acute mastitis is MC in?
lactating women!! esp primigavida
MC organism of acute mastitis??
staph aureus
s/sx acute mastitis?
U/L localized breast paincracked nipples/vsisble fissureswarmth/swelling/tenderness
tx acute mastitis?
supportive--> keep pumping and breastfeedingANTI-STAPH ABX: NAFCILLIN/DICLOXACILLIN/CEPHALOSPORINif PCN allergy--> erythromycin
breast abscess is usually a complication of??
ACUTE MASTITIS
MC organism of breast abscess??
staph aureus!!
s/sx breast abscess??
sxs of acute mastitis + INDURATION AND FLUCTUANCE
tx breast abscess??
1. DRAINAGE VIA NEEDLE ASPIRATION OR I/D2. ANTIBIOTICS= DICLOXACILLIN/CEPHALEXIN
congestive mastitis??
BILATERAL breast pain and swelling x 2-3 days PP d/t MILK STASIS--> breast drainage via pump/manually= mainstay of tx
what is the MC benign breast disorder in reproductive age women??
fibrocystic breast changes!!
s/sx fibrocystic breast changes?
multiple painful OR painless breast masses that INCR/DECR in size w MENSTRUAL HORMONAL CHANGES--> usually worse prior to menstruaion
PE fibrocystic breast?
MULTIPLENODULARMOBILESMOOTHROUND/OVOIDBILATERAL BREASTSVARYING SIZE
where are fibrocystic breast changes MC ofund??
UPPER OUTER SECTIONS OF BREASTS
dx fibrocystic breast changes??
ULTRASOUND= INITIAL f lesion suspision--> mammogram
tx fibrocystic breast changes??
SUPPORTIVE= OBSOCP CAN REDUCE SXS
is a fibroadenoma of breast benign/malignant??
benign solid tumor!!
does fibroadenoma change with menstrual cycle??
no not significantly
can fibroadenoma enlarge in pregnancy? does it grow in general?
yes can enlarge in pregnancyGRADUALLY grows over time!
PE fibroadenoma?
FIRM, NON-TENDER, SOLITARY, SMOOTH, WELL-CIRCUMSCRIBED, FREELY MOBILE, RUBBERY LUMP!usually 2-3 cm and no axilllary involvement
dx firoadenoa??
FNA= DEFINITIVE= collagen arranged in a "swirl
tx fibroadenoma?
conservative--> obs, reassure, follow upif enlarging, excision might be needed
Gynecomastia why in males?
either d/t incr estrogen OR decr androgen
gynecomastia in infants why??
d/t high maternal estrogen
what meds can cause gynecomastia??
spironolactone!!ketoconazole5-alpha reductase inhibitorsdigozinGnRH agonistsverapamil
S/SX gynecomastia??
PALPABLE MASS OF TISSUE OF AT LEAST 0.5 CM IN DIAMETER--> centrally located, BILATERAL, TTP, symmetrical
dx gynecomastia??
clinical dx--> check test levels!
tx gynecomastia??
supportive: stop offending meds/ obs if early in diseasemeds: TAMOXIFEN= ESTROGEN ANTAGONIST IN BREAST
what med is used if needed in gynecomastia?
tamoxifen= estrogen antagonist
breast CA genetic mutations??
BRCA1 BRCA2
RF breast CA?
1st degree relativeincr ageincr menstruation/estrogenendometria cancer
MC type of breast CA?
INFILTRATIVE DUCTAL CA!!
what is pagets disease of breast??
ductal CA that presents as an ECZEMATOUS , itchy, scaly, NIPPLE and AREOLA LESION--> +/- bloody discharge
what is a common premalignant lesion of breast??
LOBAR CARCINOMA IN SITU--> not canceer but incr risk of breast cancer
S/SX breast CA??
PAINLESSHARD FIXED IMMOBILE LUMP
where is breast CA MC?
UPPER OUTER QUADRANT
in breast CA where is MC metastatic site??
BONE!!--> LUNGS!!, liver, brain2BS 2LS
inflammatory breast CA presenting sxs?
Red, swollen, warm, itchy breast+ PEAU D'ORANGE= skin changes that look like peel of orange d/t lymphatic obstruction--> NO lump/bad prognosis
skin changes that look like peel of orange d/t lymphatic obstruction??
