婦產科

Gynecology

●Basic Obsterics

⊙GA= CRL+ 6.5 （65歲是老人）

⊙Gestation sac: GA 4 wk
Yolk sac: GA 5 wk
Heart motion: GA 6 wk（心臟溜溜跑）

⊙Health exam:
6 wk:VDRL, U/A（一開始）
14-18:amniocentesis for Down，母血篩檢：AFP↓, b-HCG↑, uE3↓（第二期開始）
20-24:Echo
24-28:OGTT（第三期開始）
32 :Rubella, ★HBV

⊙fetal circulation
u.v(1)→ductus venosus→IVC....→u.a(2)

⊙40 wk 腹圍： 110 cm

⊙EDC=LMP + 9/7
pre-term: 20-36 wk
near-term: 36-38 wk
term: 38-42 wk
post term: 42- wk

⊙Partogram
CxOs: S shaped: >3cm into active phase
Station: hyperbolic: >+2 into 3rd stage
1st Stage: from pain(3/10 min) to OS complete
2nd Stage: to fetal
3rd Stage: to placenta
4th Stage: within 1 hr
Active phase: < 6hr, 1 fb/ 2hr
Latent phase: < 8hr, protraction disorders

⊙Mechanism of labor:
1.engagement: pelvic inlet, station 0
2.descent
3.flexion
4.internal rotation: pass by symphysis
5.extension:
6.external rotation: 胎頭娩出
7.expulsion

⊙Expulsion of placenta
1.gush of blood
2.elongation of cord
3.elevation of fundus
4.globular shape of uterus
→Duncan: mother side / Schultz: fetal side（當媽媽的惜小孩）

⊙潛伏期過長(prolonged latent phase)：
初產婦於20小時，經產婦於14小時後仍未進入active phase：首先可以sedatives讓病人休息，如宮縮仍然不好，可給予oxytocin來加強宮縮，在緊急狀如胎兒窘迫，產程遲滯，則應行剖腹產。

⊙下降停滯(Arrest of descent)：
2nd stage，胎頭超過一小時沒有下降之謂。處理方式：行剖腹產

⊙產褥熱

→定義：產後24小時後至10天內其中有2天以上口溫超過38℃(100. 4 °F)以上稱之。常見的感染為子宮內膜炎，泌尿道感染，乳腺炎及肺炎。但因現在抗生素的使用，使體溫很快下降，且一般產婦不一定住院至10天，所以使此定義適用性降低。

→生產中risk factor：
a. 剖腹產 b. 手術性陰道生產(operative vaginal delivery) c. 會陰剪開、及生產之裂傷 d. 出血

⊙Caput succedaneum: edematous swelling

●Perinatalogy

⊙PROM: PG ↑, pH ↑, Nitrazine paper change from yellow to blue

⊙Fetal distress
→胎心加速，可能是刺激交感神經而來
→早發性減速因胎頭壓迫引起，其特徵為形狀一致且減速開始在宮縮期之早期。（如石鐘乳倒影）
→晚發性減速因胎盤機能不全，其特徵為形狀一致且減速開始在宮縮期之末期。
→不定性減速因臍帶壓迫引起，其特徵為形狀有變異且減速之開始與宮縮之開始間的時間關係不定。

⊙Reassuring FHR Patterns
a. Baseline FHR between 120 and 160 bpm (100--120 and 160--180 also accepted)
b. Good short-term baseline variability (5--15 bpm)
c. No change in FHR baseline with contractions
d. Accelerations with contractions or fetal movements
e. Mild to moderate Type I decelerations

⊙Nonreassuring FHR Patterns
a. Tachycardia > 180
b. Bradycardia < 100
c. Decreased beat-to-beat variablilty < 5 bpm
d. Severe (Type Ⅰ) deceleration < 60 bpm
e. Late (Type Ⅱ) deceleration of any magnitude
f. variable (Type Ⅲ) deceleration of moderate to severe magnitude

⊙Proteinuria in preeclampsia: >300mg/d, >100mg/dl

⊙Severe preeclampsia
SBP> 110mmHg
Kidney: Proteinuria ++, oliguria(+), Cr ↑
Liver: Bil↑, GOT↑, upper abdominal pain
Hema: low platelet (<100K)
CNS: headache, blurred vision

