Download Abassi Abdomen ppt: Slide 16 of 87

OB/GYN Study Guide #1
Class 44
1) Type & parts of Pelvis –Difference b/w Male &
Female pelvis. (Batiste Linden)
Abassi Abdomen ppt: Slide 16 of 87
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Four types of female pelvis were described. Actually, the majority of pelvis are of mixed types:
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(I) Gynecoid pelvis(50%) :
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It is the normal female type.
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1. Inlet is slightly transverse oval.
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2. Sacrum is wide with average concavity and inclination.
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3. Side walls are straight with blunt ischial spines.
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4. Sacro- sciatic notch is wide.
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5. Subpubic angle is 90-100o.
Abassi Abdomen ppt: Slide 17 of 87
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(II) Anthropoid pelvis (25%):
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It is ape-like type.
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1. All anteroposterior diameters are long.
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2. All transverse diameters are short.
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3. Sacrum is long and narrow.
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4. Sacro-sciatic notch is wide.
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5. Subpubic angle is narrow.
2) Bartholin’s Duct & Gland Location., Examination ,treatment of
bartolin’s abscess and how it can be prevented.(Lucy
Boyadzhyan)
Abassi Abdomen ppt: Slide 18 of 87
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(III) Android pelvis (20%):
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It is a male type.
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1. Inlet is triangular or heart-shaped with anterior narrow apex.
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Side walls are converging (funnel pelvis) with projecting ischial
spines.
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3. Sacro-sciatic notch is narrow.
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4. Subpubic angle is narrow <900
(#3-Amy ) MENOPAUSE
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The strict medical definition of “Menopause” is the cessation of
menstruation counting 12 months from the last period; it occurs at a mean
age of 51.4 years as a normal development in women. The normal
menopause transition begins with variation in menstrual cycle length (by >
7 days) and an elevated FSH concentration and ends one year after the
final menstrual period.
Physiology of hormones:
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Menopause occurs when ovarian follicular depletion is complete or nearing
completion and ovarian estrogen secretion is absent. As no more eggs are
released, the corpus luteum no longer secretes estrogen and progesterone
during the luteal phase of the ovarian cycle.
(#3) Menopause SYMPTOMS:
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HOT FLASHES are the most common
symptom and occur several times daily and at
night (and may cause insomnia) lasting from
2- 4 minutes starting with a sensation of heat
on the upper chest and face ; they are
accompanied by perspiration and sometimes
palpitations, and may be followed by chills and
shivering, and anxiety. Hot flashes are selflimited and would resolve without tx in 1 to 5
years.
(#3) Other Menopause Symptoms Include:
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Excess Bleeding Patterns: progesterone deficiency with
chronic anovulation may cause longer periods of unopposed
estrogen exposure.
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Oligomenorrhea: Irregular cycle patterns for six or more
months, or an episode of heavy dysfunctional
bleeding…endometrial biopsy is standard of care to rule out
the occurrence endometrial hyperplasia.
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Irregular bleeding (spotting in between periods) or heavy
bleeding during the transition period may be treated with lowdose OCP or intermittent progestin therapy.
(#3) Other Menopause Symptoms Include:
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GU symptoms: Vaginal dryness, dyspareunia and atrophic urethritis
due to these tissues sensitive response to decreased estrogen.
[Localized tx with a lower dose of estrogen or a different estrogen
preparation like a vaginal cream or ring rather than a pill are
available.]
The vaginal wall consists of three layers-the outer adventitia, middle
muscularis of two layers of smooth muscle that facilitate expansion
of the birth canal and the inner mucosa which has no glands but
bears transverse ridges called rugae. Thus, vaginal dryness needs
treatment which includes a long-acting vaginal moisturizer
(Replens) or water-soluble lubricants (Astroglide or K-Y Personal
Lubricant) at time of intercourse to avoid discomfort to the more
delicate tissues.
