• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/304

Click to flip

304 Cards in this Set

  • Front
  • Back
changes in pregnancy are usually driven by which hormones?
Progesterone
Estrogen
Renin/Aldosterone
Cortisol
Insulin
How is vascular tone changed during pregnancy? SVR? why?
Vascular tone decreases resulting in a decrease in SVR by 20% - need more blood flow to the uterus for fetus
What are the hematologic changes that occur with pregnancy in reference to blood volume and RBC volume?
Blood volume increases by 50-100%

RBC increases 25-40%
define physiologic anemia
state of anemia that occurs with pregnancy - not a true anemia b/c the decrease in RBC volume and HCT is a functio nof the increased plasma volume. Mothers w/o physiologic anemia during PG have a higher incidence of still births
Why does physiologic anemia occur in pregnant women? (benefit to fetus?)
lowers lood count and lessens the chance of thrombosis and increases blood flow to the fetus (think decreased viscosity of blood). Also, mothers tend to lose a lot of blood during the birthing process, better post-partum if blood loss is more plasma than actual red cells (think normovolemic dilution)
Changes in blood volume, plasma volume, and RBC mass that occur with pregnancy.
all increase
(peak levels seen in third trimester)
women's undiagnosed caridac conditions will often times become evident in the first trimester of pregnancy - why?
b/c increased BV will result in an increase in CO
PG is a (hyper or hypo) coagulable state? why?
Hyper!!!
minimizes blood loss during delivery (increase in all coag factors except II, V, XII) -- downside is increased predisposition to DVT and PE
platelets ____ during PG
decrease
factr XI and XIII ______ during PG
decrease
WBC ______during PG
increase
Factors (clotting) that decrease in PG
II, V, XII
Protein S ______ during PG
decrease
sensitivity to APC _______ during PG
decrease
Change in heart positiion during pregnancy? affect on location of PMI?
left axis deviation - displaced cephalad -- PMI lateral and elevated
murmur type commonly found in 96% of pregnant women
systolic murmur -- aortic, pulmonic valves are usually most pronounced
changes in heart anatomy and rate that accompany PG
rate elevated (usually 80s);
ventricular distention due to increased CO and volume overloaded state; LVH; pericardial effusion
what type of murmur should NOT be heard during PG?
diastolic murmur
rhythm changes in heart commonly associated with PG
non-specific ST and T chnages, increased dysrhythmias (PVCs, runs of SVTs)
potassium levels are commonly _____ during PG -- leads to __________
low
hypokalemia leads to dysrythmias
______ is mostly responsible for increased CO at the beginning of PG while ________ is most responsible for increased CO found at the end of PG
beginning = increased SV
end = increased HR
which organs need extra blood flow in PG state?
Placenta
kidney (needed to help with excretion of metabolic wastes produced by fetus)
skin (helps with thermal regulation)
Change in BP in the first trimester
decreased overall (both systolic and diastolic) = decreased by 10%

usually, diastolic decreases by 10-15mmHg
if you see diastolic pressure of PG woman in the 80s or higher, think __________
pre-existing HTN
CO increases by ______ during PG

HR increases by ____
40%

20%
CV changes in labor relative to Co, SVR, and volume
CO = increased proportional to dilation in cm
SVR = increased with contraction
Volume = surge of 300-500 at time of delivery (increased risk to women whith chronic heart conditions)
the placenta receives _____ of CO
20-25% (750-1000ml)
sx of PG that mimic heart dz - think auscultation, CXR, and EKG as well
S3 gallop
systolic ejection murmur
peripheral edema
JVD
reduced exercise tolerance
dyspnea
change in heart postiion and size of CXR
increased vascular markings on CXR
nonpsecific ST and T wave changes EKG
Axis deviation on EKG
LVH on EKG
Na and K levels are ________ during PG
NL or just below NL
Progesterone levels _______ during PG and cuase_______
increase
stimulate renin which stimlulates Na retention, H20 retention, K excretion
changes in RBF, GFR, and Albumin during PG -- effects of each?
RBF and GFR increase (50% at least) to aid with clearin pof metabolic waste products by fetus

Albumin decreases -- due to extra fluid retention due to stimulation of RAA system -- lowers oncotic pressure and makes PE more likely as there is less gradient in getting fluid from the lungs into the vascular system
smooth muscle relaxatoin changes seen in PG are due to which hormone?
progesterone
kidney changes during PG
enlarged kidneys, dilitatoin of ureters, pelves, calyces -- cuases urinary stasis
usually more pronounced on right side -- UTIs more common
minute ventilation, PaO2, and PaCo2 _____ in PG women. Why?
increases - need to blow off more CO2 as fetus is also producing CO2

PaCO2 decreases (facilitation diffusion gradient for transfer of CO2 from fetus to mother) -- from 40 to 30

PaO2 increases
change in pH during PG is ______ which results in ________
usually more alkaline (>7.4) -- blowing off more CO2 results in compensated respiratory alkalosis
FRC change in PG
TV?
Resp RAte?
IRV?
decreased by 20%
increased tidal volume by 30-40%
rate and IRV have no change
define minute ventilatoin
tidal volume x breaths/min
GI complication associated with PG
slowed motility due to progesterone causes constipation and early satiety

relaxation of LES due to progesterone causes GERD

nausea and vomiting pror to bHCG level

biliary statis and cholesterol saturation result in increased gallstones
skin changes assoc with PG
hair growth on abdomen and face

spinder angiomata and palmar erythema (usually signs of liver dz)

mucosal hyperemia

hpyerpigmentation

stria gravidarum (stretch marks)

rashes/acne
main food source for fetus is _______
glucose
HCG suppresses _____
TSH
free levels of thryoid hormones during PG are _________
unchanged
total T4 and T3 during PG are _______
increased
TIBG is ____ during PG
increased
sensitivity to insulin is _____ in PG woman and this change is mediated by which hormones?
sensitivity is decreased

mediated by human placental lactogen and cortisol
too much HPL in the placenta can lead to _______
gestational diabetes (too much sugars released in circulatoin) -- results in high birth weigh babies
increased free plasma cortisol in PG women is due to _________
CRH from placenta stimulated ACTH in the adrenal gland
d/o that get better in PG women
coagulative deficiencies particularly with Factor V leiden, Protein S and Protein C; autoimmune d/o such as Lupus, Rheumatoid, and MS
PG women have (increased or decreased) immune function
state of immunosuppression making them more susceptible to infection
Immune changes that occur during PG in relatoin to _______.
progesterone
NK cells ______ in PG
decreased by 30%
cell mediated cytotoxic efects are ______ during PG
decreased
humoral/ innate immunity is _______ during PG
increased (IgG crosses the placenta)
Ig that crosses the placenta
IgG
PG women are more susceptible to infections by which organisms?
CMV, HSV, Varicella, Malaria
changes in the eye in relation to PG
increased thickness of the ocrnea dur to fluid retention

