prolapse?
|
The cervix and vaginal drop outside teh introitus
|
|
|
What causes mid-cycle spotting?
|
Estradiol fluxuation associated with ovulation
|
|
|
What causes delayed menstruarion?
|
Anovulation/ threatened abortion with excessive bleeding
|
|
|
What causes profuse menstrual bleeding?
|
Endometiral polyps, DUB, adenomyosis, submucous bleeding leiomyoomas, IUD
|
|
|
What cuases intermenstrual or irregular bleeding?
|
Endometrial polyps, DUB, uterine/cervical cancer, oral OTCs
|
|
|
What cuases postmenopausal bleeding?
|
Endometrial hyperplasia, estrogen therapy, endometrial cancer
|
|
|
What is a myoma?
|
Common , benign, uterine tumors
|
|
|
What are the two types of myomas?
|
Leiomyoma, fibroid
|
|
|
What causes myomas?
|
Overgrowth of smooth muscle and CT in the uterus
|
|
|
What are the symptoms of myomas?
|
Related to number of tumors: heavy menses, cramps, urinary issues, constipation, pelvic/abdominal discomfort
|
|
|
What do myomas feel like on palpation?
|
Firm, irregular nodules in the contour of the uterus on exam. Uterus can be enlarged
|
|
|
When does endometrial carcinoma occur?
|
Most often in postmenopausal women = they will have bleeding RED FLAG
|
|
|
Where do almost all endometrial cancers originate from?
|
Glandular cells in teh lining of the uterus
|
|
|
What are the risk factors for endometrial cx?
|
Imbalance of estrogen/progestrone; women taking tamoxifen are at increased risk
|
|
|
What causes ovarian cysts?
|
Hypothalamic-pituitary dysfunction; native anatomic defects in repro system
|
|
|
Characteristics of ovarian cysts?
|
Unilateral/bilateral; can be present from neonate to postmenopause; occur during infancy/adolescence during hormone-active periods; most are functional and resolve with tx
|
|
|
Symptoms of cysts?
|
Lower abd pain; sharp, intermittent, sudden, severe. Pain is bad when the cysts rupture
|
|
|
How are ovarian carcinomas characterized?
|
Epithelial, Stromal, Germ cell
|
|
|
Where do epithelial ovarian carcinomas arise from?
|
A layer of germinal epithelium on the outside of the ovary; most common form of ovarian cx
|
|
|
Where do stromal ovarian carcinomas arise from?
|
CT cells that help form the structure of hte ovary and produce hormones
|
|
|
WHere do germ cell tumors arise from?
|
From germ cells; most often in young women
|
|
|
Who should you suspect ovarian cx in?
|
Woman older than 40 years with persistent and unexplained vague GI symptoms, like generalized abdominal discomfort and/or pain, gas, indigestion, pressure, swelling, bloadting, cramps, full feeling
|
|
|
What would you palpate on a bimanual exam with ovarian cx?
|
Enlarged overy in premenopausal woman; palpable ovary in postmenopausal woman should be considered suspicious for cx
|
|
|
Where is the most common site for ectopic pregnancy?
|
One of the tubes but can occur other places
|
|
|
What causes ectopic pregnancy?
|
A condition that blocks/slows the movement of a fertilized egg through the fallopian tube to the uterus; scars; past infection; PID; surgery
|
|
|
What are the symptoms of an ectopic pregnancy?
|
Abnormal vaginal bleeding, low back pain, mild crampling, pain in abldomen/pelvis, lightheaded, syncope, pain in shoulder, severe, sharp, sudden pain in lower abdomen
|
|
|
What are the PE findings in an ectopic pregnancy?
|
Pelvic tenderness; rigid lower abdomen; cervical motion tenderness; tender adnexas UNILATERAL
|
|
|
What are the signs of a ruptured ectopic pregnancy?
|
Tachycardia, hypotension, impending cardiovascular collapse, shock = this is a surgical emergency
|
|
|
What causes PID?
|
Gonorrhea or chlamydia
|
|
|
What are the symptoms of PID?
