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145 Cards in this Set

  • Front
  • Back
Recurrent Yeast
1. Inadeqaute treatment
2. Resistant Organism
3. underlying condition which predispose to recurrence
BV
Flagyl 500 mg TID x 5 days
Gonrorrhea
Azithro 2 grams PO
Chlaymidia
Azithro 1 gram po
Hypothyroidism
TSH > 10 mIU/L and decrease in T4 levels
Sublinical Hypothyroidism
slight elevation in TSH and normal FT4
Treatment of Hypothyroidism
1.8/mcg/kg/day elderly 1.0 ug/kg/day

check TFTs every 4-6 weeks
pH of vaginal candidiasis
vaginal pH in women with Candida infection is typically normal (4 to 4.5), which distinguishes candidiasis from trichomoniasis or bacterial vaginosis
What do you see on micro with vaginitis
Candida species can be seen on a wet mount of the discharge; adding 10 percent potassium hydroxide destroys the cellular elements and facilitates recognition of budding yeast, pseudohyphae, and hyphae
However, microscopy is negative in up to 50 percent of patients with culture confirmed vulvovaginal candidiasis
Treatment of Chronic Vaginal Candidiasis
fluconazole 150 mg every 72 hours for three doses, followed by maintenance fluconazole therapy once per week for six months
Aromastase inhibitors
aromatase enzyme cytochrome p450 enzyme converts androgens to estrogens in many tissues

tissue include the brain, bone, breast, skin, adipose and ovary, and endometrium

they block these enzymes reversibly

Letrozole and Anastrozole
Name 2 Aromatase inhibitors
Letrozole and Anastrozole

used for breast cancer

side effects- vasomotor symptoms, vaginal dryness, arthralgia, and decreased BMD

In contrast to Tamoxifen and Evista have a reduced incidence of VTE and endometrail carcinoma
Differential for breast cyst
ductal cyst
hemorrhagic or traumatic cyst
fibrocystic change
fibroadenoma
mastits
carcinoma
Breast Discharge
green or yellow
purulent--
yellow or pink serosanguineous-

Bloody serosanguineous-

cleary/watery
green or yellow ---- duct ectasia
purulent-- bacterial infection (masitis or abscess)
yellow or pink serosanguineous- intraductal papilloma, fibrocystic changes

Bloody serosanguineous- intraductal papilloma

cleary/watery very worrisome for carcinoma
Risk of Cancer

Milky galactorrhhea, green/yellow or purulent-

yellow or pink seroaunguineous-

bloody serosanguienous

clear water
Risk of Cancer

Milky galactorrhhea, green/yellow or purulent- rare

yellow or pink seroaunguineous- 5-10%

bloody serosanguienous 5-10%

clear water >30-50%
In post menopausal woman cystic mass do you excise or aspirate
excise
Evaluate a breast mass
History
How long
Discharge
skin or nipple changes
recent trauma
family history of breast, colon, uteirne,
first degree relative pre menopause

Negative mammogram persistent mass- gets Ultrasound

cystic gest aspiration for diagnosis,

persistent mass regardless should get elvaulted by general surgeon

more aggressive evaluation of solid breast masses - excisional biopsy of a palpable solid mass is advisable


careful and bilateral breast exam
identification of the site of nipple d/c, usually a solitary duct

diagnostic mammogram with contact ulstroudn

refferal to breast specialist
ductal lavage- to sample the affected duct
ductogram to evaluate for an intraductal mass

excisional biopsy of any suspicious findings generally performed under fine wire cannulation of the duct and excision around the wire under radiographic guidance
a bilateral milky discharge is galactorrhea usuaaly due to
1. persistent breast activity following pregnancy/breast feeding

2. discontinuation of OCPs

3. Idiopathic causes
Idiopathic
is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause.
Gail Model
The Gail Model is a scientifically published, nationally accepted standard for evaluating your relative risk of developing breast cancer based on your family history.

*The Gail Model Risk Assessment is not intended for women who have had lobular cancer in-situ (LCIS) or ductal cancer in-situ (DCIS) or who have had a previous breast cancer
The Breast Cancer Risk Assessment Tool was designed for use by health professionals. If you are not a health professional, you are encouraged to discuss the results and your personal risk of breast cancer with your doctor.
The tool should not be used to calculate breast cancer risk for women who have already had a diagnosis of breast cancer, lobular carcinoma in situ (LCIS), or ductal carcinoma in situ (DCIS).
The BCRA risk calculator may be updated periodically as new data or research becomes available.
Although the tool has been used with success in clinics for women with strong family histories of breast cancer, more specific methods of estimating risk are appropriate for women known to have breast cancer-producing mutations in the BRCA1 or BRCA2 genes.
Other factors may also affect risk and are not accounted for by the tool. These factors include previous radiation therapy to the chest for the treatment of Hodgkin lymphoma or recent migration from a region with low breast cancer rates, such as rural China. The tool's risk calculations assume that a woman is screened for breast cancer as in the general U.S. population. A woman who does not have mammograms will have somewhat lower chances of a diagnosis of breast cancer.
SERM
Raloxifene reduced 9 cancer /1000
has an indication for osteoporosis
decrease in vertebral fractures 7/1000
No endometrial cancer

Tamoxifen reduced 7 cancers /1000
decrease in nonvertebral fractures 3/1000
increase in VTE 4/1000
increase in endoetrial cancer
tamoxifen great risk of cataracts
Premenopausal and breast cancer
For premenopausal women at high risk of breast cancer, we suggest tamoxifen rather than observation These women are not candidates for an AI.
SERM vs AI for breast cancer prevention
Whether an AI is a more effective chemoprevention than a SERM is unknown, since they have not been directly compared. However, an AI is a reasonable alternative to tamoxifen or raloxifene for postmenopausal women at an increased risk of breast cancer.
Post menopausal bleeding
only a small amount have cancer
atrophic endometrium with inflammation
idiopathic bleeding
presence of endometrial polyp or sumucuosu /intracavitary myoa

bleeding relating to hormone replacement therapy
cervicities

atrophic vaginities urethritis

bleeding from anorectal sources
stripe less than _____ mm excludes 99% of endometrial cancer
< 4mm

could be 5 mm


The endometrial lining is thicker than 4 mm
The endometrium shows diffuse or focal increased echogenicity (heterogeneity)
The endometrium is not adequately visualized
The woman has persistent bleeding.

Persistent bleeding can be a sign of endometrial cancer even when the endometrial thickness is less than 4 to 5 mm since a thin or indistinct endometrial stripe does not reliably exclude type 2 endometrial cancer [29,30]. Therefore, women with persistent bleeding should be evaluated furthe
persistent bleeding would warrant
hysteroscopy and endocervical sampling
Physiologic herniation of midgut
8-12 weeks
Treatment of Gonorrhea
ceftriaxone 250 mg intramuscularly and either azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days
Chlamydia screen all women
less than age 25

treatment
doxy 100 mg BID x 7 days
azithro 1 gram po
Levoquin 500 mg q day x 7 days
erythromycin 500 mg QID x 7 days
Ofloxacin 300 mg BID x 7 days
Primary Herpses
Valtrex 1000 mg BID x 10 days

Acyclovir 400 mg TID x 10 days

supression 1000 mg q day
acyclovir 400 mg BID
suppressive therarpy HSV
36 weeks, Acyclovir 400 mg TID, or valtrex 1000 mg BID, increase dose because of increase GFR in pregnancy
Hypoestrogenic have
normal to low FSH
Idopathic Hirsutism vs Virilization
Testostereone
DHEA
Lymphogranuloma venereum (LGV)
Lymphogranuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3 (194). The most common clinical manifestation of LGV among heterosexuals is tender inguinal and/or femoral lymphadenopathy that is typically unilateral. A self-limited genital ulcer or papule sometimes occurs at the site of inoculation.