(#3) Other Menopause Symptoms Include:
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Atrophic urethritis leads to stress and urge incontinence which
can be problematic. Tx with Kegel exercises to strengthen the
surrounding musculature aids in reducing incontinence.
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Osteoporosis: Tx now focuses on exercise, calcium intake of
1500/mg daily and vitamin D 400 to 800 mg IU/daily to
prevent bone loss after menopause.
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Reduced cardioprotective effect in the absence of estrogen
makes women more susceptible to cardiovascular diseases.
(#3) Indications of Hormone Replacement Therapy (HRT):
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Perimenopausal women (average age 40-50): who seek
symptomatic relief and contraception may be TX with lowestrogen oral contraceptive (20 mcg of ethinyl estradiol); when
these women reach 51 years of age they are recommended to
either 1. Stop the pill altogether…by tapering the OCP by one
pill per week. OR 2. Change to an estrogen replacement
regimen if necessary for symptoms.
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HRT has risks and benefits; estrogen prevents bone loss and
fractures, yet, it is not cardioprotective-in fact it slightly
increases risk. Furthermore, risks seen with combination HRT
include increased risk of stroke, venous thromboembolism,
heart attacks and breast cancer.
(#3) Indications of Hormone Replacement Therapy (HRT):
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In Menopause, estrogen remains the gold standard for relief of hot
flashes and other menopause symptoms and the absolute risk for adverse
events is reported to be extremely low.
Therapy is short-term from 6 months to less than 5 years.
Because unopposed estrogen therapy in a woman with a uterus is known to
cause endometrial hyperplasia and cancer after a period of six months
ADDING A PROGESTIN is necessary.
Women with a history breast cancer, CHD, previous venous
thromboembolism or stroke have an increased risk for adverse events
on HRT and there are alternatives for some of their symptoms: Hot
Flashes may be alternatively be treated with:
venlafaxine 75 mg/daily OR gabapentin 200mg/daily to 400mg/ 4x daily
Abbasi (Powerpoint 86 of 87): Additionally, low doses of antidepressants
such as paroxetine (Paxil), venlafaxine (Effexor) and fluoxetine (Prozac),
or clonidine, which normally used to control high blood pressure may be
used for women concerned with such vasomotor symptoms.
(#3) Menopause Treatment Regimen:
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HRT preparations:
Combined, continuous conjugated estrogens
(0.625 mg) and medroxyprogesterone acetate
(MAP 2.5 mg) is commonly used.
However, LOWER dose estrogen is a better
option (eg, 0.3 mg conjugated estrogens or 0.5
mg estradiol).
(#3) Menopause SIGNS & TESTS
(Abbasi powerpoint 81 of 87)
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Blood and urine tests can be used to measure
hormone levels, for e.g.:
Estradiol, FSH, LH; these levels indicate where in
the menopause transition a woman may be.
Pap smears allow visualization of the vaginal lining
and subtle changes caused by decreases in estrogen
levels.
Bone density testing (DEXA scanning) may be
performed to screen for low bone density levels seen
with osteoporosis.
4) Physiology of Menstruation. Ovulation LH/FSH surge ,signs of
ovulation. What is corpus luteum & its significance.(Espinoza
Celia)
Abassi Abdomen ppt: Slide 19 of 87
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(IV) Platypelloid pelvis (5%):
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It is a flat female type.
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All anteroposterior diameters are short.
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2. All transverse diameters are long.
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3. Sacro-sciatic notch is narrow.
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4. Subpubic angle is wide.
4) Physiology of Menstruation. Ovulation LH/FSH surge ,signs of ovulation.
What is corpus luteum & its significance.(Espinoza Celia)
4) Corpus luteum (continued)
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The corpus luteum: is a temporary endocrine structure involved in production of progestogen, which
is needed to maintain the endometrium.
