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347 Cards in this Set
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hyperemesis gravidarum
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severe n/v --> hospitalization sometimes for entire pregnancy
|
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what does progesterone do to gi motility
|
slows it down
|
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gerd in pregnant women
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gets worse b/c there is decreased sphincter tone at ge jxn
|
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why are there hemorrhoids in prgnancy
|
increased venous pressure from pressure on ivc from uterus, and increased pelvic blood flow
|
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what happens to the following pfts in pregnancy:
tidal volume insp capacity vital capacity inspiratory reserve rr frc rv ev |
up
up up up = down down down |
|
what happens to abgs:
po2 pco2 hco3 |
up
down down metabolic alkalosis occurs |
|
what effect does progesterone have on smooth muscle
|
relaxes it
|
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when is gestational dm tested for
|
27-29 wks of pregnancy
|
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when is gbs testing done
|
36wks
|
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how to handle maternal gbs
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tx with iv pcn when they go into labor
|
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consequence of dehydration on pregnancy
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can lead to uterine contractions d/t 2ndary x-reaction of vasopressin with oxytocin
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describe changes of lecithin and sphingomyelin in fetus
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lecithin increases as fetus matures
sphingomyelin decreases beyond 32 wks |
|
risk factors of ectopic pregnancy
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h/o std/pid
prior ectopic preg previous tubal, abdominal, or pelvic sx endometriosis exogenous hormones ivf des use of iud, which prevents nml implantation |
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strongest risk factor for ectopic pregnancy
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prior ectopic pregnancy
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complications of ectopic pregnancy
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rupture --> hypotension, unresponsive, peritoneal irritation 2ndary to hemoperitoneum
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hcg and ectopic pregancy
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hcg is lwo for ga and does not inrease at expected rate (b/c placenta is poorly implanted so hcg does not rise as quickly)
|
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heterotopic pregnancy
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multiple gestations, with one iup and the other ectopic
|
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how should a pt be treated, if they are stable, but present w a ruptured ectopic preg
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ex-lap to evacuate the hemoperitoneum, coagulate any bleeding, adn resect the ectopic
|
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how are pts tx if they present wtih ectopic pregnancy that hasn't ruptured
|
laparoscopic resetion of ectopic pregnancy
mtx |
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deffinition of reassuring fht
|
hr in nml range (110-160)
>2 accells of >15 bpm over baseline, lasting for at least 15 sec within 20 mins |
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how to monitor mtx tx of ectopic
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monior hcg... it should drop 4-7 days following tx, if it doesn't happen, then must receive 2nd dose of mtx
|
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what week is the limit for a sab
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<20 wks ga
|
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abortus
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fetus lost before 20 wks gestation
|
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complete abortion
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complete expulsion of products of conception before 20 wks
|
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incomplete abortion
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partial expulsion of some but not all products of conception before 20 wks
|
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inevitable abortion
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no expulsion of products of conception but bleeding and dilation of cervix occur so a viable pregnancy is not likely
|
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threatened abortion
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intrauterine bleeding before 20 wks w/o dilation or expulsion of products of conception
|
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missed abortion
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death of embryo or fetus before 20 wks with complete retention of products of conception
usually proceed to complete abortion in 1-3 wks but are sometimes retained much longer |
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what should all rh-neg pregnant women with vaginal bleeding during pregnancy receive
|
rho-gam
|
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PROM
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when membranes surrounding the fetus rupture 1+ hrs prior to labor
|
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prolonged PROM
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when PROM occurs >18hrs prior to labor
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definition of premature
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when fetus is <37 wks
|
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how to differentiate between amniotic fluid and vaginal fluid
|
vaginal secretions are acidic
amniotic fluid is alkaline |
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what is the tampon test
|
use amniocentesis to inject dye into the amniotic sac to look for leakage of fluid from cervix into a tampon
|
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what is the bishop score
|
exam that includes dilation, cervical effacement, station, cervical consistency, and cervical position
each category --> score; if >8 then it is favorable for spontaneous and induced labor |
|
effacement
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how much length is left of the cervix
|
|
station
|
relation of fetal head to ischial spines
0 when the lowest part of the presenting part is at the level of the ischial spines |
|
difference btwn cephalic and vertex presentation
|
in vertex: head must be flexed
cephalic: head is down but not flexed |
|
shape of anterior fontanelle
