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253 Cards in this Set

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Refer for Mammography at age
35/40
MOST COMMON BREAST PROBLEMS
breast pain (mastalgia), nipple discharge,
palpable mass
breast pain (mastalgia), nipple discharge, palpable mass
BREAST PAIN
______pain is usually bilateral & poorly localized; usually resolves spontaneously
Cyclic
________ pain is usually a sharp, burning localized pain
May be secondary to an underlying fibroadenoma or cyst
Non cyclic
Nipple discharge
_________--spontaneous, bloody, often associated with a mass-usually unilateral & confined to one duct. Most common cause is intraductal papilloma.
_________—discharge only with compression, multiple duct involvement
Pathologic

Physiologic
T/F : All spontaneous or unilateral nipple discharge should be referred for surgical exam
TRUE
In premenopausal women normal glandular tissue is __________
nodular
Differential diagnosis of a dominant breast mass:
macrocyst, fibroadenoma, fibrocystic changes, fat necrosis, & cancer
second most common type of cancer in women worldwide. A causal link exists with HPV.
CERVICAL CANCER
Pap Smear is recommended at least every ________years age _________
3 years

20-65
_____________ covers the cervix

___________is beyond this junction into the os
Squamous epithelium

Columnar epithelium
_____________(transformation zone) is where the pap is taken
Squamocolumnar junction
_____________________
Specimen Type
Specimen Adequacy
General Categorization
Automated Review
Ancillary Testing
Interpretation/Result
Educational Notes & Suggestions
Bethesda Reporting System
HPV VACCINE
~ ___________
Protects against types _______(cause most genital warts)
Protects against types ______ (causes 70% of cervical dysplasia)
GuardAsil (Merck)


6, 11

16,18
Management of the Abnormal Pap Smear
__________—repeat in a timely fashion
__________—repeat annually or every 3 years
___________—repeat in a timely fashion
___________—treat &/or discuss with patient
___________—repeat in 4-6 months
UNSATISFACTORY
NEGATIVE
NO ENDOCERVICAL CELLS
ORGANISMS PRESENT
ASC-US (atypical squamous cells of undetermined significance
Management of Abnormal Pap Smears (cont)
___________—repeat in 4-6months or refer
____________, ________, __________—refer
Other Malignant Neoplasms (an abnormal formation of tissue that serves no useful function & grows at the expense of the healthy organism, may be benign or malignant)--refer
Low-grade squamous intraepithelial lesion) LGSIL
HG (High grade) SIL
Squamous Cell Carcinoma
Glandular Atypia
Pap smears that suggest invasive disease require further evaluation by:
colposcopy, biopsy, endocervical curettage, cryotherapy laser vaporization, loop excision, cone biopsy, hysterectomy
age (75% menopausal-late 60s)
obesity (especially upper body type)
PCOD
Unopposed exogenous estrogen
Diabetes
Personal or family history of ovarian or breast cancer
Nulliparity
Late Menopause (after age 52)
Uterine Cancer
Risk Factors
Directly related to the amount of estrogen stimulation & endometrial hyperplasia
UTERINE CANCER
Postmenopausal bleeding is ____________until proven otherwise
endometrial cancer
any nonmenstrual or intermenstrual bleeding
METRORRHAGIA
Diagnostic Evaluation for Endometrial Cancer
Endometrial Biopsy
__________(allows for more extensive sampling)
___________(endometrial thickness <6mm, usually not associated with cancer)
___________(useful in staging)
Pap Smear may be detected as “endometrial cells”
_________—most common type is hormone sensitive, low stage, with excellent prognosis
D&C
Transvaginal Uterine Sonography
Hysteroscopy with directed biopsy
Type 1
________STAGING IS USED FOR ENDOMETRIAL CANCER
FIGO
Risk factors-unopposed estrogen stimulation (anovulatory cycles, infertility, infertility drugs, nulliparity, low parity, exposure to toxins/carcinogens (dietary fat, perineal talc use, asbestos exposure)
Heredity (breast, ovarian, Lynch II Syndrome-familial predisposition to breast, endometrial, colon, prostate, ovarian cancers)
OVARIAN CANCER
Ovarian Cancer (cont)
Etiology-unknown

Classification based on type-

a) _____________(>90%; increases with age)
b) _____________ (most common in children/young adults)
c) _______________(rare-usually occur in postmenopausal women)
epithelial cell tumors
germ cell tumors
sex cord-stromal tumors
Abdominal bloating
Dyspepsia
Frequent urination
Pelvic pressure or pain
Constipation
Pelvic mass
Abdominal distention
Pleural effusion
Ascites
Adenopathy
Cachexia
CLINICAL PRESENTATION OF OVARIAN CANCER
OVARIAN CANCER STAGES:
I
II
III
IV
Stage I: Ovarian cancer that is confined to one or both ovaries.
Stage II: Ovarian cancer that has spread to pelvic organs (e.g., uterus, fallopian tubes), but has not spread to abdominal organs.
Stage III: Ovarian cancer that has spread to abdominal organs (e.g., abdominal lymph nodes, liver, bowel).
Stage IV: Ovarian cancer that has spread outside to distant sites (e.g., lung, brain, lymph nodes in the neck).
T/F: IF OVARIAN CANCER METASTASIZES, THE CLASSIFICATION NEEDS TO CHANGE ACCORDINGLY
FALSE-Once ovarian cancer is assigned a stage, the classification does not change, even if the cancer recurs or metastasizes to other sites within the body.
Ovarian cancer staging usually is described in terms of the _______ system (staging scheme developed by the International Federation of Gynecology and Obstetrics) and the ______system (classification system developed by the American Joint Committee on Cancer
FIGO
TNM
TX FOR OVARIAN CANCER:
EARLY STAGE:

ADVANCED STAGE:
Early Stage: Surgery--Five year survival rate >90%
Advanced Stage: Chemotherapy, autologous bone marrow transplantation, hormonal therapy Five year survival rate 30-40%
the bleeding manifestations of anovulatory cycles
DYSFUNCTIONAL UTERINE BLEEDING
a thickened endometrium causes by perimenopause, puberty, PCOS, obesity, unopposed estrogen replacement therapy
CAUSES OF DUB
estrogen low relative to progesterone; results in a thinned endometrium (low estrogen pills < 30 mcg, POP, Depo-Provera, Norplant, Mirena IUS)
PATTERNS OF DUB
orthostatic BP changes, > heart rate, pallor, large amount of blood in vaginal vault, uterus may be enlarged due to retained clots
ACUTE DUB
stable heart rate & BP, body habitus (obesity, stigmata of PCOS), pale or normal skin color, small amount or no blood in vaginal vault, uterus WNL
CHRONIC DUB
scanty or infrequent menstrual flow
Oligomenorrhea
_________________
Any pregnancy in which 2 or more embryos exist simultaneously
Higher perinatal morbidity and mortality than singleton gestations
_______________
Cleavage of one fertilized egg at various stages
___________
More than one egg
Multifetal Pregnancy

Monozygotic twins

Dizygotic
This is a twin placenta. Note the two umbilical cords.
•There is no membrane dividing the two umbilical cords which is indicative of a monoamniotic placenta.
•Note the entanglement of the umbilical cords.
Monochorionic-Monoamniotic Twin Placenta
Maternal Complications
Exaggerated maternal physiologic response to pregnancy
_____increase in blood volume
Hypertension
___________-uterine stretch theory
Increased Fe and Folic Acid requirements
May predispose to anemia
Increased weight and size of uterus
Respiratory difficulty d/t greater elevation of diaphragm
Compression of ______,_______, obstructive uropathy, renal failure
Postpartum uterine atony and hemorrhage
500ml