decreased intaocular pressure

avoid changes in eye correctoin during this time period
What are the four phases of uterine activity during pregnancy? What class of hormones acts during each
Quiescence - Inhibitors
Activation - Uterotrophins
Stimulation - Uterotonins
Inovlution - Oxytocin, thrombin
What hormones act during quiescence of PG
Inhibitors: progesterone, prostacycline, relaxin, NO, PTH related peptide, CRH, HPL -- inhibit uterine activity and cervical dilation up until the last month of PG
which hormones act during activation phase of PG/labor
Utertrophins -- cause uterine effacement and prime the uterus for contractoins (PGs); tells mom when baby is read to be delivered (fetal CRH) -- estrogen, progesterone, PGs, CRH
Which hormones are active during the stimulatoin phase of labor?
Uterotonins = PGs and oxytocin

labor occurs here - stimulates uterus, initiates contractoins, results in progressive cervical dilitation, uterine contractoins, and delivery
what hormones are active during involution?
Oxytocin and thrombin -- increase coagulation pathway; uterus involudes and contracts, prevents post-partum bleeding, returns utereus to the post PG state
the initiatoin of labor in humans is aminly mediated by a fetal increase in ________. Which receptors are upregulated and downregulated at intiation of labor?
DHEA
- placenta then converts this to estradiol
oxytocin and PG receptors increase while progesterone receptors decrease
oxytocin increases in the maternal serum during the _____ stage of labor and is produced by the _____
second stage

fetus
actions of oxytocin
stimulates uterine contractions

simtulates PG production from amnion/decidua
Oxytocin and PGs trigger the influx of _______ into ________ cells to stimulate ______. the process is mediated by _____ and final step that triggers contraction is ________
calcium

myometrial

uterine contractions

cAMP

Ca binding to MLCK
definition of labor
regular uterine contractions (30-60s, every 5 mins) + progressive cervical dilation
What are the requirements for management of labor?
1. continued progress wher eth efetus must move doown through pelvis (station) and continued/progressive cervical dilitation

2. reassurance of fetal status = healthy and able to tolerate labor
What are the mechanisms of labor?
1. effacement (softening, shortening and thinning of cervix w/ cervis withdarwn into the body of the uterus)
2. dilitation of cervix -- up to 10cm for complete dilatatoin and baby pass through cervix
3. Three P's = powers (uterine activity); passage (size/structure of mom's pelvis); passenger (fetus)
How is adequate power assessed?
uterine contractions are measured in terms of pressure by intrauterine catheter once contractions are 3-5/10 mins with a duration of 30-60s...if the sum of contraction in 10 minutes is not greater than 200-250 MVU, then labor is not normal and must be induced or augmented
What can be used to augment (speed up) labor?
oxytocin or AROM (artificial rupture of the membranes)
fetal macrosomia is defined as BW > _____ and is associated with _______
4500g

associated with increased likelihood of failed trial of labor
Lie refers to _____

types?

which is associated with safe vaginal delivery
the longitudinal axis of the fetus relative to the longitudinal axis of the uterus

categoirzed as longitudinal, transverse or oblique

longitudinal
Presentation refers to __________

types?

____ is associ with abnormal labor
fetal part that directly overlies the pelvic inlet

in longitudinal lie, the fetus can be cephalic (vertex) or breech

non-vertex (5%)
Altitude referes to _________

ideally = ?
position of the head with regard to the fetal spine (degree of flexion/extension of fetal head -- chin to chest)

optimally flexed with chin to chest to have the smallest possible presenting dianmeter in the cephalic presentation -- extension is associated with increased failure to progress to labor
Position of the fetus refers to ________

refernece for cephalic presentations is the ________ while refernce for breech presentation is the _______

malposition refers to any postiion in labor that is not ______
the relationship of the fetal presenting part to the maternal pelvis -- assessed on vaginal examination

occiput
sacrum

ROA, OA, or LOA
station refers to the _______

station = 0 found at ___
measure of descent of the bony presentation part of the fetus through the birth canal

leading bony edge of ischial spines which can be palpated on vag exam at approx 8 oclok and 4 oclok
What are the cardinal movements of labor -- list the major movements.
changes in position of fetal head during its passage through the birth canal. - req for fetus to successfully move through the birth canal

engagement, descent, flexion, internal rotation, extension, external rotation (restitiution), expulsion
Onset of labor (painful contractions) to point when labor becomes active
latent phase - stage 1 - labor
When the slop of cervical dilatin accelerates (req >80% effacement and >4cm dilation of cervix)
active phase - stage 1 - labor
factors affecting the duration of labor include __________
parity
maternal BMI
fetal position
fetal size
overall, both latent and active phases of the first stage of labor (increase or decrease) with multiparity
phases decrease = faster
complete diltatoin to delivery of neonate = stage __

how does mutiparity and epidural affect this length of this stage
2

multiparity and no epidural = faster
delivery of the placental occurs in which stage of labor

average time?
does parity affect this rate?
3

6 minutes
no
in stage 3 of labor, A threshold of 30 minutes was associated with a ____________ This suggests that manual removal and or extraction of the placenta is indicated after 30 minutes. Factors significantly associated with a prolonged second stage included ________
significantly increased risk of a greater than 500-ml blood loss, a drop in postdelivery hematocrit by greater than or equal to 10 percent, or a need for dilation and curettage.

preterm delivery, ≥3 previous abortions, induced labor, chorioamnionitis, and parity ≥5.
fetal heart rate mornitoring patterns are ______?
baseline
variability
periodic changes
define types of baseline patterns for fetal HR

NL
Tachy
Brady
NL = 120-160
Tachy >160
Brady < 120
variability patterns of fetal HR include?
(looks like a straight line)
absent = undetectable

minimal = </= 5bpm

moderate = 5-25
(NL strips have this usually)

marked > 25
periodic changes to fetal HR pattern include ____?

this is used to asess _____
accelerations (note that all return to baseline = periodic)
<32 wks = 10bpm over baseline

decerlatoins - variable length and depth; early or late

>32 wks = 15bpm over baseline

assesses normal acid/base status in fetus
variable deceleratoins in fetal HR patterns are due to ______

sx if UV is compressed?
sx if UA is compressed?
umbilical cord compression

UV = decreased preload, fetal hypotension, fetal increased HR

UA = increased SVR, decreased HR = protective
early decelerations in fetal HR are/are not associated with fetal compromise?
are not
late decelerations in fetal HR indicate _____
indicates uteroplacental insufficiency = hypoxia; reflex late - low O2 in CNS, increased symp tone, increased BP, baroreceptor mediated brady; myocardial depression due to acidosis
managemetn of abnormal fetal HR patterns are done by?
1. hypotension -- change maternal position to left lateral recumbent, IVF hydration, ephedrine
2. materal O2 admin
3. cessatoin of contraction -- discontinue oxytocin and uterine relaxants (terbutaline)
4. amnionfusion
5. expedite deliver (open vaginal deliver or C section)
based on the level of presentation - identify the following levels of pain

T10-T12
S2-4
T4

most common management of this pain?
T10-12 = uterine pain
S2-4=delivery pain
T4 = cesarean pain