|
junction between 2 frontal bones and 2 parietal bones and is larger and diamond shaped
|
|
shape of posterior fontanelle
|
junction between the 2 parietal bones and occipital bones
is triangular |
|
"false labor"
|
prodoromal labor
irregular contracdtions that vary in duration, intensity and intervals there is very little cervical discharge |
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definition of PROM
|
if ROm occurs >1 hr prior to onset of labor
|
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defitiion of PPROM
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if ROM occurs preterm (<37 wks ga) and >1 hr prior to onset of labor
|
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how to dx ROM
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pool test
nitrazine fern test check u/s to see if if other tests are equivocal |
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definition of false labor
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irreg ctx w/o cervical change
|
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definition of labor
|
regular uterine ctx --> cervical changes
|
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indication of IOL
|
post-term pregnancy
pre-eclampsioa PROM non-reassuring fetal testing IUGR |
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what causes an early decel and when does it occur
|
end at end of ctx, increased vagal tone leads to fetal head compressioin during ctx
|
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cause of variable decels
|
results from umbilical cord compression
|
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def of late decel
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begins at peak of ctx and returns to baseline after ctx is over
|
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1st stage of labor
|
onset of labor until complete effacement and dilation occurs
|
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2nd stage of labor
|
full dilation until delivery
|
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3rd stage of labor
|
placenta delivery
|
|
types of labor in stage 1 of labor
length of time of stage 1 prime multip |
inactive (0 to 3-4 cm dilated) and active (4-9 cm dilation - fully dilated)
10-12 hrs inactive, 1.0 cm/hr active 6-8 hrs inactive, 1.2 cm/ hr active |
|
length of time of stage 2
prime multip |
>2 hrs = prolonged +1 hr if epidural
>1 hr = prolonged +1 hr if epidural |
|
complications of vacuum extractors
|
scalp lacerations
cephalohematoma |
|
risk factors for ectopic
|
iud
tubal scarring decreased peristalsis of tube |
|
pe of ectopic pregnancy
|
tender adnexal mass
cervical bleeding |
|
lab eval of ectopic pregnancy
|
low beta-hcg for ga
decreased doubling rate of hcg |
|
what must the hcg level be in order for an iup to be visualized
|
1500-2000
|
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how to manage a pt with a ruptured ectopic pregnancy who is stable
|
ex lap to evacuate, coag, and resect pregnancy
|
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how to manage a pt with unrutptured ectopic
|
laporoscopic resection or mtx
after mtx must monitor hcg levels (they should increase then decrease) if they don't decrease must give again |
|
most common cause for 1st trimester ab
|
chromosomal abnormalities
|
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how to manage a complete ab in first trimester
|
send to path for analysis
|
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how to manage a incomplete ab in first trimester
|
d&c to complete ab
or pg's to induce cervical dilation and ctx send tissue to path |
|
how to manage a threatened ab in first trimester
|
if rh - give RHOgam
increased risk of ptl or pprom |
|
most common cause for 2nd trimester ab
|
uterine or cervical abnormality
trauma dz infx CHROMOSOMAL ABNORMALITIES ARE NOT COMMON CAUSE IN 2ND TRIMESTER |
|
how to manage a pt with 2nd trimester ab
|
d&e for complete, incomplete, and missed ab
if incomplete or mssed, can also tx with oxytocin or pg (d&e is better b/c it is a self limited procedure) |
|
presentation of 2nd trimester ab
|
vaginal bleeding
|
|
dx ptl
|
ctx that lead to a change in the cervix prior to 37 wks
|
|
dx of incompetent cervix
|
painless dilation of cervix, no ctx
|
|
tx of ptl
|
tocolytics
|
|
tx of incompetent cervix
|
cerclage placed at 14 wks
|
|
pathophys of how incompetent cervix --> 2nd trimester ab
|
when cervix dilates, fetal membranes are exposed to vaginal flora and there is an increased risk of trauma
|
|
risk factors of incompetent cervix
|
trauma
surgery conenital des exposure in utero |
|
dx of incompetent cervix
|
dilated cervix in excess of what's expected
with ctx, pt has cramping 2ndary to dilated cervix |
|
w/u for recurrent sab
|
check karyotype
hsg for anatomy hypothyroidism dm apa sle |
|
how to tx arrest of cervical dilation
|
oxytocin to augment labor and increase ctx that lead to cervical change
if no change after oxytocin is given, place intrauterine catheter to assess strenght of ctx |
|
pathogenesis of labial fusion
|
excess androgens from exogenou sexposure or increased androgen production (can be seen in cah)
|
|
pathophys of cah
tx |
increased 17-alpha-hydroxy, resulting from a 21-oh deficiency
tx with cortisol b/c it's not being produced |
|
presentation of imperforate hymen
|
primary amenorrhea with cyclic pelvic pain
pW hematocolpos (blood that builds up behind hymen) |
|
tx of imperforate hyman
|
surgery
|
|
presetation of transverse vaginal septum
|
primary amenorrhea wiht cyclic pelvic pain
|
|
presentation of lichen sclerosis
|
on vulva
if post-menopausal, 5-15% risk of ca atrophy of the vulva extreme vulvar pruritus and may also present with vulvar burning, pain and introital dyspareunia waxy sheen on the labia minora and clitoris, and hypopigmentation **vagina is not involved** |
|
squamous cell hyperplasia
|
from chronic vulvar irritation --> scratching adn rubbing and hyperkeratotic changes
skin thickening |
|
lichen simplex chronicus
|
chronic inflammation associated with vulvar pruritis from reaction to scratching
|
|
lichen planus
|
chronic eruption fo shiny violaceous papules with white striae --> vaginal adhesions and erosive vaginitis
|
|
urethral caruncles
|
small red fleshy tumors found at opening of urethral meatus
secondary to vulvovaginal atrophy |
|
bartholin cysts
|
abscesses at 4 and 8 o clock
|
|
tx of bartholin cysts
|
i&d or marsupialization
cx for gonorrhea |
|
nalothian cysts
|
dilated retention cysts of cervix 2ndary to blocked endocervical glands
|
|
mesonephric cysts
|
originate from remnants of wolffian ducts, lie deep in cervix
|
|
sx of cervial polyps
|
intermenstrual or post-coital spotting
no pain unless obstructing cervical canal |
|
tx of cervical polyps
|
excision b/c they can look similar to pre-malignant conditions
|
|
sx of leiomyomas in cervix
|
`intermenstrual bleeding, dyspareunia, bladder/rectal pressure
|
|
what embryologic origins are most reproductive organs from?
