Dr. Christensen 1/28
Transcription: Czubatyj
OB/GYN Review
I.
II.
III.
IV.
V.
Informed Consent:
a. Least important part is signature
b. Must include:
i. Procedure
vii. Complications (not particular surgeon but
ii. risks (up to and including
for procedure)
death)
viii. Self Efficacy—if patient is informed they
iii. alternatives
believe they can make proper choices
iv. expectations
ix. Demand efficacy—Patient trying to please
v. failure chance
the doctor
vi. cost (overall)
c. If have surgical emergency, don’t do any elective stuff as well
Ethics
a. Beneficence: do the right thing, advocate for the patient
b. Nonmalficence: do no harm, no added procedures
c. Futility: doing something with no expectation of working
i. Not obliged to start something futile
ii. Not allowed to stop a futile treatment once started
d. Patient Autonomy: implies informed consent – they can choose
e. Physician autonomy: you choose right thing for the patient
f. Standard of care: legal term that is what a similar physician would do in a similar
condition. Depends on geography.
Female screening
a. Pap smear
i. Start at 21 or 3 years after first sexual encounter and go yearly
ii. If low risk, q3 years
b. Mammogram
i. Start at 40-50 q2 years
ii. >50 q1 year
c. HPV—Yes starting at 30
d. BP, weight, general physical and Pelvic: yearly
e. Rectal:
i. >40 do rectal + pelvic and guiac every time
f. Colon:
i. Colonoscopy q10 years starting at 50
ii. Sigmoidoscopy q5 years starting at 50
g. Cholesterol: start at 20, q5 years until 65
h. TSH: starting at 65
i. CXR, CA-0125, TVUS: NOT screening tests—to many false +
j. Endometrial thickness—no
Maternal-fetal physiology (LOOK AT NOTES FROM CD)
a. Increased progesterone causes increased CO2 causes increased respiration causes
decreased PCO2 causes respiratory alkalosis causes kidney to dump bicarb
b. End up with a compensated respiratory alkalosis and basic urine
c. Every hormone in pregnancy goes up EXCEPT DHEA-SO4
d. Renal blood flow increases, GFR increases, glucose in urine increases
e. Never should have protein in the urine – always pathologic
Preconception care
a. All patients:
i. Folate
1. 0.4mg
2. 4mg if had previous NTD
ii. Test for DM—if +--↑ risk of birth defects
Dr. Christensen 2/28
Transcription: Czubatyj
VI.
iii. Rubella
1. if not immune—immunize
2. cannot immunize during pregnancy
iv. General—Pap, VDRL, Chlamydia, CBC
b. Normal patient
i. First visit: Pregnancy Confirmation, CBC, T&S, Rubella, VDRL, GC,
Chlamydia, HIV, HEP (core: infected, now immune; surf ab: immunized,
immune; surf ag: infected), PAP, GA, PPD, UA & C&S, breast exam, Rh testing
ii. Planned visits:
1. 16-18 weeks: AFP (triple screen/quad screen)
2. 22 weeks: ultrasound for anatomy
3. 26 weeks: glucola, if elevated do 3 hr GTT
4. 36 weeks: cervical cultures, repeat STDs, cervical check
5. 40-41 weeks: fetal surveillance (NST)
c. Diabetic: IDDM pregestational
i. Worry about:
1. Glucose: causes embryopathy.
a. Most common: CV, GI
b. Most specific: caudal regression
c. Need to check HgbA1C, fasting glu, 2 hr postprandial
d. Check
i. Eye: fundoscopic exam
ii. Heart: EKG
iii. Kidney: 24 hr urine for protein, Cr clearance
iv. Neuropathy: follow neuro exam
ii. Problems: macrosomia, placenta gives out so induce early
Triple screen
a. Increased AFP
i. Worry about: NTD, wrong dates, twins
ii. Do an u/s and repeat AFP
1. If normal and AFP still up, do an amnio AFP and AChE
2. Confirmed increase is an occult NTD
b. Decreased AFP: wrong dates, aneuploidy, IUGR
i. Get u/s to confirm dates, in not – need amnio
Trisomy 21
Trisomy 18
VII.
AFP
Down
Down
HCG
Up
Down
Estriol
Down
Down
Bishop Score/Fetal survey for inducibility:
Factor
0
1
2
3
Closed
1-2
3-4
5+
Dilation
0-30%
40-50%
60-70%
80%+
Effacement
-3
-2,-1
0
+1,+2
Station
Firm
Medium
Soft
Consistency
Posterior
Mid
Anterior
Position
a. Cervical length (bad of long)
b. Position (bad if post)
c. Consistency (bad if firm)
d. Effacement (bad if fingertip)
e. Station (bad if <0)
f. Treatment is to ripen the cervix byDilation with PGE1 or PGE2 and then pitocin
Dr. Christensen 3/28
Transcription: Czubatyj
VIII.
Cardinal movements of labor (first 2 can be flip-flopped)
a. Descent
b. Flexion
c. Internal rotation
d. Extension
e. External rotation (aka restitution)
f. Expulsion
IX.
APGAR scoring
0
1
2
0
<100
>100
HR
Absent
Irreg
Crying
Resp
None
Grimace
Cry
Reflexes
Limp
Flexion
Flex/Extension
Tone
Blue
Blue extremities
Pink
Color
a. Cannot get all pink (10) apgar at 1 min
X.
Postpartum care
a. Hormones
i. Lactation
1. ↑ PRL
2. Need decreased E2 to increase PRL so can’t use OCPs (progestin only
when breast feeding)
3. ↑ Oxytocin - + suckling
4. hypoestrogenic:
a. hot flashes
b. Dyspareunia
c. Vaginal Dryness
b. Greatly increase metabolism postpartum (↑Caloric expenditure↓Fat)
c. Increased risk of DVT
d. Psychiatric
i. Blues: normal – need reassurance
1. Should stay in bed
ii. Depression (15%): ask about suicide, harm baby, call psychiatrist
iii. Psychosis: told by Satan – need to protect family
1. Suicide/Homicide
2. Hospitalize, Call psychiatrist, antipsychotics
XI.
Ectopic Pregnancy: 1-2% of all pregnancies
a. Risks: normal risk 1-2%
i. Tubal Fulgaration
ii. IUD—progesterone
iii. Previous Ectopic
iv. History of infertility and/or PID
b. Presentation:
i. Amenorrhea
ii. Pain
iii. Culdocentesis:
1. Non-clotting blood +--has ectopic 9/10 times
2. negative = clear fluid
3. everything else is non diagnostic
c. Diagnosis:
i. 1500 quant—Gest sac with TVU/S
ii. 6500 quant—gest sac with TAU/S
iii. No diagnosis if below these 2
iv. 3000 + TVUS = no Gest Sac = ectopic
1. if quant goes up—do something
Dr. Christensen 4/28
Transcription: Czubatyj
2.
MTX
a.
b.
c.
d.
3.
D+C
a.
b.
4.