LGV is an invasive, systemic infection, and if it is not treated early, LGV proctocolitis can lead to chronic, colorectal fistulas and strictures. Genital and colorectal LGV lesions can also develop secondary bacterial infection or can be coinfected with other sexually and nonsexually transmitted pathogens.

Diagnosis is based on clinical suspicion, epidemiologic information, and the exclusion of other etiologies for proctocolitis, inguinal lymphadenopathy, or genital or rectal ulcers. C. trachomatis testing also should be conducted, if available.
Genital and lymph node specimens (i.e., lesion swab or bubo aspirate)
Doxycycline 100 mg orally twice a day for 21
daysErythromycin base 500 mg orally four times a day for 21 days

Chlamydia serology (complement fixation titers >1:64) can support the diagnosis of LGV
Granuloma Inguinale (Donovanosis)
Granuloma inguinale is a genital ulcerative disease caused by the intracellular gram-negative bacterium Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis). The disease occurs rarely in the United States, although it is endemic in some tropical and developing areas, including India; Papua, New Guinea; the Caribbean; central Australia; and southern Africa

Azithromycin 1 g orally once per week for at least 3 weeks and until all lesions have completely healed
OR
Ciprofloxacin 750 mg orally twice a day for at least 3 weeks and until all lesions have completely healed
OR
Erythromycin base 500 mg orally four times a day for at least 3 weeks and until all lesions have completely healed
OR
Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally twice a

Doxycycline 100 mg orally twice a day for at least 3 weeks and until all lesions have completely healed
Clinically, the disease is commonly characterized as painless, slowly progressive ulcerative lesions on the genitals or perineum without regional lymphadenopathy; subcutaneous granulomas (pseudoboboes) might also occur. The lesions are highly vascular (i.e., beefy red appearance) and bleed easily on contact
The causative organism is difficult to culture, and diagnosis requires visualization of dark-staining Donovan bodies on tissue crush preparation or biopsy

beefy red inguinal lesions
In addition, the painless genital ulcers can be mistaken for syphilis.[3] The ulcers ultimately progress to destruction of internal and external tissue, with extensive leakage of mucus and blood from the highly vascular lesions. The destructive nature of donovanosis also increases the risk of superinfection by other pathogenic microbes.
Small, painless nodules appear after about 10–40 days of the contact with the bacteria. Later the nodules burst, creating open, fleshy, oozing lesions. The infection spreads, mutilating the infected tissue. The infection will continue to destroy the tissue until treated. The lesions occur at the region of contact typically found on the shaft of the penis, the labia, or the perineum. Rarely, the vaginal wall or cervix is the site of the lesion. At least one case in India led to partial auto-amputation of the penis. The patient tested positive for HIV-2 and had been infected for six years

The diagnosis is based on the patient's sexual history and on physical examination revealing a painless, "beefy-red ulcer" with a characteristic rolled edge of granulation tissue. In contrast to syphilitic ulcers, inguinal lymphadenopathy is generally absent. Tissue biopsy and Wright-Giemsa stain is used to aid in the diagnosis. The presence of Donovan bodies in the tissue sample confirms donovanosis. Donovan bodies are rod-shaped, oval organisms that can be seen in the cytoplasm of mononuclear phagocytes or histiocytes in tissue samples from patients with granuloma inguinale.
They appear deep purple when stained with Wright's stain. These intracellular inclusions are the encapsulated gram-negative rods of the causative organisms. They were discovered by Charles Donovan.
Bechets Disease
rare immune-mediated small-vessel systemic vasculitis[2] that often presents with mucous membrane ulceration and ocular problems. Behçet's disease (BD) was named in 1937 after the Turkish dermatologist Hulusi Behçet, who first described the triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis

Visual acuity, or color vision loss with concurrent mucocutaneous lesions and/or systemic Behçet's symptoms should raise suspicion of optic nerve involvement
1 mg/kg/d oral prednisone)
PCOS
Rotterdam[
present if any 2 out of 3 criteria are met
1.oligoovulation and/or an ovulation
2.excess androgen activity
3.polycystic ovaries (by gynecologic ultrasound)

12 or more follicles on an ovary 2-9 mm

FSH/ LH ratio in IU 3:1 or 2:1 when measured on day 3 of the cycle

DHEAS
17 Hydroxyprogesterone r/o non classical adrenal hyperplasia

24 hour urine cortisol (to rule out cushiness)
Testosterone r/o ovarian tumor
Lipid Panel
75 gram OGTT
Prolactin
TSH
EStradiol
PCOS
In PCOS, there is a so-called "follicular arrest", i.e., several follicles develop to a size of 5–7 mm, but not further. No single follicle reaches the preovulatory size (16 mm or more). According to the Rotterdam criteria, 12 or more small follicles should be seen in an ovary on ultrasound examination. The follicles may be oriented in the periphery, giving the appearance of a 'string of pearls'

Laparoscopic examination may reveal a thickened, smooth, pearl-white outer surface of the ovary.

There are often low levels of sex hormone binding globulin
Serum (blood) levels of androgens (male hormones), including androstenedione and testosterone may be elevated. Dehydroepiandrosterone sulfate levels above 700-800 µg/dL are highly suggestive of adrenal dysfunction because DHEA-S is made exclusively by the adrenal glands. The free testosterone level is thought to be the best measure, with ~60% of PCOS patients demonstrating supranormal levels. The Free androgen index (FAI) of the ratio of testosterone to sex hormone-binding globulin (SHBG) is high and is meant to be a predictor of free testosterone, but is a poor parameter for this and is no better than testosterone alone as a marker for PCOS, possibly because FAI is correlated with the degree of obesity
Insulin-like growth factor-I – Serum IGF-I concentrations are elevated in virtually all patients with untreated acromegaly and provide excellent discrimination from normal individuals.

IGF-1
We suggest measuring serum IGF-I levels in all girls with hyperandrogenism, but particularly in those who undergo acral overgrowth or who have symptoms suggestive of a pituitary tumor. The oral estrogen of OCPs lowers IGF-I levels.
Thyroid function tests – Normal serum TSH is ordinarily adequate to rule out thyroid dysfunction. Estrogen raises total serum T4 by elevating thyroxine binding globulin levels, but low-dose OCPs do not generally cause falsely abnormal results for these tests.
Labs
Serum cortisol – A mid-day cortisol concentration of <10 mcg/dL, provides evidence against endogenous Cushing's syndrome, but normal individuals may have levels twice this high in early morning

Early-morning 17-hydroxyprogesterone – An 8 AM 17-hydroxyprogesterone (17-OHP) it wanes rapidly thereafter due to the diurnal variation of adrenal steroid secretion.