Premature Labor

great vessels, ureters
Hydramnios
Malpresentation
Placenta Previa
Placental Abruption
Premature rupture of membranes
Umbilical cord prolapse
IUGR
Congenital anomalies
Increased perinatal morbidity/mortality
TTTS
Fetal Complications
ANTEPARTUM HEMORRHAGE
-UK ETIOLOGY
-PLACENTAL:
-CERVICAL:
-VAGINAL:
-UTERINE:
-BOWEL OR BLADDER BLEEDING:
**Placental
Previa
Abruption
Vasa Previa
**Cervical
Carcinoma
Erosion
Polyp
**Vaginal
Varicose veins
Lacerations
**Uterine
Fibromyomata
**Bowel or bladder bleeding
ANTEPARTUM HEMORRHAGE
Sterile speculum exam to rule out ________
Digital cervical exam after ruling out ___________
Labs
CBC-compare to previous
_______________
Most Important
Also check for placental abruption/clots
vaginal or cervical cause

placental previa

Ultrasound exam for placental location
<37 WEEKS

>37 WEEKS
Expectant Management if <37 weeks
Delivery usually if >37 weeks
3 most common causes of maternal death
Hemorrhage
Infection
Hypertensive Disease
Failure of the uterus to contract after placental separation called _________
-Cause of 75 to 80% postpartum hemorrhages
-Leads to excessive placental site bleeding
Management
IV infusion of dilute _______
If bleeding continues,_______
___________ 0.2mg IM
uterine atony

oxytocin

Ergonovine maleate

Methylergonovine
Occurs during delivery
2nd most common cause of pp hemorrhage
Genital tract trauma
Uterine Inversion
“Turning inside out” of uterus in _______ of labor

Retained Placental Tissue
Placenta usually separates near “__________” with uterine contractions after delivery of fetus
3rd stage

Nitabuch’s Layer
_____________
Rare syndrome of unknown etiology
Hemolytic anemia, fluctuating neurological signs, renal dysfunction, fever
Usually fatal

Rare, 80% mortality
Fulminating consumption coagulopathy
Intense bronchospasm
Vasomotor collapse
Triggered by intravascular infusion of significant amount of amniotic fluid
Occurs during rapid labor

Platelets with abnormal function and/or shortened life span
Causes thrombocytopenia and bleeding tendency
IgG antiplatelet antibodies may cross placenta and result in fetal thrombocytopenia also

Inherited coagulopathy characterized by prolonged bleeding time
Factor VIII deficiency
Pregnancy elevates Factor VIII levels, as levels fall following delivery, patients susceptible to immediate hemorrhage as Factor VIII levels fall
Thrombotic Thrombocytopenia

Amniotic Fluid Embolus


ITP

VWD
Fetal Head
-Vaginal delivery necessitates accommodation of the fetal head by the bony pelvis of the mother
-_________the least compressible part of baby
-_________at birth are thin, weakly ossified, easily compressible
-Interconnected by membranes
-Overlap under pressure and change shape to conform to the maternal pelvis-________
Occipital Bone
2 Parietal Bones bilaterally
2 Temporal Bones anteriorly
Fetal head

Cranial bones

molding
Sutures
Membrane occupied spaces between cranial bones
_________
Between the parietal bones
_________
Separates occipital bone from parietal bones
_________
Separates parietal and frontal bones
_________
Between frontal bones
Sagittal Suture
Lambdoid Suture
Coronal Suture
Frontal Suture
___________Membrane filled spaces located at the point where sutures intersect
_________________
Larger, diamond shaped, 2x3 cm
Located at intersection of sagittal, frontal, and coronal sutures
Closes/ossifies at 18 months
Allows skull to accommodate tremendous growth of infant’s brain after birth
_________________
Y shaped, smaller
Located at junction of sagittal and lambdoidal sutures
Closes at 6-8 weeks of life
fontanelles

anterior

posterior
Maternal Pelvis: 4 Shapes
___________
Classic female
50% of women
Most easily accommodates fetal head-most spacious
_________
Classic male
30% of women
Limited space at all levels
_________
Anthropoid ape
20% of women
___________
Flattened gynecoid pelvis
3% of women
Curved throughout
Gynecoid
Android
Anthropoid
Platypelloid
Pelvic Inlet
Plane of Greatest Diameter
Anterior-posterior and Transverse
Plane of Least Diameter
Mid plane
Pelvic Outlet
4 pelvic planes
Progressive cervical effacement and/or dilatation from regular uterine contractions
labor
Primagravida-2 or more weeks before labor
Multigravida-occurs in early labor
Noticed as flattening of upper abdomen, increased prominence of lower abdomen
Bladder compression and increased frequency of urination
lightening
Preparatory Events Before Labor: False Labor
____________________
Irregular, usually painless uterine contractions
During last 4-8 weeks
In last month, more frequent, q 10-20min
Unpredictable, sporatic, rhythmic, mild
NOT associated with progressive cervical dilatation or effacement
Serves physiologic role of preparing uterus and cervix for true labor
Sometimes hard to distinguish from true preterm labor
Braxton Hicks Contractions
Preparatory Events Before Labor:_________________
Cervix firm and rubbery prior to labor
Cervical softening prior to delivery due to increased H2O and collagen lysis
Effacement: Thinning of cervix
Occurs as cervix taken up into the lower uterine segment
Mucous plug released as a result of effacement
Often indicates onset of labor
Bloody Show
Cervical Effacement
From onset of true labor to complete dilatation of cervix

From complete dilatation of cervix to birth

From birth of baby to delivery of placenta

From delivery of placenta to approximately 6 hours after
4 stages of labor:

1st

2nd

3rd

4th
Second Stage of Labor
Urge to bear down
Duration 30 minutes to 3 hours
__________: Visualization of head at vulva
Station
Progress of presenting part through birth canal
Cephalic presentation
Head shape changes
________-alteration of relationship of fetal cranial bones to each other as a result of compressive forces exerted by maternal body pelvis
______________
More pronounced molding
_________
Localized edematous swelling of scalp by pressure of cervix
Crowning

Molding

Cephalopelvic Disproportion (CPD)

Caput
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion
Mechanisms of Labor
Perineal Lacerations
With or without episiotomy
1st degree laceration
Involves :
2nd degree laceration
Involves :
3rd degree laceration
Involves :
4th degree laceration
Involves :
vaginal mucosa/skin

submucosal layer of vagina or perineum

anal sphincter

rectal mucosa
Period following delivery of baby and placenta to 6 weeks pp

red, 1st few days following delivery

paler, 3-4 days after delivery

yellow, white, 10 days after delivery
Puerperium

lochia rubra

lochia serosa

lochia alba
Regional Anesthesia
Local infiltration for episiotomy
_________-active labor
Spinal-immediately before delivery
________-perineal anesthesia, before delivery
_________
Anesthetize nerves of uterus, T10-L1
Inject lateral to cervix on each side
________-on delivery table, S2-S4
Inject near ishial spines
Epidural

Caudal

Paracervical

Pudendal
_______________
Narcotics
Demerol (meperidine)
Stadol (butorphanol)
Sedatives/Tranquilizers
Phenergan (promethazine)
____________
Nitrous oxide
Penthrane
Ethrane
Systemic Medications

