OB/GYN First Aid

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Vulva supply: Blood Nerve Lymph
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Blood- branches of external and internal pudendal a. Nerve- ilioinguinal and genital branch of genitofemoral (ant); post cutaneous of thigh and perineal n. (post) Lymph- medial group of superficial inguinal
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Vagina supply: Blood Nerve
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Blood- branch of uterine a.; middle rectal and inferior vaginal branch of hypogastric Nerve- hypogastric (symp) and pelvic (parasymp) plexus
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Uterus supply: Blood Nerve
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Blood- uterine a and ovarian a Nerve- sup hypogastric, inf hypogastric, common iliac n.
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Fallopian tubes supply: Blood Nerve Lymph
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Blood- uterine and ovarian a Nerve- pelvic and ovarian plexus
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Ovaries supply: Blood Nerve Lymph
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Blood- ovarian a (L1); IVC and L renal vein Nerve- aortic plexus
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Chronic Pelvic Pain Etiologies
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L- leiomyoma E- endometriosis A- adhesions, adenomyosis P- PID (MCC) I- infections N- neoplasia
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Acute Pelvic Pain Differential
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A- appendicitis R- ruptured ovarian cyst (MCC) O- ovarian torsion/abscess P- PID E- ectopic pregnancy all life-threatnening/emergent except PID
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MC functional ovarian cyst
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Follicular cysts
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Follicular cyst Tx
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2 mos- laparotomy/scopy to eval/ r/o neoplasia
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Theca lutein cyst Tx
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Tx underlying condition causing elevated hCG
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MC indication for hysterectomy
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Leiomyomas
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Sequelae of uterine fibroids
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Hyaline degen, calcification, red degen, cystic degen
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Submucosal and intramural types of fibroids usually present as ___
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menorrhagia
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Subserous type of fibroids usually present as ___
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torsion
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Tx is initiated for fibroids when: 1. 2. 3.
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1. tumor is >12 to 14 wks gestation 2. hematocrit falls 3. tumor is compressed
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Risk factors for cervical dysplasia
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O-Oral contraceptives S- Sex H- HPV (80%- 16, 18, 31, 33) A- Alcohol Ends- Education/poverty Dirt- Diethylstilbestrol (DES) Garbage- Genetics and Chemicals- Cigarettes (deficient in folic acid)
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Most common gyn malignancies
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1. Breast 2. Ovarian 3. Cervical
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Cervical Ca symptoms Early stage: Middle stage: Late stage:
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Early stage: none, irreg/prolonged vag bleeding/pink discharge, postcoital bleeding Middle stage: postvoid bleeding, dysuria/hematuria Late stage: weight loss, bloody/malodorous discharge, severe pain due to spread to sacral plexus
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Direct Met to cervix
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Rectum, intra-ab, bladder, endometrial
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Met from cervix
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lung, liver, bone
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Radical hysterectomy requires removal of:
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Uterus Cervix Parametrial tissue Upper vagina Pelvic lymphadenectomy from the bifurcation of the iliac vessels to the level of the inguinal ligament
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DES exposed fetus ages now
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41-72 y/o
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Protective factors for endometrial cancer
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combined oral contraceptives, cigarette smoking, multiparity
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Simple endometrial hyperplasia
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glandular and stromal proliferation; most differentiated and lowest risk of cancer
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Complex endometrial hyperplasia
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glandular proliferation only
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Tx of atypical endometrial hyperplasias that progress to cancer
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simple- hysterectomy complex- treated like cancer
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Histo subtypes of endometrial cancer
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Endometroid (ciliated adenocarcinoma)- 80% Papillary serous- poor prog, no hx of estrogen, presents late, more common in blacks, acts like ovarian cancer Sarcomas
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Staging of: cervical cancer endometrial cancer ovarian cancer
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cervical- clinically endometrial- surgically ovarian- surgically
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___ is the most important prognostic indicator in endometrial cancer
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grade
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Adjuvant Tx for endometrial cancer
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stages 1-2: brachytherapy stages 3-4: external beam, hormone (progestin), chemo (doxorubicin, cisplatin)
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Dx of uterine sarcoma
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>10 mitosis/HPF
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Tx of uterine sarcoma
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surgical + adjuvant: leiomyosarc- doxo and cis; mixed mesodermal- ifosphamide and cis; endometrial stromal sarcoma- progestin
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5 histo subtypes of ovarian cancer
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1. serous 2. endometroid 3. mucinous 4. undiff 5. clear cell
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A postmenopausal woman with widening girth notices that she can no longer button her pants. Dx?