It is important to obtain the sample during the early follicular phase of the menstrual cycle or while the patient is anovulatory, because 17-OHP rises during the preovulatory and luteal phases of the cycle. Under these conditions, in patients not taking oral contraceptives, a 17-OHP value of >170 to 200 ng/dL ( is suggestive of nonclassical CAH and is also compatible with the rare virilizing tumor. Confirm with ACTH test

TSH

Prolactin

17-OH Progesterone level- done in early follicular phase at 0800

serum cortisol mid day

total and free testosterone are best assessed in the early morning, on days 4 through 10 of the menstrual cycle , need to be off OCPs

total testosterone > 60 ng/dl abnomal
Androgens and PCOS
TESTING FOR ANDROGEN EXCESS — The key androgen to measure is serum testosterone. However, there are many pitfalls in testosterone assays at the low levels found in women, and reliable testosterone assays are not available to many physicians. Serum total and free testosterone are best assessed in the early morning, on days 4 through 10 of the menstrual cycle in regularly cycling women; norms are standardized for this part of the menstrual cycle. Oral contraceptive pills interfere with the assessment of androgens. They suppress gonadotropins, elevate sex hormone binding globulin (SHBG), and directly inhibit steroidogenic enzymes such as 3ß-hydroxysteroid dehydrogenase (3ß-HSD). They normalize androgens in polycystic ovary syndrome (PCOS) and also have been reported to normalize androgens in some virilizing tumors. After discontinuing oral contraceptive pills, normal women may transiently have a slightly high total testosterone level but a normal free testosterone level because SHBG turnover is slower than testosterone turnover.

Total testosterone – The automated assays that are used to measure total testosterone in most laboratories are not suitable to accurately measure levels in females. The interpretation of the laboratory results is further complicated by systematic differences between assays and excessively broad normal ranges derived from populations of apparently normal women with unrecognized androgen excess. The normal upper limit for serum total testosterone in women is approximately 60 ng/dL (2.0 nmol/L) with the new generation of liquid chromatography mass spectrometry methods.
Free testosterone – An elevation in serum (or plasma) free testosterone is the single most sensitive test to establish the presence of hyperandrogenemia. The serum free testosterone concentration is about 50 percent more sensitive for the detection of hyperandrogenemia than the total testosterone concentration. This is because elevated insulin levels (a frequent concomitant of PCOS) and elevated androgen levels both act to inhibit hepatic production of sex hormone-binding globulin (SHBG), which is the main determinant of the bioactive portion of serum testosterone, the fraction that is free or "bioavailable," the latter including the fraction that is loosely bound to albumin.

Despite these advantages, assaying the free testosterone level introduces other potential sources of error because of systematic differences between assays. Direct assays of the free testosterone concentration are inaccurate and should be avoided. The best methods calculate free testosterone as the product of the total testosterone and a function of SHBG: free testosterone = total testosterone x percent free testosterone, where percent free testosterone is most commonly determined by dialysis or calculated from the SHBG concentration. The combination of a high-normal total testosterone and a low-normal SHBG yields a high free testosterone concentration. The most accurate androgen determinations come from specialty laboratories using established, validated assays in well-characterized control women.

Dehydroepiandrosterone sulfate (DHEAS) – DHEAS is a marker for adrenal hyperandrogenism. Measurement is not necessary in the initial evaluation of PCOS in most girls. The major utility of measuring DHEAS levels is to rapidly identify an unusual virilizing adrenal disorder, such as cortisone reductase deficiency , or an adrenal tumor.

Girls with a virilizing tumor usually present with a rapid onset of virilizing features, and DHEAS levels are often markedly elevated (>700 mcg/dL, 13.6 mmol/L) if the tumor is of adrenal origin. However, a substantial minority of tumors are indolent in onset and mimic PCOS in presentation.

Oral contraceptive pills have equivocal effects on the DHEAS level.
Recommended tests — If a reliable method for measuring serum free (or bioavailable) testosterone is available to the practitioner and cost is not an issue, this test is the preferred choice for initial testing rather than measurement of total testosterone.

If a free testosterone test in a reliable specialty laboratory is not readily available, it is reasonable to begin the evaluation with a total testosterone determination. Most patients with PCOS have serum testosterone concentrations below 150 ng/dL (5.2 nmol/L). A total testosterone >200 ng/dL (6.9 nmol/L) increases the likelihood of a virilizing neoplasm. Patients who have clinical features consistent with PCOS but have an initial normal testosterone should have repeat testing, preferably an early morning serum free testosterone level in a reliable specialty laboratory along with determination of SHBG. It may be helpful to consult with a specialist at this point
21 hydroxylase deficiency in adult onset CAH measure
17 hydroxy progesteorne
Treatment of PCOS
1. Exercise and weight loss
2. OCPs- Yaz 20 mcg/3 mg drospirenone) or Orhtochyclen (20 mcg/ .25 mg of norgestimate)
3. Metformin
4. Spironolactone
5. 5 alpha reductase inhibtor- Finasterine teratongenic

6. Cyproterone- postent progestin and antiandrogen

7. Vaniqa (eflornithine hydrochloride cream 13.9%) is a topical drug that inhibits hair growth. It is not a depilatory and must be used indefinitely to prevent regrowth.



drosperinone 3 mg = 25 mg of spirnonolactone
Least androgenic progesterones
Norgestimate (eg, Ortho-Cyclen or Tri-Cyclen) and desogestrel (eg, Desogen or Ortho-Cept) appear to be the least androgenic
ortho cyclen
0.25 mg norgestimate
35 mcg of EE
Yaz
3 mg of drospirenone and 20 mcg of ethinyl estradiol
24/4

Yasmin 21/7 3 mg DRSP and 0.03 mg ethinyl estradiol
Seasonale vs Seasonique
(levonorgestrel/ethinyl estradiol tablets) of 84/7 0.15 mg of levonorgestrel, 30 mcg of ethinyl estradiol,


Seasonique (levonorgestrel, ethinyl estradiol) (levonorgestrel/ethinyl estradiol tablets and ethinyl estradiol tablets) is an extended-cycle oral contraceptive consisting of 84 light blue-green tablets each containing 0.15 mg of levonorgestrel, a synthetic progestogen and 0.03 mg of ethinyl estradiol, and 7 yellow tablets containing 0.01 mg of ethinyl estradiol.
Allesse
21 /7 0.10 mg of levonorgestrel, 20 mcg of ethinyl estradiol,
Clomid
SERM
estrogen agonist and antagonist properites

in hypothalamus estrogen levels are perceived as low causing increased GnRH release
increased FHS and LH release which stimulates follicle development

side effects- hot flashes, mood swings, headaches, if associated with visual disturbances should /dc due to reports of optic neuropathy, pelvic discomfort , decreased cervical mucus, thin endometrium
Treatment of Mom with Hyperthyroidism
frist trimester - PTU

2nd and 3rd trimester- Methimazole

aim for slightly hyperthyroidism
Osteoporosis
Increases bone density, weight bearing and exercise


Bone density 65
If risk factors- caucasion, previous fracture, <127, tobacco, etoh

Paak bone mass age 19- bone health during adelsesnce is important






67 yo present s for an annual exam

what tests should be ordered for this patient
may or may not need a pap
mammogram
bone density
lipid panel, TSH, -
Colonoscopy

Screening for bone density screen at age 65 if risk factors screen earlier

Previous scrapture, smoker, immuno compromised, <127 lbs, family history, alcohol,

Tscore- osteoporsis <2.5

Frax score- risk of osteopotoic fracture.20 perecnt, or hip fracture.3%

Calculate a frax- go online enter the date online tool.

