PANCE Blueprint Reproductive System (8%)

PANCE Blueprint Reproductive System (8%)

PANCE Blueprint Reproductive System (8%)

Follow Along with the NCCPA™ PANCE and PANRE Reproductive System Content Blueprint

  • 46 PANCE and PANRE Reproductive Content Blueprint Lessons (see below)
  • 107 Question Reproductive Exam
  • Reproductive Pearls Flashcards
  • Reproductive Pearls high yield summary tables
  • ReelDx integrated video content (available to paid subscribers)

Lessons

  1. Reproductive System Comprehensive Exam

  2. Disorders of the Uterus (PEARLS)

    1. Dysfunctional uterine bleeding

      DUB is defined as excessive uterine bleeding with no demonstrable organic cause: Polymenorrhea (cycles with intervals of 21 days or fewer), menorrhagia (abnormally heavy or prolonged bleeding) and/or metrorrhagia (uterine bleeding at irregular intervals)
      • Diagnosis of exclusion; treat with oral contraceptives and NSAIDs
    2. Endometrial cancer

      Postmenopausal vaginal bleeding, most common GYN malignancy, usually adenocarcinoma
      • Endometrial biopsy -  vaginal bleeding in a post menopausal women is CA until proven otherwise
      • Treatment: Hysterectomy bilateral salpingo-oophorectomy +/- radiation
    3. Endometriosis

      Endometriosis is a benign disease related to the menstrual cycle, usually cyclical associated with the 3 D's: Dyspareunia (painful intercourse), dyschezia (difficulty in defecating), dysmenorrhea
      • Uterus is fixed and retroflexed. Tender nodularity of cul de sac and uterine ligaments.
      • Laparoscopy: Chocolate cysts observed. Definitive study
      • Treatment: Resect endometriosis, oral contraceptive therapy
    4. Leiomyoma

      Abnormal uterine bleeding; polymenorrhea, menorrhagia, intermenstrual bleeding and/or metrorrhagia along with urinary symptoms (eg, urinary frequency or urgency). Uterine mass.
      • Black women, family history, diagnose with Ultrasound
      • Intramural fibroids are most common, definitive treatment: myomectomy or hysterectomy
    5. Prolapse

      Caucasian women, after labor/delivery, chronic cough. Vaginal fullness, abdominal pain worse late in day, after prolonged standing. Relieved by lying down.
      • Prolapse of the uterus into the vaginal canal - graded by uterine descent: 0°- No descent. 1° - descent between normal and ischial spine. 2°- between ischial spines and hymen. 3°- within hymen. 4° - through hymen.
      • Prolapse of the bladder into the front wall of the vagina (cystocele) -  leads to a “reservoir effect” where the bladder is not completely emptied when the urine is passed
      • Prolapse of the rectum into the back wall of the vagina (rectocele) - complain of a sensation of bulging in the vagina when they strain to open their bowels.
  3. Disorders of the Ovary (PEARLS)

    1. Ovarian Cysts

      Pain, menstrual delay, hemorrhagic shock from cyst rupture - Follicular cysts are most common, diagnose with ultrasound. Observe - Most resolve within 6-8 weeks (2 menstrual cycles). Persistent cysts, large cysts (>6 cm) or complex cysts can be removed
      • PCOSObesity, hirsutism, acne, amenorrhea or oligomenorrhea, menarche occurs at expected age. Strongly associated with obesity, acanthosis nigricans, insulin resistance and hyperinsulinemia. Ultrasound: String of pearls. Labs: LH:FSH > 2.0, increased androgens, increased testosterone. Treat with oral contraceptives, metformin
    2. Ovarian Neoplasms

      Patient in mid-50's with abdominal fullness, bloating, fatigue, weight loss and ascites
      • Tumor marker: CA 125second most common gynecological cancer (first is endometrial)
      • Asymptomatic premenopausal patients with simple ovarian cysts < 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives.
      • Postmenopausal women with simple cysts < 3 cm in diameter may also be followed, provided the serum CA 125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy. If the cyst is > 3 cm or the CA 125 is elevated, further evaluation is necessary.
  4. Disorders of the Cervix (PEARLS)