Ectopic treatment
Make sure not viable IUP
Absolute contraindications:
i. Hepatitis
ii. Renal disease
iii. Peptic ulcer
iv. Allergic
Relative:
i. Size >3.5
ii. Hcg—5-15K
iii. Cardiac motion
Chorionic villi
i. IUP
ii. Might interrupt pregnancy
no chorionic villi
i. ectopic
Scope:
a. Diagnostic
b. Surgery:
i. Salpingostomy—open tube, leave open
ii. Salpingestomy—take tube out
d. BHCG should double in 48 hrs but should not use this exclusively
i. If the BHCG is the same and there is no sac – abnormal pregnancy
e. Examples:
i. HCG of 1000 and no sac, repeat in 48 hours and get hcg of 1200 and no sac. Tx
options:
1. Observe
2. D&C, if find POC then abort, if not then ectopic
3. Laparoscopy
4. Treat with MTX
ii. Abdominal pain, abdominal distension, hypotension, + pregnancy
1. Needs laparotomy
f. No surg if: previous surg
g. No surg or MTX if: alcoholism with impaired liver fxn
h. If patient gets second ectopic on same side, remove it surgically
XII.
Insulin dependent pregestational diabetes
Diet-controlled
Insulin controlled
None
B, C, D
Pregestational
A1
A2
Gestational
a. Types B, C, and D are the worst patients and you see birth defects – GI, CV, and caudal
regression
b. Pre-gestational:
i. White classification—A,B,C,D
ii. 90% same as gestation
1. big babies
2. birth defects
a. CV
b. Genitourinary
c. Caudal regression—arms and legs don’t develop
iii. 10% IUGR:
1. Asymetrical—reversible (big head)
2. Symmetrical—worse
a. Perinatal viruses (TORCH)
b. Abnormal Karyotype
Dr. Christensen 5/28
Transcription: Czubatyj
XIII.
c. Low fluid (oligo)
iv. Normal fluid with symmetrical IUGR—normal baby
v. Parvovirus:
1. big baby
2. slap baby appearance
3. anemia
4. hydrops fetalis
vi. Maternal serum—Scans—Amnio
c. Gestational:
i. Risk:
1. Family history
2. Obesity
3. Large Placenta
ii. Diagnosis:
1. 50gm
2. if abnormal do GTT
iii. types:
1. A1—diet controlled
2. A2—med controlled
iv. Problems:
1. ↓ Glucose, Ca, Temp
2. ↑Bilirubin, Hct
3. Macrosomeia
a. Cephalopubic disproportion
i. Distocia—Labor slow—C-section
ii. Shoulder Distocia
b. Risks for Shoulder Distocia:
i. Big baby
ii. Most don’t have any risk factors
iii. Very slow labor
iv. Turtle sign—baby crowns when pushing, then
completely disappears when pushing stops
c. Attempt to correct shoulder distocia:
i. McRobert’s
ii. Suprapubic pressure
iii. Deliver posterior shoulder
iv. Episiotomy (4th degree)
v. Wood’s Screw
vi. Break clavicles
vii. Zavanelli—cannot get baby out, put it back in
PIH (classic pre-eclampsia (after 20wks))
a. See non-dependent edema (hands, face), protein > 300 mg/dL, BP > 140/90 on 2 sep
measurements, weight gain >2 lbs/wk
b. Prostaglandin imbalance
c. Risk factors:
i. 1st pregnancy
ii. Increased placenta volume
iii. Vascular disease
iv. History of preeclampsia
v. Chronic HTN
d. Tx:
i. Mild: admit, bedrest on left side, BPP
e. Severe: protein at 5000, bp: 160/110 1 time
i. Neuro sx: ha, vision changes, increased reflexes, seizures, clonus
ii. Heart sx: pulmonary edema, heart failure, ↑,↓CO
iii. Kidney sx: 4 + prot, Cr >1.0, oliguira (<400cc)
Dr. Christensen 6/28
Transcription: Czubatyj
XIV.
XV.
iv. Liver sx: DIC, ↑LFT, RUQ pain, HELLP (**remember high bp not part of
HELLP)
v. Tx: delivery
1. amnio for lung viability if yes induce, if no bethamethasone
vi. HTN Tx:
1. hydralazine (arterial vasodilator), labetalol (alpha/beta antagonist) if
used can cause hypotension – fetal distress
2. never use diuretics
f. Seizures: treatment is MgSO4 – can stop breath and lead to hypotension
g. If mom in trouble, try to resuscitate for 4 minutes on mom and then get baby out
Isoimmunization
a. 85% of mothers are Rh +
b. Prevention: RhoGAM – is IgG that can cross placenta
i. Will kill baby’s cells within the mother
ii. Small dose will not effect baby
c. When given
i. 28 wks
ii. Maternal –fetal transfusions
iii. Postpartum
iv. D&C (miscarriage)
v. Ectopic
vi. Mom accident (MVA)
d. Klenhauer-Betke: calculate how much fetal blood went into mom so you know how
much RhoGAM to administer
i. 300 mcg of RhoGAM kills 15 mL of fetal RBCs
e. ROM at 12 weeks, Rh -, titer of 1:32: do amnios – if see bilirubin in amniotic fluid –
indicates hemolysis – estimate danger via Liley curve
i. Zone one—no worries
ii. Zone II—slightly worried
iii. Zone III—very worried
f. Can cause hydrops fetalis in newborn if needed can transfuse O- blood (PUBS or
cordocentesis)
Twins
a. How these come about:
i. Remember that the chorion arises before the amnion
ii. Separation day: (Amnion/Chorion)
1. 1-4 days--before trophoblast differentiation, get Di-Di
2. 4-8 days--after trophoblast diff but before amnion formation get Mo-Di
3. 8-12 days--after both trophoblast diff and amnion form, get Mo-Mo
4. >12days--conjoined
b. Mo-Di
i. Bilirubin = hydrops
ii. TTTS: twin to twin transfusion syndrome
iii. Rather be little – asymmetric growth retardation
c. Mo-Mo
i. Cord accidents
d. Di-Di
i. No increased risk over previous pregnancy
ii. Increased PTL
iii. Decreased fetal weight
iv. Increased previa
v. Increased PIH
vi. Increased abruption
vii. Want to carry to 32 wks vs. 40 wks
viii. Increased c/s
ix. If first is vertex, can deliver second breech
Dr. Christensen 7/28
Transcription: Czubatyj
XVI.