what are the exceptions? |
mullerian system
ovaries are from genital ridge lower 1/3 of vagina is from ug diaphragm |
|
complication of septated uterus
|
lacks adequate blood flow to maintain pregnancy --> 1st trimester loss
|
|
tx of septated uterus
|
septal excision
|
|
what is the septum of septated uterus comprised of
|
collagen
|
|
complication of bicornate uterus
|
2nd trimester loss from iugr
|
|
dx of bicornate uterus
|
mri
|
|
uterine fibroids
|
focal proliferation of smooth muscle
regression during menopause |
|
complications of uterine fibroids
|
bleeding
infertility pain urinary frequency constipation |
|
histopath of uterine fibroids
|
monoclonal cell line (propagation of single muscle cell)
|
|
tx of uterine fibroids
|
estrogen
|
|
effect of pregnancy on fibroids
|
can grow b/c of increased estrogen
|
|
3 types of uterine fibroids
|
submucosal
intramural subserosal |
|
sx of submucosal uterine fibroids
|
prolonged heavy bleeding
|
|
which type of fibroid is most common
|
intramural
|
|
sx of subserosal uterine fibroids
|
pelvic pain
|
|
parasitic leiomyoma
|
pedunculated fibroid that attaches to pelvic viscera/omentum and develops its own blood supply
|
|
distinguishing feature between fibroid and adenomyosis
|
pseudocapsule is found in fibroids
|
|
describe relationship btwn fibroids and blood supply
|
fibroids can outgrow their blodo supply and become necrotic and --> pain
|
|
what can happen to fibroids during pregnancy
|
they grow to be much larger then they can infarct of hemorrhage
|
|
#1 sx of fibroids
|
bleeding that increaess in duration
|
|
complications of fibroids during pregnancy
|
infertility
iugr malpresentation of baby dystocia ptl |
|
physical findings of fibroids
|
lumpy bumpy uterus
cobblestone protrusions |
|
appearance of fibroids on u/s
|
hyperechogenic
|
|
tx of ofibroids
|
expectant management if dx is certain
tx only if sx are severe (progesterone, danazol, gnrh agonists) uterine artery embolization is also used in order to decrease blood supply to fibroids --> degeneration and necrosis (can't be used if pt wants to become pregnant) hysterectomy is definitive tx |
|
tx of fibroids if pt wants to become pregnant
|
myomectomy (fibroids recur 50% of time)
|
|
complication of endometrial hyperplasia
|
endometrial ca if not treated
|
|
what is endometrial hyperplasia
|
abnormal proliferation of glandular/stromal elements --> glandular crowding and cellular atypia
|
|
risk factor for endometrial hyperplasia
|
unopposed estrogen exposure
|
|
presentation of endometrial hyperplasia
|
oligomenorrhea or amenorrhea followed by abnml uterine bleeding
uterus is enlarged |
|
gold std to dx endometrial hyperplasia
|
endometrial bx (unless atypical hyperplasia is present, then use d&c)
|
|
tx of endometrial hyperplasia
|
progesterone
|
|
types of ovarian cysts
|
follicular cysts
corpus luteum cyst theca lutein cysts |
|
pathophys of follicular cysts
|
arise after follicle fails to rupture
|
|
sx of follicular cysts
|
asx
unilat --> torsion if >4cm |
|
tx of follicular cysts
|
resolve spontaneously after 60 days
|
|
pathophys of corpus luteum cysts
|
form when corpus luteum becomes enlarged, and hemorrhgic or fails to regress after 14 days
|
|
comlications of corpus luteum cyst
|
can rupture --> hemoperitoneum
|
|
presentation of theca luteun cysts
|
bilateral cysts wiht clear fluid stimulated by increased b-hcg
large and firm waxing/waning pain, nausea |
|
dx of ovarian cysts
|
pelvic u/s
check ca-125, if elevated, might suspect ca, follow levels after tx |
|
tx of ovarian cysts
|
ex lap the following:
if repro age with cyst >8cm or lasting longer than 60 days if cyst is solid or complex if <6 cm f/u w/ u/s, should resolve in 2-3 mo; can start coc if no resolution, evaluate w cystectomy and oopherectomy |
|
primary lesion in hsv
|
vesicle
|
|
primary lesion in syphilis
|
papule/chancre
|
|
primary lesion in chancroid
|
papule/pustule
|
|
primary lesion in lymphogranuloma venereum
|
papule/pustule/vesicle
|
|
primary lesion in granuloma inguinale
|
papule
|
|
describe border in lesion of hsv
|
red
|
|
describe border in lesion of syphilis
|
sharp
|
|
describe border in lesion of chancroid
|
red
|
|
describe border in lesion of lgv
|
variable
|
|
describe border in lesion of granuloma inguinale
|
rolled
|
|
number of lesions in hsv
|
many
|
|
number of lesions in syphilis
|
one
|
|
number of lesions in chancroid
|
1-3
|
|
number of lesions in lgv
|
1
|
|
number of lesions in granuloma inguinale
|
1-3
|
|
depth of lesion in hsv
|
superficial
|
|
depth of lesion in syphilis
|
superficial
|
|
depth of lesion in chancroid
|
excavated
|
|
depth of lesion in lgv
|
superficial
|
|
depth of lesion in granuloma inguinale
|
elevated
|
|
lymph node sx in hsv
|
tender
|
|
lymph node sx in syphilis
|
non tender
|
|
lymph node sx in chancroid
|
tender
|
|
lymph node sx in lgv
|
tender
|
|
lymph node sx in granuloma inguinale
|
rarely involved
|
|
special dx test for hsv
|
tzank
|
|
special dx test for sypphilis
|
dark field
|
|
special dx test for chancroid
|
gram - rod (h. ducreyi)
|
|
special dx test for lgv
organism in lgv |
none
caused by chlamydia |
|
special dx test for granuloma inguinale
organism responsible |
gram - coccobacilli
(caused by klebsiella granulomatis) |
|
tx for syphilis
|
pcn
|
|
tx for chancroid
|
ceftriaxone or azithromycin
|
|
tx for lgv
|
doxycycline
|
|
what can be a genital tract manifestation of crohn's dz
|
kinfe cut vulvar ulcers (which can precede the gi sx)
|
|
time between inoculation and sx of syphilis
|
3 wks
|
|
causative agent for lymphogranuloma venereum
|
chlamydia
|
|
describe course of lymphogranuloma venereum
|
primary stage i slocal lesion that is painless
second stage has painful inflammation and enlargement of inguinal nodes --> fever, ha, malaise, anorexia tertiary stage - proctocolitis, rectal stricture, rectovaginal fistula and elephantiasis |
|
tx of condyloma acuminata
|
cryotherapy
topical trichloroacetic acid 5-FU podophyllin |
|
causative agent of molluscum contagiosum
|
pox virus spread via close contact with infected person or autoinoculation
|
|
where can molluscum contagiosum legions occur
|
anywhere on body except on palms and soles
|
|
nml vaginal d/c ph
|
<4.5
|
|