MCC = regional analgesia/anesthesia -- others include psychoprophylaxis with TENS, acupuncture, prenatla eduction OR systemic opioid
risks of pain control in labor
neonatoal depression
delayed gastric emptying
bolus/PCA options for pain control in labor
meperidine, nalbuphine, butorphanol
types of regional analgesia/anesthesia that can be used for pain control in labor
epidural (L2-L5) - local - bupivicaine - dosing throughout labor

spinal (Csection) - intrathecal opioid or local anesthetic such as bupivicane -- administered as single dose -- usually only 1-2hr needed

local/pudendal = short acting anesthetic (lidocaine or bupivicaine) - administerd to vagina/perinium
abnormal labor (prolonged descent, prolonged dilitation) intervention optoins
augmentation -- oxytocin (req reassuring fetal status), AROM

therapeutic test

operative vaginal delivery

CSE
indications for operative vaginal delivery
prolonged 2nd stage (pushing0

fetal compromise

aftercoming fetal head/breech

maternal indicatoin (cardiac or CNS dz0
requirments for operative vaginal delivery
consent
completely dilated
ruptured membranes
anesthesia
empty bladder
known fetal position
what type of operative vaginal delivery has a higher success rate? lower maternal trauma?
forceps

vacuum
indications for cesarean?
maternal = CNS or cardiac dz

fetal = NR fetal status, malrepresentation, HSV or HIV infection

maternal/fetal = arrest of labor, abruption (bleeding behind placenta), placent previa
type of cesarean done mostly of the time?

type for preterm babies, malrepresentation babies, or obstructed uterus
MCC = low transverse CSE

preterm etc = classical = vertical cut
vaginal births followin cesareans have higher success rates if _______
prior vaginal birth
prior malpresentation
spontaneous labor
Uterine rupture during vaginal birth following cesarean is greatest for what type of cesarean?
Classical -- vertical incision
criteria for candidates to have vaginal births following cesarean
one prior LTCS (transverse cut cesarean)

no prior rupture/UT scars

immediate cesarean available
risk factors for preterm birhts (<37wks)
prior PTB = strongest
multiple gesatsions
SES
uterine anomalies
fetal anaomalies
first trimester bleed
AMA (advanced maternal age)
<18yo
PTB interventions
primary = risk factor scoring and early ID

secondary = tocolyisis - make uterus stop contracting (no meds/oxytocin)

tertiary = improve neonatal outcome with antenatal coricosteroid sand surfactant
agents used in tocolysis and benefits
idea = inhibt uterine contraction

use: MgSO4, B mimetic (terbutaline), nifedipine, indomethacin, oxytocin receptor antagonists

delay -- allwos for administration of ACS and maternal transfer
tocolyis agents that are calcium channel blockers are the most commonly used agents, list them.
nifedipine
Mg sulfate
Antepartum glucocorticoid tx is used for _________ with perterm births -- what agents are used?
agents = betamethasone
dexamethasone

used to reduce incidence of RDS (most common side effect in preterm birth), IVH, NEC (necrotizing enterocolitis), and neonatal death
17 a-hydroxyproesterone caproate is a steroid given to women with prior PTB to _______
reduce PTB and IVH, need for supplemental O2 and low BW
mothers with hx of preterm births should take this weekly
vaginal pooling, nitrazine positive and ferning = dx of _________
PPROM = preterm premature ROM or premature ROM
complicatins and management of PPROM
complications = PTB, IAI (intramniotic infection), IUFD cord accident

manage = admission, ACS, deliver at 34 wks, antibiotics (ampicillin + erythro) for 7d to prevent prematures sepsis
preterm birth effective management strategies include
AB for PPROM to increase latency and reduce neonatal morbidiy

17P for prevention of recurrent PTB

antenatal corticosteroids (ACS) for women with high risk PTB

GBS antimicrobial prophylaxis to reduce neonatal infectious morbidity
NL menstrual cycle characteristics with regard to:
interval
duration
volume
composition
interval = 24-35 d (mean = 28)
duratoin = 2-7d (mean = 5)
volume = mean of 35mL (>80mL abnormal)
compositoin = nonclotting blood, endometrial debris, dead and living endometrial cells
proliferative phase of endometrial cycle corr with the ________ of the ovarian cycle
follicular phase

FOL:
POS
luteal phase of the ovarian cycle corr with ____ phase of the endometrial cycle
secretory phase

FOL:
POS
GnRH is a ______ hormone released by the _________ and acts on the _________, stimulating release of ___________
decapeptide

hypothalamus

pituitary

FSH and LH production
effect of GnRH on FSH and LH when released pulsatile vs continuous
pulsatile = maintains concentrations of FSH and LH

continuous = leads to rapid and reversible suppression of both LH and FSH
what are gonadotropins?
FSH LH and hCG

glycoprotein heterodimers with same a subunit (same as TSH too)
FSH and LH both stimulate the _______

function?
ovary

FSH = follicular development, estrogen

LH-= androgen, ovulatoin, progesterone
which gonadotropins bind the the LH receptor?
LH
hCG (longer serum half life)
high levels of estradiol have what affects on LH release?
feeds back to pituitary so that low levels suppress LH release while high levels trigger release
function of estradiol
cuases endometrial proliferation (remember that this corr with fillicular phase of the ovarian cycle) and induces female sencondary sex characteristics like breast development and body fat distribution
estradiol and progesterone are both derived from ______
cholesterol (C27)

estradiol = C18
progesterone = C21
functions of progesterone
cuases endometrial differentiation (stops proliferation, allows embryo implantation
effect of high levels of progesterone on FSH and LH
suppresses pituitary FSH and LH
where are inhibin A and inhibin B produced?
Inhibin A = ovarian granulosa cells

Inhibin B = luteal cells
function of inhibin
inhibits pituitary FSH secretion

(TGF-B family glycoprotein heterodimer)
Day 1 of the menstrual cycle is ______
menstruation - shedding of endometrium
ovulaton occurs at day ___
14.5
endometrium is receptive for embryo implantion at day ______
20-24
FSH target for males and females

LH targets?
FSH: male - sertoli cells of testis to maintain spermatogenesis

LH: male - leydig cells to promote testosterone synthesis
effects of testosterone and DHT (active metabolite)

