unit three - UAB - Department of Obstetrics and Gynecology

A P G OM E D I C A LS T U D E N TEDUCATIONTIONALOBJECTIVESEIGHTH EDITIONASSOCIATION OF PROFESSORSOF GYNECYNECOLOLOGOGY AND OBSTETRICS2130 Priest Bridge Drive, Suite #7Crofton, MD 21114(410) 451-9560; Fax (410) 451-9568www.apgo.apgo.org.orgASSOCIATION OF PROFESSORSOF GYNECYNECOLOLOGOGY AND OBSTETRICS

APGOMedical StudentEducational Objectives8th editionThis publication was revised by theAPGO Undergraduate MedicalEducation Committee (UMEC)2003-2004William P. Metheny, PhD, ChairJessica L. Bienstock, MD, MPHSusan M. Cox, MDSonya S. Erickson, MDAlice R. Goepfert, MDMaya M. Hammoud, MDDiane M. Hartmann, MDJames J. Neutens, PhDElizabeth E. Puscheck, MD, MSPaul M. Krueger, DOThe Association of Professors of Gynecology and Obstetrics and the APGOUndergraduate Medical Education Committee gratefully acknowledge WyethPharmaceuticals for an educational grant which has made the printing of thistext possible.The opinions and discussions herein are solely those of APGO and the APGOUndergraduate Medical Education Committee and should not be attributed toWyeth Pharmaceuticals.Lead Editor: Susan M. Cox, MDGlossary Editors: Eve L. Espey, MD; Edward (Ted) Peskin, MDOther Editors: Donna D. Wachter, APGO Executive Director;Pamela M. Johanssen, APGO Communications DirectorCopyright ©2004Association of Professors of Gynecology and Obstetrics (APGO)2130 Priest Bridge Drive, Suite #7Crofton, MD 21114

PREFACEPREFACESince the 1966 origination of the APGO Medical Student EducationalObjectives, the goal has been to improve the instruction of medicalstudents in the specialty of obstetrics and gynecology. TheUndergraduate Medical Education Committee (UMEC) of theAssociation of Professors of Gynecology and Obstetrics (APGO)prepared this 8th edition of the Objectives in 2003 and 2004.To develop this major revision, UMEC edited the previous editionof the APGO Medical Student Educational Objectives to ensurecoverage of significant additions and changes in the field. UMECthen linked each objective to the level of competence a studentshould be expected to achieve, the best methods of evaluationand the representative general competency, as defined by theAccreditation Council for Graduate Medical Education (ACGME).In conducting the work, UMEC adapted the framework described byRoy M. Pitkin, MD, of UCLA, in his 1995 presidential address to theAmerican Gynecological and Obstetrics Society. Doctor Pitkindivided the existing APGO Medical Student Educational Objectivesinto three categories:· Priority 1: Topics all medical students must learn and master;· Priority 2: Topics students should be expected to learn; andThe committee began with the 64 Educational Topic Areas and theunderlying educational objectives published in the Objectives 7 thedition. Three of these Educational Topic Areas were consideredPriority 3 and do not appear in the 8 th edition; an additional threewere merged with others.The committee then developed 267 specific Learning Objectivesdistributed among the 58 Educational Topic Areas. Of this total,126 were considered Priority 1 and, as such, must be learned andmastered by all medical students during their basic ob-gyn clerkship.Priority 1 Learning Objectives are identified in this document inblue ink.The remaining 141 Learning Objectives are considered Priority 2,placing them in the category that all medical students should beexpected to learn.Also shown in the document is the level of competence a student canbe expected to achieve.Further, the document indicates linkage to the current ACGMErepresentative general competency defined for graduate medicaleducation (see page viii).· Priority 3: Topics medical students can be expected to learn.ii