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Ovarian cancer
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Hereditary ovarian cancer syndromes 1. 2. 3.
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1. Breast- ovarian ca syn: linked to BRCA-1, AD, younger women 2. Lynch II syn: HNPCC; breast, ovaries, uterus, colon 3. Site-specific ovarian ca- strong genetic link; 2 or more 1st degree relative have the dz
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Ovarian Ca met to the umbilicus is called?
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Sister Mary Joseph’s nodule
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Tx of Ovarian Ca
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Surgery + Stage 1-2: only chemo (paclitaxel and cisplatin (or carboplatin) stage 3-4: chemo + radiation if residual tumor 2cm
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Types of ovarian germ cell tumors
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dysgerminoma- MC endodermal sinus tumor immature teratoma embryonal and choriocarcinoma mixed- MC is endodermal sinus + dysgerminoma
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Tumor marker for: dysgerminoma endodermal sinus tumor embryonal and choriocarcinoma
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dysgerminoma- LDH endodermal sinus tumor- AFP embryonal and choriocarcinoma- B-hCG
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Tx of Ovarian germ cell tumors
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surgery + adjuvant chemo (bleomycin, etoposide, cisplatin) – BEP therapy chemo for all stages except grade 1, stage 1 immature teratoma
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Types of Sex cord- stromal tumors
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granulosa- theca cell sertoli-leydig cell
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Tumor marker for: granulosa-thecal cell sertolic-leydig cell
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granulosa- theca cell- inhibin sertoli-leydig cell- testosterone
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Classic presenting triad of fallopian cell carcinomas
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pain, vaginal bleeding, leukorrhea
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Hydrops tubae perfluens
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pathognomonic finding for fallopian cell carcinomas; cramping pain relieved with watery discharge
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Risk factors for vulvar cancer
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HPV, HSVII, lymphogranuloma venerum, pigmented moles, poor hygiene
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Gestational trophoblastic tumor types
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hyadtidiform mole invasive mole choriocarcinoma placental site trophoblastic tumor
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DNA of complete mole DNA of partial mole
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complete mole- paternal only (46XX) partial mole- paternal and maternal (69XXY)
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All early preclampsia (?weeks) is molar pregnancy until proven otherwise
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<20 weeks
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Gestational trophoblastic neoplasias secrete_____
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hCG, lactogen, thyrotropin
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Average age of menopause onset
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51
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Premature ovarian failure age
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35
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Risk factor for decreasing age of menopause
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smoking (by 3 yrs), genetics, chemo/radiation
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Sheets of trophoblasts
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choriocarcinoma
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Placental site trophoblastic tumor
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infiltration of the myometrium by intermediate trophoblasts; stain + for HPL; unlike other GTNs, hCG is only slightly elevated
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After Tx of partial or complete moles, hCG should return to normal w/in
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2 mos; if hCG rises, doesn’t fall, or falls and then rises again, molar preg is considered malignant
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Polymenorrhea—
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menses with regular intervals that are too short (under 21 days)
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Menorrhagia—
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menses that are too long in duration (over 7 days) and/or menses associated with excessive blood loss (> 80 mL) occurring at normal intervals
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Hypermenorrhea—
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menses that are too long in duration (over 7 days) and/or menses associated with excessive blood loss (> 80 mL) occurring at regular but not necessarily normal intervals
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Oligomenorrhea—
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menses with intervals that are too long (cycle lasts more than 35 days)
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Metrorrhagia—
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bleeding occurring at irregular intervals; intermenstrual bleeding
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Kleine regnung—
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bleeding for 1 to 2 days during ovulation (scant)
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Menometrorrhagia-
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combination of both menorrhagia and metrorrhagia; menses too long in duration or excessive blood loss + irregular bleeding intervals
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Differential for Menorrhagia
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L- leiomyoma A- adenomyosis C- cervical cancer C- coagulopathy E- endometrial cancer, polyps, cancer
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Differential for premenopausal Metomenorrhagia
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P- polys I- inc estrogens N- neoplasia C- contraceptive complications
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Only contraceptive effective in protecting against STDs