PEAU D'ORANGEpresent w inflammatory breast CA
in women<40, what is recommended modality to eval for breast CA??
ULTRASOUND!!
in women>40, what is recommended modality to eval for breast CA??
MAMMOGRAM
what breast masses are highly suspicious for malignancy?
spiculated + microcalcification
what is most accurate diagnostic test for breast CA?
open biopsy
in estrogen receptor positive tumors of breast, premenopause pt what med tx??
Tamoxifen!!
mst useful med tx in ER positive post menopausal women in breast CA??
aromatase inhibitor hormonal therapy= LETROZOLE/ANASTROZOLE/EXEMENSTANE
WHEN should you start screening for breast CA?
50-74 y.o. every 2 years
in women >35 or postmenopasual w high risk of Breast CA, what med can u use??
SERM::TAMOXIFENRALOXIFENE
tamoxifen is associated w incr risk of...
endometrial Cancer
MCC of cervical CA genetic??
HPV 16 AND 18
genetic cause of genital warts??
HPV 6 + 11
hen do you give HPV vax?
women age 11 and up to 26 years!!GARDASIL 9= PREFERRED<15= 2 doses of HPV vaccine at least 6 months apart>15 or immunocompromised--> 3 doses over a min of 6 months
inability to maintain pregnancy secondary to PREMATURE CERVICAL DILATION esp in 2nd trimester??
cervical insufficiency
PE cervical insufficiency?
PAINLESS dilation and effacement of cervix
dx incompetent cervix??
TRANSVAGINAL U/S: Cervical length </= 25 mm before 24 weeks
Tx incompetent cervix??
1. CERCLAGE + BED REST+/- weekly injection of 17 alpha-hydroxyprogesterone
infertility define
failure to conceive after 1 year
how to diagnose infertility?
HYSTEROSALPINGOGRAPHY
what med induces ovulation for infertility??
clomiphene
when do you start giving PAPs??
every 3 years starting at 21.. if >30 and HPV neg= q 5 years
if ASCUS in 21-24 y.o. what is next step?
repeat pap in 1 year
if LSIL in 21-24 y.. what is next step?
repeat PAP in 1 year
if LSIL >25 what is next step?
colposcopy
if HSIL what is next stp?
COLPOSCOPY/ escisional treatment
if ASC-H (canr exclude HSIL) what is next step?
colposcopy
mainstay of tx of HSIL CINII/III??
EXCISION OR ABLASIONexcision= LEEP or cold knifeablation = cryocautery, laser cautery, or electrocautery
MC type of cervical cancer?
SQUAMOUS CELL CARCINOMA
what HPVs associated w cervical CA?
HPV 16/18
what is most common node group involved in spread of cervical cancer??
PARACERVICAL!!
MC presenting sx of cervical cancer??
POST COITAL BLEEDING/SPOTTING
dx cervical CA??
colposcopy w biopsy
which abortion is only one that is potentially viable??
THREATEND!!
which abortions are the cervical os dilated??
INCOMPLETEINEVITABLE== ALL UR IdiotsS ARE DILATED (*******es)
spontaneous abortions all occur before..
20 weeks
MCC of spontaneous abortions?
chromosomal abnormalities!!
POC intactcervical os closeddx?
THREATENED abortion
POC intactcervical os DILATEDdx?
INEVITABLE abortion
some POC expelledcervical os DILATEDDx??
INCOMPLETE abortion
ALL POC EXPELLEDcervical os closeddx??
COMPLETE abortion
POC intactcervical os closedno bleeding or sxsDX??
MISSED ABORTION!!
all women who are RH- should reveive what after abortions??
anti-D Rh immunoglobulin
fetal heart monitoring in placental insufficiency??
LATE DECELRATION
dizygotic is..
FRATERNAL.. fertilization of 2 ova by 2 diff sperm
monozgotic is..
IDENTICAL.. fertilization of 1 ovum that splits
what eleevated levels in multiple gestations??
beta-hCGmaternal AFP
WHEN does mom start feeling fetal movmement??
16-20 weeks!!
fundal height at 20 weeks??
AT UMBILICUS!!
fundal height 12 weeks??
above pubic symphysis
fundal height at 38 weeks?
below xiphoid process
fundal height at 36 weeks?
xyphoid process
how to estimate date of delivery??
