["630 SEC TION III Renal\u2003 \uf07d\u2009RENAL\u2014Pharmacology Angiotensin- Captopril, enalapril, lisinopril, ramipril. converting enzyme inhibitors Inhibit ACE \u008e \u0090 AT II \u008e \u0090 GFR by preventing In chronic kidney disease (eg, diabetic constriction of efferent arterioles. \u008f\u00a0renin due nephropathy), \u0090\u00a0intraglomerular pressure, MECHANISM to loss of negative feedback. Inhibition of ACE slowing GBM thickening. also prevents inactivation of bradykinin, a CLINICAL USE potent vasodilator. Captopril\u2019s CATCHH. ADVERSE EFFECTS Hypertension, HF (\u0090\u00a0mortality), proteinuria, diabetic nephropathy. Prevent unfavorable heart remodeling as a result of chronic hypertension. Cough, Angioedema (both due to \u008f\u00a0bradykinin; contraindicated in C1 esterase inhibitor deficiency), Teratogen (fetal renal malformations), \u008f Creatinine (\u0090\u00a0GFR), Hyperkalemia, and Hypotension. Used with caution in bilateral renal artery stenosis because ACE inhibitors will further \u0090 GFR \u008e\u00a0renal failure. Angiotensin II receptor Losartan, candesartan, valsartan. blockers Selectively block binding of angiotensin II to AT1 receptor. Effects similar to ACE inhibitors, but MECHANISM ARBs do not increase bradykinin. CLINICAL USE Hypertension, HF, proteinuria, or chronic kidney disease (eg, diabetic nephropathy) with intolerance to ACE inhibitors (eg, cough, angioedema). ADVERSE EFFECTS Hyperkalemia, \u0090\u00a0GFR, hypotension; teratogen. Aliskiren Direct renin inhibitor, blocks conversion of angiotensinogen to angiotensin I. Aliskiren kills renin. MECHANISM Hypertension. CLINICAL USE ADVERSE EFFECTS Hyperkalemia, \u0090\u00a0GFR, hypotension, angioedema. Relatively contraindicated in patients already taking ACE inhibitors or ARBs and contraindicated in pregnancy.","HIGH-YIELD SYSTEMS Reproductive \u201cLife is always a rich and steady time when you are waiting for something `\tEmbryology\t 632 to happen or to hatch.\u201d `\tAnatomy\t 644 `\tPhysiology\t 649 \u2014E.B. White, Charlotte\u2019s Web `\tPathology\t 657 `\tPharmacology\t 675 \u201cLove is only a dirty trick played on us to achieve continuation of the species.\u201d \u2014W. Somerset Maugham \u201cI liked that in obstetrics you end up with twice the number of patients you started with.\u201d \u2014Adam Kay \u201cLife is a sexually transmitted disease and the mortality rate is one hundred percent.\u201d \u2014R.D. Laing Organizing the reproductive system by key concepts such as embryology, endocrinology, pregnancy, and oncology can help with understanding this complex topic. Study the endocrine and reproductive chapters together, because mastery of the hypothalamic-pituitary-gonadal axis is key to answering questions on ovulation, menstruation, disorders of sexual development, contraception, and many pathologies. Embryology is a nuanced subject that spans multiple organ systems. Approach it from a clinical perspective. For instance, make the connection between the presentation of DiGeorge syndrome and the 3rd\/4th pharyngeal pouch, and between the M\u00fcllerian\/Wolffian systems and disorders of sexual development. As for oncology, don\u2019t worry about remembering screening or treatment guidelines. It is more important to recognize the clinical presentation (eg, signs and symptoms) of reproductive cancers and their associated labs, histopathology, and risk factors. In addition, some of the testicular and ovarian cancers have distinct patterns of hCG, AFP, LH, or FSH derangements that serve as helpful clues in exam questions. 631 uploaded by medbooksvn","632 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Embryology ` \u2009R E P R O D U C T I V E \u2014 E MB R Y O LO GY Important genes of embryogenesis GENE CHARACTERISTICS Homeobox (HOX) Produced at multiple locations \u008e\u00a0segmental organization of embryo in cranial-caudal axis. genes Mutations \u008e\u00a0limb malformations. Isotretinoin \u008e\u00a0\u008f\u00a0HOX gene expression. Sonic hedgehog (SHH) Produced at notochord, limb buds (zone of polarizing activity) \u008e\u00a0CNS development, anterior- posterior limb axis patterning. Mutations \u008e\u00a0holoprosencephaly. Wnt-7 Produced at limb buds (apical ectodermal ridge) \u008e\u00a0dorsal-ventral limb axis patterning. Fibroblast growth Produced at limb buds (apical ectodermal ridge) \u008e\u00a0proximal-distal limb outgrowth. factor (FGF) Early embryonic development DayDa1y 1 DayDsa2ys-32-3 DayDa1y4 14 EpiEbplaibstlast BilaBmilainmairndairscdisc HypHoybploabstlast ZygZoytgeote PrimPriitmivietive PrimPriitmivietivsteresatrkeak (2N(42CN)4C) stresatrkeak DayDa1y5 15 AmAnmionticot\ufb02icui\ufb02duid EctEocdteordmerm FerFteilriztialitzioatnion CoCrpourspaulsbaiclbanicsans DayDa4y 4 DayDa1y6 16 MeMsoedseordmerm (2N(22CN)2C) DevDeelvoeplionpging MoMruolarula EndEondeordmerm DayDa0y 0 follfioclleicle DayDa5y 5 BlaBstloasctyosctyst DayDsa6ys-160-10 YolYkoslakcsac ImpImlapnltaantitoantion OvaOryvary OvOulvautiloantion N =Ns=etsoetf o23f 2c3hrcohmroomsomsoems es MyMomyoemtrieutmrium C =Cs=etsoetf o23f 2c3hrcohmroamtidatsi\/dDsN\/DANcAocpoiepsies 2\u00b0 o2o\u00b0 coyotceyte EarElyarcloyrcpourspus (1N2(1CN)2C) luteluutmeumEndEonmdoemtrieutmrium Week 1 hCG secretion begins around the time of blastocyst implantation. Blastocyst \u201csticks\u201d on day six. Week 2 Week 3 Formation of bilaminar embryonic disc; two layers = epiblast, hypoblast. Week 4 Formation of trilaminar embryonic disc via gastrulation (epiblast cell invagination through primitive Week 8 streak); three layers = endoderm, mesoderm, ectoderm. Notochord arises from midline mesoderm and induces overlying ectoderm (via SHH) to become neural plate, which gives rise to neural tube via neurulation. Heart begins to beat (four chambers). Cardiac activity visible by transvaginal ultrasound. Upper and lower limb buds begin to form (four limbs). Genitalia have male\/female characteristics (pronounce \u201cgeneightalia\u201d).","Endoderm Day 16 Ectoderm Day 19 Neural groove Mesoderm Neural crest Reproductive\u2003 \uf07d \u2009R E P R O D U C T I V E \u2014EndEomderbmr y o lo g y SECTION III 633 Notochord Neural groove Day 16 Ectoderm Day 19 Neural crest Neural fold Mesoderm Neural crest Day 20 Embryologic derivatives Endoderm Notochord Day 16 Ectoderm Day 19 Neural groove Day 20 Neural fold Day 22 Mesoderm Neural crest Neural crest Endoderm Notochord Neural tube EctodDaeyr1m9 Neural groove Neural fold Day 22 External\/outer layer Neural crest Neural crest Day 20 Surface ectoderm Epidermis; adenohypophysis (from Rathke CranNeiuorapl thubaeryngioma\u2014benign Rathke pouch Notochordpouch); lens of eye; epithelial linings of oral tumor with cholesterol crystals, calcifications. Day 20 Neural foldcavity, sDeanys2o2ry organs of ear, and olfactory Neuroectoderm\u2014think CNS. Neuralecrpeistt helium; anal canal below the pectinate line; parotid, sweat, mammarNyeugrallatunbde s. Neural tube Brain (neurohypophysis, CNS neurons, oligo\u00ad Day 22 dendrocytes, astrocytes, ependymal cells, pineal gland), retina, spinal cord. Neural crest Neural tuEbenterochromaffin cells, Melanocytes, EMO PASSES Odontoblasts, PNS ganglia (cranial, dorsal Neural crest\u2014think PNS and non-neural root, autonomic), Adrenal medulla, Schwann cells, Spiral membrane (aorticopulmonary structures nearby. septum), Endocardial cushions (also derived partially from mesoderm), Skull bones. Mesoderm Muscle, bone, connective tissue, serous Middle\/\u201cmeat\u201d layer. linings of body cavities (eg, peritoneum, Mesodermal defects = VACTERL association: pericardium, pleura), spleen (develops within foregut mesentery), cardiovascular structures, Vertebral defects lymphatics, blood, wall of gut tube, proximal Anal atresia vagina, kidneys, adrenal cortex, dermis, testes, Cardiac defects ovaries, microglia, tracheal cartilage. Tracheo-Esophageal fistula Renal defects Notochord induces ectoderm to form Limb defects (bone and muscle) neuroectoderm (neural plate); its only postnatal derivative is the nucleus pulposus of the intervertebral disc. Endoderm Gut tube epithelium (including anal canal \u201cEnternal\u201d layer. above the pectinate line), most of urethra and distal vagina (derived from urogenital sinus), luminal epithelial derivatives (eg, lungs, liver, gallbladder, pancreas, eustachian tube, thymus, parathyroid, thyroid follicular and parafollicular [C] cells). uploaded by medbooksvn","634 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Embryology Teratogens Most susceptible during organogenesis in embryonic period (before week 8 of development). Before implantation, \u201call-or-none\u201d effect. After week 8 (fetal period), growth and function affected. TERATOGEN EFFECT ON FETUS Medications ACE inhibitors Renal failure, oligohydramnios, hypocalvaria. Alkylating agents Multiple anomalies (eg, ear\/facial abnormalities, absence of digits). Aminoglycosides Ototoxicity. \u201cA mean guy hit the baby in the ear.\u201d Antiepileptic drugs Neural tube defects, cardiac defects, cleft palate, skeletal abnormalities (eg, phalanx\/nail Diethylstilbestrol hypoplasia, facial dysmorphism). Most commonly due to valproate, carbamazepine, phenytoin, Fluoroquinolones phenobarbital; high-dose folate supplementation recommended. Folate antagonists Vaginal clear cell adenocarcinoma, congenital M\u00fcllerian anomalies. Isotretinoin Cartilage damage. Neural tube defects. Most commonly due to trimethoprim, methotrexate. Lithium Craniofacial (eg, microtia, dysmorphism), CNS, cardiac, and thymic defects. Contraception Methimazole mandatory. Pronounce \u201cisoteratinoin\u201d for its teratogenicity. Tetracyclines Ebstein anomaly. Thalidomide Aplasia cutis congenita (congenital absence of skin, typically on scalp). Warfarin Discolored teeth, inhibited bone growth. Pronounce \u201cteethracyclines.\u201d Limb defects (eg, phocomelia\u2014flipperlike limbs). Pronounce \u201cthalimbdomide.\u201d Substance use Bone and cartilage deformities (stippled epiphyses, nasal and limb hypoplasia), optic nerve atrophy, Alcohol cerebral hemorrhage. Use heparin during pregnancy (does not cross placenta). Cocaine Tobacco smoking Fetal alcohol syndrome. Preterm birth, low birth weight, fetal growth restriction (FGR). Cocaine \u008e vasoconstriction. Other Preterm birth, low birth weight (leading cause in resource-rich countries), FGR, sudden infant Iodine lack or excess Maternal diabetes death syndrome (SIDS), ADHD. Nicotine \u008e vasoconstriction, CO \u008e impaired O2 delivery. Maternal PKU Congenital hypothyroidism. Methylmercury Caudal regression syndrome, cardiac defects (eg, transposition of great arteries, VSD), neural X-rays tube defects, macrosomia, neonatal hypoglycemia (due to islet cell hyperplasia), polycythemia, respiratory distress syndrome. Fetal growth restriction, microcephaly, intellectual disability, congenital heart defects. Neurotoxicity. \u008f concentration in top-predator fish (eg, shark, swordfish, king mackerel, tilefish). Microcephaly, intellectual disability. Effects minimized by use of lead shielding.","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Embryology SECTION III 635 Types of errors in morphogenesis Agenesis Absent organ due to absent primordial tissue. Aplasia Absent organ despite presence of primordial tissue. Hypoplasia Incomplete organ development; primordial tissue present. Disruption 2\u00b0 breakdown of tissue with normal developmental potential (eg, amniotic band syndrome). Deformation Extrinsic mechanical distortion (eg, congenital torticollis); occurs during fetal period. Malformation Intrinsic developmental defect (eg, cleft lip\/palate); occurs during embryonic period. Sequence Abnormalities result from a single 1\u00b0 embryologic event (eg, oligohydramnios \u008e Potter sequence). Field defect Disturbance of tissues that develop in a contiguous physical space (eg, holoprosencephaly). Fetal alcohol One of the leading preventable causes of syndrome intellectual disability in the US. 2\u00b0 to maternal alcohol use during pregnancy. Newborns may present with developmental Microcephaly delay, microcephaly, facial abnormalities Small palpebral \ufb01ssures (eg,\u00a0smooth philtrum, thin vermillion border, Flat nasal bridge small palpebral fissures, flat nasal bridge), limb Smooth philtrum dislocation, heart defects. Holoprosencephaly may occur in more severe presentations. One Thin vermillion border mechanism is due to impaired migration of neuronal and glial cells. Neonatal abstinence Complex disorder involving CNS, ANS, and GI systems. 