PREFACEPREFACEESSENTIAL ELEMENTSThe committee identified 15 current Essential Elements byaggregating 37 of the 58 Educational Topic Areas. These EssentialElements are listed in Table 1, below, followed by the relatedEducational Topic Area numbers. The committee proposes thatthese 15 elements authenticate the medical student experience inthe ob-gyn clerkship at the highest level.Table 1. . Essential Elements of Ob-GynUnderndergraduataduate Medical Education(continued)EssentialElementEssential Element DescripiptionRelatelatededEducationalTopic AreaeaNumberTable 1. . Essential Elements of Ob-GynUnderndergraduataduate Medical EducationF. Embryonic and fetal development –what does and does not affect it;what is and is not teratogenic9EssentialElementEssential Element DescripiptionA. Clinical skills in the medical interviewand physical examB. Collect and interpret a cervical cytology –first line disposition, limitations ofcervical cytologyC. Thorough grounding in moderncontraceptive technologyRelatelatededEducationalTopic AreaeaNumber1, 2, 4, 5333G. Health and well-being of populations –social and health policy aspect ofwomen’s health, ethical issues,sterilization, abortion, domesticviolence, adolescent pregnancy, accessto health care, etc.H. Menstrual cycle, including menopauseI. InfertilityJ. Intrapartum careK. Breast health, including breastfeeding6, 7, 16, 33,57, 58, 3443, 45, 46, 4748, 381114, 40D. Differential diagnosis of the “acuteabdomen” – pelvic infection, ectopicpregnancy, adnexal torsion, appendicitis,diverticulitis, renal calculiE. Physiologic adjustments that accompanynormal gestation, especially lab testresults15, 368, 10L. Vaginal and vulvar disordersM. Sexuality – patient and physicianN. Common problems in obstetricsO. Screening for reproductive cancers355617, 18, 23, 3051, 52, 53, 54,55iv

PREFACEPREFACETO FACULCULTYThe APGO Medical Student Educational Objectives, 8 th edition,is designed to provide an organized and understandable set ofobjectives for all medical students, regardless of their futurespecialty plans. The knowledge, skills and attitudes are intendedto be both a resource for course design for clerkship directors and auseful study guide for medical students. APGO strongly recommendsthat the 267 Objectives shown herein be included in the curriculumof all medical student clerkships, with special emphasis on the 126identified as “must learn and master.”This edition adds expected competence levels to be achieved bystudents, as well as best methods of evaluating the achievement ofeach objective. The linkage of each objective to the current ACGMEcompetencies is shown to relate the Objectives to the expectations forthe students’ residencies.We welcome your comments and suggestions for future editions.TO STUDENTTUDENTSAll medical students ask the question “What do I need to know?”This book is meant to clearly communicate the answer to thatquestion. The APGO Medical Student Educational Objectives, 8 thedition, represents the latest information available regarding theknowledge, skills and attitudes that you must acquire, regardless ofyour future specialty plans, as you proceed through your obstetricsand gynecology clerkship.In addition, this book defines the level of competence you will beexpected to achieve for each objective, as well as the best methods ofevaluating your achievement of the objective, and shows the linkageto the competencies you will be expected to obtain during yourresidency. Your clerkship director will modify these objectives, ifneeded, to emphasize various aspects of the discipline, since one bookcannot serve the needs of all courses. This book can also serve as astudy guide to prepare for your national licensure tests.We welcome your comments and suggestions for future editions.vi