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Male Condom
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To ensure sterility after vasectomy:
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have 2 consecutive – sperm counts or use contraception for 6 wks or 15 ejaculations
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___ is the most popular tubal method and most difficult to reverse
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electrocautery
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___ is the most easily reversed tubal method but also the most likely to fail
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clipping
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Pomeroy method
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A segment of isthmus is lifted and a suture is tied around the approximated base. The resulting loop is excised, leaving a gap between the proximal and distal ends. This is the most popular laparoscopic method.
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Parkland method
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Similar to the Pomeroy but without the lifting, a segment of isthmus is tied proximally and distally and then excised.
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Madlener method
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Similar to the Pomeroy but without the excision, a segment of isthmus is lifted and crushed and tied at the base.
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Irving method
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The isthmus is cut, with the proximal end buried in the myometrium and the distal end buried in the mesosalpinx.
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Kroener method
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Resection of the distal ampulla and fimbrae following ligation around the proximal ampulla
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Uchida method
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Epinephrine is injected beneath the serosa of the isthmus. The mesosalpinx is pulled back off the tube, and the proximal end of the tube is ligated and ex- cised. The distal end is not excised. The mesosalpinx is reattached to the ex- cised proximal stump, while the long distal end is left to “dangle” outside of the mesosalpinx.
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Luteal phase pregnancy
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preg dx after tubal sterilization but conceived before
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Spermicide
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Nonoxynol-9 and octoxynol-3; effective for only about 1 hour
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Major differences btwn combination OCP pills and progestin only:
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a mature follicle is formed (but not released); no sugar pill is used
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Progestin-only polls are used for:
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lactating women (doesn’t suppress milk), women >40 y/o, women who can’t take estrogen
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Risk of oral contraceptives
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inc VTEs/stroke, MI, depression
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Contraindications of oral contraceptives
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Thromboembolism CVA or CAD Breast/endometrial cancer Cholestatic jaundice Undiagnosed vaginal bleeding Hepatic disease Known/suspected pregnancy Concomitant anticonvulsant therapy Some antibiotics Relative contraindications: Migraines, hypertension (HTN), lactation
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Contraindications for injectable hormones
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pregnancy, undiagnosed vaginal bleeding, breast cancer, liver dz
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Indications for implant hormonal agents
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OCP contraindicated/intolerated, smokers >35 y/o, women w/ DM, HTN, CAD
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Contraindications for implant hormonal agents
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thrombophelibitis/embolism pregnancy liver dz/cancer breast ca concomitant anticonvulsant therapy
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IUDs:
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Paragard–made with copper and lasts 10 year Progestasert- releases progesterone and lasts 1 year
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Indications for IUDs
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OCP contraindicated/intolerated smokers >35 y/o
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Infertility- ? mons of unprotected sex
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12
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Primary infertility Secondary infertility
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Primary- in absence of previous pregnancy Secondary- after previous pregnancy
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Drugs that can impair sperm function and quantity
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CCB Furantoin
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Average thelarche— Average pubarche— Average menarche—
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Average thelarche—10 years old due to ↑ estradiol Average pubarche—11 years old due to ↑ adrenal hormones Average menarche—12 years old due to ↑ estradiol
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Precocious puberty age
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<8
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Primary amenorrhea: Secondary amenorrhea:
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Absence of menses by age 16 Absence of menses for ≥ 6 months in a woman who previously had normal menses
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Savage’s syndrome
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ovarian resistance to FSH/LH
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Asherman’s syndrome:
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Uterine scarring and adhesions following dilation and curettage (D&C)
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Progestin challenge test:
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Give progestin for 5 days and then stop. This stimulates progesterone withdrawal. If ovaries are secreting estrogen, sloughing will occur and menses results. No menses indicates no ovaries, no estrogen, or blood flow obstruction.