Hysterectomy 5 years for cervical dysplasia
Needs a pap and needs it for 20 years

For the past 2 years she has had a new sexual partern should she have a pap
Having a new pap is not an indication for a pap


Workup for hyperthyroidism





Bone Density at 65 unless risk factors-
Steroid use, osteoporosis, smoking, alcohol, family history, gnrh, aromatase inhibitors,-

Frac scoring- 2 reasons
To see if earlier screening
10 year any risk of fracture 9.3% or greater (this is what the score in the exam)

T score

Osteopenia- lifestyle changes,
10 year of hip fracture 3% and 10% year risk of any fracture of 20%- means osteopenia has frac of 20%

Alendronate 70 mg once a weight- emty, osteonecrosis of jaw more IV and Chemotherapy

Calcitonin

Concominant
Paratyhroid Hormone
Vitain D
24 hr calciu urine-
TSH and FT4
Telopeptides


• CLINICAL RISK FACTOR ASSESSMENT
• Advanced age
• Personal history of fracture as an adult
• Glucocorticoid therapy
• History of fragility fracture in a first-degree relative
• Low body weight
• Cigarette smoking
• Excessive alcohol consumption
• Medical diseases
• Other risk factors
• - Possible risk factors
Bone turnover markers (BTMs)






Bisphosphonates inhibit the digestion of bone by encouraging osteoclasts to undergo apoptosis, or cell death, thereby slowing bone loss



When order bone scans
65 or older

or risk factors

T score- compares a patient to a 32 year

Compares a person to same age, ethnicity

Osteopoenia -1.0

Osteoporosis -2.5

Initiate less than -2.5
Calcuate frax score-

Bisphosonates

Gerds
Osteonecrosis of the jaws
Path frcture of the jaw

Weight bearing exercise
Calcium and vitamin d

Check TSH every 5 years for thyroid


Osteoporosis
Dexta scan- if frac score same as 65 fear old
Steroids, heparin, family history,

Initate treatment age 65- T score 2.5
Ostepenia 1.5 if risk fracture on

10 year risk of fracture

fosamax 70 mg weekly-
contraindications to fosamax

selective estrogen receptor modulator raloxifene- venous thrombolism, hot flashes,

dose of raloxifene- jaw fracture
mechanism of action

next dexta scan in 2 years
800 IU vitain D, 1300 mg calcium

vitamin goes up 800 at 71, 600 for everone else

1300 mg teen age because that bone mass, then 1000,
when stop medications

osteonecrosis therapy- radiation therapy, dental work ,

if repeat scan stable in 2 years when do you repeat if worse then would get
if stable on treatment no new risk factors then

contracindications- renal failure,"", inability to sit up

drug free holiday after 5-10 years



thyroid function, hypoparathyroidis

17 yo 1200 mg

peak bone mass- late teans

FRAX has been most widely used as an aid in decision making regarding treatment initiation when the patient’s BMD score is in the low bone mass (osteopenia) range

Treatment should be considered when there is a 3% risk of hip fracture or a 20% risk of a major osteoporotic fracture (defined as a fracture of the forearm, hip, shoulder, or clinical spine) or both in the next 10 years. It is important to note that FRAX is valid with or without the incorporation of the femoral neck BMD score.

Caucasian females and males found that final peak bone mass occurred around 19 years in women

Hip femoral neck, lubar spine

The fracture risk assessment tool is valid for women older than 40 years, and the National Osteo-porosis Foundation recommends it be used in women who are postmenopausal, are not receiving osteoporosis treatment, have a T-score indicating low bone mass, and have no prior hip or vertebral fracture. Another limitation is the use of categorical variables where the effect is known to be related to the degree of exposure (eg, alcohol intake, corticosteroid use, smoking, and number of prior fractures).

The fracture risk assessment tool is not considered valid for women who are taking prescription drugs for osteoporosis


First Tier
Complete blood count
Metabolic profile
24-Hour urinary calcium level
25-Hydroxyvitamin D level
Thyroid stimulating hormone le

Second Tier
Celiac panel
Serum protein electrophoresis


Bisphosphnonates
1. Alendronate (Fosamax)
2. Risedronate (onthly
3. Ibandronate Boniva (monthly)
4. Zoledronate (REclast) 5 mg every 2 year IV for prention, 5 mg once a year for treament

Raloxifene_ SERM

Salmon Calcitonin- reduces vertebral fractures, use 5 years post menopause, Calcitonin is a peptide composed of 32 amino acids that binds to osteoclasts and inhibits bone resorption Calcitonins from many species are effective in humans, but salmon calcitonin is the one most widely used. It is highly potent in humans because of its high affinity (40 times that of human calcitonin) for the human calcitonin receptor and its slow rate of clearance The only other calcitonin used clinically is human calcitonin, which is less potent but also less antigenic than salmon calcitonin. Most clinical trials of calcitonin have used salmon calcitonin, but human calcitonin is as effective

Really only use for bone pain from osteoporotic
Menopausal Symptoms
Works for Hot Flahses

Estrogen- standard, low, ultra low
Combined estrogen/progesterone
Progestin- Depoprovera
SSRI, SNRI
Paxil 7.5 mg q day
Clonidine 0.1 mg q day
Gabapentin 600-900 mg q day
Tibolone 2.5 mg /day
Stellate Ganglion block

Treatment of Menopausal Vaginal Symptoms
1. Ospemifene 60 mg q day- SERM
2. Vaginal Lubricants
3. Vaginal Moistureizers
4. Vaginal estrogen

Stop hormones age 65

Black Cohash may help but can get liver failure


Don’t need progesterone with vaginal estrogen
SERM approved for vaginal dyspareunia
Ospemifene 60 mg q day- SERM
Uteral Sacral Vaginal Vault Suspension
At vaginal angle gram anterior pelvic fascia
don't go into vagina
then posterior grab the endopelvic fascia
then get middle part of the uteral sacral ligament
go through it twice

use 0 ethibond, hold the first not
Close the Enterocele
1. Mcall Culdoplasty- uteral sacral plication- 20 silk or ethibond- grab posterior peritneum and ligament an plicate them together

2.Moschcowitz culdoplasty

3. Halban - vertical closure long acting monofilament sutures anterior rectal wall to posterior wall of vagina
Doderlein proceudre
Doderlein procedure — Another method for vaginal hysterectomy is the Doderlein vaginal hysterectomy . Using this method, an incision is made in the vaginal epithelium at the junction of the bladder and anterior cervix. The pubovesicocervical fascia is dissected from the lower uterine segment and the anterior cul-de-sac is entered. The cervix is pushed posteriorly and the uterine fundus is delivered through the anterior cul-de-sac. The hysterectomy is then begun much in the same manner that one would proceed with an abdominal procedure.
Contraception and Breast Cancer
Copper IUD, Condoms, Diaphram


Mirena may have higher rates of reoccurrence
Obesity and Contraception
increasing BMI has increased failure rate with contraception.

Also increased VTE with Obesity

progestones would be better- IUD, Depo Provera, Minipill
How do IUDs work
act both pre and post fertilization
inhibition of sperm
altered tube motility
ovum destruction

plus mirena endometrial suppression and altered cervical mucus
What is low dose OCP and ultra low OCP
0.02mg of estrogen (usually ethinyl estradiol) are classed as ‘ultra low dose’ contraceptive pills. 0.02mg of estrogen is sufficient for contraception but the side effects of spotting and breakthrough bleeding are more common with these types of ultra low dose birth control pills than with low dose pills containing 0.030mg or 0.035mg of estrogen.
HTN and OCPs
okay if you nor personal family history of CVA low dose combination okay

Older >35, poor HTN smokers, close family CVA combined OCPs should not be used

progestin only methods pose no significant risks in patients with HTN
OCPs and DM
hormonal OCPS have o effect on glucose metabolis

older progesterones did antagonize insulin,

younger women with well controlled DM and no vascular disease OCPs okay

IF > 35 with vascular disease, or poor control OCPs should be avoided

watch Latinas and Navajos
SLE and OCPs
combination OCPs is safe in women with mild to moderate lupus disease who do not have