Inhalation analgesia
to use vacuum extractor, fetus MUST be ___________ presentation
VERTEX
________ is more informative than Apgar Score
cord pH sampling
the baby’s “lifeline.”
Shiny Schultz vs Dirty Duncan presentation
Often sent to pathology after delivery for examination and testing
Placenta
Eccentric insertion of umbilical cord
Inserts usually at edge like “badminton” racquet
No clinical significance:
Battledore Placenta
Blood vessels course unprotected for long distances through the membranes to insert into the margins of the placenta
Blood vessels may pass over cervical os or other position where they may be compressed by fetus or ruptured with rupture of membranes
Vessels insert and separate while still in the membranes and not on the placenta. Can lead to hemorrhage and tearing
May be life threatening:
Velamentous Insertion
Large central circular depression on fetal surface of placenta surrounded by an elevated ridge
Amnion and chorion fold back on themselves, forming a double layer of fetal membranes
Increased incidence of early Ab and bleeding in late pregnancy
Circumvallate Placenta
Implantation of part or all of the placenta in the lower uterine segment
Associated with increased perinatal and maternal mortality
Placenta Previa
Placenta Previa
Tends to be associated with:
Fetal anomalies
Twin Gestation
History of _________
Advanced __________
Previous C/S
Grand multiparity due to change in size and contour of uterine cavity
________ causes by separation of the placenta as the lower uterine segment thins and lengthens during late pregnancy
Blood maternal in origin
multiple uterine curretages

maternal age

Bleeding
Painless bright red vaginal bleeding in 3rd trimester-sometimes earlier
Uterus non tender and non irritable
AVOID digital cervical exam until U/S
Placenta Previa Symptoms
_____________________
Correct apparent or potential shock
IV, Type and Match, H & H
Prior to term, prolongation of pregnancy desired-expectant mgt
If term, abdominal delivery, C/S
Assess for placenta accreta-common
Rh isoimmunization
Post partal blood loss due to diminished contractile ability of lower uterine segment
Placenta Previa Management
Placenta ____________
Placenta attaches too deep in uterine wall but does not penetrate uterine muscle
Chorionic villi in contact with myometrium
Placenta __________
Penetrates uterine muscle
Chorionic villi invade myometrium
Placenta ___________
Attaches through uterine wall to another organ
Chorionic villi invade serosa
Accreta

Increta

Percreta
______________
Partial or complete detachment of placenta from normal site of implantation on uterine wall
Complete or marginal
Increased perinatal and maternal morbidity
Classification of the degree of separation based upon percentage of maternal surface covered with adherent clot
Placental Abruption
Placental Abruption Etiology
Uncertain and speculative
Trauma-MVA
Most spontaneous and nontraumatic
_____tension
_______ umbilical cord
Uterine anomaly or tumor
Drugs-________
Hyper

Short

cocaine
Abruption:
As it evolves, blood coagulates and dissects or separates the placenta from the uterus
Blood infiltrates myometrium-_____________
________ abruption painful, no vaginal blood
________abruption, painless, +vaginal bleeding
Couvelaire uterus

Central

Marginal
Abruption Symptoms
________ Bleeding
_________Pain
Symptoms proportionate to degree of separation
Total blood loss may not be apparent-______________
Tachycardia, shock, hypertonic uterus, _________fundal height
Non reassuring FHR tracing
Vaginal

Uterine

retroplacental clot

increases
Abruption Management
Variable and depends on :

Priorities are _________ and safe and timely delivery
Assess FHT and UC patterns continuously
In absence of fetal distress-vaginal delivery
gestational age, fetal distress, cervical dilatation, hemodynamic status

replacement of lost blood
________
Occurs with velamentous insertion of the cord (vessels separate while still in the membranes.)
Presence of fetal blood vessels overlying cervical os
Bleeding from vasa previa from the fetus-exsanguination with very little blood loss
Immediate C/S usually
Vasa Previa
Refers to the process of physical changes by which a child’s body becomes an adult body, capable of reproduction
puberty
__________ overlaps puberty. It refers to psychosocial & cultural characteristics of development as well as the physical changes of puberty.
Adolescence
Breast Development
________ – (Tanner stage 2) First sign is usually a firm, tender lump under the center of the areola of one or both breasts (average __ years)

Swelling of the breast tissue extends beyond the edges of the __________ (Tanner stage 3)

Breasts approach mature size & shape (AKA ___________) (Tanner stage 4)

__________of mature breast (Tanner stage 5)
Thelarche
11

areolae

secondary mound forming

Contour
Pubic Hair
__________ – initially usually visible along the labia (Tanner stage 2)

________are to numerous to count & appear on the _______(Tanner stage 3)

___________ densely filled with hair (Tanner stage 4)

Pubic hair spreads to the _________hair towards the umbilicus (Tanner stage 5)
Pubarche

Hairs / Mons

Pubic Triangle

thighs & abdominal
Mucosal surface of the vagina changes in response to increasing levels of _________, becoming thicker & a duller pink in contrast to the brighter red of the prepubertal vaginal mucosa

_____________ – whitish secretions which are a normal effect of estrogen
Over the next 2 years the uterus & ovaries increase in size. The ovaries may contain small cysts visible by ________.
estrogen

Physiologic leukorrhea

ultrasound
Menstruation & Fertility
________is the first menstrual bleeding
Average age in the U.S. is ______years (usually 2 tears after thelarche)
Menses usually irregular & nonovulatory in the beginning
Within __years, most cycles are ovulatory
Menarche

12.7

2
In response to rising levels of estrogen, the lower half of the pelvis _______

_________increases to a greater % than with males (esp. breasts, hips, thighs). This produces the typical female shape.
widens

Fat tissue
Sequence of hair appearance:

Arm & leg hair increases over the next __years
Axillary hair, perianal hair, upper lip hair, preauricular hair, & periareolar

10
The estrogen-induced height growth spurt begins with ________

________grow first

Peak velocity ___ in/yr midway between thelarche & menarche
In the 2 years following menarche, growth slows to about 2 inches & involves the _______rather than the limbs
thelarche

Legs & feet

3-4 inches per year

spine
Rising levels of ________can change the fatty acid composition of perspiration, resulting in an adult body odor
__________changes precede thelarche & menarche by 1 or more years
Androgens also increase the secretion of oil (sebum) from the skin & increases susceptibility to _________
androgens

Body odor

acne
_______________ occurs in a PG Rh-negative patient carrying a Rh-positive fetus

Immune system of mom (Rh-) stimulated to produce IgG antibodies to Rh antigen

___________ then cross placenta and destroy fetal RBC’s
Rh isoimmunization

Antibodies
___ exposures to Rh antigen required to produce antibodies and sensitization

Antibody response called _______________
2

Rh sensitization
Most sensitization occurs at _________

With succeeding pregnancies, Anti Rh antibodies in mom’s system can cross placenta and destroy fetal RBC (________)
delivery

hemolysis
____________ test (maternal serum):
Detects fetal RBC’s in maternal circulation

Percutaneous Umbilical Blood Sampling (PUBS):
_________ to check for amount of bilirubin
Perform if fetomaternal hemorhage suspected
Kleinhauer Betke

Amniocentesis
__________ Test
Checks for antibodies attached to RBC
Performed on baby’s blood of Rh negative mom
Determines whether the mom has formed harmful antibodies and transferred them through the placenta to the fetus

____________ Test
Checks for antibodies circulating in baby’s system but not yet attached to RBC
Direct Coombs

Indirect Coombs
_______ 300mcg (anti Rh gamma globulin) given IM to Rh negative mother
At ___ weeks
Again within ___ hours of delivery

Remember: Rh incompatibility develops only when mother is Rh negative and infant is Rh postive
RhoGam

28

72
Pre Eclampsia - Pregnancy Induced Hypertension (PIH)

Triad of symptoms
_______ - 140/90 or
Increase of 30 systolic/15 diastolic mmHg
_______
__________

Seen at opposite ends of spectrum of
Maternal age—young, old
Gravidity—primigravida, grand multi gravida
Hypertension

Edema

Proteinuria
HELLP Syndrome-

Form of severe pre eclampsia
Hemolysis, Elevated Liver Enzymes, Low Platelets
Addition of grand mal seizures to pre eclampsia
eclampsia
Pre Eclampsia Management
Goal: _____________

Outpatient management if pressures stable and NO proteinuria
Bed rest in _________
position
Increases uteroplacental perfusion
Avoids vena cava syndrome

Inpatient
Induction of labor if >___ weeks or if failure to stabilize and improve regardless of gestational age
Prevent Eclampsia

left lateral

36
Antihypertensive Therapy:
IV __________
Oral Aldomet, Atenolol, Labetolol

Anticonvulsant Therapy:

_________ (Epsom Salt) IV or IM
______ (diazaepam) half life of 72 hours-Neonatal effects
Hydralazine

Magnesium Sulfate (MgSO4)

Valium
Pregnancy associated with increased tissue resistance to insulin

Glucose screen for gestational diabetes _______ weeks
Diabetes of Pregnancy

24-28
“White’s Classification of Diabetes in Pregnancy”

