HY lecture notes:
Hyperemesis gravidarum = excessive vomiting in early pregnancy leading to ketonuria. Vomiting in early pregnancy is normal, but at what point is it not? HG is diagnosed when there are urinary ketones present.
HG is caused by beta-hCG, which peaks at 8-10 weeks. So the vignette you’ll get is of a woman who is 10 weeks gestation with excessive vomiting. They’ll either ask you for how to diagnose (urinary ketones), or they’ll tell you urinary ketones are 2+ and will ask for management –> answer = admission to hospital + parenteral anti-emetic therapy (metoclopramide).
Acid-base / biochemical profile in HG = low K, low Cl, high bicarb, high pH.
Dermoid cyst = mature cystic teratoma; can present with calcification
Endometriosis vs primary dysmenorrhea is super HY.
PD is “normal” period pain in young women –> girl misses school because pain is so bad (so you’re like, “oh wow could this be endometriosis”), but they’ll say examination is unremarkable –> answer = prostaglandin hypersecretion (PGF2alpha). Dx is clinical (P/E). Tx = NSAIDs. OCPs can also be used to help regulate/stabilize cycles, but if both are listed, choose NSAIDs.
Endometriosis presents as young as 20-23 on the USMLE; classically causes nodularity of the uterosacral ligaments on physical exam; most common location is the ovary (can cause pelvic pain if hemorrhagic cyst, aka chocolate cyst). Details such as pain with defecation, dyspareunia (pain with sex) are too easy for 2CK but fair game for Step 1. Diagnose with exploratory laparoscopy. Tx with NSAIDs + OCPs, but definitive is laparoscopic removal of lesions.
Adenomyosis –> diffusely enlarged uterus due to endometrial tissue growing within the myometrium. They’ll say there’s bleeding per vaginum in a woman who has a very large uterus. They might tell you there’s a 38-year-old woman had a tubal ligation two years ago (i.e., there’s no way she’s pregnant), but on physical exam she has a uterus consistent with 8 weeks gestation –> adenomyosis. Dx by ultrasound showing diffusely large uterus. Tx = NSAIDs + OCPs. Leuprolide and other agents may be considered for intractable bleeding.
Uterine fibroids, aka leiomyomata uteri –> most common tumor in women period (more common than fibroadenoma of breast). They do not progress to leiomyosarcoma (meaning they can sometimes be observed), and in fact, if they tell you a woman has a few fibroids picked up incidentally on USS, sometimes with dull abdominal pain, answer = observe / re-ultrasound in six months. If fibroids are not causing intractable bleeding, they can be observed. If bleeding, NSAIDs and OCPs can be used.
Fibroid types (obgyn shelf certainly asks, and it’s on the NBME forms):
Submucosal –> on the side of the endometrium –> bleeding + large, smooth uterus –> USS will differentiate from adenomysosis.
Subserosal –> on the external side of the uterus (e.g., closer to the bladder) –> no bleeding + enlarged globular uterus –> USS to diagnose.
Intramural –> variable symptoms –> grows deep within the myometrial layers.
Pedunculated –> can project from the uterus in any number of directions; there’s a Q on one of the obgyn forms where they say there’s a beefy red mass protruding from the cervical canal –> answer = pedunculated submucosal leiomyoma. The “beefy red” implies glandular tissue. This isn’t cervical cancer, which instead may be inconspicuous (which is why we do Pap smears and colposcopic biopsies to Dx); but if cervical cancer is conspicuous, they’ll describe it as an “exophytic ulcerated mass” growing from the cervix in a woman who hasn’t had a Pap smear for many years.