PREFACEPREFACEKEYMust/Should/CanMust learn and master objectives are highlighted in blue ink; all othersare in black ink.Levels of CompetenceK = KnowsKH = Knows HowSH = Shows HowD = DoesAs defined by Miller GE in The assessment of clinical skills/competence/performance. Acad Med 1990;65:S63-7.Methods of Evaluation and ACGME Toolbox of Assessment Methods©Chart ReviewChecklistDirect ObservationKey Features Exam (KF)Multiple Choice Examination (MCQ)Oral ExamObjective Strutured Clinical Exam (OSCE)Standardized Patient (SP)NOTE: The Methods of Evaluation and ACGME Outcome ProjectGeneral Competencies list is used with permission of theAccreditation Council for Graduate Medical Education (ACGME).©2000 ACGME and ABMS. A product of the joint initiative of theACGME Outcome Project of the Accreditation Council for GraduateMedical Education and the American Board of Medical Specialties(ABMS). Version 1.1.Log on to the ACGME Web site at www.acgme.org/Outcome fordetailed descriptions on the ACGME Outcome Project Toolbox ofAssessment Methods.viiiKEY (continued)ACGME Outcome Project General Competencies1. Patient Carea. Caring and respectful behaviorsb. Interviewingc. Informed decision-makingd. Develop and carry out patient management planse. Counsel and educate patients and familiesf. Performance of procedures- Routine physical exam- Medical proceduresg. Preventive health servicesh. Work within a team2. Medical Knowledgea. Investigatory and analytic thinkingb. Knowledge and application of basic sciences3. Practice-based Learning and Improvementa. Analyze own practice for needed improvementsb. Use of evidence from scientific studiesc. Application of research and statistical methodsd. Use of information technologye. Facilitate learning of others4. Interpersonal and Communication Skillsa. Creation of therapeutic relationship with patientsb. Listening skills5. Professionalisma. Respectful, altruisticb. Ethically sound practicec. Sensitive to cultural, age, gender, disability issues6. Systems-based Practicea. Understand interaction of their practices within thelarger systemb. Knowledge of practice and delivery systemsc. Practice cost effective cared. Advocate for patients within the health care system

CONTENTONTENTSUNIT FOUR: REPRODUCTIVE ENDOCRINOLOLOGOGY,INTERTILITTILITY AND RELATED TOPICS42 Puberty43 Amenorrhea44 Hirsutism and Virilization45 Normal and Abnormal Uterine Bleeding46 Dysmenorrhea47 Menopause48 Infertility49 Premenstrual Syndrome andPremenstrual Dysphoric DisorderPage9092949698100102104UNIT ONEapproacoachtothepatientUNIT FIVE: NEOPLASIA50 Gestational Trophoblastic Neoplasia51 Vulvar Neoplasms52 Cervical Disease and Neoplasia53 Uterine Leiomyomas54 Endometrial Carcinoma55 Ovarian Neoplasms108110112114116118UNIT SIX: HUMAN SEXUALITALITY56 Sexuality and Modes of Sexual Expression122UNIT SEVEN: VIOLENCE AGAINSAINST WOMEN57 Sexual Assault58 Domestic Violence126128xii

UNIT ONEunit oneUNIT ONE: APPROACH TO THE PATIENTUNIT ONEThe student will be able to:unit oneObjective Level of Evaluation ACGMECompetence Method CompetencyEducational Topic 1: historyRationale: A gynecological evaluation is an important partof primary health care and preventive medicine for women.A. Complete a comprehensivewomen’s medical interview, including:1. Menstrual history2. Obstetric history3. Gynecologic history4. Contraceptive history5. Sexual history, includimg sexualorientation and sexual function6. Family history7. Social historyDChecklist1a, 1b, 4bA gynecological assessment should be a part of every woman’sgeneral medical interview and physical examination.Certain questions must be asked of every woman, whereas otherquestions are specific to particular problems.To accomplish these objectives, optimal communication must beachieved between patient and physician.B. Assess risk for unintendedpregnancy, sexually transmittedinfections, cervical pathology,breast malignancy, gynecologicmalignancies and domestic violenceC. Assess compliance withrecommended screening measuresspecific to women (e.g. cervicalmalignancy, gynecologic exam,breast exam, diagnostic breastimaging) in risk-appropriatecircumstancesDDChecklistChecklist1a, 1b, 2b,3b1a, 1b, 2b,3bD. Demonstrate interpersonal andcommunication skills that buildtrust by addressing contextual factors(e.g. culture, ethnicity, language/literacy, socioeconomic class,spirituality/religion, age, sexualorientation, disabilitiy)DChecklist1a, 1b, 4a,4b, 5cE. Communicate the results of theob-gyn and general medical interviewby well-organized written and oralreportsDChartreview1b, 1h2

