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163 Cards in this Set
- Front
- Back
183
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183
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What happens with estrogen at puberty?
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Estrogens reverses from inhibitory to activating (results in GnRH pulses, then LH FSH secretion)
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Sequence of puberty in women
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Thelarche, Pubarche, Peak height velocity, menarche
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When does menarche typically occur in relation to thelarche?
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Tanner stage 4
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How long is normal menstrual cycle?
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24-35 days
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Which part of menstrual cycle is the most variable?
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Follicular phase (normally 14 days)
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How long is the luteal phase
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Always almost exactly 14 days
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Primary vs Secondary amenorrhea
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Before or after menarche respectively
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Define primary amenorrhea
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No menses by 16 w/ normal development, no menses by 14 w/o normal development
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Define secondary amenorrhea
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No menses for 6 months
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Typical hypothalamic causes of amenorrhea
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Athletics (Both dec GnRH and low fat)
Anorexia (low fat) |
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Typical pituitary causes of Amenorrhea
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Prolactinoma (via dec GnRH sec to inc Prolactin)
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Bromocriptine
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Dopamine agonist used to treat prolactinomas
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Turners
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45 X - most common cause of prim amenorrhea.
Can be 46 XX w/ defective X (and can give sec amenorrhea) Has high gonadotropins |
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POF Gene
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Premature Ovarian failure gene (hypothesized)
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Uterine/Outflow causes of amenorrhea
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Vaginal septum, imperforate hymen
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Imperforate hymen
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Hymen doesn't canalize.
Presents with primary amenorrhea, bulging hymen, and hematocolpos or hematometria |
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Vaginal septum
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Failure of canalization of vagina. NO bulge at introitus
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184
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184
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Where does HCG come from?
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Syncytiotrophoblast
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What does HCG do?
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Prevents involution of corpus luteum so the CL can continue to make estrogen/progesterone until placenta takes over (8-12 wks)
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Estrogen effects in pregnancy
(on breast, skin, kidney) |
Breast - Duct growth
Skin - Chloasma, Palmar erythema Renal - Increased sodium loss |
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Progesterone effects in pregnancy (breast, vascular, kindey, GI, Uterus)
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Breast - Alveolar hypertrophy
Vascular - Smooth muscle relaxation (dec PVR) Renal - Increased reabsorption GI - Dec motility Uterus - hypertrophy |
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How does pregnancy affect maternal glucose conc?
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Increased standard dev (Higher when fed, lower when fasting)
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HPL
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Human placental lactogen - Increases insulin level, but decreases sensitivity in peripheral tissue
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How do pregnancy hormones (Est, Prog, HPL) affect insulin
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Increase
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How does pregnancy affect blood pressure
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Decreases PVR, so BP decreases (only during 2nd trimester)
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3 components of the cervix
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Smooth Muscle, Collagen, Fibrous CT
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What happens to the cervix prior to labor?
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Collagen breakdown
increased fibrous & glycoprotein ground substance |
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Bishop Score
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Measurements of the cervix indicating it's readiness for labor
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Puerperium
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After pregnancy - Hypercoagulable, return of ovulation, weight loss
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185
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185
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Stages in blastocyst development
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2, 4, 8, morula, early blast, late blast
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Decidua basalis
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uterus directly underneath chorion
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Decidua capsularis
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Outside of amnionic sack w/o contact with uterus
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Decidua vera
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Uterus away from amnionic sack
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Explain circulation in placenta
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Works like the lung… Arteries from fetus carry deox blood into placenta, veins carry oxygenated blood out.
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What are the layers of the placenta
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Amnion, chorion, decidua (basalis or parietalis)
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Three functions of placenta
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1. Steroid, peptide hormone synthesis 2. Transport 3. Respiratory gas exchange
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Functions of Progesterone, 16-OH, 17-OH
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MARSH
1. Mammary devel 2. Adrenal (fetal) hormone substrate 3. Relax smooth muscle 4. Slow GI motility 5. Hyperventilate |
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5 Functions of Estrogen (E1, E2, E3)
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PUBLiC
Progesterone receptors (inc) Uterine blood flow (inc) Blood vol (inc) Lactation (inhibit) Carb metab. change |
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Explain HcG throughout pregnancy
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Peaks at about 8 weeks, and then declines as placental hormones take over
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What are the two barriers to diffusion in the placenta
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1. Syncytiotrophoblast 2. Fetal capillary endothilia
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What two things are specifically transported by receptor mediated endo in the placenta
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IgG, LDL
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What two things are specifically not transported across the placenta?
