OB/GYN Case Study Pearls – Flashcards
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Dx: thinned epidermis, hyperkeratosis, elongation of rete pegs on bx
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Lichen sclerosis of vulva
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What is the main difference b/w lichen sclerosis and lichen planus?
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Lichen sclerosis does not involve vagina but lichen planus does
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What is the first step to do in a post-menopausal woman with severe vulvar itching?
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Consider getting a bx - lichen sclerosis vs cancer --> cancer can also be pruritic
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When examining a patient for bartholin gland abscess, where should you look?
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Bartholin glands are in labia majora at 5 and 7 o'clock
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At what point should you get a biopsy for a Bartholin gland cyst?
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Women > 40 y/o
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What organism is responsible for bartholin gland cysts?
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Polymicrobial note: they're not usually sexually transmitted
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What should you screen post-menopausal women for?
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Annual mammography, stool occult test Tdap every 10 years Pneumococcal, herpes zoster vaccine Annual influenza vaccine Lipid profiles q5 yrs until age 75 Thyroid function q5 yrs Fasting blood glucose q3 yrs Osteoporosis screening for 65+
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How often should women with HIV get pap smears?
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X2 in the first year after diagnosis If those are normal, then annual
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What are the pap smear guidelines?
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21-29: q 3 yrs 30-65: q 5 yrs w/ co-testing....or q 3 yrs w/ pap cytology alone 65+: None if they've had negatives and are low risk
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At what age should the Zoster [shingles] vaccine be offered?
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60 Note: it's live attenuated
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What's the most common cause of mortality in women < 20 y/o?
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MVA
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What's the most common cause of mortality in women > 39 y/o?
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Cardiovascular dz
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What's the single most important modifiable risk factor contributing to mortality?
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Smoking
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At what age should pap smears be stopped?
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65 y/o if they've been normal
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T/F: Raloxifene can be used to treat hot flashes in menopause
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False
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What menopausal hormone therapy would you give if a woman had her uterus vs did not?
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Uterus present: Estrogen + Progestin [add progestin to prevent endometrial cancer No uterus: just estrogen is fine
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How do FSH levels change once a menopausal woman is on HRT?
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They don't! It remains elevated
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What is the order in which hormone levels fall in menopause?
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1. Anti-Mullerian hormone 2. Inhibin B 3. Estradiol
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Where is the most common location for an osteoporosis fracture to be found?
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Thoracic spine
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T/F: Continuous estrogen-progestin therapy may be associated w/ risk of CV dz and breast cancer
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True, but not so much if it's started in 50s right when menopause starts as opposed to starting in 60s
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What medications would you offer a woman who was sexually assaulted?
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IM 250 mg ceftriaxone PO 2 gm metronidazole, 1 gm azithromycin [G, C, trich] HBIG and HepB vaccine if not previously vaccinated Emergency contraception --can also consider HIV post exposure prophylaxis
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What test should be ordered prior to emergency contraception?
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Always get pregnancy test - even if pt is not sexually active prior to an assault
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How often should pregnant women be assessed for intimate partner violence?
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First visit + Every trimester + Post-partum
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Pyelonephritis signs/sx after surgery indicates what? What tests would you get?
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Ureter damage! IV Pyelogram or CT w/ contrast
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What type of ureter injury after surgery can not show up for 7-10 days after the surgery?
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Thermal spread injury - electrocautery device was not in direct contact but close enough so injury occurred over time
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Where is the most common location for ureteral injury during surgery?
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Cardinal ligament - the ureters are just 2-3 cm lateral to cervix and go under uterine artery
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What's the most important intervention in preventing surgical site infections after hysterectomies?
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Pre-op antibiotics - given 15-60 min prior to incision time Typically a 1st gen cephalosporin
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What are the 5 W's of post-op fever?
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1. Wind: atelectasis, pneumonia -- seen post-op day 1 2. Water: UTI - pod#3 3. Walking: DVT or PE - pod#5 4. Wound: infection - pod#7 5. Wonder drugs: drug-induced fever - >7 pod's
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What type of injury can occur if the ureter is dissected around?
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Devascularization
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What are the main risk factors for pelvic organ prolapse?
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Multiple vaginal births Aging Prior pelvic surgery Hysterectomy Constipation IBS Genetic predisposition Lack of estrogen Obesity
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What is a culdoplasty and what can it be useful for?