Cancers:
a. Cervical
i. Risk Factors
1. HPV (16,18, 30s [not 6] ) LES, Multiple partners
2. Smoking
3. HIV—immune suppression, transplant
4. Transformational Zone (TZ)
ii. Presentation:
1. No symptoms (abnormal Papcolposcopy)
2. Post-coital bleeding (pap/biopsy)
3. Terrible triad—cancer spread to pelvic side walls
a. Edema
b. Sciatica
c. Hydronephrosis
d. Prognosis not good
iii. Diagnosis:
1. Biopsy—not Pap
2. Leep, Cone, Cervical
iv. Staging:
1. stage I—cervix only
2. Stage III and IV—mets
v. Treatment:
1. Radiation therapy:
a. Brachy
i. Up close
ii. Radiate cervix
iii. Cesium, Radium in cervix
iv. 400 Rads is fatal
v. Cervix receives 20,000 RADS
b. Tele
i. Cobalt used
ii. Radiate pelvis
iii. Kill off lymph nodes
2. Hysterectomy (radical—remove tissue around organs also) if caught
early
vi. Follow Up:
1. early—90% cure rate
2. late—very little chance
3. Return—fatal
4. return inside pelvis—remove pelvis—pelvic exoneration
vii. Papsmear:
1. Systems:
Papinicolou
WHO (created by UN)
Bethesday (created by US
Negative
Satisfactory
Class 1
Atypical—inflammatory
Inflammatory
Class 2
Atypical—HPV
LGSIL
Class 2
Mild Dysplasia: CIN1
LGSIL
Class 3a
Moderate dysplasia: CIN2
HGSIL
Class 3b
Severe Dysplasia: CIN3
HGSIL
Class 4
Cancer
Cancer
Class 5
a. Bethesda also has:
i. ASCUS
1. Atypical Squamous cells of undetermined
significance
Dr. Christensen 8/28
Transcription: Czubatyj
2.
b.
c.
d.
e.
f.
b.
c.
Tx options are—colposcopy, repeat pap (if
still abnormal colpo), HPV tping—high
risk—colpo, low risk nothing
ii. AGUS now replaced by AGC—Atypical Glandular
cells
Treatment
NEG—repeat in 1-3 years
UNSAT—repeat immediately
ASCUS—see above
LG, HG, ACG, CA--colposcopy
Endometrial:
i. 2 types:
1. Type 1
a. Excess estrogen
b. Early grade, stage
c. Very curable
2. Type II:
a. N estrogen involved “ovarian cancer”
b. Clear cell, papillary serrous
c. Bad prognosis
ii. Risk Factors:
1. ↑ Estrogen:
a. Obesity
b. Aromatase in adipose tissue converts testosterone to estrogen
2. Physician:
a. Adding Estrogen
b. Prempro (provera+Premaria)
c. Granulosa cell tumor
d. PCOS—no ovulation = no progesterone (stops endometrial ca)
e. Tamoxifen--↓Breast Cancer, ↑endometrial Cancer
iii. Diagnosis:
1. Endometrial Biopsy:
a. + - treat cancer
b. – D+C or hysteroscopy
2. Never use Pap for diagnosis
iv. Treatment:
1. TAH + BSO + staging (lymph node dissection)
2. BSO pathology:
a. Good:
i. Watch
ii. May recur in vaginal cuff
iii. Pap, pelvic exams
b. Bad:
i. Grade III, deep invasion, spread
ii. Radiation therapy—radiate pelvis
Ovarian:
i. Types:
1. Epithelial (90%)
a. most common benign and malignant
i. <50% benign
ii. >50% malignant
b. 5cell types:
i. Type -- normal counter part—marker
ii. Serrous—fallopian tube—CA125
iii. Clear cell—Kidney—CA125
iv. Brenner—Bladder—CA125
Dr. Christensen 9/28
Transcription: Czubatyj
2.
3.
v. Endometrial—Endometrium—CA125
vi. Mucinous—endocervix—CEA
vii. Germ Cell—AFP
viii. Placental site trophoblastic tumor (PSTT)—HPL
ix. Krukenberg—mets GI--CEA
x. Serrous and clear cell also in endometrium
c. False Positives for CA125:
i. Endometriosis
ii. Peritonitis
iii. Fibroids
iv. Pregnancy
v. Cirrhosis ***
Stromal (hormonally response)
a. types:
i. Granulosa cell
1. Makes estrogen
2. Maker—inhibin
ii. Leydig cell tumor:
1. Testosterone
2. Marker = testosterone
b. Presentation:
i. Leydig—Virulization—temperol balding, beard, etc
ii. Granulosa:
1. Child—abdominal mass, breast
development, vaginal bleeding
2. Post menopausal—adnexal mas, endometrial
cancer
c. Treatment:
i. Find and remove
ii. Post menopausal—check for endometrial cancer
Germ Cell Tumor
a. types:
i. Dermoids (teratoma)—can cause torsion—remove
them
1. Dermal
2. Specialized
a. Struma Overii—thyroid hormone
i. Hyperthyroid
ii. Adnexal mass
b. Carcinoid:
i. Serotoninbreakdown
product—Carcinoid
Syndrome
ii. Flushing, Wheezing,
Diarrhea
c. Immature (malignant)—no markers
ii. Dysgerminomas:
1. Seminoma
2. Most concern LDH
iii. Choriocarcinoma
1. HCG
2. Gestational Trophoblastic Disease
iv. Endodermal sinus tmors—AFP
Dr. Christensen 10/28
Transcription: Czubatyj
b.
c.
d.
4.
d.
Mets:
a.
Risk Factors:
i. None
ii. Age (teenagers)
iii. Dysgerminomas found in patients with undescended
testes (always find out if patient is XX or XY)
iv. Infertility/amenorrhea
Presentation
i. Young
ii. Rapidly growing mass
iii. Ruptures
iv. Intraperitoneal bleeding
Treatment:
i. USO
ii. Surgical staging
iii. Chemo (cure rate>90%)
Rules:
i. Bilateral
ii. Breast
iii. Colon
iv. Endometrial
b. Krukenberg tumor—gastric cancer, signet cell, CEA marker
ii. Risks for ovarian Ca:
1. Ovulation (1-99) (OCPs↓), (clomaphene↑)
2. Genetics
a. BrCa1—2 cancers—ovarian/breast
b. BrCa2—1 cancer—breast
c. Lynch1—hereditary nonpolyp colon cancer (HNPCC)
d. Lynch2
i. HNPCC
ii. Ovary
iii. Breast
iv. Endometrial
v. Prostate
e. Site specific ovarian cancer—ovarian cancer in family tree
f. <5% of ovarian cancer fits genetics—95% only have ovulation
as risk factor
3. Talc powder—controversial
iii. Presentation:
1. Vague
2. GI complaints
3. Pelvic mass
4. ↑CA125
iv. Treatment:
1. TAH+BSO+staging+Chemo
2. most patients respond, most recur—once recur—incurable
3. Die of GI block—vomiting can’t stop
4. live maybe 3 years after recurrence
Breast
i. Risk factors:
1. age
2. gender
3. breast cancer on one side already
Dr. Christensen 11/28
Transcription: Czubatyj
Tamoxifen
Raloxifen
Premorin
Prempro
ii. medium risk factors:
1. Gail model
a. Age
b. Race
c. Age of menarche
d. # of first degree relatives with breast Ca
e. # of abnormal breast biopsies
f. Age of first child
2. gives #--if >1.8 offer tamoxifen
iii. Others Risk factors
1. Genetics
a. BrCa1,2
b. Lynch 2
c. Leifromeni—p53 defect
i. Kids—sarcoma
ii. Men—breast cancer
2. obesity:
a. hormonal replacement therapy
i. prempro—causes breast Ca, stroke, MI, dementia,
↓Colon Ca, osteoporosis
ii. premorin—no—strokes (CVA)—prevents hot
flashes, osteoporosis, colon cancer
iii. OCP—no
b. Fat and alcohol increase,
c. smoking is protective
3. Alcohol
4. smoking ↓ breast Ca
5. ↑Exercise↓Breast Ca
iv. Presentation:
1. Lump—suspiscious—biopsy
2. Mammogram—
a. Positive if
i. Microcalcifications
ii. Spiculations
b. Tests:
i. Needle localized
ii. Stereotactic biopsy
v. Treatment:
1. modified Radical mastectomy
a. lymph node dissection
b. some tissue
2. Lumpectomy
a. Quadrant of bast
b. LND—if +
i. Premenopausal—chemo
ii. Postmenopausal—tamoxifen
iii. Usually everyone gets both
vi. SERMS (selective estrogen receptors modulator)
↓ Breast Ca
↑ Endometrial Ca
↓Osteoporosis
↑Vasomotor
↓Breast Ca
↓Endometrial ca
↓Osteoporosis
↑Vasomotor
No change
↑Endometrial Ca
↓Osteoporosis
↓Vasomotor
↑
↓
↓
↓Vasomotor
Dr. Christensen 12/28
Transcription: Czubatyj
e.