2\u00b0 to maternal substance use (most syndrome commonly opioids) during pregnancy. Newborns may present with uncoordinated sucking reflexes, irritability, high-pitched crying, tremors, tachypnea, sneezing, diarrhea, and possibly seizures. Treatment (for opioid use): methadone, morphine, buprenorphine. Universal screening for substance use is recommended in all pregnant patients. uploaded by medbooksvn","636 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Embryology Placenta 1\u00ba site of nutrient and gas exchange between mother and fetus. Fetal component Cytotrophoblast Inner layer of chorionic villi; creates cells. Syncytiotrophoblast Outer layer of chorionic villi; synthesizes and secretes hormones, eg, hCG (structurally similar Maternal component to LH; stimulates corpus luteum to secrete progesterone during first trimester). Lacks MHC I Decidua basalis expression \u008e\u00a0\u0090\u00a0chance of attack by maternal immune system. Derived from endometrium. Maternal blood in lacunae. Branch villus Endometrial vein Maternal Endometrial artery circulation Umbilical vein Maternal circulation (O2 rich) OHN2u2Otr,ieenletcs trolytes Hormones Umbilical arteries IgG (O2 poor) Drugs Viruses Fetal circulation HCUOr2eO2a, waste products Syncytiotrophoblast Hormones Cytotrophoblast Amnion Endothelial cell Lacunae \ufb01lled with Chorion maternal blood Decidua basalis Amniotic flui Intramembranous Derived from fetal urine (mainly) and fetal lung absorption liquid. Urine Cleared by fetal swallowing (mainly) and intramembranous absorption. Swallowed \ufb02uid Polyhydramnios\u2014too much amniotic fluid. May be idiopathic or associated with fetal Expelled malformations (eg, esophageal\/duodenal lung \ufb02uid atresia, anencephaly; both result in inability to swallow amniotic fluid), maternal diabetes, fetal anemia, multifetal gestation. Oligohydramnios\u2014too little amniotic fluid. Associated with placental insufficiency, bilateral renal agenesis, posterior urethral valves (in males); these result in inability to excrete urine. Profound oligohydramnios can cause Potter sequence.","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Embryology SECTION III 637 Twinning Dizygotic (\u201cfraternal\u201d) twins arise from 2 eggs that are separately fertilized by 2 different sperm (always 2 zygotes) and will have 2 separate amniotic sacs and 2 separate placentas (chorions). Monozygotic (\u201cidentical\u201d) twins arise from 1 fertilized egg (1 egg + 1 sperm) that splits in early pregnancy. The timing of splitting determines chorionicity (number of chorions) and amnionicity (number of amnions) (take separate cars or share a CAB): \u0083\t Splitting 0\u20134 days: separate chorion and amnion (di-di) \u0083\t Splitting 4\u20138 days: shared Chorion (mo-di) \u0083\t Splitting 8\u201312 days: shared chorion and Amnion (mo-mo) \u0083\t Splitting 13+ days: shared chorion, amnion, and Body (mo-mo; conjoined) Dizygotic (fraternal) [~2\/3] No twinning Monozygotic (identical) [~1\/3] 2 eggs, 1 egg, 1 sperm 2 sperm 2-cell stage 2-cell stage 2-cell stage Morula Days 0\u20134 Splitting Dichorionic diamniotic 25% 2-cell stage Morula Blastocyst Morula Monochorionic Morula diamniotic 75% Days 4\u20138 Splitting Blastocyst Blastocyst Blastocyst Formed Days 8\u201312 Splitting Monochorionic embryonic disc monoamniotic Chorionic Amniotic rare cavity cavity Monochorionic Formed Formed monoamniotic embryonic disc embryonic disc conjoined\u2014rare Day 13+ Splitting or axis duplication Chorion (outer) Amnion Endometrium (inner) Dichorionic No twinning if diamniotic no splitting Twin-twin transfusion Occurs in monochorionic twin gestations. Unbalanced arteriovenous anastomoses between twins in syndrome shared placenta \u008e\u00a0net blood flow from one twin to the other. Donor twin \u008e\u00a0hypovolemia and oligohydramnios (\u201cstuck twin\u201d appearance). Recipient twin \u008e\u00a0hypervolemia and polyhydramnios. uploaded by medbooksvn","638 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Embryology Umbilical cord Two umbilical arteries return deoxygenated Single umbilical artery (2-vessel cord) is blood from fetal internal iliac arteries to associated with congenital and chromosomal Urachus placenta. anomalies. Patent urachus Urachal cyst One umbilical vein supplies oxygenated blood Umbilical arteries and vein are derived from Vesicourachal from placenta to fetus; drains into IVC via allantois. diverticulum liver or via ductus venosus. Umbilical Amnion arteries Umbilical arteries Umbilical Wharton jelly vein Allantois Umbilical vein Allantois forms from yolk sac and extends into cloaca. Intra-abdominal remnant of allantois is called the urachus, a duct between fetal bladder and umbilicus. Failure of urachus to involute can lead to anomalies that may increase risk of infection and\/or malignancy (eg,\u00a0adenocarcinoma) if not treated. Obliterated urachus is represented by the median umbilical ligament after birth, which is covered by median umbilical fold of the peritoneum. Total failure of urachus to obliterate \u008e\u00a0urine discharge from umbilicus. Partial failure of urachus to obliterate; fluid-filled cavity lined with uroepithelium, between umbilicus and bladder. Cyst can become infected and present as painful mass below umbilicus. Slight failure of urachus to obliterate \u008e\u00a0outpouching of bladder. Umbilicus Normal Patent urachus Urachal cyst Vesicourachal diverticulum Vitelline duct Also called omphalomesenteric duct. Connects yolk sac to midgut lumen. Obliterates during week Patent vitelline duct 7 of development. Vitelline duct cyst Meckel diverticulum Total failure of vitellinUemdbuiliccutsto obliterate \u008e\u00a0meconium discharge from umbilicus. Partial failure of vitelline duct to obliterate. \u008f risk for volvulus. A Slight failure of vitelline duct to obliterate \u008e\u00a0outpouching of ileum (true diverticulum, arrow in A ). Usually asymptomatic. May have heterotopic gastric and\/or pancreatic tissue \u008e\u00a0melena, hematochezia, abdominal pain. Normal Patent vitelline duct Meckel diverticulum Umbilicus Normal Patent vitelline duct Vitelline duct cyst Meckel diverticulum","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Embryology SECTION III 639 Pharyngeal apparatus Composed of pharyngeal (branchial) clefts, CAP covers outside to inside: arches, pouches. Clefts = ectoderm Pharyngeal clefts\u2014derived from ectoderm. Also Arches = mesoderm + neural crest called pharyngeal grooves. Pouches = endoderm Pharyngeal arches\u2014derived from mesoderm Arch Pouch Pharyngeal \ufb02oor (muscles, arteries) and neural crest (bones, cartilage). Cleft\/ 1st Cartilage groove Nerve Pharyngeal pouches\u2014derived from endoderm. Membrane 2nd Artery Cleft 3rd Muscle Arch 4th Pouch 6th Pharyngeal cleft 1st cleft develops into external auditory meatus. derivatives 2nd through 4th clefts form temporary cervical sinuses, which are obliterated by proliferation of 2nd arch mesenchyme. Pharyngeal cleft cyst\u2014persistent cervical sinus; presents as lateral neck mass anterior to sternocleidomastoid muscle that does not move with swallowing (vs thyroglossal duct cyst). Pharyngeal pouch Ear, tonsils, bottom-to-top: 1 (ear), 2 (tonsils), 3 dorsal (bottom = inferior parathyroids), 3 ventral derivatives (to = thymus), 4 (top = superior parathyroids). POUCH DERIVATIVES NOTES 1st pharyngeal pouch Middle ear cavity, eustachian tube, mastoid air 1st pouch contributes to endoderm-lined cells structures of ear 2nd pharyngeal pouch Epithelial lining of palatine tonsil 3rd pharyngeal pouch Dorsal wings \u008e\u00a0inferior parathyroids Third pouch contributes to thymus and both Ventral wings \u008e thymus inferior parathyroids Structures from 3rd pouch end up below those from 4th pouch 4th pharyngeal pouch Dorsal wings \u008e\u00a0superior parathyroids 4th pharyngeal pouch forms para\u201c4\u201dllicular cells Ventral wings \u008e\u00a0ultimopharyngeal body \u008e\u00a0parafollicular (C) cells of thyroid uploaded by medbooksvn","640 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Embryology Pharyngeal arch When at the restaurant of the golden arches, children tend to first chew (1), then smile (2), then swallow stylishly (3) or simply swallow (4), and then speak (6). derivatives ARCH NERVESa MUSCLES CARTILAGE NOTES 1st pharyngeal CN V3 chew Muscles of mastication Maxillary process Pierre Robin sequence\u2014 arch (temporalis, masseter, \u008e\u00a0maxilla, zygomatic micrognathia, lateral and medial bone glossoptosis, cleft 2nd pharyngeal CN VII (seven) pterygoids), mylohyoid, palate, airway arch smile (facial anterior belly of digastric, Mandibular process obstruction expression) tensor tympani, anterior \u008e\u00a0meckel cartilage 2\/3 of tongue, tensor veli \u008e\u00a0mandible, Treacher Collins palatini malleus and incus, syndrome\u2014autosomal sphenomandibular dominant neural Muscles of facial expression, ligament crest dysfunction stapedius, stylohyoid, \u008e\u00a0craniofacial platysma, posterior belly of Reichert cartilage: abnormalities (eg, digastric stapes, styloid process, zygomatic bone lesser horn of hyoid, and mandibular stylohyoid ligament hypoplasia), hearing loss, airway compromise 3rd pharyngeal CN IX Stylopharyngeus Greater horn of hyoid arch swallow stylishly 4th and 6th 4th arch: CN 4th arch: most pharyngeal Arytenoids, Cricoid, Arches 3 and 4 form pharyngeal X (superior constrictors; cricothyroid, Corniculate, posterior 1\/3 of tongue arches laryngeal branch) levator veli palatini Cuneiform, Thyroid simply swallow (used to sing and Arch 5 makes no 6th arch: all intrinsic ACCCT) major developmental 6th arch: CN muscles of larynx except contributions X (recurrent\/ cricothyroid inferior laryngeal branch) speak a\u2009Sensory and motor nerves are not pharyngeal arch derivatives. They grow into the arches and are derived from neural crest (sensory) and neuroectoderm (motor).","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Embryology SECTION III 641 Orofacial clefts Cleft lip and cleft palate have distinct, multifactorial etiologies, but often occur together. Cleft lip Due to failure of fusion of the intermaxillary Frontonasal process Cleft palate segment (merged medial nasal processes) with Lateral nasal process the maxillary process (formation of 1\u00b0 palate). Cleft lip Medial nasal process Due to failure of fusion of the two lateral Cleft palate palatine shelves or failure of fusion of lateral Intermaxillary segment palatine shelf with the nasal septum and\/or Maxillary process Uvula 1\u00b0\u00a0palate (formation of 2\u00b0 palate). 1\u00b0 palate Nasal septum Palatine shelves (2\u00b0 palate) Genital embryology Default development. Mesonephric duct Indi erent gonad Gubernaculum Female degenerates and paramesonephric duct Male develops. Mesonephros Paramesonephric Paramesonephric SRY gene on Y chromosome\u2014produces testis- (M\u00fcllerian) duct determining factor \u008e\u00a0testes development. duct Mesonephric Sertoli cells secrete M\u00fcllerian inhibitory factor Mesonephric duct (Wolffian) duct (MIF, also called antimullerian hormone) that Urogenital sinus suppresses development of paramesonephric ducts. Testis-determining factor No androgens Androgens Leydig cells secrete androgens that stimulate MIF development of mesonephric ducts. Epididymis Testis Ovary Metanephric Develops into female internal structures\u2014 kidney fallopian tubes, uterus, proximal vagina (distal vagina from urogenital sinus). Male remnant is Degenerated Urinary Oviduct appendix testis. paramesonephric bladder Ureter M\u00fcllerian agenesis (Mayer-Rokitansky-K\u00fcster- duct Hauser syndrome)\u20141\u00ba amenorrhea with Degenerated absent uterus, blind vaginal pouch, normal Vas deferens mesonephric female external genitalia and 2\u00b0 sexual duct characteristics (functional ovaries). Associated Uterus with urinary tract anomalies (eg, renal Vagina agenesis). Develops into male internal structures (except prostate)\u2014Seminal vesicles, Epididymis, Ejaculatory duct, Ductus deferens (SEED). Female remnant is Gartner duct. uploaded by medbooksvn","642 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Embryology Sexual differentiation Undi erentiated Paramesonephric Absence of Sertoli cells or lack of M\u00fcllerian gonads (M\u00fcllerian) duct inhibitory factor \u008e\u00a0develop both male and Mesonephric female internal genitalia and male external (Wol an) duct genitalia (streak gonads) XY (SRY) XX (no SRY) 5\u03b1-reductase deficiency\u2014inability to convert testosterone into DHT \u008e\u00a0male internal Testes Ovaries genitalia, atypical external genitalia until puberty (when \u008f testosterone levels cause Leydig cells Sertoli cells masculinization) Testosterone MIF Estrogen Testosterone In the testes: 5\u02dc -reductase Leydig leads to male (internal and external) sexual differentiation. DHT Sertoli shuts down female (internal) sexual differentiation. 