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Questions and Answers
Which of the following is considered a predisposing factor for amniotic fluid embolism?
Which of the following is considered a predisposing factor for amniotic fluid embolism?
Which of the following is NOT a sign or symptom of amniotic fluid embolism?
Which of the following is NOT a sign or symptom of amniotic fluid embolism?
What is a potential outcome for patients who survive amniotic fluid embolism?
What is a potential outcome for patients who survive amniotic fluid embolism?
What complication can arise within 30 minutes of amniotic fluid embolism?
What complication can arise within 30 minutes of amniotic fluid embolism?
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What is the primary diagnostic method for vasa previa during the antenatal period?
What is the primary diagnostic method for vasa previa during the antenatal period?
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Which condition requires urgent cesarean delivery if the fetus is alive and it is the first stage of labor?
Which condition requires urgent cesarean delivery if the fetus is alive and it is the first stage of labor?
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What characterizes cord prolapse as opposed to cord presentation?
What characterizes cord prolapse as opposed to cord presentation?
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Which of the following is a sign of vasa previa during labor?
Which of the following is a sign of vasa previa during labor?
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What should be done if a fetus is found to be dead during the management of vasa previa and it is the second stage of labor?
What should be done if a fetus is found to be dead during the management of vasa previa and it is the second stage of labor?
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What is a significant predisposing factor for umbilical cord presentation?
What is a significant predisposing factor for umbilical cord presentation?
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Which of the following assessments is critical in diagnosing cord prolapse?
Which of the following assessments is critical in diagnosing cord prolapse?
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What is one of the immediate actions to take if cord prolapse is suspected?
What is one of the immediate actions to take if cord prolapse is suspected?
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Which position can help relieve pressure on the umbilical cord during contractions?
Which position can help relieve pressure on the umbilical cord during contractions?
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If a mother is in labor during the second stage and experiences cord prolapse, what is a possible intervention?
If a mother is in labor during the second stage and experiences cord prolapse, what is a possible intervention?
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What is a crucial risk associated with cord prolapse for the fetus?
What is a crucial risk associated with cord prolapse for the fetus?
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What characterizes a complete rupture of the uterus?
What characterizes a complete rupture of the uterus?
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What is a defining characteristic of uterine dehiscence?
What is a defining characteristic of uterine dehiscence?
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What is one of the potential postoperative symptoms after uterine artery embolization?
What is one of the potential postoperative symptoms after uterine artery embolization?
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What is a common postoperative instruction for patients undergoing uterine artery embolization?
What is a common postoperative instruction for patients undergoing uterine artery embolization?
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Which risk is associated with uterine artery embolization?
Which risk is associated with uterine artery embolization?
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What should be monitored postoperatively after a uterine artery embolization procedure?
What should be monitored postoperatively after a uterine artery embolization procedure?
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What is a reason some women may not be candidates for MRI focused ultrasound treatment?
What is a reason some women may not be candidates for MRI focused ultrasound treatment?
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In a hysterectomy, what is typically removed?
In a hysterectomy, what is typically removed?
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Which of the following types of hysterectomy involves a vertical or transverse incision?
Which of the following types of hysterectomy involves a vertical or transverse incision?
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What is the expected effect of uterine artery embolization on fibroids?
What is the expected effect of uterine artery embolization on fibroids?
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What is the main goal of Kegel exercises in the treatment of prolapse?
What is the main goal of Kegel exercises in the treatment of prolapse?
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Which factor does NOT contribute to preventing prolapse from worsening?
Which factor does NOT contribute to preventing prolapse from worsening?
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What is a pessary used for in the treatment of prolapse?
What is a pessary used for in the treatment of prolapse?
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Which of the following is true regarding surgical treatment for prolapse?
Which of the following is true regarding surgical treatment for prolapse?
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What is a potential surgical complication from prolapse surgery?
What is a potential surgical complication from prolapse surgery?
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How often should Kegel exercises be performed to effectively strengthen pelvic floor muscles?
How often should Kegel exercises be performed to effectively strengthen pelvic floor muscles?
