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347 Cards in this Set

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hyperemesis gravidarum
severe n/v --> hospitalization sometimes for entire pregnancy
what does progesterone do to gi motility
slows it down
gerd in pregnant women
gets worse b/c there is decreased sphincter tone at ge jxn
why are there hemorrhoids in prgnancy
increased venous pressure from pressure on ivc from uterus, and increased pelvic blood flow
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
when is gestational dm tested for
27-29 wks of pregnancy
when is gbs testing done
36wks
how to handle maternal gbs
tx with iv pcn when they go into labor
consequence of dehydration on pregnancy
can lead to uterine contractions d/t 2ndary x-reaction of vasopressin with oxytocin
describe changes of lecithin and sphingomyelin in fetus
lecithin increases as fetus matures
sphingomyelin decreases beyond 32 wks
risk factors of ectopic pregnancy
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
strongest risk factor for ectopic pregnancy
prior ectopic pregnancy
complications of ectopic pregnancy
rupture --> hypotension, unresponsive, peritoneal irritation 2ndary to hemoperitoneum
hcg and ectopic pregancy
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)
heterotopic pregnancy
multiple gestations, with one iup and the other ectopic
how should a pt be treated, if they are stable, but present w a ruptured ectopic preg
ex-lap to evacuate the hemoperitoneum, coagulate any bleeding, adn resect the ectopic
how are pts tx if they present wtih ectopic pregnancy that hasn't ruptured
laparoscopic resetion of ectopic pregnancy
mtx
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
how to monitor mtx tx of ectopic
monior hcg... it should drop 4-7 days following tx, if it doesn't happen, then must receive 2nd dose of mtx
what week is the limit for a sab
<20 wks ga
abortus
fetus lost before 20 wks gestation
complete abortion
complete expulsion of products of conception before 20 wks
incomplete abortion
partial expulsion of some but not all products of conception before 20 wks
inevitable abortion
no expulsion of products of conception but bleeding and dilation of cervix occur so a viable pregnancy is not likely
threatened abortion
intrauterine bleeding before 20 wks w/o dilation or expulsion of products of conception
missed abortion
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
what should all rh-neg pregnant women with vaginal bleeding during pregnancy receive
rho-gam
PROM
when membranes surrounding the fetus rupture 1+ hrs prior to labor
prolonged PROM
when PROM occurs >18hrs prior to labor
definition of premature
when fetus is <37 wks
how to differentiate between amniotic fluid and vaginal fluid
vaginal secretions are acidic
amniotic fluid is alkaline
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
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
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
definition of PROM
if ROm occurs >1 hr prior to onset of labor
defitiion of PPROM
if ROM occurs preterm (<37 wks ga) and >1 hr prior to onset of labor
how to dx ROM
pool test
nitrazine
fern test
check u/s to see if if other tests are equivocal
definition of false labor
irreg ctx w/o cervical change
definition of labor
regular uterine ctx --> cervical changes
indication of IOL
post-term pregnancy
pre-eclampsioa
PROM
non-reassuring fetal testing
IUGR
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
cause of variable decels
results from umbilical cord compression
def of late decel
begins at peak of ctx and returns to baseline after ctx is over
1st stage of labor
onset of labor until complete effacement and dilation occurs
2nd stage of labor
full dilation until delivery
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
how to manage a pt with a ruptured ectopic pregnancy who is stable
ex lap to evacuate, coag, and resect pregnancy
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
how to manage a complete ab in first trimester
send to path for analysis
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
caused by persistent pid
most common pathogens associated with pid
gc/chlamydia
clinical dx of tubo-ovarian abscess
usually in the setting of pid + adnexal or posterior culdesac mass or fullness
elevated wbc with left shift
elevated esr
imaging study of tubo-ovarian abscess
u/s
pelvic ct in obese pt with limited u/s study
definitive dx of tubo-ovarian abscess
laparoscopy, but only used when the clinical presentation is unclear
ddifference btwn tubo-ovarian abscess and tubo-ovarian complexes
complexes are not walled off like a true abscess, and they are more responsive to abx tx
who should be suspsected of having a tubo-ovarian abscess
any pt with pid that is not responding to tx
tx of tubo-ovarian abscess
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
sx of tss
fever >102
erythematous rash
desquamation of soles and palms 1-2 wks after illness
hypotension
cx in tss
usually negative, b/c exotoxin is absorbed though vaginal mucosa
tx of tss
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
adrenarche
regeneration of zona reticularis in adrenal cortex and production of androgens

dheas and dhea and androstenedione are produced (until age 13-15)
gonadarche
follows adrenarche with pulsatile release of gnrh --> lh and fsh released from ant. pit (and ovaries then produce estrognes)