UNIT ONEUNIT ONEUNIT ONE: approach to the patientThe student will be able to:Educational Topic 2: examination Objective Level of Evaluation ACGMECompetence Method CompetencyA. Interact with the patient to gainher confidence and cooperation, andassure her comfort and modestyDChecklist1a, 4a, 4b,5aRationale: An accurate examination complements the history,provides additional information, and helps determine diagnosisand guide management. It also provides an opportunity toeducate and reassure the patient.B. Perform accurate examinations ina sensitive manner, including:1. Breast examination2. Abdominal examination3. Complete pelvic examination4. Recto-vaginal examinationDChecklist1a, 1f, 4a,5a, 5cC. Use accurate medical terminologyto describe the:1. Normal female anatomy acrossthe life cycle2. Appearance of commonpathology of the female urogenitaltract3. Appearance of common breastchanges and disordersDDirectObserv.,ChartReview1f, 1hD. Communicate the relevantresults of the examination inwell-organized written and oralreportsDChartreview1eE. Share resultsSHOSCE1eF. Educate the patient regardingbreast self-examinationDChecklist1e, 3b4

UNIT ONEUNIT ONEUNIT ONE: APPROACH TO THE PATIENTEducational Topic 3: pap smear andculturesThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Perform an adequate Pap smearDChecklist1fRationale: The Pap smear is one of the most effective screening testsused in medicine today. Proper technique in performing the Papsmear and obtaining specimens for microbiologic culture willimprove accuracy.B. Obtain specimens to detectsexually transmitted infectionsC. Handle specimens properly toimprove diagnostic accuracyD. Provide an explanation to thepatient regarding the purpose ofthese testsDDDChecklistChecklistChecklist1f1f1e6

UNIT ONEUNIT ONEUNIT ONE: APPROACH TO THE PATIENTEducational Topic 4: diagnosis andmanagement planThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyRationale: Accurately identifying problems and selecting the most likelydiagnosis leads to effective management plans.A. Generate a problem listB. Form a diagnostic impression,including differential diagnosisDDChecklist,ChartreviewChecklist,Chartreview1c, 1d, 2a,3b1c, 2a, 2b,3bC. Consider economic, psychosocialand ethical issuesDChecklist,Chartreview5b, 6cD. Develop a management planthat includes:1. Laboratory and diagnosticstudies2. Treatment3. Patient education4. Continuing care plansDChecklist,Chartreview1d, 1e, 1f8

UNIT ONEUNIT ONEUNIT ONE: APPROACH TO THE PATIENTEducational Topic 6: legal and ethicalissues in obstetrics and gynecologyThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Explain the issues involvedin informed consentKHOSCE, SP,Oral exam1a, 1b, 1c,4bRationale: Legal obligations to protect patients’ interests are effectiveonly if understood and applied. Recognizing and understanding thebasis of ethical conflicts in obstetrics and gynecology will allow betterpatient care and prevent critical errors in treatment planning.B. Demonstrate the role ofconfidentiality in clinical activitiesC. List the local laws requiringthe reporting of suspected childabuse and domestic violenceDKChecklist,OSCE, SPMCQ,OSCE,Oral exam4a, 5a, 5b1b, 6a, 6bD. Discuss the legal and ethicalissues in the care of minorsKOral exam,OSCE, SP5a, 5b, 5cE. Describe issues of justicerelating to access to obstetricgynecologiccareKMCQ,Oral exam,KF5a, 5b, 6a,6bF. Explain the basis of ethicalconflict in maternal-fetalmedicineKMCQ,Oral exam,Checklist5b, 5cG. Discuss ethical issues raised byinduced abortion, contraceptionand reproductive technologyKMCQ,OSCE,Oral exam5a, 5b, 5c,6a12

UNIT ONEUNIT ONE: APPROACH TO THE PATIENTEducational Topic 7: preventive careand health maintenanceUNIT ONEThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyRationale: The student will recognize the value of routine healthsurveillance as a part of health promotion and disease prevention.A. List age-appropriate screeningprocedures and recommended timeintervals for mammogram, bonedensity, Pap tests, STI evaluationand other screening testsB. Counsel patient regardingcontraception, domestic abuse/violence and prevention ofsexually transmitted infectionsSHSHMCQ,Oral exam,SP, ChartreviewSP, OSCE1g, 2a, 2b1e, 4a, 4b,5a, 5c14

