OB/GYN PA class
What is the normal sequence of pubertal development?
1. Thelarche (8-9)- breast development
2. Adrenarche/pubarche (9-10)- Axillary and pubic hair
3. Growth spurt- change in height after menarche is less than 5 inches
4. Menarche (12-13)
Regulation of menstruation
Pituitary Gland- LH and FSH
Theca Cells - Androgens (estrogen precursors)
Granulosa Cella - Androgens (Estradiol)
When does ovulation usually occur in relation to onset of next menstrual period?
14 days before the next period
What is the average interval from one cycle to next? What is range of normal?
Normal cycle length - 21 to 35 days (avg 28)
Normal duration- 3 to 5 days
Candida- Usual Clinical Manifestations
- satellite pustules
- white, curd like dc
Candida- Diagnostic Tests
- Normal vaginal pH
- KOH prep
- culture (only for pts who do not respond to meds)
Topical (Miconazole, Clotrimazole, Terconazole)
Trichomoiasis- Usual Clinical Manifestations
- Vaginal pH > 4.5
- Yellow-green frothy dc
- Punctate hemorrhage
Trichomoiasis- Diagnostic Tests
- Saline prep
- pH > 4.5
- PO Metronidazole 2g single dose
- Treat partner and use condoms until treated
Bacterial Vaginosis- Usual Clinical Manifestations
- Thin, gray dc
- Prominent vaginal odor
- Minimal inflammation
- No pruritis
Bacterial Vaginosis- Diagnostic Test
- pH > 4.5
+ Amine Test
+ Saline microscopy (oral whiff test)
Bacterial Vaginosis- Treatment
- PO metronidazole 500 mg BID x 7 days
What organisms are most likely to cause a Bartholin's gland abscess?
Gonorrhea, chlamydia (3x more common)
What is the best initial course of management for a Bartholin's gland abscess?
- Word Catheter
- Doxycycline 100 mg BID + Metronidazole 500 mg BID
- Amoxicillin + Clavulanic acid (875 mg BID)
What is the purpose of a Pap smear?
check for suspicion of cervical cancer
What is the optimal methodology for obtaining a pap smear?
- Liquid media- thin prep
- Spatula - exocervix- squamous cells
- Cytobrush - endocervix- glandular cells- adenocarcinoma
What is the appropriate screening interval for a pap smear in a 21-yo nulligravid, unmarried, sexually active woman?
every 3rd year bt 21-29, only w/ cytology
What is the appropriate screening interval in a 60-yo married woman who has never had an abnormal pap smear?
HPV testing + every 5th year
screening with cytology alone every 3 years
What are the principal risk factors for cervical cancer?
- young age at first intercourse
- multiple sexual partners
- HPV infection w/ high risk strains
- other STDs
What are the best methods to prevent cervical cancer?
- safe sexual practices
- cervical cytology
- HPV vaccine
24 yo married woman, G2P2002, no prior hx of abnormal pap smear, has following cytology: "Atypical squamous cells of undetermined significance, ASC-US". What should be the next step?
Check HPV status (reflex)
rescreen at appropriate interval
28 yo woman, G3P2103, cytology "High grade squamous intraepithelial lesion; HSIL". Next step?
Colposcopy and biopsy
56 yo multiparous, postmenopausal woman had following pap: "endometrial cells present. no squamous abnormalities noted." Next step?
r/o endometrial cancer, biopsy
What conditions should be considered in the DDx of acute lower abd pain in a young woman?
- Adnexal torsion
- Ectopic pregnancy
- Ruptured ovarian cyst
- TOA (tubal ovarian abcess)
- rapidly growing neoplasm
What are the usual manifestations of endometriosis?
- dysparenuia (deep seated pelvic pain)
- chronic pelvic pain
- rectal bleeding
- nasal bleeding
- abn tissue in laparotomy scars
What is the best test for the dx of endometriosis?
- biopsy of visible lesions
- direst visualization by laparaoscopy
What are the usual tx for endometriosis?
- oral contraceptive
- GnRH agonist
- laparscopic surgery
- open laparatomy
What are the principal risk factors for endometrial cancer?
- increasing age
- early menopause
- late menopause
- family history
- low parity
- unopposed estrogen stimulation (PCO, HRT)
What is the most common histologic type of endometrial cancer?
What is the best diagnostic test for endometrial cancer?
(Others: platelet count, platelet function assay, pelvic US, mammogram, H/H, CXR, colonoscopy)
What is the usual tx for early stage endometrial cancer?