Class __ -Gestational DM, glucose intolerance developing during pregnancy, fasting blood glucose normal

Class ___ or __ -also abnormal fasting blood glucose

Approximately 60-70% of GDM patients will develop Type 2 DM
A

A/B or B
Polyhydramnios
Pre Eclampsia
Ketoacidosis and Diabetic Coma
Vascular End Organ Deterioration - Cardiac, Renal, Ophthalmic, Peripheral Vascular
Neurologic - Peripheral neuropathy, GI disturbance
GDM Maternal Complications
Congenital anomalies result from hyperglycemia during first 4-8 weeks of pregnancy
Macrosomia with traumatic delivery
Delayed organ maturity - amniocentesis for fetal lung maturity
Congenital Anomalies - CV, Neural tube defects (spina bifida)
IUGR
GDM Fetal Complications
Small for gestational age, birth weight below 10th percentile for given gestational age

Discrepancy between Uterine Size and Gestational Age, Size<Dates
Intrauterine Growth Restriction (IUGR)
etiology of IUGR:

_______-Poor nutrition, Tobacco, Drugs, Alcohol

________-Pre Eclampsia, HTN, Chronic Renal Disease,

_____-Intrauterine infections, congenital anomalies
Maternal

Placental

Fetal
IUGR Management:
Diagnosed by ________ exam

Modify any associated factors:
Nutrition, tobacco, alcohol

Non Stress Tests, Contraction Stress Tests

Delivery
ultrasound
Calf area, swelling and tenderness of involved extremity
On exam, erythema, tenderness, warmth, palpable cord over involved superficial veins
NOT life threatening and does NOT lead to PE
Pain meds, elevation, local application of heat
Superficial Thrombophlebitis
1 in 2000 ante partum, and 1 in 700 postpartum
Pain with dorsiflexion of foot-Homan’s Sign
Acute swelling and pain
Doppler ultrasound, anticoagulant therapy
Heparin-high molecular weight, does not cross placenta
Warfarin-low molecular weight, crosses placenta, teratogenic in early PG
Deep Venous Thrombosis (DVT)
1 in 2500 in pregnancy
DVT the instigating factor
Pulmonary Embolism (PE)
Increased GFR of PG causes increased excretion of iodine and reduced plasma iodine levels

Increased incidence of prematurity, IUGR, and higher neonatal morbidity and mortality, fetal anomalies, PTL

Cause: ______ Disease-usually remission during PG and exacerbation postpartally
Thyroid Disease

Graves
Major complication/risk
Precipitating factors include infection, labor, C/S, or noncomplicance with meds
Thyroid Storm
Occurs 3-6 months after delivery
Hyperthyroid state of 1-3 months followed by hypothyroidism
Sometimes misdiagnosed as depression
Recurrent Postpartum Thyroiditis
May adversely affect neuropsychological development of child
Check TSH level prenatally
Maternal hypothyroidism
Occur more frequently in PG due to a combination of hormonal and mechanical factors

Decreased ureteral tone and motility combined with compression of ureters at pelvic brim resulting in dilatation of upper ureter, renal pelvis, and bladder
UTI
___________ most frequent medical complication of UTIs necessitating hospitalization
Fever, chills and shaking, CVA or flank tenderness
Pyuria and bacteriuria

Treatment with antimicrobial agents
Ampicillin, cephalexin, nitrofurantoin, sulfisoxazole
Pyelonephritis
Cultured from vaginal canal in 5 -25% of pregnant women

If has + history, IV antibiotics in labor
Group B Strep (GBS)
Symptoms

Maternal:
Postpartum endometriosis in mother
Associated with premature rupture of membranes

Neonatal:
Early onset neonatal sepsis-within first day of life
Group B Strep (GBS) infection
TORCH
Toxoplasmosis - no litter box cleaning
Other (Syphillis)
Rubella
CMV
HSV - abdominal delivery
Seizure Meds - ________

Fetal hydantoin syndrome in 10% of exposed babies
30% may have isolated craniofacial anomalies, limb reduction deficits, mental retardation, CV anomalies
Dilantin
Seizure Meds - __________

Drug of choice in PG, risk low
True teratogenicity difficult to assess because usually taken in combination with other drugs
Phenobarbital
Seizure Meds - avoid _________

Congenital malformations in utero similar to dilantin


_________ deficiency a result of anticonvulsant therapy
Depakote (Valproic acid)

Folic acid
Cholestasis and pruritis without other major liver dysfunction
Tendency to recur with each pregnancy, hereditary deficiency aggravated by high estrogen levels of pregnancy
Associated with oral contraceptives
Benign course with no maternal hepatic sequelae
May be inherited as an autosomal dominant disorder
Intrahepatic/Idiopathic Cholestasis of Pregnancy
Main Sx of Cholestasis - __________, usually in 3rd trimester

_________ may be observed in late PG
Itching

Jaundice
Treatment
__________ binds to bile acids in gut
Supplement fat soluble vitamins (6)
Itching disappears within hours of delivery
Cholestyraine

A, D, E, K
Chronic hypertension with superimposed pre eclampsia

D/C _____ -Associated with fetal anomalies
ACE-I’s
Severe ________ associated with high spontaneous Ab rate, increased incidence of IUGR, and IUFD

Monitor closely during PG to assure adequate maternal and fetal assessment

Avoidance of dehydration, aggressive treatment of respiratory infections, allergen avoidance to prevent exacerbation of symptoms

Treatment similar to non pregnant
Goal to maintain maternal O2 >___mmHg to assure fetal oxygenation
asthma

80
Monthly up to 32 weeks
Every 2 weeks until 36 weeks
Weekly after 36 weeks until delivery
Prenatal Care Visits
Commonly Performed Labs:

_____________ between 24 and 28 weeks when insulin requirements are maximal

Serum __________at 16 to 20 weeks to predict open neural tube defect
Folic Acid and Avoid Hot Tubs

_________ fetal survey to detect gross anomalies, establish EDC +/- 2 weeks

___ skin test
Blood Glucose/OGTT

Alpha fetoprotein (AFP)

Ultrasound

TB
Other tests:

Cervical cultures for ____ and ____

Toxoplasmosis antibody test

HBsAg Titer

Sickle Cell Preparation or Hemoglobin Electrophoresis in all previously unscreened ____________ women

RhoGam at 26-28 weeks if Rh _________
GC and GBS

African American

negative
Gestational Age Assessment, Assure S=D
Fundal Height Measurement
From symphysis pubis to top of fundus

From __ weeks to term is equivalent to gestational age
S>D may indicate ____________
S<D may indicate _______
If discrepancy, perform US exam

20 weeks-fundus at umbilicus
22

multiple gestation

IUGR
Abdominal Exam At 28 weeks to identify:

__________-relationship of parts of fetus to each other
Normally complete flexion, fetus folded with convex back, arms crossed
If deflexed consider brow presentation, extended head

_____-relationship of long axis of fetus to long axis of mother
Longitudinal, Transverse, Oblique
Attitude

Lie
Abdominal Exam cont’d:

_________- Portion of fetus that descends through birth canal
When lie longitudinal, presenting part either cephalic (head) or breech
When lie is transverse, presenting part is shoulder usually

_________-relationship of some definite part of the fetus to maternal pelvis
Occiput in vertex presentations
Sacrum in breech presentations

_______________-determine fetal location
Each visit during the 3rd trimester
Presenting Part

Position

Leopold Maneuvers
Special Concerns:
_________ - Important in maintaining health and feeling of well being
Amount maintained at pre pregnant level

_______ - Frequent rest periods
Avoid exposure to teratogens

_______ - Not harmful during pregnancy, frequent stretch breaks

__________ - Avoid live virus vaccines

_____________ - May continue except in patients at risk for Ab or PTL

_________ - Avoid only if ROM suspected
Exercise

Work

Travel

Immunizations

Sexual Intercourse

Bathing
_________ Test:
Observe fetal heart rate in response to mom’s perception of fetal movement

