Adam Shared "OB/GYN" - 185 Picmonics

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OB/GYN

Granulosa Cell Tumor
Granulosa Cells
Non-germ cell tumor
Endometrial Carcinoma
Call-Exner bodies
Estrogen producing
Precocious Puberty
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42 secs
Pelvic Inflammatory Disease (PID)
Mechanism
Neisseria gonorrhoeae
Chlamydia Trachomatis
Symptoms
Cervical Motion Tenderness
Chandelier Sign
Salpingitis
Tubo-ovarian abscess
Hydrosalpinx
Complications
Ectopic Pregnancy
Infertility
Adhesions
Fitz-Hugh-Curtis Syndrome
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2 mins
Acute Abdominal/Pelvic Pain in Women 12160
Mittelschmerz
Recurrent mild & unilateral mid-cycle (around day 14) pain prior to ovulation
Pain lasts hours to days
No peritoneal signs
Ultrasound: Not indicated
Rupture of the follicle releases the egg; concomitant release of some blood during process irritates peritoneum
Reassure patients
Ruptured ovarian cyst
Sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity
Nausea & vomiting
Unilateral, tender adnexal mass on examination
Can cause hemoperitoneum often while on anticoagulants
Diffuse severe abdominal pain, pleuritic chest pain, and shoulder pain (due to phrenic nerve irritation)
Gynecologic emergency typically occurring in premenopausal patients
Diffuse abdominal rigidity with rebound and guarding is present
Symptoms arise due to ischemia and eventually necrosis
Decreased hematocrit due to intra-abdominal blood loss
Twisting around its supporting structures (infundibulopelvic ligament or utero-ovarian ligament) which contains ovarian blood supply
Ultrasound + Doppler: Pelvic free fluid and possible adnexal mass if the cyst is incompletely drained
Enlarged ovary with decreased or absent blood flow
Dermoid cysts in particular have a higher likelihood of torsion than other types of ovarian masses
Treatment: prompt surgical laproscopy with detorsion, cystectomy, possibly removal of the adnexa (if necrosis despite restoration)
Untreated torsion may lead to chronic pelvic pain, infertility, hemorrhage, or peritonitis and sepsis
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Normal Physiological Changes During Pregnancy 2804
Multiple skin tags
Nocturnal leg pain is also common due to muscle cramping from lactic and pyruvic acid accumulation
Renal/Urinary
Increased Glomerular filtration rate & renal size
Increased cardiac output & renal blood due to progesterone with increased renal excretion
Decreased blood urea nitrogen & serum creatinine
Urinary frequency, nocturia
Increased urine output & sodium excretion
Mild hyponatremia
Hormones reset threshold to to increase ADH release from pituitary
Increased basement membrane permeability --> increased renal protein excretion
Heme
Dilutional anemia
Increased Plasma volume & red blood cell mass
Prothrombotic state
Hormone mediated decrease in total protein S antigen & activity; increase in fibrinogen & coagulation factors
Pregnant patients often have mildly decreased (> 70,000/mm3) platelet counts, a condition known as gestational thrombocytopenia
Cardiovascular
Increased Heart Rate
Decreased systemic vascular resistance
Systolic ejection murmur
Decreased blood pressure
Edema
Pulmonary
Chronic respiratory alkalosis with metabolic compensation, increased PaO2 & decreased PaCO2 (metab comp with decrease HCO3)
Progesterone directly stimulates central respiratory centers (medulal) to increase tidal volume & minute ventilation
Decreased functional residual volume
Dyspnea
Hgb goes down because its a concentration but theres both more plasma and RBCs (just even more plasma)
Tidal volume (VT) increases
Functional residual capacity decreases
Clotting factors increase (VII, VIII, X, von Willebrand) and anticlotting factors decrease (Protein C, Protein S, and Antithrombin III)
↑ Fibrinogen (so “normal” fibrinogen at delivery is likely DIC); ↑ D-Dimer (so dont use D-dimer for thrombosis testing)
Creatinine should decrease through pregnancy. “Normal” values at the upper end of normal should be considered pathologic
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Osteogenesis Imperfecta
Pathophysiology
Autosomal Dominant
Decreased Type I Collagen Production
Symptoms
Phenotypically Diverse
Brittle Bone Disease
Fractures from Minimal Trauma
Confused with Child Abuse
Hearing Loss
Dental Imperfections
Blue Sclera
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1 min
Achondroplasia
Mechanism
Autosomal Dominant
Advanced Paternal Age
Most Common Cause of Dwarfism
Mutation of FGFR3 (Fibroblast Growth Factor Receptor 3)
Defective Endochondral Ossification
Symptoms
Delayed Motor Milestones
Shortened Limbs with Normal Axial Skeleton Size
May Develop Hydrocephalus
Symptoms of Spinal Stenosis
Normal Life Span and Fertility
