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163 Cards in this Set

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