Exam 1

Benign Breast Disease:

Most common; occurs 30-50 yrs

Types:

• Fibrocystic disease: nonproliferatives

  • NO cancer r/x

• Fibroadenoma: Proliferative w/out atypia

  • Slight cancer r/x

• Lobular carcinoma in situ (LCIS): Proliferative w/atypia

  • High r/x

Fibrocystic (FCD):

Most common benign condition

• Premenopausal (30-50) → hormones flunctuate (estrogen + progesterone) → breat tissue changes → symptoms can flunctuate

• Fibrosis + cyst formation

• Does NOT ^ cancer r/x

R/x:

• Family h/x

• Diet, ETOH, Activity lv, Obesity

• HIgh inflammatory foods:

  • Sat, Trans fats

  • Fried foods & High-glycemic carbs

• Hormone replacement therapy

  • Oral contraceptives may be protective

D/x:

• Clinical examination → Mammography/US/MRI → possible biopsy

Fibrocystic Disease s/s & t/x

Pain + tenderness + swelling + nodularity; CYCLICAL

• Breast pain, discomfort, tender, swelling

• Nodularity & Bumps

T/x: Managing s/s & improving comfort

• Comfort:

  • Well-fitted bra

  • Analgesics: Ibuprofen or Tylenol

• Diet:

  • Low sat, fat, caffeine, comple carb diet

• Hormones:

  • Consider oral contraceptives

  • Changing hormone replacement therapy

• Supplements:

  • Flaxseed

  • Monk’s pepper

  • Black cumin oil

BI-RADS 🩻

0 → Nothing

2 → Benign

• FCD is an example

3 → Probably bening

4 → Suspicious

5 → Likely cencer

6 → Cancer w/proven biopsy

Breast d/x tools:

Mammography: low dose X-ray → detect abnormalities

US

• average-risk

MRI:

• High risk patients for cancer

Biopsy

Fibroadenomas

Most common benign breast tumor

• 17-35; proliferative w/out atypia

• Influenced by estrogen → common during high exposure like:

  • Pregnancy, Estrogen RT, Before menopause

S/s:

• Nontender + Well-defined + mobile, palpable mass

• Varies in size

D/x:

• US: GOLD-standard

• Definitives →

  • COre-needle biposy

  • Excision

T/x:

• Excision/Lumpectomy when:

  • Presents with significant manifesations

  • Rapidly growing (>3-4cm)

• Cryoablation: liquid nitrogen used

Mastitis:

Inflammation/infection of breast tissue

Lactational: during breastfeeding → n1pple breaks → staph. aureus enters

• w/in 3 months of birth

R/x:

• Anything promoting milk statis or n1pple injury

  • Overproduction of milk

  • Inadequate emptying → milk stasis

  • Nipple trauma

  • Previois mastitis h/x

Nonlactational:

• Periductal mastitis: in aerola

  • Smoking or Obesity

• Granlomatous mastitis: more concerning

  • Palpable mass, pain

  • Skin ulcerations, milky discharge

---

D/x:

• US

• Incision & drainage or aspiration required for abscess

  • After it is cultured → i/x

• If severe infection → Blood cultures

• Breast milk culture:

  • For severe infections or when pt is not responding to t/x

Mastitis Clinical Presentation & T/x:

Erythema → redness + Warm + Painful + Swollen + Sick/Malaise

May lead to:

• Abscess → sepsis

T/x:

• continue emptying the breast for lactational mastitis

• Before feeding, apply a warm compress to promot milk flow → after feeding → cold compress → reduces pain and inflammation

• NSAIDs may be used → Pain

How do you prevent lactational breast infections?

Perform hand hygiene before touching breasts

Treat nipple cracks/sore

Keep breasts clean between feedings

Hydrate, probiotics

Breast Cancer:

Carcinoma: from epithelial cells of ducts and lobules

• Lobules: produce milks → ducts: carry milk to nipple

& Sarcoma

R/x:

• Nonmodifiable:

  • Family h/x

  • Age at menarche or menopause

  • Parity

• Modifiable:

  • Alcohol and Diet

  • Exercise and Excess weight after menopause

  • Red m3at

D/x:

• US → Mammography → MRI

• Definitive d/x → Core-needle biopsy

Breast cancer s/s & t/x:

Pailness + solid + immovable + irregular borders

Advanced s/s:

• Swollen axillary lymph nodes

• Skin dimpling “Peu de orange”

• Nipple retraction

• Erythema & skin thickening

t/x:

• Lumpectomy

• Mastectomy

• Radiation Therapy, Chemo

Types of Breast Cancer:

Carcinoma in situ

Invasive carcinoma

• Invasive Ductal Carcinoma: most common

• Invasive lobular carcinoma

Genetic Factors that ^ r/x of breast cancer

BRCA1 & BRCA2

• These genes suppress tumors; alterations causes them

What does genetic testing help with?