Normal fetus responds to fetal movement with an acceleration in FHR of ____ beats or more per minute for at least 15 seconds.
Two such accelerations in ___ minute interval interpreted as healthy fetus
Reactive Test
Non Stress

15

20
Ultrasound:
Amniotic fluid -
___________ suggests fetal compromise and umbilical cord compression

Fetal Breathing and Fetal Movements -
Chest wall movement
___ breathing movements in 10 minutes or __ body movements in 10 minutes considered healthy
Oligohydramnios

30

3
Biophysical Profile:
fetal breathing movements
gross body movements
fetal tone
reactive non stress test
qualitative amniotic fluid volume

Score 2 or 0 on each criteria
____ Normal
____ Equivocal
____ Abnormal
8-10

6

<6
____________ test:
Assesses uteroplacental function

Dilute solution of IV _______ OR
Nipple Stimulation

Elicit __ contractions in 10 minutes
FHR response to contractions observed

Positive CST -
Non reassuring FHR response
Delivery
Contraction Stress

oxytocin

3
Withdraw amniotic fluid, around 15-20 weeks
Examine fluid for evidence of Rh sensitization, Down’s syndrome, other chromosomal abnormalities

Maternal Serum Alpha-Fetoprotein (AFP)
Elevated in women carrying fetus with ______________
perform at 16th to 18th week
Repeat if elevated, if remains elevated - ____
Amniocentesis

open neural tube defect

US
Ultrasonography - ID structural defects

__________ Abnormalities: Anencephaly, hydrocephaly, neural tube defect,
_____________ Abnormalities: Omphalocele, gastroschisis
______ Abnormalities: agenesis
________ Dysplasias
Congenital _______ Defects
Cranio spinal

Gastrointestinal

Renal

Skeletal

Heart
____________ Sampling -
Transabdominal or Transcervical-Ultrasound Guided
_______ weeks, earlier than amnio
Needle through abdomen or cervix into placenta

Chromosomal studies
Risk of spontaneous Ab, fetal injury, Rh immunization
chorionic villi

10-12
Age-women over ___ at increased risk
Down’s syndrome, other chromosomal abnormalities

Autosomal Recessive Disorders - __ recessive genes must be present
Tay Sachs, SSA, Thalassemia, Cystic Fibrosis

Autosomal Dominant Disorders - Only 1 abnormal gene necessary for disease manifestation
____ chance of passing gene and disorder to offspring
Neurofibromatosis, muscular dystrophy

_____ Linked Disorders - Fragile X MR, Duchenne’s MD
34

2

50%

Sex
Any agent or factor that can cause abnormalities of form or function in an exposed fetus
Dose & Timing - Most vulnerable period between ___ weeks, organogenesis

Drugs and Chemical Agents - alcohol (FAS), Thalidomide, Vitamin A in high doses, Tobacco

Infectious Agents - Viruses (Rubella), Bacteria, Parasites

Radiation
Teratogens

3-8
Sperm produced in the seminiferous tubules of the testes in a process called ____________

Seminiferous tubules contain many germinal epithelial cells called ____________

Type A Spermatagonia-Type B Spermatagonia-Primary Spermatocytes-Spermatids-Sperm (23 unpaired chromosomes)

Spermatogenesis takes ___ days
spermatogenesis

spermatogonia

74
After sperm are in the epididymis for 18 hours to 10 days, the develop capability of _________

Most sperm stored in the _________. Can remain there for several months depending on sexual activity
motility

vas deferens
____________ is the physiologic change sperm must undergo in the female reproductive tract prior to fertilization.

________ lies over sperm head as a kind of “chemical drill bit” designed to enable the sperm to burrow its way to the oocyte.
Overlying plasma membrane breaks down, releasing hyaluronidase-enzyme
Capacitation

Acrosome
_________ - union of sperm and ovum, fertilization restores the diploid number of chromosomes and determines sex
zygote
Fertilized ovum reaches endometrial cavity about __ days after ovulation, undergoes further development for 2 to 3 days before implanting. Implantation usually occurs on ___ day following
ovulation

Before implantation the zygote grows to a solid mass of over 100 cells called a ________
3

7th

morula
Shortly after implantation, a cavity develops in the mass of cells and the embryo begins to develop - _________ Stage

___________ then proliferates rapidly forming placenta and various membranes of pregnancy
Blastocyst

Trophoblast
Placenta: Transfer of substances occurs by
___________ (passive, random movement, concentration gradient)
_______________ (passive, concentration gradient, proteins act as carriers)
____________ (requires energy)

As placenta ages, permeability increases
Near term, begins to decrease again due to age
Simple diffusion

Facilitated diffusion

Active transport
Mean PO2 in maternal blood ___ mmHg
Mean PO2 in fetal blood ___ mmHg
PCO2 of fetal blood ___ mmHg higher than maternal
50

30

2-3
________ - facilitated diffusion, carrier molecules in trophoblast cell membrane

_________ diffuse more slowly than glucose, so
glucose preferentially used by fetus

Ketone Bodies, Potassium, Sodium, Chloride Ions diffuse from maternal to fetal circulation
Glucose

Fatty Acids
Most important function: causes corpus luteum to secrete estrogen and progesterone to maintain pregnancy

After about 7 weeks, placenta secretes enough E and P
Human Chorionic Gonadotropin Beta hCG
Increases to about 30 times normal by end of pregnancy
Largest quantity-________(usually small amount in nongravid female)
Cause enlargement of the ________
Cause enlargement of the breasts and growth of the breast ductal structure
Cause enlargement of the female external genitalia
Relax the ___________, symphysis pubis becomes elastic to ease passage of fetus through birth canal/maternal pelvis
estrogens

estriol

uterus

pelvic ligaments
Essential for pregnancy
Causes uterine endometrium to proliferate, creating environment conducive to implantation. Also provides nutrients to developing morula and blastocyst
Decreases contractility of the gravis uterus-prevents uterine contractions from causing __________
Helps prepare breasts for lactation
Progesterone

spontaneous Ab
Secreted around 5th week of pregnancy
Increased progressively through pregnancy in direct proportion to weight of ________
Promotes _________ development
Causes deposition of protein tissue similar to growth hormone
Actions on glucose and fat metabolism in the mother
Causes decreased ________ sensitivity and decreased glucose utilization by mom, thereby making larger quantities of glucose available to the fetus
Important for fetal growth
Human Placental Lactogen(hPL)

placenta

breast

insulin
Moderately increased throughout pregnancy
Possibly mobilize maternal amino acids for fetal tissue synthesis
Glucocorticoids
Specifically causes uterine contractions
Uterus more responsive near term
Increased quantities near onset of labor
Uterine stretching causes increased release
Oxytocin (Posterior Pituitary)
Biologically active lipids
Not true hormones, not synthesized in one gland and transported via circulating blood to a target organ. Synthesized at or near site of action
Synthesized in the endometrium and myometrium
Cause contraction of the uterus
Play role in ripening cervix, used for cervical ripening prior to labor induction or abortion
Prostaglandins
___________ stimulates absorption of sodium and secretion of potassium, maintaining Na K balance and protects against hypovolemia
PG women retain fluid
________ rises in pregnancy due to high E and P
Aldosterone secretion declines in toxemic pregnancies
Aldosterone

Renin
___________ glands enlarge during PG
Cause calcium absorption from maternal bones, maintains normal calcium concentration in maternal serum as fetus removes calcium for bone ossification
Parathyroid
Thyroid gland enlarges about 50% during PG
Increased production of _________

_________ - Higher amniotic fluid concentrations in laboring than non laboring women
Possible association with onset of parturition

________ - Secreted by ovaries and placenta
Causes relaxation of ligaments of symphysis pubis
thyroxine

Leukotrienes

Relaxin
Absence of adequate amniotic fluid during mid pregnancy associated with _____________ at birth—often incompatible with life

Abnormalities of amniotic fluid result of changes in fetal renal function, swallowing, lung fluid production or transchorionic water flow
pulmonary hypoplasia
___________ - Decreased volume of amniotic fluid

