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253 Cards in this Set
- Front
- Back
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Refer for Mammography at age
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35/40
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MOST COMMON BREAST PROBLEMS
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breast pain (mastalgia), nipple discharge,
palpable mass |
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breast pain (mastalgia), nipple discharge, palpable mass
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BREAST PAIN
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______pain is usually bilateral & poorly localized; usually resolves spontaneously
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Cyclic
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________ pain is usually a sharp, burning localized pain
May be secondary to an underlying fibroadenoma or cyst |
Non cyclic
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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 |
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T/F : All spontaneous or unilateral nipple discharge should be referred for surgical exam
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TRUE
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In premenopausal women normal glandular tissue is __________
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nodular
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Differential diagnosis of a dominant breast mass:
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macrocyst, fibroadenoma, fibrocystic changes, fat necrosis, & cancer
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second most common type of cancer in women worldwide. A causal link exists with HPV.
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CERVICAL CANCER
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Pap Smear is recommended at least every ________years age _________
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3 years
20-65 |
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_____________ covers the cervix
___________is beyond this junction into the os |
Squamous epithelium
Columnar epithelium |
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_____________(transformation zone) is where the pap is taken
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Squamocolumnar junction
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_____________________
Specimen Type Specimen Adequacy General Categorization Automated Review Ancillary Testing Interpretation/Result Educational Notes & Suggestions |
Bethesda Reporting System
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HPV VACCINE
~ ___________ Protects against types _______(cause most genital warts) Protects against types ______ (causes 70% of cervical dysplasia) |
GuardAsil (Merck)
6, 11 16,18 |
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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 |
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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 |
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Pap smears that suggest invasive disease require further evaluation by:
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colposcopy, biopsy, endocervical curettage, cryotherapy laser vaporization, loop excision, cone biopsy, hysterectomy
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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 |
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Directly related to the amount of estrogen stimulation & endometrial hyperplasia
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UTERINE CANCER
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Postmenopausal bleeding is ____________until proven otherwise
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endometrial cancer
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any nonmenstrual or intermenstrual bleeding
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METRORRHAGIA
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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 |
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________STAGING IS USED FOR ENDOMETRIAL CANCER
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FIGO
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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
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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 |
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Abdominal bloating
Dyspepsia Frequent urination Pelvic pressure or pain Constipation Pelvic mass Abdominal distention Pleural effusion Ascites Adenopathy Cachexia |
CLINICAL PRESENTATION OF OVARIAN CANCER
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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). |
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T/F: IF OVARIAN CANCER METASTASIZES, THE CLASSIFICATION NEEDS TO CHANGE ACCORDINGLY
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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.
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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
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FIGO
TNM |
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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% |
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the bleeding manifestations of anovulatory cycles
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DYSFUNCTIONAL UTERINE BLEEDING
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a thickened endometrium causes by perimenopause, puberty, PCOS, obesity, unopposed estrogen replacement therapy
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CAUSES OF DUB
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estrogen low relative to progesterone; results in a thinned endometrium (low estrogen pills < 30 mcg, POP, Depo-Provera, Norplant, Mirena IUS)
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PATTERNS OF DUB
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orthostatic BP changes, > heart rate, pallor, large amount of blood in vaginal vault, uterus may be enlarged due to retained clots
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ACUTE DUB
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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
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CHRONIC DUB
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scanty or infrequent menstrual flow
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Oligomenorrhea
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_________________
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 |
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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
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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 |
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Hydramnios
Malpresentation Placenta Previa Placental Abruption Premature rupture of membranes Umbilical cord prolapse IUGR Congenital anomalies Increased perinatal morbidity/mortality TTTS |
Fetal Complications
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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 |
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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 |
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<37 WEEKS
>37 WEEKS |
Expectant Management if <37 weeks
Delivery usually if >37 weeks |
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3 most common causes of maternal death
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Hemorrhage
Infection Hypertensive Disease |
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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 |
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Occurs during delivery
2nd most common cause of pp hemorrhage |
Genital tract trauma
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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 |
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_____________
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 |
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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 |
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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 |
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___________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 |
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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 |
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Pelvic Inlet
Plane of Greatest Diameter Anterior-posterior and Transverse Plane of Least Diameter Mid plane Pelvic Outlet |
4 pelvic planes
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Progressive cervical effacement and/or dilatation from regular uterine contractions
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labor
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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
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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
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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
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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 |
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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 |
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Descent
Flexion Internal Rotation Extension External Rotation Expulsion |
Mechanisms of Labor
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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 |
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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 |
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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 |
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_______________
Narcotics Demerol (meperidine) Stadol (butorphanol) Sedatives/Tranquilizers Phenergan (promethazine) ____________ Nitrous oxide Penthrane Ethrane |
Systemic Medications
Inhalation analgesia |
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to use vacuum extractor, fetus MUST be ___________ presentation
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VERTEX
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________ is more informative than Apgar Score
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cord pH sampling
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the baby’s “lifeline.”