NAEGALES RULE--> 1st day of LMP + 7 days - 3 months
what test for chromosomal abnormalities??
nuchal translusency at 10 weeksif incr thickness--> chronic villious sampling or amniocentesis
when to screen for gestational diabetes??
24-28 weeks!!
neural tube defects incr incidence w whtat defficiency??
FOLATE DEFICIENCy!!
MC neural tube defect??
spina bifida w myelomeningocele
screening in neural tube defects??
incr AFP and incr acetylcholinesterase!!
when do you give anti-dRh immunoglobulin??
in RH- woen at 28 weeks gestation!!
when to do GBS screening??
36 weeks!!
toxic shock syndrome MCC?? MC organism?? TX??
MCC: TAMPON USEMC ORGANISM: S. AUREUSTX: IV FLUIDS + CLINDA + VANCO
when is RH alloimunization??
RH neg mom + RH pos fetus --> subsequent pregnancies w RHpos will lead to HEMOLYSIS OF FETAL RBS!!
does placenta previa have pain??
NOPE!!
should you perform a Digital vaginal exam in placenta previa??
nO!!
initial screening of placenta previa??
trasnabdominal ultrasound and confirm w transvag ultrasound
if patient stable w placenta previa, tx??
watchful wating, no sex
placenta abruptio??
ABD PAIN + DARK RED BLEEDING
MC RF OF PLACENTA ABRUPTIO??
HTN!!!prior smoking/cocaine use
rf of placenta previa??
multiple gestationshx previaprevious x-section
PE of placenta abruptio??
TENDER, RIGID, HYPERTONIC UTERUS!!DO NOT PERFORM PELVIX EXAM
PE placenta previa??
soft nontender uterus
what BP meds are CI in pregnancy??
ACEI/ARB
pre-eclampsia define??
BPA>140/90 + PROTEINURIA after 20 weeks gestation!!
gestational hypertension define??
BP >140/90 without proteinuria AFTER 20 WEEKS
if >37 weeks w preclampsia tx??
DELIVERY!!
eclampsia define
PREECLAMPSIA + SEIZURES/COMA!! >>> will have abrupt onset of tonic clonic seizures!!
tx eclampsia??
IV mag sulfate for seizureiV labetalol/hydralazine for BPthen delivery once mom is stable
HEELP SYNDROME??
hemolytic anemiaelevated liver enzymeslow platelets
when to screen for gestational diabetes?first screening test???second screening test?
24-28 weeks50 gram one hour GTT2nd: 100 gram 3 hour GTT
1ST LINE management in gestational diabetes??1st line med management?
1st line gener: diabetic diet and exerciseMED= INSULIN BC DOESNT CROSS PLACENTA
fetal complications of gestational diabetes??
macrosomia--> will l/t shoulder dystociapreterm laborneonatal hpocglycmianeonatal hypocalcemia
shoulder dystocia is MC seen in..
macrosomic infants of diabetics!!
fetal complications of shoulder dystocia??
BRACHIAL PLEXUS INJURIESCLAVICULAR FRACTURES
When is c section indicated in macrosomia??
if fetus >4500 g in diabetic mom or >5000 g in nondiabetic
frank breech presentation
*MC*both hips flexedboth knees extendedfrank....s.sdskapos
complete breech presentatin
both hips and knees flexed
incomplete breech
one of both hips are not flexed
MCC c section??
failure to progress in labor!!
what ABX do you give preop c section??
IV Cefazolin!!
tx of vomiting in pregnancy??1dt line1st line med??2md ine ,ed??
1st line--> lifestyle mod--> ginger!!1st line med= PYRIDOXINE (VIT B6) +/- doxylalamine!!2nd line med= meclizine/ dimenhydrinate
stage 1 labor
onset of labor to FULL dilation of cervix (10 cm)
Stage 2 phase of labor
full dilation to delivery of fetus
stage 3 phase of labor
Postpartum until delivery of placenta!!
3 signs of placental separation:
1. gush of blood2. lengthen of umbilical cord3. anterior-cephalad movement of uterine fundus (becomes globular and firmer)
how long does stage 3 labor take??
0-30 min!!
premature rupture of membrane occurs when??
after 38 weeks gestation!!
S/SX premature rupture of membranes??
GUSH OF FLUID/PERSISTENT LEAKAGE OF FLUID
DX PROM??