The corpus luteum develops from an ovarian follicle during the luteal phase of the menstrual cycle or
estrous cycle, following the release of a secondary oocyte from the follicle during ovulation. The follicle
first forms a corpus hemorrhagicum before it becomes a corpus luteum, but the term simply refers to the
visible collection of blood left after rupture of the follicle and has no functional significance. While the
oocyte (later the zygote) traverses the Fallopian tube into the uterus, the corpus luteum remains in the
ovary.
The corpus luteum is typically very large relative to the size of the ovary; in humans, the size of the
structure ranges from under 2 mm to 5 mm in diameter.
The corpus luteum is essential for establishing and maintaining pregnancy in females.
In the ovary, the corpus luteum secretes estrogens and progesterone, which are responsible for the
thickening of the endometrium and its development and maintenance, respectively.
The corpus luteum secretes estrogen and progesterone that inhibit LH and FSH
If the egg is not fertilized, the corpus luteum stops secreting progesterone and decays (after approximately
14 days in humans). It then degenerates into a corpus albicans, which is a mass of fibrous scar tissue.
The uterine lining sloughs off without progesterone and is expelled through the vagina. In an estrus cycle
(sexually receptive) , the lining degenerates back to normal size.
If the egg is fertilized and implantation occurs, the trophoblast cells of the blastocyst secrete the hormone
human chorionic gonadotropin (hCG).
hCG signals the corpus luteum to continue progesterone secretion, thereby maintaining the thick lining
(endometrium) of the uterus and providing an area rich in blood vessels in which the zygote(s) can
develop. From this point on, the corpus luteum is called the corpus luteum graviditatis.
The introduction of prostaglandins at this point causes the degeneration of the corpus luteum and the
abortion of the fetus. However, the placenta eventually takes over progesterone production and the corpus
luteum degrades into a corpus albicans
4) Physiology of Menstruation. Ovulation LH/FSH surge ,signs of
ovulation. What is corpus luteum & its significance. continued
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Ovulation is the release of a single, mature egg from a follicle that developed in the ovary. It usually occurs
regularly, around day 14 of a 28-day menstrual cycle. Once released, the egg is capable of being fertilized
for 12 to 48 hours before it begins to disintegrate.
Signs of ovulation can be any of the following, although many women may only notice 1 or 2 of these:
• Change in cervical fluid
• Change in cervical position and cervical firmness
• Brief twinge of pain or dull ache that is felt on one side of the abdomen
• Light spotting
• Increase in sex drive
• Elevated level of the luteinizing hormone which can be detected on a test
• Body temperature chart that shows a consistent change: Just after ovulation, there should be a rise
of approximately 0.4-0.6 F (about 0.2 Celsius). The day of ovulation there will be a slight rise. The
following two days will climb progressively higher. The rise on the day of ovulation is not
distinguishable from the normal ups and downs in the entire pre-ovulatory phase. It is only
recognized in retrospect when it forms an upward line with the two days afterward. The postovulatory tempertures remain at this new, higher level, until menses when they drop and start the
cycle over again. Again, it is only useful when a woman tracks several of her cycles and (if they are
regular) she will be able to determine when she will ovulate.
• Breast tenderness
• Abdominal bloating
• Heightened sense of vision, smell or taste
5) Evaluation of lump in the breast such as fibro adenoma ,fibrocystic
diseases& carcinoma of Breast.(Burguez Edgar)
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The typical case is the presence of a painless, firm, solitary, mobile, slowly growing
lump in the breast of a woman of childbearing years.
Fibroadenomas arise in the terminal duct lobular unit of the breast. They are the
most common breast tumor in adolescent women. They also occur in a small
number of post-menopausal women. Their incidence declines with increasing age,
and they generally appear before the age of thirty years, probably partly as a result
of normal estrogenic hormonal fluctuation. Although fibroadenoma is considered a
neoplasm, some authors believe fibroadenoma arises from hyperplasia of normal
breast lobule components.
Most fibroadenomas are treated by surgical excision. They are removed with a
small margin of normal breast tissue if the preoperative clinical investigations are
suggestive of the diagnosis. A small amount of normal tissue must be removed in
case the lesion turns out to be a phyllodes tumour on microscopic examination.