Identifying genetic risk

• Allows better screening recs, awareness, and risk factors

Who is at an increased risk for breast cancer:

>20%:

• BRCA mutation

• Previous chest radiation when 10-30 years of age

• Hereditary syndromes:

  • Li-Fraumeni syndrome:

  • Cowden syndrome:

  • Bannayan-Riley-Ruvalcaba syndrome:

What is Pelvic Organ Prolapse?

pelvic organs move downard and bulge into vagina

Types:

• Uterine Prolapse

• Cystocele: Bladder

  • “Anterior vaginal wall prolapse”

  • s/s:

    • Incontinence, frequency, diff. emptying

• Rectocele: Rectum herniates to vagina

  • “posterior vaginall wall prolapse”

  • S/s:

    • Constipation, issues emptying bowel

D/x:

• Histroy + Physical exam

  • Speculum, Bimanual, Rectovaginal

POP r/x:

Age, Menopause, Obestiy, Parity, Smoking, Large Baby

PREGNANCY AND CHILD BIRTH

• 1 baby = 4x risk

• 2 babies = 8x risk

^ intra-abd psi (chronic constipation)

Connective tissue disorders

POP s/s & t/x

Vaginal pressure or sensation

Cystocele:

• Incontinence, Frequency, poor emptying

Rectocelle:

• Constipation, poor emptying

Sexual effects:

• Urinary/Fecal incontinence during intercourse → embarassement → v QOL

T/x:

Edu:

• Good weight, weight loss

• Hydration, avoid heavy lifting

• Kegel:

1. I/x pelvic floor muscles

2. Squeeze them

3. Hold for 3 secs

4. Release & releax

5. Repeat 10-15x/day → 3 sessions in a day

6. Do when standing, sitting, lying down

• Pelvic floor PT

Vaginal Pessary: device put inside vagina to support prolapsed organ

• Many types to accomodate needs of patient

Pelvic Floor PT:

• Pelvic muscle strengthening, Biofeedback, Core strengthening

• Helps v pain, degree of prolapse, ^ stability

• If fails → possible surgery

Genital Fistulas:

Abnormal connection between organs

Types:

• Vesicovaginal: Bladder w/vagina

  • urine

• Urethrovagina

  • urine

• Rectovaginal

  • Poopie and gas leaks

Fistula r/x & D/x:

Vesico/Urethral:

• Congenital anomaly

• Pelvic surgery complications

• Trauma, Cancer, RT, PID, Diverticulitis

• Labor complications

Rectovaginal:

• Congenital anomlies

• Traumatic birth

• Chrons

• Preianal sepsis

D/x:

• Pelvic exam

• Cytoscopy

• MRI

• Flexible Sigmoidoscopy

• Dye Test:

  • Sterile Dyed fluid → Bladder → cough & bear down or use tampon → Checks dye in vagina

Fistula s/s & t/x

Urine, Feces, Gas through vagina

May lead to:

• Recurrent UTI’s, Vaginal Infections

• Poor body image, Sexual issues → v QOL

Hygiene:

• Keep clean, dry, and use absobent underwear or inconitinence pads

  • v Odor, ^ comfort

T/x:

• Surgery based on type and pt’s preferences

Ovarian Cysts & Fibromas

FLuid filled scas on or within ovary

• common & benign

• Most durign premenopause

Types:

• Follicular Cyst

  • MOST common & no s/s

  • Follicle → releases eggs in ovulation → egg remains in follicle → cyst formation

• Corpus Luteum Cyst:

  • Corpus leteum continues growing → cyst fomation → resolves on its own

• Dermoid Cyst: “Mature teratoma”

  • Benign germ cell tumors

  • Comefrom reproductive cells and develop later in fetus; may have:

    • Teeth, Bone, Hair, Glands

• Ovarian Fibroma:

  • Firm, White, Benign, made with Fibrous Tissue

  • Sex cord-stromal tumor

  • Happens often with postmenopause women

Ovarian Cysts & Fibromas s/s & d/x:

Most are asymptomatic

S/s:

• Pelvic pain, pressure/fullness

• GI discomfort, Issue with Urination

• Dysmenorrhea or Dyspareunia

• Fever

IF RUPTURED CYST → sudden/sharp pain

Worsening s/s:

• Sudden pelvic pain, ^ BP, bloating

• N/V, Abnormal uterine bleeding

D/x:

• Physical exam

  • Size, Shape, Mobility

• Labs:

  • Pregnancy test (hCG)

  • CBC

• US or CT

Ovarian Cysts & Fibromas t/x:

t/x:

• Combined estrogen-progestin oral contraceptives (COCs) for recurrent/painful cysts

  • estrogen + progestin → X ovulation → cervical mucus, endometrial tissue, & tubal transport changes → treats follicular cysts

  • A/E: at ^ r/x when smoking

    • N/V, appetite changes → ^ Weight

    • Abd cramps/blioating, larger/tenderer breasts

    • v libido, darker facial skin

  • Report any vision changes, thromboemboilism s/s, depression, or anbnormal bleeding to Provider

• Surgery mostly for:

  • Ovarian fibromas, torsion

  • Large dermoid cysts

  • Symptomatic masses

Polycystic Ovary Syndrome (PCOS); patho, r/x, d/x

Metabolic disorders in females (most common)

• Ovary dysfunction + Androgen excess + Polycystic ovaries

R/x:

• Obesity, Insuline resistance, T1DM, Gestational DM

• Premature adrenarche, 1st degree family h/x

• Valproate

D/x:

• Labs:

  • Serum androgen, testosterone

  • 17-hydroxyprogesterone

  • Sex-hormone binding glubulin

• Helps rule out Oligomenorrhea/ovulation

• Transvaginal US: shows large ovary w/small peripheral cysts

PCOS s/s & t/x:

Reproductive:

• Anovulation

• Irregular periods,

• Hirstuism, Acne

• Androgenic alopecia

Systemic:

• Insulin resistance → DM

• Sleep apnea, Fatty liver

• Depression

• HTN

• Dyslipidemia

T/x:

• v effects of excess androgen + Improve reproductive function + v Long term risks (T2DM or CV disease)

  • COC ONLY DONE if pt does not want to get pregnant

    • Regulates period cycle & v androgen

  • Balanced diet & exercises

  • Meformin: used when insuline resistance present

    • v resistance, v androgen production, regulates cycle

    • A/E;

      • N/V, Diarrhea, Gas

      • Heatburn, Headaches, v energy

      • Lactic acidosis

    • TAKE WITH MEALS and monitor HgA1C 2x/year

Uterine Anomalies:

Endometrial Polyps:

• Overgrowth of tissues in endometrium

• Mosty benign BUT may ^ r/x of endometrial cancer

Leiomyomas: “Fibroids”

• Common benign tumors that come from uterine smooth muscle

• Come from round ligament

R/x:

• Endometrial:

  • Older age, Obesity, HRT

  • Tamoxifen

• Leiomyomas:

  • 30-50

  • Obesity, Insulin resistance, HTN, ^ lipids

  • Smoke, v activity, ETOH, Caffeine

  • VD v

  • (^ risk for PCOS)

D/x:

• Endometrial

  • Pelvic US or Biopsy

• Leiomyomas:

  • US

  • MRI: most accurate

Uterine Anomalies: s/s & t/x

Endometrial polyps:

• Asymptomatic OR AUB that is spotting and has mid-cycle bleeding

Leiomyomas:

• Asymptomatic or

• AUB, Pelvic pain, Bowel & Bladder changes

• Low back pain, Dyspareunia

T/x:

• Endometrial:

  • Should be removed to prevent endometrial cancer

  • Polypectomy w/hysteroscopic guidance

• Leiomyomas:

  • If they want to be pregnant → COCs, NSAIDs, Hormone therapy, Myomectomy (preserves uterus)

  • Hysterectomy, Uterine Artery Embolization, MRgFUS

• Tamoxifen: selective estrogen receptor modulator

  • Blocks estrogen activity in breast to prevent estrogen-sensitive tumor formation

  • A/E:

    • Vision changes → regular eye exams

    • Thromboemolic events

Malignant Gynecological Neoplasms:

Many different tumors and where they orgiginate:

• Endometrial cancer

• Ovarian cancer

• Cervical cancer

• Vagina cancer

• Vulvar cancer

Endometrial Cancer:

R/x:

• Estrogen Hormone Therapy

• Obesity, Older age

• Chronic anovulation

• HTN

• DM

• Tamoxifen

Genetic R/x:

• Lynch syndrome

• BRCA1/BRCA2 mutations

• Cowden syndrome

S/s:

• AUB

D/x:

• Histological evaluation of endometrial tissue

  • Via biopsy or hysterectomy specimen

Ovarian Cancer:

R/x:

• Older age

• Family h/x

• BRCA1/BRCA2 mutations

• Lynch syndrom

• Nulliparity/Infertiliy

• Endometriosis

S/s:

• Early on → asymptomatic

• Abd pain, bloating, N/V, Anoreixa,

• Early satiety

• Urgency, frequency

• POSSIBLE Abd mass

D/x:

• elevated CA-125 which is a tumor marker

  • D/x this and checks response to t/x

    • May also be elevated w/

      • Fibroids

      • Menstruation

      • Pregnancy

      • Endometrial cancer

What happens during advanced ovarian cancer?

Ascities → Pleural effusion → SOB

DVT, Bowel Obstruction

EMERGENCY T/x

Cervical Cancer:

HPV is deteced in 99.7% of this cancer

• Due to HPV infection

R/x:

• HPV related:

  • Early sexual activity

  • Multiple rizz, STI h/x

  • Early age at first birth

  • Immunosuppressed

• Non-HPV related:

  • SDOH + Smoking

  • COC

  • Genetics

S/s:

• Irregular, Heavy vaginal bleeding

• Bleeding after s3xual intercourse

• May be Asymptomatic

D/x:

• Pap test

• HPV testing

• Colposcopy → biposy → histological evaluation

Vaginal Cancer:

Rare; metastases from another organ

Possible other sources:

• Uterus, Ovary, Kidney, Breast

R/x:

• HPV infection

• Cervical cancer h/x

S/s:

• Asymptomatic

• Bleeding after rizzing, postmenopause bleeding

• Watery, bloody, foul-smelling discharge

• Vaginal mass

Vulvar cancer

Very rare, linked with 65-74 yrs or HPV infection

R/x:

• Vulvar neoplasia, vulvar lichen sclerosus

• H/x, Smoking

• Immune system v

• Northen Europe

S/s:

• Vulvar lesions, itching, and bleeding

• Rarer:

  • Groin lymphadenopathy, rectal bleeding

  • Low-exremity bleeding

  • Dysuria, poor ability to have bowel movements

Nursing Care for Gynecological Cancer

A/x:

• Abd mass, swelling

• Pain after rizzing

• Urinary s/s

• AUB, N/V, v weight

Diagnostic support

T/x support

• Aid with chemo, Radiation therapy, surgery

Amenorrhea

May be from dysfunction in:

• Hypothalamus, Pituitary, Ovaries, Uterus, Vagina

Primary: never had a period by 15

Secondary: had but stopped

• Pregnancy

Functional Hypothalamic Amenorrhea (FHA):

• Stress + Exercise + v Weight → slower hypothalamus reproductive function →amenorrhea

amenorrhea may be a precursor to PCOS or FHA

• FHA clues:

  • <18 BMI, Hair loss, Dental enamel erosion

D/x:

• LH + FSH → distinguish causes

  • v = FHA

  • high = primary ovarian insuffiiceincy OR Turner syndrome

• TSH + free T4 → thyroid disease (hypo/hyper)

• Testosterone → PCOS

• Estraiol → v = hypogonadotropic hypogonadism

• Prolactin → pregnancy, prolactinoma, hyperprolactin, CNS tumors

Amenorrhea nursing care

FHA: restore health

• Nutrition, lower excessive exercise, therapy

Dysmenorrhea

Increased prostaglandings → contraction → pain

• endometriosis and uterine fibroids may cause this

• Begin at the start of menstruation → lasts 1-3 days

S/s:

• Lower abd cramping, lowerback and thigh pain

• N, Diarrhea, Dizzy, Headache

• Fatigue → Poor sleep

• Food cravings

D/x:

• H/x + Physical A/x

• Pelvic US

T/x:

• NSAIDs → v PG production → v pain

  • Take as soon as s/s beign

• Hormonal birth control

  • COC, Vaginal ring, IUD → All thin endometrial lining → PG v → v cramps

• Heat, exercise, Yog, Acupuncture

AUB:

C/x:

• Structural:Polyps, Endometriosis, Fibroids, Cancer

• Nonstructural: Hormones, Ovulation, Meds, Infection

S/s:

• Soaking pad/tampon q/1-3hrs

• Bleeding >1wk

• Blood clots >2.5 cm

• Anemia

• Abnormal cycles

• Dyspareunia, Pevlic pain → Infertile

D/x:

• CBC → Anemia/Infection

• HcG → pregnancy

• Hormones

• US

• Endometrial biopsy

T/x:

• COCs, IUD

• NSAIDs, GnRH meds, Oral progestins

• Antifibrinollytics

• Endometrial ablation, Hysterectomy

Regular Menstruation cycle

Every 24-38 days & for <7 days

Progestin:

Changes endometrium, X follicle maturation & ovulation

• good for AUB

• A/E:

  • Abd pain, bloating,

  • Mastalgia, tenderness

  • Depression, Dizzy, Headache

  • MK pain

• Avoid if Liver impairment

Tranexamic Acid

Antifirbirnolyics → X fibronylisis → Prevent blood clot break down → v bleeding

• For nonacute AUB

• A/E:

  • Thromboembolism

  • Hypersensitivity

  • clots →Vision change, Seizures

• AVOID use if:

  • DVT, DIC, COC use

Endometriosis:

Chronic inflammation → endometrial tissue growth OUTSIDE uterus

• Endometrial tissue extra → Hormone stimulation → thicker tissue → breaks down → bleeds → inflammation + pain

R/x:

• 25-35 yrs (reproductive years)

• Abnormal cycles, tall, low BMI, nulliparity

S/s: severity of symptoms does NOT indicate that disease is severe

• Dysmenorrhea

• Chronic pelvic

• Dyspareunia

• Infertility

• AUB, low back pain

• GI/GU issues

D/x:

• Biopsy, US

T/x:

• Assess first

• Heating pads, warm bath, massage, yoga

• COCs, GnRH agonists, NSAIDs

• Surgery when other means unsuccessful

  • Ablation

Leuprolide:

GnRH agonist → blocks Gonadotropin secretion → t/x endometriosis

A/E:

• Hot flashes, v libido

• Sweating

• ^ weight

• Headache, Injection reactions

• Possible Depressionor Suicidal thoughts

• GLucose changes w/DM

Avoid breastfeeding during t/x

PMS:

Happen during luteal phase, before menstruation → improve or resolve when menstruation beings

R/x:

• Obesity, Diet, sexual abuse/trauma

S/s:

• Physical:

  • Joint, low-back pain, Muscle ache

  • Sensitive breasts

  • Bloating, Hot flashes, Headaches

  • Skin changes, ^ weight

• Emotional

  • Irritable, Anxiety, Loneliness, Mood swings

  • Anger, Depression

• Behavior:

  • Appetite ^, exhaustion

  • Restless, Insomnia/or too much sleep

T/x:

• Exercsie, Relaxation techniques

• Reflexology, Acupuncture

• Ca, Mg, Chasteberry supplements → v prolactin levels

PMDD:

Severe form of PMS; mood disorder

• Cyclical → ADL interference

• High suicidal risk

R/x:

• Schizo, ADD/ADHD

• Anxiety, MDD, Bipolar Disorder

S/s: same as PMS but more severe

D/x:

• DSM5 → severe recurrent s/s OVER TIME

T/x:

• Same as PMS; if severe →

  • Citalopram

    • A/E:

      • GI upset, fatigue dry mouth, insomnia

      • SS, suicial thoughts, mania, hyponatremia

      • Avoid driving

  • COCs

Menopause:

After 12 months of no periods

• Perimenopause: leading up to it

  • Irregular cycles, hormone changes

  • 47 years → lasts 4-5 years

• v estrogen → negative feedback decreases → ^ FSH

D/x:

• Serum FSH → ^

• Pregnancy test

• TSH + Prolactin

• Waiting 12 months is gold standard :o

Menopause s/s & t/x

Hot flashes & Night sweats → poor sleep → insomnia

Vaginal dry, Dyspareunia, frequency

Mood changes

High LDL levels, Metabolic Syndrome, Cardio complications

Lower bone density → v lean body mass → ^ adipose tissue

Osteoporosis

T/x:

• Exercise, Smoking cessation, managing stress, good diet

  • High fiber, complex carbs, polyunsat fats

• Report any herbs taken to provider

• HRT → v some s/s

  • Replaces estrogen w/progesterone

    • v risk of estrogen sensitive cancers

• For hot flashes & night sweats → Systemic Estrogen Therapy

  • Estrogen + Progesterone

  • Avoid ppl w/

    • Blood clots

    • Breast, Endometrial cancer

    • Heart disease

• Low Dose Vaginal Therapy:

  • Only estrogen

  • Treats Vaginal and Urinary s/s

  • Via cream or inserting directly into vagina

Male Infertility

Unable to get pregnant after 6-12 months after trying

Male:

• Testicles:

  • Varicocele, ETOH

  • Trauma, Smoking

  • Cancer t/x, DM, CF, infection

• Endocrine Disorder

  • Secondary hypogondotropic hypogonadism (HH)

    • dysfunction of hypothalamus or pitutiarary → v hormone → unable to stimulate testes effectively → v sperm production