1o sexual Internal male External male External female Internal female characteristics genitalia genitalia genitalia genitalia Seminal vesicle Penis Clitoris Fallopian tubes Epididymis Scrotum Labia Uterus Prostate Distal vagina Ejaculatory duct Proximal vagina Ductus deferens 2o sexual Pubic, axillary, and facial hair, Breast development Pubic and axillary hair characteristics \uf068 penis size\/length, growth spurt, etc Uterine (M\u00fcllerian \u0090\u00a0fertility and \u008f\u00a0risk of complicated pregnancy (eg, spontaneous abortion, prematurity, FGR, duct) anomalies malpresentation). Hysterosalpigogram of normal uterus demonstrates normal uterine cavity and intraperitoneal spill of contrast (indicative of patent fallopian tubes). Septate uterus Bicornuate uterus Incomplete resorption of septum A . Common anomaly. Treat with septoplasty. Uterus didelphys Incomplete fusion of M\u00fcllerian ducts B . Complete failure of fusion \u008e\u00a0double uterus, cervix, vagina. Normal Normal NoSrmepatlateNoSrempatalte BicorSneupattaeBteicornSeupataete DBidcoelrpnhuyastDeBiidceolrpnhuyaste Didelphys Didelphys AB","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Embryology SECTION III 643 Male\/female genital homologs Genital groove Genital Female Labia tubercle minora Male Urogenital Labioscrotal Glans Glans penis fold swelling clitoris Labia Penile urethra Opening of majora Urogenital Anus urethra Scrotum sinus Opening of vagina Urachus Kidney Allantois Vesical Urachus Fallopian part tube Urinary Testis Genital Pelvic Urogenital Urinary Kidney bladder Ureter tubercle part sinus bladder Ovary Ductus Phallic Uterus Glans deferens Rectum part Glans penis clitoris Vagina Spongy Dihydrotestosterone Estrogen Glans clitoris urethra Vestibular bulbs Genital tubercle Greater vestibular glands Glans penis Genital tubercle (of Bartholin) Corpus cavernosum Urogenital sinus Urethral and paraurethral Urogenital sinus glands (of Skene) and spongiosum Urogenital folds Labia minora Bulbourethral glands Labioscrotal swelling Labia majora (of Cowper) Prostate gland Ventral shaft of penis (penile urethra) Scrotum Congenital penile abnormalities Hypospadias Abnormal opening of penile urethra on ventral Hypospadias is more common than (under) surface due to failure of urethral folds epispadias. Associated with inguinal hernia, to fuse. cryptorchidism, chordee (downward or upward bending of penis). Epispadias Abnormal opening of penile urethra on dorsal (top) surface due to faulty positioning of Can be seen in 5\u03b1-reductase deficiency. genital tubercle. Exstrophy of the bladder is associated with epispadias. uploaded by medbooksvn","644 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Anatomy Descent of testes and ovaries DESCRIPTION MALE REMNANT FEMALE REMNANT Gubernaculum Band of fibrous tissue Anchors testes within scrotum Ovarian ligament + round ligament of uterus Processus vaginalis Evagination of peritoneum Forms tunica vaginalis Persistent patent processus Obliterated vaginalis \u008e\u00a0hydrocele ` \u2009R E P R O D U C T I V E \u2014 A N AT O MY Gonadal drainage Left ovary\/testis \u008e left gonadal vein \u008e left renal \u201cLeft gonadal vein takes the longer way.\u201d Venous drainage vein \u008e IVC. IVC Lymphatic drainage Right ovary\/testis \u008e right gonadal vein \u008e IVC. Because the left testicular vein enters the left Left renal vein Testicular veins renal vein at a 90\u00b0 angle, flow is less laminar on left than on right \u008e left venous pressure Pampiniform > right venous pressure \u008e varicocele more plexus common on the left. Ovaries\/testes\/fundus of uterus \u008e\u00a0para-aortic lymph nodes. Body of uterus\/cervix\/superior part of bladder \u008e\u00a0external iliac nodes. Prostate\/cervix\/corpus cavernosum\/proximal vagina\/inferior part of bladder \u008e\u00a0internal iliac nodes. Distal vagina\/vulva\/scrotum\/distal anus \u008e\u00a0superficial inguinal nodes. Clitoris\/glans penis \u008e\u00a0deep inguinal nodes.","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Anatomy SECTION III 645 Female reproductive anatomy Perimetrium Fallopian tube Myometrium Infundibulum Ampulla Isthmus Endometrium Ovarian vessels Infundibulopelvic ligament Ureter Ovarian ligament Round ligament Fimbriae Ovary Uterus Uterine fundus Mesosalpinx (of broad ligament) Uterine body Mesovarium (of broad ligament) Uterine cavity Mesometrium (of broad ligament) Uterine isthmus Uterine vessels Bladder Internal os Vaginal artery (internal ori\ufb01ce) Anterosuperior view Vagina Cervical canal STRUCTURES CONTAINED NOTES Cervical os Posterior view Ovarian vessels Also called suspensory ligament of ovary (external ori\ufb01ce) CONNECTS Ovarian vessel ligation during oophorectomy Cervix Ovary, fallopian tube, Ovary to lateral pelvic round ligament risks damaging the ureter LIGAMENT wall Uterine vessels Derivative of gubernaculum Infundibulopelvic Ovary to uterine horn ligament Uterine horn to labia Travels through inguinal canal Derivative of gubernaculum Ovarian ligament majora Round ligament Uterus to lateral pelvic Fold of peritoneum comprising the mesometrium, mesovarium, and mesosalpinx Broad ligament wall Cervix to lateral pelvic Condensation at the base of broad ligament Cardinal ligament Uterine vessel ligation during hysterectomy risks wall Uterosacral ligament damaging the ureter Cervix to sacrum Adnexal torsion Twisting of ovary and fallopian tube around infundibulopelvic ligament and ovarian ligament \u008e\u00a0compression of ovarian vessels in infundibulopelvic ligament \u008e\u00a0blockage of lymphatic and Torsion venous outflow. Continued arterial perfusion \u008e\u00a0ovarian edema \u008e\u00a0complete blockage of arterial inflow \u008e\u00a0necrosis, local hemorrhage. Associated with ovarian masses. Presents with acute pelvic pain, adnexal mass, nausea\/vomiting. Surgical emergency. Pelvic organ prolapse Herniation of pelvic organs to or beyond the vaginal walls (anterior, posterior) or apex. Associated with multiparity, \u008f\u00a0age, obesity. Presents with pelvic pressure, bulging sensation or tissue protrusion from vagina, urinary frequency, constipation, sexual dysfunction. \u0083\t Anterior compartment prolapse\u2014bladder (cystocele). Most common type. \u0083\t Posterior compartment prolapse\u2014rectum (rectocele) or small bowel (enterocele). \u0083\t Apical compartment prolapse\u2014uterus, cervix, or vaginal vault. Uterine procidentia\u2014herniation involving all 3 compartments. uploaded by medbooksvn","646 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Anatomy Female reproductive TISSUE HISTOLOGY\/NOTES epithelial histology Vulva Stratified squamous epithelium Vagina Ectocervix Stratified squamous epithelium, nonkeratinized Transformation zone Stratified squamous epithelium, nonkeratinized Endocervix Uterus Squamocolumnar junction (most common area for cervical cancer; sampled in Pap test) Fallopian tube Ovary, outer surface Simple columnar epithelium Simple columnar epithelium with long tubular glands in proliferative phase; coiled glands in secretory phase Simple columnar epithelium, ciliated Simple cuboidal epithelium (germinal epithelium covering surface of ovary) Male reproductive anatomy Ureter Head of epididymis E erent ductule Bladder Seminal vesicle Rete testis Vas deferens Ampulla Symphysis pubis Ejaculatory duct Vas deferens Prostate Bulbourethral Septa gland (Cowper) Urethra Testis Seminiferous Corpus cavernosum Scrotum tubules Tunica Epididymis albuginea Prepuce Glans Tail of epididymis Super\ufb01cial dorsal vein Skin Pathway of sperm during ejaculation\u2014 Dorsal nerve Super\ufb01cial (dartos) fascia SEVEN UP: Dorsal artery Deep (Buck\u2019s) fascia Seminiferous tubules Tunica albuginea Epididymis Deep dorsal vein Vas deferens Corpus cavernosum Ejaculatory ducts Tunica albuginea Deep artery (Nothing) Corpus spongiosum Urethra Penis Urethra","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Anatomy SECTION III 647 Genitourinary trauma Most commonly due to blunt trauma (eg, motor vehicle collision). Renal injury Bladder injury Presents with bruises, flank pain, hematuria. Caused by direct blows or lower rib fractures. Urethral injury Presents with hematuria, suprapubic pain, difficulty voiding. \u0083\t Superior bladder wall (dome) injury\u2014direct trauma to full bladder (eg, seatbelt) \u008e\u00a0abrupt \u008f\u00a0intravesical pressure \u008e\u00a0dome rupture (weakest part) \u008e\u00a0intraperitoneal urine accumulation. Peritoneal absorption of urine \u008e\u00a0\u008f\u00a0BUN, \u008f\u00a0creatinine. \u0083\t Anterior bladder wall or neck injury\u2014pelvic fracture \u008e\u00a0perforation by bony spicules \u008e\u00a0extraperitoneal urine accumulation (retropubic space). Occurs almost exclusively in males. Presents with blood at urethral meatus, hematuria, difficulty voiding. Urethral catheterization is relatively contraindicated. \u0083\t Anterior urethral injury\u2014perineal straddle injury \u008e\u00a0disruption of bulbar (spongy) urethra \u008e\u00a0scrotal hematoma. If Buck fascia is torn, urine escapes into perineal space. \u0083\t Posterior urethral injury\u2014pelvic fracture \u008e\u00a0disruption at bulbomembranous junction (weakest part) \u008e\u00a0urine leakage into retropubic space and high-riding prostate. Anterior urethral injury Posterior urethral injury Deep penile Retropubic Torn (Buck) fascia space bulbomembranous junction Bloody extravasation Perforation of spongy urethra (rupture of Buck fascia) \u2003 Autonomic Erection\u2014parasympathetic nervous system Point, squeeze, and shoot. innervation of male (pelvic splanchnic nerves, S2-S4): S2, 3, 4 keep the penis off the floor. sexual response \u0083\t NO \u008e \u008f cGMP \u008e smooth muscle PDE-5 inhibitors (eg, sildenafil) \u008e\u00a0\u0090\u00a0cGMP relaxation \u008e vasodilation \u008e proerectile. \u0083\t Norepinephrine \u008e \u008f [Ca2+]in \u008e smooth breakdown. muscle contraction \u008e vasoconstriction \u008e antierectile. Emission\u2014sympathetic nervous system (hypogastric nerve, T11-L2). Expulsion\u2014visceral and somatic nerves (pudendal nerve). uploaded by medbooksvn","648 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Anatomy Seminiferous tubules FUNCTION LOCATION\/NOTES CELL Maintain germ cell pool and produce 1\u00b0 Line seminiferous tubules A spermatocytes Germ cells Spermatogonia Sertoli cells Secrete inhibin B \u008e inhibit FSH Line seminiferous tubules Secrete androgen-binding protein \u008e maintain Non\u2013germ cells Leydig cells Convert testosterone and androstenedione to local levels of testosterone HYPOTHALAMUS Produce MIF estrogens via aromatase GnRH Tight junctions between adjacent Sertoli cells Sertoli cells are temperature sensitive, line form blood-testis barrier \u008e isolate gametes seminiferous tubules, support sperm synthesis, from autoimmune attack and inhibit FSH Support and nourish developing spermatozoa Homolog of female granulosa cells Regulate spermatogenesis Temperature sensitive; \u0090 sperm production and \u008f temperature seen in varicocele, \u0090 inhibin B with \u008f temperature cryptorchidism Secrete testosterone in the presence of LH; Interstitium testosterone production unaffected by Endocrine cells temperature Homolog of female theca interna cells Anterior Inhibin B Spermatogonium pituitary Sertoli cell Spermatocyte FSH Spermatids LH Spermatozoon A Leydig cell Androgen- binding protein Testosterone Capillary Sertoli cell nucleus Lumen of seminiferous tubule SPERMATOGENESIS","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Physiology SECTION III 649 ` \u2009R E P R O D U C T I V E \u2014 P H Y S I O LO GY Spermatogenesis Begins at puberty with spermatogonia. Full \u201cGonium\u201d is going to be a sperm; \u201czoon\u201d is development takes 2 months. Occurs in \u201czooming\u201d to egg. Spermatogonium seminiferous tubules. Produces spermatids Diploid that undergo spermiogenesis (loss of Tail mobility impaired in ciliary dyskinesia\/ (2N, 2C) cytoplasmic contents, gain of acrosomal cap) Kartagener syndrome \u008e infertility. to form mature spermatozoa. Blood-testis Tail mobility normal in cystic fibrosis (in CF, barrier absent vas deferens \u008e infertility). 