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What characteristic describes laparoscopic surgery for prolapse?
What characteristic describes laparoscopic surgery for prolapse?
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When is surgery generally recommended for prolapse treatment?
When is surgery generally recommended for prolapse treatment?
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Which condition is commonly associated with heavy menstrual flow?
Which condition is commonly associated with heavy menstrual flow?
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What symptom is characteristic of endometriosis occurring before menstruation?
What symptom is characteristic of endometriosis occurring before menstruation?
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Premenstrual syndrome (PMS) is primarily associated with which phase of the menstrual cycle?
Premenstrual syndrome (PMS) is primarily associated with which phase of the menstrual cycle?
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Which treatment is NOT commonly recommended for managing PMS or PMDD?
Which treatment is NOT commonly recommended for managing PMS or PMDD?
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What is the most common symptom of premenstrual dysphoric disorder (PMDD)?
What is the most common symptom of premenstrual dysphoric disorder (PMDD)?
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Which of the following is a known risk factor for endometriosis?
Which of the following is a known risk factor for endometriosis?
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In endometriosis, which symptom can indicate the presence of adhesions affecting the uterus and tubes?
In endometriosis, which symptom can indicate the presence of adhesions affecting the uterus and tubes?
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What is the general approach for managing endometriosis in asymptomatic women?
What is the general approach for managing endometriosis in asymptomatic women?
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Which of the following medications is used to suppress ovulation in the treatment of endometriosis?
Which of the following medications is used to suppress ovulation in the treatment of endometriosis?
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What is a significant psychological symptom of premenstrual syndrome (PMS)?
What is a significant psychological symptom of premenstrual syndrome (PMS)?
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Study Notes
Obstetric Emergencies
- Vasa Previa: A fetal blood vessel lies over the opening of the cervix (os) in front of the presenting part.
- Diagnosis: Antenatal ultrasound, vaginal examination (if no rupture of membranes), speculum examination. If membranes rupture, urgent cesarean section (C/S) is required within minutes.
- Diagnosis: Fresh vaginal bleeding at the same time as membrane rupture. Fetal distress depends on the amount of blood loss.
- Management: Urgent situation, pediatrician present, continuous fetal heart rate (FHR) monitoring. If a living fetus and first stage of labor, urgent C/S. If dead fetus or second stage, vaginal delivery. If delivered alive baby, need resuscitation, blood transfusion, and hemoglobin (Hb) level.
Presentation and Prolapse of Umbilical Cord
- Cord Presentation: Umbilical cord lies in front of the presenting part with intact membranes.
- Cord Prolapse: Umbilical cord lies in front of the presenting part with ruptured membranes.
- Occult Cord Prolapse: Cord lies alongside, not in front, of the presenting part.
- Predisposing Factors: High or ill-fitting presenting part, high parity (multiple pregnancies), prematurity, malpresentation, polyhydramnios (excess amniotic fluid).
Cord Presentation: Diagnosis and Management
- Diagnosis: Vaginal examination, decelerations.
- Management: No rupture of membranes (ROM): continuous electronic fetal monitoring, mother's position to reduce cord compression, cesarean section (C/S) birth.
Cord Prolapse: Diagnosis and Management
- Diagnosis: Vaginal examination after ROM to exclude prolapse and fetal heart rate (FHR), bradycardia, variable, or prolonged deceleration.
- Management: Urgent medical assistance, stop oxytocin, replace the cord if it is out of the vagina to prevent spasm, maintain temperature, and prevent drying; give oxygen. Hold presenting part away from cord, chest-knee position, trendelenburg position, exaggerated Sims' position, bladder filling with saline.
- Risks for fetus: Hypoxia and death, greatest risk for premature babies and low birth weight (LBW).
Rupture of the Uterus
- Most serious complications: Often fatal for fetus and mother.
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Types:
- Complete: Tear in the uterine wall with or without expulsion of the fetus.
- Incomplete: Tear of the wall but not the perimetrium.
- Dehiscence: Rupture of a scarred uterus, fetal membranes remain intact; fetus remains in the uterus but not in the peritoneal cavity.