ph of d/c in bacterial vaginosis
|
>4.5
|
|
ph of d/c in trich
|
>4.5
|
|
ph of d/c in candidiasis
|
<4.5
|
|
ph of d/c in atrophic vaginitis
|
>5
|
|
ph of d/c in cervicitis
|
>4.5
|
|
appearance of d/c in bv
|
white, gray homogenous
|
|
appearance of d/c in trich
|
white, gray homogenous
|
|
appearance of d/c in candidiasis
|
thick, white, curdlike
|
|
appearance of d/c in cervicitis
|
mucopurulent
|
|
microscopic exam of bv
|
clue cells
decreased lactobacilli |
|
microscopic exam of trich
|
flagellate protozoa, wbc
|
|
microscopic exam of candidasis
|
budding yeast, w hyphae
|
|
microscopic exam of cervicitis
|
many wbc
|
|
tx of chlamyida
|
azithromycin or doxy
|
|
tx of bv
should this be treated in pregnancy |
metronidazole
yes, if a woman has sx, b/c can --> pprom |
|
tx of pubic lice
|
permethrin
|
|
tx of yeast infx
|
fluconazole
|
|
tx of gc
|
ceftriaxone
|
|
tx of trich
|
metronidazole
|
|
vulvar ca staging
stage 0 |
vulvar ca staging
carcinoma in situ intraepithelial carcinoma |
|
vulvar ca staging
stage 1 |
T1 N0 M0
tumor confined to vulva and/or perineum <2 cm at greatest dimension nodes not palpable |
|
\vulvar ca staging
stage 2 |
t2 n0 m0
vulvar ca staging tumor confined to vulva and/or perineum >2 cm at greatest dimension nodes not palpable |
|
vulvar ca staging
stage 3 t3 n0 m0 t3 n1 m0 t1 n1 m0 t2 n1 m0 |
tumor of any size with adjacent spread to lower urethra and or vagina, anus
and/or unilateral regional ln mets |
|
vulvar ca staging
stage iv a |
t1 n2 m0
t2 n2 m0 t3 n2 m0 t4 any n m0 tumor invades any of the following: upperurethra, bladder mucosa, rectal mucosa, pelvic and or b/l regional node mets |
|
vulvar ca staging
stage iv b |
any t, any n, m1
any distant mets, including pelvic ln |
|
what does t3 mean for vulvar ca
|
tumor of an size with adjacent spread to urethra and/or vagina and/or to anus
|
|
n0 in vulvar ca
|
no ln mets
|
|
n1 in vulvar ca
|
u/l regional ln mets
|
|
n2 in vulvar ca
|
b/l regional ln mets
|
|
t4 in vulvar ca
|
tumor of any size infiltrating the bladder mucosa and or rectal mucosa, includin the upper part of the urethral mucosa and or fixed to the bone
|
|
m0 in vulvar ca
|
no clinical mets
|
|
m1
|
distant mets (incl pelvic ln mets()
|
|
dinstingiushing feature of stage 3 vulvar ca
|
n1 involvement
|
|
dinstinguishing features of stage 4a vulvar ca
|
n2 involvment
|
|
in vaginal ca, stage 0
|
carcinoma in situ
|
|
in vaginal ca, stage 1
|
carcinoma limited to vaginal mucosa
|
|
in vaginal ca, stage 2
|
carcinoma involving the subvaginal tissue, but not extending onto the pelvic wall
|
|
in vaginal ca, stage 3
|
ca extending onto pelvic wall
|
|
in vaginal ca, stage 4
|
ca extending into mucosa of bladder or rectum or distant mets
|
|
appropriate management of ascus (general)
|
hpv dna testing on all
repeat pap is acceptable, but not preferred (q3 mo until 3 consecutive - paps) |
|
management of ascus if + high risk hpv
|
colpo
|
|
management of ascus if - high risk hpv
|
repeat pap in 12 months
|
|
management of ascus in menopausal women
|
intravaginal estrogen cream nightly for 3-6 wks, then repeat pap
if - repeat in 3-4 mo and if again negative, return to routine pap sequence if + for high risk hpv, colpo |
|
management of ascus in women with infections or severe inflammation
|
treat infection and repeat pap in 4-6 weeks
if negative, repeat in 3-4 mo and if - again, return to routine pap sequence if + colpo |
|
management of asc-h
|
colpo
|
|
when should colpo be done in lsil
|
prior high grade lesions/dysplasia, cin2/3, h/o cis
prior ascus, lsil/hsil s h/o tx if f/u is unlikely postmenopausal pt s atrophy heavy smoking hx |
|
when should f/u pap be performed in lsil
|
q 4-6 mo until 3 nml paps have been obtained, then return to nml schedule
|
|
management of hsil
|
colpo with ecc and directed bx of most abnormal lesions
|
|
endometritis
|
infection of the uterine endometrium
|
|
endomymometritis
|
infections of endometrium that invades into the myometrium
|
|
when are endomyometritis and endometritis seen
|
most commonly after c-section, but also d&e, d&c, and iud placement
|
|
relationship between pid and endometritis
|
present in 70-80% of pid; it ascends from cervix then to fallopian tubes --> acute salpingitis and widespread [id
|
|
dx of endomyometritis
|
uterine tenderness on bimanual exam and elevated wbc
|
|
sx of chronic endometritis
|
usually asx, but can lead to other pelvic infections or endomyometritis
|
|
etiology of chronic endometritis
|
polymicrobial infection with skin and gi flora + regular flora of lower reproductive tract
|
|
how to dx chronic endometritis
|
endometrial bx that shows plasma cells
|
|
tx of severe endomeyometritis
|
clindamycin + gentamycin
|
|
tx of less severe endometritis
|
cephalosporins until the pt is asx and/or afebrile for 48 hrs
|
|
tx of chronic endometritis
|
3 wk course of doxycycline
|
|
complications of pid
|
20% of pts w pid --> infertility
10x increase of ectopic pregnancy chronic pelvic pain, dyspareunia, and pelvic adhesions |
|
alternative name for pid
|
acute salpingitis
|
|
sx of acute salpingitis
|
abdomina or pelvic/adnexal pain
increased vaginal d/c abnml odor abnml bleeding gi disturbances urinary tract sx |
|
dx of pid
|
elevatd wbc
fever pelvic pain cmt adnexal tenderness DEFINITIVE DX IS WITH LAPAROSCOPY (esp if acute appendicitis can't be ruled out by clinical exam) maintain a low threshold for dx |
|
fitzhugh-curtis syndrome
|
perihepatitis from ascending infx resulting in ruq pain and tenderness and lft elevations
|
|
tx of pid
|
pts are often hospitalized
tx w broad spectrum cephalosporin + doxycycline |
|
pathogenesis of tubo-ovarian abscess
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caused by persistent pid
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most common pathogens associated with pid
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gc/chlamydia
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clinical dx of tubo-ovarian abscess
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usually in the setting of pid + adnexal or posterior culdesac mass or fullness
elevated wbc with left shift elevated esr |
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imaging study of tubo-ovarian abscess