46 Spermiogenesis single chromo- 1\u00b0 spermatocyte 2\u00b0 spermatocyte Spermatid Mature spermatozoon somes Diploid Haploid Haploid Haploid (sex= X-Y) (2N, 4C) (1N, 2C) (1N, 1C) (1N, 1C) Replication Sperm (interphase) 23 Acrosome Tail single Tight junction 92 46 (sex= X) Head sister Nucleus sister chromatids 23 Neck (sex= X-X) single (sex= X) Middle 46 piece sister 23 chromatids chromatids single ( )sex= (sex= Y-Y) (sex= Y) X-X Y-Y 23 single (sex= Y) N = ploidy C = # of chromatids Meiosis I Meiosis II uploaded by medbooksvn","650 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Physiology Estrogen Ovary (17\u03b2-estradiol), placenta (estriol), adipose Potency: estradiol > estrone > estriol. tissue (estrone via aromatization). Estradiol is produced from 2 ovaries. SOURCE FUNCTION Development of internal\/external genitalia, Pregnancy: breasts, female fat distribution. \u0083\t 50-fold \u008f in estradiol and estrone Progesterone \u0083\t 1000-fold \u008f in estriol (indicator of fetal well- Growth of follicle, endometrial proliferation, being) SOURCE \u008f myometrial excitability. FUNCTION Estrogen receptors expressed in cytoplasm; Upregulation of estrogen, LH, and progesterone translocate to nucleus when bound by receptors; feedback inhibition of FSH and estrogen. LH, then LH surge; stimulation of prolactin secretion, \u0090\u00a0prolactin action on breasts. \u008f transport proteins, SHBG; \u008f HDL; \u0090 LDL. LH Cholesterol LHR Cholesterol Theca cells Granulosa cells cAMP Desmolase Theca cell Androstenedione Follicle Granulosa cell Androstenedione cAMP Aromatase FSHR FSH Estrone Estradiol Estrogen Corpus luteum, placenta, adrenal cortex, testes. Fall in estrogen and progesterone after delivery disinhibits prolactin \u008e lactation. \u008f During luteal phase, prepares uterus for progesterone is indicative of ovulation. implantation of fertilized egg: \u0083\t Stimulation of endometrial glandular Progesterone is pro-gestation. secretions and spiral artery development Prolactin is pro-lactation. \u0083\t Production of thick cervical mucus \u008e\u00a0inhibits sperm entry into uterus \u0083\t Prevention of endometrial hyperplasia \u0083\t \u008f body temperature \u0083\t \u0090 estrogen receptor expression \u0083\t \u0090 gonadotropin (LH, FSH) secretion During pregnancy: \u0083\t Maintenance of endometrial lining and pregnancy \u0083\t \u0090 myometrial excitability \u008e \u0090\u00a0contraction frequency and intensity \u0083\t \u0090 prolactin action on breasts","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Physiology SECTION III 651 Oogenesis 1\u00b0 oocytes begin meiosis I during fetal life and complete meiosis I just prior to ovulation. Ovulation Meiosis I is arrested in prophase I (one) for years until ovulation (1\u00b0 oocytes). Meiosis II is arrested in metaphase II (two) until fertilization (2\u00b0 oocytes). If fertilization does not occur within 1 day, the 2\u00b0 oocyte degenerates. Oogonium 1\u00b0 oocyte 2\u00b0 oocyte Ovum Diploid Diploid Haploid Haploid (2N, 2C) (2N, 4C) (1N, 2C) (1N, 1C) Arrested in Arrested in prophase I metaphase II until ovulation until fertilization 23 single chromosomes 46 Ovum sister chromatids 46 92 Polar body single sister chromosomes chromatids N = ploidy Polar body Polar body C = # of chromatids (can degenerate Polar body or give rise to 2 polar bodies) Replication Meiosis I Meiosis II (interphase) Follicular rupture and 2\u00b0 oocyte release. Mittelschmerz (\u201cmiddle hurts\u201d)\u2014pain with Caused by sudden LH release (LH surge) ovulation. Associated with peritoneal irritation at midcycle. Estrogen normally inhibits from normal bleeding upon follicular rupture. LH release, but high estrogen at midcycle Typically unilateral and mild, but can mimic transiently stimulates LH release \u008e LH surge acute appendicitis. \u008e ovulation. uploaded by medbooksvn","652 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Physiology Menstrual cycle Regular cyclic changes periodically preparing the female reproductive system for fertilization and Ovarian cycle pregnancy. Occurs in phases based on events taking place in ovaries and uterus. Uterine cycle 1ST DAY OF MENSES TO OVULATION OVULATION TO 1ST DAY OF NEXT MENSES Follicular phase\u2014follicular development; late Luteal phase\u2014corpus luteum formation from stages are stimulated by FSH; can fluctuate in follicular remnants; stimulated by LH; lasts a length. fixed 14 days. Proliferative phase\u2014endometrial development; Secretory phase\u2014endometrial preparation for stimulated by estrogen. implantation; stimulated by progesterone. PHASES OF OVARIAN CYCLE: FOLLICULAR PHASE LUTEAL PHASE LH Hypothalamus GnRH Anterior FSH FSH pituitary LH Stimulates Ovulation Primordial Developing Mature Corpus Corpus follicles follicle (Graa\ufb01an) luteum albicans follicle Ovary Produces Produces Progesterone Estrogen Endometrium Menses Proliferative Ovulation Secretory Menses PHASES OF UTERINE CYCLE:","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Physiology SECTION III 653 Abnormal uterine Deviation from normal menstruation Terms such as dysfunctional uterine bleeding, bleeding volume, duration, frequency, regularity, or menorrhagia, metrorrhagia, polymenorrhea, intermenstrual bleeding. and oligomenorrhea are no longer Pregnancy recommended. Causes (PALM-COEIN): \u0083\t Structural: Polyp, Adenomyosis, Leiomyoma, Malignancy\/hyperplasia \u0083\t Nonstructural: Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Not yet classified Fertilization (conception) most commonly Main sourcePlacental hormone secretion generally increases occurs in upper end of fallopian tube (the of hormones:over the course of pregnancy, but hCG peaks at ampulla). Occurs within 1 day of ovulation. Corpus luteum8\u201310 weeks of gestation. Transition Implantation in the uterine wall occurs 6 days Placenta Human placental after fertilization. Syncytiotrophoblasts secrete lactogen hCG, which is detectable in blood 1 week Hormone level Estrogens after fertilization and on home urine tests Prolactin 2\u00a0weeks after fertilization. Progesterone Embryonic\/developmental age\u2014time since hCG fertilization. Used in embryology. 7 14 21 28 35 42 Gestational age\u2014time since first day of last Weeks of gestation menstrual period. Used clinically. Gravidity (\u201cgravida\u201d)\u2014number of pregnancies. Parity (\u201cpara\u201d)\u2014number of pregnancies that resulted in live births. Physiologic changes Maternal changes that nurture the developing fetus and prepare the mother for labor and delivery. in\u00a0pregnancy Mediated by \u008f\u00a0hormones (eg, estrogen, progesterone) and mechanical effects of gravid uterus. CARDIOVASCULAR \u0090\u00a0SVR (\u0090\u00a0afterload) and \u008f\u00a0blood volume (\u008f\u00a0preload) \u008e\u00a0\u008f\u00a0SV \u008e\u00a0\u008f\u00a0CO \u008e\u00a0\u008f\u00a0placental perfusion. \u008f\u00a0HR is the major contributor to \u008f\u00a0CO in late pregnancy. Hemodilution \u008e\u00a0\u0090\u00a0oncotic pressure ENDOCRINE \u008e\u00a0peripheral edema. GASTROINTESTINAL \u008f insulin resistance and secretion \u008e\u00a0\u008f\u00a0lipolysis and fat utilization (to preserve glucose and amino HEMATOLOGIC acids for fetus). Pituitary enlargement (lactotroph hyperplasia). \u008f\u00a0TBG, \u008f\u00a0CBG, \u008f\u00a0SHBG. MUSCULOSKELETAL \u0090\u00a0GI motility, \u0090\u00a0LES tone, gallbladder stasis; predispose to constipation, GERD, gallstones. SKIN Dilutional anemia (\u008f\u008f\u00a0plasma volume, \u008f\u00a0RBC mass), hypercoagulable state (to \u0090\u00a0blood loss at RENAL delivery). \u008f\u00a0micronutrient requirements predispose to deficiency (eg, iron, folate). RESPIRATORY Lordosis (to realign gravity center), joint laxity (to facilitate fetal descent). Hyperpigmentation (eg, melasma, linea nigra, areola darkening), striae gravidarum (stretch marks), vascular changes (eg, spider angiomas, palmar erythema, varicosities). Vasodilation \u008e\u00a0\u008f\u00a0renal plasma flow \u008e\u00a0\u008f\u00a0GFR \u008e\u00a0\u0090\u00a0BUN and \u0090\u00a0creatinine. Mild glucosuria, proteinuria. Hydronephrosis and hydroureter (more prominent on the right) predispose to pyelonephritis. Respiratory center stimulation \u008e\u00a0chronic hyperventilation (\u008f VT, unchanged RR) \u008e mild respiratory alkalosis (to \u008f\u00a0fetal CO2 elimination). uploaded by medbooksvn","654 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Physiology Human chorionic gonadotropin SOURCE Syncytiotrophoblast of placenta. FUNCTION Maintains corpus luteum (and thus progesterone) for first 8\u201310 weeks of gestation by acting like LH (otherwise no luteal cell stimulation \u008e\u00a0abortion). Luteal-placental shift is complete after 8\u201310\u00a0weeks; placenta synthesizes its own estriol and progesterone and corpus luteum degenerates. Used to detect pregnancy because it appears early in urine (see above). Has identical \u03b1 subunit as LH, FSH, TSH (states of \u008f\u00a0hCG can cause hyperthyroidism). \u03b2 subunit is unique (pregnancy tests detect \u03b2\u00a0subunit). hCG is \u008f in multifetal gestation, hydatidiform moles, choriocarcinomas, and Down syndrome; hCG is \u0090\u00a0in ectopic\/failing pregnancy, Edwards syndrome, and Patau syndrome. Human placental Also called human chorionic somatomammotropin. lactogen Syncytiotrophoblast of placenta. SOURCE Promotes insulin resistance to supply growing fetus with glucose and amino acids. Concurrently FUNCTION stimulates insulin secretion; inability to overcome insulin resistance \u008e gestational diabetes. Apgar score Score 2 Score 1 Score 0 Assessment of newborn vital signs following delivery via a 10-point scale evaluated Appearance Pink Extremities blue Pale or blue at 1\u00a0minute and 5 minutes. Apgar score Pulse \u2265 100 bpm < 100 bpm No pulse is based on appearance, pulse, grimace, Grimace Cries and Grimaces or activity, and respiration. Apgar scores <\u00a07 Activity pulls away weak cry No response to may require further evaluation. If Apgar Respiration stimulation score remains low at later time points, there is \u008f risk the child will develop long-term neurologic damage. Active movement Arms, legs \ufb02exed No movement Strong cry Slow, irregular No breathing Neonatal birth weight Low birth weight High birth weight (macrosomia) Birth weight < 2500 g DEFINITION Prematurity, FGR Birth weight > 4000 g RISK FACTORS Fetal: constitutional\/genetic COMPLICATIONS \u008f\u00a0mortality (SIDS), \u008f\u00a0morbidity Maternal: obesity, diabetes mellitus \u008f\u00a0risk of maternal or fetal trauma (eg, shoulder dystocia)","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Physiology SECTION III 655 Lactation After parturition and delivery of placenta, rapid \u0090 in estrogen and progesterone disinhibits prolactin \u008e\u00a0initiation of lactation. Suckling is required to maintain milk production and ejection, since Menopause \u008f\u00a0nerve stimulation \u008e\u00a0\u008f\u00a0oxytocin and prolactin. Androgens Prolactin\u2014induces and maintains lactation and \u0090 reproductive function. Oxytocin\u2014assists in milk letdown; also promotes uterine contractions. SOURCE Breast milk is the ideal nutrition for infants < 6 months old. Contains immunoglobulins FUNCTION (conferring passive immunity; mostly IgA), macrophages, lymphocytes. Breast milk reduces infant infections and is associated with \u0090 risk for child to develop asthma, allergies, diabetes mellitus, and obesity. Guidelines recommend exclusively breastfed infants get vitamin D and possibly iron supplementation. Breastfeeding facilitates bonding with the child. Breastfeeding or donating milk \u0090 risk of breast and ovarian cancers. Diagnosed by amenorrhea for 12 months. Hormonal changes: \u0090 estrogen, \u008f\u008f FSH, \u008f LH \u0090\u00a0estrogen production due to age-linked (no surge), \u008f GnRH. decline in number of ovarian follicles. Average age at onset is 51 years (earlier in people who Causes HAVOCS: Hot flashes (most common), smoke tobacco). Atrophy of the Vagina, Osteoporosis, Coronary artery disease, Sleep disturbances. Usually preceded by 4\u20135 years of abnormal menstrual cycles. Source of estrogen (estrone) Menopause before age 40 suggests 1\u00b0 ovarian after menopause becomes peripheral insufficiency (premature ovarian failure); conversion of androgens, \u008f androgens may occur in females who have received \u008e\u00a0hirsutism. chemotherapy and\/or radiation therapy. \u008f\u008f FSH is specific for menopause (loss of negative feedback on FSH due to \u0090 estrogen). Testosterone, dihydrotestosterone (DHT), androstenedione. DHT and testosterone (testis), androstenedione Potency: DHT > testosterone > (adrenal) androstenedione. Testosterone: Testosterone is converted to DHT by \u0083\t Differentiation of epididymis, vas deferens, 5\u03b1-reductase, which is inhibited by finasteride. seminal vesicles (internal genitalia, except prostate) In the male, androgens are converted to estrogens \u0083\t Growth spurt: penis, seminal vesicles, by aromatase (primarily in adipose tissue and sperm, muscle, RBCs testes). \u0083\t Deepening of voice \u0083\t Closing of epiphyseal plates (via estrogen Anabolic-androgenic steroid use\u2014\u008f\u00a0fat-free converted from testosterone) mass, muscle strength, performance. Suspect in \u0083\t Libido males who present with changes in behavior (eg, aggression), acne, gynecomastia, erythrocytosis DHT: (\u008f risk of thromboembolism), small testes \u0083\t Early\u2014differentiation of penis, scrotum, (exogenous testosterone \u008e\u00a0hypothalamic- prostate pituitary-gonadal axis inhibition \u0083\t Late\u2014prostate growth, balding, sebaceous \u008e\u00a0\u0090\u00a0intratesticular testosterone \u008e\u00a0\u0090 testicular gland activity size, \u0090 sperm count, azoospermia). Females may present with virilization (eg, hirsutism, acne, breast atrophy, male pattern baldness). uploaded by medbooksvn","656 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Physiology Tanner stages of sexual development Tanner stage is assigned independently to genitalia, pubic hair, and breast (eg, a person can have Tanner stage 2 genitalia, Tanner stage 3 pubic hair). Earliest detectable secondary sexual characteristic is breast bud development in females, testicular enlargement in males. Stage I Stage II Stage III Stage IV Stage V No sexual hair Pubic hair appears Coarsening of pubic Coarse hair across pubis, Coarse hair across pubis and Flat-appearing chest with (pubarche) hair sparing thigh medial thigh raised nipple Testicular enlargement Penis size\/length \u008f Penis width\/glans \u008f Penis and testis enlarge to Breast bud forms Breast enlarges Breast enlarges, raised adult size