f.
g.
Vulvar:
i.
ii.
iii.
iv.
v.
Most Squamous Cell Carcinoma from TZ, HPV (almost always type 16)
2nd most common = melanoma
Adenocarcinoma—15-20%
DES—clear cell carcinoma of cervix/vagina
Lymph node drainage:
1. uterus cervixPelvicaorticthoracic
2. Vulvainguinalpelvicaorticthoracic
3. Vagina: (behaves like)
a. L 1/3—Inguinal
b. M1/3—behaves like both
c. U1/3—Cervical
vi. Stains:
1. Lugol—iodine stains glycogen—used for vaginal
2. Vulva uses Talofin Blue
Gestational Trophoblastic Disease
i. Mole—uncontrolled placenta—placenta grows out of control
ii. Complete:
1. characteristics:
a. Daddy’s girl
b. All paternal DNA—sperm meets blighted ovum 23X46XX
c. trophoblast
d. No embryo, just placenta
2. Diagnosis in ER
a. SD+C
i. 85% resolve
ii. GTD= 15% recur—1-3%-->choriocarcinoma (CCA)
b. recur:
i. act like cancer
ii. grow into tissue
iii. recurrent or invasive mole
iv. Kill patient if not treated
v. Chemo (MTX)
c. CCA:
i. Doubling time 24hrs
ii. 65% cure rate
iii. Incomplete:
1. characteristics:
a. 2 sperm fertilize 1 egg
b. 23x2 + 23X = 69
c. trophoblast+fetus
2. Diagnosis in ER—same as complete except 99% resolve and 1% recur
iv. 1/20,000 pregnancy turn into CCA—check HCG
v. Cytotrophoblasts--*synciotrophoblasts (both can turn into CCA
vi. * = intermediate cell
1. placental site trophoblastic tumor (PSTT)
2. if INT cellCCA
a. human placental lactogen
b. hysteroscopy
Vaginal:
i. Mets
ii. SCC
iii. DESclear cell Ca of Vagina
1. 25%:
a. t shaped uterus
b. Cox comb cervix
Dr. Christensen 13/28
Transcription: Czubatyj
c. infertility
d. adenosis—glands where not supposed to be
2. 1/10,000—Ca
iv. Sarcoma bacteriodes
1. infertile with mass coming out of vagina
2. Rhabdomyosarcoma
XVII. Polycystic Ovarian Syndrome:
a. Hirsutism, oligomenorrhea, +/- obesity, may be infertile
b. Diagnosis:
i. Polycystic ovaries on TVUS—string of pearls
ii. Anovulation by increased LH/FSH and increased androgens (LH/FSH >2:1)
iii. Increased fasting insulin because have insulin resistance
iv. Glucose/Insulin is decreased
v. Abnormal GTT
c. What to do:
i. May have increased chance of endometri ca (>30yo) so do endo biopsy
ii. Regulate cycles
iii. Worry regarding insulin resistance, therefore give metformin
XVIII. Amenorrhea:
a. Primary—no period by 16 or 14 if appear abnormal
i. Constitutional
ii. Imperforate hymen
1. cyclic pain
2. blue bulge at perineum
3. treatment—cruciate opening
iii. Septum
iv. Mullerian Agenesis
1. no mullerian tract—vagina, cervix, uterus, tubes
2. ovaries normal
3. renal problems
4. XX
5. Need creation of neovagina
v. Testicular Feminization (XY)—no testosterone receptor
1. very increased testosterone
2. +MIF, Y chromosome present, no uterus
3. Negative axillary/pubic hair (KEY)
4. excess test—converts to estrogen—breast development
5. have undescended testes
a. 25% of dysgerminoma
b. Need orchiectomy post puberty and neovagina
b. Development:
Disease
Karyo
Breast
Uterus/
Pubic/Ax
Cancer
Other
Treatment
Vagina
hair
risk
XX
+
+
No
Neovagina
MA
XY
+
Yes
Neovagina,
T Fem
orchiectomy
45 XO
Infantile
+
No
Osteoporosis
OCPs
Gonadal
dysgen
46XX
Infantile
+
No
Osteoporosis
OCPs
Gonadal
dysgen
46 XY
Infantile
+
YesOsteoporosis
OCPs
Gonadal
testic
Orchiectomy
dysgen (no MIF)
46XX
Infantile
No
Osteoporosis
Malignant
17
HTN, make
OHase
tons of
deficient
Aldosterone
Dr. Christensen 14/28
Transcription: Czubatyj
c.
XIX.