  • Spermatogenics Defect: 65-80% of cases

• Genetic Disorder

• Sperm transport problem

D/x:

• Semen analysis:

  • Simple, noninvasive

  • Checks:

    • quantiy, function (motility and vitality), and structure, pH

    • WBC # → infection or inflammation

  • Avoid gooning for 2-7 days and no Lube or Saliva when collecting

  • Analyze quickly due to sperm’s short lifespan

Female Infertility:

R/x:

• ^ age, smoking, ETOH

• Obesity, underwegiht, ^^^/vvv weight

• Amenorrhea

Underweight:

• <17, ED, Strenuous exercise

<35 → 12 momnts

>35 → 6 months

Ovarian Dysfunction:

C/x:

• PCOS, FHA, Thyroid disease

• Menopause

D/x:

• FSH, Estradiol, AMH, TSH

• Antral follicle count: Checks ovarian reserve

  • Uses US → predicts likelihood of IVF success

Ovulation Induction: anovulation + obesity

• 5-10% weight loss encouraged

Fallopian Tube Obstruction

C/x:

• Pelvic infection (PID)

• Ruptured appendix

• STI:

  • Chlamydia

  • Gonorrhea

• Endometriosis

• Abd surgery

D/x:

• Hysterosalpingogram (HSG)

• Chromopertubation: a/x whether the fallopian tubes are open/closed

Uterus & Cervix Problems

C/x:

• Fibrioids, Intrauterine adhesions

• Endometrial polyps

Cervical mucus can interfere w/uterus

D/x:

• Transvaginal US

• Hysteroscopy

• Sonohysterogram → uterine cavity

Meds for Ovulation induction:

Clominophen:

• blocks estrogen feedback →Induces ovulation → ^ GnRH → ^ FSH/LH →follicle growth

• Utilize Home urinary LH kits w/IUI

• A/E:

  • OHSS:

    • Large ovaries, many cysts, blood accumulation here → hypovolemic shock, AKI, ARDS → Severe and fatal

  • Hot flashes, N/V, Vision issues

Aromatase X:

• Block estrogen prodution → ^ FSH → follicle growth

• Less likely to have twins

Letrozole:

• Stimulates Ovulation via same patho

• A/E:

  • Hot flashes, Night sweats, bone pain, fatigue

• NOT USED W/PREGNANCY

Dopamine Agonists:

• Dopamine → blocks prolacting → ^ LH/FSH → ovulation

Bromocriptine: Blocks prolactin secretion

• For highprolact infertility

• Monitor BP due to Othohypo risk

Metformin:

• ^ sensitivity → better menstrual regularity → more spontaneous ovulation

HcG meds:`

Substitue for LH to stimulate ovulation

• May also t/x male hypogonadism

• MAY LEAD TO OHSS

Follitorpoin Alfa/Beta

Stimulate ovearian follicular growth for females

Induces spermatogenesis in males

May help develop follicles w/ALT

Risk for OHSS, cysts, or abd pain

• Subcut injection

Menotropins:

FSH + LH purified → induction for both males and females

• OHSS concern

• Give in lower abdomen subcut and rotate sites

Gonadotropin Therapy:

May increase r/x of multiple gestation AND OHSS

• US, Labs, Close a/x

GnRH agonists/antagonists

• X ovulation

  • When too many follicles, OHSS concern

  • Controlling IVF cycle

Laparoscopic Ovarian Drilling

2nd line for induction

• Punctures via laser → ^ LH and FSH

• R/x for infection and adhesion formation

Male infertility t/x:

Inducing spermatogenesis which takes 30-40 days

• Dopamine agonists for Hyperprolactinemia → ^ genesis

• Large varicoceles → surgery

• Azoospermia → ART (IUI)

IUI:

Sperm inserted → uterus

• Sexual dysfunction, mild infertility, Donor Sperm

• May used conjucted w/ovulation induction

• Done 2 ways:

  • Day after LH surge (urine found)

  • hCG administered

• test for pregnancy 14 days after

ART:

Done outside of the body

Types:

• Preimplantation Genetic testing (PGT):

  • to check for inherited disorderes

  • Used w/Genetic counseling

• IVF:

  • Stage 1: Stimulate ovaries

    • FSH/LH gonadotropins or GnRH agonists → hCG 36 hrs before retrieval

  • Stage 2: Retrive eggs

    • Uses conscious sedation

  • 3: lab fertilization

    • Processed sperm or ICSI (single strong sperm; done w/severe male infertility)

  • 4: embryo → uterus

    • 3-5 days after

    • Progesterone injections: improves uterine lining

• GIFT: gamete intrafallopian transfer

  • Egg + sperm → fallopian mechanically

• ZIFT:

  • Egg + sperm → in viro → later → fallopian tube

IVF risks and complication

Things that v success rates:

• Older mom age, poor reserve

• Smoking, fibroids

• Hydrosalpinx

  
  

R/x:

• OHSS

• Allergies, Infection, Thromboemolis

• Multiple gestations AND Fetal complications

Other ways to build family:

Gestational Surrogacy:

• Gestational carrier: does birth for parents

  • Mostly via IVF

  • “Daddy moke, daddy tom, daddy mark”

  • Done when:

    • No uterus, pregnancy contraindiated

Adoption:

• Open

• Domestic

• International

• Foster-Care

Bacterial Vaginosis:

Healthy flora cooked → anearobic bacteria growth (Gardnerella Vaginalis)

S/s:

• Vaginal discharge, odor

• Dyspareunia, Itching, burning

• Asymptomatic → not automatically t/x

D/x:

• Vaginal gram stain

T/x:

• Metrodinazole

• Clindamycin cream

Chlamydia:

Silent infection due to not many s/s (Chlamydia trachomatis)

• First affects Cervix, urethra → mucopurulent cervix discharge, dysuria, frequency

• <25 = tested for chlamydia; pregnant woman → test (possible blindness for baby)

D/x:

• Nucleic Acid Ampli Test (NAAT)

• Vaginal swabs → females

• Urine → males

T/x:

• Doxyciline, Azithromycin, Levofloxacin

Edu:

• Avoid rizzing till u done w/t/x

Gonorrhea:

Neisseria gonorrhoeae → urogenital tract, PHARYNX, rectum

S/s males:

• Dysuria and Burning

D/x:

• NAATs

• Urine, Specimens,

T/x:

• Ceftriaxone

• Others:

  • Gentamicin, Azithro, Cefixime

Syphilis:

Treponema Pallidum; if left unt/x → systemic disease; STAGES

1. Painless Chancre; happens in site of entry (tongue, vagina, anus)

• lasts 3-6 weeks

2. Rash + Systemic s/s

• Skin lesions, non-itching rash, swollen lymph, fever, hair loss, sore throat, fatigue

• 6weeks → 6 months

3. Latent: No s/s

4. Tertiary: Organ dmg

• CV, Nervous, Skeletal, Vestibular

• Gummas in liver, bone, skin, mouth

D/x:

• Treponemal + nontreponemal serologic tests: helps avoid false +

T/:

• Primary, Secondary, or early latent: Penicillin 2.4 million units IM once

• Late latent: 7.2 million total or 3 separate doses

• Tertiary:

  • Depends on systems affected

  • Doxy, Tetracycline, Ceftriaxone

Neurosyphilis:

Severe headaches,

Muscle weakness, Numbness, AMS, Confusion & poor focus

Tabes dorsalis

PID:

Upper GU tract:

• Endometrium ,Fallopian Tubes, Peritoneum, Ovaries

• Bacteria ascends from lower GU to upper tract

  • N gonorrhea, C. trachomatosis

S/s:

• Pelvic Pain + Fever (101) + Cervical motion tenderness → scarring → infertile

• Dyspareunia, AUB, Discharge

• May lead to:

  • Ectopic pregnancy

D/x:

• Wet mount

• Transvaginal

• Doppler

T/x:

• Broad sprectrum antibiotics

• May require IV therapy if severe

IUD + PID:

Most riskful after 3 weeks of insertion

HIV:

Acute infection: Mild flu like s/s after 2-4 weeks

• Malaise, low grade fever, aches, swollen lymps, sore throat, rash

• Chill in Basal Ganglia Roots

D/x:

• Serum antigen/antibody combination assay

T/x:

• Tenofovir + Emtricitabine

  • A/x VItamin D

  • And Kidney/Liver dysfunction → Lactic Acidosis

• Dolutegravir:

  • Prevents HIV DNA integration → X replication

  • Liver issues, Fatigue, N/V, Allergic reaction

• Raltegravir:

  • SJS, Rash, Suicidal Thoughts

HIV prevention:

PrEP:

• For high risk BEFORE EXPOSURE

PEP: after exposure

• MUST BE DONE W/in 72 hrs → 28 days length of t/x

Herpes Simplex Virus (HSV):

Transmitted via: Lesions, Genitl/Oral secretions

• HSV1 → oral herpes + genital herpes

• HSV2 → genital herpes

S/s:

• Painful vesicles → rupture → painful ulcers

  • Lasts 2-3 weeks

• Malaise, Aches, F/C, swollen lymph nodes

Recurrent outbreaks may be less severe and shorter → after → prodormal manifestations

T/x:

• Acylclovir, -CLOVIR

• START AS SOON AS POSSIBLE

• Does not cure it btw

Cytomegalovirus (CMV):

Most have little s/s:

• MIld:

  • Sore throat, fever, fatigue, swollen lymphs

• Severe:

  • Lungs, Eyes, Stomach, Liver, Intestines, Esophagus affected

PREGNANCY RELATED:

• Maternal CMV infections done via fetus and lead to long term problems:

  • Brain, liver, lungs, spleen, growth, hearing

T/x:

• No t/x

• Immunocompromised pts tho:

  • Valganciclovir:

    • A/E:

      • Anemia, v Platelets, Neutropenia, ^ Cr, Retina detached

    • Edu: Take w/meals

Hepatitis A:

Does not become chronic; fecal-oral

• Lasts <2 months

• HAV vaccine → prevention

S/s;

• Fever, headache, malaise, N/V, Diarrhea

• Anorexia, Abdpain

• Clay stools, Dark Urine, Jaundice

HBV:

Yk, HBV can last on surfaces for 7 days

• the earlier u get it → the more cooked u are for a chronic infection → Hepatitis, cirrhosis, liver cancer → death

Serology:

• HBsAG → current or chronic

• AntiHB → immunity/recovery

• Total antiHBC → previous or current infection

• IgM antiHBC → acute infection

HPV:

Most infections clear right after but some can → genital warts, precancer → different cancers

• 16+18 = cervical cancer

• 6+11 = genital warts + respiratory pappilamatosis

Vaccine:

• Gardasil 9

Trichomoniasis:

Protozoal

S/s:

Females

• Thin, Yellow-green, odor discharge

• Burning, itching, dysuria

Males:

• Penile discharge, burning/itching, urinaiiton

D/x:

• Wet mount

T/x:

• Metrodinazole

• Tididanole

• TREAT BOTH PARTNERS

Vulvovaginal Canddiasis

Yeast infection; may not originally not from s3x

• Antibiotics, Pregnancy, Immunocormpromised,Oral contraceptives combined

• HRT

• Prevention:

  • Loose fitting clothing OR cotton underwear

  • avoid tubs or douching, or too much Antibiotcs

Simple:

• Mild/ Infrequent

Complicated:

• Recurrent infection >3x/year

• Immunocompromised, HIV, DM, Pregnancy

S/s:

• Thick + Curdy + Itchy

• Vulvar edema, Soreness

• Healthy pH compared to other infections

D/x:

• Wet mount

• Complicated → culture or PCR

T/x:

• Azole cream or Fluconazole

  • 1-3 days longer

TORCH infections:

Toxoplasmosis

• From soil, cat, fruits/veggies, uncooked food

• Pregnancy → cross placenta → congenital toxoplasmosis

  • Ocular or Neuro disease, Miscarriage, Still birth, death

• Severity based on gestational age when infection happens; earlier = worse

---

O- other

Zika:

• Mosquite, s3x, congenital, transfusions/transplants

• S/s:

  • Rash, fever, joint pain, conjuctivitis

  • Pregnancy → small head & neuro issues + death

• Not t/x → rest + fluids + Tylenol

Varicella-Zoster:

• Chickenpox + shingles → airborne precations

• Highly contagious

• S/s:

  • MIld fever, malaise, red-itchy rash, fluid blisters

Herpes Zoster: latent in n.s.

• Reactivation → Shingles → painful unilateral versicles → thoracic and lumbar region

Congenital Varicella: 8-20 weeks of gestation

---

Rubella:

• Mild in children but severe during pregnancy

• large airborne droplets

• Mild fever, lymphadenopathy, maculopapular rash

Congenital rubella syndrome:

• Ocular defects, heart defects, intellectual issues

• How to prevent? Vaccines (MMR, MMRV)

Toxoplasmosis T/x:

Cook meals, hygiene, dont eat cat sh#t

No t/x, if severe:

• Pyrimethamine:

  • Bleeding risks and seizures

  • Folate dificiency

• Sulfadiazine:

  • Take with da water (8oz)

  • Folate dificiency

• Leucovorin Calcium: lowers hemtologic toxicity

  • Also prevents folate deficiency w/pyrimethamine or sulfadiazine

Uterus and Mammary changes during prengnancy:

Uterus:

• Early:

  • Amenorrhea → ^ estrogen → hypertrophy + hyperplasia

• ^ blood flow to uterus

• Sprial arteries thicken and uterus prepares for deep pplacental implantation

Mammry:

• ^ Estrogen + Progesterone → breast tissue differentiation → milk duct additions → colostrum

• ALso ^ tenderness, heaviness, and leaking of colostrum

CV & Hematologic changes during pregnancy:

Blood volume ^ to supply own tissue + placenta + fetus

• third trimester = ^ 30-50% → ^ volume → ^ CO → ^ SV → ^ HR

  • Peaks around 20-24 weeks

• V Peripheral vascular resistance due to: → v BP around middle of 3rd trimester

  • ^ progesterone, vasodilation

Gravid uterus → ^ psi on femoral vessels → Varicose veins (normal finding)

Labs:

• V HcT → low viscosity → lower resitance of b.f. → ^ delivery to utero+placenta

• ^ clotting factors → 5x higher risk to have blood clots

Immune, Resp, GI, GU, Endocrine changes during pregnancy:

Immune: slightly compromised

REsp:

• ^ o2 demand = ^ RR

• as uterus grows → diaphragm pushes upwards → harder to breath → ^ RR

  • ^ Chest diameter to compensate

• Lightening: fetus stays deeper in pevlic nearing end of pregnancy → easier to breath

GI:

• Growing uterus pushes stomach and GI → earlier fullness and reflux/heartburn

• Progesterone relaxes smooth muscles → delayed emptying, tone, and absorption → ^ constipation risk and higher likely hood for reflux

GU:

• ^ kidney size due to higher CO →^ GFR to filter more blood

• Early:

  • ^ blood flow → ^ GFR → ^ urine → frequency

  • Nocturia

  • Possible slight glycosuria + proteinuria (MILD)

• Later:

  • Bladder compression → urge to void + frequency

Endocrine:

• ^ BMR

• 1st & 2nd → ^ fat storage → 3rd → use fat resovoir for fetus

Pregnancy hormones;

hCG:

• rises during early pregnancy; main for testing

• Maintains corpus luteum at the start

Progesterons: Protects the pregnancy

• Establishes placents, maintains walls

• Supports blood vessel growth

• Prevents contractions, SMC relaxation, slower GI

Estrogen: Growth + blood supply

• Promotes b.v. growth, maintains lining

• Aids organ dev. and mother’s mammary glands

Prolactin:

• Milk production

Relaxin:

• Uterine relaxation, softens serivx

• Helps joints be more flexible

Oxytocin:

• Contraction, ^ prostaglandin release

Cortisol + Alosterone → hypervolemia + edema

Placental growth hormone:

• For growth, and cretes insulin resistance to allow more glucose to go to baby

Center of gravity during pregnancy & expected painful changes

Shifts foward → Lumbar lordosis + Anterior pelvic tilt

• Lower back pain

• Gait change + hip pain

• Diastiss rect: abd muscles separate which can create a bulging area that makes urinary incontinence & back pain

Carpal tunnel syndrome:

• Due to hormones, fluids

• Numbeness, tingling, weak

Pregnancy change for Integumentary:

Stria Gradidarum: stretch msarks

• Increased uterine size and striae develop

• Purpe and pink

Linea Nigra: darkened linea alba

• Midline connective abd tissue

• Prominent in umbilicus → symphysis

Hyperpigmentation:

Melasma: facial hyperpigmentation

• In bridge of nose, cheeks, forehead, skin

Why does prenatal care matter?