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u/s
pelvic ct in obese pt with limited u/s study |
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definitive dx of tubo-ovarian abscess
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laparoscopy, but only used when the clinical presentation is unclear
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ddifference btwn tubo-ovarian abscess and tubo-ovarian complexes
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complexes are not walled off like a true abscess, and they are more responsive to abx tx
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who should be suspsected of having a tubo-ovarian abscess
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any pt with pid that is not responding to tx
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tx of tubo-ovarian abscess
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broad-spectrum abx in an inpt setting (cefotoxin is tx of choice)
surgery can be avoided unless the pt has peritoneal signs after pt is afebrile for 48 hrs, must repeat a pelvivc exam cure for more serious tubo-ovarian abscess = salpingo-oopherectomy +/- TAH |
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sx of tss
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fever >102
erythematous rash desquamation of soles and palms 1-2 wks after illness hypotension |
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cx in tss
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usually negative, b/c exotoxin is absorbed though vaginal mucosa
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tx of tss
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hospitilization is ALWAYS necessary
if pt has hypotension, admit to icu iv antibiotics doesn't shorten the dz course, but it does decrease the risk of recurrence |
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adrenarche
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regeneration of zona reticularis in adrenal cortex and production of androgens
dheas and dhea and androstenedione are produced (until age 13-15) |
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gonadarche
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follows adrenarche with pulsatile release of gnrh --> lh and fsh released from ant. pit (and ovaries then produce estrognes)
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thelarche
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breast development
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pubarche
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development of pubic and axillary hair
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what is the order of puberty development
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adrenearche
gonadarche thelarche pubarche peak height velocity menarche |
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at what age does adrenarche occur in females
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6-8 yo and increases from ages 13-15
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at what age does gonadarche occur
when does it occur |
age 8, initially these changes occur during sleep and don't produce any phenotypic changes, but eventually it stops being pulsatile and continues throughout the day
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at what age does thelarche begin
why does it occur |
age 10
it is usually in response to increased amounts of estrogen |
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what occurs during thelarche
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breast bud development
estrogenation of the vaginal mucosa growth of vagina and uterus |
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at what age does pubarche occur
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age 11
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at what age does peak growth velocity begin
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9-10 yo
max peak is at 12 yrs (9cm /yr) |
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what causes the increased growth rate
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increased estrogen levels, increased levels of growth hormone nad somatomedin c
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aside from low % body fat, what else is related to delayed menarche in otherwise normal females
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exercise and stress on body may inhibit ovulation through positive effects on norE and gnrh, thus interfering with menarche
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what occurs during follicular phase
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fsh is released and --> developmenet of primary ovarian follicle
follicle produces estrogen --> proliferation of uterine lining |
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what occurs during the luteal phase
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the follicule involutes and --> corpus luteum (secretes progesterone) which maintains the endometrial lining in preparation to receive a fertilized egg
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what happens if no fertilized egg implants into the endometrium
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corpus luteum degenerates adn progesterone levels fall, endometrial lining is sloughed off and menstruation occurs
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how does the follicular phase begin
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prior to the start of follicular phase, progesterone and estrogen levels decline during menstruation and this stimulates fsh release
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what does the dominant follicle do during the follicular phase
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it releases estrogen that enhances follicular maturation and increases production of fsh and lh receptors
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how are the estrogens produced by dominant follicle
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theca interna cells produce androstenedione in response to lh stimuation