Pre-pubertal (thelarche), mound forms areola, mound on mound Adult breast contour, areola ~ 11.5\u201313 years \ufb02attens ~ 8 11.5 years ~ 13\u201315 years Usually > 15 years Precocious puberty Appearance of 2\u00b0 sexual characteristics (eg, pubarche, thelarche) before age 8 years in females and Delayed puberty 9 years in males. \u008f sex hormone exposure or production \u008e\u00a0\u008f linear growth, somatic and skeletal maturation (eg, premature closure of epiphyseal plates \u008e\u00a0short stature). Types include: \u0083\t Central precocious puberty (\u008f GnRH secretion): idiopathic (most common; early activation of hypothalamic-pituitary gonadal axis), CNS tumors. \u0083\t Peripheral precocious puberty (GnRH-independent; \u008f sex hormone production or exposure to exogenous sex steroids): congenital adrenal hyperplasia, estrogen-secreting ovarian tumor (eg,\u00a0granulosa cell tumor), Leydig cell tumor, McCune-Albright syndrome. Absence of 2\u00b0 sexual characteristics by age 13 years in females and 14 years in males. Causes: \u0083\t Hypergonadotropic (1\u00b0) hypogonadism: Klinefelter syndrome, Turner syndrome, gonadal injury (eg, chemotherapy, radiotherapy, infection). \u0083\t Hypogonadotropic (2\u00b0) hypogonadism: constitutional delay of growth and puberty (\u201clate blooming\u201d), Kallmann syndrome, CNS lesions.","Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology SECTION III 657 ` \u2009R E P R O D U C T I V E \u2014 PAT H O LO GY Sex chromosome Aneuploidy most commonly due to meiotic nondisjunction. disorders Klinefelter syndrome\u2002 Male, 47,XXY. Dysgenesis of seminiferous tubules Small, firm testes; infertility (azoospermia); tall \u008e\u00a0\u0090\u00a0inhibin\u00a0B \u008e \u008f FSH. Turner syndrome stature with eunuchoid proportions (delayed Abnormal Leydig cell function \u008e \u0090 testosterone Double Y males epiphyseal closure \u008e\u00a0\u008f\u00a0long bone length); \u008e \u008f LH. gynecomastia; female hair distribution. May present with developmental delay. Menopause before menarche. Presence of inactivated X chromosome (Barr \u0090 estrogen leads to \u008f LH, FSH. body). Common cause of hypogonadism seen Sex chromosome (X, or rarely Y) loss often due to in infertility workup. \u008f\u00a0risk of breast cancer. nondisjunction during meiosis or mitosis. Female, 45,XO. Meiosis errors usually occur in paternal gametes Short stature (associated with SHOX gene, \u008e\u00a0sperm missing the sex chromosome. preventable with growth hormone therapy), Mitosis errors occur after zygote formation \u008e\u00a0loss ovarian dysgenesis (streak ovary), broad chest with widely spaced nipples, bicuspid aortic of sex chromosome in some but not all cells valve, coarctation of the aorta (femoral < \u008e\u00a0mosaic karyotype (eg. 45,X\/46XX). brachial pulse), lymphatic defects (result in (45,X\/46,XY) mosaicism associated with webbed neck or cystic hygroma; lymphedema increased risk for gonadoblastoma. in feet, hands), horseshoe kidney, high-arched Pregnancy is possible in some cases (IVF, palate, shortened 4th metacarpals. exogenous estradiol-17\u03b2 and progesterone). Most common cause of 1\u00b0 amenorrhea. No Barr body. 47, XYY. Phenotypically normal (usually undiagnosed), very tall. Normal fertility. May be associated with severe acne, learning disability, autism spectrum disorders. Other disorders of sex Formerly called intersex states. Discrepancy between phenotypic sex (external genitalia, influenced development by hormonal levels) and gonadal sex (testes vs ovaries, corresponds with Y chromosome). 46,XX DSD Ovaries present, but external genitalia are virilized or atypical. Most commonly due to congenital 46,XY DSD adrenal hyperplasia (excessive exposure to androgens early in development). Ovotesticular DSD Testes present, but external genitalia are feminized or atypical. Most commonly due to androgen insensitivity syndrome (defect in androgen receptor). 46,XX > 46,XY. Both ovarian and testicular tissue present (ovotestis); atypical genitalia. uploaded by medbooksvn","658 SECTION III Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology Diagnosing disorders Testosterone LH Diagnosis by sex hormones \u008f \u008f \u008f \u0090 Androgen insensitivity syndrome \u0090 \u008f Testosterone-secreting tumor, exogenous \u0090 \u0090 androgenic steroids Hypergonadotropic (1\u00b0) hypogonadism Hypogonadotropic (2\u00b0) hypogonadism Diagnosing Uterus Breasts Diagnosis disorders by physical characteristics \u2295 \u229d Hypergonadotropic (1\u00b0) hypogonadism in genotypic female Hypogonadotropic (2\u00b0) hypogonadism in genotypic female \u229d \u2295 M\u00fcllerian agenesis in genotypic female Androgen insensitivity syndrome in genotypic male Aromatase deficien y Inability to synthesize endogenous estrogens. Autosomal recessive. During fetal life, DHEA produced by fetal adrenal glands cannot be converted to estrogen by the placenta and is converted to testosterone peripherally \u008e virilization of both female infant (atypical genitalia) and mother (acne, hirsutism; fetal androgens can cross placenta). Androgen insensitivity Defect in androgen receptor resulting in female-appearing genetic male (46,XY DSD); female syndrome external genitalia with scant axillary and pubic hair, rudimentary vagina; uterus and fallopian tubes absent due to persistence of anti-M\u00fcllerian hormone from testes. Patients develop normal functioning testes (often found in labia majora; surgically removed to prevent malignancy). \u008f testosterone, estrogen, LH (vs sex chromosome disorders). 5\u03b1-reductase Autosomal recessive; sex limited to genetic males (46,XY DSD). Inability to convert testosterone to deficien y DHT. Atypical genitalia until puberty, when \u008f testosterone causes masculinization\/\u008f growth of external genitalia. Testosterone\/estrogen levels are normal; LH is normal or \u008f. Internal genitalia are normal. Kallmann syndrome Failure to complete puberty; a form of hypogonadotropic hypogonadism. Defective migration of neurons and subsequent failure of olfactory bulbs to develop \u008e\u00a0\u0090 synthesis of GnRH in the hypothalamus; hyposmia\/anosmia; \u0090 GnRH, FSH, LH, testosterone. Infertility (low sperm count in males; amenorrhea in females).","Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology SECTION III 659 Placental disorders Formerly called morbidly adherent placenta. Myometrium Endometrium Placenta accreta Abnormal invasion of trophoblastic tissue into Serosa spectrum uterine wall A . Risk factors: prior C-section or Normal A other uterine surgery (areas of uterine scarring placenta impair normal decidualization), placenta Placenta previa previa, \u008f maternal age, multiparity. Three Placenta Vasa previa types depending on depth of trophoblast accreta Placental abruption invasion: Placenta \u0083\t Placenta accreta\u2014attaches to myometrium increta (instead of overlying decidua basalis) without Placenta invading it. Most common type. percreta \u0083\t Placenta increta\u2014partially invades into myometrium. Placenta \u0083\t Placenta percreta\u2014completely invades (\u201cperforates\u201d) through myometrium and serosa, sometimes extending into adjacent organs (eg, bladder \u008e hematuria). Presents with difficulty separating placenta from uterus after fetal delivery and severe postpartum hemorrhage upon attempted manual removal of placenta (often extracted in pieces). Attachment of placenta over internal cervical os (a \u201cpreview\u201d of the placenta is visible through cervix). Risk factors: prior C-section, multiparity. Presents with painless vaginal bleeding in third trimester. Low-lying placenta\u2014located < 2 cm from, but not covering, the internal cervical os. Fetal vessels run over, or < 2 cm from, the internal cervical os. Risk factors: velamentous insertion of umbilical cord (inserts in chorioamniotic membrane rather than placenta \u008e fetal vessels travel to placenta unprotected by Wharton jelly), bilobed or succenturiate placenta. Presents with painless vaginal bleeding (fetal blood from injured vessels) upon rupture of membranes accompanied by fetal heart rate abnormalities (eg, bradycardia). May lead to fetal death from exsanguination. Also called abruptio placentae. Premature separation of placenta from uterus prior to fetal delivery. Risk factors: maternal hypertension, preeclampsia, smoking, cocaine use, abdominal trauma. Presents with abrupt, painful vaginal bleeding in third trimester; can lead to maternal hypovolemic shock (due to hemorrhage) and DIC (due to release of tissue factor from injured placenta), fetal distress (eg, hypoxia). May be life threatening for both mother and fetus. Normal placenta Placenta previa Vasa previa Placental abruption uploaded by medbooksvn","660 SECTION III Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology Uterine rupture Full-thickness disruption of uterine wall. Risk factors: prior C-section (usually occurs during labor in a subsequent pregnancy), abdominal trauma. Postpartum hemorrhage Presents with painful vaginal bleeding, fetal heart rate abnormalities (eg, bradycardia), easily palpable fetal parts, loss of fetal station. May be life threatening for both mother and fetus. Ectopic pregnancy A Greater-than-expected blood loss after delivery. Leading cause of maternal mortality worldwide. Etiology (4 T\u2019s): Tone (uterine atony \u008e soft, boggy uterus; most common), Trauma (eg, lacerations, incisions, uterine rupture), Tissue (retained products of conception), Thrombin (coagulopathy). Treatment: uterine massage, oxytocin. If refractory, surgical ligation of uterine or internal iliac arteries (fertility is preserved since ovarian arteries provide collateral circulation). Implantation of fertilized ovum in a site other Fallopian tube Interstitium Isthmus (highest risk than the uterus, most often in ampulla of tubal rupture) of fallopian tube A . Risk factors: tubal Uterus pathologies (eg, scarring from salpingitis [PID] Ampulla or surgery), previous ectopic pregnancy, IUD, Ovary (most IVF. common site) Normal pregnancy Infundibulum Presents with first-trimester bleeding and\/ Fimbriae or lower abdominal pain. Often clinically mistaken for appendicitis. Suspect in patients Ectopic pregnancy with history of amenorrhea, lower-than- expected rise in hCG based on dates. Confirm with ultrasound, which may show extraovarian adnexal mass. Treatment: methotrexate, surgery.","Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology SECTION III 661 Hydatidiform mole Cystic swelling of chorionic villi and proliferation of chorionic epithelium (only trophoblast). A Presents with vaginal bleeding, emesis, uterine enlargement more than expected, pelvic pressure\/ B pain. Associated with hCG-mediated sequelae: hyperthyroidism, theca lutein cysts, hyperemesis gravidarum, early preeclampsia (before 20 weeks of gestation). Treatment: dilation and curettage +\/\u2013 methotrexate. Monitor hCG. KARYOTYPE Complete mole Partial mole COMPONENTS 46,XX (most common); 46,XY 69,XXX; 69,XXY; 69,XYY Most commonly enucleated egg 2 sperm + 1 egg HISTOLOGY + single sperm (subsequently Only some villi are hydropic, FETAL PARTS duplicates paternal DNA) focal\/minimal trophoblastic STAINING FOR P57 PROTEIN Hydropic villi, circumferential proliferation and diffuse trophoblastic UTERINE SIZE proliferation Yes (partial = fetal parts) hCG No \u2295 (maternally expressed) IMAGING Partial mole is P57 positive \u229d (paternally imprinted) \u2014 RISK OF INVASIVE MOLE \u008f RISK OF CHORIOCARCINOMA \u008f Fetal parts \u008f\u008f\u008f\u008f < 5% Rare \u201cHoneycombed\u201d uterus or \u201cclusters of grapes\u201d A , \u201csnowstorm\u201d\u00a0 B on ultrasound 15\u201320% 2% uploaded by medbooksvn","662 SECTION III Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology Choriocarcinoma Rare malignancy of trophoblastic tissue A A B (cytotrophoblasts, syncytiotrophoblasts), without chorionic villi present. Most commonly occurs after an abnormal pregnancy (eg, hydatidiform mole, abortion); can occur nongestationally in gonads. Presents with abnormal uterine bleeding, hCG-mediated sequelae, dyspnea, hemoptysis. Hematogenous spread to lungs \u008e\u00a0\u201ccannonball\u201d metastases B . Treatment: methotrexate. Hypertension in pregnancy Gestational BP > 140\/90 mm Hg after 20 weeks of gestation. No preexisting hypertension. No proteinuria or hypertension end-organ damage. Hypertension prior to 20 weeks of gestation suggests chronic hypertension. Treatment: antihypertensives (Hydralazine, \u03b1-methyldopa, labetalol, nifedipine), deliver at 37\u201339 weeks. Hypertensive moms love nifedipine. Preeclampsia New-onset hypertension with either proteinuria or end-organ dysfunction after 20 weeks of gestation (onset of preeclampsia < 20 weeks of gestation may suggest molar pregnancy). Caused by abnormal placental spiral arteries \u008e\u00a0endothelial dysfunction, vasoconstriction, ischemia. Risk factors: history of preeclampsia, multifetal gestation, chronic hypertension, diabetes, chronic kidney disease, autoimmune disorders (eg, antiphospholipid