_______ mediates the effcts of testosterone on bone and brain and othe rorgans
increasing protein anabolism
nitrogen retention
increasing bone densityand muscle mass
modulating the immune system

estrogen
testosterone precursor

testosterone can be converted to ________
precursor = adrostenedione

can be converted to DHT (bioactive form by 5 a reductase) and estradiol (by aromatase)
main inhibitor of LH production in males is ______

inhibitor of FSH in males
estradiol

estradiol and inhibin B (peptide produced by sertolic ells of the testes)
what does FSH need in order to induce spermatogenesis in sertoli cells
testosterone
Days 1-4 of menstrual cycle correspond with what actions and hormonal changes
Early follicular phase, proliferative (menstrual phase)

actions: follicle development and endometrial proliferatoin

hormones: low E2 and inhibin; increasing FSH;
Days 5-13 of menstrual cycle correspond with what actions and hormonal changes
mid/late follicular phase; proliferative uterine phase

actions: selection of dominant follicle and endometrial proliferation

hormones: increasing E2 and inhibin; decreasing FSH

Note: during this phase, LH receptors begin to develop on the follicle and subsequently, progesterone production begins - so P increases here too
Days 13-14 of menstrual cycle correspond with what actions and hormonal changes
Ovulatoin and proliferative Uterine phase

actions: oocyte maturatoin and release

hormones: high E2, LH surge
Days 15-19 of menstrual cycle correspond with what actions and hormonal changes
early luteal and early secretory phase

actions: endometrial differentiation

hormones: increasing P, E2 and inhibin
Days 20-24 of menstrual cycle correspond with what actions and hormonal changes
Midluteal ovarian and early secretory uterine phases

actions: allow embryo implantation

hormones: high P, E2, inhibin
Days 25-28 (non pregnant woman) of menstrual cycle correspond with what actions and hormonal changes
late luteal and late secretory phases

actions: prepare for menses and recruit new follicular cohort

hormones: decrasing E2, P, and inhibin; increasing FSH
Days 25-28 (pregnant female) of menstrual cycle correspond with what actions and hormonal changes
Decidua uterine phase

actions: maintain CL P production

hormones: increasing hCG and P
What hormone drives the growth of the follicular cohort in d1-5 of the menstrual cycle?
FSH
growing follicles produce what hormones?
increased E2 and inhibin
FSH-R increases
vascularity of theca layer increases
increased estradiol induce what changes in the endometrium?
endometrial proliferation and hypertrophy
Why does FSH increase at d1 of the menstrual cycle?
few days before d1, the corpus luteum from the previous cycle fails, so falling levels of inhibin A and progesterone and estrogen relieve inhibition of pituitary, so FSH increases
as inhibin and E2 rise, _______ decreases during late follicular phase. At moderate E2 levels, there is (increased or decreased) LH storage and _____ release.
moderate E2 -- increased LH storage, inhibited release
by day 5-7, FSH levels __________ resulting in _________.
FSH levels decrease -- results in selection of dominant follicle, which produces increasing amounts of E2 -- other follicles become atretic
increasing E2 throughout the proliferative phase induces what changes in the uterine lining?
proliferation and hypertrophy of the endometrium
During follicular phase, what are LH levels doing?
increased production, but not release!!
At d14, the dominant follicle has made an abundance of E2 due to ___________. What helps to further increase further E2 production?
increased FSH and later LH receptor acquisition

small amount of progesterone production stimjulates a signsificant FSH surge, which further increases E2
When does the LH surge occur and what does it result in?
LH surge occurs at d14 -- release of oocyte and completion of meiosis I
after ovulation, ____ forms which secretes _______
corpus luteum (formed by FSH secreting granulosa cells and some LH secreting thecal cells) -- secretes E2 and P
during ovulatoin, high E2 (>200pg/mL) sustained over >50hrs causes massive release of _______
LH
Progesterone levels do not significantly begin to rise until _________
d14 ovulation
The menstrual cycle
for reference
the lifespan of the corpus luteum is __________ unless rescued by log increases in _________
lifespan = 14 +/- 2d

hCG
hormones produced by the corpus luteum
E + P + inhibin
what hormone(s) recruits a new follicular cohort once the CL fails?
FSH
differentiation of the endometrium to become receptive to embryo implantation is facilitated by which hormone
progesterone
Without pregnancy, _______ levels fall with CL atresia, resulting in __________
progesterone and estrogen

sloughing of the endometrial layer and menstruation
CL-derived estrogen, prog, and inhibit suppress ______ producion. With atresia, these levels rise.
FSH
absence of menses > 6 months
amenorrhea
absence of menses for a period of 35d to 6months
oligomenorrhea
menses having regular intervals <21d
polymenorrhea
regular intervals of menses for a period of >7d OR >80mL in volume
menorrhagia
irregular intervals of menses for >7d OR >80mL in volume
metrorraghia
indications for hysterectomy for women <30yo
menstrual dysfunction
cervical dysplasia
indications for hysterectomy in general
uterine myomas
prolapse
endometriosis
DDX for d/o of menstruation
Complications of PG
benign anatomical lesions
inflammatory dz
reproductive tract malignancy
coagulation d/o
systemic illness
dysfunctional uterine bleeding
complicatoins of PG that may cause d/o of menstruation
threatened or imcomplete abortion
ectopic pregnancy
gestational trophoblastic dz
retained products of conception
Benign anatomical lesions that may cause d/o of menstruation
endometrial polyp
submucous myoma
adenomyosis
Inflammatory disease taht may cause d/o of menstruation
endometriosis
reproductive tract malignancy that may cause d/o of menstruation
cervical
endometrial
coagulation d/o that may cause d/o of menstruation
von Willebrand's disease (MCC hereditary bleeding d/o)

thrombocytopenia

PLT function abnormalities
systemic illness that may result in d/o of menstruation
thyroid dysfucntion
renal/hepatic dz
What is dysfunctional uterine bleeding?
dx of exclusion

abnormal uterine bleeding not related to PG, pelvic path, or systemic dz. Categorized by by anovulation (90%) or ovulatory (10% but with midcycle bleeding or polymenorrhea due to abnormally short follicular or luteal phase
The latency period of sexual issues in children corresponds with ________
low level of activity int he hypothalamic-pit-gonadal axis
masturbation and orgasm begin at what age in children
masturbation - 2yrs
50% achieve orgasm by 4 yrs of age
at what age have 50% of boys reached Tanner 2 or higher (define this)
age 12
age 13.5 = 90%
tanner 2 = testes greater than 2.5cm long - w/ or w/o pubic hair
Erection is caused by intrapenile ______ release. It is produced by a rx (describe) and results in the relaxation of trabeculae in the ____________ thus (increasing/decreasing) blood flow from the hypogastric arterial system and blocking (venous or arterial ) outflow
Intrapenile NO release
relaxes the traveculae of the corpora cavernosa and the corpus spongiosum at the glans to increase blood flow from the arterial system that then fills the erectile chambers. The in crase in pressure of the blood blocks venous otflow causing penile engorgemetn and erection

the enzyme NOS, along with NADPH and O2, convert ARg into citurline and NO
Define each in relation to male sexual response cycle:

EXCITEMENT
PLATEAU
ORGASM
RESOLUTION
Excitement = erection
Plateaus = penis is completely erect, glans swells, testes pulled higher and closer to body, cowpers glands secrete lubricant, may contain sperm
Orgasm: increase in P, BP, R as orgasm is reached = point of no return
Resolution - loss of erection and enter refractory phase where arousal is absent for a while
Define erectile dysfunctoin
cannot acquire or maintain an erection of sufficient rigidity for intercourse for 3 or more months. 75% of attempts
define delayed ejaculation
difficulty achieving orgasm
Causes of Erectile dysfunction
Atherosclerosis - inadequate blood flow