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Obliterating the cul-de-sac...can be used if you're fixing a vaginal vault repair b/c it prevents enterocele formation by blocking out intestines from being able to sneak down there
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What are the 3 general tx options for pelvic organ prolapse?
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1. Kegels 2. Pessaries 3. Surgery [Colporrhaphy, vaginal vault suspension, etc]
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What is considered a surgical site infection? What about deep SSI?
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SSI = infection related to op procedure at or near incision within 30 days of procedure Deep SSI = involves deep soft tissue such as fascia or muscle
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What are the 3 types of wound complications that can occur with gyn surgery?
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1. Superficial separation: separation of subq tissue anterior to fascia - assoc w/ infection or hematoma 2. Dehiscence 3. Evisceration
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Presentation of superficial wound separation?
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Red, tender, indurated incision and fever 4-10 days post-op
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Tx for superficial wound separation?
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Drain purulence Broad spectrum antimicrobial agent Wet-to-dry dressing changes
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What is fascial disruption?
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Separation of fascial layer, usually leading to a communication of peritoneal cavity with the skin
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What is evisceration?
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Protrusion of bowel or omentum thru incision -- all layers have separated
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What's the single most important factor for preventing a surgical site infection?
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Antibiotic prophylaxis Ex: 1 gm cefazolin IV given 15-60 min prior to incision An additional dose given if surgery is > 4hrs w/ EBL 1500 mL Double the dose for >35 BMI
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What type of incisions have a greater risk of fascial disruption?
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Vertical >>> transverse
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What conditions are more likely to be seen with wound dehiscence?
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DM - poor blood supply Cushing disease or corticosteroid use - immunosuppression Obesity Cancer Vertical incision
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What type of gyn surgeries should antibiotics be given for?
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Yes: Hysterectomies - clean-contaminated surgeries that enter thru vagina or uterus prolpase surgery, stress urinary incontinence, therapeutic abortions Not given for clean cases that don't enter vagina or uterus, such as a laparoscopic oopherectomy, hysteroscopy, incomplete ab, IUD insertion
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Dx: copious amounts of serosanguineous fluid draining from an abdominal incision
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Fascial disruption
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When is the most common time period for a fascial disruption or evisceration to occur?
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5-14 days post-op
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What are the big 3 risk factors for fascial disruption?
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1. Obesity 2. Malnutrition 3. Chronic cough
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What is a normal amount of post-void residual volume should be left?
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100 would indicate overflow incontinence]
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What is the gold standard for diagnosing salpingitis?
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Laparoscopy
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What is the most common cause of mucopurulent cervical discharge?
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Chlamydia [gonorrhea is next most common]
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Why should you examine cervix or vagina when pt complains of a purulent vaginal discharge?
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Trichomonas is a common imitator of cervicitis
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What's the classic triad of PID?
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1. Lower abdominal tenderness 2. Cervical motion tenderness 3. Adnexal tenderness
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Tx for tubo-ovarian abscess?
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IV antibiotics - esp anaerobic coverage [one of few abscesses that don't need to be drained right away]
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Define acute vs subacute vs chronic pelvic pain.
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Acute: < 2 wks Subacute: 2 wks - 6 months Chronic: at least 6 months
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What are some causes of chronic pelvic pain?
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Endometriosis Adhesions Chronic PID Ovarian remnant syndrome Leiomyomata Adenomyosis GU, GI, neuromuscular, psychological, too
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What is the next step for chronic pelvic pain after NSAID and OCP trial as been attempted?
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Laparoscopy
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What's the best treatment for primary dysmenorrhea?
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Primary dysmenorrhea = Pain starting w/i 6 mos of period This is from too much Prostaglandin F2 alpha levels that cause uterine contractions Tx = NSAIDs
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Why may fishy discharge from BV get worse after intercourse?
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pH of alkaline semen
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What do you not see with BV that you do with candida, trichomonas?
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Not inflammatory -bacterial vaginosis not vaginitis
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What are the 3 most common vaginal infections?
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1. Bacterial vaginosis 2. Trichomonal vaginitis 3. Candidal vulvovaginitis
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T/F: BV is always sexually transmitted
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False - it doesn't have to be
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Name Amsel's criteria for BV [Need 3/4].
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1. Homongenous, gray-white discharge 2. Vaginal pH >4.5 3. Positive whiff test 4. Clue cells
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Tx for BV?