- surgery (good operative candidate)
- radiation (poor operative candidate)
What are the major organisms that cause pelvic inflammatory disease (PID)?
Gonorrhea and chlamydia
or normal background flora (coliforms and gram +/- anaerobes)
What are the major disorders that should be considered in the DDx of PID?
- ectopic pregnancy
- ruptured ovarian cyst
- adnexal torsion
What lab studies are appropriate in eval of a pt with suspected PID?
- pregnancy test
- gonorrhea, chlamydia, other STDx
What is the appropriate outpatient tx for PID?
- 400 mg Oflaxacin/500 mg Levofloxacin + 500 mg Metronidazole BID x 14 days
- 250 mg IM Ceftriaxone + 100 mg Doxycycline BID x 14 days +/- 500 mg Metronidazole BID x 14 days
What is the appropriate inpatient tx for PID?
- 2g Cefotetan q 12h + 100 mg Doxycycling q 12 h
- 900 mg Clindamycin q 8h + 7 mg/kg/1BW Gentamycin q 24 h
What are the usual clinical manifestations of PCOS?
- irregular/absent menses
- androgen excess (acne, hirsutism)
- carbohydrate intolerance
- enlarged polycystic ovaries w/ thick capsule
What are the potential long term sequelae of PCOS?
- persistent infertility
- endometrial hyperplasia
- endometrial cancer
Which type of ovarian tumor is most likely in a teen or young adult?
germ cell (cystic teratoma)
What is the most common type of ovarian mass in a young adult?
Which type of ovarian tumor is most likely in a postmenopausal patient?
What is the most appropriate imaging study to assess an ovarian mass?
What are the definitions of primary and secondary amenorrhea?
1* = normal secondary sexual characteristics + no menses by age 16, or no normal secondary sexual characteristics + no menses by age 14
2* = no period in 3 months
What are two of the unusual causes of primary, not secondary, amenorrhea?
genetic (androgen insensitivity syndrome, turner's syndrome)
anatomic (agenesis, vaginal septum)
What is the most common cause of secondary amenorrhea?
hyperprolactinemia, premature ovarian failure, hypothyroidism, hpothalamic-pituitary dysfunction
What is the usual cause of primary dysmenorrhea?
excessive release of prostaglandins from a secretory endometrium
What is the most effective tx for primary dysmenorrhea?
Meds: *NSAIDs, OC
SX: myomectomy, polypectomy, hysterectomy, ablation of endometriosis
What are the principle causes of abnormal uterine bleeding?
* Anovulatory (dysfunctional bleeding)
- endometrial hyperplasia or cancer
- endometrial polyp
- chronic endometritis
- bleeding disorder (Von Willebrand's or thrombocytopenia)
- thyroid disease
What are the two test of greatest value in assessment of a pt with abnormal uterine bleeding?
- r/o endometrial cancer (US and biopsy)
- platelets/platelet function assay/ TSH/H&H
What is the preferred test for the dx of gonorrhea and chlamydia?
- nucleic acid probe (urine or secretions)
What are the drugs of choice for tx an uncomplicated chlamydia infection?
* 1000 mg Azithromycin PO x1
What are the drugs of choice for tx an uncomplicated gonococcal infection?
250 mg Ceftriazone IM x1 + 1000 mg Azithromycin PO x1
What are the major long term sequelae of gonorrhea and chlamydial infections?
- ectopic pregnancy
- chronic pelvic pain
In a primary care practice, what is the most likely stage of syphilis at the time of initial diagnosis?
Latent (caught on screening test)
What are the most useful dx tests for dx of syphilis?
- VDRL/RPR screening test
- MHA/FTA confirmatory test
What is the characteristic lesion of primary syphilis?
What is the characteristic lesion of secondary syphilis?
rash on sole of feet and palm of hands
What is the characteristic lesion of tertiary syphilis?
- destructive gummas
- aortic valve injury
- CNS manifestations (dementia, tabes dorsalis, pupillary abnormalities)
What is the drug of choice for tx syphilis?
(Doxycycline, Tetracycline, Ceftriaxone)
What are the most useful test for the dx of HSV infection?
- Viral culture (gold standard)
What are the drugs of choice for tx HSV infectin?
* Acyclovir 400 mg PO TID x 7 days
- Valacyclovir 1000 mg PO BID x 7 days
What is the difference b/t the theoretical failure rate of contraception and user fail rate?
theoretical failure rate - w/ perfect use
user fail rate- effectiveness in actual practice
What are the possible methods of natural family planning?