granulosa cells convert androstenedione to estradiol when stimulated by fsh |
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when must fertilization of the egg occur
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within 24 hrs of ovulation
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how does the luteal phase begin
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granulosa and theca interna cells form the corpus luteum when stimulated by lh
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how long does it take for the placenta to create its own hcg
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8-10 wks
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at what age is menopause considered premature
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before age 40
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what is releated to early menopause
what is related to premature menopause |
smoking
premature ovarian failure and is usually idiopathic; if it occurs before age 5, then is might be genetic |
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what is diagnostic test for menoupause
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elevated fsh
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how long should hrt be given for
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no more than 6-12 mo, at the lowest dose to decrease sx
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contraindications to hrt
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chronic liver impairment
prgnancy known esrogen dependent neoplasm h/o thromboembolic dz undiagnosed vaginal bleeding |
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definition of primary amenorrhea
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no menstruation by age 16
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pathophys of imperforate hymen
presentation of pt |
hymen fails to canalize during fetal development and remains as a solid membrane across introitus
pw pelvic or abdominal pain from accumulation and dilation of vaginal vault and uterus by menses; on pe, pt will have bulging membrane just inside vagina, with purple-red discoloration, c/w hematocolpos |
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tx of imperforate hyman
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cruciate incision is made and hymen is sewn open
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pathophys of transverse vaginal septum
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failure of mullerian derived upper vagina to fuse with urogenital sinus derived lower vagina
although it is usually patent, sometimes it's not - can be confused with imperforate yman |
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how to differentiate transverse vaginal septum from imperforate hyman
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hymeneal ring will be present below transverse vaginal septum; not the case in imperforate hymen
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mrkh
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mullerian agenesis or dysgenesis
absencse of uterus or partial vaginal agenesis |
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difference between mrkh and vaginal atresia
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in vaginal atresia, the mullerian system is developed, but distal vagina is composed of fibrosed tissue
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physical findings in partial vaginal agenesis or vaginal atresia
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pelvic mass consistent with uterus, as felt on rectal exam
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tx of vaginal atresia
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neovagina is created and can be connected to upper genital tract
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pathophys iof testicular feminization
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androgen insensitivity, secondary to absence of testosterone receptors
mif was secreted early in develipment and pts have absence of all mullerian derived structures |
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physical features of testicular feminization
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absence of pubic hair and axillary hair
estrogen is produced and pts have breasts, but they have primary amenorrhea b/c they have no uterus |
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pathophys of primary ovarian failure
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low levels of estradiol but elevated levels of gonadotropics (hypergonadotropic hypogonadism)
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causes of primary ovarian failure
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savage syndrome
turner syndrome |
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savage syndrome
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failure of ovaries to respond to fsh and lh 2/2 receptor defect
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turner syndrome's effect on ovaries
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ovaries undergo rapid atresia, that by puberty there are no primordial oocytes
17-a-oh-ase can also be deficient, so there is amenorrhea and absence of breast development b/c there is no estradiol |
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swyer syndrome
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congential absence of testes in a genotypical male --> phenotypical picture similar to ovarian agenesis
b/c testes never develop, mif is not released adn pts have internal and external female genitalia they will not have breasts though, b/c there is no estrogen |
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kallmann syndrome
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congenital absence of gnrh
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relationship between hemosiderosis and pituitary fxn
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iron deposition can occur in pituitary --> destruction of cells that produce fsh and lh
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conditions that would cause breasts and uterus to be absent and primary amenorrhea