Fibroadenomas have not been shown to recur following complete excision or
transform into phyllodes tumours following partial or incomplete excision.
5) Fibrocystic Diseases
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It is called puerperal mastitis when it occurs in lactating mothers and nonpuerperal otherwise. Inflammatory breast cancer has symptoms very similar to
mastitis and must be ruled out.
The symptoms are similar for puerperal and nonpuerperal mastitis but predisposing
factors and treatment can be very different.
Puerperal mastitis
 Puerperal mastitis is the inflammation of breast in connection with pregnancy,
breastfeeding or weaning. It is caused by blocked milk ducts or milk excess. It
is relatively common, estimates range depending on methodology between 533%. However only about 0.4-0.5% of breastfeeding mothers develop an
abscess.
Nonpuerperal mastitis
 The term nonpuerperal mastitis describes inflammatory lesions of the breast
occurring unrelated to pregnancy and breastfeeding. Skin related conditions
like dermatitis and foliculitis are a separate entity. Names for non-puerperal
mastitis are not used very consistently and include Mastitis, Subareolar
Abscess, Duct Ectasia, Periductal Inflammation, Zuska's Disease and
others.
5) Carcinoma of Breast
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Breast cancer is a cancer that starts in the breast, usually in the inner lining of the milk ducts or lobules.
There are different types of breast cancer, with different stages (spread), aggressiveness, and genetic
makeup.
The first symptom, or subjective sign, of breast cancer is typically a lump that feels different from the
surrounding breast tissue.
Indications of breast cancer other than a lump may include changes in breast size or shape, skin dimpling,
nipple inversion, or spontaneous single-nipple discharge.
When breast cancer cells invade the dermal lymphatics—small lymph vessels in the skin of the breast—its
presentation can resemble skin inflammation and thus is known as inflammatory breast cancer (IBC).
Symptoms of inflammatory breast cancer include pain, swelling, warmth and redness throughout the breast,
as well as an orange-peel texture to the skin referred to as peau d'orange.
In a clinical setting, breast cancer is commonly diagnosed using a "triple test" of clinical breast examination
(breast examination by a trained medical practitioner), mammography, and fine needle aspiration cytology.
Both mammography and clinical breast exam, also used for screening, can indicate an approximate
likelihood that a lump is cancer, and may also identify any other lesions. Fine Needle Aspiration and
Cytology (FNAC), which may be done in a GP's office using local anesthetic if required, involves
attempting to extract a small portion of fluid from the lump. Clear fluid makes the lump highly unlikely to
be cancerous, but bloody fluid may be sent off for inspection under a microscope for cancerous cells.
Together, these three tools can be used to diagnose breast cancer with a good degree of accuracy.
6) Diagnostic modalities in breast diseases. Such as Triple screen tests
etc(Dinh y Nha)
7) Breast Cancer ,predisposing factors ,screening tests and its management
(gasparyan Svetlana)
8) Specific types of menstrual problem, Causes & its workup.( Luwam Ghebreab)
9) When you will use different modalities of treatment in an adolescent girl and
negative pregnancy test such as Reassurance, Low dose OCP & Inj
Estradiol ( Pamela Hardine)
10) In ER, what would be your approach in an adolescent girl bleeding profusely
as per my lecture such as history, Examination ,Tests & Treatment
(Trelayne Maitre)
11) Estrogen –Use of Oral & Injection estrogen in controlling bleeding in DUB(
.Luz Herrera)
12) What is your diagnosis for question #11?
"Erwin Hernandez"
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a) Cardiogenic shock
b) Septic shock (I think this is the answer)
c) Neurogenic shock
d) Hypovolemic shock (not sure if this was
one of the choices)
13) Causes of Nipple discharge such as medications etc & its work up (Sara
Golfeiz).