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Metronidazole - can't take EtOH Clindamycin
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Tx for trichomonas?
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Metronidazole PO 2gm x1 dose
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Tx for candidal vaginitis?
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PO fluconazole Imidazole cream
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Why is vaginal metronidazole not given to treat trichomonas?
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Low therapeutic levels in urethra or Skene's glands where the trichomonads can live
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T/F: Candidiasis is usually not sexually transmitted
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True
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What are the 4 groups of women who are more likely to get candida infections?
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1. Pregnant 2. DM 3. Antibiotics 4. Immunocompromised
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What are the adverse outcomes of BV ?
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Preterm delivery Postpartum endometritis PID
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What's the difference b/w syphillis, chancroid, lymphogranuloma venerum, granuloma inguinale?
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Syphilis: painless ulcer, painless inguinal adenopathy Chancroid: painful ulcer, tender LAD Lymphogranuloma venerum: Chlamydia trachomatis L1-3, painless ulcer, tender lymph nodes Granuloma inguinale: Klebsiellagranulomatis, painless and beefy red ulcers, no lymphadenopathy
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What's a typical evaluation for a genital ulcer?
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1. Syphilis serology and darkfield microscopy 2. HSV PCR testing 3. HSV antibody
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Tx for primary, secondary, or early latent [<1 yr] syphillis?
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IM Penicillin G x1
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Tx for late latent [>1 yr] or unknown duration?
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IM Penicillin G qwk for 3 wks
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Neurosyphillis Tx?
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IV penicillin
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Define: Cystitis- Urethritis- Urethral Syndrome-
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Cystitis: >100,000 colony forming units Urethritis: urethral infection usually Chlamydia trachomatis Urethral Syndrome: recurrent urgency, dysuria episodes caused by urethral inflammation but urine cultures are persistently negative
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What should your main suspicion be for gross hematuria?
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Nephrolithiasis
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Tx for uncomplicated cystitis [UTI] in a normal person?
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3 days of Trimethoprim-Sylfa [Bactrim] -- Can't be used in pregnancy tho b/c of kernicterus
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What should you consider if you think someone has a UTI and then they have no growth on culture and no response to standard antibiotics?
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Think about a urethritis caused by Chlamydia, gonococcus, trichomonas Get grain stain and cultures of urethra
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What's the most common symptom of uterine fibroids?
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Menorrhagia
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What's the most common reason for hysterectomy?
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Symptomatic uterine fibroids
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What is the threshold for Beta-hcg that you should see an intrauterine pregnancy on U/S? What should you do if a patient is below this threshold?
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"Ultrasound Threshold" = 1500-2000 mIU/mL Get serial Beta-hcg's -- if it rises by 66% in 48 hrs then it's a intrauterine pregnancy
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What is indicated if Beta-hcg is 2500 but there is no gestational sac seen in uterus?
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Ectopic - hcg levels exceed the threshold but no IUP seen on U/S
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If a patient has a complete abortion, what should your next step be?
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Follow up with Beta-hcg's Make sure it goes down to 0 Expect it to 1/2 every 48-72 hrs
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How would you differentiate b/w an insufficient cervix and inevitable abortion?
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Insufficient cervix = painless dilation of cervix, so there won't be any contractions Inevitable abortion = + contractions
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Where are most ectopic pregnancies?
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Ampulla of fallopian tube
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Some practitioners use progesterone levels instead of Beta-hcg in evaluating IUP's vs ectopics...what are the cut-offs for progesterone levels?
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>25 ng/mL = Normal IUP < 5 ng/mL = Abnormal IUP
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What are the 3 options for contraception for women who've had a DVT?
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DVT - Can't have any estrogen-containing products 1. Depo shot 2. Nexplanon implant 3. Levonorgestrel IUD --> these are all progesterone only
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What is the difference b/w Plan B vs Plan B One Step vs. Ella?
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Plan B: 0.75 mg levonorgestrel PO at time 0, 12 hrs later w/i 72 hrs of unprotected intercourse Plan B One Step: 1.5 mg taken as one pill Ella: also emergency contraception, Ulipristal made of progestin antagonist/agonist
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What are the actions of estrogen and progestin as OCP components?
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Estrogen: maintains thin endometrium, prevents unscheduled bleeding, inhibits follicular development Progestin: inhibits ovulation, cervical mucus thickening, thins the endometrium
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What are the benefits of the Mirena vs Skyla vs Liletta IUD's?