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Causes:
- Antenatally: previous classical C/S scar, neglected labor with previous C/S scar, high parity.
- Use of oxytocin, prostaglandins (with previous C/S scar).
- Obstructed labor: excessive thinning of lower segment, extension of severe cervical laceration upwards with assisted birth.
- Trauma (explosion or accident), non-pregnant uterine perforation resulting in rupture of the pregnant uterus.
- Intrapartum signs for complete rupture: Sudden collapse of the mother, severe abdominal pain, increase maternal heart rate (HR), alterations in fetal heart rate (FHR): variable decelerations, fresh vaginal bleeding, contractions stopped, change in contour of the abdomen, palpable fetus in the abdomen, presenting part regressed.
- Incomplete rupture: Found after birth or during C/S, common with previous C/S, scanty blood loss (avascular tissue), expect it when mother shock is more than blood loss, abdominal pain, and postpartum hemorrhage
Amniotic Fluid Embolism
- Rare: Incidence 1-12 cases per 100,000 deliveries. Unpredictable and unpreventable.
- Occurs when: Amniotic fluid enters maternal circulation via the uterus or placenta site.
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Two phases:
- Initial phase: Pulmonary vasospasm (causing hypoxia, hypotension, pulmonary edema, and cardiovascular collapse).
- Second phase: Development of left ventricular failure, hemorrhage and coagulation disorder, further uncontrollable hemorrhage.
- High mortality/morbidity: 61% mortality rate.
- Diagnosis/treatment: early diagnosis, transfer to ICU, emergency drill for maternal resuscitation.
- Predisposing factors: occur at any gestation, commonly associated with labor, amniotic fluid enters through placental bed, raising of intra-amniotic pressure during termination of pregnancy, placenta abruption, artificial rupture of membrane (AROM), insertion of intra-uterine catheter, or internal podalic version during C/S.
Acute Inversion of the Uterus
- Complication of the third stage of labor: Rare and life-threatening, occurring in approximately 1 in 20,000 births.
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Categorization (by severity):
- 1st degree: Fundus reaches the internal os.
- 2nd degree: Body of the uterus is inverted to the internal os.
- 3rd degree: Uterus, cervix, and vagina are inverted and visible.
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Categorization (by timing):
- Acute: within 24 hrs of birth.
- Sub-acute: after 24 hrs, but within 4 weeks.
- Chronic: after 4 weeks (rare).
Causes of Acute Inversion:
- Associated with uterine atony and cervical dilatation, mismanagement of third stage, excessive cord traction, fundal pressure, atonic uterus, and pathological adherent placenta. Other causes are unknown, primiparity, fetal macrosomia, short umbilical cord, and sudden emptying of a distended uterus.
Signs and Diagnosis of Inversion:
- Profound shock; severe abdominal pain from stretching of the peritoneal nerves and pulled ovaries
- Abdominal palpation: indentation of the fundus if severe inversion, may be palpable on vaginal examination or visible. Bleeding may or may not be present depending on placental site adherence
Management of Acute Inversion (Immediate action):
- Keep the woman informed, assess vital signs (V/S) including level of consciousness, call for medical help immediately.
- Attempt to replace the uterus with no delay by holding the hand palm toward the posterior fornix, then towards the umbilicus using (Johnson's maneuver). Keep hand in situ until firm contraction.
Management of Acute Inversion (cont.):
- Give oxytocin if needed.
- If delay and uterus becomes edematous, elevate the foot of the bed.
- IV cannula, cross-match, analgesia (morphia)
- Keep placenta in situ if still attached
- Hydrostatic method: build pressure in vagina to restore uterus to normal position. Insert several liters of saline using a giving set into the vagina, seal the introitus by hand or ventouse cup, give medication to relax the cervical constriction ring.
- May need surgical correction by laparotomy.
Shock
- A complex syndrome involving reduction in blood flow, causing irreversible organ damage.
- Types: Hypovolemic (bleeding or severe vomiting), cardiogenic (impaired ability of the heart to pump blood), neurogenic (insult/abuse to nervous system), septic (severe generalized infection), anaphylactic (allergy or drug reaction).