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2 mins
Paget's Disease of Bone
Pathophysiology
Men > Age 40
Increased Osteoblast and Osteoclast activity
Mosaic Pattern
Signs and Symptoms
Increased Skull Diameter
Hearing Loss
Fractures
Bone Ache and Joint Pain
High Output Heart Failure
Diagnosis
Bone Scan
Normal Parathyroid hormone (PTH) and Calcium
Elevated ALP
Treatment
Bisphosphonate
Calcitonin
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2 mins
Hyperemesis Gravidarum
Signs and Symptoms
Excessive Vomiting
Significant Weight Loss
Dehydration
Hypotension
Electrolyte Imbalance
Interventions
Antiemetics
Frequent Small Meals
IV Therapy
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1 min
Genito-Pelvic Pain/Penetration Disorder (Vaginismus) 3861
Risk factors
Sexual trauma
Lack of sexual knowledge
History of abuse
Clinical features
Pain with vaginal penetration
May occur with tampon insertion or gynecologic exam
Distress/anxiety over symptoms
No other medical cause
Treatment
Desensitization therapy
Kegel exercises
Vulvodynia
Formerly termed vestibulodynia
Painful entry dyspareunia
Physical examination shows pain to superficial touch of the vaginal vestibule
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Magnesium Sulfate
Mechanism
Muscle Relaxant
Indications
Preterm Labor Contractions
Preeclampsia
Side Effects
Warm Feeling
Hypotension
Decreased Deep Tendon Reflexes (DTRS)
Decreased Respiratory Rate
Decreased Urine Output
Paralytic Ileus
Antidote
Calcium Gluconate
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2 mins
Oxytocin (Pitocin)
Mechanism of Action
Increase Uterine Contractions
Indications
Labor Induction
Control Postpartum Hemorrhage
Side Effects
Uterine Rupture
Water Intoxication
Contraindications
Fetal Lung Immaturity
Cervix Not Ripened
Active Genital Herpes Infection
Considerations
Use Lowest Dose
IV Pump
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3 mins
hCG 580
Source: Syncytiotrophoblast of placenta
Other functions include promotion of male sexual differentiation and stimulation of the maternal thyroid gland
Production begins at day eight after fertilization, levels double every 48 hours until they peak at six to eight weeks gestation
Placental hormone secretion generally increases over the course of pregnancy, but hCG peaks at 8–10 weeks
Function
Maintains corpus luteum (and thus progesterone) for first 8–10 weeks of pregnancy by acting like LH (otherwise no luteal cell stimulation causes abortion)
After 8–10 weeks, placenta synthesizes its own estriol and progesterone and corpus luteum degenerates
Used to detect pregnancy because it appears early in urine (2 weeks) or via blood (1 week)
Has identical α subunit as LH, FSH, TSH (states of increased hCG can cause hyperthyroidism)
β subunit is unique (pregnancy tests detect β subunit)
hCG is increased in multiple gestations, hydatidiform moles, choriocarcinomas, and Down syndrome
hCG is decreased in ectopic/failing pregnancy, Edward syndrome, and Patau syndrome
Stimulates the production of thyroid hormones by binding to thyrotropin (TSH) recepto rs on thyroid follicular cells
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Estrogen 577
Source: Ovary (17β-estradiol), placenta (estriol), adipose tissue (estrone via aromatization)
Potency: estradiol > estrone > estriol
Induction of prolactin production during pregnancy
FUNCTION
Development of genitalia and breast, female fat distribution
Growth of follicle, endometrial proliferation, increased myometrial excitability
Upregulation of estrogen, LH, and progesterone receptors; feedback inhibition of FSH and LH, then LH surge; stimulation of prolactin secretion
Increased transport proteins, SHBG, thyroxine-binding globulin; increased HDL; decreased LDL
Pregnancy
50-fold increase in estradiol and estrone
1000-fold increase in estriol (indicator of fetal wellbeing)
Estrogen receptors expressed in cytoplasm; translocate to nucleus when bound by estrogen
Increased GnRH receptor on anterior pituitary
Production
LH stimulates desmolase in theca cells to form androgen from cholesterol
FSH stimulates aromatase in granulosa cells to make androgens into estrogen
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Acute Mastitis, Periductal Mastitis and Mammary Duct Extasia (
Acute mastitis
Staph Aureus infection
Associated with breast feeding (fissures develop in nipple and bacteria enter)
Erythematous breast, purulent nipple discharge, may have abscess
Continue breastfeeding, dicloxacillin
Periductal mastitis
Usually seen in smokers
Smoking causes relative Vit A decifiency, Vit A deficiency causes squamous metaplasia of periductal cells
Cells produce keratin and block the duct resulting inflammation
Subareolar mass with nipple retraction - due to inflammation and fibrosis
Mammary duct ectasia (dialation)