NOTESUNIT TWOOBSTETRICS16

UNIT TWOUNIT TWO: OBSTETRICSsection a: normal obstetricsEducational Topic 8: maternal-fetalphysiologyRationale: Knowledge of the physiologic adaptations to pregnancywill allow the student to better understand the impact of pregnancyin health and disease.UNIT TWOThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Discuss the maternalphysiologic anatomic changesassociated with pregnancyB. Describe the physiologicfunctions of the placenta andfetusKHKMCQ, KF,Oral exam,OSCE,Checklist,Models, SPMCQ,Oral exam1c, 1d, 1e,1f, 1g, 2a,2b2a, 2bC. Discuss the effect of pregnancyon common diagnostic studiesKHMCQ, KF,Oral exam,OSCE,Checklist1c, 1d, 1f,2a, 2b, 3b,3d, 6c18

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection a: normal obstetricsEducational Topic 9: preconception careThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyRationale: The proven benefits of good health prior to conceptioninclude a significant reduction in maternal and fetal morbidity andmortality.A. Describe how certain medicalconditions affect pregnancyB. Describe how pregnancy affectscertain medical conditionsKKMCQ,Checklist,Oral examMCQ,Checklist,Oral exam1e, 1g, 2a,2b1e, 1g, 2a,2bC. Counsel patients regardinghistory of genetic abnormalitiesSHChecklist,OSCE, SP1c, 1e, 4a,4bD. Counsel patients regardingadvanced maternal ageSHOSCE, SP,Checklist1c, 1e, 4a,4bE. Counsel patients regardingsubstance abuseSHOSCE, SP,Checklist1a, 1b, 1e,2a, 2b, 4a,4b, 5a, 5b,5cF. Counsel patients regardingnutrition and exerciseSHOSCE, SP,Checklist1e, 1g, 1h,2a, 2bG. Counsel patients regardingmedications and environmentalhazardsSHOSCE, SP,Checklist1b, 1e, 1g,2a, 2bH. Counsel patients regardingimmunizationsSHOSCE, SP,Checklist1e, 1g, 2a,2b, 3b, 6a,6c20

UNIT TWOUNIT TWO: OBSTETRICSsection a: normal obstetricsUNIT TWOThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyEducational Topic 10: antepartum careA. Diagnose pregnancyDSP, OSCE,Checklist1a, 2a, 2bRationale: Antepartum care promotes patient education andprovides ongoing risk assessment and development of anindividualized patient management plan.B. Assess gestational ageC. Distinguish an at-risk pregnancyDSHSP, OSCE,ChecklistOSCE, SP,Simulation2a, 2b1a, 2a, 2bD. Assess fetal growth, well-being,maturity and amniotic fluid volumeSHOral exam,SP, Patientrecord2a, 2bE. Describe appropriate diagnosticstudiesKHOral exam,MCQ,Checklist1c, 2a, 2bF. Describe nutritional needs ofpregnant womanKMCQ,Oral exam,OSCE2a, 2bG. Describe adverse effects of drugsand the environmentKMCQ,Checklist,Oral exam2a, 2bH. Perform a physical examinationon obstetric patientsDPatientrecord, SP,Simulation1a, 1b, 1fI. Answer commonly-askedquestions concerning pregnancy,and labor and deliverySHOral exam,MCQ,OSCE1e, 1g, 2a,2b22J. Counsel a woman with anunintended pregnancyKHMCQ, KF,Oral exam1a, 1b, 1c,1d, 1e, 2a,2b, 4a, 4b,5a, 5b, 5c