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Mild or absent but usually a foul smelling discharge, pain with sex/ urniation; irregular bleeding; pain in RIGHT UPPER abdomen
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What are the PE findings in PID?
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BILATERAL adnexal tenderness; usually pt cannot tolerate this exam; all symptoms of chronic PID are bilateral and adnexal areas ore fairly fixed
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What is salpingitis?
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Inflammation of the fallopain tubes
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What are the two stages of salpingitis?
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1 ) aquisition of vaginal/cervical infection; 2) ascent of infection to upper genital tract
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What organisms cause acute salpingitis?
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N. Gonorrheae and Chlamydia
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What are the symptoms of salpingitis?
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Lower quadrant pain; constant, dull cramping; pain worsened by motion or activity; purulent discharge and bleeding; nausea, vomiting, fever
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What type of discharge is found in salpingitis?
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mucopurulent
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What causes ambiguous genetalia?
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Presence/absence of male hormones from genetic abnormalities
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A deficiency in male hormones in a male fetus results in?
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Ambigous genetalia
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What do male hormones in a femal fetus result in?
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Ambigous genetalia
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What family hx is significant in ambigious genetalia?
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Hx of: genetic abnormalities, CAH, unexplained deaths in early infancy, infertility, abnormal development during puberty
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What does ambiguous genetalia in a genetic female look like?
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Large clit that looks like small penis, urethral opening in clitoris, fused labia, lump of tissue within the labia
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What does ambiguous genetalia in a genetic male look like?
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Small penis, urethral opening anywhere along penis or on peritoneaum, small scrotom, separated scrotum, undescended testicles
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What is hydrocolpos?
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Distention of hte vagina caused by accumulation of fluid due to congenital vaginal obstruction
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What causes hydrocolpos?
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Imperforate hymen, transverse vaginal septum
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What does hydrocopos look like?
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Small midline lower abd mass or cystic mass between labia, may resolve or need sx, need to do ultrasound for a mass displacing bladder
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What are the causes of vulvovaginitis?
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Sexual abuse; trichomnal, monilial, gonococcal infection; secondary infection from foreign body; nonspecific infection from baths; diaper irritation; urethritis; injury; pinworms
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Recent pharyngitis can cause what in the femal genital tract?
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A beta-hemolytic streptococcus vaginitis (GABHS)
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What is a physiologic response to increasing estrogen levels?
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Increased vaginal discharge
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What are the symptoms of vulvovaginitis in young kids?
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discharge on diaper/panties, abnormal odor, redness
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What manual things can cause vulvovaginitis?
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Wiping from butt to front, tight fitting panties, vaginal irritants like soap
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What vulvovaginitis symptom suggests pinworm infection?
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Pruritus especially at night
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A recent upper respiratory infection can cause what in the female genital tract?
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Vulvovaginitis
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what does PROM cause?
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A high risk of perinatal morbidity/morality and maternal morbidity/morality
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What are the causes of PROM?
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Not known; but maybe hydramnios
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When is ROM considered premature?
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If labor does not begin in 12 hours following ROM
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How can PROM be verified?
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Sterile speculum exam and collecting fluid; testing fluid with Nitrazinepaper and microscope exam
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What is the pH of amnionic fluid?
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7.15 the Nitrazine paper will turn blue-green
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What will amnionic fluid look like on a slide?
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A fern pattern
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Ultrasound eval of amnionic fluid will reveal?
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Decreased/absent with PROM
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What causes bleeding in early pregnancy?
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Unknown causes - not significant; life-threatining = ectopic
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What causes bleeding in late pregnancy?
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Benign = cervical changes; life threatening = abruptio placentae
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Women who are bleeding in labor or have suspected placenta previa should not be?
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Examined without prep for an emergency C-section
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Why does the vagina atrophy?
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No hormones around and after menopause
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What are the symptoms of vaginal atrophy?
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Pan during sex; mucosa is dry and pale, sometimes red and hemorrhaged; white, gray, yellow, green, blood-tinged discharge; sometimes thick and watery
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