I/x maternal health problems, screen for anomalies, i/x r/x, monitor progression, promote positive behaviours, reduces morbidity

• WHO recommends >8 contacts total

Signs of Pregnancy:

Presumptive: subjective experienced by pt

• Amenorrhea, breast changes, enlargement, N/V, fatigue, urinary frequency, Melasma, fetal movement, larger uterine

Probable signs

• Home pregnancy test/HcG test

• Goodell’s sign: cervix becomes soft 8wks

• Hegar’s sign: soft lower uterine segment 6wks

• Chadwick’s sign: bluish/purpule color of cervix/vagIna

• Ballottement: gently taps through vagina → fetus moves upward and returns downward 16-28wks

• Braxton Hicks (16-28)

Positive signs:

• Ultra sound (4-6), fetal heart activity (10-12), fetal movement (20)

Prenatal visits:

H-H-P-L-D-E

• History

• Health a/x

• Pregnancy dating

• Labs

• Diagnostics

• Education & health promotion

History for prenatal visits

• Previous illness/surgeries

• Menstrual h/x

• Family h/x

• ETOH, drugs, smoking

• STI’s, partner violence, mental health, pets

• Obsterical h/x:

  • Date of LMP, previous pregnancies/births, any issues, cramps, fetal movement, genetic conditions

GTPAL:

• Gravida: # of pregnancies

• Term: births at 37 weeks or later

• Preterm: at least 20 weeks; Before 37 weeks

• Abortion: losses before 20 weeks

• Living: number of living children

Gravida vs Para:

(twins/triplets count as one for birth events)

Gravida: # of times pt has been pregnant

• Nulligravida: never been

• Primigravia: first time

• Multigravida: multiple

Para: how many births occured AFTER 20 weeks

• Nulli

• Primi

• Multi

Before 20 wks = abortion

FUll term: 39-40.6 weks

<37 weeks = preterm

Post term > 4 weeks

Important tests during pregnancy:

Naegele’s Rule: estimates date of birth (EDB)

• First day of LMP - 3 months + 7 days + 1 year

• May not be guarantted due to different variety of pts

US:

• Helps a/x EDB when LMP is unknown

• Transvaginal US: early in pregnancy used

  • Full bladder is NOT required

Crown-Rump Length:

• 8 6/7→ 13 6/7 weeks

• Measure gestational age

Later dating measurements:

• Biparietal diameter

Fundal height:

• Measures from pubic symphysis to top of fundus

• for 20-36 weeks

• measures via cm

  • If 28 weeks = 28 cm (26-30cm)

  • 2cm of variation btw

    • Anatmoy, previous ones, fetal growth, uterine position

Other important screenings/assessments (a/x):

Substance use

Tobacco use:

• leads to preterm birth, v growth, miscarriage

Alcohol and Teratogenic drugs

STI a/x: 5 P’s

• Partners: # and gender

• Practices:

  • Genital/Anal/Oral s3x

  • How they met, drugs used during intercourse?

  • S3x tradiing for money

• Protection:

  • Condoms, meds, vaccines, HIV prevention

• Past h/x:

  • Previous STIs

• Pregnancy intention

  • Intended?

Partner violence and depression

• Possible preterm birht, and lower birth weight

Physical examination and Lab testing for prenatal visits:

Physical:

• Height, Weight, BMI, VS Breast and Pelvic exams

• Fetal HR via Doppler OR fetoscope

  • 110-160/min

  • If hard to assess → use UltraSound (US)

Labs:

• CBC:

  • Hgb, HcT

    • If low → Iron and vitamin C supplements

• Urinalysis + culture

  • Proteinuria → Kidney disease, infection, stress

    • Possible sign of preeclampsia later in pregnancy

  • Glucose → gestational diabetes

  • Culture → possible infection

• HBsAg: to prevent fatal hepatitis transmission

  • If mother positive → Hepatitis B vaccine + Hepatitis B immuneglobulin in FIRST 12 HOURS OF LIFE

• Rh Factor: presence of Rho D protein on RBCs

  • + = present D antige; - = absent D antigen

  • If mother and fetus have opposites → mother produces antibodies → attacks fetal RBCs

    • Often occurs w/previous births or invasive procedures

  • RhoD immune globulin: prevents Rh sensitization

    • Routinely given around 28 weeks of gestation or fter potential exposure (bleeding, trauma, invasive procedures)

    • also give 72 hrs after birth

    • Possible anapylaxis or hemolytic reactions

    • dont give if pt is Rh-positive

    • Reduces MMR and Variclla vaccines effectiveness

Rubella immunity

Titers done during pregnancy to see if bebe is immune

Infections may lead to:

• deaf, cataracts, cardiac defects

• low birth weight, liver + spleen dmg

Give MMR vaccine postpartum

Prenatal screenings:

HIV:

• Should be done at initial visit to prevent transmission → repeat test after or for those w/high risk exposure

STI screening:

• If positive → Treat → retest 4 weeks later

Shyphillis screening:

• Uses Rapid plasma reagin → if positive → Penicillin t/x

• Nontreponemal + treponemal testing

  • should also be done in reverse to see possible current infections or t/x effectiveness

CDC Prenatal Infection Screening — Timing

First prenatal visit:

Infection	Who?
Syphilis	All pregnant clients
HIV	All pregnant clients
HBV	All pregnant clients
HCV	All pregnant clients
Chlamydia	<25 years OR older + increased risk
Gonorrhea	<25 years OR older + increased risk

Third TRIMESTER:

Infection	Who?
Syphilis	All pregnant clients
HIV	All pregnant clients
HBV	All pregnant clients
HCV	All pregnant clients
Chlamydia	<25 years OR older + increased risk
Gonorrhea	<25 years OR older + increased risk