PAEA OBGYN EOR Topics with Questions and Answers, Exams of Public Health

Download PAEA OBGYN EOR Topics with Questions and Answers and more Exams Public Health in PDF only on Docsity! PAEA OBGYN EOR Topics with correct questions and answers 1. G2 P1001 2. G4 P1111 3. G3 P2103 - ✅✅✅1. currently pregnant, 1 term delivery, 1 living child 2. currently pregnant, 1 term delivery, 1 preterm delivery, 1 abortion/miscarriage, 1 living child (cannot tell if it is term or preterm child by formula) 3. currently pregnant, twins at term, 1 at preterm, 3 living children G (# pregnancies) T (# term deliveries at 37 weeks or more including stillbirths) P (# preterm deliveries at 20-37 weeks) A (abortions <20 weeks including miscarriages) L (# living children) a previable fetus is defined as - ✅✅✅<24 weeks old (varies w/ guidelines) what are the routine test during the first prenatal visit? - ✅✅✅blood pressure, blood type & Rh, CBC, UA (glucose & protein), random glucose, HBsAg, Hep C, HIV, syphilis, rubella titer, VZV titer, pap, sickle cell & CF screening diagnosis of pregnancy can be detected by serum B-hCG at ____ days after conception and by urine B- hCG at ____ days after conception - ✅✅✅serum B-hCG: 5 days after conception urine B-hCG: 14 days after conception how is estimated date of delivery (EDD) determined? - ✅✅✅Naegele's Rule: from 1st day of LMP 1. subtract 3 mos, add 7 days, add 1 year 2. add 9 mos & 7 days ex: LMP started 8/7/16 = EDD: 5/14/17 when estimating gestational age on US what measurements can you use? - ✅✅✅1. crown rump length (CRL) 2. biparietal diameter 3. head circumference 4. abdominal circumference 5. femur length what physical exam and lab tests should be performed on initial visit of a pregnant patient? - ✅✅✅full physical exam, BP, pelvic exam w/ pap smear (unless done in last 6 mos), G/C Cx's, bimanual exam to check size of uterus and help estimate # weeks into pregnancy, US if unsure of LMP to date # weeks labs: CBC (r/o anemia), blood type & Ab screen + Rh status, RPR, HBSAg, rubella Ab screen, VZV Ab screen if no h/o chickenpox, UA w/ Cx, blood glucose, HIV, sickle cell/CF screen, PPD in high risk pts, screening for aneuploidy offered (inc or dec free B-hCG, PAPP-A low w/ down syndrome, inc nuchal translucency @10-13 weeks US) what are the screening tests for aneuploidy (including down syndrome)? when are they performed? - ✅✅✅ALL offered around 10-13 weeks 1. free B-hCG (high or low can be indicative of abnormalities) 2. PAPP-A (usually low w/ DS) 3. nuchal translucency (inc thickness on US) 4. if any above + can be offered chorionic villus sampling (or if they have any RF for aneuploidy such as advanced maternal age/AMA, previous child w/ chromosomal abnmlity, abnml US, prior pregnancy losses) but inc r/o spontaneous abortion w/ procedure *amniocentesis offered around 15-18 weeks w/ same indications as CVS (both can diagnose chromosomal abnormalities and have risk of spontaneous abortion) the uterus softening at 6 weeks is what sign? - ✅✅✅Ladin's sign the uterine isthmus softening after 6-8 weeks gestation is what sign? - ✅✅✅Hegar's sign how often are OB visits scheduled? - ✅✅✅Q4 weeks first 2 trimesters, 1-28 wks Q2 weeks 28-36 wks Qwk 36-birth what tests/physical examinations should be performed at third trimester visits? - ✅✅✅-repeat Ab titers in unsensitized Rh(-) mothers followed by RhoGAM @ 28 weeks & w/I 72 hrs of childbirth -group B streptococcus screening @ 32-37 weeks via vaginal-rectal Cx -H/H @ 35 weeks -biophysical profile/BPP if there are complications: (5 variables: fetal breathing, fetal tones, amniotic fluid levels, NST (nonstress test), & gross fetal movements - 2 pts each) -non-stress testing: baseline fetal HR 120-160 -Leopold maneuvers to determine fetal presentation, or US if cannot determine (can do external cephalic version if breech presentation) -after 37 weeks sweeping membranes offered at weekly visits to help induce labor In high risk individuals what tests are run again in the third trimester? prophylactic tx? - ✅✅✅-G/C Cx -if + HSV, prophylactic acyclovir initiated at 36 weeks -if + GB strep, IV PCN given when presenting in labor what are the hematologic effects of pregnancy? - ✅✅✅-dilutional anemia (plasma vol inc by 50% but RBCs only inc by 20-30%) -WBC increases (especially during stress of labor- ppl confuse this with sepsis) -platelets dec -hypercoagulable state (inc thromboembolic events d/t Virchows triad- venous stasis, endothelial damage, hypercoagulability & inc in factors VII-X and fibrinogen) -iron deficiency anemia (d/t inc demand on hematopoiesis) nonstress testing is reactive when? - ✅✅✅-2 or more accelerations in 20 minutes -fetal HR inc 15 or more bpm from baseline lasting 15 or more seconds what are the effects of pregnancy on the heart and BP? - ✅✅✅-CO increases by 30-50% (first in SV then in HR and a dec in SVR) -BP decreases slightly (so if there is an inc be suspicious of preE/eclampsia) dyspnea of pregnancy occurs in 60-70% of pts and is d/t - ✅✅✅dec PaCO2 levels, inc tidal volume, decrease TLC what GI changes occur in pregnancy? - ✅✅✅N/V (>70%), delayed gastric empyting & dec gastroesophageal sphincter tone (= GERD), dec motility of lg bowel (= constipation) what kidney changes occur in pregnancy? - ✅✅✅-50% inc in GFR -the kidneys inc in size and the ureters dilate (cause of inc r/o pyelonephritis) what are the effects of pregnancy on the endocrine system? - ✅✅✅-hyperestrogenic state (produced by placenta) -placenta also produces hCG (doubles Q48 hrs in early pregnancy peaking at 10-12 wks) which maintains corpus luteum early on -corpus luteum produces progesterone which maintains uterine lining -human placental lactogen is produced by placenta and responsible for nutrient supply to fetus but can cause a diabetogenic state (bc insulin antagonist) -prolactin greatly increases -inc in T3/4 while fT4 and TSH remain minimally changed what are the effects of pregnany on the msk system? - ✅✅✅-change in center of gravity = low back strain -carpal tunnel syndrome is common what are the effects of pregnancy on the dermatologic system? - ✅✅✅-spider angiomatas -palmar erythema -hyperpigmentation of nipples, umbilicus, abdominal midline (linea nigra), perineum, face (melasma) approximately what increase in calories is recommended in nml BMI pregnant patients? what amount of weight gain is recommended in