Meds - SSRIs, BP meds, diuretics, cimetidine

DM - circulation and neural effects

Obesity - circulatory problems

Recreational Drugs - Nicotine, ETOh, cocaine

Hormone Levels - testosterone, thyroid

Post operative complication - prostate surgery

Psychological Interference - depression, anxiety

Relationship problems

Age
How do we decipher between erectile dysfunction and sexual dysfunction?
Nocturnal or early morning erections means that system works -- not erectile dysfunction
what is absolutely needed for erectile function
NOS (to produce NO - tobacco decreases NOS)

Hypogastric blood flow (allows engorgement and provides O2 - decreased blood flow due to atherosclerosis)
what hormones play a role in maintaining intra-penile NOS levels
testosterone
What chronic dz can lead to impotence?
Hyperthyroidism
Hypothyroidism
Hyperprolactinemia
Risk factors for erectile dysfunction
smoking
obesity
drugs
cycling
Oral treatment of erectile dysfunction
type 5 PDE -- breaks down cGMP -- inhibit this, increase cGMP, promote corporeal smooth muscle relaxation which allows blood to be trapped

CI with nitrates and alpha blockers

sildenafil (viagra), vardenafile (levitra), tadalafil (cialis)

works for causes of ED that are both psychological and physical (not endocrine)
The menstrual cycle
for reference
Tanner scale for pubic hair
Pubic hair (both male and female)
Tanner I
no pubic hair at all (prepubertal Dominic state) [typically age 10 and younger]
Tanner II
small amount of long, downy hair with slight pigmentation at the base of the penis and scrotum (males) or on the labia majora (females) [10–11.5]
Tanner III
hair becomes more coarse and curly, and begins to extend laterally [11.5–13]
Tanner IV
adult-like hair quality, extending across pubis but sparing medial thighs [13–15]
Tanner V
hair extends to medial surface of the thighs [15+]
tanner scale for male genitals
Genitals (male)
Tanner I
prepubertal (testicular volume less than 1.5 ml; small penis of 6 cm or less) [typically age 9 and younger]
Tanner II
testicular volume between 1.6 and 6 ml; skin on scrotum thins, reddens and enlarges; penis length unchanged [9-11]
Tanner III
testicular volume between 6 and 12 ml; scrotum enlarges further; penis begins to lengthen to about 9 cm [11-12.5]
Tanner IV
testicular volume between 12 and 20 ml; scrotum enlarges further and darkens; penis increases in length to 12 cm and circumference [12.5-14]
Tanner V
testicular volume greater than 20 ml; adult scrotum and penis of 18 cm in length [14+]
tanner scale for female genitals
Breasts (female)
Tanner I
no glandular tissue; areola follows the skin contours of the chest (prepubertal) [typically age 10 and younger]
Tanner II
breast bud forms, with small area of surrounding glandular tissue; areola begins to widen [10-11.5]
Tanner III
breast begins to become more elevated, and extends beyond the borders of the areola, which continues to widen but remains in contour with surrounding breast [11.5-13]
Tanner IV
increased breast size and elevation; areola and papilla form a secondary mound projecting from the contour of the surrounding breast [13-15]
Tanner V
breast reaches final adult size; areola returns to contour of the surrounding breast, with a projecting central papilla. [15+]
first pubertal change in females is _______
thelarche (breast buds )
around age 10 9range = 7-13yo
growth spurt in females occurs during Tanner _____ around age ________. how does this differ from boys?
Tanner 3
age 12
usually just preceeds menarche - accompanied by acne and axillary perspiration

boys usually experience a growth spurt approximately 2 yrs after puberty
axillary hair arises during Tanner ___
Tanner 4
Menarche usually occurs between Tanner stages ______ and _____, around age _______
Tanner 3 and Tanner 4
age = 12.5
MCC STDs among female adolescents - only 1/2 of respondents had had sex.
HPV (18%)
Chlamydia (4%)
Trich (3%)
HSV2 (2%)
infection rate among sexually active female adolescents in 2008
40%
Anatomic changes that occur in the following during arousal:

Vagina
Clitoris
Labia minora
Vagina:
- increased lenght and width
-increased blood flow
-increased lubrication

Clitoris
- increased blood flow and engorgement

Labia minor:
- increased blood flow and engorgement
congenital defect where bowel externalized through the fetal abdomen
gastroschisis
common infections in the prenatal setting that can be diagnosed in the prenatal setting
TORCH - passed from mother to fetus

T-toxoplasmosis/toxoplasma gondii
O-other infections (Hep B, Syphilis, Varicella-Zoster virus, HIV, Parvovirus B19)
R-Rubella
C-CMV
H-HSV

Note: parvovirus, CMV and toxoplasmosis can be diagnosed in the prenatal setting
hematologic abnormalities that can be diagnosed and treated in the prenatal setting
anemia
thrombocytopenia
the vast majority of abnormal conceptuses end up ______.
(%) of conceptions ending in spontaneous abortion?
how many are aneuploid?
spontaneous abortion

30% of all conceptus end in SB
1/2 are aneuploid
Qualification of screening tests to patients in general
offered to low risk pt
generally low cost and low risk
reproducible and widely available
balanced between sensitivity (# of abnormal individuals identified by test) and specificity (how many negatives are true negatives)
ABNORMAL SCREENING GENERALLY RESULTS IN DX TESTING
Diagnostic testing in the prenatal period is used for what purpose?
single gene and karyotyping of abnormalities (done by fetal cells)

structural or physiological abnormalities (imaging - U/S, MRI, fetoscopy)
how do we define the trimesters of PG
Trimester 1: 0-12 weeks (baby more likely to spontaneously abort, organs form up to 9 wks)

Mid-trimester = 13-24 weeks = pre-viable baby, organogenesis complete

3rd trimester = 24 wks and later -- likely to survive
risk factors for aneupoloidy
maternal age (>35, increases dramatically)
propr aneuoploidy
multiple prior spontaneous abortoins
prior unexplained stillbirth
(these risk factors still only ID 20% of fetuses with aneuploidy)
risk for Down's syndrome for a mother at advanced maternal age
1/250
Amniocentesis is typically done during what phase of gestation?

risk of PG loss with procedure?

What tests can be done with amniotic fluid?
between 14 and 20 weeks (2nd trimester)

1/400

squames floating in fluid can be karyotypes (7-10d for results)

can also do biochemical, PCR, DNA testing (AF-AFP (spina bifida), GI enzymes)
can test for infection (CMV, Rubella, Toxo, Parvo)
Chorionic Villus Sampling id done between what period of gestation?