thelarche
breast development
pubarche
development of pubic and axillary hair
what is the order of puberty development
adrenearche
gonadarche
thelarche
pubarche
peak height velocity
menarche
at what age does adrenarche occur in females
6-8 yo and increases from ages 13-15
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
at what age does thelarche begin
why does it occur
age 10
it is usually in response to increased amounts of estrogen
what occurs during thelarche
breast bud development
estrogenation of the vaginal mucosa
growth of vagina and uterus
at what age does pubarche occur
age 11
at what age does peak growth velocity begin
9-10 yo
max peak is at 12 yrs (9cm /yr)
what causes the increased growth rate
increased estrogen levels, increased levels of growth hormone nad somatomedin c
aside from low % body fat, what else is related to delayed menarche in otherwise normal females
exercise and stress on body may inhibit ovulation through positive effects on norE and gnrh, thus interfering with menarche
what occurs during follicular phase
fsh is released and --> developmenet of primary ovarian follicle
follicle produces estrogen --> proliferation of uterine lining
what occurs during the luteal phase
the follicule involutes and --> corpus luteum (secretes progesterone) which maintains the endometrial lining in preparation to receive a fertilized egg
what happens if no fertilized egg implants into the endometrium
corpus luteum degenerates adn progesterone levels fall, endometrial lining is sloughed off and menstruation occurs
how does the follicular phase begin
prior to the start of follicular phase, progesterone and estrogen levels decline during menstruation and this stimulates fsh release
what does the dominant follicle do during the follicular phase
it releases estrogen that enhances follicular maturation and increases production of fsh and lh receptors
how are the estrogens produced by dominant follicle
theca interna cells produce androstenedione in response to lh stimuation
granulosa cells convert androstenedione to estradiol when stimulated by fsh
when must fertilization of the egg occur
within 24 hrs of ovulation
how does the luteal phase begin
granulosa and theca interna cells form the corpus luteum when stimulated by lh
how long does it take for the placenta to create its own hcg
8-10 wks
at what age is menopause considered premature
before age 40
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
what is diagnostic test for menoupause
elevated fsh
how long should hrt be given for
no more than 6-12 mo, at the lowest dose to decrease sx
contraindications to hrt
chronic liver impairment
prgnancy
known esrogen dependent neoplasm
h/o thromboembolic dz
undiagnosed vaginal bleeding
definition of primary amenorrhea
no menstruation by age 16
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
tx of imperforate hyman
cruciate incision is made and hymen is sewn open
pathophys of transverse vaginal septum
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
how to differentiate transverse vaginal septum from imperforate hyman
hymeneal ring will be present below transverse vaginal septum; not the case in imperforate hymen
mrkh
mullerian agenesis or dysgenesis
absencse of uterus or partial vaginal agenesis
difference between mrkh and vaginal atresia
in vaginal atresia, the mullerian system is developed, but distal vagina is composed of fibrosed tissue
physical findings in partial vaginal agenesis or vaginal atresia
pelvic mass consistent with uterus, as felt on rectal exam
tx of vaginal atresia
neovagina is created and can be connected to upper genital tract
pathophys iof testicular feminization
androgen insensitivity, secondary to absence of testosterone receptors
mif was secreted early in develipment and pts have absence of all mullerian derived structures
physical features of testicular feminization
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
pathophys of primary ovarian failure
low levels of estradiol but elevated levels of gonadotropics (hypergonadotropic hypogonadism)
causes of primary ovarian failure
savage syndrome
turner syndrome
savage syndrome
failure of ovaries to respond to fsh and lh 2/2 receptor defect
turner syndrome's effect on ovaries
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
swyer syndrome
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
kallmann syndrome
congenital absence of gnrh
relationship between hemosiderosis and pituitary fxn
iron deposition can occur in pituitary --> destruction of cells that produce fsh and lh
conditions that would cause breasts and uterus to be absent and primary amenorrhea
gonadal agenesis in 46 xy
enzyme deficiencies in testosterone synthesis
conditions that would cause breasts to be present, uterus to be absent, and primary amenorrhea
testicular feminization
mullerian agenesis
mrkh
conditions that would cause uterus present breasts absent, and primary amenorrhea
gonadal failure/agenesis in 46 xx
disruption of hypothalamic pituitary axis
conditions that would cause breasts and uterus present, but amenorrhea
hypothalamic, pituitary, or ovarian pathogenesis similar to 2ndary amenorrhea
congenital abnormalities of genital tract
tx of for absent breasts
estrogen replacement (to cause breast development and prevent osteoporosis)
tx of hypergonadotrophic hypogonadism