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gonadal agenesis in 46 xy
enzyme deficiencies in testosterone synthesis |
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conditions that would cause breasts to be present, uterus to be absent, and primary amenorrhea
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testicular feminization
mullerian agenesis mrkh |
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conditions that would cause uterus present breasts absent, and primary amenorrhea
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gonadal failure/agenesis in 46 xx
disruption of hypothalamic pituitary axis |
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conditions that would cause breasts and uterus present, but amenorrhea
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hypothalamic, pituitary, or ovarian pathogenesis similar to 2ndary amenorrhea
congenital abnormalities of genital tract |
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tx of for absent breasts
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estrogen replacement (to cause breast development and prevent osteoporosis)
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tx of hypergonadotrophic hypogonadism
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irreversible ovarian failur eoccurs so tehy will require estrogen replacement therapy
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definition of 2ndary amenorrhea
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absence of menses for >6 mo or absence of 3 menstrual cycles in women who previously had menstrual cycles
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#1 cause of 2ndary amenorrhea
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pregnancy
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anatomic abnormalities --> 2ndary amenorrhea
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cevical stenosis
asherman syndrome |
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asherman syndrome
etiology |
presence of intrauterine synechiae or adhesions, 2ndary to intrauterine surgery or infections
d&c, myomectomy, c-section, endometritis |
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etiology of cervical stenosis
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scarring of cervical os 2ndary ot surgical or obstetric trauma
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etiologies of ovarian failure
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torsion
surgery infection radiation chemo |
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describe what chronic anovulation can do to hormone levels
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elevated estrogen and androgen
increased androgen release from ovaries and adrenal cortex is converted peripherally in adipose tissue into estrone elevated androgens --> decrease in production of shbg --> increased free estrogens and androgens hyperestrogenic state --> increased lh:fsh ratio, atypical follicular development, anovulation, and increased androgen production |
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dx of 2ndary amenorrhea
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b-hcg is always first
tsh and prl levels should also be checked |
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progesterone challenge test
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give progesterone for 7-10 days to mimic progesterone w/d
if there is bleeding following the termination of progesterone = presence fo estrogen and adequate outflow tract |
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if progesterone challenge test is + and there is hirsutism, what is the differential
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pcos
adrenal tumor ovarian tumor cushing syndrome thyroid d/o adult onset adrenal hyperplasia |
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what if there is no response to progesterone challence
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r/o asherman's syndrome and cervical stenosis
give estroge + progesterone to see if bleeding occurs measure fsh and lh to differentiate btwn hypothalamic pituitary d/o and ovarian failure |
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major cause of m&m in elective termination of pregnancy
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general anesthesia
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how is elective termination of pregnancy accomplished in first trimester
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suction curettage
manual vacuum aspiration medical abortion (mifepristone or mtx - both + misoprostol) |
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how is elective termination of pregnancy accomplished in second trimester
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surgical evacuation of uterus
medical induction of labor |
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after what week are elective termination of pregnancy no longer done (unless to save mother's life)
why is this the limit? |
24 wks
this is the fetal stage of viability |
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what should be given to Rh- women at elective termination of pregnancy
when should it be given |
Rhogam at time of termination
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what is the most common way of accomplishing elective termination of pregnancy in 1st trimester
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suction curettage
although ru486 (mifepristone) might take over now |
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how is suction curettage performed for elective termination of pregnancy
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(D&C)
dilation of cervix and removal of POC using a suction cannula sharp curettage can be performed to ensure the uterus is completely evacuated using a paracervical block |
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when can vacuum aspiration be performed
describe process |
only up until week 7
insertion of soft flexible cannula into cervical os with manual extraction of poc using vacuum syringe |