    1. Cervical cancer

      Friable, bleeding cervical lesion on exam. Squamous cell carcinoma. Most caused by HPV (High risk types, 16 and 18)
    2. Cervicitis

      Usually occurs due to sexually-transmitted diseases, such as chlamydia or gonorrhea, herpes, HPV, trichomonas
      • Cervical motion tenderness. Ceftriaxone for gonorrhea + Azithromycin for Chlamydia
    3. Cervical Dysplasia

      HPV especially types 16, 18. Associated with cigarette smoking
      • Transformational zone most commonly affected, Gardasil vaccine at age 11-12 it can be administered starting at 9 years of age
      • Pap smear every 3 years starting at age 21 (regardless of sexual activity). Every 5 years if pap smear and HPV are negative starting at age 30
      • ASC-US or LSIL, CIN-1: Reflex HPV, if positive and at least 25 years old – colposcopy, if negative or under 25 years old – retest in 1 year
      • HSIL, CIN-2, CIN-3, CIS: Colposcopy. Outside cervix – LEEP or cryotherapy
    4. Incompetent Cervix

      History of cone biopsy, DES exposure. Causes 2nd trimester abortion
      • Cervical cerclage. Placed at 14-16 weeks and removed at 36 weeks to allow for delivery
  5. Disorders of the Vangina/Vulva (PEARLS)

    1. Cystocele (bladder hernia)

      Prolapse of the bladder into the front wall of the vagina -  leads to a “reservoir effect” where the bladder is not completely emptied when the urine is passed
    2. Vaginal and Vulvar Neoplasm

      • Vaginal cancer  - abnormal vaginal bleeding. Squamous cell carcinoma caused by HPV
      • Vulvar Cancer - vaginal pruritis is most common presentation. Squamous cell and melanoma – pruritic black lesions. Paget’s – pruritic red lesions
    3. Vaginal Prolapse

      Feeling of vaginal or pelvic pressure, heaviness, bulging, bowel or bladder symptoms. Common after hysterectomy.
      • Baden-Walker grades of female genital prolapse – uses the hymen as crossing point
        • Grade 1 – descent above the hymen, Grade 2 – descent to the hymen, Grade 3 – descent beyond the hymen, Grade 4 – total prolapse
    4. Rectocele

      Prolapse of the rectum into the back wall of the vagina - complain of a sensation of bulging in the vagina when they strain to open their bowels
    5. Vaginitis

      • Trichomonas: Frothy yellow, green, gray vaginal discharge and strawberry cervix. Wet mount: Flagellated protozoa. pH: Basic. Treatment: Metronidazole
      • Bacterial vaginosis: Organism: Haemophilus aka Gardnerella. Signs: Fishy odor, thin gray discharge. Wet mount: Clue cells. pH: Basic > 4.5. Treatment: Metronidazole
      • Candida: Thick white vaginal discharge. Associated with recent antibiotic use, diabetes mellitus, steroid use. KOH prep: Pseudohyphae. pH: Normal 4. Treatment: Fluconazole
  6. Menstrual Disorders (PEARLS)

    1. Amenorrhea

      Primary: no menses by age 16
      • Turner’s syndrome – XO karyotype, webbed neck, broad chest. Androgen insensitivity – breast development only. Imperforate hymen – observed on speculum exam. Mullerian agenesis – secondary sex characteristics, no uterus
      Secondary: previously had menses, amenorrhea for 6 months
      • Most often pregnancy. Also caused by weight changes, hypothyroid, prolactinoma
    2. Dysmenorrhea

      Pain with menses or precede menses by 1 to 3 days. Pain tends to peak 24 h after onset of menses and subsides after 2 to 3 days
      • Primary: Begins early after menarche, not associated with pelvic pathology, associated with prostaglandins, treatment with NSAIDs and oral contraceptive pills
      • Secondary: New onset in an older women, associated with a secondary pathologic (structural) cause - adenomyosis, endometriosis, fibroid, PID, IUD, treat underlying cause
    3. Premenstrual syndrome