Tx: ACEI contraindicated
MgSO4: anticonvulsion

⊙Ectopic:
→serum b-HCG > 66% ↑/48hr
→cervical ectopic: uterine resection

⊙Preterm labor:
1.bed rest, sedation, hydration
2.Ritodrine(Yutopar): b2 agonist
3.MgSO4:
4.Steroid: 28-32wk, for prevention of RDS

⊙Major maternal mortality:
1st: Amniotic fluid embolism
2nd: HTN, ecclampsia
3rd: PPH

⊙APH: >28wk
1.Placenta previa: total(47%), painless vaginal bleeding, migration of placenta, double setup
2.Placenta accreta: myometrium attachment
3.Placenta abruptio: Triad: vaginal bleeding, uterine tenderness, fetal distress
4.Uterine rupture: 1% in VBAC

⊙PPH: <24hr / <6wk, >500ML, 4T:
1st: Tone: uterine atony
2nd: Trauma: vaginal injury
3rd: Tissue: retained placenta
4th: Thrombin: hypofibrinogenemia（死胎、羊水栓塞及胎盤分離過早，都可能用掉血液的 Fibrinogen 而產生凝血問題。）

Tx: uterine massage, ergonovine, pitocin, PGF2a

⊙三胞胎以上的發生率以公式來推算約為80^n-1分之一

⊙Twins
→囊胚 (blastocyst)之外層→→絨毛膜(chorionic)→→羊膜形成(amniotic)→→胚胎盤(embryonic disk)已形成（綿羊）
→Diamniotic- dichorionic twin 30％
→Diamniotic-monchorionic twin 68％, Twin-twin transfusion syndrome， TTTS
→monoamniotic- monochorionic twin 2％, cord entanglement, interlocking twin，周產期死亡率最高，約在50％以上
→conjoined twin, 1/1500

→頭產／頭產：45％

⊙Phenytoin: distinctive craniofacial abnormalities, mental and growth deficiency and, less frequently, oral clefts and cardiac anomalies.

●General Gynecology

⊙Catamenial pneumothorax: due to atopic endometriosis

⊙Bacterial vaginosis
→nonspecific vaginitis, Haemophilus vaginitis, or Gardnerella vaginitis.
→★clue cells: the most reliable indicator of BV
→Whiff test: KOH solution, determine if a strong ★fishy odor is produced
→Vaginal pH elevation: normal: 3.8 to 4.5/ BV: rise above 4.5
→Gram-negative bacteria: especially Gardnerella vaginalis, are most common

⊙Trichomoniasis: "★strawberry cervix"

⊙Candida vulvovaginitis:
vaginal pain, itching, or redness; a thick, white "★cheesy" vaginal discharge; pain or discomfort on urination; and sometimes whitish or yellowish patches on the skin of the vaginal area

⊙PID: Mixed infection, Tx: 3-combined
Cefa/Unasyn + Clindamycin + Gentamicin

⊙Vaginal vessels:
uterine, middle rectal, vaginal, internal pudendal a.

⊙When isolating Neisseria gonorrhoeae and Neisseria meningitidis on THAYER-MARTIN Agar or other culture media, it accelerates the growth of these microorganisms considerably and thus reduces the time required for incubation.

⊙Round lig: fundus→inguinal canal→labia majora（都是圓圓的）

⊙Myoma symptoms
(1) 不正常的子宮出血:
(2) 痛:
(3) 壓迫症狀:
(4) 不孕:
(5) 自然流產:
→求偶素 (estrogen) 的刺激: 停經後大部份的子宮肌瘤會縮小及懷孕時子宮肌瘤通常會變大都顯示其與求偶素有密不可分的關係，但是也有些子宮肌瘤並不受求偶素的影響, 故求偶素並不是引起子宮肌瘤的唯一因素。

⊙Myoma without symptoms op indication:
1.size> 10cm
2.infertility
3.rapid growth
4.torsion

⊙Endometrial Hyperplasia
→長時間動情激素(estrogen)對子宮內膜過度刺激及沒有黃體素 (progestin) 對內膜的保護
→不正常的陰道出血。易出先現的時期如初經時或常見於更年期後。
→degree of atypicality of the hyperplasia
→Endometrial cystic hyperplasia(★Swiss Cheese hyperplasia): Increased glandular to stromal ratio. No cytologic atypia. The glands are cystically dilated.
→演變為惡性腫瘤之機率
(1) 單純性囊性增生(無細胞異型) 1%
(2) 複雜性腺瘤性增生(無細胞異型) 3%
(3) 單純性囊性增生(有細胞異型) 8%
(4) 複雜性腺瘤性增生(有細胞異型) 29%