- calendar rhythm
- basal body temperature chart
- observation of cervical mucus
33 yo married multiparous woman wishes to use an IUD. she has never had an STD. however, her menstrual periods are heavy, and severe dysmenorrhea. Which IUD is best?
Which type of male condom is most effective in preventing transmission of HIV infection?
What is the active ingredient in spermicides?
What is the max length of time the cervical cap should be left in place after insertion?
How long should the diaphragm be left in place after coitus?
What is the most frequent complication associated w/ use of diaphragm?
What is the primary mechanism of action of combo oral contraceptives?
* Inhibition of ovulation
- alteration of cervical mucus
- alteration of endometrium
What is the overall effectiveness of combo OCs?
99% when used properly
What is the difference bt "absolute risk" and "relative risk"?
absolute risk- stated w/o context, no comparison, just a probability of occurance
relative risk- comparison bt different risk levels
What are the absolute contraindications to use combo OCs?
- estrogen-dependent tumor
- Hx of DVT or PE
- undiagnosed genital tract bleed
- liver dz, heart dz
- smoking + age > 35
- diabetes w/ long duration and vascular dz
- poorly controlled HTN
- migraine w/ aura
- organ transplant
- major surgery w/ immobilization
What are the major non contraceptive medical benefits of combo OCs?
- menstrual blood loss
- severity of dysmenorrhea
- frequency of functional ovarian cysts
- frequency of ectopic pregnancy
- frequency of breast cancer
- frequency of PID
- frequency of ovarian and endometrial cancer
Which pts are candidates for contraceptive patch and contraceptive ring?
those looking for convenience, or with forgetfulness, lack of responsibility or education
What is the most appropriate regimen for emergency post-coital contraception?
- Plan B (Levonorgestrel .75 mg q 12 hrs x2 w/in 72 hrs of unprotected intercourse)
- copper IUD w/ in 5 days
What are the advantages and disadvantages of progestin-only OCs?
advantages: lactating women
disadvantages: increased pregnancy, *breakthough bleeding
What are the advantages and disadvantages of Depo-Provera?
Advantages: better hygeine, every 3rd month, less expensive, amenorrhea
Disadvantages: bone loss, breakthrough bleeding, weight gain, depression
What are the most common clinical manifestations of menopause?
- hot flashes
- vaginal dryness
- sleep disturbance
- mood changes
What is the best test to confirm the dx of menopause?
- FSH is increased- check consecutive labs
- pregnancy test, TSH, BMD
What are the specific objectives of hormone replacement therapy?
Relieve vasomotor symptoms
- Decreases hot flushed
- Decreased vaginal dryness
- improvement in sleep disturbances and mood changes
What are the potential harmful effects of HRT in pts who are > 60 yo and/or who have pre-existing CAD?
increased risk of CAD, CVA, DVT/PE, breast cancer
In addidtion of HRT, what other intervention are appropriate in a pt in early menopause?
Weight bearing, flexibility, aerobic exercise
What are the principal complications associated w/ osteoporosis?
- Vertebral compression fx (nerve injury, decreased height, pain)
- Hip fx (immobility, mortality, PE)
- distal radius/ulna fx (Foosh)
What is the best test to conform dx of osteopenia and osteoporiss?
BMD, T score
Osteopenia -1.0 to -2.5
Osteoporosis > -2.5
In addition of estrogen replacement, what other meds are of value in preventing or tx osteoporosis?
Bisphosphonate (antiresorptive agents)
What is the most common cause of most pelvic support defects?
- Prior hysterectomy
What is the most appropriate tx for vaginal vault prolapse?
What are the most appropriate tests for the eval of pt w/ urinary incontinence?
PE- identify neuromuscular dz
Urine C&S- exclude infection
Cystoscopy- polyps, tumor, inflammation
Urodynamic testing- confirm stress incontinence
What is the most effective medical tx for a pt w/ urge incontinence?
Muscarinic receptor blockers
Oxybutynin ER 5-15 mg daily
What is the preferred surgical approach for a pt w/ stress incontinence?
*Transvaginal procedure (TOT,TVT)
- Collagen injection
What lifestyle changes are of value in the management of a pt w/ urge or stress incontinence?
- reduce weight
- stop smoking
- decrease caffeine intake
- retrain bladder (kegals)
What is the frequency of infertility in the US?
10% of couples unable to conceive w/in one year
What are the most common cuases of infertility in the male?
low sperm count
diminished sperm motility
What are the most common causes of infertility in the female?