Secondary amenorrhea workup
i. Preg test—if – continue
ii. Progestin withdrawal test
1. Bleeding = +annovulation
a. TSH
b. Prolactin
c. PCO
2. no bleeding: - check estrogen and progesterone
iii. Estrogen + Progesterone:
1. negative :
a. asherman’s
b. HSG
c. hysteroscopy
2. Bleeding:
a. uterus works—problem somewhere else
b. check FSH level
i. ↑ = menopausal ovary
ii. ↓ or = =ovary okay
1. Pit CT/MRI
a. + = Pituitary tumor
b. - = hypothalamus
i. Hypothalamic
ammenorhea
ii. – progesterone
iii. – estrogen = osteoporosis
d. Summary:
i. + Progestin—bleeding—annovulation
ii. – Progesterone = asherman’s
iii. ↑FSH = ovarian failure
iv. Everything normal= hypothalamic
Virulization:
a. Sites:
i. Ovary
1. Leydig cell tumor
2. Adnexal mass
3. Testosterone levels
ii. Adrenal
1. General:
a. 17-21-11—Cortisol
b. 21-11-18--aldosterone
2. 21-hydroxylase deficiency
3. ↓cortisol
4. **check ** ↑17-hydroxyprogesterone
iii. Drugs (steroids)
1. Normal testosterone
2. No adrenal mass
3. UDS
b. Presentation:
i. Infant—ambiguous genitalia
ii. Adult (19+)
1. period stops—ammenorhea, Congenital Adrenal Hyperplasia (CAH)
2. happens slowly
c. Other:
i. CAH or adrenal hyperplasia
ii. Adrenal Adenoma—any age, DHEA sulfate
Dr. Christensen 15/28
Transcription: Czubatyj
iii. PCO—high LH, Low FSH (LH/FSH ratio >2)
Abnormal/Normal Bleeding:
a. Causes:
i. Adenomyosis
1. tons of bleeding
2. tender boggy enlarged uterus
3. dysmenorrheal, dysparenuia, chronic pelvic pain
ii. Coagulopathy (Von willebran’s disease and ITP)
1. Will die with first menstrual period if no intervention taken
iii. Dysfunctional Uterine Bleeding:
1. Diagnosis of exclusion
2. no fibroids, ca, adenomyosis, endometriosis
3. some type of hormone problem
a. decreased E2, spotting due to endometrial atrophy
b. decreased Pg—see in teens who have 1-2 periods/p=year that
are terrible and land them in hospital
c. Increased PG—Give DepoP or OCP and they will spot/bleed
iv. Endometriosis:
1. Pain and infertility
2. Adnexal tenderness
3. Only 1/3 have irregular bleeding
v. Leiomyoma
1. most are asymptomatic
2. If symptoms—pain, pressure, irregular bleeding
3. Have a multinodular, irregular uterus
vi. Carcinoma:
1. Postmenopausal bleeding—endometrial Ca
2. Postcoital bleeding—cervical ca
3. Vague complaints—ovarian ca
4. Painless lump—vulvar ca
5. Usually metastatic—vaginal ca
b. Dysmenorhea:--pain during period
i. Primary:
1. periods always were painful
2. ↑serum prosoglandins
3. no Pathology
4. Treatment—NSAIDS, OCPs Wrong diagnosisscope
ii. Secondary:
1. Pain is new
2. Endometriosis—laparoscopy
3. Adenomyosis—hysterectomy
4. Diagnosis needed:
a. Endo—Lupron, Laser, Hyst
b. Adeno—TAH
iii. GI complaints, Pelvic pain—Spastic Cholitis
iv. Interstitial Cholitis--+ K sensitivity Test
XXI.
Climacteric:
Drug
Breast Cancer
Endometrial Cancer
Premarin*
No change
↑
Tamoxifen
↓
↑
Raloxifen
↓
↓
Prempro**
↑
↓
*--conjugated Estrogens
**--combined conjugated estrogen/medroxyprogesterone acetate
XX.
XXII.
PMS:
Dr. Christensen 16/28
Transcription: Czubatyj
a.
Cyclic Depression
i. Sleep
ii. Intent
iii. Guilt
iv. Energy
v. Concentration poor
vi. Appetite
vii. Psychomotor
viii. Suicide
ix. SIGECAPS
b. 5+ for >2 weeks—depression episode
c. PMS = 5-10 days out of the cycle before the cycle
d. Somatic Symptoms
i. Headache
ii. Abdominal pain
iii. GI
iv. Etc
e. Diagnosis made by Diary
i. Rule out hyperthyroid (TSH test)
ii. Alcoholism
iii. Depression Questionare -, history of alcohol not prominent
f. Treatment:
i. Fluoxetine (prozac)—SSRI
ii. Alprazolam (Zanex)
XXIII. Reasons for surgery with fibroids:
a. Severe symptoms
b. Anemia
c. Organ damage
d. Suspiscios for cancer—almost never—sarcoma
i. Post menopausal fibroid
ii. Rapidly growing fibroid
e. other treatments:
i. Surgery
ii. Lupron
iii. Watch
iv. Myomectomy—never do unless patient wants to retain fertility
v. Uterine Artery (UA) embolization
XXIV. Sexual response Cycle:
a. Female:
i. Libido
ii. Excitement
iii. Orgasm
iv. Plateau
v. Resolution
b. male is the same except instead of plateau has refractory
c. Libido is most common problem, poor prognosis
i. No interest in sex (aversion disorder)
ii. Depression, drugs (alcohol, SSRI, Illicit), relationships (domestic violence)
d. Excitement:
i. Lubrication—pain with intercourse, no lubrication
ii. Infection—herpes, yeast, HPV, warts
iii. Scarring
iv. Meds—Anticholinergic—anything that causes dry mouth will cause dry vagina
e. Orgasm: anorgasmic
i. Primary—never had—directed masturbation is treatment
ii. Secondary
Dr. Christensen 17/28
Transcription: Czubatyj
1. had, cannot have currently—often because of relationship
2. Sensate focus exercises—foreplay
iii. 80% success rate
XXV. Domestic Violence:
a. Risk factors:
i. Partner (they were abused, drugs, Alcohol), won’t leave, overly protective
ii. Patient previously abused
b. Signs/symptoms—hypervigilance—jumps when you enter the room, unexplained
multiple injuries, partner won’t leave, overly protective
c. Diagnosis—History, Injuries, inquire about partner
d. Encourage patient to have plan for safety—follow up
e. Most common outcome—patient goes back to abuser
XXVI. Recurrent Pregnancy Loss (1st and 2nd trimester) 3 in a row
a. Need at least 3 in a row before doctor is worried
b. Causes:
i. Karyotype
ii. Infection—ureaplasm
iii. Anatomy—uterus—Fibroids, septum
iv. Immunology—Incompatibility
v. Thrombophilia
1. Factor V leiden
2. Protein C andProtein S
vi. 50% are unknown causes
XXVII. IUFD: >20wks:
a. Etiology:
i. Unknown
ii. Diabetes
iii. Sepsis
iv. Cord Accident