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Mirena: 5 years Skyla: 3 years, designed for younger women Liletta: 3 years, cheaper
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What are some contraindications to IUD insertion?
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1. Current pregnancy 2. Current STI 3. Unexplained vaginal bleeding 4. Malignancy 5. PID or infection in last 3 months 6. Untreated cervical or endometrial cancer or breast cancer [breast cancer is just for levonorgestrel releasing IUD only] 7. Anatomic abnormalities - fibroids, etc 8. Wilsons dz for copper IUD 9. Current or recent puerperal or postabortion sepsis
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What birth control method causes decreased bone density?
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Depot shots
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What are the contraindications to combo hormonal contraception?
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1. DM w/ vascular dz 2. Uncontrolled HTN 3. Heavy smoking over age 35 4. Migraines with auras
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Why are progestin-only methods superior to the Yupze method for emergency contraception [combined OC regimen]?
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Progestin-only has 1. Better efficacy 2. Less nausea -- Yupze method often requires an anti-emetic be given with it
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What birth control option has less sickle cell crisis and epilepsy?
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Depot shot [DMPA]
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What contraceptive option may have the greater risk of DVT?
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Patch
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What are the 2 most common complications of a spontaneous abortion?
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1. Hemorrhage 2. Infection
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4 main components of treating septic abortion?
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1. Maintain BP 2. Monitor BP, oxygenation, urine output [oliguria indicates septic shock] 3. Start antibiotic therapy 4. Uterine curettage - done 4 hrs after antibiotic therapy has started so tissues are perfused with therapy
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Describe fibrocystic changes of breast vs fibroadenoma
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Fibrocystic changes: multiple, irregular, lumpiness, varies with cycle Fibroadenoma: firm, rubbery, mobile, solid, does not vary with cycle
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What type of breast mass necessitates a histological confirmation?
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Any 3D dominant breast mass
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What's the biggest risk factor for breast cancer?
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Age
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T/F: Normal imaging of a palpable breast mass rules out cancer
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False! It does not - you must have histological analysis of any dominant breast mass Mammograms have a 10% false negative rate
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What's the most common cause of unilateral serosanguineous nipple discharge from a single duct?
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Intraductal papilloma
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T/F: A lifetime of mammograms starting at 40 y/o increases risk of cancer
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False!
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Management of a pt with galactorrhea, regular menses, normal serum prolactin?
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She's probably low risk for a prolactinoma - f/u w/ annual serum prolactin tests Normal menses indicates normal hypothalamic function
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Tx for hyperprolactinemia [and resultant galactorrhea] due to hypothyroid?
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Levothyroxine
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Tx for pituitary adenoma causing symptommatic hyperprolactinemia or macroadenoma w/ asx?
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Dopamine agonist [dopamine keeps prolactin in check] - Bromocriptine or Cabergoline
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What is a long term consequence of hyperprolactinemia?
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Prolactin shuts off GnRH pulse --> Less FSH, LH --> Less estrogen --> Osteoporosis
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What's the most sensitive test for assessing pituitary adenomas?
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MRI
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Define primary amenorrhea.
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No menses by age 16
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What are the 2 most common causes of primary amenorrhea when there's normal breast development?
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1. Mullerian agenesis 2. Androgen insensitivity syndrome -use serum testosterone or karyotype to differentiate -Androgen insens syndrome has scant to no pubic or axillary hair, but Mullerian agenesis is normal
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A 16 y/o girl presents to clinic with the complaint of not having her period yet. You suspect primary amenorrhea and think of Mullerian agenesis and androgen insensitivity syndrome because of the presence of normal breast development. What other clinical clue would tell you that it was one or the other before you ordered a serum tesosterone or karyotype?
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Androgen insensitivity syndrome has little to none pubic and axillary hair Mullerian agenesis will
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A 16 y/o girl presents to clinic with the complaint of not having her period yet. You suspect primary amenorrhea and think of Mullerian agenesis and androgen insensitivity syndrome because of the presence of normal breast development. What would be near the top of your differential dx for her primary amenorrhea if she had breasts of Tanner Stage 1?
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Turner Syndrome [XO]
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What is the definition of delayed puberty? What is the most common cause?
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No breast tissue by age 14 Gonadal dysgenesis
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What are the 5 basic infertility factors?