underweight, nml, and overweight patients? - ✅✅✅300 cal per day (500 cal when breastfeeding) -underweight: 28-40 lb -nml: 20-30 lb -overweight: 15-25 lb what nutritional requirements requirements besides caloric intake increase during pregnancy? - ✅✅✅- protein -iron (IDA common in pregnancy) -folate (prevent NTD) -calcium -other vitamins and minerals what is the most common fetal position inside the womb during the third trimester? what are other potential positions? - ✅✅✅-MC: cephalic (vertex) -breech (butt or legs down) -transverse -oblique during the first stage of labor what are the most common positions of the fetal head? how can you tell what position is presenting? - ✅✅✅-OA (occiput anterior best- where baby comes out face down), LOA, ROA -OT and OP are considered malpositioned -palpate the anterior and posterior fontanelles (anterior is bigger and more central) in persistent OT & OP fetal head positions during labor what is the management to prevent prolonged labor or need for c-section? - ✅✅✅-manual rotation to OA (can use forceps or vaccuum as well) -if unable to rotate can attempt vaginal delivery with forceps or vaccuum in OP position (50% delivery rate) but not OT (rare vaginal delivery) -if all else fails- do c/s what are the indications for induction of labor? how do you induce? - ✅✅✅indications: postterm pregnancy, preeclampsia, LGA, nonreassuring fetal testing, intrauterine growth restriction, chorioamnionitis, IUFD, etc. labor is induced with prostaglandins (to "ripen" cervix; misoprostol or PGE2), oxytocic agents (oxytocin aka Pitocin), mechanical dilation of the cervix, and/or artificial ROM (amniotomy) an external tocometer is placed on the pt's abdomen near the fundus and is used to measure - ✅✅✅contractions by sensing pressure when abdomen gets firmer- best for measuring frequency of contractions and to monitor fetal heart rate accels/decels what degree of fetal heart rate variability is reassuring? - ✅✅✅moderate (little variability may mean fetus is asleep or inactive and absent variability may mean fetal death) aka lines will appear squiggly instead of flat like top line a reactive fetal heart tracing is defined as ___ accelerations of at least ___ beats per minute over the baseline that last for at least ___ seconds within 20 minutes - ✅✅✅2 accelerations, at least 15 bpm above baseline, for at least 15 seconds in 20 minutes what kind of fetal heart deceleration is a result of fetal head compression during a contraction? - ✅✅✅early decel (begins and ends with contraction) what kind of fetal heart deceleration is a result of umbilical cord compression? - ✅✅✅variable decel (can occur at any time and drops more precipitously than early or late decels) what type of fetal heart deceleration is a result of uteroplacental insufficiency and are the most worrisome type? - ✅✅✅late decel (begin at peak of contraction and slowly return back to baseline after contraction has finished) they may degrade into bradycardias as labor progresses when is a fetal scalp electrode indicated (FSE) to monitor fetal heart tracings? - ✅✅✅a fetus with late decels bc the FSE is more sensitive by tracking the potential difference created by depolarization of the fetal heart; it also is better because the tracings do not get lost during contractions or fetal position changes like they do with the Doppler describe what category I-III fetal heart rate tracings are? - ✅✅✅-cat I: nml FHR w/ nml baseline, moderate variability, & no variable/late decels -cat II: indeterminate FH tracing (variable/late decels, brady/tachycardia, or minimal/marked variability) -cat III: abnml FH tracing (absent variability, recurrent late/variable decels, or bradycardia; sinusoidal pattern consistent w/ fetal anemia) in obese patients or those where the external tocometer is not adequately assessing the frequency or strength of contractions, what else can be placed? - ✅✅✅IUPC (intrauterine pressure catheter) -baseline pressures b/t 10-15 mmHg -early contractions inc by 20-30 mmHg -late contractions inc by 40-60 mmHg what are 2 ways to assess hypoxemia in a fetus during labor? - ✅✅✅1. fetal scalp pH (nick scalp for blood sample and assess acidemia- not really used in US anymore) 2. oximeter (placed against their cheek- not really used either) during the second stage of labor, what types of decels are normal as long as they resolve quickly after each contraction and there is no loss of variability - ✅✅✅early and variable decels are common -nonreassuring fetal status during 2nd stage: repetitive late decels, bradycardias, or loss of variability in nonreassuring fetal status during 2nd stage of labor (repetitive late decels, bradycardias, or loss of variability) what actions should be taken? - ✅✅✅-O2 face mask -turned to left side to dec IVC compression and inc uterine perfusion -oxytocin (if being used) should be d/c'd what are the highest risks of operative vaginal deliveries (forceps and vacuum extraction)? - ✅✅✅-forceps (facial nerve palsies) -vacuum (cephalohematomas and shoulder dystocias) *these can be performed during a prolonged 2nd stage, maternal exhaustion or need to hasten a delivery what is given during stage 3 of labor to strengthen uterine contractions to decrease placental delivery time and blood loss? - ✅✅✅oxytocin (pitocin) retained placenta is defined as placental delivery/stage 3 lasting >___ minutes; it is common in preterm deliveries but can also be a sign of _________; how is it removed? - ✅✅✅>30 minutes -sign of placenta accreta (placenta invaded into or byond endometrial stroma) -manual extraction (hand placed in intrauterine cavity and fingers used to shear placenta off surface of uterus) what are the indications for cesarean section? - ✅✅✅-2-4 hrs w/o cervical change in setting of adequate uterine contractions in active phase of labor -breech presentation -transverse lie -shoulder presentation -placenta previa -placental abruption -fetal intolerance of labor -nonreassuring fetal status -cord prolapse -failed operative vaginal delivery -active herpes lesions -at least 2-3 previous c/s (risk of uterine rupture) VBAC (vaginal birth after cesarean)/ TOLAC (trial of labor after cesarean) are common but have a slight risk ~1% of _________ - ✅✅✅uterine rupture *1% after 1 c/s, 2% after 2 c/s, but after 3 risk goes way up so do a c/s Dx/Tx? painful dark red vaginal bleeding in the 3rd