      Caused by an imbalance of estrogen and progesterone along with excess prostaglandin production
      • Symptoms during luteal phase (1-2 weeks before menses) - Bloating, irritability. PMDD - causes marked disruption in functioning.
      • Symptoms resolve at the onset of menses.
    4. Menopause is a clincal diagnosis and is defined by cessation of menses for at least 12 months
      • Average age is 51.5. Definitive diagnosis: FSH > 30 mIU/mL
      • Women who have a uterus should be given a progestin in addition to estrogen because unopposed estrogen increases risk of endometrial cancer.
      • Know the contraindications for HRT: ↑ triglycerides, Undiagnosed vaginal bleeding, Endometrial cancer, history of breast CA or estrogen sensitive cancers, CVD History, DVT or PE history
  7. Disorders of the Breast (PEARLS)

    1. Breast abscess

      Often is a complication of mastitis - symptoms are the same with the addition of localized mass and systemic signs of infection
      • Staphylococcus aureus is the most common cause. Incision and drainage + antibiotics (nafcillin/oxacillin IV or cefazolin PLUS metronidazole)
    2. Breast Cancer

      Most common malignancy in women. Risk factors (increased exposure to estrogen): Menarche before age 12, old age of first full term pregnancy, no pregnancies, menopause after age 52
      • Mammogram every 2 years from age 50-74. Every 2 years beginning at age 40 if increased risk factors – 10 years prior to the age the 1'st degree relative was diagnosed. Clinical breast exam: every 3 years in women age 20-39 y/o then annually after age 40. Breast self exam – monthly beginning at age 20 – immediately after menstruation or on days 5-7 of the menstrual cycle.
    3. Fibroadenoma

      Young adult female with painless, firm solitary (rubbery feeling) well defined mobile breast mass. No changes with menstrual cycle
    4. Fibrocystic disease

      Multiple bilateral breast masses that increase in size and pain before menses, usually resolves with the start of the menstrual cycle. Aspiration of cysts- straw colored fluid with no blood
    5. Gynecomastia

      Physiologic gynecomastia: affects pubescent boys. Watch and wait, typically resolved in 1 year
      • Drugs: particularly spironolactone, anabolic steroids, and antiandrogens
      • Klinefelter’s syndrome- XXY karyotype, tall, thin, long limbs. Hypogonadism. Treatment: Danazol
    6. Galactorrhea

      Bilateral milky breast secretions that occur in a non-lactating patient
      • Rule out prolactin-secreting pituitary adenoma, TSH, CT or  MRI. Treat with dopamine agonist - bromocriptine
    7. Mastitis

      Occurs in breastfeeding mothers. Organism: S. aureus, treat with Dicloxacillin, warm compresses. Continue to breastfeed
      • Infectious (unilateral) - Unilateral, fever, chills and color change
      • Congestive (bilateral) - Bilateral breast engorgement that usually occurs in primigravidas
      • Inflammatory breast cancer presents with breast tenderness and color change, but fever and chills are not usually present
  8. Pelvic inflammatory Disease

    Causative agents include Gonorrhea and Chlamydia. Chandelier sign (cervical motion tenderness). Complications: infertility, ectopic pregnancy, tubo-ovarian abscess (adnexal mass)
  9. Contraceptive Methods

  10. Infertility

    Failure to conceive after 1 year of unprotected intercourse
    • First step: Test male sperm, anovulation is the most common cause - amenorrhea and abnormal periods - 65% female, 20-40% male, 15% unknown. Treatment for anovulatory women: Clomiphene citrate
  11. Uncomplicated Pregnancy

    1. Normal labor/delivery

    2. Prenatal diagnosis/care

  12. Complicated Pregnancy (PEARLS)

      • Threatened – vaginal bleeding, closed cervical os
      • Inevitable – vaginal bleeding, open cervical os, no passage of tissue
      • Incomplete – vaginal bleeding and tissue passage from open cervical os
      • Complete – complete passage of fetal tissue
    1. Abruptio placentae

      When you see painful vaginal bleeding in the third trimester think abruptio placenta
      • Delivery of the fetus and placenta is definitive treatment, blood type, cross-match and coag studies as well as placement of large bore IV line, Cesarean section most often is the preferred route for delivery
    2. Cesarean section