What is done with the sample?

risk associated with PG loss?
10-12 wks (first trimester)

Karyotype and DNA
PCR for infections
(can't test AFP for spina bifida)

1/200 (2x amnio)
What is cordocentesis?
Risk of loss of PG?
used for?
sampling of fetal blood - using needle

risk = 1-2%

used more for tx than dx -- think intrauterine transfusion, fetal blood count, give blood/meds to anemic babies

able to rapid daryotype frm WBCs, Viral PCR, Fetal serum testing -- due to advances in other less invasive forms of testing, more for tx than dx
How do we do prenatal screenin and testing in the 1st trimester vs second?
first trimester: first screen with U/S then move to chorionic villus sampling

Second trimester: U/S then amnio or cordocentesis
What infections can be tested for prenatally?
CMV
Toxoplasmosos
Parvovirus B19
Rubella
What do we look for on U/S for first trimester screening?
Trisomy 21 (Down's)
Trisomy 18
fetal demise
IUGR
CARDIAC AND THORACIC DISORDERS
What dz do we look for on U/s for second trimester screening (includes serum screening of mom)?
OPEN FETAL DEFECTS - SPINA BIFIDA
Trisomy 21
Trisomy 18
IUGR
PRETERM BIRTH
Fetal demise
alpha-fetoprotein is produced in what fetal organs?

abnormally high levels of MS-AFP are due to what causes?

when do we test?
fetal liver -- excreted by kidneys

overproduction (liver dz)
excess leakage from fetal circulation (spina bifida, skin d/o with breach, amphalocele, gastrochesis)
excess excretion (nephrotic syndrome)
excess leakage from amniotic fluid compartment (placental dz)

15-20wks gestation
First Trimester screening - does not detect _____

what parameters are used from Trisomy 21, 18
neural tube defects (AFP levels are compromised with T18 - can't be done during this period)

maternal serum sample for pregnancy associated protein A (PAPP-A) and B-HCG (free)

U/S for nuchal translucency - value combined with above serum values for detection - measure fluid at the back of the neck

both T21 and T18 have low PAPP-A values

T21 has high B-HCG
T18 has low B- HCG
second trimester serum screening for chromosomal abnormalities is ____________ and usually done at _________ weeks.
gestational age dependent
usually done at 15-20 weeks
How is Down's syndrome Screened in the second trimester?
Tests of the mother's blood drawn during the second trimester may be used to estimate the risk of having a baby with Down syndrome. These blood tests measure normal substances (called markers) in the mother's blood that are secreted by the placenta or the fetus. The markers that are used in the screening process include alpha-fetoprotein (AFP), unconjugated estriol (uE3), human chorionic gonadotropin (hCG), and inhibin A. Depending on the clinician and hospital, women are offered a triple screen, in which the AFP, uE3, and hCG are measured, or a quadruple screen, which adds the inhibin A measurement to the test. The quadruple screen is more accurate than the triple screen

In pregnancies affected by Down syndrome, the markers often exhibit a characteristic pattern: levels of AFP and estriol in the mother's blood are, on average, 25 to 30 percent lower than normal, while hCG and inhibin A are two times higher than normal.

.In pregnancies affected by Down syndrome, the markers often exhibit a characteristic pattern: levels of AFP and estriol in the mother's blood are, on average, 25 to 30 percent lower than normal, while hCG and inhibin A are two times higher than normal.

In pregnancies affected by Down syndrome, the markers often exhibit a characteristic pattern: levels of AFP and estriol in the mother's blood are, on average, 25 to 30 percent lower than normal, while hCG and inhibin A are two times higher than normal.

In pregnancies affected by Down syndrome, the markers often exhibit a characteristic pattern: levels of AFP and estriol in the mother's blood are, on average, 25 to 30 percent lower than normal, while hCG and inhibin A are two times higher than normal.

In pregnancies affected by Down syndrome, the markers often exhibit a characteristic pattern: levels of AFP and estriol in the mother's blood are, on average, 25 to 30 percent lower than normal, while hCG and inhibin A are two times higher than normal
What does a positive screen mean for down's?

How is it diagnosed?
A positive result means that a woman's risk of having a child with Down syndrome is at or above a specific cut-off level. Screening tests do not indicate for certain if the baby is affected. Further testing is needed to definitively say if the child is affected

triple screen = 60% (40% of positive women are not identified)

quadruple screen = 70%
dx = amniocentesis if later in PG, CVS with early detection
in a targeted U/S - how many aneuplid fetuses will have U/S markers?
1/2
Duodenal atresia can be seen on U/S - why is this significant?
1/3 with chrom abnormality

will need to be delivered at tertiary hospital b/c needs surgery

increased risk of preterm labor and membrane rupture
high levels of AFP in the maternal serum screening done inth esecond trimester may indicate increased risk of?

what would you do next?
if normal, then what?
A baby with a neural tube defect of the brain (anencephaly) or spinal cord (spina bifida)
A baby with a birth defect of the abdominal wall
More than one fetus
Pregnancy complications, such as miscarriage, slowed growth or death of the fetus, and premature detachment of the placenta (placental abruption)


FOLLOW WITH U/S
Confirming the length of the pregnancy
Determining whether more than one fetus is present
Determining whether the fetus has died
Detecting many birth defects

NL? fetal problem less likely but NTD still possible -- do a chromosomal analysis with cells from amniotic fluid to confirm AchE levels to confirm anencephaly or spinal bifida
triple and quadruple screening tests for Down's determine _________
estimate risk of Down syndrome and othe rchromosomal abnormalities - may not be necessary if screened in first trimester
why do we do targeted Ultrasonography in second trimester moms?
Targeted ultrasonography aims to identify certain structural birth defects that indicate an increased risk of a chromosomal abnormality. This test can also detect certain variations in organs that do not affect function but may indicate an increased risk of a chromosomal abnormality. However, normal results do not necessarily mean that the risk of a chromosomal abnormality is reduced.
Ultrasonography uses
Confirm the length of the pregnancy
Locate the placenta
Indicate whether the fetus is alive
After the third month, detect certain obvious structural birth defects, including those of the brain, spinal cord, heart, kidneys, stomach, abdominal wall, and bones
In the 2nd trimester, detect findings that tend to indicate a higher-than-normal chance of a chromosomal abnormality in the fetus (targeted ultrasonography)

Ultrasonography is often used to check for abnormalities in the fetus when a pregnant woman has abnormal results on a prenatal blood test or a family history of birth defects.