Hypovolemic Shock: Management
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Call for help, 2 wide-bore cannula, cross-match, maintain airway, side-lying with 40% O2 (4-6 L/min).
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Replace fluid:
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Crystalloids (Normal Saline, Hartmann's, Ringers): 2 liters (fluid may leak into tissue)
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Colloids (Gelofusine or Haemocel): 1-2 liters in 24 hours
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Packed RBC's,
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Fresh Frozen Plasma.
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Warmth, not too harsh,
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Arrest hemorrhage.
Hypovolemic Shock Observation
- Fetal heart rate (FHR), level of consciousness (Glasgow Coma Scale should be >12), assess respiratory status (rate, pattern, pulse oximetry, ABGs, oxygen therapy), blood pressure (every 30 min), continuous heart rhythm monitoring, hourly output, skin color assessment, hemodynamic measures, observe bleeding, hematocrit and hemoglobin (Hb) to assess loss.
Septic Shock
- Clinical Signs: Tachycardia, pyrexia (fever), rigors (shivering), change in mental state, gastrointestinal symptoms, signs of shock, disseminated intravascular coagulation (DIC).
- Management: fluids, oxygenation, full infection screening: use vaginal swap, urine, and blood culture, IV line, indwelling catheters, intravenous antibiotics. Remove any retained conceptus, possible ICU stay, keep family informed.
Uterine Fibroids
- Uterine Fibroids (myomas): slow-growing benign tumors arising from the muscle tissue of the uterus. Usually happen after age 50.
- Most Common In: African American women, those who have never been pregnant.
- Grow Larger When: Taking birth control pills, pregnancy, and hormone therapy.
- Causes: Unknown, possibly genetic factors.
- Treatment Needed When: Fibroids grow large enough to cause pressure on other organs (such as bladder), grow rapidly, cause abnormal bleeding, or cause problems with fertility.
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Types: Classified by location.
- Intracavitary: inside the uterine cavity; usually easily removed using hysteroscopic resection.
- Submucous: partially in the uterine cavity and partially in the uterine wall; also often easily removed by hysteroscopic resection.
- Intramural: inside the uterine wall; usually no treatment is needed unless they cause symptoms or are large.
- Subserous: outside the uterine wall; may need treatment if symptoms or large.
- Pedunculated: on a stalk; may twist and cause pain; easy to remove with laparoscopy
- Cervical: Developed in the cervix.
- Broad Ligament: Developed in the broad ligaments.
- Signs and Symptoms: Bleeding, displacement of surrounding viscera, backache, low abdominal pressure, constipation, urinary incontinence, dysmenorrhea (painful menstruation) dyspareunia (painful intercourse), nausea and vomiting, abdominal mass, and anemia.
- Complications During Pregnancy: Tumors affected by estrogen will increase in size, causing preterm labor, miscarriage, and dystocia (difficulty with labor).
Ovarian Cysts
- Definition: Any collection of fluid surrounded by a very thin wall within an ovary. Ovarian follicles larger than about two centimeters are considered ovarian cysts.
- Dependence: Dependent on hormonal influences associated with the menstrual cycle.
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Types:
- Follicular cysts: Result of a mature graafian follicle failing to rupture. Symptoms only occur if it ruptures (severe pelvic pain). It shrinks after 2-3 menstrual cycles if not surgically treated.
- Corpus luteum cysts: Occur after ovulation due to increased progesterone causing increased fluid in the corpus luteum. Symptoms include tenderness over the ovary, delayed menses, and irregular or prolonged menstruation. Pain can be severe if it ruptures to cause intraperitoneal hemorrhage. Disappears after 2-3 cycles.
- Theca-lutein cysts: Uncommon, bilateral. Associated with molar pregnancies, ovulation induction drugs, and gestational diabetes.
- Polycystic ovary syndrome (PCOS): Multiple follicular cysts in one or both ovaries. Causes excess estrogen. Ovaries are typically double in size. Diagnosed in adolescence.