syndrome), obesity, age > 35 years. Complications: placental abruption, coagulopathy, renal failure, pulmonary edema, uteroplacental insufficiency; may lead to eclampsia and\/or HELLP syndrome. Treatment: antihypertensives, IV magnesium sulfate (to prevent seizure); definitive is delivery. Prophylaxis: aspirin. Eclampsia Preeclampsia with seizures. Death due to stroke, intracranial hemorrhage, ARDS. Treatment: IV magnesium sulfate, antihypertensives, immediate delivery. HELLP syndrome Preeclampsia with thrombotic microangiopathy of the liver. Hemolysis, Elevated Liver enzymes, Low Platelets. May occur in the absence of hypertension and proteinuria. Blood smear shows schistocytes. Can lead to hepatic subcapsular hematomas (rupture \u008e\u00a0severe hypotension) and DIC (due to release of tissue factor from injured placenta). Treatment: immediate delivery.","Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology SECTION III 663 Supine hypotensive Also called aortocaval compression syndrome. Seen at > 20 weeks of gestation. Supine position syndrome \u008e\u00a0compression of abdominal aorta and IVC by gravid uterus \u008e\u00a0\u0090\u00a0placental perfusion (can lead to pregnancy loss) and \u0090\u00a0venous return (hypotension). Relieved by left lateral decubitus position. Gynecologic tumor Incidence (US)\u2014endometrial > ovarian > CEOs often go from best to worst as they get epidemiology cervical; cervical cancer is more common older. worldwide due to lack of screening or HPV vaccination. Prognosis: Cervical (best prognosis, diagnosed < 45 years old) > Endometrial (middle- aged, about 55\u00a0years old) > Ovarian (worst prognosis, >\u00a065\u00a0years). Vulvar pathology Non-neoplastic Bartholin cyst and Due to blockage of Bartholin gland duct causing accumulation of gland fluid. May lead to abscess abscess 2\u00b0 to obstruction and inflammation A . Usually in reproductive-age females. Lichen sclerosus Chronic, progressive inflammatory disease characterized by porcelain-white plaques B that can be hemorrhagic, eroded, or ulcerated. May extend to anus producing figure-eight appearance. Lichen simplex \u008f incidence in prepubertal and peri-\/postmenopausal females. Presents with intense pruritus, chronicus dyspareunia, dysuria, dyschezia. Benign, but slightly \u008f risk for SCC. Hyperplasia of vulvar squamous epithelium. Presents with leathery, thick vulvar skin with enhanced skin markings due to chronic rubbing or scratching. Benign, no risk of SCC. Neoplastic Carcinoma from squamous epithelial lining of vulva C . Rare. Presents with leukoplakia, biopsy Vulvar carcinoma often required to distinguish carcinoma from other causes. HPV-related vulvar carcinoma\u2014associated with high-risk HPV types 16, 18. Risk factors: multiple partners, early coitarche. Usually in reproductive-age females. Non-HPV vulvar carcinoma\u2014usually from long-standing lichen sclerosus. Females > 70 years old. Extramammary Paget Intraepithelial adenocarcinoma. Carcinoma in situ, low risk of underlying carcinoma (vs Paget disease disease of the breast, which is always associated with underlying carcinoma). Presents with pruritus, erythema, crusting, ulcers D . A BCD uploaded by medbooksvn","664 SECTION III Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology Imperforate hymen Incomplete degeneration of the central portion of the hymen. Accumulation of vaginal mucus at birth \u008e\u00a0self-resolving bulge in introitus. If untreated, leads to 1\u00b0 amenorrhea, cyclic abdominal pain, hematocolpos (accumulation of menstrual blood in vagina \u008e\u00a0bulging and bluish hymenal membrane). Vaginal tumors Usually 2\u00b0 to cervical SCC; 1\u00b0 vaginal carcinoma rare. Squamous cell Arises from vaginal adenosis (persistence of glandular columnar epithelium in proximal vagina), carcinoma found in females who had exposure to diethylstilbestrol in utero. Clear cell Embryonal rhabdomyosarcoma variant. Affects females < 4 years old; spindle-shaped cells; desmin adenocarcinoma \u2295. Presents with clear, grapelike, polypoid mass emerging from vagina. Sarcoma botryoides Cervical pathology Disordered epithelial growth; begins at basal layer of squamocolumnar junction (transformation Dysplasia and zone) and extends outward. Classified as CIN 1, CIN 2, or CIN 3 (severe, irreversible dysplasia or carcinoma in situ carcinoma in situ), depending on extent of dysplasia. Associated with HPV-16 and HPV-18, which A produce both the E6 gene product (inhibits TP53) and E7 gene product (inhibits pRb) (6 before 7; P before R). Koilocytes (cells with wrinkled \u201craisinoid\u201d nucleus and perinuclear halo A ) are Invasive carcinoma pathognomonic of HPV infection. May progress slowly to invasive carcinoma if left untreated. Typically asymptomatic (detected with Pap smear) or presents as abnormal vaginal bleeding (often postcoital). Risk factors: multiple sexual partners, HPV, smoking, early coitarche, DES exposure, immunocompromise (eg, HIV, transplant). Often squamous cell carcinoma. Pap smear can detect cervical dysplasia before it progresses to invasive carcinoma. Diagnose via colposcopy and biopsy. Lateral invasion can block ureters \u008e\u00a0hydronephrosis \u008e\u00a0renal failure. Primary ovarian Also called premature ovarian failure. insufficie y Premature atresia of ovarian follicles in females of reproductive age. Most often idiopathic; associated with chromosomal abnormalities (eg, Turner syndrome, fragile X syndrome premutation), autoimmunity. Need karyotype screening. Patients present with signs of menopause after puberty but before age 40. \u0090 estrogen, \u008f\u00a0LH, \u008f\u00a0FSH.","Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology SECTION III 665 Most common causes Pregnancy, polycystic ovarian syndrome, obesity, HPO axis abnormalities\/immaturity, premature of anovulation ovarian failure, hyperprolactinemia, thyroid disorders, eating disorders, competitive athletics, Cushing syndrome, adrenal insufficiency, chromosomal abnormalities (eg, Turner syndrome). Functional Also called exercise-induced amenorrhea. Severe caloric restriction, \u008f\u00a0energy expenditure, and\/or hypothalamic stress \u008e functional disruption of pulsatile GnRH secretion \u008e \u0090\u00a0LH, FSH, estrogen. Pathogenesis amenorrhea includes \u0090\u00a0leptin (due to \u0090\u00a0fat) and \u008f cortisol (stress, excessive exercise). Associated with eating disorders and \u201cfemale athlete triad\u201d (\u0090\u00a0calorie availability\/excessive exercise, \u0090\u00a0bone mineral density, menstrual dysfunction). Polycystic ovarian Hyperinsulinemia and\/or insulin resistance hypothesized to alter hypothalamic hormonal feedback syndrome response \u008e\u00a0\u008f\u00a0LH:FSH, \u008f\u00a0androgens (eg, testosterone) from theca interna cells, \u0090\u00a0rate of follicular maturation \u008e\u00a0unruptured follicles (cysts) + anovulation. Common cause of \u0090\u00a0fertility in females. A Diagnosed based on \u2265 2 of the following: cystic\/enlarged ovaries on ultrasound (arrows in A ), oligo-\/anovulation, hyperandrogenism (eg, hirsutism, acne). Associated with obesity, acanthosis nigricans. \u008f\u00a0risk of endometrial cancer 2\u00b0 to unopposed estrogen from repeated anovulatory cycles. Treatment: cycle regulation via weight reduction (\u0090\u00a0peripheral estrone formation), OCPs (prevent endometrial hyperplasia due to unopposed estrogen); clomiphene (ovulation induction); spironolactone, finasteride, flutamide to treat hirsutism. Primary dysmenorrhea Painful menses, caused by uterine contractions to \u0090\u00a0blood loss \u008e\u00a0ischemic pain. Mediated by prostaglandins. Treatment: NSAIDs, acetaminophen, hormonal contraceptives. Ovarian cysts Usually asymptomatic, but may rupture, become hemorrhagic, or lead to adnexal torsion. Follicular cyst Functional (physiologic) cyst. Most common ovarian mass in young females. Caused by failure Corpus luteal cyst of mature follicle to rupture and ovulate. May produce excess estrogen. Usually resolves Theca lutein cyst spontaneously. Functional cyst. Caused by failure of corpus luteum to involute after ovulation. May produce excess progesterone. Usually resolves spontaneously. Also called hyperreactio luteinalis. Caused by hCG overstimulation. Often bilateral\/multiple. Associated with gestational trophoblastic disease (eg, hydatidiform mole, choriocarcinoma). uploaded by medbooksvn","666 SECTION III Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology Ovarian tumors Most common adnexal mass in females > 55 years old. Present with abdominal distention, bowel obstruction, pleural effusion. Risk \u008f with advanced age, \u008f number of lifetime ovulations (early menarche, late menopause, nulliparity), endometriosis, genetic predisposition (eg, BRCA1\/BRCA2 mutations, Lynch syndrome). Risk \uf090\u00a0with previous pregnancy, history of breastfeeding, OCPs, tubal ligation. Epithelial tumors are typically serous (lined by serous epithelium natively found in fallopian tubes, and often bilateral) or mucinous (lined by mucinous epithelium natively found in cervix). Monitor response to therapy\/relapse by measuring CA 125 levels (not good for screening). Germ cell tumors can differentiate into somatic structures (eg, teratomas), or extra-embryonic structures (eg, yolk sac tumors), or can remain undifferentiated (eg, dysgerminoma). Sex cord stromal tumors develop from embryonic sex cord (develops into theca and granulosa cells of follicle, Sertoli and Leydig cells of seminiferous tubules) and stromal (ovarian cortex) derivatives. Epithelial tumors Surface Germ cell tumors epithelium Sex cord stromal tumors Egg CHARACTERISTICS Follicle Cortex (stroma) TYPE Benign. Most common ovarian neoplasm. Lined by fallopian tube\u2013like epithelium. Benign. Multiloculated, large. Lined by mucus-secreting epithelium A . Epithelial tumors Serous cystadenoma Usually benign. Nests of urothelial-like (bladderlike) epithelium with \u201ccoffee bean\u201d nuclei. Mucinous cystadenoma Most common malignant ovarian neoplasm. Psammoma bodies. Brenner tumor Serous carcinoma Malignant. Rare. May be metastatic from appendiceal or other GI tumors. Can result in Mucinous carcinoma pseudomyxoma peritonei (intraperitoneal accumulation of mucinous material).","Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology SECTION III 667 Ovarian tumors (continued) TYPE CHARACTERISTICS Germ cell tumors Mature cystic Also called dermoid cyst. Benign. Most common ovarian tumor in young females. Cystic mass teratoma with elements from all 3 germ layers (eg, teeth, hair, sebum) B . May be painful 2\u02da to ovarian enlargement or torsion. Monodermal form with thyroid tissue (struma ovarii C ) may present with hyperthyroidism. Malignant transformation rare (usually to squamous cell carcinoma). Immature teratoma Malignant, aggressive. Contains fetal tissue, neuroectoderm. Commonly diagnosed before age 20. Typically represented by immature\/embryoniclike neural tissue. Dysgerminoma Malignant. Most common in adolescents. Equivalent to male seminoma but rarer. Sheets of uniform \u201cfried egg\u201d cells D . Tumor markers: \uf08f\u00a0hCG, \uf08f\u00a0LDH. Yolk sac tumor Also called endodermal sinus tumor. Malignant, aggressive. Yellow, friable (hemorrhagic) mass. 50% have Schiller-Duval bodies (resemble glomeruli, arrow in E ). Tumor marker: \uf08f\u00a0AFP. Occurs in children and young adult females. Sex cord stromal tumors Fibroma Benign. Bundle of spindle-shaped fibroblasts. Meigs syndrome\u2014triad of ovarian fibroma, ascites, pleural effusion. \u201cPulling\u201d sensation in groin. Thecoma Benign. May produce estrogen. Usually presents as abnormal uterine bleeding in a postmenopausal female. Sertoli-Leydig cell Benign. Gray to yellow-brown mass. Resembles testicular histology with tubules\/cords lined by pink tumor Sertoli cells. May produce androgens \u008e\u00a0virilization (eg,\u00a0hirsutism, male pattern baldness, clitoral enlargement). Granulosa cell tumor Most common malignant sex cord stromal tumor. Predominantly occurs in females in their 50s. Often produces estrogen and\/or progesterone. Presents with postmenopausal bleeding, endometrial hyperplasia, sexual precocity (in preadolescents), breast tenderness. Histology shows Call-Exner bodies (granulosa cells arranged haphazardly around collections of eosinophilic fluid, resembling primordial follicles; arrow in F ). Tumor marker: \uf08f\u00a0inhibin. \u201cGive Granny a Call.