1. Anitphospholipid antibody
2. Vascular disease
3. Nephritis

Progestin only and contraceptives are safe in these patients

25% of patients who conceive with lupus choose to terminate their pregnancy
Vaccines for 18 yo
Gardicil
TDAP
Hepatitis B and A
MMR
Meningococcal
When can d/c paps
age 65-70 if no history of abnormal cytology in past 1- years, and if three annual screenings have been negative
Mammograms start
biannual age 40
annual age 50
BRCA testing in
1. Women with a personal history of breast and ovarian cancer

2. Women with ovarian cancer and a first or second degree relative with either ovarian cancer or premenopausal breast cancer

3. Women with ovarian cancer who are ashkenazi jewish

4. women with breast cancer at or before age 40 and are ashkenazi jewish

5. women with breast cancer at or over age 50 and a first or second degree relative with ovarian or male breast cancer

6. Women who have a first degree relative who has been identified as carrying the BRCA 1 or 2 mutation
Prepubertal vulvovaginal pruritis differential
inflammation/infection
trauma or foreign body
urologic pathology
genital tract neoplasm
Treatment of Labial adhesions
2-6 weeks of topical estrogen followed by gentle separation of the thinned adhesions in the office with a topical anesthetic

use of emollient such as petroleum will aid in preventing recurrent adhesions

surgical separation should not be required unless there is a history of prior surgical separation
Patient safety in a surgical enviornment
The care team review in the presence of the patient

1. the intended procedure
2. the intended procedure site
3. any implants or grafts to be employed
4. documents and pertinent studies are all present

mark site prior to anesthesia

Time out
1. correct patient/ID
2. correct operative site
3. implants or grafts to be employed
Common errors when writing a prescription
legibility of the order

missing components dosage, strength, time

improper use of decimals and of trailing zeros

use of non standard abbreviations,

improper use of PRN orders

similar trade names of medications or sound alike names

errors in verbal medication order transfer
What do combination OCPs do to cholesterol
estrogen component
decreases LDL
increases HDL
moderated increase in TG

progestin component has an opposite and unfavorable effect on lipid profile

women with controlled dyslipidemias or cholesterol <160 can be on 35 mcg or lower

in these women choice of a lower progestin pill or a less androgenic pill will improve the effect on lipid panel

monthly monitor of lipids first few months

If LDL >1600 look at other methods

women with controlled dyslipidemia but with other risk factors HTN, DM, tobacco use, obesity or family history of early onset CAD look at other methods
5 comments of Metabolic Panel
1. Resting BP >130/85
2. Waist circumference >35 inches (thinks smokers OCPs)
3. Elevated Fasting Glc >100 mg/dl
4. HDL <50 mg/dl
5. Elevated TG >150 mg/dl
depo lupron
amenorrhea in most patients
improved hematocrit
myoma size reduction 50% in 3 months

cannot treat for >12 months due to osteoporosis

FDA approval only fro preop improve HCT
UAE
can decrease the amount of bleeding, and pains
reduciton in mass is not constantly demonstrated

because no histology can't rule out malignancy
not recommended in menopause
What is a normal CA-125 level
normal value is less than 35 U /ml.
Name types of transfusions reactions
Occur in 20% of cases

1. Simple Febrile Reaction- antibody reaction against the donor leukocytes in the product. self limited mange by antipyretics

but can be similar to hemolytic reaction-fever, headache, myalgias, tachyardia, dyspena, chest pain

2. Allergic Reaction occur in 1%, of transfusions, urticaria during the transfusions in the absence of other symptoms. Allergy is due to plasma proteins in the product, Antihistamines, and complete the reaction

3. Anaphylactic reaction- bornchospasm, wheezing, or collapse, IM or SC Epi 1:1000 0.3 to 0.5 cc

4. Hemolytic reaction- recipients antibodies induce hemolysis of donor RBCs in the product. Occurs in 1 to 4 per one million transfusions, mortality is high, massive RBC destruction and DIC

symptoms fever, headache, myalgias, pain in back and at transfusion site, signs of coagulopathy and cardiopulmonary compromise

treament
1. Immediate cessation of transfusion
2. support renal fucntion with IV hydration, mannitol and furosemide
3. Labs- Renal, Liver, Chemistries, coagulation profile
4. DIC managed with FFP, possibly steroids and heparin
5. Donor blood and a blood sample from recipient is sent stat to blood bank for identification of hemolytic reaction and of ABO incompatibility
Differential Diagnosis of a cyst
phsyiologic ovarian cyst
benign neoplasm
malignant neoplas
endometrioma
abscess collection
fallopian tube
peritoneal or congenital remnant cyst (paratubal cyst)
Work up of Cyst
pelvic exam and rectal exam

exclude pregnancy

Ultrasound characterization
Maligant signs on a cyst
septations or complex internal architecture
irregularity of the internal cyst wall or modularity
bilateral cyst
doppler flow assessment
complex internal archicterure
solid masses
any elevation of tumor markers
Cyst less than _____ cm diameter is not neoplastic 95% of the time
5 cm
Cysts what size do you take out
take out > 10 cm

5-10 watch for 6-8 weeks if not resolved generally can take out

surgical management is undertaken for any enlargement of a cyst in a menopausal women
In menopausal patients neoplastic masses are benign > ______ of the time
over 80% of the time
Differential diagnosis with adnexal mass and vaginal bleeding
early IUP with implantation bleed

threatened SAB, incomplete SAB, completed SAB

multiple gestation involving SAB of one twin
ectopic
molar pregnancy
heterotopic

Labs
HCG quant
rH and blood type
Pelvic and transvaginal U/S
Ectopics tend to intramural or intraluminal
intramural- because they implant in the time
there is always some degree of postoperative scarring and potential for tubal occlusion

salpingostomy does carry a risk of future ectopic pregnancy
Methotrexate can use
no contraindications

desires future fertility

able to follow up

HCG is less than 15K

adnexal mass is less than 3.5 cm
No fetal cardiac activity

No
blood dyscrasias
No liver disease
No peptic ulcer
No renal insuffiency
No chronic pulmonary disease
BMI
weight in Kg over Height in M2
Ectopic change from laparoscopic to laparotomy if
active bleeding prevents ID of bleeding site
cornual ectopic pregnancy

hemodynamically unstable

severe adenxal disease
Cornual Pregnancy
conrual or intersitial
1% of ectopics

cornual excision is generally successful

preop consent possible hysterctomy
usually laparotomy

salpingostomy
hysteroscopic and lparoscopic
normal CA 125
0-35 U/ml
In a post-menopausal woman with a palpable adnexal mass and CA-125 level greater than 65 U/mL, the positive predictive value is >95% for ovarian malignanc
Cervical Pregnancy
if cervical pregnancy is suspected, bimanual examination is avoided until imaging studies have excluded the diagnosis. If bimanual examination is performed, the endocervical canal should not be explored as this is likely to cause hemorrhage. A prominent finding on bimanual examination of cervical pregnancy is a soft cervix that is disproportionately enlarged compared to the uterus; this has been called "an hour-glass" shaped uterus. By comparison, enlargement of the uterus without significant cervical enlargement is characteristic of intrauterine pregnancy, although the cervix softens and becomes mildly congested.