1. sterile speculum exam= pooling of secretions in posterior fornix2. nitrazine paper test: turns blue if pH>6.53. Fern test: amniotic fluid dries in fern pattern
KOH test tests for...
ODOR!!
labor induction tx??
prostaglandin cervical gel OR oxytocin
PROM complications??
chorioamnionitisendometritis
preterm prelabor rupture of membranes is before ____ weeks??
37 weeks!!
if <34 weeks and PPROM, what do you give??
administer CORTICOSTEROIDS (BETAMETHASONE) to enhance fetal lung maturity!!
when is postpartum depression??
major depression 2 weeks-12 months post partum!!
how to induct labor?
early--> prostaglandin gellater--> IV OXYTOCIN (PITOCIN)
APGAR SCORE!!
Appearance/skin color changes PulseGrimaceActivity (muscle tone)Respiration
MCC postpartum hemorrhage
uterine ATONY!!
PE postpartum hemorrhage??
SOFT FLACCID BOGGY UTERUS w dilated cervix
1st line tx uterine atony??
BIMANUAL MASSAGE + COMPRESSION1st line med= IV oxytocin--> methylergoovine
define PP hemorrhahe
bleeding >500mL if vaginalbleeding >1000mLif c sectio
MC location of ectopic pregnancy??
AMPULLA OF FALLOPIAN TUBE!!
STRONGEST RF OF ECTOPIC PREGNANCY??
PREVIOUS ECTOPIC PREGNANCY!!ALSO hx of PID, IUD use
classic triad of ectopic pregnancy??
1. unilateral pelvic pain/lower abdominal pain2. vaginal bleeding3. amenorrhea+ CERICAL MOTION TENDERNESS
in extopic pregnancy, serum betahcg fails to..
DOUBLE
transvaginal ultrasound results in ectopic pregnancy??
ABSENT GESTATIONAL SAC+++BETA-HCG> 2000
tx stable.unruptured ectopic pregnancy??
METHOTREXATE!!--> destroys trophoblastic tissueif unstable--> laparascopic salpingostomyf/u w serial beta-hcg!!
neoplasm d/t abnormal placental development w trophoblastic tissue??
MOLAR PREGNANCY= GESTATIONAL TROPHOBLASTIC DISEASE
painless vag bleedingpreeclampsia before 20 weekshyperemesis graidarumuterine size and date descrepanciesBETA HCG MARKEDLY ELEVATED >100,000dx?/dx test??tx??
DX: MOLAR PREGNANCYDX TEST: TRANSVAG U/S= "snowstorm"/ "cluster of grapes"TX: Surgical uterine evac= mainstay of tx--> obtain CXR TO LOOK FOR METS= choricarcinoma
in abnormal uterine bleeding, endometrial biopsy should be done in all women >35 y.o. w ...
obesity, HTN, or diabetes, post-menopausal bleeding to r/o cancer!!also need to do betahcg 1st in everyoneeeee
1st line tx of abnormal uterine bleeeidng??definitive tx??
1st line- estrogen-progestin OCPdefinitive= hysterectomy
dysmenorrhea is..
painful menstruation d/t incr prostaglanding 1-2 days before period and resolved within 3 days after onset of menses
1st line med management fo dysmenorrhea??
NSAIDS!!
Premesntrual syndrome s/sx??
physicalemotion: IRRITABILITY!!behavioral
when do sxs occur in PMS??
1-2 weeks before menses (luteal phase)relieves within 2-3 days of onset of mense*NEEED 7 DAYS SX FREE DURING FOLLICULAR PHASE*
1st line med therapy of PMS??
SSRI!!--> flupxetine/sertralne
failure of menses by 15 in presence of secondary sex failure of menses by 13 without secondary sex characteristicsdx??dx test??
NEED TO CHECK HCG AND FSH!!wanna do karyotyping if no secondary sex characteristics to r/o turnersPRIMARY AMENORRHEA!!
secondary amenorrhea define
no menses for >3 months in a pt w previously normal menstruation
MCC secondary amenorrhea??
pregnancy!!
female athlete triad??
hypothalamic amenorrheaeating disorderosteoporosis
leiomyoma is MC in..
AFRICAN AMERICANs
leimoyoma growth is _____ dependent
estrogen
MC sx leimoyooma??
bleeding
PE leiomyoma??
firmnontenderASSYMETRICMOBILE MASS OR MASSES IN ABDOMEN
DX LEIMYOMA??