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Protein, IgM
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Ductus Arteriosis
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Pulmonary artery to vena cava (to bypass lungs)
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Ductus Venosus
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From Umbilical vein to vena cava to bypass liver
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Foramen Ovale
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In heart to sort of bypass lungs
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What are two key differences in fetal circulation
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Right heart to Aorta, Left heart to head.
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Where does amniotic fluid come from
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Mostly fetal kidneys, some from fetal lung
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What thyroid related compounds can cross the placenta?
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Only Iodide and thyroid stimulating IgG's
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Hemochoral
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Means the blood leaves the mothers circulatin to enter the placenta. It’s the most permeable, but has no autoreg
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What is the expecting date of a pregnant women?
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Add 7 days and 9 months to the day of her last menses.
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186
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186
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Defintion of reccurrant miscarriage
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3 or more miscarriages
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Incompetent cervix (& treatment)
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Painless cervial dilation results in preterm birth.
Treat: Cervical cerclage |
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Placenta Previa
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When the placenta is covering the cervical oss. Clinically, Painless bright red bleeding in third trimester
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Marginal vs Complete placenta previa
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Marginal is off to one side
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Placenta Accreta
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Deeply invested placenta that doesn't come out properly
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Abruptio Placenta
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Premature seperation of placenta from uterine wall. Clinically - Painful uterine bleeding in 3rd trimester
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Symmetric vs Assymetric fetal growth restriction
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Asymmetric is "Head sparing"
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Causes of symmetric fetal growth restriction
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Constitutional, Cong. Infection, Cong malformation, Drugs, Chromosomal
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Causes of assymetric fetal growth restriction
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Chronic vasculopathy (hypertens, lupus, diabetes), chronic abruption, immunological, idiopathic
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Preeclampsia
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Unknown etiology. Causes hypertension, proteinuria, oliguria, thrombocytopenia, edema after 20 wks gestation (can advance to eclampsia which causes seizures)
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187
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187
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Gestational Trophoblastic Disease
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Any lesion that represents aberrant fertilization. From fetal tissue, marked by hCG
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Molar pregnancy - clinical
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Irregular bleeding, large uterine size, no fetal heart, high hCG
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Karyotype of Complete Molar Pregnancy
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46 XX, all paternal
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Mechanism of complete molar pregnancy
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Fertilization of empty egg, followed by sperm duplication. Associated w/ trophoblastic neoplasia.
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Complete Molar Pregnancy - Findings
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No blood vessels, fetus or amnion, Swelling of villous stroma, Snowstorm & vesicular cysts on ultrasound, hydropic villi on histo
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Karyotype of partial molar pregnancy
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69 XXY (2 from father)
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Invasive/Persistant GTD
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Excessive trophoblastic proliferation and local invasion. Responsive to chemo (rarely metastatic)
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Invasive/Persistant GTD - findings
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Theca Lutein Cysts, Myometrial invasion, stable or rising hCG
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Choriocarcinoma
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GTD Neoplasia. Most common after sponatneously aborted pregnancy. Sheets of anaplastic trophoblast w/o chorionic villi
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Metastasis of Choriocarcinoma
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Most commonly pelvis, vagina, lung.
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Placental Site Trophoblastic Tumor - findings
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No invasion. No chorionic villi, intermediate cytotrophoblastic cells. Often hPL or PAP
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Maternal mortality and Live Birth order
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Second is lowest, increasing after.
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What does folic acid prevent?
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Spina bifida and heart defects
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Pregnancy and stroke volume/heart rate
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Stroke volume increases early, heart rate increases late.
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Common causes of death in abortion
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Anesthesia, hemorrhage, infection, embolism
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188
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188 NEED SYLLABUS
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RU-486
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(Mifepristone) Progesterone competitive antagonist (although effects of inhibition may be irreversible)
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Location of action of Mifepristone
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Progesterone receptors in the decidua. Causes necrosis
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Prostaglandin & RU-486
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Greatly increases efficacy by producing uterine contractions
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Misoprostol
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A vaginal (or oral) prostaglandin used after RU486. Can induce abortion alone. Also used in gynecology to open cervix.