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MCC of hirsutism
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PCOD
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Hypo or hyper- thyroidism causes an increase in prolactin
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Hypo
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Management of PMS
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diet ( low alcohol, caffeine, fats, tobacco, refined sugar, NaCl), OCPs, NSAIDs, SSRIs, GnRH agonists
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1. MC method of family planning: 2. MC reason for neonatal sepsis: 3. MC reason for hospitalization in women of repro age: 4. MC postoperative complication: 5. MCC of primary amenorrhea: 6. MCC of fetal morbidity and mortality:
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1. tubal sterilization 2. chorioamnionitis (GBS, E. coli) 3. endometriosis 4. pulm atelectasis 5. gonadal dysgenesis 6. preterm labor
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Androgen that the adrenal gland makes
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DHEA and DHEA-S
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High LH:FSH ratio in the context of androgen excess indicates that ____ is the source.
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ovary
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A baby with ambiguous genitalia, dangerously hypotensive, and with elevated 17- hydroxyprogesterone.
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21-hydroxylase deficiency
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Hyperthecosis
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when an area of luteinization occurs in the ovary, along with stromal hyperplasia. The luteinized cells produce androgens and hirsutism and virilization may result.
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Luteoma of pregnancy
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benign tumor that grows in response to HCG; virilization can occur in both the mother and the female fetus; tumor disappears postpartum
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Androgen secreting ovarian neoplasms: differences btwn sertoli-leydig cell tumors and hilar (leydig) cell tumors
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sertoli-leydig- present in young women w/ palpable masses hilar cell tumor- present in post-menopausal women w/ nonpalpable masses
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A baby with ambiguous genitalia is born to a mother who complains of increased facial hair growth over last few months.
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Luteoma of pregnancy
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Theories of endometriosis
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retrograde, vascular/lymphatic, mesothelial (peritoneal) metaplasia
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Diagnosis of Endometriosis
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1. Laparoscopy or laparotomy: Ectopic tissue must be seen for diagnosis: Blueimplants—new Brownimplants—older Whiteimplants—oldest 2. Biopsy: Positive findings contain glands, stroma, hemosiderin.
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Medical Tx of endometriosis
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GnRH agonists, progesterone (w/ or w/o estrogen), Danazol (androgen/ FSH/LH suppressant)
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Medical Tx of adenomyosis
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GnRH agonist, Mifepristone (Progesterone antagonist)
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Adenomysosis versus endometriosis
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Adenomyosis- older women, doesn’t respond to hormonal stimulation, non-cyclical Endometriosis- young women, responsive to estrogen, cyclical
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Blood levels of hCG become detectable when?
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8-10 days after fertilization (3 – 3.5 weeks after the LMP)
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UPT- False- False +
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-: too early, urine is dilute +: proteinuria, UTI
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Pregnancy-induced HTN superimposed on chronic HTN
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systolic BP rises by 30 and diastolic rises by 15
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abortus
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<20 wk or <500g
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recurrent abortion
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3 or more abortions
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____ is the leading cause of pregnancy-related death during T1
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Ectopic pregnancy
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Classic triad of ectopic pregnancy:
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Amenorrhea Vaginal bleeding Abdominal pain These usually indicate rupture.
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Medical treatment of abortion: 1st trimester 2nd trimester
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1st- antiprogesterone (mifepristone or epostane) or MTX + misoprostol 2nd- intravaginal prostaglandin E2 or F2a w/ urea

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