      C-sections constitute about 32% of deliveries in the United States
      • most common reasons for cesarean are a previous cesareandystocia or failure to progressbreech presentation and fetal distress
    3. Dystocia

      Dystocia is defined as an abnormal labor progression  - macrosomia ( big baby),  small pelvis, poor contractions.
      • Shoulder Dystocia: failure of the shoulders to deliver spontaneously after delivery of the fetal head - Turtle Sign – retraction of the delivered head against the maternal perineum McRoberts maneuver and Woods “Corkscrew”
    4. Ectopic pregnancy

      Most often in ampullaSerial quantitative Beta HCG and transvaginal ultrasound
      • Ring of fire sign (hypervascular lesion with peripheral vascularity on Doppler). HCG is > 1,500, but no fetus in utero. Normal pregnancy HCG increases by 66% every 48 hours 
       
    5. Fetal distress

      Non-stress testing
      • GOOD- Reactive NST - > 2 accelerations in 20 minutes, with increased fetal heart rate 15 bpm lasting > 15 seconds, indicates fetal well being
      • BAD - Nonreactive NST - No fetal heart rate accelerations or < 15 bpm lasting < 15 seconds, get contraction stress test
      Contraction stress test - measures fetal response to stress at times of uterus contraction
      • GOOD - Negative CST - No late decelerations in the presence of 2 contractions in 10 minutes, indicates fetal well being, repeat CST as needed
      • BAD - Positive CST - Repetitive late decelerations in the presence of 2 contractions in 10 minutes, worrisome especially if nonreactive NST, prompt delivery
      APGAR - Appearance, Pulse, Grimace, Activity, Respiration (view scoring system)
      • Score from 1-10 with > 7 normal, 4-6 fairly low, 3 and under critically low
      • Test is done at 1 and 5 minutes after birth
    6. Gestational diabetes

      Most common complication: macrosomia. Glucose tolerance test between 24 and 28 weeks of gestation - 50 g (1 hour) glucose challenge test (non-fasting). Positive if blood glucose is > 130 mg/dL
      • If ≥ 130 mg/dl after 1 hour then get a 3 hour 100 g glucose tolerance test (GOLD STANDARD)
      • Results are positive if - One hour > 180, Two hour > 155, Three hour > 140
      • Insulin is considered first line therapy, glyburide, dietary management
    7. Gestational trophoblastic disease

      Beta HCG higher than expected, size-date discrepancy, hyperemesis
      • Mole Types: Complete mole - no fetal parts “Grape-like” mass or “snowstorm” on transvaginal ultrasound.
      • Incomplete mole - fetal parts
      • Choriocarcinoma - cancer of gestational contents
    8. Hypertension disorders in pregnancy

      Treatment goal: < 140/90. Treat with Methyldopa, Hydralazine, metoprolol
      • Contraindicated: ACE inhibitors, ARBs, diuretics, calcium channel blockers
      • Preeclampsia - Classic triad: HTN, + Proteinuria and edema after 20 weeks GA
      • Eclampsia - HTN, +Proteinuria + seizures or coma. TX magnesium  and delivery
      • HELLP syndrome is a manifestation of preeclampsia with hemolysis, elevated liver enzymes, and low platelets.
    9. Multiple gestation

      One in 80 births, 3% chance of twins, monitor for complications
      • Elevated beta-HCG. Two or more fetuses observed on ultrasound
      • Monozygotic: identical, Dizygotic: fraternal
    10. Placenta previa

      Painless vaginal bleeding *bright red in 3rd trimester (versus painful, dark red vaginal bleeding in placenta abruptio) usually no abdominal pain
      • No pelvic/cervical digital exam, no intercourse, no vigorous exercise
    11. Postpartum hemorrhage

    12. Premature rupture of membranes

    13. RH incompatibility

      Rh negative mother, Rh positive fetus - 1'st pregnancy is always unaffected Give Rhogam at 28 weeks, within 72 hours of delivery and during any uterine bleeding throughout pregnancy
      • Given if Rh negative mother and father Rh positive or unknown. Risk of hydrops fetalis