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Oxytocin
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Receptors in myometrium, produces labor. Dependant on cervical ripeness (add prostaglandins)
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What happens in cervical ripening?
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Collagen becomes disorganized & lengthened, Inc hyularonic acid, Increase Water, break collagen bridges
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Bishop Scores
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>8 is good - vaginal delivery is fine. < 4 unfavorable
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Prepidil
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Prostaglandin for cervical ripening near term (used w/ preterm too)
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189
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189 NEED SYLLABUS
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Pearl index for birth control
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Failures/100 women-yrs
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Life-table Analysis
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Failures/month use
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Decidualization
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Thinning of the uterus w/ dominant progesterone
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19 Nortestosterone
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First generation progestin. Somewhat nonselective, so cause androgen side effects
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Drospirenone
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Spironolactone analogue w/ antimineralocorticoid & anti-androgenic activity. Contraindicated in ACE inhibitors, ang-II antagonists, K sparing diuretics, heparin, aldosterone antag, nsaid's
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Explain dose related function of estrogens
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Ovulation suppression - 20 ug. Endometrial control 30-35. Thrombotic complications >50 ug
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Progestin effects on: Carbohydrates Lipids Nitrogen Skin
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Carb - Inc Insulin, Dec gluc tolerance
Lipids decreases cholesterol, TG, HDL, raises LDL Nitrogen - Retention Skin Increase sebum |
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Explain Contraception and MI
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Increases risk of MI in SMOKERS, actually decreases risk in non smokers
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Advantages to injectable contraception
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Lower dose --> few side effects. Very low failure rate (dis - one more day of bleeding)
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Which birth control has loswest estrogen exposure? Highest?
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Lowest - ring. Highest - patch (pill is in the middle)
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Name two implantable contraception
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Norplant and Implanon
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How does progestin work as contraception
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Slows GnRH, Suppresses LH surge, Involutes endometrium, and thickens cervical mucous
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Mechanism of emergency contraception
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Delays ovulation
impedes tubal transport prevents implantation |
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How many unprotected women will become pregnant in a given month
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8/100
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Mirena
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Levonorgestrel-releasing IUD
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190
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190 NEED SYLLABUS
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Embryology of the breast
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2 ventral bands appear in 5th-6th week (Milk Line). Milk line extends from axilla to inguinal region, and later disappears except in the pectoral area.
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Athelia
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Absence of nipple
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Polythelia
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Supernumary nipples along the milk line
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Amastia
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absence of breast (usually one)
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Anisomastia
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Significant size differences between breasts
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Symmastia
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Medial confluence of the breast
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Which hormones stimulates breast devel
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Estrogen - Ductal growth Progest & Est - Lobuloaveolar growth (also need insulin, cortisol, thyroxine, prolactin, GH)
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Montgomery glands
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Mammary sebacious glands that lubricate the nipple & secrete milk
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Coopers ligaments
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Attach skin to pectoralis fascia
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Medial blood supply to the breast
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Internal mammilary
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Lateral blood supply to the breast
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Lateral thoracic, axillary, intercostal
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Prolactin and pregnancy
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Dopamine is inhibed by estrogen resulting in more prolactin release
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What upregulates prolactin receptors
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Prolactin
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Estrogen and milk
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Estrogen required to prepare the breast for lactation, but must be removed to lactation to occur (because it interferes with prolactin binding)
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Progesterone and milk
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Decreased progesterone --> lactogenesis. Blocks induction of lactogenesis, but cannot block established lactation (b/c no receptors on lactation mammary tissue)
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Afferent arc of milk let down
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Suckling stimulates nerve roots 4&5, stimulates hypothalamic production of oxytocin & decreases hypothalamic dopamine (increasing prolactin)
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Efferent arc of milk let down
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Oxytocin to breast causes emptying of alveolar lumen
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Give 3 lactotrope activators
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PRF TRH Estrogen (cause eventual release of prolactin)
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Chlopromazine