irreversible ovarian failur eoccurs so tehy will require estrogen replacement therapy
definition of 2ndary amenorrhea
absence of menses for >6 mo or absence of 3 menstrual cycles in women who previously had menstrual cycles
#1 cause of 2ndary amenorrhea
pregnancy
anatomic abnormalities --> 2ndary amenorrhea
cevical stenosis
asherman syndrome
asherman syndrome
etiology
presence of intrauterine synechiae or adhesions, 2ndary to intrauterine surgery or infections

d&c, myomectomy, c-section, endometritis
etiology of cervical stenosis
scarring of cervical os 2ndary ot surgical or obstetric trauma
etiologies of ovarian failure
torsion
surgery
infection
radiation
chemo
describe what chronic anovulation can do to hormone levels
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
dx of 2ndary amenorrhea
b-hcg is always first
tsh and prl levels should also be checked
progesterone challenge test
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
if progesterone challenge test is + and there is hirsutism, what is the differential
pcos
adrenal tumor
ovarian tumor
cushing syndrome
thyroid d/o
adult onset adrenal hyperplasia
what if there is no response to progesterone challence
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
major cause of m&m in elective termination of pregnancy
general anesthesia
how is elective termination of pregnancy accomplished in first trimester
suction curettage
manual vacuum aspiration
medical abortion (mifepristone or mtx - both + misoprostol)
how is elective termination of pregnancy accomplished in second trimester
surgical evacuation of uterus
medical induction of labor
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
what should be given to Rh- women at elective termination of pregnancy
when should it be given
Rhogam at time of termination
what is the most common way of accomplishing elective termination of pregnancy in 1st trimester
suction curettage
although ru486 (mifepristone) might take over now
how is suction curettage performed for elective termination of pregnancy
(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
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
effecctiveness of first trimester termination of pregnancy
98-99%
if less than 6wks ga, might miss a small fetus with suction curette
can check for serial hcg levels
side effects of 1st trimester elective termination of pregnancy
infection
bleeding
uterine perforation
incomplete ab
?higher risk for cervical insufficiency and uterine scarring
moa mifepristone
progesterone receptor antagonist that binds to progesterone receptors in uterus, blocking progesterone from stimulating the endometrial lining
when can mifepristone be used
49 days from lmp and can be used with a prostaglandin analog
confirm with hcg or u/s
moa mtx
dihydrofolate reductase inhibitor that interferes w dna synthesis, preventing placental villi proliferation
efficacy of mifepristone
65-85% alone
92-98% if given with misoprostol
efficacy rate for mtx + misoprostol
94-96%
side effects of medical ab
abdominal cramps or pain
n/v/diarrhea
excessive or prolonged uterine bleeding (10-17d)
what is the difference between d7c and d&e for elective termination of pregnancy
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)
what is used to dilate cervix in d&e for elective termination of pregnancy
osmotic dilators such as laminaria (synthetic or seaweed based dilators placed inside the cervix the day before the procedure)
after the cervix is dilated for a d&e, what is done next in elective termination of pregnancy
suction cannula that goes into the uterus to extract the fetal tissue and placenta
if it is more advanced ga, forceps might be needed
effectiveness of d&e for elective termination of pregnancy
98-99%
side effects of d&e for elective termination of pregnancy
cervical laceration
hemorrhage
uterine perforation
infectioni
retained tissue
which is safer d&e or induction of labor in 2nd trimester elective termination of pregnancy
d&e
(4/100,000 mortality rate for d&e)
process of iol for 2nd trimester elective termination of pregnancy
cervical ripening agents are used
amniotomy
high dose iv oxytocin infusion
effectiveness of iol for 2nd trimester elective termination of pregnancy
80-100%
side effects of iol for elective termination of pregnancy during 2nd trimester
retained placenta
incomplete ab
infection
possible increase in live births and gi side effects (if oral and vaginal preps are used)
drugs that decrease sperm quality
cimetidine
sulfasalazine
spironolactone
nitrofurans
erythromycin
tetracyclines
anabolic steroids
chemo
heavy thc/etoh
how is low semen volume overcome in infertility tx
washed sperm for intrauterine insemination
but ultimately must treat the underlying cause
cuases fo rlow sperm count/low semen volume
hypothalamic-pit failure (give human menopausal gonadotropins)
varicoceles (can be repaired by ligation)
intracytoplasmic sperm injection (insert the sperm directly into the egg)
how does endometriosis relate to infertility
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
relationship between pid and infertility
can cause pelvic adhesions
how to increase fertility rates in women w endometriosis
vaporization of endometrial implants
fertility is achieved in 30-75% of the time
complication of ivf
increased risk of ectopic pregnancy
advantage of tuboplasty to aid with fertility
allows for more than one future pregnancy (c/w ivf)