- Dermoid cysts: Germ cell tumors (hair, bone); removed surgically.
- Ovarian fibromas: Connective tissue, solid, in menopause, range in size up to 23 or 34 kg, unilateral; removed surgically if large to cause pelvic pressure.
- Treatment: Expectant management, monitor cyst size, and use analgesics for pain. Oral contraceptives to suppress ovulation in some cases, surgical removal if the cyst is larger than 8 cm or it cannot be shrunk.
- Nursing care/education: Treatment options, pain management, comfort measures, pre- and post-operative care, symptoms of infection, incision care, recurrence, and follow-up.
Oophorectomy
- Definition: Surgical removal of one or both ovaries. Also called ovariectomy or ovarian ablation.
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Types:
- Unilateral: Removing one ovary; menstruation may continue and have children.
- Bilateral: Removal of both ovaries; menstruation stops and loses ability to have children.
- Purpose: Remove cancerous ovaries, remove source of estrogen that stimulates cancers, remove large ovarian cysts in women with PCOS, excise an abscess, treat endometriosis, lower the risk of ectopic pregnancy, and lower risk of cancer in women with family history of ovarian or breast cancer.
- Procedure: Done under general anesthesia using a vertical or horizontal incision; abdominal muscles are pulled apart, ovaries often fallopian tubes are then removed. Can also be done using a laparoscopic procedure with smaller incisions.
Oophorectomy: Disadvantages of Abdominal Incision
- If woman has many adhesions from previous surgery.
- Check surrounding tissue for disease as a vertical incision is mandatory if cancer is suspected.
- Bleeding, more painful than vaginal or laparoscopic procedures, a longer recovery period, longer hospitalization times (2-5 days) and 3-6 weeks to return to normal activities.
Oophorectomy: Preparation
- Blood and urine tests, ultrasound or x-rays, colon preparation (if expansive surgery is anticipated). Light dinner, and nothing by mouth or fluids after midnight.
Oophorectomy: Aftercare
- Discomfort, hormone replacement therapy to ease menopause symptoms, antibiotics to reduce risk of post-surgery infection (from 2 to 6 weeks). Counseling and support groups, when cancer, chemotherapy, or radiation treatments are involved.
Oophorectomy: Risks
- Reactions to anesthesia, internal bleeding, blood clots, accidental damage to other organs, post-surgery infections, menopause symptom changes (sex drive, hot flashes), and increased risk of cardiovascular disease and osteoporosis, psychological difficulties.
Disorders of Pelvic Floor: Prolapse and Incontinence
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Pelvic Relaxation: Weakness or laxity in the supporting structures of the pelvic region (bladder, rectum, or uterine tissue). Tissues may bulge into the vagina.
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Priority in women's health: Routine screening, identifying symptoms, correcting prolapse, including urinary incontinence.
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Risk Factors: Multiple vaginal births, post menopause, pelvic floor surgery, connective tissue disorders, and obesity.
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Types: Cystocele and urethrocele (bladder), rectocele (rectum), uterine prolapse (uterus), vaginal vault prolapse (vaginal vault).
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Causes: Weakening of pelvic floor muscles, fascia (tissue) and ligaments, which leads to pelvic organs dropping and pushing into the vaginal wall.
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Risk factors: Multiple vaginal births, after menopause, pelvic floor surgery, connective tissue disorders, and obesity.
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Symptoms: vary, possibly no symptoms. Pressure and pain, urinary symptoms, bowel problems. and sexual problems.
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Treatment: Weight loss, avoidance of lifting heavy objects, quitting smoking and Kegels. Surgery is only if major symptoms or inconvenience.
- Less Invasive treatments: Kegels, pessary (device inserted into vagina to support pelvic area and uterus), and pelvic reconstructive surgery; can be vaginal, abdominal, or laparoscopic.
- Surgical Treatment: Repositioning of prolapsed organs, repair of vaginal defects (sometimes with graft), recovery time is typically only one to three days.
- Surgical Complications: urinary tract infections, temporary or permanent incontinence, bleeding, and rare damage to the urinary tract, chronic irritation and pain during intercourse. Recurrence rates continue to decrease as surgical techniques and planning improve.