14) Causes of tender breast ( Mastalgia) & its management such as as
engorgement of breast after delivery of baby.(PhamTrang)
15) Complications of PID in terms of severity and its management. ( Jemison
Bridget)
16) D/d of acute febrile conditions in a young menstruating lady.. Its work up
,prevention &management.( Aisha Syed)).
17) D/d of Acute abdominal pain in a young non pregnant lady.(Ana Nazaryan)
18) Causes & Treatment of Tubo-Ovarian Abscess( TOA) (Monica Lara)
19) What is the relationship of OCPs with STDs. & why –(Sima Patel)
20) Why adhesions develop after treatment of STDs leading to
infertility and how it can be prevented..( lakmali )
21) Indications of Metronidazole in STDs & How metronidazole cab be
used in clinical practice in different conditions .Interactions &
side effects.( Erwin Hernandez)
22) Causes of Dyspareunia and its work up.? (Ushie Ada)
23) Characteristic of True pelvis and how it should be analyzed.(
Pierre Keltzey)
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The true pelvis, or lesser pelvis, is that part of the pelvic cavity
which is situated below and behind the pelvic brim. The majority of
pelvis are of mixed types: gynecoid, anthropoid, android, and
platypelloid.
Gynecoid: Normal female type.
Inlet is slightly transverse oval, sacrum is wide with avg.
concavity and inclination, side walls are straight with blunt ischial
spines, sacro- sciatic notch is wide, subpubic angle is 90-100o.
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Anthropoid: Ape-like type.
All anteroposterior diameters are long, all transverse diameters
are short, sacrum is long and narrow, sacro-sciatic notch is wide,
subpubic angle is narrow.
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Android: Male type.
Inlet is triangular or heart-shaped with anterior narrow apex, side
walls are converging (funnel pelvis) with projecting ischial spines,
sacro-sciatic notch is narrow, subpubic angle is narrow <90o.
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Platypelloid: Flat female type.
All anteroposterior diameters are short, all transverse diameters
are long, sacro-sciatic notch is narrow, subpubic angle is wide.
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Its bony walls are more complete than those of the greater pelvis. It
is divided into a pelvic inlet bounded by the superior circumference,
and pelvic outlet bounded by the inferior circumference, and a
cavity of the lesser pelvis.
From this description it will be seen that the cavity of the lesser
pelvis is a short, curved canal, considerably deeper on its posterior
than on its anterior wall that contains the pelvic colon, rectum,
bladder, and some of the organs of generation; on the female the
uterus and vagina occupy the interval between these viscera.
24) What is the significance of relationship of Ureter with Uterine
vessels? How it Ligation of ureter should be prevented in
surgery.(Mohammad Naghibi)
25) GnRh – what are its effects & its therapeutic indications in clinical
practice.( Jade Small)
26) Menarche –Early vs. Delayed menarche ,how would you counsel in
a constitutional delay of menarche ( Kimberly troiter)
27) What is Asherman’s syndrome , Causes & Prevention (Manuel
Tovar)
28) Management Of Peritonitis in a patient of PID-Step by
Step(Ricardo Vega)
29) What is the role of Hypothalamic –Pituitary system in
DUB(Sangmoah John)
30) Different Ligaments of Uterus and from which ligament the
sensory pain fibers pass through.(Adrian Orellano)
31) Indications of hospitalization in patients of STDs. What are
empirical treatment in STDs.(Ogonna olelewe)
32) Hormonal dependent tumors in breast & Uterus .How it should be
monitored in
Different situations ( Riley Rachel)
33) Pregnancy test ,What is its importance in the management of DUB
and how would take consent from the patient( Phou seng)
34) Parts & positions of uterus & its clinical significance( Veronica
ratevosian)
35) Pelvic Diaphragm & Levator Ani and what are its importance in
child birth (Charles Sangmoah).