Caused by conditions that prevent or reduce amniotic fluid production, most commonly related to abnormalities in fetal ________
May produce fetal ________ as a result of umbilical cord compression
Passage of _________ in utero results in thick, particulate suspension that may cause respiratory compromise
Oligohydramnios

kidneys

hypoxia

meconium
____________ - Excessive amount of amniotic fluid, usually over 2 liters, usually accumulates slowly
Increased risk of premature labor due to hyperdistension of the uterus
Maternal respiratory discomfort
Umbilical cord prolapse
Fetal malpresentation

Etiology discussed in terms of sites of fluid secretion
Fetal anomalies involving decreased swallowing or GI absorption — __________, duodenal atresia, tracheoesophageal fistula
Abnormalities of transchorionic water flow — __________

Dx by ___________ accompanied by a complete ultrasonic fetal evaluation
Screen for Rh antibodies, diabetes, viral titers
Polyhydramnios

anencephaly

diabetic PG

ultrasound
_____________ Contractions become progressively stronger toward the end of pregnancy, then become excessively strong in labor

____________ is the process by which the baby is born
Braxton Hicks

Parturition
The fetus is connected by the __________ to the placenta

Umbilical _______ carries oxygenated blood from the placenta to fetus

________ does the work of exchanging CO2 and O2, so fetal lungs are not used for breathing, and blood is shunted away from the lungs

Blood returned to placenta via 2 umbilical _________
umbilical cord

vein

Placenta

arteries
With 1st breath at birth, ________ open & fetal circulation changes

Sphincter in ____________ constricts so that all blood entering the liver passes through the hepatic sinusoids

___________(normal connection between aorta and pulmonary artery) no longer needed-closes
alveoli

ductus venosus

Ductus arteriosus
3 Fetal Shunts:

___________ - Shunts blood from PA to aorta

___________ - Shunts blood from umbilical vein and liver to IVC

___________ - Shunts highly O2 blood from RA to LA
Ductus arteriosus

Ductus venosus

Foramen ovale
Adult Structures:

Ductus arteriosus - ___________

Ductus venosus - ___________

Foramen ovale - ___________

Umbilical vein - ___________
Ligamentum arteriosum

Ligamentum venosum

Fossa Ovalis

Ligamentum teres
Maternal Physiological Adjustments in Pregnancy: Gastrointestinal Changes

Stomach and intestines displaced
Delayed gastric emptying
Appetite increased with cravings—_____, Ptyalism
Vascular swelling of gums
_________ due to elevated pressure in veins
Nausea and vomiting—exact etiology unknown
Gastric sphincter relaxation—_________
GI motility decreased—__________
Gallbladder somewhat dilated with increased tendency for dysfunction, promotion of stasis
Retained bile salts—___________
Liver functionally unchanged
Pica

Hemorrhoids

Gastric Reflux

Constipation

pruritis gravidarum
Maternal Physiological Adjustments in Pregnancy: Hematological

________ volume increases beginning at 6th week in PG, intravascular
RBC increases beginning at 12th week
Disproportionate increase in plasma volume over RBC volume—hemodilution—”__________________”
Physiologic fall in Hgb and Hct
Serum Fe _________—60mg elemental Fe daily provided in 300mg ferrous sulfate d/t increased erythropoiesis of PG
Plasma

Physiologic Anemia of PG

decreased
Maternal Physiological Adjustments in Pregnancy: hypercoagulable state
Fibrinogen __________
Factors VII, VIII, IX, and X increase
Prothrombin, Factor V and XII are _________
Bleeding time does not change
Platelet & WBC count may _________
increases

unchanged

increase
Maternal Physiological Adjustments in Pregnancy: Cardiac (CO=SVxHR)

CO begins to increase by 5th week
Fx of increased ____ and decreased systemic ______________
HR

vascular resistance
Maternal Physiological Adjustments in Pregnancy: Pulmonary

________
Increased chest diameter, subcostal angle changes
Increased diaphragmatic excursion and diaphragm elevation
Heart displaced _____ and ______
Hyperventilation, Tidal Volume Decreased, O2 consumption up 15-20%
Dyspnea

left and upward
Maternal Physiological Adjustments in Pregnancy: Renal

GFR increases
Creatinine Clearance increases
Plasma osmolality decreases
Increased sensitivity to renin and angiotensin
Renal glycosuria common
Proteinuria
Minimal renal enlargement bilaterally
Both renal pelvises and ureters are dilated “________________”
Greater urinary stasis, UTI’s, pyelo
Loss of urinary control
Bladder capacity diminished
hydronephrosis of PG
Maternal Physiological Adjustments in Pregnancy: Endocrine

Carbohydrate Metabolism
Overall effect is that PG is diabetogenic
First half: tendency to __________
Second half: tendency to __________

Progressive insulin resistance as PG progresses
Reduced peripheral uptake of glucose for a given dose of insulin
Fx of _____, like growth hormone, increases lypolysis and resistance of tissue to insulin
hypoglycemia

hyperglycemia

hPL
Maternal Physiological Adjustments in Pregnancy: Genital Tract

Increased vascularity and hyperemia of vagina, perineum, vulva
Increased secretions
Characteristic violet color of vagina-_________sign
Chadwick’s
Maternal Physiological Adjustments in Pregnancy: Skin Changes

_________ or melasma gravidarum — Mask of PGMore common in darked skin people, more pronounced in summer, fades after delivery, can occur in nonPG on OCP’s

_______ - Reddish slightly depressed on breasts, thighs, abdomen, appear as silver, glistening lines in future pregnancies

__________ - hyperpigmentation
E and P and some melanocyte stimulating effect
Chloasma

Striae

Linea nigra
Fetus not growing in the usual place-uterine cavity.
Implantation of the zygote outside the uterus or in an abnormal location within the uterus

Almost all (98%) of ectopic pregnancies occur in the ___________ tubes….”______________”
Ectopic Pregnancy

fallopian

Tubal Pregnancy
Narrow fallopian tubes not designed to accommodate a growing embryo
Thin walls of the tube stretch to the point of rupture

Risk increases for women with a previous ectopic pregnancy, tubal scarring
Fallopian tube damage, surgery, endometriosis
Several induced abortions
History of infertility
Use of medicines to stimulate ovulation
Pelvic Inflammatory Disease (PID)
Ruptured appendix
Destruction of the uterine cavity lining
2.5 times increased incidence with ________
Life threatening condition-____________
smoking

hemorrhage
Combined intrauterine and extrauterine pregnancy (____________) may occur rarely

In the U. S. underdiagnosed or undetected __________is currently the most common cause of maternal death in the _______ trimester
heterotropic

ectopic pregnancy

first
Symptoms
_______ usually the first sign, usually adnexal or lower quadrant
May be in pelvis, abdomen or can extend up to the shoulders due to blood from a ruptured ectopic pregnancy building up under the __________
Described as sharp and stabbing with sudden onset
May be intermittent and vary in intensity
Amenorrhea or irregular vaginal bleeding
Adnexal mass by clinical exam or ultrasound
Vertigo
Diaphoresis
Pain

diaphragm
Pelvic Inflammatory Disease
Abortion: Threatened or Incomplete
Ovarian Pathology: Torsion or Cyst
Acute Appendicitis
DDx Ectopic Pregnancy
Diagnosis:
________ to locate pain, tenderness or a growing mass in the abdomen
CBC may show anemia and __________
ABO and RH
Lab testing for _______
Usually doubles every 2 days during normal pregnancy. Rate slower in ectopic pregnancy
Lab testing for level of progesterone
No intrauterine pregnancy on transvaginal ultrasound with serum beta hCG of >2000mU/ml
________ EXAM THE MOST IMPORTANT DIAGNOSTIC TOOL
Pelvic exam

leukocytosis

Beta hCG

ULTRASOUND
Occurs in 60%
Blood leaks from the tubal ampulla over a period of days
Blood accumulates in peritoneum
Slight vaginal spotting reported
Palpable pelvic mass
Abdominal distention and mild paralytic ileus often present
Chronic Ectopic Pregnancy
Common Sites of Ectopic Pregnancy:
___________ - Mid portion of the fallopian tube
_______ - Fallopian tube area closer to the uterus
________ - Distal end of tube, away from uterus
_______ - Within uterine muscle, “horn”
Peritoneum or abdominal viscera
Ovary
Cervix
Ampullary