Benign and Malignant Breast Disorders
- Anatomy: Lobules produce breast milk, ducts to nipples, fatty/connective tissue, blood vessels, lymph vessels; cancer can start in ducts, lobules. Cancer invading lymph vessels can spread to lymph nodes under the arm and then more organs.
- Benign Breast Lumps (80%): Fibrocystic changes, fibroadenomas, lipomas, nipple discharge, mammary duct ectasia, intraductal papilloma, macromastia, and micromastia.
- Fibrocystic Changes: Common in 20-30-year-olds; may relate to estrogen/progesterone imbalance. Symptoms: lumpiness, pain that increases before and decreases after menstruation, tenderness, fullness, possible development of cysts. Diagnosis: ultrasound (fluid-filled – aspirated; solid -mammography, fine needle aspiration [FNA], core biopsy). Treatment: conservative (diuretics, salt/fluid restriction, Vitamin E, caffeine restriction, smoking/alcohol avoidance, pain relievers [NSAIDs], bras, heat), possibly surgical removal.
- Fibroadenomas: Most common after fibrocystic, mostly solid/encapsulated, non-tender, often in the upper outer quadrant, less than 3 cm. Diagnosis: history taking, physical exam, mammogram, ultrasound, MRI, FNA. Treatment: surgical removal if suspicious, possible severe symptoms.
- Lipomas: Soft tumors composed of fat, typically in women older than 45, generally non-tender, easily diagnosed by mammograms. Treatment may be by surgical removal.
- Nipple Discharge: Bilateral serous discharge; normal if stimulation (galactorrhea) bilateral, spontaneous (milky, sticky) discharge; normal in pregnancy. Diagnosis: Prolactin levels taken at 8-10 AM in most cases, microscopic analysis, thyroid profile, pregnancy test, mammogram.
- Mammary Duct Ectasia: Inflammation of ducts behind nipple; chronic inflammation, dilation of ducts. Often occurs in perimenopausal women. Symptoms: thick, sticky nipple discharge (white, brown, green, or purple), burning pain, itching, palpable mass. Diagnostic workup: mammogram, aspiration of fluid, culture of fluid. Management: reassurance, antibiotics, drainage of any abscess, excision of affected duct.
- Intraductal Papilloma: Rare, benign. Cause is unknown. Symptoms: unilateral, spontaneous, serous, bloody discharge in women 30-50 years of age; small (less than 0.5cm). Treatment: eliminate malignancy, excision of affected segment.
- Macromastia/Micromastia: Breast hyperplasia; treatments: reduction mammoplasty, augmentation mammoplasty.
- Malignant Conditions: Breast cancer is a leading cause of death in Jordanian women. Three times more common than gynecologic cancers; 1 in 9 women will be diagnosed with invasive breast cancer during their lifetime.
- Risk factors 20: Gender, Age, Family History, Menarche/Menopause, Previous Breast Cancer, Having had children, Hormonal Replacement Therapy, Alcohol use, Antiperspirants, Underwear Bras, Induced Abortion, Breast implants, Antibiotics use, Night work, environmental pollutant, inherited genetic mutations, high breast density, high dose radiation to chest, previous history of certain cancers, race, and socioeconomic class.
- Chemo Prevention: Medications (like Raloxifene, Anastrazole, Tamoxifen) are used for prevention but identifying the appropriate woman to benefit from these treatments still needs further research.
- Pathophysiology: Genetic alterations in DNA (deoxyribonucleic acid [DNA]) in breast epithelial cells of ductal or lobular tissue, often with inherited or spontaneous genetic alterations. Cancer growth depends on estrogen and progesterone effects. Invasive versus noninvasive cancer. Invasive: ductal, lobular, nipple (Paget's disease).
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Description
Test your knowledge on the critical aspects of amniotic fluid embolism, vasa previa, and related obstetric emergencies. This quiz covers mortality rates, predisposing factors, diagnosis methods, and urgent interventions required during labor. Enhance your understanding of these vital topics in obstetric care.