36) Types of Perineal Tear and how it should be prevented .Do you
think patient may file a lawsuit .(Kim ngo)
37) What is Episiotomy, its types and complications? (G Lo)
38) Issues of privacy & confidentiality in treating STDs and in
managing pregnancy and its related complications.( Maryam
Moffrah)
39) Menstrual related Problems such as Dysmenorrheal and how would
you differentiate Primary Vs Dysmenorrheal. (ROBERT
INZUNZA)
40) Causes of Amenorrhea (acquired) & its evaluation. (JAIME M)
41) Causes of perimenopausal /menopausal women and its work
up.(Matera Joseph)
42) Post coital bleeding in a young girl .Evaluation & work up.(Murphy
Makel)
43) Pap smear –Indication, Interpretation & Treatment. ( Shane
malang)
44) Uterine Fibroids – Manifestation ,Dx and treatment options in
different patients(Jerry Love)
45) Endometriosis Manifestation ,Dx and treatment .(Alexis Manneh)
46) Screening of breast & Ovarian cancers in families( William
Ngamfon)
47) Early detection & prevention of Cervical Cancer.(Maral Manachan)
48) Unilateral breast mass in a young pregnant lady its Evaluation &
work up.( Jennifer lam)
49) Toxic shock syndrome ,Prevention ,Dx & treatment (Augestine
kehinde)
50) Pap Smear in low risk vs. High risk population.
Explain
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What is a Pap Smear
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A Pap smear (also known as the Pap test) is a medical
procedure in which a sample of cells from a woman's
cervix (the end of the uterus that extends into the vagina) is
collected and spread (smeared) on a microscope slide. The
cells are examined under a microscope in order to look for
pre-malignant (before-cancer) or malignant (cancer)
changes.
50. (cont.) Low Risk Patients
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When to start
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3 years after vaginal intercourse, no later than age 21
Frequency of Pap smear testing
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Yearly with exceptions:
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every 2 years if liquid-based kit
every 2-3 years if three normal tests in a row in women >30
years old
At what age to stop having Pap smears
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Total hysterectomy for benign disease
> 70 years old with at least three normal Pap smear results and
no abnormal Pap results in the last 10 years (American Cancer
Society 2004)
50. (cont.) High Risk Patients
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HPV: The principal risk factor is infection with the genital wart virus, also called the human papillomavirus
(HPV), although most women with HPV infection do not get cervical cancer. About 95%-100% of cervical
cancers are related to HPV infection. Some women are more likely to have abnormal Pap smears than other
women.
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Smoking: One common risk factor for premalignant and malignant changes in the cervix is smoking.
Although smoking is associated with many different cancers, many women do not realize that smoking is
strongly linked to cervical cancer. Smoking increased the risk of cervical cancer about two to four fold.
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Weakened immune system: Women whose immune systems are weakened or have become weakened by
medications (for example, those taken after an organ transplant) also have a higher risk of precancerous
changes in the cervix.
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Medications: Women whose mothers took the drug diethylstilbestrol (DES) during pregnancy also are at
increased risk.
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Other risk factors: Other risk factors for precancerous changes in the cervix and an abnormal Pap testing
include having multiple sexual partners and becoming sexually active at a young age.
What is Pelvimetry & Cephalo Pelvic
Disproportion-CPD?
Tabers 2009
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Pelvimetry: Measurement of the diameters of the pelvis.
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CT pelvimetry. procedure for measurement of the bony pelvis and fetal head
through use of CT images; currently the more accurate imaging technique.
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manual pelvimetry. measurement of the essential diameters of the bony pelvis
using the hands.
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radiographic pelvimetry. procedure for measurement of the bony pelvis and fetal
head using anteroposterior and lateral radiographs, with a device for the correction
of magnification.
Wikipedia
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Cephalo-pelvic disproportion exists when the capacity of the pelvis is inadequate
to allow the fetus to negotiate the birth canal. This may be due to a small pelvis, a
nongynecoid (see below) pelvic formation, or a large fetus, and combinations of
these. Certain medical conditions may distort pelvic bones, such as rickets or a
pelvic fracture, and lead to CPD.