trimester, contractions, fetal bradycardia, possible shock symptoms, tender/rigid uterus - ✅✅✅-dx: placental abruption (premature separation of placenta from uterine wall) -tx: hospitalization for hemodynamic stabilization, immediate delivery usually bc c/s *DIC (disseminated intravascular coagulation) occurs in 10% of pts what is the MC cause of placental abruption (premature separation of placenta from uterine wall)? - ✅✅✅-*HTN* -others include: smoking, ETOH, cocaine, folate deficiency, high parity, AMA (advanced maternal age), trauma, chorioamnionitis where is the MC site of ectopic pregnancies? - ✅✅✅-98.3% in fallopian tubes (especially ampulla) -1.4% in abdomen -0.15% in ovary -0.15% on cervix what are some risk factors for ectopic pregnancy? - ✅✅✅-previous abdominal surgery (adhesions) -PID -previous ectopic -tubal ligation -endometriosis -IUD use -assisted reproduction what is the classic triad of sx's with ectopic pregnancy? - ✅✅✅1. unilateral pelvic/abdominal pain 2. vaginal bleeding 3. + pregnancy (noticed by test or by amenorrhea) how is a ectopic pregnancy (that has not ruptured) diagnosed and treated? - ✅✅✅-Dx by serial quant *B- hCG that do not double q 1-2 days* & *TVUS* -Tx: *methotrexate* (disrupts cell multiplication) w/ *B-hCG monitoring* for *≥15% drop* OR laproscopic salpingotomy or salpingectomy + RhoGAM if Rh- MTX can be given in single/double or multiple doses (4) w/ *Leucovorin* (med to help protect against harmful s/e of MTX) -single/double dosing: monitor B-hCG on days 0, 4, 7 for a ≥15% drop -multiple dosing (4 doses): monitor B-hCG on days 0, 1, 3, 5, 7 until ≥15% drop on 2 successive draws what are the indications/contraindications for giving MTX to tx an ectopic pregnancy? - ✅✅✅-indications: hemodynamically stable, early gestation <4 cm, B-hCG <5,000, no FHT (fetal heart tones) -contraindications: *ruptured* ectopic, h/o TB, *B-hCG >5,000*, *+FHT*, noncompliant pt Dx/Tx? severe unilateral abdominal pain, dizziness, N/V, signs of shock (syncope, tachycardia, hypotension), vaginal bleeding, cervical motion tenderness, adnexal mass, US showing absence of gestational sac, hCG that isn't doubling q1-2 days - ✅✅✅-ruptured ectopic pregnancy -Dx by serial quant B-hCG (check for doubling) and TVUS -Tx: laparoscopic salpingostomy to remove ectopic gestation- may need salingectomy; RhoGAM if Rh- an incompetent cervix/cervical insufficiency is painless dilation and effacement of the cervix usually occurring in the ____ trimester and puts the fetus at risk for... - ✅✅✅-*2nd* trimester -infection (fetal membranes exposed to vaginal flora) -trauma/rupture of membranes *cervical incompetence causes ~15% of all 2nd tri losses* what are the RF for cervical incompentence/cervical insufficiency? - ✅✅✅-MC is prev surgery or cervical trauma -previous D&C -LEEP (loop electrocautery excisional procedure) -cervical conization -congenital abnormality of cervix (from diethylstilbestrol/DES exposure in utero) how is incompetent cervix/cervical insufficiency differentiated from preterm labor? - ✅✅✅Dx by pelvic exam or US but preterm labor has contractions while cervical insufficiency has only mild cramping caused by cervical dilation how is cervical incompetence treated? - ✅✅✅-in previable pregnancies (<24 wks GA) elective termination an option -betamethasone to inc fetal lung maturity -strict bed rest -cerclage (suture cervix shut) Dx/Tx? sudden onset painless bright red vaginal bleeding in the 3rd trimester with nml fetal heart tracing; on PE soft, non-tender uterus - ✅✅✅-dx: placenta previa (diagnose by pelvic US- DO NOT do pelvic exam) -tx: hospitalization for stabilization, bed rest, tocolytics (*magnesium sulfate*) to inhibit uterine contraction, amniocentesis (to assess fetal lung maturity and give betamethasone if needed), *delivery when stable* (if L:S >2 aka lungs matured, >36 wks gestation, blood loss >500mL) *vaginal* if partial or marginal placenta, *c/s* if complete what are the differences b/t marginal, partial and complete placenta previa? - ✅✅✅-marginal- 2-3 cm of cervical os -partial: covering cervix partially ahead of fetal presenting part -complete: total coverage of cervical os *can deliver vaginally w/ marginal or partial if fetus is matured but c/s indicated for complete placenta previa what is the pathophysiologic cause of gestational diabetes? - ✅✅✅-placental release of *growth hormone*, *corticotropin releasing hormone* & *human placental lactogen (HPL)* -these antagonize insulin (works similar to growth hormone as a counterregulatory hormone increasing glucose availability for the growing fetus) 4. placental site trophoblastic tumor <1% what are the risk factors for gestational trophoblastic disease? - ✅✅✅-extremes in age (<20y or >35y) -prior h/o GTD -nulliparity -Japanese descent -smoking -infertility -spontaneous abortion -blood group A -h/o OCP use -diet low in B-carotene, folic acid and animal fat what is the difference between a complete vs partial molar pregnancy? - ✅✅✅-*complete*: empty egg (no DNA/nucleus) fertilized by 1-2 sperm; 46XX w/ all paternal chromosomes w/ no fetus; higher r/o development into choriocarcinoma -*partial*: egg fertilized by 1-2 sperm associated w/ an abnormal fetus what is the pathophysiology of gestational trophoblastic disease? - ✅✅✅unknown cause but forms placental (aka trophoblastic) proliferation that causes swelling of the chorionic villi appearing as grape- like clusters on US what s/sx can you see with gestational trophoblastic disease? - ✅✅✅-*painless VB* ~6-20wks -uterine size/date discrepancies (*larger than expected*) -early preE (before 20 wks d/t inc hCG) -hyperemesis gravidarum (occurring early d/t inc hCG) -choriocarcinoma (mets to lungs MC, lower genital tract, pelvic mass) -*B-hCG markedly elevated >100,000* -US showing "snowstorm" or "*cluster of grapes*" & *absent FHT* what is the tx for gestational trophoblastic disease benign and malignant? - ✅✅✅-*benign*: suction curettage (D&C) asap to avoid malignant development then followed weekly until B-hCG levels undetectable (+ RhoGAM to Rh- mothers & avoidance of pregnancy x1yr) -*malignant*: chemo w/ *methotrexate* (very responsive) &/or hysterectomy when is RhoGAM indicated? - ✅✅✅in Rh- mothers @ *28 wks* and w/i *72 hrs postpartum* OR if any potential for mixing of fetal blood (spontaneous abortion, vaginal bleeding, amniocentesis, abruption, placenta