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Along with vigorous nipple stimulation, can cause relactation
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Metoclopramide
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Relactation medicine
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2 medications for lactation suppression
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High dose estrogen (risk of DVT), Dopamine agonists - Bromocriptine (Neither are routinely used)
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Which medication is preferred for a lactating mother
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Progestin
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Masatitis
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Usually S Aureus infection. Shooting pain in the breast. Treat w/ dicloxacillin
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Breast abcess
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Palpable mass in breast, or febrile after 2-3 days antibiotic treatment. Treat with incision, drainage, IV antibiotics
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Benign Fibrocystic breast disease
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1/2 of women 20-50. Exaggerated response to cyclic ovarian hormones/Imbalance in estrogen/progesterone. Causes pain in the breast (usually upper out)
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Fibroadenoma
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Adolescent - 20's. Benign, but increase risk of cancer. Surgical excision if etiology unknown
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Cystosarcoma Phyllodes
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Fibroepithelial tumor. Rare, but most frequent breast sarcoma. 50's. 25%malignant, 10% metastatic. Treat = wide local excision
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Intraductal Papilloma
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Bloody nipple discharge in perimenopausal women. Usually located under areola. Tx = excisional biopsy
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Fat necrosis
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Often from blunt trauma. Ca and stellate contractions on mammogram. Tx = excisional biopsy (no inc risk of cancer)
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Duct Ectasia
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Discharge (green, grey, yellow, brown or black). Ductal inflammation, often nipple retraction
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Orange peel look on breast skin
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Carcinoma of the breast
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191
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191
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Which area of the breast duct is most likely to have damage/neoplasia?
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Acinar area
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2 layers of normal breast duct lining
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One columnar on luminal side & 1 luminal (myoepithelial) layer
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Paget's disease
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Intraepidermal spread of tumor cells. Can be mammary or nonmammary
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Which mammogram picture shows the pec muscle?
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Mediolateral view
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Simple vs radical mastectomy
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Simple just removes the breast, radical is breast & axillary nodes
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4 basic types of breast cancer
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Ducat, invasive & in situ. Lobular invasive & in situ
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Common features of invasive ductal carcinoma
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No myoepithelial layers. Invades in tubular structures.
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Common features of invasive lobular carcinoma
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'Targetoid' appearance. Invades in single file lines.
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4 benign breast diseases that are likely to turn into cancer
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1. Atypical ductal epithelial hyperplasia. 2. Atypical lobular hyperplasia 3. Lobular carcinoma in situ 4. Ductal carcinoma in situ
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Types of fibrocystic changes
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Proliferative –
Florid hyperplasia adenosis papilloma fibroadenoma. Nonproliferative – Cysts, apocrine metaplasia, simple hyperplasia |
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Benign breast disease w/ no increased cancer risk
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CABS
Cysts, Apocrine metaplasia, Benign calcification, Simple hyperplasia |
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Bening breast disease w/ 1.5 – 2x RR
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Florid ductal hyperplasia. Sclerosing adenosis (radial scar), Fibroadenoma, Intraductal pappiloma
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What is the most common cause of nipple discharge?
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Intraductal Papilloma
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Benign breast disease w/ 4-5x RR
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Atypical hyperplasia (ALH, ADH)
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High risk breast diseases
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LCIS DCIS
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Which class of breast cancer is worse?
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Ductal (80% of breast cnacers)
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ER+ Breast cancer
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Usually low grade ductal cancer. Bland cytological features. Forms tubules
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Basal like & Her2 + breast cancers
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High grade ductal cancers. Form sheets of cells w/ high grade nuclei
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Rank the 3 main groups of breast cancer (receptor groups)
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ER+ is best, Her2 is middle, Basal like is worst.
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What is the most important prognostic indicator in breast cancer
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Lymph node status
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What 4 things are ER+ patients associated with
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1. Older age. 2. Better prognosis. 3. Lower grade. 4 Her2 negativity
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Tamoxifen
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ER antagonist for breast cancer treatment.
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What 4 things are Her2+ patients associated with
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1. Young 2. High grade 3. Poor prognosis 4. ER negativitiy
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Herceptin
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Monoclonal antibody used to treat Her2+ patients
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Her 2
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Oncogene on chrom 17
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