v. Ruptured Membranes
vi. Abruption
b. Fibrinogen levels ↓  DIC
c. Test Coagulation, PT, PTT, fibrinogen
XXVIII. Placental Issues:
Placental Abruption
Placenta Previa
Vasa Previa
Placenta comes out before baby
Placenta over cervix
Uncovered vessels that can be
easily ruptured
Contraction with or without pain
Painless bleeding
Baby bleeds
+/- Bleeding
+/- Contractions
Spotting/Fetal Distress
DIC
DIC—only when patient is about
Sinusoidal pattern
to die (late)
Convaliar uterus
No convalair uterus
IUFD
IUFD--late
Risk Factors
HTN
AMA, previous uterine surgery
Velametous insertion
PIH, Chronic HTN
Twins, Grand Multiparity
Succentorial obe (extra lobe)
Drugs (cocaine, alcohol,
Smoking
smoking)
Fibroids, ↓Folate, Vena Cava
Acreta, Increta, Percreta
syndrome
(deadly—labor and hematuria)
Had one before
Treatment:
C/S for live birth
Control bleeding, give steroids
C/S
Vaginal delivery if baby dead
C/S
Dr. Christensen 18/28
Transcription: Czubatyj
XXIX. Rupture of Membranes:
a. ROM—rupture of membances
b. AROM—artificial rupture of membranes—you did it (+/- labor)
c. SROM—spontaneous rupture of membranes (+ labor)
d. PROM—premature rupture of membranes (no contractions)
e. PPROM—premature previable rupture of membranes (<37 weeks, no contractions)
i. Check for infection
1. Chorioamnionitis
a. Mother:
i. ↑temp, ↑ pulse
ii. ↑WBC, ↑uterine tenderness
iii. ↑pus
b. Baby:
i. Tachycardia
ii. ↓variability—acidosis
c. amnio:
i. just like spinal tap
ii. ↓glucose, ↑ protein, + WBC, IL-6
2. + :
a. no tocolytics
b. no steroids
c. ? induction
3. Negative:
a. tocolytics
b. steroids
f. Diagnosis:
i. Nitrozine
1. pH paper + (↑pH
2. False + --sperm, blood, betadine, UTI
ii. Ferning:
1. NaCl
2. 2nd 3rd trimester
3. False - --rupture has sealed, sample urine
g. You can do transvaginal U/S on ROM and Placenta Previa—just don’t touch cervix
h. Cannot culture Vaginal fluid—need a cervical culture, but check vaginal fluid for
maturity
XXX. Preterm Labor:
a. Etiologyinfection of cervix and/or vagina
b. Are they in labor—cervical change with contractions
c. Infection:
i. Yes:
1. Induce labor if mother is dieing
2. no interference otherwise
ii. No:
1. tocolytics:
a. Alcohol—BAL 300 (don’t use anymore)
b. Β2 Mimetic
i. Ritidrine—relaxes uterus, β1 crossover
ii. Terbutaline—relaxes uterus, β1 crossover
c. Mg Sulfate
i. Ca antagonist
ii. ↓ Respirations
d. NSAIDS—Indomethacin
i. ↓ Platelets, GI disruption—mother
ii. Premature closer of ductus arteriosus—baby
iii. Do not give after 34 weeks
Dr. Christensen 19/28
Transcription: Czubatyj
2.
Steroids:
a. Prednisone—doesn’t cross placenta
b. Β-methasone—affects mother and baby equally
XXXI. Decels:
a. Look at contraction and decal to see if they match
b. Look if symmetrical
c. Early—head compression
d. Late—uteroplacentalinsufficiency
e. Variable:
i. Cord compression—low fluid on BPP—may try amnioinfusion
ii. bad signs
1. Back to baseline very slowly
2. 60x60—60 beats in 60 seconds
3. Decel within a Decel
f. tachycardia:
i. >160 bpm
ii. fever (maternal of fetal)
iii. ↓variability—acidosis
iv. Late Decel + ↓ Variability—baby usually born braindead
XXXII. Mortality:
a. Direct Maternal—Directly caused by pregnancy—PE, etc
b. Indirect Maternal—underlying disease caused death while pregnant
c. Nonmaternal—trauma, nothing to do with pregnancy
XXXIII. BPP (biophysical profile)
a. 41 weeks—NST looking for accelerations
i. Reactive—repeat in 3-5 days
ii. Nonreactive—try VAS (vibratory acoustic stimulation)
1. if becomes reactive—repeat in 3-5 days
2. nonreactive:
a. BPP:
i. NST
ii. Movement
iii. Tone
iv. Breathing
v. AFI
vi. 10/10 theoretically best, 8/8 in real life
1. 8/8 because of NST
2. worried if AFI is low—baby problem or
ruptured—Deliver if term
b. Contraction Stress Test (oxytocin Challenge Test) give PIT
i. Looking for 3 contraction in 10min
ii. Late/NR--+ OCT—deliver—50% false +
iii. No late, Reactive—negative
c. If nonreactive—No delivery—DO BPP
b. >42 weeks:
i. Macrosomia
1. Labor dystocia
2. ↑C/S
3. Shoulder dystocia
4. DM—4000-4500, otherwise its 4500-5000 (grams)
ii. Uteroplacental insufficiency:
1. programmed suicide in cells—placenta begins to die off
2. ↓ BP--↑Fetal distress (severe Lates)
3. meconium, ↑Fetal death (IUFD)
4. dysmature baby—looks like YODA (long hair, long fingernails
XXXIV. IUGR:
Dr. Christensen 20/28
Transcription: Czubatyj
Assymetric
Symmetric <10th procetile
Late
Early (organogenesis)
Nutritional problem (HTN, Drugs, PIH, Vascular
Infection( TORCH)/Karyotype (aneuplody)
Disease
Toxo, other, rubella, CMV, herpes
a. Fluid:
i. Normal:
1. Assymetric—small baby, ↑calorie
2. Symmetric—small baby
ii. Low:--problem no matter if asymmetric or symmetric
b. <20 weeks--↓fluid—test Karyotype (make sure baby is viable) otherwise no need to test
for infection
XXXV. Postdates: >42 weeks
a. Etiology:
i. Incorrect dates
1. bad GYN history
2. Irregular cycle
ii. Smoking is not part of it…will cause earlier delivery
iii. ZEBRAS:
1. abdominal pregnancy
a. induced labor—nothing happens
b. C/S
c. Don’t remove placenta
d. Remove baby, clamp cord
2. Hormones:
a. Fetal AnencephalyNo fetal brain—no trigger for labor
b. Sulfatase ↓--↓Estrogen—no labor
c. Fetal Adrenal Hypoplasia—no estrogen
XXXVI. Graphs:
I. Freidman curves
o Normal:
10
Dilation
Station
Active
0
-3
Plateau
Latent
0
+3
Dr. Christensen 21/28
Transcription: Czubatyj
o Abnormal dilation
10
Plateau
Arrest of dilation
Dilation
Prolonged
latent
Active
Protracted
active
Latent
0
+3
o Abnormal descent
-3
Station
Failure to
descend
0
Arrest of
descent
+3
XXXVII.
a.