previa, etc.) will an Rh- mother w/ negative Ab's (P0) baby be affected? - ✅✅✅no, mother does not have Ab yet BUT you give RhoGAM to prevent the building of Ab that will attack a future fetus' RBCs what will happen to the fetus of an Rh- mother w/ +Ab's untreated w/ RhoGAM in a previous pregnancy - ✅✅✅Ab's may cross placenta and attack fetal RBCs resulting in hemolytic anemia, jaundice (from inc bili), kernicterus ("), hepatosplenomegaly, fetal hydrops (fluid accumulation in 2 places: pericardial effusion, ascites, pleural effusion, subQ edema), CHF if Rh incompatibility occurs and the fetus suffers erythroblastosis fetalis w/ mod-severe anemia what is the tx? - ✅✅✅antigen negative RBCs through US guided umbilical vein transfusion what are the 2 main phases of the menstrual cycle? - ✅✅✅1. follicular phase (days 1-14) 2. luteal phase (days 14-28) in the follicular phase (days 1-14) of the menstrual cycle, FSH is increasing which causes a _______ to develop which produces ________ to help proliferate the lining of the endometrium; at the end of this phase _______ surges causing ovulation - ✅✅✅-primary ovarian follicle -estrogen estrogen also causes the *LH* surge = ovulation in the luteal phase (days 14-28), after ovulation, the leftover follicle becomes the _________ which produces _________ which maintains the endometrial lining for fertilization - ✅✅✅-corpus luteum -progesterone in the luteal phase, the endometrial lining is prepared for fertilization from progesterone from the corpus luteum; the ________ degrades causing a drop in progesterone/estrogen and _________ begins - ✅✅✅-corpus luteum -menstruation (sloughing of endometrium) in the luteal phase, the endometrium is prepared for fertilization by progesterone from the corpus luteum; if fertilization does occur __________ gets released by the developing trophoblast/placenta which maintains the __________ to continue making progesterone/estrogen - ✅✅✅-hCG -corpus luteum light flow or spotting is called - ✅✅✅cryptomenorrhea heavy or prolonged bleeding at normal menstrual intervals is called - ✅✅✅menorrhagia irregular bleeding between expected menstrual cycles is called - ✅✅✅metrorrhagia irregular, excessive bleeding between expected menstrual cycles - ✅✅✅menometrorrhagia infrequent menstruation (prolonged cycle length >35 days but <6 mos) is called - ✅✅✅oligomenorrhea frequent cycle interval (<21 days) is called - ✅✅✅polymenorrhagia absence of menstruation is called - ✅✅✅amenorrhea what is the range of duration of a normal menstrual cycle? - ✅✅✅24-38 what is the difference between abnormal uterine bleeding and dysfunctional uterine bleeding? - ✅✅✅AUB has specific causes (PALM-COEIN) such as polyps, fibroids or malignancy nml/low FSH/LH -HPO axis failure -puberty delay (athletes, illness, anorexia) in a pt with primary amenorrhea who's uterus is absent but breasts are present, what may be the cause? - ✅✅✅-mullerian agenesis (46XX) -androgen insensitivity (46 XY) in a pt with primary amenorrhea who's uterus and breasts are absent, what may be the cause? - ✅✅✅*RARE* -usually caused by a defect in testosterone synthesis; presents like a phenotypic immature girl but will often have intraabdominal testes the definition of 2° amenorrhea is the absence of menses >___ mos in a pt w/ previous nml menstruation - ✅✅✅>3 mos what is the MC cause of 2° amenorrhea? & others? - ✅✅✅1. pregnancy! 2. (40%) ovarian d/o (PCOS & premature ovarian failure) 3. (35%) hypothalamus dysfxn (hypothalamic disorders, anorexia, exercise, stress, nutritional deficiencies, systemic disease) 4. (19%) pituitary dysfxn (prolactin secreting pituitary adenoma) 5. uterine d/o (endometrial scarring/Asherman's syndrome) in ovarian disorders aka premature ovarian failure causing 2° amenorrhea, what will the hormonal imbalances be? what symptoms will be present? how is this tested for? - ✅✅✅-dec estradiol (d/t ovarian abnormality) -inc FSH/LH (trying to stimulate ovaries) sx's (of estrogen deficiency): hot flashes, sleep/mood disturbances, dyspareunia dry/thin skin, vaginal dryness/atropy -progesterone challenge: 10mg medroxyprogesterone/Provera for 10 days; + withdrawal bleeding confirms ovarian dysfxn; - withdrawal bleeding means 1. HPO failure (hypoestrogenic) or 2. uterine dysfxn (asherman's or outflow obstruction) what are the hypothalamic dysfxn causes of 2° amenorrhea? - ✅✅✅-hypothalamic disorders -anorexia (or wt loss 10% below ideal BW) -exercise -stress -nutritional deficiencies -systemic disease what will hormone levels show in amenorrhea 2° to hypothalamic dysfxn? - ✅✅✅-nml/low FSH/LH -low estradiol -nml prolactin what is the tx for amenorrhea 2° to hypothalamic dysfxn? - ✅✅✅stimulate gonadotropic secretion: -*Clomiphene* -menotropin/Pergonal what will the hormone levels of amenorrhea 2° to pituitary dysfxn show? what is the workup and tx? - ✅✅✅-*inc prolactin* (d/t prolactin-secreting pituitary adenoma) -dec FSH/LH (prolactin inhibits GnRH) -MRI of pituitary sella -tx: transphenoidal tumor removal surgery what are the causes of amenorrhea 2° to uterine scarring (aka Asherman's syndrome)? how is it diagnosed? tx? - ✅✅✅-postpartum hemorrhage -s/p D&C -endometrial infxn -Dx by pelvic US or hysteroscopy (tx this way too) -tx: estrogen to stimulate endometrial regeneration of the denuded area primary dysmenorrhea (painful periods) is due to? - ✅✅✅inc prostaglandins that usually causes pain starting 1-2 years after menarche *NSAIDs great for this! what are the causes of secondary dysmenorrhea (painful periods)? tx? - ✅✅✅-endometriosis, adenomyosis, leiomyomas, adhesions, PID -tx: *NSAIDs* 1st line (inhibits prostaglandins) started before onset of menses, ovulation suppression (OCPs, Depo-Provera, Nuva-Ring) -further workup: laparoscopy to r/o endometriosis and PID; G/C/Trich testing menopause is defined as cessation of menses >____ amount of time d/t loss of ovarian function - ✅✅✅>1 yr (avg age is 50-52) premature menopause aka premature ovarian failure aka primary ovarian insufficiency is defined as before age ____ - ✅✅✅40 what are some sx's of menopause from estrogen deficiency changes? - ✅✅✅-menstrual cycle alterations -vasomotor (hot flashes, nt sweats) -mood changes -skin/hair/nail changes -inc cardiovascular events -hyperlipidemia -osteoporosis -vaginal atrophy (dryness, dyspareunia) what are the oncogenic strains of HPV? genital