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1. Ovulatory - irregular menses, obestiy 2. Uterine - fibroids 3. Tubal - G/C 4. Male factor - Hernia, varicocele, mumps 5. Peritoneal factor [endometriosis] - dysmenorrhea, dyspareunia, dyschezia
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What are the 3 D's of endometriosis?
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1. Dyspareunia 2. Dyschezia 3. Dysmenorrhea
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What is fecundability and what is the value for normal couples?
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Probability of achieving pregnancy within one menstrual cycle 20-25%
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When using an at-home ovulation kit, when does ovulation predictably occur after LH surge?
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36 hrs after onset of LH surge
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What is the single most important factor dictating a successful pregnancy for assisted reproductive technologies?
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Quality of the oocyte
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What is the basis of tx for endometrial vs cervical cancer?
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Endometrial - surgery Cervical - radiotherapy
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What type of endometrial cancer is more aggressive and why?
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Type II - usually involves clear cell or papillary serous subtypes and seen in atypical pt w/o hx of annovulation
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What can advanced cervical cancer present with?
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Leg swelling + flank tenderness - indicate local spread
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T/F: All pt's who have had hysterectomies will never need a pap smear again b/c the cervix is taken out, too
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False - if it was performed for cervical dysplasia [ex: CIN3] then Pap smear of vaginal cuff is still needed
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What's the most common cause of death due to cervical cancer?
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Bilateral ureteral obstruction --> Uremia
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What is the treatment of choice for epithelial ovarian cancers?
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Surgical therapy and cancer debulking Or, combo chemo
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What's the most common gynecological malignancy?
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Endometrial cancer
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When should you operate on an adnexal mass [based on age, size]?
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Prepuberty if mass is > 2 cm Reproductive age: if 5-10 and complex, or just >10 Menopausal: >5 cm
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What is the tumor marker for epithelial ovarian cancers?
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CA-125
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What's the time frame for post partum blues?
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They can only last 2 weeks - if they last longer, consider post partum depression
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What step do you take if you've waited for 30 minutes and the placenta has not been delivered?
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Manual extraction [don't do oxytocin]
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What is the best initial relaxing agent for a uterine inversion?
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Halothane [terbutaline, magnesium have also been used]
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How long is considered "Delayed cord clamping" that has been used for preterm infants to increase their total iron and hemoglobin?
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30-60 seconds [don't leave on too long b/c it may cause hyperbilirubinemia]
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T/F: Almost one half of shoulder dystocia cases are in babies that weight <4000 gms
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True
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What is the general rule for when to avoid performing an amniotomy?
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Avoid it if the fetal part is unengaged -- it can lead to cord prolapse if baby is not engaged!
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What's the most common cause of late postpartum hemorrhage?
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Subinvolution of uterus - placental implantation site doesn't decrease in size as expected so when the eschar overlying the placental site falls off there's more bleeding than expected
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What is the next step in evaluating an abnormal triple screen?
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Basic U/S
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What % of Down Syndrome is identified by the triple screen?
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60%
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What is the effect of teratogens in first 2 weeks vs 15-60 days?
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2 weeks: all or none effect 15-60 days: organogenesis can be affected
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How is vasa previa diagnosed before a delivery [and potential fetal exsanguination]?
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Color doppler
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Tx for vasa previa diagnosed prior to onset of labor?
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Scheduled c/s before ROM
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What is the order of testing you should do for a placenta previa work up?
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1. U/S first 2. Speculum exam 3. Digital exam
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What is a corpus luteum cyst?
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Cyst that develops from mature Graffian follicles and assoc w/ normal endocrine function/secretion of progesterone
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What is next step in management of a pregnant pt who is less than 10-12 weeks gestation who has a corpus luteum cyst excised during pregnancy?
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Progesterone should be supplemented b/c CL is what makes progesterone until placenta takes over
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Tx for intrahepatic cholestasis of pregnancy?
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1. Ursodeoxycholic acid 2. Plan for early delivery 37-38 wks b/c of inc risk of stillbirth
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How do you tell intrahepatic cholestasis of pregnancy from pruritic urticarial papules and plaques of pregnancy?
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ICP: Pruritis w/ or w/o jaundice and no rash PUPP: Intense pruritis w/ erythematous plaques on abdomen and extremities Side note: herpes gestationis is skin condition only seen in pregnancy that's characterized by intense itching, vesicles on abdomens and extremities