1. anovulation- PCOS, weight change, stress
2. tubal obstruction - PID, tubal anomaly
What dx tests should be performed to eval an infertile couple?
- semen analysis
- serum progesterone
- clomid challenge test
What is the most appropriate tx for major causes of infertility?
- Repair of varicocele
- intrauterine insemination
- donor sperm
- clomiphene citrate
- gonadotropin stimulation
- egg donation
Blocked fallopian tube
- sx repair of obstruction
- in vitro
- meds (OC, GnRH agonists)
What are the most common causes of first trimester pregnancy loss?
- karyotype abnormality
- serious systemic disease (antiphospholipid syndrome, diabetes)
What are the principal maternal and fetal indications for pregnancy termination?
maternal (serious systemic dz- cardiomyopathy, TOF, pulm HTN, eisenminger's, marfan's)
fetal (fatal genetic abnormality, life threatening structural abnormality)
What are the 2 options for 2nd trimester pregnancy termination?
dilation and evacuation
What are the 2 options for 1st trimester pregnancy termination?
Mifepristone + misoprostol
What are the most important predisposing factors for an ectopic pregnancy?
*What is the most common site for an ectopic pregnancy?
What 2 tests are of greatest value in dx an ectopic pregnancy
1. serum HcG (failure to double w/ in 72 hrs)
2. US (absence of intrauterine prenancy, adnexal mass, blood in cul-de-sac)
What is the most appropriate management for a small unruptured ectopic pregnancy?
What is the most appropriate management for a larger, ruptured ectopic pregnancy?
surgery- removal of ectopic vs removal of tube
What is a molar pregnancy?
- tumor of placental tissue
- may develop de novo or after a spontaneous abortion or term pregnancy
What are the common genotypes of complete and partial moles?
complete = 46 XX
partial = triploid 69
What are the most common clinical manifesations of a molar pregnancy?
- persistent bleeding in early 1/2 of pregnancy (or after a spontaneous abortion or term pregnancy)
- uterus large for dates (no FHT)
What are the most valuable tests for dx a molar pregnancy?
- quantitative hCG is very high
How should a pt w/ a molar pregnancy be tx?
- suction evacuation
- monitor serum HcG (until it reaches 0)
- chemo for persistent GTC (methotrexate*/actinomycin D)
- contraception x 6 months
- early US in next pregnancy
A 26 yo woman is now pregnant. She has had 2 term singleton pregnancies; both infants are alive. She also has had one spontaneous abortion. What is her gravidity and parity?
What are the most common medical dz that complicate pregnancy?
- connective tissue disorder
- acquired HD
Which meds are clearly teratogenic?
Valproic acid (spina bifida)
carbamazepine (spina bifida, facial malformations)
antineoplastic agents (varied defects)
warfarin (facial deformity, intracranial bleeding)
lithium (cardiac malformation)
tetracycline (staining of teeth)
ACEI and ARB (renal injury)
quinolones (cartilage injury)
BB (growth restriction)
topiramate (facial cleft)
isotretinoin (growth restriction; brain, face, thymus, heart defects)
heat and radiation
What are the potentially harmful effects of smoking in preganancy?
low birth weight
What is the purpose of screening for hep B in pregnancy?
virus may be passed to baby -> chronic infection
What is the purpose of the Quad Screen test?
Test for trisomy 18, 21, neural tube defect
28 yo woman, G2P1001, at 6 wks gestation has BMI of 21. What is an appropriate weight gain during pregnancy for this pt?
What is the best dx test to resolve discrepancies bt uterine size and dates?
What are the most likely maternal complications associated w/ chronic hypertension in pregnancy?
- renal dz
- superimposed pre-eclampsia
What are the most likely fetal complications associated w/ maternal hypertension in pregnancy?
What are the clinical criteria for dx of pre-eclampsia
- BP > 140/90 after 20 wks
- proteinuria > 300 mg/24 hrs
What are the 2 key criteria that determine management of pre-eclampsia?
*Tx depends on severity of pre-eclampsia
- BP > 160/110
- Proteinuria > 5 g
- Oliguria < 30 mL/hr
- increased DTRs
What are the usual clinical manifestations of placental abruption?
- abd pain
- tetanic uterine contraction
- dark red vaginal bleeding
- abnormal fetal HR pattern
What are the usual clinical manifestations of placenta previa?