warts? - ✅✅✅-oncogenic: *16, 18*, 31, 33, 35 -genital warts: 6, 11 what are the treatment options for genital warts? - ✅✅✅in office: -trichloroacetic acid -podophyllin -cryotherapy -surgical removal outpatient: -imiquimod/Aldara -podofilox genital herpes is caused by what type? tx? - ✅✅✅HSV-2 -acyclovir 400mg TID dx/tx? lower abdominal tenderness, +/- purulent discharge, +/- bleeding, +chandelier sign (cervical motion tenderness) - ✅✅✅-dx: pelvic inflammatory disease (MC d/t gonorrhea & chlamydia) -tx: doxycycline 100mg BID x14d + ceftriaxone 250mg IM once syphilis is an infection caused by - ✅✅✅the spirochete Treponema pallidum how is syphilis transmitted? - ✅✅✅direct contact through sexual activity or mucous membranes- forms a chancre at inoculation site and from there goes to regional lymph nodes before disseminating (incubation period b/t 3d-3mos in 3 phases) what are the phases of syphilis? - ✅✅✅1. primary: (3-4wks) *chancre* and nontender LAD near it 2. secondary: (3wks-6mos after) maculopapular rash (palms/soles common), condyloma lata (wart-like lesions on mucous membranes), systemic sx (fever, LAD, arthritis, meningitis, HA, hepatitis/ inc alk phos) 3. tertiary: (1-20yrs after infxn) gumma (noncancerous granulomas). neurosyphilis (HA, meningitis, dementia, vision/hearing loss, incontinence, tabes dorsalis), Argyll-Robertson pupil (small, irregular pupil), cardiovascular (aortitis, AR, aortic aneurysms) what are the tests and tx for syphilis? - ✅✅✅-tests: darkfield microscopy, EIA (enzyme immunoassays), RPR -tx: *PCN G* but if PCN allergic: Doxycycline, Macrolide, Ceftriaxone dx? cause? tx? a soft, shallow, painful genital ulcer with painful inguinal LAD - ✅✅✅-dx: chancroid -cause: haemophilus ducreyi -tx: Azithromycin a painless genital ulcer with painful inguinal LAD caused by chlamydia is called? tx? - ✅✅✅- lymphogranuloma venerum (seen in developing countries) -Azithromycin 1g po once OR Doxycycline 100mg po BID x10d (same tx as for cervicitis d/t chlamydia) what is the highest mortality and 2nd MC gynecological cancer? - ✅✅✅ovarian cancer what are the risk factors for ovarian cancer? & protective factors? - ✅✅✅-RF: + FHx, inc # of ovulatory cycles (infertility, nulliparity, >50y, late menopause), BRCA1/2, Peutz-Jehgers, Turner's syndrome -protective factors: OCPs (dec # of ovulatory cycles), high parity, TAH although ovarian cancer is rarely symptomatic until late in dz course- what are some sx's? - ✅✅✅- abdominal distention/pain -back pain -early satiety -urinary frequency -irregular menses -menorrhagia -post-menopausal bleeding -constipation dx/tx? palpable abdominal mass, +/- ascites, swollen umbilical lymph nodes (sister Mary Joseph's node), back pain, post-menopausal bleeding - ✅✅✅-dx: ovarian cancer -workup: biopsy (90% epithelial), TVUS, MMG -tx: if early stage, TAH-BSO + selective lymphadenectomy; if later- tumor debulking & monitor with serum CA-125; chemo- paclitaxel/Taxol + Cisplatin or Carboplatin what are the 2 types of functional ovarian cysts? - ✅✅✅1. follicular- follicles fail to rupture and continue to grow 2. corpus luteal cysts- corpus luteum that fails to degenerate after ovulation functional ovarian cysts (follicular & corpus luteal) are mostly asymptomatic until they undergo what changes? then what will sx's be? - ✅✅✅-rupture -undergo torsion -become hemorrhagic -sx: *unilateral lower quadrant pain*, AUB, dyspareunia dx/tx? pt comes in with unilateral (R) pelvic pain and a mobile/palpable cystic adnexal mass; pelvic US shows a smooth, thin-walled unilocular cyst on on the R ovary; there's also a complex, thicker-walled cyst w/ peripheral vascularity on the L ovary - ✅✅✅-dx: R: follicular cyst, L: corpus luteal cyst -tx: supportive- most cysts <8cm are functional & usually resolve spontaneously (rest, NSAIDs, rpt US in 6 wks, OCPs to prevent future cysts, if postmenopausal & >8cm do laparoscopy/laparotomy) what is the MC benign ovarian neoplasm? tx? - ✅✅✅*dermoid cystic teratomas* -tx: removal (d/t risk of torsion or malignancy development) *90% of ovarian neoplasms are benign in reproductive age women! what age range receives cytology (pap smear) w/o HPV testing for screening Q3yr? what age do you start doing cytology + HPV co-testing? - ✅✅✅-cytology only: start at age 21 to 29 -cytology + HPV: 30 and up what strains of HPV are associated with cervical cancer? - ✅✅✅*16, 18* (70%), *31, 33*, 45, 52, & 58 what are the 2 types of cervical cancer? which is the MC? - ✅✅✅1. squamous (90%) 2. adenocarcinoma (10%) what are the MC symptoms seen in a symptomatic cervical cancer pt? - ✅✅✅-MC: post-coital bleeding/spotting -metrorrhagia -pelvic pain what is the stage and treatment for cervical Bx that comes back as carcinoma in situ? - ✅✅✅-stage 0 -tx: excision (LEEP vs cold knife conization), ablation (cryotherapy or laser), or TAH-BSO what is the stage and treatment for cervical Bx that comes back as "microinvasion"? - ✅✅✅-stage Ia1 -tx: conization, TAH-BSO, XRT what is the tx for stage I and IIA cervical carcinoma? - ✅✅✅-TAH-BSO -XRT + chemo (Cisplatin) what is the stage for cervical cancer that extends locally beyond the cervix? if it extended to the lower 1/3 of the vagina? if there were local METS (bladder, rectum)? what is the tx for all of these stages? - ✅✅✅-stage II: extends locally beyond cervix -stage III: extends to lower 1/3 of vagina -stage IVA: local METS (bladder, rectum) -tx for stage IIB-IVA: XRT + chemo (Cisplatin +/- 5FU) *NO SURGERY* what is the stage and treatment for cervical carcinoma that has distant mets? - ✅✅✅-stage IVB -tx: palliative XRT + chemo (Cisplatin +/- 5FU) what age is the Gardasil vaccine recommended in? what strains does it protect against? - ✅✅✅age 11-26 (not FDA approved outside these ages) -6, 11, 16, 18 *Gardasil 9 targets 6, 11, 16, 18, 31, 33, 45, 52, 58 getting immunized with Gardasil with only 2 doses (at least 6 mos apart) is available in what ages? what is the schedule for the 3 dose vaccination? - ✅✅✅11-14 *15-26 = 3 doses at 0, 2, and 6 mos (have to give the doses over a minimum of 6 mos) at what age do you discontinue getting paps? - ✅✅✅age 65 as long as last 2 paps were nml what type of vaginal cancer is most common? what is the tx? - ✅✅✅-squamous (90%) (clear cell if DES exposure in utero) although vaginal cancer is very rare -tx: XRT what type of vulvar cancer is most common? risk factors? tx? - ✅✅✅-squamous (90%) -RF: HPV 16, 18, 31, DES exposure in utero -tx: surgical excision, radiation therapy, chemotherapy (5-FU) a 50 yo women comes in with c/o vaginal/vulvar itching, post-coital bleeding and on exam has red/white ulcerative, crusted lesions... Bx will most likely show? - ✅✅✅vulvar carcinoma (most likely squamous cell carcinoma) what is the pathophysiology behind endometrial hyperplasia? what are the risk factors? - ✅✅✅- pathophys: unopposed estrogen (unopposed by progesterone) causes thickening/build up of endometrial lining -RFs: chronic anovulation, PCOS, perimenopause, obesity (conversion of androgen to estrogen in adipose tissue) most commonly seen in post-menopausal women a 55 yo women with post-menopausal bleeding, menometrorrhagia receives a TVUS showing a *>4mm* endometrial stripe... what is the most likely Dx? - ✅✅✅-endometrial hyperplasia/gland proliferation -do an endometrial Bx to confirm -indications for a EMBx: >35yo, *>4mm* endometrial stripe on TVUS, pts on estrogen therapy, h/o Tamoxifen, AGUS (atypical glandular cells of undetermined significance) on pap smear or persistent bleeding how is endometrial hyperplasia WITHOUT atypia treated? & WITH atypia? - ✅✅✅-w/o atypia: *progestin* (po or IUD Mirena) stops estrogen from being unopposed and limits endometrial growth; repeat EMBx in 3-6 mos -w/ atypia: hysterectomy (TAH +/- BSO) progestin tx if pt not surgical candidate or if wishes to preserve fertility what estrogen dependent cancer is the MC gynecological cancer and is most often seen in 50-60 year olds with VB? - ✅✅✅-endometrial cancer -RF: nulliparity, chronic anovulation, PCOS, obesity, estrogen replacement therapy, late menopause, early menarche, h/o Tamoxifen, HTN, DM what medication is protective against endometrial and ovarian cancers? - ✅✅✅combination OCPs (estrogen + progesterone) what is the most common type of endometrial cancer? - ✅✅✅*adenocarcinoma* (80%), sarcoma (5%) what is the tx for stage I-IV endometrial cancer? - ✅✅✅-stage I: hysterectomy (TAH-BSO) +/- post-op XRT -stage II/III: TAH-BSO + lymph node excision +/- post-op XRT -stage IV: systemic chemotherapy (carboplatin + paclitaxel) or triple drug therapy (cisplatin + doxorubicin + paclitaxel) BRCA 1 & 2 genetic mutations are associated with what cancers? - ✅✅✅breast and ovarian cancers 8. monocloncal Ab tx- useful in HER2 (+) br ca (more aggressive) (*trastuzumab/Herceptin*) s/e: cardiotoxicity what neoadjuvant medication could be given to a 55yo w/ ER (+) breast cancer? - ✅✅✅1. *Tamoxifen* (anti-estrogen) binds ER and blocks them 2. aromatase inhibitors (*Letrozole, Anastrozole*) that reduce production of estrogen (best used in PMP women) what neoadjuvant hormone therapy could you give to a pt with HER2 (human epidermal growth factor receptor) (+) breast cancer? - ✅✅✅monocloncal Ab tx- (trastuzumab/Herceptin) but s/e are cardiotoxicity how often should clinical breast exams, self breast exams, and screening MMGs take place? & in what age group? - ✅✅✅-clinical breast exam: q3y age 20-39, annually @ age ≥40 -self breast exam: monthly ≥20yo right after menstruation -MMG: annually ≥40yo or 10y before 1st deg relative Dx is there preventative tx available for breast cancer? - ✅✅✅-SERM (Tamoxifen, Raloxifene) in PMP women or >35y @ high risk x5 yr -aromatase inhibitors (Letrozole, Anastrozole) -prophylactic mastectomy what is the difference b/t congestive and infective mastitis? - ✅✅✅-congestive: bilateral breast enlargement 2-3 days postpartum -infective: usually unilateral in lactating women d/t nipple trauma (especially primagravida) w/ *s. aureus*, strep, candida w/ tenderness, swelling, warmth, & nipple discharge what is the difference between infectious mastitis vs breast abscess? - ✅✅✅-mastitis is usually redness, swelling, warmth, and tenderness in one quadrant of the breast -breast abscess is more localized induration w/ fluctuance and is rare what are the tx recommendations for infectious mastitis vs congestive mastitis vs breast abscess? - ✅✅✅- infectious mastitis: warm compress, *cont pumping/nursing*, *anti-staph abx* (Dicloxacillin, Nafcillin, Cephalosporin) -congestive mastitis: if want to cont breast feeding then manually empty breast after each feed, warm compress, analgesics; if want to stop breast feeding then ice packs, tight-fitting bras, analgesics and avoid breast stimulation -breast abscess- *I&D*, *d/c breastfeeding* from affected breast dx/tx? bilateral, often tender, multiple, mobile, well demarcated lumps in breast tissue that may inc/dec in size w/ menstrual hormonal changes - ✅✅✅-dx: fibrocystic breast d/o (can do US or FNA that reveals straw-colored fluid aka no blood) -tx: supportive *MC breast d/o dx/tx? a smooth, well-circumscribed, nontender, mobile, rubbery lump composed of glandular & fibrous tissue (collagen arranged in "swirls") that does not usually wax/wane in size w/ menstrual cycle - ✅✅✅- dx: fibroadenoma of breast -tx: no tx- usually resolve over time what are the 3 etiologies of a dystocia in labor? - ✅✅✅1. *p*ower- uterine contractions aren't strong enough 2. *p*assenger- too big or position not cephalic 3. *p*assage- pelvis, uterus or soft tissue abnormalities what are the non-manipulative and manipulative maneuvers for a shoulder dystocia? - ✅✅✅-non- manipulative: *McRobert's maneuver* (hyperflex hips- knees to chest to open pelvis) + *suprapubic pressure* -manipulative: *Woods "Corkscrew"* maneuver 180 degree shoulder rotation *c-section if cannot fix w/ maneuvers what are the risks of a prolonged shoulder dystocia? - ✅✅✅-umbilical cord compression or fetal asphyxiation -damage to C5/6 nerve roots = Erbs palsy what are some risk factors for having premature rupture of membranes? - ✅✅✅-STDs -smoking -prior preterm delivery -multiple gestation how can you diagnose premature rupture of membranes? tx? - ✅✅✅-pooling test on speculum exam -nitrazine paper (will turn blue if pH>6.5 aka amniotic fluid) -ferning appearance of amniotic fluid on a microscopic slide -US to check the amniotic fluid index (AMI) or fluid levels -tx: await spontaneous labor and monitor for infection (chorioamnionitis or endometritis) after water has broken or amniotomy performed it is important not to do what that may cause the umbilical cord to prolapse past the head - ✅✅✅do not elevate fetal head from pelvis to release more amniotic fluid umbilical cord prolapse