Chronic inflammation that causes dilation (ectasia) of subareolar duct
Periareolar mass with green-brown nipple discharge
Plasma cells on biopsy
Rare; classically arises in muliparous postmenopausal women
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risk factors for preterm birth
hx of preterm birth
short interpregnancy interval
Bright Red Vaginal Bleeding
periodontal disease
cervical surgery
short cervical length
low maternal BMI, smoking, alcohol
progesterone therapy can decr risk
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Epithelial Ovarian Carcinoma 12052
Epithelial ovarian carcinoma refers to a malignancy involving the ovary, fallopian tube, and peritoneum
Clinical Presentation
Acute: Shortness of breath, obstipation/constipation with vomiting, abdominal distension, ascites, decreased bowel sounds
Subacute: Pelvic/abdominal pain, bloating, early satiety
Firm, non-mobile pelvic mass with nodularity in a postmenopausal patient is concerning for EOC
Asymptomatic adnexal mass
Occurs primarily in postmenopausal women and women with BRCA mutations
Laboratory findings
Increase CA-125
CA-125 testing has particularly low specificity in premenopausal women, not used during initial evaluation
Useful mainly in postmenopausal women and is not recommended for the initial evaluation of an adnexal mass in premenopausal patients
Ultrasound findings
Solid mass
Thick septations
Ascites
Management
Pelvic ultrasonography is the first-line test for evaluation of a palpable adnexal mass
Exploratory laparotomy
The ovaries, uterus, omentum, and any cancerous lesion will be removed and pelvic and paraaortic lymph nodes will be dissected
Chemotherapy with platinum-based agents is initiated after surgery
O: Paclitaxel
The ideal time for surgery is in the early second trimester
Chemotherapy can be admin istered in the second and third trimesters , although recommendations vary depending on the tumor type
Don't biopsy, risk of seeding
Risk factors
Family history
Genet ic mutations (BRCA 1, BRCA2)
Age ≥50
Hormone replacement therapy
Endomet riosis
Inferti lity
Early menarche /late menopause
Protective factors
Oral contraceptive pills
Multipar ity
Breastfeeding
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Contraindications to External Cephalic Version 3118
Offered at 37 weeks
External cephalic version (ECV) involves maneuvers to convert a breech into a vertex presentation for delivery
ECVs has potential to cause fetal distress, perform only when arrangements have been made for a back-up emergency cesarean delivery
Internal podalic for twin delivery to convert the second twin from a transverse/oblique to a breech for subsequent delivery
Contraindication
Indications for cesarean delivery regardless of fetal lie (eg, failure to progress during labor, non-reassuring fetal status)
Placental abnormalities (eg, placenta previa or abruption)
Oligohydramnios
Ruptured membranes
Hyperextended fetal head
Fetal or uterine anomaly
Multiple gestation
Abnormal fetal heart tracings
Classical C section as its not advised to proceed with vaginal birth afterwards
Active labor is a relative contraindication for external cephalic version
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Abruptio Placentae
Mechanism
Premature Separation of Placenta
Assessment
Tearing Pain
Bleeding (Often Concealed)
Rigid Uterus
Contractions
Interventions
Prepare for Vaginal Delivery
Considerations
Increased Risks for Neonate
Rh (Rhesus) Incompatibilities
Increased Risk for Shock
Monitor Fetal Heart Rate
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2 mins
Syphilis - Diagnostic Serology 4792
Negative screening but strong clinical evidence of primary syphilis (chancre) --> empiric intramuscular benzathine penicillin G
Repeat nontrep serology in 2-4 weeks (establish baseline titers); 4-fold titer decrease at 6-12 months --> adequate treatment
First prenatal visit testing, if one is positive then confirm with the other (high false positive rate)
Penicillin allergy should have a penicillin skin test to evaluate for the presence of an lgE-mediated response
If positive, desensitize patient to penicillin before treatment with intramuscular penicillin G benzathine
1 dose weekly for 3 weeks
Nontreponemal (RPR, VDRL)
Antibody to cardiolipin-cholesterol-lecithin antigen
Quantitative (titers)
Possible negative result in early infection
Nontreponemal tests may have higher false-negative rates (20%-30%) in patients with primary syphilis
Decrease in titers confirms treatment
Treponemal (FT A-ABS, TP-EIA)
Antibody to treponemal antigens
Qualitative (reactive/nonreactive)
Greater sensitivity in early infection
Positive even after treatment
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Management of PPROM 3274
Symbols
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