- painless, bright red vaginal bleeding
- abnormal fetal HR is less likely than abruption
- coagulopathy less likely
What are the major factors that cause preterm delivery?
- premature PROM
- multiple gestation
- uterine anomaly
- fetal anomaly
- incompetent cervix
- cocaine abuse
- non-genital infection (PNA, pyelonephritis)
- genital infection (lower or upper tract)
What are the 4 most serious complications of prematurity?
- hyaline membrane dz
- IVH (intraventricular hemorrhage)
- NEC (necrotizing enterocolitis)
- infection (group B strep, E. coli)
Why are corticosteriods administered to mothers at risk for preterm delivery?
decreased frequency of RDS, IVH, NEC
What % of all pregnancies in US are unplanned?
Key advantages of IUD?
Mirena 5 years, copper IUD 7 years
Mirena- decrease in menstrual blood loss and cramping
Inexpensive in long run
Disadvantages of IUD?
Pain with insertion
Copper IUD- exacerbation of dysmenorrhea and menorrhagia
High initial cost
CDC- medical eligibility criteria for contraceptive. What does class 3 mean?
Theoretical or proven risks usually outweighs the advantages
What percent of twins are monozygotic?
What is the best test to identify twins and assess zygosity?
US- placentation- zygosity
Monochorionic, monoamniotic = monozygotic
Monochorionic, diamniotic = monozygotic
Dichorionic, diamniotic = either
What factors are associated with an increased risk of dizygotic twins?
Positive family history
Use of ovulation induction
What are the most common antepartum complications associated with a twin gestation?
Impaired growth of one or both twins
Twin to twin transfusion syndrome
What are the most common intrapartum and postpartum complications associated with a twin gestation?
Abnormal FHR tracing
Cesarean delivery (abn labor, presentation, FHR)
Postpartum hemorrhage (uterine atony)
What tests are of greatest value in identifying complications related to twins?
Early US to determine zygosity
2nd trimester scan (anomalies and cervical length)
3rd trimester scan (fetal growth)
Antepartum monitoring (FHR, any evidence of impaired blood supply)
What factors should be considered in determining the mode of delivery for twins?
Both abnormally positioned- cesarean
Cephalic/breech- cesarean- or- vaginal twin 1, twin 2 vaginal or breech extraction
What is the principal cause of higher order multiples?
Ovulation induction with gonadotropins
Three stages of labor
1st- onset of contractions until fully dilated
2nd- from full dilation until delivery of baby
3rd- from delivery of baby until delivery of placenta
2 phases of first stage of labor
Latent- dilation below 4 cm, early dilation and cervical effacement
Active- starting at 4 cm, more rapid cervical dilation
What are the most likely causes of abnormal labor?
*poor uterine contractility
What are the most common indications for cesarean delivery?
Dystocia (labor abnormalities)
Which type of anesthetic provides the most consistent and uniform effect during labor and delivery?
What is the most common intra operative complication of cesarean delivery?
What is the most common postoperative complication of cesarean delivery?
Infection (endometritis, UTI, wound infection)
What is the preferred type of uterine incision for cesarean delivery?
Low transverse (Kerr)
Most appropriate steps in management of a pt that has a stalled dilation for more than 2 hours?
- evaluate fetal presentation, position
- evaluate uterine contractility, maternal pelvis
- tx maternal infection
- perform amniotomy
- administer oxytocin
Most appropriate step in managing pt with fetal head remaining at station for 2 hours even with strong contractions?
Patiently wait, possible episiotomy
What are the principal causes of postpartum hemorrhage?
1. ** uterine atony- drugs, chorioamnionitis, uterine overdistention, multiple gestation, polyhydramnios, uterine malformation
2. Retained placenta- accreta, increta, percreta
3. Lacerations- cervical or vaginal
4. Coagulopathy- severe preeclampsia, abruptio placentae, sepsis, amniotic fluid embolism
What are the principal risk factors for postpartum endometriosis?
Multiple vaginal exams
Pre existing vaginal infection (GBS, BV)
What are the most appropriate antibiotics for tx of postpartum endometritis?
**clindamycin + gentamycin
Metronidazole + penicillin/ampicillin + gentamycin
Broad spectrum cephalosporin/penicillin (cefotetan/ticarcillin-clavulanic acid)
What is the best test for dx of a pulmonary embolism?
What is the most appropriate tx for a pulmonary embolism?
- anti coagulation (unfractionated heparin, lmw heparin, Coumadin)
- thrombolytic therapy/embolectomy
- screen for heredity thrombophilia