Ultrasonography is done before chorionic villus sampling and amniocentesis to confirm the length of the pregnancy so that these procedures can be done at the appropriate time during the pregnancy.
main advantage of CVS over Amnio?

what do you have to use amnio over CVS for?
results are earlier in PG than amnio - can make decision earlier, earlier treatment

AFP testing
common characterisitics of women haivng abortions
20-29yo
non-white
poor/low income
1 or more children
effects of unintended PG on infant, child and parent health
later onset of prenatal care
lower rates of breastfeeding

some have noted increased rates of risk behaviors and higher rates of low BW infants

no difference in well baby care or childhood immunization
birth parents choos adoptive parents and are involved after adoption is completed
open adoption
birth parents choose adoptive parents but not involved after birth/adoption complete and communication may occur ONLY through 3rd party
semi-open adoption
adoption where there is no identifiying info on either side - only medical hx shared -- common with larger agencies
closed adoption
types of abortion that can be done during the following time perods:

First Trimester

which methods are preferred?
First trimester =
vacuum aspiration (5-12wk)
dilation and Curettage (5-12)
mifepristone and misporstol - (5-10)

vacuum aspiration or drugs
most of US abortions are medical abortions (drugs - mifepristone (RU486) followed 2d later by misoprostol orally is the most effective mehtod of termination 49 days (up to 63 days) from LMP or less - bleeding usually for 14d after)
Abortion options for second trimester (13-22wks) - preferred options?
Options:
Vacuum aspiration (13-15 -- specially traned providers only)

Dilation and evacuation

Mifepristone and repated doses of misoprotol or gemeprost

Vaginal PGs (repeat doses)

hypertonic solutions

intra/extra amniotic PGs

Preferred = D&E, mifepristone, vaginal PGs
how is expulsion of fetus confirmed?
hCP or U/S - medical abortion have risk of teratogenicity so f/u is essential -- must be willing to undergo surgery if it fails
Suction procedure for abortoin usually done during what time period?
manual vacuum = up to 12 weeks but not before 6 wks b/c higher likelihood of retained products of abortoin

13-15wks -- electric vacuum aspiration
when do you need to dilate the cervix for abortion?

how is it done during this time?
after 9-10 wks

dilate cervix, remove intrauterine contents, requires anesthesia, more expensive
D&C vs D&E
D&C = up to 12 weeks, typically done with min anesthesia, outpatient

D&E = 12+weeks, heavy sedatoin and anesthesia, skilled operator

both are for 1st trimester PG
how do we terminate pregancies in the 2nd trimester?
Dilation and Evacuation = surgical procedure done at 12+weeks

dilate to 2-3cm, may take up to 48 hrs, done with hygroscopic dilators or misoprostol -- then drain amniotic fluid to decrease risk of embolism (mom goes into RHF if not) and bring fetal parts into lower uterine segment --- then use forcepts to remove fetus and placenta , may require disarticulatoinof fetus, risk of bleeding and performation

medical abortion - used 14+ weeks - like labor induction

cervical ripening (misoprostal) + multiple agents (pitocin), inpatient, expensive, delivery w/in 24 hrs, deliver intact fetus, can autopsy if needed, risk of failure here
what is multiFetal pregnancy reduction (MFPR)?

options for monochorionic twins?
Needle - inject fetus with KCl- induces arrythmia and induces death of affected baby to increase outcome of co-twin or triplets

high order multiples an dhigh risk PG category

monochorionic twins:
umbilical cord ligation
radiofrequency ablation
ETOH/sclerosing agents
complications of abortion and risk factors for complications?
Complicaitons = uterine perforation, missed or failed abortion, hematometria (blood in uterus), hemorrhage, risk for preterm births with future pregancy, death of mom after 20wks is signficiant

risk factors = parity, maternal age, gestational age
With normal PG serum B-HCG is first detectable _______ after ovulation with levels that peak at _______. Levels increase by ________ every 48h. Progesterone levels are _______
1st detection = 6-12d after ovulation

BHCG = gold standard!!

levels peak at 10wks

66-100% increase every 48hrs (usually doubles)

abnormal if <50%

progesterone > 25ng/mL (<5 abnormal but in between = indeterminant)
what structures are evident on U/S of early PG and when do they present?
gestational sac - presents at 4-5wks - grows 1mm/d between 4 and 6 weeks - estimate gestational age by adding 30 to mean sac diameter in mm - not to be used as final

embryonic disc/crown length/fetal pole - presents at 5wks

yolk sac (small round circle) - not seen psat 10wks

Heart beat - expect at 6wk
what is the 5-10-20 rule
5mm fetal pole (CRL): heart beat

10mm gestational sac: yolk sac seen here

20mm gestational sac: fetal pole should be present

if numbers are not met think miscarriage

can't tell anything on U/S until the BHCG level is above 1600
loss of PG before 20 weeks is considered _________. Most occur ________
spontaneous abortion

most occur before 12 weeks (80%)
risk factors for spontaneous abortoin
maternal and paternal age
prior SABs
presence of cardiac activity (if you see heart beating at 6 wks - 7%risk; heart beat at 8 weeks = 2% risk)
presence of bleeding
_____% of women will have bleeding in their first trimester but will have normal pregnancy
20%

40% will have bleeding, 1/2 will have SAB
any bleeding in the first trimester is termed _______
threatened abortoin
(50% will miscarry or have an SAB)
intrauterine PG without heartbeat on U/S dx
embryonic demise
spontaneous abortion - asymptomatic - occured within 5wks of determination of SAB
missed abortoin
on U/S, fetus has only the gestational sac or gestational sac + yolk sac
blighted ovum or anembryonic demise
intrauterine PG with cervix dilated during the first trimester or early second trimester
inevitable SAB
some tissue already starting to pass through cervix - </= 20week fetus
incomplete SAB
A gestational sac exceeding ____, or BhCG _____mIU/mL or greater (3rd International Standard) but no fetal pole on ultrasound, suggests anembryonic gestation (blighted ovum). About half of cases of blighted ovum are caused by genetic or chromosome abnormalities
17mm

5100
SAB where sx of bleeding and cramping may be present but there is nothing on U/S
complete SAB
pt less than 20 weeks gestation, lower abdomen is tender, tachy, hypotensive -- what is the dx?
Septic SAB -- usually caused by Strep or E coli
Causes of SAB may be one of four types of etiologies:
genetic (trisomy 16, turners - 45X monosomy)

maternal (abnormal reproductive tract, infection, health proglems like DM or HTN)

exogenous (ETOH, tobacco, cocaine, caffeine, radiation)

thrombotic (hypercoag due to anti-phospholipid Ab syndrome, Antithrombin III defiiciency, Factor V leiden mutation, prothrombin mutation, Factor C and S deficiency)
MCC for SABs
50-75% = aneuploidy with trisomy being the most common (Trisomy 16)

most are errors in gametogenesis (nondisjunction with advanced maternal aged women)

TRISOMY>MONOSOMY 45X (TURNERS) > TRIPLOIDY > STRUCTURAL ABNORMALITY
important labs for SAB
bHCG - confirms abortion
CBC - is the pt anemic? hypercoagulable?
Blood type - Rh status - give Rhogam to prevent production of anti-D Ab that may attack future pregnancies
types of tx for SAB and when to use which
expectant management -- wait and watch -- 25-80% success rate if already inevitable, but if missed SAB, then chance of passing it is 0

medical management with misoprostol (cytotec) -- never know exactly when it is going to happen so counsel away from this b/c it is difficult for the pt, but can be used with 85% success with 1-2 doses

surgical management (D&C)
regarding future risk of SABs once you have an SAB, when would you do a workup?
recurrent pregnancy loss =
2 consecutive SABs with advanced maternal age