edically using multidose methotrexate (MTX) therapy with intraamniotic and/or intrafetal injection of local potassium chloride (KCL) (eg, intracardiac injection of about 5 mEq potassium chloride) when fetal cardiac activity is present
Dilation and evacuation is a conservative surgical option. The main complication is a high incidence of severe hemorrhage, which can be reduced by preoperative measures such as transvaginal ligation of the cervical branches of the uterine arteries, Shirodkar cerclage, angiographic uterine artery embolization, or intracervical vasopressin injection. The latter is given by injecting 20 to 30 mL of vasopressin (0.5 U/mL) solution with a 1.5-inch 21 gauge needle circumferentially deep into the dense cervical stroma. Transvaginal ligation of the cervicovaginal branches of the uterine artery can be performed, as well. This is done by deviating the cervix to one side and placing a suture at 3 and 9 o'clock on the lateral side of the cervix. The suture is placed high just below the lateral vaginal fornix, similar to sutures placed for hemostasis during cold knife conization. We use 2-0 polyglactin (Vicryl) [3,9]. However, our preference is preoperative angiographic uterine artery embolization
If postoperative implantation site bleeding occurs, it can often be controlled by placing a size 26 Foley catheter with a 30 mL balloon into the dilated cervix, with the tip extending into the uterine cavity. Sterile water (as much as 95 mL) is used to inflate the balloon and tamponade the bleeding vessels for 24 to 48 hours. A purse string suture can be placed around the external cervical os and tied after inflation of the balloon to prevent expulsion. After 24 to 48 hours, the balloon is gradually deflated over a period of hours to days and removed, but may be reinflated at any time if bleeding picks up or recurs. The catheter also allows constant uterine drainage.

Gelfoam provides temporary obstruction (two to six weeks) of the feeding blood vessels [6,19] and allows for development of collateral blood flow [32]. Because collateral flow begins to develop within hours of the procedure, surgical evacuation should be performed soon after embolization to achieve the full benefit of the procedure. The optimal interval between uterine artery embolization and surgical evacuation has not been established, intervals of several hours to 24 hours have been described
Novasure
Novasure at leat 4 cm length and 2.5 cm wide
perform in early follicular phase
up to 12 cm
7.5-8 mm dilate up to
bipolar radiofrequency
by measuring the distance

uterine perforation
bleeding
hematometra- Intrauterine scarring is an expected result of endometrial ablation. When areas of endometrium are adherent and there is endometrial bleeding behind the occlusion, hematometra will occur
cervical stenosis
uterine cavity occlusion
Postablation tubal sterilization syndrome
Pelvic infection




between the internal and external cervical os. In most of the patients,
cervical dilation is associated with a resistance during the passage of the
distal tip of the Hegar dilator through the internal cervical os. As soon
as this resistance is felt, advancement of the dilator should be stopped
and a finger should be placed at the point of contact between the external
cervical os and Hegar dilator. Hegar dilator is then withdrawn and the
length from its tip to the noted location on the shaft of the dilator is
measured. The cavity length
Postablation tubal sterilization syndrome
Some women who have undergone tubal ligation prior to endometrial ablation experience cyclic or intermittent pelvic pain. The proposed etiologies of this are: (1) bleeding from active endometrium that is trapped in the uterine cornua and/or (2) uterine contracture and intrauterine scarring. The incidence of this complication is as high as 10 percent in some reports [84]. Prevention, diagnosis, and management of these symptoms are the same as for other presentations of hematometra. In addition, some surgeons assess women with these symptoms laparoscopically and excise the tubal stumps to prevent the distension of the proximal tubal segments during menses.

The diagnosis of PATTS is initially suspected clinically in patients with cyclic cramping with or without menses with a history of endometrial ablation and tubal sterilization. Ultrasound has not been reliably sensitive at diagnosing PATSS. The confirmatory diagnosis is made surgically
Reasons for Endometrial Ablation
The basic preoperative criteria for any patient opting for endometrial ablation are, at a minimum, the following:

Abnormal uterine bleeding of benign etiology (as evidenced by preoperative endometrial sampling and histologically benign findings)
No desire for future fertility
Desire to retain the uterus or to avoid hysterectom
Absolute contraindications for endometrial ablation
include the following:

Pregnancy or a desire for future pregnancy

Active urogenital or pelvic infection (eg, cystitis,

vaginitis, cervicitis, endometritis, salpingitis, pelvic inflammatory disease [PID], or tubo-ovarian abscess [TOA])

Suspected or documented premalignant or malignant

conditions of the endometrium or uterus
Additional contraindications may include the following:

Recent uterine infection
A cavity that exceeds the device’s functional length and uterine diameter
Hydrosalpinx
History of classical cesarean section
History of a transmural myomectomy
Uterine anomalies
What percentage go onto have a hysterectomy after uterine ablation
20-30%
Thermalchoice
37% amennorrhea
81% normal menses

4-12 cm cavity
35 cc of fluid in balloon
Novasure amennoreha and
36% amennoreha

76% normal menses
Anesthesia
I use a dilute solution of 0.5% lidocaine with 1/200,000 epinephrine. This allows a larger volume of anesthetic to be used in a given dose. Epinephrine also prolongs the anesthetic effect, reduces the amount of systemic absorption, and facilitates transfer of the anesthetic agent into the nerve fiber by increasing local pH. Epinephrine’s effect is predictable, with a transient (40- to 60-second) period of palpitation that quickly disappears. For those patients for whom epinephrine is considered too risky, I’d suggest an alternative anesthesia or anesthetic environment.
I administer the agent via a 22-gauge spinal needle. I place the needle on the anterior exocervical epithelium and ask the patient to cough. This pushes the cervix against the needle, allowing it to penetrate to the point that the bevel is just below the epithelial surface. I inject 1 to 3 mL of the agent at about the 12 and 6 o’clock positions.
I grasp the posterior cervix with a single-toothed tenaculum and retract it anteriorly, a technique that aids in identifying the attachment of the uterosacral ligaments. Repeating the cough technique, I inject a small amount of anesthetic agent into the vaginal epithelium at the junction with the cervix; then I advance the needle to a depth of 4 to 5 mm, aiming to position the tip on the medial aspect of the ligament but not so deep that it is in the peritoneal cavity. Taking care to aspirate before injecting, I place approximately 5 to 8 mL of anesthetic solution in each side. I remove the tenaculum from the posterior cervix and reattach it at about the 12 o’clock position. Exerting a slight amount of traction, I inject about 4 to 6 mL of the lidocaine-epinephrine solution in each side of the cervix at about the 4 to 5 o’clock position on the patient’s left side, and 7 to 8 o’clock on the right, to a depth of 3 to 5 cm, aiming to deposit the bulk of the solution in the region of the lower uterine segment and upper cervix. Care must be taken to aspirate to minimize the risk of inadvertent systemic administration.
After the anesthetic is injected, I push a conical-tipped syringe filled with 2% lidocaine gel against the exocervix and inject approximately 5 to 10 mL of the gel into the endometrial cavity. I remove the syringe and place 2 to 3 cotton-tipped applicators soaked in 4% liposomal lidocaine cream in the cervical canal, from the internal to the level of the external os. I then let the patient rest for 10 to 20 minutes before starting the procedure.
Slings
bleeding- from vginal artery and inferior vesicle artery, both supplying the area of the vesicle neck and the urethra.

if perf the bladder the tape is withdrawn and the procedure terminated
Larsen
Sacrospinous Ligament Suspension of the Vagina

O nylon

midurethral retropubic sling
Vesicovaginal Fistula
bladder mucosa is identified and closed with interrupted 4-0 synthetic absorbable suture. An attempt should be made to keep the suture in the submucosal layer

A second layer, the bladder muscle, is closed with interrupted 2-0 synthetic absorbable suture. vicryl
seek an external blood supply for the fistula site. This can be the bulbocavernosus muscle from beneath the labia majora, or in cases where a large fistula exists or where the fistula is high in the vaginal canal, the gracilis muscle from the leg or the rectus abdominis muscle can be brought in to cover the fistula site. or gracilis muscle from leg

It is sutured to the perivesical tissue with interrupted 3-0 synthetic absorbable sutures

vaginal mucosa must be mobilized for closure without tension. Generally, the wound is closed with interrupted 0 synthetic absorbable suture.