\u201d A BC DE F uploaded by medbooksvn","668 SECTION III Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology Uterine conditions CHARACTERISTICS TYPE Presence of endometrial tissue (glands and stroma) in myometrium. May be due to invagination of basal layer of endometrium or metaplasia of remnant progenitor cells. Presents with abnormal Non-neoplastic uterine bleeding, dysmenorrhea. Diffusely enlarged (\u201cglobular\u201d), soft (\u201cboggy\u201d) uterus on exam. Adenomyosis Presence of endometrial tissue (glands and stroma) outside uterus. May be due to ectopic Endometriosis implantation of endometrial tissue (via retrograde menses, blood vessels, lymphatics) or metaplasia of remnant progenitor cells. Typically involves pelvic sites, such as superficial Endometrial peritoneum (yellow-brown \u201cpowder burn\u201d lesions A ) and ovaries (forms blood-filled \u201cchocolate\u201d hyperplasia cyst called endometrioma). Presents with chronic pelvic pain (eg, dysmenorrhea, dyspareunia), abnormal uterine bleeding, infertility. Normal-sized uterus on exam. Endometritis Abnormal endometrial gland proliferation. Usually caused by excess estrogen unopposed by Intrauterine progesterone. Associated with obesity, anovulation (eg, PCOS), hormone replacement therapy. adhesions Presents with abnormal uterine bleeding. \u008f\u00a0risk for endometrial carcinoma (especially with nuclear atypia). Neoplastic Leiomyoma Inflammation of endometrium B . Usually occurs after delivery due to inoculation of uterine cavity by vaginal microbiota. C-section is the most important risk factor (sutures and necrotic tissue act Endometrial as nidus for polymicrobial infection). Presents with fever, uterine tenderness, purulent lochia. carcinoma Fibrous bands\/tissue within endometrial cavity. Caused by damage to basal layer of endometrium, A usually after dilation and curettage. Presents with abnormal uterine bleeding (\u0090\u00a0menses), infertility, recurrent pregnancy loss, dysmenorrhea. Also called Asherman syndrome when symptomatic. Benign tumor of myometrium (also called fibroid). Most common gynecological tumor. Arises in reproductive-age females. \u008f\u00a0incidence in Black population. Typically multiple; subtypes based on location: submucosal, intramural, or subserosal. Usually asymptomatic, but may present with abnormal uterine bleeding, pelvic pressure\/pain, reproductive dysfunction. Estrogen sensitive; tumor size \u008f\u00a0with pregnancy and \u0090\u00a0with menopause. Enlarged uterus with nodular contour on exam C . Histology: whorled pattern of smooth muscle bundles D and well-demarcated borders. Malignant tumor of endometrium. Most common gynecological cancer in resource-rich countries. Usually arises in postmenopausal females. Presents with abnormal uterine bleeding. Endometrioid carcinoma\u2014most common subtype of endometrial carcinoma. Associated with long-term exposure to unopposed estrogen. Histology: confluent endometrial glands without intervening stroma E . BCDE","Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology SECTION III 669 Breast pathology Nipple Lactiferous duct Terminal duct Stroma lobular unit Intraductal papilloma Fibroadenoma Abscess\/mastitis Fibrocystic change Phyllodes tumor Paget disease DCIS LCIS Ductal carcinoma Lobular carcinoma Benign breast diseases Most common in premenopausal females 20\u201350 years old. Present with premenstrual breast pain Fibrocystic changes or lumps; often bilateral and multifocal. Nonproliferative lesions include simple cysts (fluid-filled duct dilation, blue dome), papillary apocrine change\/metaplasia, stromal fibrosis. Risk of cancer is Inflammatory usually not increased. Proliferative lesions include processes \u0083\t Sclerosing adenosis\u2014acini and stromal fibrosis, associated with calcifications. Slight \u008f\u00a0risk for Benign tumors cancer. A \u0083\t Epithelial hyperplasia\u2014cells in terminal ductal or lobular epithelium. \u008f\u00a0risk of carcinoma with atypical cells. Fat necrosis\u2014benign, usually painless, lump due to injury to breast tissue. Calcified oil cyst on mammography; necrotic fat and giant cells on biopsy. Up to 50% of patients may not report trauma. Lactational mastitis\u2014occurs during breastfeeding, \u008f\u00a0risk of bacterial infection through cracks in nipple. S aureus is most common pathogen. Treat with antibiotics and continue breastfeeding. Fibroadenoma\u2014most common in females < 35 years old. Small, well-defined, mobile mass. Tumor composed of fibrous tissue and glands. \u008f\u00a0size and tenderness with \u008f\u00a0estrogen (eg, pregnancy, prior to menstruation). Risk of cancer is usually not increased. Intraductal papilloma\u2014small fibroepithelial tumor within lactiferous ducts, typically beneath areola. Most common cause of nipple discharge (serous or bloody). Slight \u008f\u00a0risk for cancer. Phyllodes tumor\u2014large mass of connective tissue and cysts with \u201cleaflike\u201d lobulations A . Most common in 5th decade. Some may become malignant. Gynecomastia Breast enlargement in males due to \u008f\u00a0estrogen compared with androgen activity. Physiologic in newborn, pubertal, and older males, but may persist after puberty. Other causes include cirrhosis, hypogonadism (eg, Klinefelter syndrome), testicular tumors, drugs (eg, spironolactone). uploaded by medbooksvn","670 SECTION III Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology Breast cancer Commonly postmenopausal. Often presents as Risk factors in females: \u008f\u00a0age; history of atypical a palpable hard mass A most often in upper hyperplasia; family history of breast cancer; race outer quadrant. Invasive cancer can become (White patients at highest risk, Black patients at fixed to pectoral muscles, deep fascia, Cooper \u008f\u00a0risk for triple \u229d breast cancer); BRCA1\/BRCA2 ligaments, and overlying skin \u008e\u00a0nipple mutations; \u008f\u00a0estrogen exposure (eg, nulliparity); retraction\/skin dimpling. postmenopausal obesity (adipose tissue converts androstenedione to estrone); \u008f\u00a0total number of Usually arises from terminal duct lobular unit. menstrual cycles; absence of breastfeeding; later Amplification\/overexpression of estrogen\/ age of first pregnancy; alcohol intake. In males: progesterone receptors or HER2 (an EGF BRCA2 mutation, Klinefelter syndrome. receptor) is common; triple negative (ER \u229d, PR \u229d, and HER2 \u229d) form more aggressive. Axillary lymph node metastasis most important prognostic factor in early-stage disease. TYPE CHARACTERISTICS NOTES Noninvasive carcinomas Ductal carcinoma in Fills ductal lumen (black arrow in B indicates Early malignancy without basement membrane situ neoplastic cells in duct; blue arrow shows penetration. Usually does not produce a mass. engorged blood vessel). Arises from ductal atypia. Often seen early as microcalcifications on mammography. Paget disease Extension of underlying DCIS\/invasive breast Paget cells = intraepithelial adenocarcinoma cancer up the lactiferous ducts and into the cells. contiguous skin of nipple \u008e\u00a0eczematous patches over nipple and areolar skin C . Lobular carcinoma in \uf090\u00a0E-cadherin expression. No mass or \u008f\u00a0risk of cancer in either breast (vs DCIS, same situ calcifications \u008e\u00a0incidental biopsy finding. breast and quadrant). Invasive carcinomas Invasive ductal Firm, fibrous, \u201crock-hard\u201d mass with sharp Most common type of invasive breast cancer. margins and small, glandular, ductlike cells in desmoplastic stroma. Invasive lobular \uf090\u00a0E-cadherin expression \u008e\u00a0orderly row of cells Often bilateral with multiple lesions in the same (\u201csingle file\u201d D ) and no duct formation. Often location. lacks desmoplastic response. Lines of cells = Lobular. Inflammatory Dermal lymphatic space invasion \u008e\u00a0breast pain Poor prognosis (50% survival at 5 years). with warm, swollen, erythematous skin around Often mistaken for mastitis or Paget disease. exaggerated hair follicles (peau d\u2019orange) E . Usually lacks a palpable mass. A B CD E","Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology SECTION III 671 Penile pathology Abnormal curvature of penis A due to fibrous plaque within tunica albuginea. Associated with Peyronie disease repeated minor trauma during intercourse. Can cause pain, anxiety, erectile dysfunction. A Consider surgical repair or treatment with collagenase injections once curvature stabilizes. Distinct from penile fracture (rupture of tunica albuginea due to forced bending). Ischemic priapism Painful sustained erection lasting > 4 hours. Associated with sickle cell disease (sickled RBCs block venous drainage of corpus cavernosum vascular channels), medications (eg, sildenafil, Squamous cell trazodone). Treat immediately with corporal aspiration, intracavernosal phenylephrine, or surgical carcinoma decompression to prevent ischemia. B Seen in the US, but more common in Asia, Africa, South America. Most common type of penile cancer B . Precursor in situ lesions: Bowen disease (in penile shaft, presents as leukoplakia \u201cwhite plaque\u201d), erythroplasia of Queyrat (carcinoma in situ of the glans, presents as erythroplakia \u201cred plaque\u201d), Bowenoid papulosis (carcinoma in situ of unclear malignant potential, presenting as reddish papules). Associated with uncircumcised males and HPV-16. Cryptorchidism Descent failure of one A or both testes. Impaired spermatogenesis (since sperm develop best at A temperatures < 37\u00b0C) \u008e subfertility. Can have normal testosterone levels (Leydig cells are mostly unaffected by temperature). Associated with \u008f risk of germ cell tumors. Prematurity \u008f risk of cryptorchidism. \u0090\u00a0inhibin B, \u008f FSH, \u008f LH; testosterone \u0090 in bilateral cryptorchidism, normal in unilateral. Most cases resolve spontaneously; otherwise, orchiopexy performed before 2 years of age. Testicular torsion Rotation of testicle around spermatic cord and vascular pedicle. Commonly presents in males 12\u201318 years old. Associated with congenital inadequate fixation of testis to tunica vaginalis \u008e Varicocele horizontal positioning of testes (\u201cbell clapper\u201d deformity). May occur after an inciting event (eg, A trauma) or spontaneously. Characterized by acute, severe pain, high-riding testis, and absent cremasteric reflex. \u229d Prehn sign. Treatment: surgical correction (orchiopexy) within 6 hours, manual detorsion if surgical option unavailable in timeframe. If testis is not viable, orchiectomy. Orchiopexy, when performed, should be bilateral because the contralateral testis is at risk for subsequent torsion. Dilated veins in pampiniform plexus due to \u008f venous pressure; most common cause of scrotal enlargement in adult males. Most often on left side because of \u008f resistance to flow from left gonadal vein drainage into left renal vein. Right-sided varicocele may indicate IVC obstruction (eg, from RCC invading right renal vein). Can cause infertility because of \u008f\u00a0temperature. Diagnosed by standing clinical exam\/Valsalva maneuver (distension on inspection and \u201cbag of worms\u201d on palpation; augmented by Valsalva) or ultrasound A . Does not transilluminate. Treatment: consider surgical ligation or embolization if associated with pain or infertility. uploaded by medbooksvn","672 SECTION III Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology Extragonadal germ cell Arise in midline locations. In adults, most commonly in retroperitoneum, mediastinum, pineal, and tumors suprasellar regions. In infants and young children, sacrococcygeal teratomas are most common. Benign scrotal lesions Testicular masses that can be transilluminated (vs solid testicular tumors). Hydrocele Accumulation of serous fluid within tunica vaginalis. Types: A \u0083\t Congenital (communicating)\u2014due to incomplete obliteration of processus vaginalis. Common cause of scrotal swelling A in infants. Most resolve spontaneously within 1 year. \u0083\t Acquired (noncommunicating)\u2014due to infection, trauma, tumor. Termed hematocele if bloody. Spermatocele Cyst due to dilated epididymal duct or rete Paratesticular fluctuant nodule. testis. Pampiniform plexus Testicular artery Vas deferens Epididymis Testes Tunica vaginalis Normal Hydrocele Spermatocele Varicocele Testicular torsion Testicular tumors Germ cell tumors account for \u223c 95% of all testicular tumors. Arise from germ cells that produce sperm. Most often occur in young males. Risk factors: cryptorchidism, Klinefelter syndrome. Can present as mixed germ cell tumors. Do not transilluminate. Usually not biopsied (risk of seeding scrotum), removed via radical orchiectomy. Sex cord stromal tumors develop from embryonic sex cord (develops into Sertoli and Leydig cells of seminiferous tubules, theca and granulosa cells of follicle) derivatives. 