→progestin(provera) 10mg daily for 10 days 或estrogen-progestin oral contraceptives
→欲生育者: clomiphene citrate (Clomid)

→Novak textbook (1996)中提及之標準治療方法:
a. 單純性增生(simple hyperplasia)
medroxyprogesterone acetate 10-20mg/day for 14 days per month or megesterol acetate 20-40 mg daily for 2 - 3 months
b.異型增生 (atypical hyperplasia), 複雜性增生(complex hyperplasia): Megesterol acetate(Megace) 40 mg daily for 2 - 3 months

⊙Menopause

→depletion of ovarian follicles with degenerationof the granulosa and theca cells。
→血中 estradiol的值會小於15pg/ml，而FSH會大於40mIU/ml，LH的值也會增高。
→女性荷爾蒙缺乏所導致的續發效應
(1) 泌尿生殖器方面：子宮、子宮頸會縮小、子宮內膜變薄、陰道與尿道黏膜萎縮、陰道潤滑減少。甚且，圍繞陰道與尿道的組織會失去彈性。
(2) 骨質疏鬆症 (Osteoporosis)：在女性荷爾蒙缺乏下，骨質resorption的速度加快，而骨形成的速度卻保持不變。骨質的流失分兩種， Cortex 及 Trabecular ，前者在停經後以每年 1-1.5 ％的速度流失，後者在停經前就開始有變化，以每年 1-3 ％的速度流失

大約 25 ％的骨質流失後， X 光檢查就可以偵知有 Osteoporosis 的存在，所以 CT 的檢查可以更早知道。現在更有 DEXA （ Dual-energy X-ray Absorptiometry ）的方法可以來診斷骨質疏鬆症。

(3) Vasomotor effect：最常見的症狀是熱潮紅，常發生於夜晚，持續約幾十秒到數分鐘，常伴隨嘔心、頭暈、盜汗、頻脈、失眠等。
(4) 心臟血管系統方面：女性荷爾蒙會增加HDL而減低LDL的濃度，因而減低心臟血管疾病的發生，如CVA, AMI等。
(5) CNS 方面及行為的改變：有些人會抱怨失眠易動怒、記憶減退、無法集中注意力等。

⊙尿失禁

a)暫時性尿失禁－如發生於尿路感染或精神錯亂者。
b)應力性尿失禁－因支撐膀胱頸的組織變弱，或具高移動性尿道，或尿道本身功能不全。當病患的腹壓上昇時，導致尿失禁發生。此種尿失禁為婦女最常見的，約佔80％。
c)不穩定逼尿肌(detrusor instability)－患者之逼尿肌呈不穩定之收縮，常會造成頻尿或急性尿失禁(urge incontinence)，此佔婦女尿失禁中約為10％。
d)滿流性尿失禁－因長期憋尿或神經病變，導致膀胱功能失常，膀胱容積變大且缺乏張力，會導致滿流性尿失禁。
e)綜合性尿失禁－合併數種不同原因的尿失禁，在婦女尿失禁中，約有20％之病患同時罹患了上述的b)及c)二種。
f)其它種類之尿失禁－如腦血管病變，像中風之病人，或長期臥床之病患，也會導致機能性尿失禁。

●Gynecologic Oncology

⊙Bethesda report system:
1.ASCUS
2.LSIL: HPV, CIN I
3.HSIL: CIN II,III→Colposcopy/ Conization

⊙Conization indications:
1.SCJ junction not visible
2.CIN II, III
3.Pap & Colposcopy not compatible
4.Microinvasion

⊙Cervical ca. staging:
I: cervix
IIa: < upper 2/3 of vagina
IIb: parametrium
IIIa: > lower 1/3 of vagina
IIIb: pelvic wall, hydronephrosis
IVa: rectum, bladder
IVb: distant meta

→→Stage I, IIa: R/T or radical hysterectomy
→→Radical histerectomy (Stage III):（可保留卵巢功能）
1.cardinal lig.
2.uterosacral lig.
3.vagina upper 1/3

⊙Ovarian ca. D/D:
1.Ectopic pregnancy
2.Follicular cyst
3.Ovarian neoplasm
4.TOA(Tubo-ovarian abscess)
5.Myoma uteri
6.Chocolate cyst