Isthmic

Fimbrial

Cornual
Treatment:
Salpingectomy
Resection
Hysterectomy
Single dose IM ___________
methotrexate
Natural termination of pregnancy prior to 20 weeks gestation or fetal weight less than 350gms

Assessment
Intrauterine pregnancy at less than 20 weeks
Low or falling B hCG levels
Bleeding, midline cramping, pain
Open cervical os
Complete or partial expulsion of products of conception
Spontaneous Abortion
Present with cervical dilatation >2cm and minimal symptoms
When cervix dilated 4cm or more, active labor or rupture of membranes occurs
Associated with cervical conization or surgery, cervical injury, DES exposure, and abnormalities of the cervix
Ultrasound may be used 14-16 weeks to evaluate anatomy of lower uterine segment and cervix for funneling/shortening
Incompetent Cervix
Bleeding with or without cramping, pregnancy continues, cervix not dilated
Threatened Ab
Cervix dilated, membranes may be dilated, bleeding and cramping, no passage of products of conception---but inevitable
Inevitable Ab
Complete expulsion of fetus and placenta, pain ceases, spotting may persist
Complete Ab
Partial expulsion of POC, usually placenta remains in uterus, mild cramping, bleeding persists
Incomplete Ab
Pregnancy has ceased to develop, but no expulsion of conceptus, brown vaginal discharge, no free bleeding, minimal to no pain
Missed Ab
Laboratory Findings:
Low or falling ____ levels
____ if bleeding
ABO and Rh
Rhogam (Rho(D) immune globulin if Rh –
__________ to pathology, possible genetic analysis
hCG

CBC

Products of conception
Ultrasound Findings:
Gestational sac at _____ weeks from LMP
Fetal pole at __ weeks
Fetal cardiac activity at ___ weeks
Serial observations required to evaluate changes in size of embryo
Small sac without a fetal pole diagnostic of abnormal PG
5-6

6

6-7
Ectopic pregnancy
Menses
Hydatidiform mole
DDX of Spontaneous Ab
Treatment Threatened Ab:
_______ 24-48 hours with gradual resumption of activities
Abstinence from coitus and douching
________ treatment contraindicated
_________ only if signs of infection
Bedrest

Hormonal

Antibiotics
Treatment Missed or Inevitable Ab:
___________ regarding inevitable fate of PG
Planning for elective termination, IV oxytocin, D&C
Cervical laminaria or prostaglandin vaginal suppository
Counseling
Surgical Treatment Incomplete Ab:
Removal of ____ remaining in uterus to stop bleeding and prevent infection
__________ and para cervical block
_________ exploration with forceps, curretage or uterine aspiration
POC

Analgesics

Uterine
Surgical Tx Cerclage and Restriction of Activities:
Treatment for ______________
Suture to close cervix using McDonald or Shirodkar method
Used with caution with advanced cervical dilatation or prolapsed membranes into vagina
___________ and __________ are contraindications
Cervical cultures for GC, chlamydia and GBS
incompetent cervix

Ruptured membranes and infection
Loss of 3 or more previable (<500 gm) pregnancies in succession
Occurs in 0.4 to 0.8% of PG
Recurrent Ab
Aimed at detection of maternal or paternal defects contributing to Ab
General and GYN exams essential
PCOS (Stein Leventhal) should be ruled out
Glucose, thyroid functions
Anticardiolipin Ab, Leiden Factor V
Baby ASA
Chromosomal analysis of both parents
Preconception Therapy
Early prenatal care with frequent visits
Complete bedrest ONLY for bleeding or pain
Hormonal therapy contraindicated
Excellent prognosis if cause of Ab can be determined
Post Conception Therapy
Breast cancer is the most common cancer in American women

____ of women with breast cancer have an inherited risk for cancer due to genes passed on from their parents

one in nine will develop breast cancer
10%
Being Female
Advancing Age
Strong Family Hx
Reproductive Hx
Having a Previous Breast Tumor
Finding of premalignant changes in your breast tissue

Never having children

Having your first child after age 30
Obesity - Alcohol - Estrogen therapy
Risks for developing breast cancer
__________ can detect changes in breast tissue that may be associated with cancers and premalignant changes

the best means to find early curable cancers - cancers too small to be detected by touch

Additional imaging tests - _________ - for better definition
Mammograms

ultrasound
The _________ diagnosis is the most important information in planning treatment

A biopsy of the abnormal tissue is ___________ to make the diagnosis of breast cancer

Most mammogram abnormalities are not cancer; most are due to _________ changes
tissue

required

benign
Breast Ca Tx:
Surgery to remove all the tumor
________________ surgery - most patients
Removal of the full breast - __________- may be required for some patients
Breast preserving

mastectomy
Breast Ca Tx:
ADJUVANT THERAPY: Medical therapy to decrease the chance of tumor recurrence - to improve the chances for cure
___________- many different therapies
___________- tamoxifen, aromatase inhibitors
Chemotherapy

Hormonal therapy
Breast Ca Tx:
___________- to prevent tumor recurrence in the remaining breast tissue; required for breast preserving therapy
RADIATION THERAPY
Tamoxifen benefited women with:
the breast cancer gene
age greater than ___ years
premalignant changes in previous biopsies

SE:
small increase in risk for ________ cancer
_________
55

uterine

blood clots
Mammography is Recommended annually after age ___ with a baseline at age ___
40

35
Physical Exam
Diagnostic Mammogram
Ultrasound
Fine needle aspiration cytology
Core biopsy either free handed stereotactic or ultrasound guided
Open biopsy with or without needle localization
Evaluation of a Breast Mass
Nodule
Stellate Mass
Architectural Distortion
Calcification
cancer forms
Ductal Carcinoma In Situ (DCIS)
Lobular Carcinoma In Situ (LCIS)
Invasive Ductal Carcinoma (IDC)
Invasive Lobular Carcinoma (ILC)
types of cancer
________ Findings: Single, nontender, firm to hard mass with ill defined margins, mammographic abnormalities, and no palpable mass

_____ Findings: Skin or nipple retractions, axillary lymphadenopathy, breast enlargement, redness, edema, pain, fixation of mass to skin or chest wall
Early

Late
__________ disease, when accompanied by proliferative or atypical changes is associated with increased risk

Concomitant administration of estrogen and ___________ markedly increases incidence when compared with estrogen alone
Fibrocystic

progesterone
SERM - Selective Estrogen Receptor Modulator

Approved for pre menopausal use to prevent breast cancer
Tamoxifen
_________ (Evista) approved for osteoporosis also shows promise in preventing breast cancer

__________ inhibitors (Arimidex, Femara)also show promise
Raloxifene

Aromatase
Infiltrating ductal carcinoma
Nipple erosion or ulceration usually
Not common, about 1% of all breast cancers
Paget's Carcinoma
Most malignant form of breast cancer
Less than 3% of all cases
Overlying skin erythematous, edematous, warm
Often mistaken for infection
Inflammtory Carcinoma
Rare
Average age 60
Prognosis, even in Stage 1 is worse in men than women
Men have estrogen too
Male Breast Carcinoma
Variations of Normal Puberty
________ – gradual – hormonal/physical/purpose
_______– affected by genetic & environmental factors (nutritional status, social circumstances & exogenous hormones)
__________differences (nutrition/weight variations)
_________influences – accounts for at least 50% of all variations in well-nourished populations; strongest between mothers & daughters
Onset