Post Partum Hemorrhage:
Early—in delivery room:
Dr. Christensen 22/28
Transcription: Czubatyj
i. Atony—prolonged labor, pit, infected uterus, grand multiparity
ii. Massage uterus—meds
1. Pit—like ADH--hyponatremia
2. Methergine
a. HTN
b. LSD like
c. Psychosis
3. PGF2α:
a. Asthma
b. Hemo + rate
b. PGE:
i. 1—cervical ripening
ii. 2—cervical ripening
iii. Both induce labor
c. PGF2α:
i. Causes contraction
ii. Never use on viable pregnancy
XXXVIII. Necrotizing Fascitis:
a. Increased T, wound infection, blistering, pain, worst sign is loss of pain
b. Everything scoops off muscle in debridement but muscle is intact
c. 2 types:
i. Type 1—group A strep
ii. Type 2—mixed
d. Treatment—radical debridement in the OR
e. Do NOT bleed
f. RF—DM, HTN, source of infection
XXXIX. Stats:
a. Errors:
i. Type I (false positive error)—falsely rejecting the null hypothesis
ii. Type II (flase negative error)—falsely accepting the null hypothesis (worse
because no one will go back and retest
b. Level of Evidence:
i. I—gold standard—randomized control trial
ii. II-1—controlled randomized
iii. II-2—retrospective and prospective studies
iv. II-3—dramatic series/time series
v. III—opinions of respected experts
c. Quality of Evidence:
i. A—strong support for
ii. B—fair support for
iii. C—neither—level of support of most things done in medicine
iv. D—fair support against
v. E—strong support against
d. 2x2 table DRAW on BACK)
i. specificity
ii. sensitivity
iii. PPV
iv. NPV
v. Accuracy
e. prospective study:
i. look at smokers and nonsmokers and see who gets lung ca
ii. analysis by RR (risk you smoke/risk you don’t smoke)
iii. Attributable risk = R smoking – R nonsmoking
f. Retrospecive study:
i. Look at those who got lung ca, see who smoked and look at those who didn’t get
lung cancer, look who smoked
Dr. Christensen 23/28
Transcription: Czubatyj
XL.
XLI.
ii. Analysis by OR = odds you smoked/ odds you were a nonsmoker
Infertility:
a. Definition
i. Attempting conception for 1 year (85% will conceive on their own)
ii. AMA is exception (>35yo) send to specialist
iii. Primary—never conceived
iv. Secondary—had kids, but can’t now
b. Factors:
c. Cervix—Post Coital Test—Spiteterkeit*?—mucus stretches at ovulation
d. Uterus—Histosalpingogram (HSG), Hysteroscopysurgery
e. Tubes—HSG, Tubal Dye Perfusion—tubalplasty, Tubal bypass (Invitro Fertilization)
f. Ovaries—Ovulation—Basal Body Temp (BBT)
i. ↑ temp caused by progesterone
1. Figure out day, subtract 2—day of ovulation
2. PCO? If alatory
ii. Ovulation Induction:
1. Clomefine
2. side effects
a. hyperstimulationmultiple gestations
b. OHD—ovarian hyperstimulatory Disease—looks like ovarian
Ca
g. Periteneum—Laparoscopy, Lupron
i. Adhesions
ii. Endometriosis
h. Male—semen analysis (check twice)
i. NEVER Do anything invasive until Male Factor is Ruled Out
Contraception
a. Sterilization
i. Male is better than female, and cheaper
ii. Hysterectomy never used for sterilization
b. hormonal:
i. efficacy vs. effectiveness
ii. theoretical vs actual
iii. types:
1. OCP—
a. ↓ effectiveness (forget to take). ↑DVT, Factor V leiden,
Vascular Disease, ↑ Mi, ↑CVA, ↓ endometrial and ovarian
CA, ovarian cysts, ↓bleeding, ↓dysmenorrhea
b. Do not give tosmokers >35yo
2. Depo-provera--↑effectiveness—weight gain—about 8lbs—contra DM
3. Patch—like OCP—No 1st pass, no liver effect
4. Ring—like OCP—no 1st pass, no liver effects
5. Norplant—5 years, Levoprogesterone
c. IUD:
i. Copper—Paraguard—Few failures, no change in risk for ectopic or PID, 10 yrs,
no benefit for bleeding, ↓sperm motility, capacitation
ii. Progesterone—Progestasert--↑Failure, 1 year, ↑ectopic, ↓dysmenorhea, ↓blood
loss, thickens mucus, atrophies endometrium, Unilteral TOA, actinomyces
israelii
iii. Levoprogesterone—Mirena—like progersterone, 5 yrs, no change for ectopics
d. Barrier: 85% effectiveness
i. Diaphragm
1. Cystitis
2. TSS
ii. Sponge—Nanoxidil 9—Vaginal ulcers--↑HIV risk
iii. Condom—High failure rate—used incorrectly—Latex allergy
Dr. Christensen 24/28
Transcription: Czubatyj
iv. Cervical Caps—cervical dysplasia
Rhythm <85%
i. Calender—regular cycle—block off 2 weeks for ovulation
ii. BBT--↑temp—day before is ovulation
iii. Spinnbarkeit—check cervical mucus
XLII. Abortion:
a. 1st trimester: >8wks
i. D+C suction
1. very few risks, post aborted syndrome= retained productsrepeat D+C
2. if + Chlamydia/GC—can spread infection into tubes—PID
3. post abortion regret—Informed consent—give patient all options
ii. RU 486:
1. Antiprogestin—1st 42 days—does not cause expulsion
2. give with PGEexpulsion
3. 15% need D+C anyway
iii. MTX
iv. “Menstrual Extraction”
1. D+C done in 1st 6 weeks of pregnancy
2. good chance of missing pregnancy
3. pregnancy then continues
4. limb reduction defects
b. 2nd trimester:
i. D+E
1. Dilation and extraction
2. surgical complications
ii. PG induction PGE, PGF2α
1. Fever
2. N/V
3. live born—KCl—kills baby, inject into heart
4. do not give PGF2α with asthma
iii. Urea/Saline injection—DIC, PE, Shock, Death—high complication rate
iv. Hysterectomy—extreme
XLIII. Vaginitis
Org
Discharge
pH
Whiff
Saline
KOH
Tx
White, mid
4.5
Neg
Lacto
Neg
None
Lacto
cycle
normal
Thin, grey,
>4.5
+--fishy
Clue cells
Neg
Metronidizole
BV
sticky, foul
smelling
Green,
>4.5
+/Trich
Neg
Flagyl
Trich
bubbley,
Pear shaped
Metronidizole
“strawberry
Maybe treat
cervix”
partner also
Cottage
<4.5
Neg
Spores,
Spores
Difluconazole
Yeast
cheese/ no
hypahe…1/3 hypahe (1/3
(diflucan)
discharge,
not visible
not visible)
Imidazole
just itching
Watery,
>4.5
Neg
WBC
Neg
Estrogen
Atrophic
clear
e.
XLIV. Ulcers:
a. Painful:
i. HSV—multiple small ulcers (2-3mm)
ii. Chancroid—1 or 2 large ulcers (>1cm)
iii. Behcet’s
1. eyes
Dr. Christensen 25/28
Transcription: Czubatyj
2.
3.
b.
VDRL
+
+
-
Painless:
i. Syphilis—chancre
1. Diagnosis
a. Dark field
b. VDRL, FTA
FTA
+
+
2.
XLV.
mouth
perineum
stages:
a.
b.
c.
d.