→→ATH+BSO+Omentectomy+Appendectomy (Stage I,II)

⊙C/T of ovarian ca.
→Stromal: Cisplatin + Taxol
→Germ cell:BEP, VAC, VBP

⊙Diagnosis of Ovarian ca.
→排除消化道轉移至卵巢之惡性腫瘤：
下消化道檢查（LGI），內視鏡（Endoscope），大腸鏡（Colonofiberoscope）

→當超音波有以下發現時，須高度懷疑為卵巢惡性腫瘤：
(a)實質性（solid）(b)兩側性（bilaterality）(c)不規則形狀（irregular shape）(d)乳突物（papillation）(e)腹水（ascites）(f)阻力指數小於0.4（resistance index, R.I. ＜0.4)

→腫瘤標記(Tumor marker)：
a.上皮細胞癌(epithelial stromal tumor):CA125, TPA, CA19-9, CEA
b.生殖細胞腫瘤(germ cell tumor)
絨毛膜癌（choriocarcinoma）→ beta-HCG (hCG)
內胚層竇狀瘤(endodermal sinus tumor) →alpha-fetoprotein (AFP)
胚胎上皮癌（embryonal carcinoma）→ AFP＋hCG
惡性胚胎瘤（dysgerminoma）→ LDH
畸形瘤的惡性轉化（malignant transformation of teratoma）→ SCC antigen
c.性腺基質癌(sex-cord stromal tumor)
granulosa ─ theca cell tumor → estrogen
gonadoblastoma → testosterone, DHEA

⊙Papillary carcinoma中的psammoma body指一圈圈同心層狀排列的球狀的calcification。一般認為出現psammoma body就是代表是papillary malignancy，不管是在thyroid或ovary都一樣。Ovary的papillary cystic adenocarcinoma也會出現psammoma body。Benign的nodular goiter也會出現calcification，但與同心層狀排列的psammoma body不同，是cystic degeneration，hemorrhage之後necrosis造成calcification是irregular不規則排列的calcification。

⊙子宮內膜癌的診斷主要靠 Fractional D&C: 除了刮取endometrium 以外，也要刮取 endocervical tissue, 6mm為標準做為內膜切片的適應症

⊙Complete/partial mole
→46XX（都來自父親！！） / 9XXY(Triploid)
→Echo: ★snow storm
→hCG ↑

⊙Vulvar ca
A.腫瘤大小：平常以直徑 2 公分為早期外陰癌之上限。
B.腫瘤侵犯深度：微侵襲癌 (Microinvasive carcinoma)，或稱為 Stage Ia，其預後較侵襲癌為佳，它的定義是:
直徑小於 2 公分。侵犯深度小於基底膜下 1 mm。早期基質侵犯 (Early stromal invasion)。未侵犯淋巴血管間隙 (lymph vascular space)。癌細胞分化良好 (Grade 1)。

C.組織學種類及細胞分化程度。
D.淋巴結侵犯情形：淋巴散佈方向為鼠蹊部淋巴結---> 骨盆腔之淋巴結 (包括髂淋巴結及閉孔淋巴結)。
E.腫瘤位置: 陰蒂 (clitoris) 腫瘤比陰唇 (labia) 腫瘤之預後較差。

●Reproductive Endocrinology

⊙催經針：progesterone
排卵針：clomid (weak estrogen)
避孕針：high dose estrogen
避孕藥：estrogen + progesterone
墮胎藥：anti-progesterone (RU486)
安胎針：progesterone

⊙Puberty:breast→→menstruation→→pubic hair

⊙Puberty: Tanner stage
Stage 2: budding, pubic hair

⊙Puberty: 5 stages
1.Adrenarche：
此階段腎上腺皮質功能逐漸活躍。這個階段一般約從6歲開始至13-15歲。血液中的 dehydroepiandrostenedione ( DHA) , dehydroepiandrosterone sulfate ( DHAS) 及 androstenedione 逐漸增加。有些疾病如 Kallmann's syndrome 或 Addison's disease 會造成不正常的 Adrenache 。

2.Thelarche：
這個階段一般出現於 9-10 歲。乳房的發育主要是受到 estrogen 的刺激而體積變大，乳暈顏色深以及乳腺的分化成熟。乳房可用 Tanner staging來評估其發育的的情形。