OR

3 consecutive SABs
consider _______ any time bleeding occurs in early PG
spontaneous abortion
Treatment of the following:

threatened abortion - normal U/S with minimal bleeding and cervical dilation
threatened abortion - observation
treatment for missed abortion - nonviable PG w/o bleeding or cervical dilation w/o passage of POC.
emergency D&C
treatment of incomplete abortion = heavy bleeding, cervical dilation with passage of some but not all POC
emergency D&C
completed abortion treatment = passage of all POC with decreased cramping and minimal bleeding with cervical dilation
observation
septic abortion treatment - hx of nonsterile abortion attemptresulting in uterine infection
admit to hospital for IV multiple agent Ab
ectopic pg constitute ___ of PG related mortality and ____% of all pregancies...most common locatoins?
9% of pg related mortality
2% of all pg
most common in ampulla (80%) > isthmic region (12% - most dangerous b/c can get bigger than other types w/o sx making tx more challenging) > fimbria
risk of bleeds with removal of ectopic pg is most common with which types
cervical and abdominal
give MTX in large dose to help resolve before surgery
risk factors for ectopic pregnancy
PID - infection with gonnorrhea or chlamydia -- infection ascended into fallopian and may have caused scar confers 4x risk

prior tubal surgery - 10x risk with scarring/reanastomoses

prior tubal sterilization

IUD in place = 3x risk

assisted reproductive technologies - old IVF procedures and multiple egg production induction

prior ectopic PG - 1 in 4 chance
pt presents with abdominal pain, rebounding, guarding, shoulder pain, absence of menses with irregular vaginal bleeding, dizziness and syncope
ectopic PG

large volumes of blood loss = hypotension, tachy, syncope

blood in belly = ab pain, rebounding, guarding

referred shoulder pain due to tickling of phrenic nerve
administer rhogam to mother's with spontaneous abortion, ectopic pregnancies, normal birthing if they are _______
Rh negative and you are questionable about fetus being Rh +
bHCG>1600

emtpy uterus on U/S

no heavy bleeding
+ ab pain, shoulder pain, syncope/dizziness, hypotension, tachy, etc.

what is your dx?
ectopic PG
why do you need to check liver and kidney labs (AST, ALT, Cr) which ectopic PG pt?
administratoin of MTX is toxic to both organs and cannot be given if pt presents initially with liver or kidney damage/failure
most ectopics resolve on their own and will not have a corresponding BHCG - true or false
true
if you have a pt with an ectopic pregancy, when would you give MTX over surgical laparascopy/laparotomy or salpingectomy vs ostomy?
unruptured
<4cm
no evidence of active bleed
no hepatic, hematoligic, or renal dz
pt is reliable and can come back for many f/u appt
salpingostomy vs salpingectomy - indication?
fallopian tube surgery

salpingostomy = remove PG without removal of the tube; do this if the other fallopian tube is not present

salpingectomy = tube removal -- do this if a lot of bleeding is present or if the other fallopian tube is healthy
how does a hx of ectopic PG
affect your ability to conceive?

with salpingitis? procedure?
conception rate = 60%

decreased future fertility with salpingitis but same if salpingectomy/ostomy performed and you still have a healthy tube on the other side
4 types of gestation trophoblastic disease
hydatidiform/benign mole OR molar pregnancy (80%)
invasive mole (10-15%)
choriocarcinoma (2-5%)
placental site trophoblastic tumor
most curable form of GTD
choriocarcinoma

cure rate = 90%
most benign moles are complete vs incomplete/partial? what are the risk factors?
complete - fertilization of a empty egg by a sperm that reduplicates = most common (46XX)

(partial/incomplete = haploid egg fertilized by two sperm = 69XXX, or 69XXY)

age >40 or <20
southeast asian
mole type?
46XX - all paternal chromosomes
no fetal tissue
20% with persistent dz after D&C
5% with mets turning into choriocarcinoma

what are the sx/dx?
complete mole - GTD

abnormal vaginal bleeding
elevated bHCG (>100K - all GTD with high levels except placental), U/S with snowstorm pattern, bilateral ovarian theca leutein cysts (due to high HCG - form cysts that becomes a substrate in thyroid to get thyrotoxicosis - diaphoretic, tachy, hyperthyroid)
69XXY
coesistent fetus
ovum fertilized by 2 sperm

does this usually result in persistent or metastatic dz?
incomplete/partial mole

NO - persistent dz seldom (3%) - very rarely mets

SAB with dx on path
elevated bHCG
fewer and less severe sx of those for complete moles
how are molar pg treated?
evacuate the uterus or hysterectomy if pt is done chilbearing with close follow up -- weekly bHCG until negative, then follow once a month for one year for negative bHCG
how are molar pg treated if presented with persistant or metastic dz when
1. confined to uterus
2. metastatic
confined to uterus? MTX +/- hysterectomy

metastatic dz
MTX if low risk but if high risk use multi agent chemo
risk factors for molar pregnancy
Previous molar pregnancy: after having one molar pregnancy, the risk of having molar disease associated with a future pregnancy is about 1%. The risk is about 1 in 6.5 for women who have already had two molar pregnancies. With recurrent molar pregnancies there is an increased risk of malignant sequelae. The risk of a second molar event is highest in the second year after initial diagnosis and reduced thereafter
Age: significant increase risk in females aged 15 years or under and 40 years or older. Significantly lower incidence in women aged 20-29 years. No significant difference in age between women with one molar pregnancy and those who develop a subsequent molar pregnancy
Nutritional factors: high prevalence of vitamin A deficiency corresponds to geographic locations where there is high incidence of hydatidiform mole
History of prior spontaneous abortion and infertility is associated with an increased risk of both complete and partial mole
placental site trophoblastic tumors arise from ___________

__________ cells are absent

compared to other GTD, ________ is minimal and follow _______ for dx
arises from mole or NL PG

syncytiotrophoblastic cells absent

bHCG is minimal compared to amount of dz

follow hPL
mole associated with thyrotoxicosis and snowstorm U/S
GTD - complete mole
MCC presenting sx with molar pg?
vaginal bleeding - abnormally heavy or prolonged

pre-ecclampsia in the first trimester
associated with hyperthyroidism and bilateral theca lutein ovarian cysts
molar pregnancy - usually complete mole

hyperthyroid b/c bhcg acts like TSH

cysts may rupture and cause severe ab pain and peritonitis
why do you need to send the POC + placenta to lab following abortion of any kind?
to not miss the dx of partial mole - GTD neoplasia may occur after molar pg or abortion or even yrs after a normal term pg - mets commonly to lungs and abdomen
deficiency associated with GTD
Vitamin A deficiency
test of choice in investigating abnormal vaginal bleeding
transvaginal U/S

mole - think absence of fetal heartbeat or snowstorm
when to bHCG levels start to fall?
after 10 weeks
what level fo bHCG must a pt have in order to dx PG on U/S?
1600 or above
maternal infections that can lead to SAB?
parvo, varicella, CMV, rubella
ectopic pg
complete mole (GTD)
"snowstorm"

think marked elevatin in bHCG, fluid filled villi of trophoblastic tissue forms this pattern, bilateral ovarian theca luein cycsts, thyroid dz/thyrotoxicosis
anembryonic pg