Untreated syphilis
Biological false + for syphilis
Treated syphilis
No symptoms or early
infection/not infected
primary—chancre
secondary—rash, fever, lymphadenopathy, murmur
Latent no symptoms, infectious for 1 year
tertiary:
i. organ damage
ii. AA—abdominal aneurysm—athersclerosis
iii. TT—trunkal aneurysm—treponem
3. Treatment:
a. Penicillin alone is not ok—needs to be long lasting
b. Bicillin—PCN in oil or IV PCN (14days—ofen for tertiary)
c. PCN allergy
i. Tetracycline—teeth problems in fetus
ii. Erythromycin—macrolide—does not cross placenta
d. Pregnancy and PCN allergy
i. ICU and desensitize
ii. LGV—Lymph Granular Venerum
1. Chlamydia
2. painless ulcer + lymph clumping (bubore—lymph coalesce into a big
one)
iii. Granuloma Inguinale
1. chamylla bascterium
2. Bleeding painless ulcer
iv. CANCER
1. 60yrs old—top of list
2. 20yrs old—not
c. Non cancerous vulvar lesions:
i. Lichen sclerosis—caused by lack of estrogen (kids and post menopausal)
1. white patch, itchy
2. Commonly referred as onion skin or tissue paper
3. treatment—steroid cream
ii. Paget’s Disease—is a CIS
1. if on nipple—find cancer underneath about 100% of the time
2. if on vulva—find cancer underneath about 15% of the time
3. red scaly itchy
4. Commonly referred to as cake frosting or cake icing
Cervicitis:
a. Silent
i. GC and Chlamydia—found during prenatal care
ii. For G/C ceftrioxone + doxycycline (for chlamydia) (+zithromax if pregnant, doxy)
b. Mucopurelent Cervicitis
i. pus coming out of cervix
Dr. Christensen 26/28
Transcription: Czubatyj
ii. No other signs of PID
iii. G stain—WBS—chalmydia—Doxy
iv. G+ diplococci
c. If GC is positive treat for both GC and chlamyia (ceftrioxone + doxy)
d. If Chlamydia is only + just trat Chlamydia (doxy)
XLVI. PID:
a. Risk Factors:
i. Age—risk ↑ when younger
ii. Exposure
iii. Menstruation (GC follows flow during/after cycle)
iv. Contraception (↓PID)—OCPs
b. Diagnosis: Laparoscopy is gold standard
i. Big 3:
1. cervical motion tenderness
2. Lower abdominal tenderness
3. Adnexal tenderness
ii. >1 of the following:
1. Fever, ↑WBCs, ↑sed rate
2. Discharge, abnormal bleeding, + culture
3. Mass on U/S, pus in culdesac
iii. 50% diagnostic accuracy
c. What to do:
i. Indications for admission:
1. Tried outpatient therapy but failed
2. Can’t tolerate PO
3. sepsis—severe illness (↑P, ↓urine, etc)
4. Pregnancy
5. IUD
6. HIV
7. first episode
8. nulliparity—no longer on the list
9. Uncertain diagnosis—Appendicitis
a. CT
b. Compression U/S
ii. When admitted:
1. Regiment A:
a. Cefaoxitin + doxy
b. Ceflotetan
c. “Foxy Doxy”
2. regiment B (Gent/Clinda/Amp—triples
3. Outpatient—Ceftraoxone + Doxy
iii. Consequences:
1. Ectopics, infertility—chlamydia, chronic pelvic pain, recurrent/chronic
PID—end up with hysterectomy that doesn’t alleviate pain
2. Note—if have Chlamydia in a pregnant woman treat with azithromycin
XLVII. Incontinence:
Etiology
Diagnosis
Treatment
UA, C+S not needed if 1st time
E.coli—sulfa, cephalosporin,
UTI
macrodantan
Anti-cholinergic
Spastic bladder Cystometrogram (pressure spikes
when filling bladder with fluid
Urge incontinence
Post void residual >50 in cath
Self Cath, treat DM
Neurogenic bladder
Physical Exam
Remove mass
Pelvic Mass (preg, Fibroids)
Dye test (cause surgery in US,
Surgery
Fistula (continuous leaking)
preg in world)
True incontinence
Exam—atrophy, thinning of
Unknown
Atrophy, post menopausal
Dr. Christensen 27/28
Transcription: Czubatyj
Stress incontinence
folds, etc
Hypermotile urethra, bulges when
cough (qtip test)
Retropelvic urethroplexy
XLVIII. Endometriosis
a. Polygenic, multifactorial—unknown—related to immunology
b. Retrograde mentration—cervical stenosis (cones/LEEPs)
c. Implantation—Lap scar, episiotomy scar
d. Metaplasia—perineum turning into endometrium
e. Heme/Lymph spread—pulmonary endometriosis
Endometriosis
Adenomyosis
External to uterus
Internal to uterus
Growing outside uterus
Growing in myometrium
Sx—pain, dysmenorrheal, dyspareunia, adnexal
Sx—pain, dysmenorrheal, dyspareunia, fertile
tenderness, fixed uterus, nodules on culdesac,
(previous C/S) enlarged, tender, boggy uterus
infertile
Dx—laparoscopy
Dx—US or MRI
Tx—laser therapy or HRT
Tx—hysterectomy
Bleeding—1/3 patients
Bleeding is main reason for visit
Causes:
Cause is unknown for sure—Labor, C/S, surg
1)retrograde menstruation (cervical
stenosis)
2)Implantation (prev surgery)
3)Lymph/heme spread (cyclic hemoptysis)
4)metaplasia (people with no uterus—
mullerian agenesis
5)Immune surveillance (immune
suppressed)
XLIX. Pelvic Pain:
a. GYN:
i. Endometriosis—Laparoscopy--Lupron
1. Infertility, Dysmenorhea
2. uterus small, tender ovaries
ii. Adenomyosis--hysterectomy
1. bleeding, bleeding, bleeding
2. Anemia, clots, tender, bogy uterus
iii. adhesions:
1. tender pelvic exam
2. PID/infertility
iv. Fibroids—don’t usually cause pain
v. cysts
b. Non-GYN:
i. Spastic cholitis/ IBS
1. alternating constipation/diarrhea with gas
2. bloating, cramping
ii. Interstitial Cystitis:--inflamed bladder wall
1. Pelvic pain, urgency, frequency
2. negative UA
3. diagnosis—K test—pain with K in bladder or cystoscopy
4. Tx—DMSO/elmiron
iii. Muscoloskeletal
iv. Carnett’s sign—tense abdominal wall, pain gets worse
1. if positive—hernia, trigger point
2. of negative—visceral
Dr. Christensen 28/28
Transcription: Czubatyj
3.
L.
Remember tha spigellian hernia occurs at the lateral border of the
rectus muscle
v. SIGECAPs—depression (5 for 2wks)
vi. History of ↑ incidence of abuse/violence
Impaired Physicians:
a. Must report intoxication, is a law in MI
b. At night can report to charge nurse
c. During day can report anonymously through various avenues
d. If you are intoxicated and call in—you should call a colleague
e. Criteria for drug dependence—works for any addictions
i. Craving
ii. Lose control
iii. Do despite consequences