3.Pubarche：
陰毛及腋毛通常出現在 10 至 11 歲。此階段主要是受到腎上腺功能的影響。評估此階段的發育也可以用 Tanner staging 。

4.Growth Spurt：
這個階段約在 11 至 12 歲時出現。女孩子較男孩子早 2歲出現。影響此階段的內分泌主要是 growth hormone 及 estogen。

5.Menarche：
此階段在 12 至 13 歲時出現且通常在 growth spurt 之後。 Menarche 代表著下視丘，腦下垂體及卵巢開始成熟。

⊙Vaginal bleeding
1.Submucous myoma
2.Uterine/ Cervical Tumor
3.Endometriosis
4.Abortion
5.Trauma
6.DUB: withdraw / breakthrough bleeding
→Perimenopausal:
(endometrial polyp) > endometrial atrophy> endometrial ca....

⊙Dysmenorrhea
1.Primary: PGF2a, < 20 Y/O!!
2.Secondary:
→Cervical stenosis
→endometriosis
→PID
→Pelvic congestion syndrome
→Psychological

⊙Amenorrhea

當一個具有正常生長和第二性徵的女孩到了 16 歲或一個不具正常生長和第二性徵的女孩到了 14 歲仍沒有月經出現，即稱為原發性無月經症。一個婦女過去有正常月經，然後至少六個月以上沒有來月經。或是婦女過去月經稀少（ Oligomenorrhea ），然後連續 12 個月以上沒有月經稱為繼發性無月經。

0.Exclusion:
(1)Prgnancy
(2)TSH
→Hyperthyroidism: Thyroxin↑→liver SHBG↑→free E2↓→LH surge↓
→Hypothyroidism: Thyroxin↓→TRH↑→prolactin↑→GnRH↓
(3)Prolactin
(4)Progesterone challenge test

1.Genital anomaly:
→Asherman's syndrome: intrauterine adhesion by D&C
→Muellerian anomalies: imperforate hymen....
→Muellerian agenesis: Rokitansky syndrome無子宮與陰道
→Androgen insensitivity: Testicular feminization

2.Ovarian disorder:
→gonadal dysgenesis: Turner's syndrome(45XO): 50% in primary

3.Ant.pituitary disorder:
→prolactin secreting tumor
→Sheehan's syndrome

4.Hypothalamic disorder:
→BW loss, anorexia nervosa, exercise
→Kallmann's syndrome: & anosmia無嗅覺

⊙Polycystic Ovarian Syndrome (PCOS)

→menstrual disorder, hirsutism, infertilly, obesity, enlarged polycystic ovaries
→被囊下有無數的小囊泡，以〝項鍊狀〞排列在卵巢的邊緣, thickened tunica albuginea, Hyperthecosis, Luteinization of the stroma
, Thickening of basement membrane, Reduction of granulosa cells.

1.LH/FSH↑3:1（LH本來就較高）
2.high androgen
3.high endogenous estrogen production
→除非要懷孕，否則口服類固醇避孕藥最好。
→GnRH analogues
→想懷孕的婦女，應給予促進排卵的藥物，先從Clomiphene citrate給起，若沒反應再給HMG或GnRH。

⊙Gonad→(Testis determing factor from chr. Y, TDF)→testis（否則變成卵巢）

→Leydig cell→(hCG)→Testosterone→Wolffian duct(Mesonephrine duct)
→Sertoli cell→Muellerian inhibition factor(MIF)（故男性沒有Mueller的女性器官）

⊙Hermaphroditism（用染色體定義性別）
1.Female Pseudohermaphroditism: 46XX, androgen excess, CAH(21-hydroxylase def.)
2.Male Pseudohermaphroditism: 46XY, androgen def. 5a-reductase def.(DHT in peripheral) Androgen insensitivity
3.True hermaphroditism: XX, 70%, sex chromatin-positive, have testis and ovary, MC(+)

⊙Arias-Stella's phenomenon

Highly excretive gland epithelium due to increased gonadotropin stimulation. An endometrial gland cell abnormality consisting of hyperchromatic nuclei, which may be present in normal or ectopic pregnancy. It is not a sign of endometrial adenocarcinoma, with which it was previously sometimes confused.

⊙Decidual reaction

A transformation of the lining of the uterus (the endometrium) in pregnancy. Complete confluence of endometrial stromal cells (lying between the endometrial glands) occurs, caused by prolonged (14 days or more) exposure to progesterone or a progestogen; normally happens only with pregnancy.