is an obstetric emergency and is tx'd by - ✅✅✅emergent delivery- assisted vaginal or stat c-section (whichever will be quicker) can do maneuvers in the meantime to elevate fetus off of cord if in fetal distress preterm labor is defined as regular uterine contractions (>4-6/hr) with *progressive cervical changes* (effacement/dilation) before ____ weeks gestation - ✅✅✅<37 wks *it is the MC cause of perinatal mortality what degree of dilation & effacement is preterm labor likely? - ✅✅✅2-3cm dilation 80% effacement *diagnosis made clinically from 2 fevers and uterine tenderness (other sx's include foul lochia, chills, lower abdominal pain) what are the differences b/t 1st-4th degree lacerations postpartum? - ✅✅✅-1st deg: skin/mucosa only -2nd deg: extend into perineal body but do not involve anal sphincter -3rd deg: extend into or completely through anal sphincter -4th deg: through anal mucosa (may be a button hole laceration so perform rectal exam) how are 1st-4th degree tears repaired? - ✅✅✅-1st deg: interrupted suture -2nd deg: suture anchored at apex of lac, then through hymenal ring and used to bring together the perineal body; then skin closed with subcuticular sutures -3rd deg: repair anal sphincter w/ severel interrupted sutures, then the rest same as above for 2nd deg -4th deg: repair anal mucosa meticulously to prevent fistula formation, repair rectum, and repair the rest as above w/ 3rd deg *all w/ dissolvable sutures what is the size of the uterus postpartum/puerperium after delivery? after 2 weeks? after 6 weeks? - ✅✅✅-after delivery: @ umbilicus -2 weeks: into pelvic cavity -6 weeks: nml size what is normal discharge/bleeding in the postpartum/puerperium period? - ✅✅✅-especially days 4-10, pinkish brown vaginal bleeding called *lochia serosa* that should cease by *3-4 weeks* postpartum T/F: lactating/breast feeding mothers remain anovulatory - ✅✅✅*true* but still use back up contraception just in case when do regular menses return postpartum? - ✅✅✅6-8 weeks (if not breastfeeding) a cystocele is the (anterior or posterior?) bladder herniating into the (anterior or posterior?) vaginal wall; how is it tx'd? - ✅✅✅-*posterior* bladder through *anterior* vaginal wall -kegels, wt control, pessary, anterior colporrhapy (reinforce fascia w/ sutures) a rectocele is the (anterior or posterior?) rectum herniating into the (anterior or posterior?) vaginal wall; how is it tx'd? - ✅✅✅-*anterior* rectum into *posterior* vaginal wall -kegels, wt control, pessary, posterior colporrhapy (reinforce fascia w/ sutures) an enterocele forms when small bowel descends into _______ herniating into the upper vaginal wall - ✅✅✅pouch of Douglas what are the risk factors for uterine prolapse? - ✅✅✅weakness of pelvic support structures (MC after childbirth, multiparity, obesity, repeated heavy lifting) explain grades I-IV of uterine prolapse - ✅✅✅-I: descent into upper 2/3 of vagina -II: cervix approaches introitus -III: outside introitus -IV: entire uterus outside of vagina- complete prolapse symptoms of pelvic organ prolapse include: pelvic/vaginal fullness/heaviness, "falling out" sensation, lower back pain, vaginal bleeding, purulent discharge, urinary frequency/urgency, stress incontinence; what PE maneuver can be done to check? - ✅✅✅valsalva to inc abdominal pressure and produce a bulging mass on exam what are the tx options for pelvic organ prolapse? - ✅✅✅-kegels/PT to strengthen pelvic floor -weight loss -pessaries -estrogen tx (improves atrophy) -hysterectomy -colporrhaphy (reinforcement of fascia w/ sutures) -uterosacral or sacrospinous ligament fixation a 33 yo women comes in with acute R pelvic pain, adnexal mass; Ddx? workup? - ✅✅✅-Ddx: ovarian torsion, ectopic pregnancy, ruptured ovarian cyst/abscess, appendicitis, etc. -w/u: pelvic US ovarian torsion is usually seen in women of reproductive age with acute unilateral pelvic pain and adnexal mass; how is it tx'd? - ✅✅✅-detorsion and ovarian conservation -only perform salpingo-oopherectomy if PMP or necrotic ovary abstaining from sex during the fertile period as a means of contraception is called __________ and uses what signs to monitor this window? - ✅✅✅-natural family planning -signs: body temp, cervical mucus, calendar, urine progestin test -failure rate is up to 25% coitus interruptus (withdrawal of penis from vagina before ejaculation) has a ____% failure rate d/t sperm being in pre-ejaculatory fluid - ✅✅✅20% what is the chemical in spermicide called? what is the failure rate of spermicide? - ✅✅✅-nonoxynol-9 -27% failure rate do female or male condoms have a higher failure rate? - ✅✅✅male- 20% female- 21% a rubber cuplike device that holds spermicide against cervix - ✅✅✅-diaphragm: failure rate of 15% -must remain in place 6-24h after intercourse -requires pelvic exam & fitting what barrier methods of contraception can increase risk for developing toxic shock syndrome? - ✅✅✅diaphragm, fem cap, contraceptive sponge (synthetic progesterone aka progestin is hard to metabolize) what OCP is approved for PMDD (premenstrual dysphoric disorder)? - ✅✅✅combination (estrogen + progestin) aka Drospirenone containing *also helps with bloating what OCP is slightly less effective than combination OCPs but safe to take during lactation (& postpartum period in general)? - ✅✅✅progestin only "Mini Pill" (postpartum at higher risk for thromboembolic events so this is why we avoid estrogen containing OCPs!) what are the 2 long acting progestin contraceptive methods outside of IUDs? how long do they last? s/e? - ✅✅✅1. Implanon (implantable etonogestrel)- lasts 3 yrs 2. Depo Provera (injectable medroxyprogesterone)- lasts 3 mos s/e for both include *menstrual irregularities*!!! what is the transdermal method of contraception? how is it used? is it less effective if the pt is over or underweight? - ✅✅✅-*Ortho Evra* (norelgestromin/ethinyl estradiol) -applied Qwk x 3 weeks followed by 1 week off -*less effective* if pt is *underweight* (gets absorbed better through adequate amt of body fat) how is nuvaring (etonogestrel/estradiol) used? - ✅✅✅-inserted for 3 weeks, taken out for 1 week -removed during intercourse but must be replaced w/i 3 hrs what is the most common site affected by endometriosis? - ✅✅✅-MC: *ovaries* -posterior cul de sac -broad & uterosacral ligaments -rectosigmoid colon -bladder what are some risk factors for