5% of all testicular tumors. Mostly benign. Germ cell tumors Developing sperm Sex cord stromal tumors Leydig cell Sertoli cell","Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology SECTION III 673 Testicular tumors (continued) TYPE CHARACTERISTICS Germ cell tumors Seminoma Malignant. Painless, homogenous testicular enlargement. Most common testicular tumor. Analogous to ovarian dysgerminoma. Does not occur in infancy. Large cells in lobules with watery cytoplasm and \u201cfried egg\u201d appearance on histology, \u008f\u00a0placental alkaline phosphatase (PLAP). Highly radiosensitive. Late metastasis, excellent prognosis. Embryonal carcinoma Malignant. Painful, hemorrhagic mass with necrosis. Often glandular\/papillary morphology. \u201cPure\u201d embryonal carcinoma is rare; most commonly mixed with other tumor types. May present with metastases. May be associated with \u008f\u00a0hCG and normal AFP levels when pure (\u008f\u00a0AFP when mixed). Worse prognosis than seminoma. Teratoma Mature teratoma may be malignant in adult males. Benign in children and females. Yolk sac tumor Also called endodermal sinus tumor. Malignant, aggressive. Yellow, mucinous. Analogous to ovarian yolk sac tumor. Schiller-Duval bodies resemble primitive glomeruli. \u008f\u00a0AFP is highly characteristic. Most common testicular tumor in children < 3 years old. Choriocarcinoma Malignant. Disordered syncytiotrophoblastic and cytotrophoblastic elements. Hematogenous metastases to lungs and brain. \u008f hCG. May produce gynecomastia, symptoms of hyperthyroidism (\u03b2 subunit of hCG is similar to \u03b2 subunit of TSH). Non\u2013germ cell tumors Leydig cell tumor Mostly benign. Golden brown color; contains Reinke crystals (eosinophilic cytoplasmic inclusions). Produces androgens or estrogens \u008e\u00a0precocious puberty, gynecomastia. Sertoli cell tumor Also called androblastoma (arises from sex cord stroma). Mostly benign. Primary testicular Malignant, aggressive. Typically diffuse large B-cell lymphoma. Often bilateral. Most common lymphoma testicular cancer in males > 60 years old. Hormone levels in germ cell tumors PLAP SEMINOMA YOLK SAC TUMOR CHORIOCARCINOMA TERATOMA EMBRYONAL CARCINOMA \u008f \u2013 \u2013 \u2013 \u2013 \u2013 \u2013\/\u008f \u2013\/\u008f (when mixed) AFP \u2013 \u008f\u008f \u008f\u008f \u2013 \u008f \u03b2-hCG \u2013\/\u008f \u2013\/\u008f Epididymitis and Most common causes: orchitis \u0083\t C trachomatis and N gonorrhoeae (young males) \u0083\t E coli and Pseudomonas (older males, associated with UTI and BPH) Epididymitis \u0083\t Autoimmune (eg, granulomas involving seminiferous tubules) Orchitis Inflammation of epididymis. Presents with localized pain and tenderness over posterior testis. \u2295\u00a0Prehn sign (pain relief with scrotal elevation). May progress to involve testis. Inflammation of testis. Presents with testicular pain and swelling. Mumps orchitis \u008f infertility risk. Rare in males < 10 years old. uploaded by medbooksvn","674 SECTION III Reproduc tive\u2003 \uf07d\u2009reproductive\u2014Pathology Benign prostatic Seminal vesicle Common in males > 50 years old. Characterized hyperplasia by smooth, elastic, firm nodular enlargement Ampulla of (hyperplasia not hypertrophy) of transition Prostatitis vas deferens zone, which compress the urethra into a Prostatic Peripheral zone vertical slit. Not premalignant. adenocarcinoma Central zone Transition zone Often presents with \u008f frequency of urination, Fibromuscular zone nocturia, difficulty starting and stopping urine stream, dysuria. May lead to distention and Urethra hypertrophy of bladder, hydronephrosis, UTIs. \u008f total PSA, with \u008f fraction of free PSA. PSA is made by prostatic epithelium stimulated by androgens. Treatment: \u03b11-antagonists (terazosin, tamsulosin), which cause relaxation of smooth muscle; 5\u03b1-reductase inhibitors (eg, finasteride); PDE-5 inhibitors (eg, tadalafil); surgical resection (eg, TURP, ablation). Characterized by dysuria, frequency, urgency, low back pain. Warm, tender, enlarged prostate. Acute bacterial prostatitis\u2014in older males most common bacterium is E coli; in young males consider C\u00a0trachomatis, N gonorrhoeae. Chronic prostatitis\u2014either bacterial or nonbacterial (eg, 2\u00b0 to previous infection, nerve problems, chemical irritation). Common in males > 50 years old. Arises most often from posterior lobe (peripheral zone) of prostate gland and is most frequently diagnosed by \u008f PSA and subsequent needle core biopsies (transrectal, ultrasound-guided). Histologically graded using Gleason grade, which is based on glandular architecture and correlates closely with metastatic potential. Prostatic acid phosphatase (PAP) and PSA are useful tumor markers (\u008f total PSA, with \u0090 fraction of free PSA). Osteoblastic metastases in bone may develop in late stages, as indicated by lower back pain and \u008f serum ALP and PSA. Metastasis to the spine often occurs via Batson (vertebral) venous plexus.","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Pharmacology SECTION III 675 ` \u2009R E P R O D U C T I V E \u2014 P H A R M A C O LO GY Control of reproductive hormones Hypothalamus Clomiphene via blocking negative feedback GnRH + Degarelix Goserelin - Leuprolide \u2013\/+ Anterior pituitary LH FSH Ovary LH LH FSH Testis - Oral contraceptives Danazol Ketoconazole - CYP450c17 - Ketoconazole Danazol Spironolactone Androstenedione Testosterone Testosterone - Anastrozole 5\u03b1\u2212reductase- Finasteride Letrozole - Aromatase Exemestane Dihydrotestosterone Flutamide Spironolactone Estriol Estrone Estradiol Androgen-receptor complex Tamoxifen \u2013\/+ Raloxifene Gene expression in androgen- Gene expression in estrogen- responsive cells responsive cells uploaded by medbooksvn","676 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Pharmacology Gonadotropin- Leuprolide, goserelin, nafarelin, histrelin. releasing hormone analogs Act as GnRH agonists when used in pulsatile fashion. When used in continuous fashion, first transiently act as GnRH agonists (tumor flare), but MECHANISM subsequently act as GnRH antagonists (downregulate GnRH receptor in pituitary \u008e\u00a0\u0090\u00a0FSH and CLINICAL USE \u0090\u00a0LH \u008e \u0090 estrogen in females and \u0090 testosterone in males). ADVERSE EFFECTS Can be used in lieu of GnRH. Uterine fibroids, endometriosis, precocious puberty, prostate cancer, infertility. Pulsatile for pregnancy, continuous for cancer. Hypogonadism, \u0090\u00a0libido, erectile dysfunction, nausea, vomiting. Degarelix GnRH antagonist. No start-up flare. Prostate cancer. MECHANISM Hot flashes, liver toxicity. CLINICAL USE ADVERSE EFFECTS Ethinyl estradiol Binds estrogen receptors. MECHANISM Hypogonadism or ovarian failure, menstrual abnormalities (combined OCPs), hormone CLINICAL USE replacement therapy in postmenopausal females. ADVERSE EFFECTS \u008f risk of endometrial cancer (when given without progesterone), bleeding in postmenopausal patients, clear cell adenocarcinoma of vagina in females exposed to DES in utero, \u008f risk of thrombi. Contraindications\u2014ER \u2295 breast cancer, history of DVTs, tobacco use in females > 35 years old. Selective estrogen receptor modulators Clomiphene Antagonist at estrogen receptors in hypothalamus. Prevents normal feedback inhibition and \u008f\u00a0release of LH and FSH from pituitary, which stimulates ovulation. Used to treat infertility due to anovulation (eg, PCOS). May cause hot flashes, ovarian enlargement, multiple simultaneous pregnancies, visual disturbances. Tamoxifen Antagonist at breast, partial agonist at uterus, bone. Hot flashes, \u008f\u00a0risk of thromboembolic events (especially with tobacco smoking), and endometrial cancer. Used to treat and prevent recurrence of ER\/PR \u2295 breast cancer and to prevent gynecomastia in patients undergoing prostate cancer therapy. Raloxifene Antagonist at breast, uterus; agonist at bone; hot flashes, \u008f\u00a0risk of thromboembolic events (especially with tobacco smoking), but no increased risk of endometrial cancer (vs tamoxifen, so you can \u201crelax\u201d); used primarily to treat osteoporosis. Aromatase inhibitors Anastrozole, letrozole, exemestane. Inhibit peripheral conversion of androgens to estrogen. MECHANISM ER \u2295 breast cancer in postmenopausal females. CLINICAL USE","Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Pharmacology SECTION III 677 Hormone replacement Used for relief or prevention of menopausal symptoms (eg, hot flashes, vaginal atrophy), therapy osteoporosis (\u008f estrogen, \u0090 osteoclast activity). Unopposed estrogen replacement therapy \u008f risk of endometrial cancer, progesterone\/progestin is added. Possible increased cardiovascular risk. Progestins Levonorgestrel, medroxyprogesterone, etonogestrel, norethindrone, megestrol. MECHANISM Bind progesterone receptors, \u0090 growth and \u008f vascularization of endometrium, thicken cervical mucus. CLINICAL USE Contraception (forms include pill, intrauterine device, implant, depot injection), endometrial cancer, abnormal uterine bleeding. Progestin challenge: presence of bleeding upon withdrawal of progestins excludes anatomic defects (eg, Asherman syndrome) and chronic anovulation without estrogen. Antiprogestins Mifepristone, ulipristal. Competitive inhibitors of progestins at progesterone receptors. MECHANISM Termination of pregnancy (mifepristone with misoprostol); emergency contraception (ulipristal). CLINICAL USE Combined Progestins and ethinyl estradiol; forms include pill, patch, vaginal ring. contraception Estrogen and progestins inhibit LH\/FSH and thus prevent estrogen surge. No estrogen surge \u008e no LH surge \u008e no ovulation. Progestins cause thickening of cervical mucus, thereby limiting access of sperm to uterus. Progestins also inhibit endometrial proliferation \u008e\u00a0endometrium is less suitable to the implantation of an embryo. Adverse effects: breakthrough menstrual bleeding, breast tenderness, VTE, hepatic adenomas. Contraindications: people > 35 years old who smoke tobacco (\u008f risk of cardiovascular events), patients with \u008f\u00a0risk of cardiovascular disease (including history of venous thromboembolism, coronary artery disease, stroke), migraine (especially with aura), breast cancer, liver disease. Copper intrauterine device MECHANISM Produces local inflammatory reaction toxic to sperm and ova, preventing fertilization and implantation; hormone free. CLINICAL USE Long-acting reversible contraception. Most effective emergency contraception. ADVERSE EFFECTS Heavier or longer menses, dysmenorrhea. Insertion contraindicated in active PID (IUD may impede PID resolution). Tocolytics Medications that relax the uterus; include terbutaline (\u03b22-agonist action), nifedipine (Ca2+ channel blocker), indomethacin (NSAID). Used to \u0090\u00a0contraction frequency in preterm labor and allow time for administration of glucocorticoids (to promote fetal lung maturity) or transfer to appropriate medical center with obstetrical care. uploaded by medbooksvn","678 SECTION III Reproduc tive\u2003 \uf07d\u2009REPRODUCTIVE\u2014Pharmacology Danazol Synthetic androgen that acts as partial agonist at androgen receptors. MECHANISM Endometriosis, hereditary angioedema. CLINICAL USE ADVERSE EFFECTS Weight gain, edema, acne, hirsutism, masculinization, \u0090 HDL levels, hepatotoxicity, idiopathic intracranial hypertension. Testosterone, methyltestosterone MECHANISM Agonists at androgen receptors. CLINICAL USE Treat hypogonadism and promote development of 2\u00b0 sex characteristics. ADVERSE EFFECTS Virilization in females; testicular atrophy in males. Premature closure of epiphyseal plates. \u008f\u00a0LDL, \u0090\u00a0HDL. Antiandrogens MECHANISM CLINICAL USE ADVERSE EFFECTS DRUG 17\u03b1-hydroxylase\/17,20-lyase Prostate cancer Hypertension, hypokalemia inhibitor (\u0090\u00a0steroid synthesis) BPH, male-pattern baldness (\u008f\u00a0mineralocorticoids) Abiraterone Gynecomastia, sexual 5\u03b1-reductase inhibitor Prostate cancer Finasteride (\u0090\u00a0conversion of testosterone to dysfunction Prostate cancer Flutamide, DHT) PCOS Gynecomastia, sexual bicalutamide dysfunction Nonsteroidal competitive Ketoconazole inhibitors at androgen Gynecomastia receptor (\u0090\u00a0steroid binding) Spironolactone Amenorrhea 17\u03b1-hydroxylase\/17,20-lyase inhibitor Androgen receptor and 17\u03b1-hydroxylase\/17,20-lyase inhibitor Tamsulosin \u03b11-antagonist selective for \u03b11A\/D receptors in prostate (vs vascular \u03b11B receptors) \u008e \u0090 smooth muscle tone \u008e \u008f urine flow. MECHANISM BPH. CLINICAL USE Direct arteriolar vasodilator. Minoxidil Androgenetic alopecia (pattern baldness), severe refractory hypertension. MECHANISM CLINICAL USE","HIGH-YIELD SYSTEMS Respiratory \u201cWhenever I feel blue, I start breathing again.\u201d `\tEmbryology\t 680 `\tAnatomy\t 682 \u2014L. Frank Baum `\tPhysiology\t 684 `\tPathology\t 692 \u201cUntil I feared I would lose it, I never loved to read. One does not love `\tPharmacology\t 706 breathing.\u201d \u2014Scout, To Kill a Mockingbird \u201cLove is anterior to life, posterior to death, initial of creation, and the exponent of breath.\u201d \u2014Emily Dickinson \u201cLove and a cough cannot be concealed.\u201d \u2014Anne Sexton Group key respiratory, cardiovascular, and renal concepts together for study whenever possible. Respiratory physiology is challenging but high yield, especially as it relates to the pathophysiology of respiratory diseases. Develop a thorough understanding of normal respiratory function. Get familiar with obstructive vs restrictive lung disorders, ventilation\/ perfusion mismatch, lung volumes, mechanics of respiration, and hemoglobin physiology. Lung cancers and other causes of lung masses are also high yield. Be comfortable reading basic chest x-rays, CT scans, and PFTs. 679 uploaded by medbooksvn"]
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