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effecctiveness of first trimester termination of pregnancy
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98-99%
if less than 6wks ga, might miss a small fetus with suction curette can check for serial hcg levels |
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side effects of 1st trimester elective termination of pregnancy
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infection
bleeding uterine perforation incomplete ab ?higher risk for cervical insufficiency and uterine scarring |
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moa mifepristone
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progesterone receptor antagonist that binds to progesterone receptors in uterus, blocking progesterone from stimulating the endometrial lining
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when can mifepristone be used
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49 days from lmp and can be used with a prostaglandin analog
confirm with hcg or u/s |
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moa mtx
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dihydrofolate reductase inhibitor that interferes w dna synthesis, preventing placental villi proliferation
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efficacy of mifepristone
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65-85% alone
92-98% if given with misoprostol |
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efficacy rate for mtx + misoprostol
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94-96%
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side effects of medical ab
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abdominal cramps or pain
n/v/diarrhea excessive or prolonged uterine bleeding (10-17d) |
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what is the difference between d7c and d&e for elective termination of pregnancy
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in d&e, there is wider cervical dilation and extraction forceps may be needed to assist in complete evacuation of uterus (esp after 16 wks)
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what is used to dilate cervix in d&e for elective termination of pregnancy
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osmotic dilators such as laminaria (synthetic or seaweed based dilators placed inside the cervix the day before the procedure)
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after the cervix is dilated for a d&e, what is done next in elective termination of pregnancy
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suction cannula that goes into the uterus to extract the fetal tissue and placenta
if it is more advanced ga, forceps might be needed |
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effectiveness of d&e for elective termination of pregnancy
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98-99%
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side effects of d&e for elective termination of pregnancy
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cervical laceration
hemorrhage uterine perforation infectioni retained tissue |
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which is safer d&e or induction of labor in 2nd trimester elective termination of pregnancy
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d&e
(4/100,000 mortality rate for d&e) |
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process of iol for 2nd trimester elective termination of pregnancy
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cervical ripening agents are used
amniotomy high dose iv oxytocin infusion |
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effectiveness of iol for 2nd trimester elective termination of pregnancy
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80-100%
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side effects of iol for elective termination of pregnancy during 2nd trimester
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retained placenta
incomplete ab infection possible increase in live births and gi side effects (if oral and vaginal preps are used) |
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drugs that decrease sperm quality
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cimetidine
sulfasalazine spironolactone nitrofurans erythromycin tetracyclines anabolic steroids chemo heavy thc/etoh |
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how is low semen volume overcome in infertility tx
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washed sperm for intrauterine insemination
but ultimately must treat the underlying cause |
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cuases fo rlow sperm count/low semen volume
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hypothalamic-pit failure (give human menopausal gonadotropins)
varicoceles (can be repaired by ligation) intracytoplasmic sperm injection (insert the sperm directly into the egg) |
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how does endometriosis relate to infertility
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endometrial tissue can invade the local tissue and lead to severe inflammation and adhesions
interferes w tubal mobility, cause tubal obstruction, or lead to adhesions that hold the fallopian tube away from ovary or trap released oocyte |
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relationship between pid and infertility
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can cause pelvic adhesions
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how to increase fertility rates in women w endometriosis
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vaporization of endometrial implants
fertility is achieved in 30-75% of the time |
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complication of ivf
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increased risk of ectopic pregnancy
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advantage of tuboplasty to aid with fertility
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allows for more than one future pregnancy (c/w ivf)
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