4-2-0 and then 3
Bowel prep
Mefoxin

clear liquids 48 hrs before
mag citrate or golytley
Rectovaginal fistula
interrupted sutures 30 vicryl


low anterior resection
interrupted sutures without tension
2 layers
omental pedicle sewed in
Urinary retention after a sling
normal scar contraction can cause over tightening

diagnose by urethroscopy

redirection of the sling site and division of side adjacent to the urethra
Cystotomy
Bladder Mucosa in 2 laters
bladder submucosa
muscularis layer



foley left in for 5 days or 24 hrs
Ureteroneocystotomy
implant as lose to the bladder base

2 sutures 40 vicryl plased on each side of the end of the ureter then placed through the submucosa and muscularis of the bladder

reinforce with suture reapproxiation of the bladder muscularis over the lowr ureter

Ureterual stent left in for 10-14 days

IVP perform at the time and again in 8-12 weeks
Veres needle
he angle of Veress needle insertion should vary accordingly from 45 degrees in non-obese women to 90 degrees in very obese women

aspirate

pressure below 10

hanging drop test
Palmers point
left side, a 2-mm transverse skin incision was made 3 cm below the left costal margin on the midclavicular line.

2 FB below costal margin


OG tube must me inserted to deflate the stomach

verress needle perpendicular be perpendicular at this point
don't put trendelenbur until trochars are in
4 days post op what is differential diagnosis
incomplete closure of vaginal apex with peritoneal fluid drainage

physliologic leukorrhea

vesico vaginal fistula

uretero vaginal fistula (uroma)

rectovaginal fistula
Dual Tampon test
tampon in vagina- bladder is filled with methylene blue
dye on the tampon indicates vesico vaginal fistula

if no dye on the tampon the bladder is drained and a second tampon is placed and IV indigo carmine is administered- if blue then uretero-vaginal fistula
Management of vesico vaginal fistula-
foley placed in bladder for 4-6 weeks
small fistula may heal

if continues to drain fix at 12 weeks

repair of fistula

excise the fistula tract with fresh tissue margins

bladder submucosa with 30 Vicryl

bladder muscularis with 20 or 30 suture

closure of vaginal mucosa with similar suture
Signs of fistula
passage of flatus from the vagina

chronic vaginal drainage at weeks to months following operation

passage of stool per vaginum

persistent pain or irritation in the introital or low posterior vaginal area after delivery
Diagnosis of rectal vaginal fistula
assessment of integrity of anal sphincter by exam and ultrasound

salin in the vaginal vault, air is then insufflated into the rectum and the appearance of bubbles in the vaginal vault identifies the fistula site
Closure fo rectal vaginal fistula
all inflammation must be allowed to subside
sometimes requiring 12 weeks delay in repair

tissue cleanliness with sits baths

complete excision of the tract with 2 cm margin
Gyrus Halo spread

watts
2-3 mm

35 watts
Post op Ileus
anorexa, nausea,
abdominal distension
decrease in bowel activity
24-72 hours after surgery

Abd xray- gas distension of bowel loops

management- NPO, IV fluids, amabulations
SBO
recurrent emesis often bilious

xray- air fluid levels in the bowel,
stair step pattern
NG tube decompression

passage of cantor tube for mechanical relief of obstruction
Hysteroscopy
NS (only true isoolmoar irritant) no hyponatremia, but intravascular fluid overload and third spacing
Fluid overload with hysteroscopy
instillation into a vein

uterine perforation

trans fallopian drainage of fluid
Fluids used with hysteroscopy
sorbitol 2-3%

glycine solution (no longer used because of hyper ammonia
Complications of Hysteroscopy
uterine perforation

bleeding from intracavatary operative site

thermal injury to extra uterine structures with or without uterine perforation

air embolism

intrasvascular fluid overload hyseroscopic irrigant solution
Hysteroscopy complication
assess vital sign , pulse ox
listen to lungs

Hgb and BMP

lasix 20-40 mg IV

foley cath

conisder chest xray or EKG
Hystersocpy
assess fluid/ balance deficit every 3-5 minutes
limit operating time to 45 minutes

at fluid deficit of 1000 cc stop and assess Na and Hgb

Give Lasix 20 mg IV at 1000 cc

Na levels below 120 mg/dl carry high risk of hyponatremic seizure and are managed with 3% NaCL slowly only at 20-25% of volume estimated water deficit to maxim of 150 cc
Don't use nova sure with
very small uterine cavities

menopausal women due to atrophic and thinner walled nature of the uterus

Uteri with a known or suspected congenital anomaly

irregular uterine cavity- submucous or intracavitary myoma

large uterine cavities

any situation where the integrity of the endometrial cavity is in doubt

if shuts down, may need to do hysteroscopic assessment of the endometrial cavity
Differential diagnosis fo fever and abdominal pain
PID
TOA
Septic Abortion
ectopic pregnancy
appy
pyelonephritis
perforation of viscus older
chole
pancreatitis
pneumonia with diaphragmatic inflammation
small bowel obstruction
Inpateint treatment of PID
pregnancy

acute peritoneal signs

other surgical emergency

failure of outpatient management

no response to oral therapy

patient inability to comply
work up menorrhagia
thyroid
bleeding disorder
anovulation
adneomyosis
endometrial hyperplasia
cervical lesion malignancy
Management of Fibroids alternative to hysterecotomy
NSAIDs
OCPs
GnRH agonists
Aromatase inhibitor
Antiprogestins- Mifepristone
Uterine artery embolization
MRI guided ultrasound
Myomectomy- abdominal, lapaoscpic, hysteroscopic
Fever abdominal pain
acute abdomen goes to surgery
triple antibiotics
copious irrigation, deibriedment
placement of drains

closure of fascia with delayed absorbable suture like polydioxanone retains strength for 12 weeks

close only the fascia

dont close the subcutaneous space
Aromastase inhibitors
block both ovarian and peripheral estrogen production

can be used to manage fibroids

vasomotor symptoms, vaginal dryness, decrease in bone mineral density, and increase in fracture risk

adverse affect on cholesterol /lipid profile
Complications of UAE
fever from degeneration of myoma
infarction of myoma
bacterial seeding into the myoma bed or vessel with myometritis

uterine perforation by the catheter, inraperitoneal bleeding, peritonitis, or injury to a viscus

bacteremia from the arterial puncture site

bleeding or hematoma at the arteriotomy site

myometrial necrosis

perforation of the uterine artery by catheter with intaperitonneal bleeding , peritonitis, injury to a viscus

bleeding or hematoma at the arteriotomy site

myometrial necrosis

perforation of the uterine artery by catheter with intraperitoneal bleeding or broad ligament or retroperitoneal

perforation of uterus with potential for bowel injury
3 ways to place a drain by interventional radiology
1. percutaneous through the lower back
2. transgluteal
3. transrectal
Size greater than dates
incorrect gestation dating
multi fetal pregnancy
uterine fibroids
larged adnexal mass
molar preganncy
Gestational Trophoblastic Disease
Partial mole GTN seen in 3-8 % of cases