endometriosis? - ✅✅✅-*nulliparity* -family hx -early menarche -onset <35y what is the classic triad of endometriosis? - ✅✅✅1. premenstrual pelvic (or lower back) pain 2. dysmenorrhea 3. dyspareunia +/- dyschezia (painful defecation d/t common sites affected) does endometriosis affect fertility? - ✅✅✅yes bc most commonly effects ovaries so causes >25% of all infertility cases what is used to definitely diagnose endometriosis? - ✅✅✅laproscopy w/ Bx what is a "chocolate cyst"? - ✅✅✅an *endometrioma*- endometriosis involving the ovaries large enough to be considered a tumor, usually filled w/ old blood appearing chocolate-colored what are the management options of endometriosis? - ✅✅✅medical (ovulation suppression) -*combination OCPs* + *NSAIDs* for premenstrual pain -*progesterone* (causes endometrial tissue atrophy, suppresses GnRH) -*leuprolide* (GnRH analog causing pituitary FSH/LH suppression) -*danazol* (testosterone- induces pseudo-menopause) surgical: -laparoscopy w/ ablation- used if fertility desired -TAH-BSO otherwise PCOS is an endocrine syndrome characterized by a triad of what 3 things? - ✅✅✅1. secondary amenorrhea (anovulatory) or oligomenorrhea 2. obesity (insulin resistance/insensitivity) 3. hirsutism (androgen excess from estrogen) other manifestations: acne, male pattern baldness, T2DM, HTN, acanthosis nigricans, bilateral enlarged smooth mobile ovaries on PE d/t functional cysts from immature follicles what is the cause of PCOS? - ✅✅✅-exact cause unknown but: -genetic predisposition -in utero exposure to certain drugs or nutritional disorders -postnatal insulin-resistant hyperinsulinism (either genetically programmed or as a result of obesity) the pathophysiology of PCOS is from excess/unopposed estrogen which is driven by? - ✅✅✅*increased LH levels* which are driven by *increased insulin levels* what lab/radiology results will a pt with PCOS have? - ✅✅✅-*inc testosterone*, ≥3:1 LH:FSH ratio (nml is 1.5:1), inc lipid panel, in blood glucose, pelvic US with bilateral enlarged ovaries with peripheral cysts aka *"string of pearls"* appearance -turns out LH:FSH ratio is BS according to UpToDate but its on PPP so who knows... what do you need to make the diagnosis of PCOS? - ✅✅✅Rotterdam Criteria: *2 out of 3* 1. polycystic ovaries on US 2. clinical hyperandrogenic signs (hirsutism, acne, male-pattern hair loss) 3. oligo and/or anovulation/amenorrhea what other conditions do you need to rule out when diagnosing PCOS? - ✅✅✅-thyroid dysfxn (can cause menstrual irregularities) -pituitary adenoma -ED visits -suspicious signs (inconsistent explanation of injuries, delay in seeking tx, missed appts, frequent ED visits, late prenatal care, inappropriate affect, overly attentive partners, reluctance to be examined) how is intimate partner violence (IPV) managed? - ✅✅✅-emotional support -f/u visits -referral to counseling or psych -give domestic violence hotline, group or social worker info -careful documentation -only required to report if pt is *disabled, elderly, under 18, or weapons involved* what all should be evaluated/treated in a sexual assault pt? - ✅✅✅-psychological assessment -evaluation of areas of trauma -examination of breast, pelvic, and anorectal areas -colposcopy to detect genital trauma -use of evidence collection kit -labs: pregnancy test, STI testing, drug screening -prophylactic STD tx (ceftriaxone 250mg IM for gonorrhea, azithromycin 1g po for chlamydia, metronidazole 2g po for trich) -hep B vaccine, HPV vaccine for those not previously immunized -prophylactic HIV tx w/ antiretroviral (controversial) -post-coital contraception (plan B) -offer acute crisis counseling what is urinary incontinence due to increased abdominal pressure (sneezing, laughing, coughing, running, etc.) known as? what is it due to? - ✅✅✅*stress incontinence*- d/t laxity of pelvic floor muscles (childbirth, surgery, postmenopausal, post prostatectomy) what is the tx for stress incontinence (d/t inc abdominal pressure)? - ✅✅✅-*pelvic floor exercises* (kegel, biofeedback w/ sensor detecting pressure changes of kegels); 87% improvement -*alpha agonists* (midodrine, pseudoephedrine) inc urethral sphincter tone and flow resistance; 19-74% improvement -*surgery* (artificial sphincter) inc urethral outlet resistance; 88% improvement -*anti-incontinent devices*: vaginal cones help to strengthen pelvic floor muscles, pessaries -*estrogen*: cream or estradiol-impregnated vaginal ring to help with atrophy what is urge incontinence? what is the cause? sx? - ✅✅✅-urine leakage accompanied by or preceded by urge -caused by *detrusor muscle overactivity* by muscarinic acetylcholine receptors; "overactive bladder" -sx: urgency, frequency, small volume voids, nocturia how is urge incontinence treated? - ✅✅✅-*bladder training* (timed frequent voids and dec fluid intake) -*anti-cholinergics* (*oxybutinin* or tolterodine) blocks ACh receptors in bladder but s/e are can't see, can't spit, *can't pee*, can't shit -TCAs (imipramine) central/peripheral anticholinergic effect and alpha adrenergic agonist -*mirabegron* (B3-agonist = bladder relaxant) -*surgical*: injection of botox or bladder augmentation -*diet*: avoidance of spicy food, citrus fruits, chocolate and caffeine overflow incontinence is caused by? - ✅✅✅urinary retention (incomplete voiding) d/t *dec detrusor activity* (atony) "underactive bladder" w/ multiple etiologies (DM, MS, autonomic dysfxn, spinal injury) or BPH outlet obstruction overflow incontinence aka "underactive bladder/atony" is diagnosed by a post void residual volume of? - ✅✅✅>200mL (of urine still left in bladder) what is the tx for overflow incontinence aka "underactive bladder/atony"? - ✅✅✅-intermittent or indwelling *catheter* is 1st line -cholinergics *bethanacol* to inc detrusor activity -if d/t BPH: alpha blockers: *tamsulosin* to dec urethral resistance infertility is defined as inability to conceive after what amt of time? - ✅✅✅1 yr what are the etiologies of infertility? - ✅✅✅-40% male abnormal spermatogenesis -30% female anovulatory cycles or ovarian dysfxn -congenital or acquired disorder can cause the rest... how is infertility evaluated? tx'd? - ✅✅✅-sperm eval -hysterosalpingography (eval tubal patency or abnormalities) -hormone levels tx: -*clomiphene* (SERM- induces ovulation) -intrauterine insemination -in vitro fertilization (especially if fallopian tube defect is present)