Age

Racial/ethnic

Genetic
Puberty as a Neurohormonal Process
The brain’s hypothalmus begins to release pulses of _____
Cells in the anterior pituitary respond by secreting________ into the circulation
The ovaries/testes respond to the rising amounts of LH & FSH by growing & beginning to produce ________________
Rising levels of estradiol & testosterone produce the body changes of female & male puberty
GnRH

LH & FSH

estradiol & testosterone
The conclusion of puberty is ________________

___________(potential fertility) precedes completion of growth in girls by 1-2 years & 3-4 years in boys
reproductive maturity

Nubility
Menopause
__________– usually become irregular, occasional menorrhagia, flow diminishes, then stops. No bleeding for one year, menopause has occurred.
_________– feelings of intense heat over face & trunk, with flushing of the skin & sweating. Occurs in 80% of women as a result of the decrease in ovarian hormones.
Cessation of Menstruation

Hot flushes
__________– decreased estrogen secretion, thinning of the vaginal mucosa & decreased vaginal lubrication. Can lead to dyspareunia. Pelvic exam reveals pale, smooth vaginal mucosa & a small cervix & uterus. **Tx:**___________

___________– may be a late sequela of menopause. Bone density tests & medications to increase bone density, including calcium & vitamin D. **TX**_____________
Treatment of Menopause (cont)
Vaginal atrophy – hormone therapy, including estrogen vaginal cream, or estradiol vaginal ring

Osteoporosis – 800mg Calcium/day from food sources & 1000mg of elemental calcium as a supplement at menopause (taken with meals to > absorption). Daily weight bearing exercise. Most at risk: Asian & Caucasian women with thin frames, family history & smokers.
__________treated with oral conjugated estrogens, estradiol, estrone sulfate, transdermal estradiol. Add a progestin to prevent endometrial hyperplasia or cancer if the woman has an intact uterus. Use for the shortest time possible. Other useful meds-SSRI, esp. paroxetine (Paxil) & Effexor
Vasomotor symptoms
Surgical Menopause
____________results in severe vasomotor symptoms, rapid onset of dyspareunia, & osteoporosis unless treated. Conjugated estrogens (or equivalent) of 1.25mg/day taped to .625 after age 45-50.
Oophorectomy
___________
Cause: the protozoan T. vaginalis
Symptoms: Men-often none, occ. NGU
Symptoms: Women-a diffuse frothy, malodorous, yellow-green vaginal discharge with vulvar irritation, cervical petechiae or no s/s
Diagnosis: , positive whiff test, Ph >4.5
Trichomonas
Trich Treatment
Considered an STD
Must treat partner(s)
________2gm po
________2gm po
________500mg po BID X 7 days
No alcohol while on these meds
Metronidazole
Tinidazole
Metronidazole
___________
Cause: C. trachomatis ( WBCs on smear)
Symptoms: men-clear urethral discharge, dysuria
Symptoms: women-clear cervical discharge, or no discharge, dysuria, mild CMT
Diagnosis: culture, GenProbe, urine tests
Chlamydia
CT Treatment
_________-1gm po in a single dose
__________100mg po BID X 7 days
Compliance is a common issue
Importance to dual treat contacts and to treat empirically/epidemiologically
Bulk of cases in those between ages of ______years – screen appropriately
Azithromycin
Doxycycline

16-24
____________
Cause: gram-negative intracellular diplococci (on smear), N. gonorrhoeae
Symptoms: men-mucopurulent uretheral discharge
Symptoms: women-mucopurulent cervical discharge
Diagnosis: smear, culture, empirically/epi
Gonorrhea
GC Treatment
__________125mg IM X1
__________500mg po in a single dose
Dual treat if no confirmatory tests available
Dual treat partners, unless have test results
Also important to educate on cause/prevention & ancillary testing for other STIs
Ceftriaxone (Rocephin)
Ciprofloxacin
____________
Over diagnosed/ Difficult to diagnose/ exclusionary-clinical findings
Cervical motion tenderness on exam (_____________)
It is a spectrum of inflammatory disorders of the upper female genital tract
Causes: GC, CT, H. influenzae, G. vaginalis, enteric gram neg rods, etc
Pelvic Inflammatory Disease

Chandelier sign
PID Treatment
If severe: hospitalize & treat with IV _________/________ plus po or IV ______
Oral treatment: _________250 mg & ______100mg po BID X 14 days; may add __________500 mg po BID X 14 days
Recheck in 3 days, if no better, hospitalize, additional testing, surgical intervention.
Treat sex partners empirically
Cefotetan/Cefoxitin
Doxy

Ceftriaxone (Rocephin)
Doxy
Metronidazole
COAC Treatment
_________10-25% in tincture of benzoine-apply to each wart-wash off in 1-4 hours. May repeat weekly.
_____________80% apply to each wart. May repeat weekly.
_____________ May repeat every 1-2 weeks.
___________5% (Aldara) Self applied 3 X per week for up to 16 weeks. Wash off in
6-10 hours.
Surgical removal
1.Podophylin
2.Trichloroacetic Acid [TCA]
3.Cryotherapy (liquid nitrogen or cryoprobe)
4.Imiquimod
___________
Cause: T. pallidum
Symptoms: Primary infection-________; secondary-skin rash, mucocutaneous lesions (palmar/plantar rash), & lymphadenopathy; latent-no s/s found only on serologic testing; tertiary-cardiac, auditory, gummatous lesions
Diagnosis: darkfield, serologic testing (RPR, VDRL, IGG, FTA)

Congenital ~
Syphilis

chancre

"Snuffles"
__________
Caused by Hemophilus ducreyi
More prevalent in developing countries
Symptoms-women-none; men-single painful ulcer with ragged serpipinous border. Classically occurs with ________________, many rupture. Usually found near the coronal sulcus, glans, or shaft of the penis.

Diagnosis: clinically, a painful ulcer, often accompanied by a ______. Can use darkfield, culture, or biopsy to confirm.
Chancroid

painful inguinal lymphadenopathy

bubo
Treatment: Azithromycin 1 gm po or ceftriaxone 250mg IM or Cipro 500mg BID X 3 days. Aspirate lymph nodes DO NOT I&D. Treat sex partners. Test for HIV & syphilis, & GC/CT
tx for chancroid
syphilis tx
Benzathine penicillin G 2.4 million units IM in a single dose

if PCN allergic Doxy 100mg po bid X 28 days **CI in pregnant pts**
__________Cause: polymicrobial clinical syndrome resulting from replacement of the normal H2O2-producing Lactobacillus species in the vagina with high concentrations of anaerobic bacteria (Prevotella, Mobiluncus), G. vaginalis, & Mycoplasma hominis. It is the most prevenlant cause of _________; 50% are asymptomatic.
Bacterial Vaginitis
vaginitis
BV
Symptoms: homogenous thin, white vaginal discharge; fishy odor (more noticeable after intercourse)
Diagnosis: vaginal exam, presence on ________cells on microscopic exam, pH _____ & positive whiff test (10% KOH). Presence on pap is not diagnostic.
clue

>4.5
BV Treatment
Partner treatment not necessary
__________500mg po BID X 7 days
Metro Gel applicator full in vagina QD X 5 days
_________2% cream applicator full in vagina HS X 7 days
______________insert one HS X 3 days
Metronidazole

Clindamycin

Clindamycin vaginal ovules
_____________
Cause: C. albicans or other Candida species (yeasts)
Symptoms: women- pruritus, vaginal soreness, dysparenunia, external dysuria, & white clumpy vaginal discharge (cottage cheese).
Symptoms: men- balanitis (red papules, satellite lesions). Severe infections, immunocompromised.
Candida Vulvovaginitis
Vulvovaginal Candidiasis (cont)
Diagnosis: clinically, wet prep (KOH) demonstrates yeast or _________, pH __, gram stain, cultures
History-recent ___________use, DM, immunocompromised, history of frequent yeast infections.
pseudohyphae

< 4.5

broad spectrum antibiotic
Candida treatment
_______cream intravaginally X 3-7 days
_______150 mg po in a single dose
________vaginally X 3-7 days
Numerous OTC preparations
Terconazole

Fluconazole

Miconazole