Complete Mole 8-20% of cases

Labs- CMP, CBC, HCG
Chest XRAY or CT, CT- Abd and Pelvis
MRI or CT with contrast of brain

be sure to exclude possiblitlity of New intrauterine pregnancy with ultrasound

treatment based on if non metastatic GTN confined to uterus, Metastatic with good prognosis, Metastatic with poor prognosis
Gestational Trophoblastic Disease

what are poor prognostics
metastatic with poor prognosis

pretherapy HCG > 40, K

long duration >4 months from antecedent pregnancy

antecedent pregnancy was a term pregnancy

brain or live mets

prior chemo
treatment of Nonmetastatic GTN
Hysterectomy if child bearing completed (requires less chemo)

Methotrexate IM weekly (dose vary) until at least 2 negative weekly HCG titers
Low Risk Metastatic GTN
Hysterectomy is again optional to decrease duration of chemo

single agent again treatment with MTX (IM weekly) until at least 2 negative weekly HCG titers
High risk Metastatic GTN
EMA/CO Etoposide/MTX & Folate/Dactinomycin

cyclophosphamide/vincristine

surgical excision or embolization of liver or brain mets when necessary

biopsy of lesions suspicious for GTN vaginal mets is not necessary
How does Methotrexate work
acts by blocking the dihydrofolate redeuctase enzyme and blocking purine synthesis for DNA. Is S phase dependent
Contraindications to Methotrexate
Renal insufficiency - MTX undergoes renal cleared

previous reaction to methotrexate

preexisting immune or marrow suppression

acitve peptic ulcer disease

COPD

possibility of an intrauterine pregnancy
Preop diabetic
hold routine insulin
intraoperative sliding scale or by baseline infusion at 1 unit/hr

Ideal management fasting glc < 120
Pulmonary Function Tests which are concerning

FEV-1
FVC
PO2
FEV-1- (forced expiratory volume in 1 second) < 1 liter

FVC forced vital capacity <70% of predicted

PO2 < 60 mmg hg should preclude general anesthesia
Doing Leep
inject at 4 and 8 of the cervical vaginal junction corresponding to uteral sacral nerves as they travel in the uteral sacral ligaments
Local C/S under anesthesia
Infiltration anaesthesia for Caesarean Section
Michael Cooper
Indications:
Local anaesthetic infiltration for caesarean section (CS) is a rarely used technique. It has application in the rare situation where both general and regional anaesthesia is contraindicated and in countries with limited health resources. There are few contemporary reports of this technique (1, 2) and most descriptions come from countries (3, 4) where:
1. anaesthetic expertise is lacking, or limited,
2. anaesthetic equipment or gas supplies are unavailable, or
3. a single individual is required to both operate and anaesthetise.
Local anaesthetic infiltration has also been used in rare situations such as:
1. Myotonic dystrophy where it has been used in conjunction with spinal anaesthesia for CS with bupivacaine applied directly to the myometrium to relieve incoordinate cycles of uterine spasm / atony (5)
2. Familial dysautonomia (Riley-Day syndrome) (1)
Advantages of local anaesthetic infiltration:
1. Allows for immediate commencement of surgery in emergency situations.
2. Useable when central neural blockade (CNB) is technically difficult,
eg. kyphoscoliosis (2) , unpredictable in result or contraindicated.
3. Retains the patient's protective airway reflexes.
4. Avoids the sudden haemodynamic changes that may occur with CNB.
Technique:
A long (18 cm) spinal needle minimises the number of individual injections required.
Skin:
The skin of the anterior abdominal wall is supplied by the anterior and lateral cutaneous branches of the lower six intercostal nerves and the iliohypogastric and ilioinguinal nerves. For a transverse suprapubic (Pfannensteil) incision simple subcutaneous infiltration is adequate.
Fat:
The fat layer is relatively devoid of innervation and a large amount of local anaesthetic may be wasted by infiltrating this layer, which is relevant to the often large total dose used.
Fascia:
Direct infiltration can be used; other authors have recommended bilateral rectus sheath blocks (6, 7).
Retropubic space:
This can be a difficult area to anaesthetise and may require additional infiltration retropubically and into the pyramidales muscles.
Parietal peritoneum:
Many authors report this to be a difficult area to anaesthetise and several techniques have been described.
1. The injection of several mls of solution through the fascia (before its division) helps to separate the layers and to anaesthetise the parietal peritoneum.
2. Once the peritoneum is opened, the instillation of 10-15ml of local anaesthetic into the peritoneal cavity.
3. Once the peritoneum is opened, radiate intraperitoneal injections.
Visceral peritoneum / uterus:
These do not need infiltration, but doing so separates the visceral layer of the peritoneum from the lower uterine segment.
Some authors (7, 8) have described field block anaesthetic techniques for vertical classical skin incisions which involve multiple injections and increased discomfort for the patient. They may take longer and require greater skill and use a greater volume of local anaesthetic than simple direct infiltration. These papers, which described the authors personal experiences in the 1950s and 60s cite local anaesthesia as giving better neonatal outcomes than general anaesthesia for CS.

Macintosh (9) warns of the risk of rectus sheath block in a patient with abdominal distension (from whatever cause). As the anterior and posterior layers of the sheath are almost in apposition, the needle may pass through both structures giving the false impression that only the anterior layer has been penetrated.

Drugs, vasoconstrictor and volume:
Many different agents have been used depending on the availability of the drug and the familiarity of the operator with the agent.

Bearing in mind the maximum recommended doses of local anaesthetic agents (Table 36.3), the volume required may be as high as 100ml. Not all of this may be required initially, and further infiltration may be necessary after delivery to close the superficial layers.

Obviously, local anaesthetic toxicity (Chapter 89) to mother and fetus is a significant risk. This should influence the choice of agent in terms of :
1. The concentration which is required for effective infiltration anaesthesia.
2. The decision to add a vasoconstrictor in order to increase the amount of drug that can be used with safety.
3. The toxicity and metabolism profile of the local anaesthetic.
4. The fetal / maternal ratio of the local anaesthetic. Substantial uptake of lignocaine in the fetal liver can occur (10). Ester local anaesthetics such as 2-chloroprocaine have a half-life in neonatal blood of 43 secs (11). Fetal acidosis favours drug ionisation, retention of local anaesthetic within the fetus and increased risk of fetal toxicity.

Choice of agent:
Lignocaine 0.5% or chloroprocaine 1% with 1:200,000 adrenaline is adequate for infiltration anaesthesia and both agents are rapid in onset. The addition of adrenaline allows for the use of a greater overall dose. Longer acting agents such as bupivacaine have a slower onset time and a lower free drug concentration in the fetal blood (12). The addition of hyaluronidase has been described (8) but may increase absorption.

Surgical technique:
Gentle tissue handling is required and retractors are generally not well tolerated. If adequate retropubic anaesthesia has been obtained, a Doyen retractor can be used. Adequate exposure of the uterus can be obtained by using corner stitches to rotate the uterus (4). Manoeuvres that can cause significant pain are:
1. Disengagement of the fetal head from the pelvis.
2. Peritoneal traction (may also cause vagal effects).
3. Externalisation of the uterus.
Blood loss is not increased using this technique (4).
In their series of 141 caesarean sections, Ranney and Stannage (7) reported 61 patients having a second, 14 a third and 2 a fourth operation. Only three patients wanted to have general anaesthesia for their repeat procedure.
Lidocaine dose
7 mg/kg with epi of 1% lidocaine

4.5 mg/kg without epi of 1% lidocaine

10 mg/ml

use 0.5 %

60 cc without epi
100 cc with epi