TRANSVAGINAL U/S= FOCAL HETEROGEINIC HYPOECHOIC MASS W SHADOWING!!
are leiomyoma benign or cancerous??
BENIGN!!
tx sx leiomyoma who want kids??
MYOMECTOMY= preserves fertility
average age of menopause in US??
50-52
most sensitive initial test in menopause??
INCR SERUM FSH>30!!will aslo have incr LH and decr estrogen
if no uterus, tx menopausal sx??
estrogen
if uterus, tx menopausal sxs??
estrogen + progestin
MC menopasua sx??
HOT FLASHES!!
hx menorrhagiahx dysmenorrheaSYMMETRICALLY ENLARGED GLUBULAR BOGGY UTERUS TENDERdx??patho??tx??
dx: ADENOMYOSISETIO: islands of endometrial cells within the myometrium!!TX: total abd hysterectiomy
endometriosis MC site??
ovaries!!
RF endometriosis??
NULLIPARITYprolonged estrogen exposurelate menopauseearkly menarchelate first preganncy
1. cyclic premnstrual pelvic pain2. dysmenorrhea3. dyspareunia. no hx pregnancywomen 25-35 y.o.dX??initial test??definitive diagnosis??
DX: ENDOMETRIOSISINITIA: U/SDEFINITIVE= LAPARASCOPY W BIOPS= CHOCOLATE CYST!!
chocolate cyst on lap dx??
endometriosis!!
1st line tx endometriosis??
combined OCPs!!
MCC uterine prolapse??
childbirth!!
MC type of endometrial cancer??
ADENOCARCINOMA
endometrial cancer mainly affect pre/post menopausal??
POST!!
RF endometrial cancer??
incr estrogen!!--> PCOS/ TAMOXIFEN/ nulliparit/ early menarche
mc sx endometrial cancer??
post menipausal bleeding
definitive dx endometrial cancer??
endometrial biopsy
combo OCPs are protective against what type of CA??
endometrial AND ovarian
what is used to monitor ovarian ca??
CA 125
MC ovarian cysts??
follicular!!
MC type of ovarian CA??
epithelial
genes associated w ovarian cancer??
BRCA1BRCA2
highest mortalit of all gyn cancers??
OVARIAN!!
ovarian torsion DX test initial?? definitive??
initial= U/S w dopplerDefinitive= surgical exploration (laparoscopic exploration w detorsion--> also tx))
ovarian torsion tx??
LAPAROSCOPIC EXPLORATION W DETORSION
PCOS diafnosis labs?
INCR TESTINCR LH : FSH >/= 3:1
PCOS clnical manifestations and PE??
2. menstrual dysfunction2. INCR ANDROGEN= HIRSUTISM/ACNE3. INSULIN RESISTANCE= OBESITY/T2DM4. BILATERAL ENLARGED SMOOTH MOBILE OVARIES; acanthosis nigricans
pelvis ultrasound of pCOS??
string of pearls!!
1st line PCOS??
comboOCPs
if infertile, tx??
clomiphene
hx multiple sex partnersfeverlower abd tenderness, +Cervical motion tenderness (chandelier sign)purulent servical dischargeDX??workuptx??
DX: PELVIC INFLAMMATORY DISEASEWORKUP= 1ST PREGNNANYC TEST; 2ND= NAATTX: IM CEFTRIAXONE + DOXY X 14 DAYSif inpt--> cefoxitin + IV doxy
MCC PID??
chlamydia--> gonorrheahx multiple sex partners, unprotected sex
perihepatitis + PID??
fitz hugh curtislaparoscopy= violin string adhesions
Bacterial vaginosis dx??
+WHIFF AMINE TEST--> fishy odor+ CLUE CELLSCOPIOIS thin, white-grey vag dischargeph>4.5
TX BV??
metronidazole x 7 days *Safe in pregnancy*
copiois frothy green discharge cervical petechiae= strawberry cervixdx??rx??
dx: trichomoniasis *STD*tx: metronidazole!! *NEED TO TREAT PARTNERS vs BV dont need to*
BV is due to overgrowth of..
GARDNERELLA VAGINALIS!!
WHAT supplement do u give in pregnancy to decr neural tube defectS??
folic acid!!