Shiny Schultz vs Dirty Duncan presentation Often sent to pathology after delivery for examination and testing |
Placenta
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Eccentric insertion of umbilical cord
Inserts usually at edge like “badminton” racquet No clinical significance: |
Battledore Placenta
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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
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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
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Implantation of part or all of the placenta in the lower uterine segment
Associated with increased perinatal and maternal mortality |
Placenta Previa
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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 |
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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
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_____________________
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
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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 |
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______________
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
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Placental Abruption Etiology
Uncertain and speculative Trauma-MVA Most spontaneous and nontraumatic _____tension _______ umbilical cord Uterine anomaly or tumor Drugs-________ |
Hyper
Short cocaine |
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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 |
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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 |
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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 |
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________
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
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Refers to the process of physical changes by which a child’s body becomes an adult body, capable of reproduction
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puberty
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__________ overlaps puberty. It refers to psychosocial & cultural characteristics of development as well as the physical changes of puberty.
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Adolescence
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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 |
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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 |
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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 |
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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 |
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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 |
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Sequence of hair appearance:
Arm & leg hair increases over the next __years |
Axillary hair, perianal hair, upper lip hair, preauricular hair, & periareolar
10 |
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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 |
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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 |
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_______________ 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 |
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___ exposures to Rh antigen required to produce antibodies and sensitization
Antibody response called _______________ |
2
Rh sensitization |
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Most sensitization occurs at _________
With succeeding pregnancies, Anti Rh antibodies in mom’s system can cross placenta and destroy fetal RBC (________) |
delivery
hemolysis |
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____________ 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 |
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__________ 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 |
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_______ 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 |
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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 |
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HELLP Syndrome-
Form of severe pre eclampsia |
Hemolysis, Elevated Liver Enzymes, Low Platelets
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Addition of grand mal seizures to pre eclampsia
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eclampsia
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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 |
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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 |
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Pregnancy associated with increased tissue resistance to insulin
Glucose screen for gestational diabetes _______ weeks |
Diabetes of Pregnancy
24-28 |
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“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 |
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Polyhydramnios
Pre Eclampsia Ketoacidosis and Diabetic Coma Vascular End Organ Deterioration - Cardiac, Renal, Ophthalmic, Peripheral Vascular Neurologic - Peripheral neuropathy, GI disturbance |
GDM Maternal Complications
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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
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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)
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etiology of IUGR:
_______-Poor nutrition, Tobacco, Drugs, Alcohol ________-Pre Eclampsia, HTN, Chronic Renal Disease, _____-Intrauterine infections, congenital anomalies |
Maternal
Placental Fetal |
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IUGR Management:
Diagnosed by ________ exam Modify any associated factors: Nutrition, tobacco, alcohol Non Stress Tests, Contraction Stress Tests Delivery |
ultrasound
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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
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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)
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1 in 2500 in pregnancy
DVT the instigating factor |
Pulmonary Embolism (PE)
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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 |
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Major complication/risk
Precipitating factors include infection, labor, C/S, or noncomplicance with meds |
Thyroid Storm
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Occurs 3-6 months after delivery
Hyperthyroid state of 1-3 months followed by hypothyroidism Sometimes misdiagnosed as depression |
Recurrent Postpartum Thyroiditis
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May adversely affect neuropsychological development of child
Check TSH level prenatally |
Maternal hypothyroidism
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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
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___________ 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
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Cultured from vaginal canal in 5 -25% of pregnant women
If has + history, IV antibiotics in labor |
Group B Strep (GBS)
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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
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TORCH
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Toxoplasmosis - no litter box cleaning
Other (Syphillis) Rubella CMV HSV - abdominal delivery |
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Seizure Meds - ________
Fetal hydantoin syndrome in 10% of exposed babies 30% may have isolated craniofacial anomalies, limb reduction deficits, mental retardation, CV anomalies |
Dilantin
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Seizure Meds - __________
Drug of choice in PG, risk low True teratogenicity difficult to assess because usually taken in combination with other drugs |
Phenobarbital
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|
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 |
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___________
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
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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 |
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____________
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
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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 |
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____________
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 |
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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 |
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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 |
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___________
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" |
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__________
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 |
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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
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tx for chancroid
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syphilis tx
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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** |
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__________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.
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Bacterial Vaginitis
vaginitis |
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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 |
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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 |
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_____________
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
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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 |
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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 |