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection a: normal obstetricsEducational Topic11: intrapartum careThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. List the signs and symptomsof laborKHMCQ, KF,Oral exam2a, 2b, 4a,5a, 5cRationale: Understanding the process of normal labor and deliveryallows optimal care and reassurance for the parturient and timelyrecognition of abnormal events.B. Describe the three stages oflabor and recognize commonabnormalitiesKHMCQ, KF,Oral exam2a, 2b, 4a,5a, 5cC. Describe the steps of a vaginaldeliverySHChecklist,OSCE1f, 2a, 2b,4a, 5a, 5cD. Describe different methods ofdelivery with the indications andcontraindications of eachKHMCQ, KF,Oral exam1f, 2a, 2b,4a, 5a, 5cE. Describe the evaluation ofcommon puerperal complicationsKHMCQ, KF,Oral exam2a, 2b, 4a,5a, 5c24

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection a: normal obstetricsEducational Topic 12: immediate careof the newbornRationale: Assessment of the newborn allows recognition of theabnormalities requiring intervention.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Discuss the immediate careof the newbornB. Describe how to performa circumcisionKHKHMCQ,Checklist,Oral examMCQ,Checklist,Oral exam1a, 1c, 1d,1f1f26

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection A: normal obstetricsEducational Topic 13: postpartum careThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyRationale: Knowledge of normal postpartum events allowsappropriate care, reassurance and early recognition ofabnormal events.A. Discuss the normal maternalphysiologic changes of thepostpartum periodB. Descsribe the componentsof normal postpartum careKHKMCQ, KF,Oral exam,OSCE,ChecklistMCQ, KF,Oral exam,OSCE1c, 1d, 1f,2a, 2b1e, 1f, 1g,4a, 5cC. Discuss the appropriatepostpartum patient counselingKHMCQ, KF,Oral exam,OSCE1a, 1b, 1c,1d, 1e, 1g,3a, 4a, 4b,5c, 6a, 6b28

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection a: normal obstetricsEducational Topic 14: lactationRationale: Knowledge of the physiology and function of the breastduring lactation allows appropriate counseling to the pregnant andpostpartum woman.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. List the normal physiologic andanatomic changes of the breastduring pregnancy and thepostpartum periodsB. Recognize and treat commonpostpartum abnormalities ofthe breastKSHMCQ,Oral examChecklist,SP, OSCE2a, 2b1d, 1e, 1f,1h, 2a, 2bC. List the reasons why breastfeeding should be encouragedKMCQ,Oral exam,Checklist2a, 2bD. Identify commonly usedmedications which are appropriateand inappropriate to use whilebreast feeding.KMCQ,Oral exam,SP, OSCE2a, 2bE. Counsel the lactating patientabout commonly asked questions,such as frequency, duration,inadequate production of milk, etc.KHSP, OSCE1e, 2a, 2b,4a, 4b30

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 15: ectopic pregnancyThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyRationale: Ectopic pregnancy is a leading cause of maternalmorbidity and mortality in the United States. Early diagnosisand management may not only save lives, but may also preservefuture fertility.A. Develop a differential diagnosisfor bleeding and abdominal painin the first trimesterB. Identify risk factors forectopic pregnancyC. Be able to evaluate a patientsuspected of having an ectopicpregnancySHKSHOral exam,SP, OSCEMCQ,Oral exam,SP, OSCESP, OSCE,Checklist1b, 1c, 1d,1f, 2a, 2b2a, 2b1b, 1d, 1f,2a, 2bD. Diagnose an ectopic pregnancyKHMCQ,OSCE, SP1c, 1d, 1f,2a, 2bE. Describe treatment options forpatients with ectopic pregnancyKMCQ,Oral examSP1c, 1d, 2a,2b, 3b32

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 16: spontaneousabortionRationale: Bleeding is common in early pregnancy. A logicalapproach to its evaluation may not only affect the outcome ofthe pregnancy, but also will help to reassure the patient.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Develop a differential diagnosisfor first trimester vaginalbleedingB. Differentiate the types ofspontaneous abortionC. Define recurrent abortionSHSHKMCQ,OSCE, SPMCQ,OSCE, SPMCQ, KF1d, 1f, 2a,2b, 4a, 4b1f, 2a, 2b2bD. List the complications ofspontaneous abortionKMCQ, SP,KF2bE.Identify the causes andcomplications of septicabortionKHMCQ, SP,KF1b, 1c, 1d,1f, 1g, 2a,2b, 3a, 6a,6b34

UNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 17: medical andsurgical conditions of pregnancyRationale: Medical and surgical conditions may alter the course ofpregnancy and pregnancy may have an impact on the management ofthese conditions.The student will be able to:UNIT TWOObjective Level of Evaluation ACGMECompetence Method Competencya. Herpesb. Rubellac. Group B Streptococcusd. Hepatitise. Human Immunodeficiency Virus(HIV), Human Papillomavirus(HPV) and other sexuallytransmitted infectionsf. Cytomegalovirus (CMV)g. Toxoplasmosish. Varicella and parvovirusKHKHKHKHKHKHKHKHMCQ, KF,Oral exam,OSCE,Checklist1b, 1c, 1d,1e, 1f, 1g,2a, 2b, 3b,3a, 4a, 4b,5a, 5cObjective Level of Evaluation ACGMECompetence Method CompetencyA. Recognize the following medical and surgical conditions in pregnancy:1. Anemia2. Diabetes mellitusKHKHMCQ, KF,Oral exam,OSCE,ChecklistMCQ, KF,Oral exam,OSCE,Checklist1b, 1c, 1d,1e, 1f, 1g,2a, 2b, 3b,4a, 4b1b, 1c, 1d,1e, 1f, 1g,2a, 2b, 3b,4a, 4b5. Cardiac disease6. Asthma7. Alcohol, tobacco andsubstance abuseKHKHKHMCQ, KF,Oral exam,OSCEMCQ, KF,Oral exam,OSCEMCQ, KF,Oral exam,OSCE1b, 1c, 1d,1e, 1f, 1g,2a, 2b, 3b,4a, 4b1b, 1c, 1d,1e, 1f, 1g,2a, 2b, 3b,4a, 4b1b, 1c, 1d,1e, 1f, 1g,2a, 2b, 3b,4a, 4b, 5a,5c3. Urinary tract disordersKHMCQ, KF,Oral exam,OCSE,Checklist1b, 1c, 1d,1e, 1f, 1g,2a, 2b, 3b,4a, 4b8. Surgical abdomenSHOral exam,SP, OSCE1b, 1c, 1d,1e, 1f, 1g,2a, 2b, 3b,4a, 4b, 5a,5c4. Infectious diseases, including:B. Discuss the potential impact of the above conditions on the gravidpatient and the fetus/newborn, as well as the impact of pregnancy on eachcondition, if any36C. Describe the initial management of each condition in the pregnantpatient

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 18: preeclampsiaeclampsiasyndromeThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Define hypertension inpregnancyKHMCQ, KF,Oral exam,OSCE1b, 1c , 1f,2a, 2bRationale: Preeclampsia-eclampsia syndrome accounts for significantmorbidity and mortality in both the mother and newborn.B. Classify hypertension inpregnancyC. Describe the pathophysiologyof preeclampsia-eclampsiasyndromeKKHMCQ, KF,Oral examMCQ, KF,Oral exam2a, 2b2a, 2bD. Enumerate the symptoms ofpreeclampsia-eclampsia syndromeKHMCQ, KF,Oral exam,OSCE1b, 1e, 2a,2bE. Summarize the physicalfindings of preeclampsia-eclampsiasyndromeKHMCQ, KF,Oral exam,OSCE1f, 2a, 2bF. Diagnose preeclampsiaeclampsiasyndromeKHMCQ, KF,Oral exam,OSCE1b, 1c, 1f,2a, 2bG. Manage a patient withpreeclampsia-eclampsia syndromeKHMCQ, KF,Oral exam,OSCE,Checklist1c, 1d, 1f,2a, 2bH. Counsel a patient concerningthe indications of MgS04KMCQ, KF,Oral exam,OSCE1e, 2a, 2b38I. Counsel the patient concerningthe maternal and fetalcomplications associated withpreeclampsia-eclampsia syndromeKHMCQ, KF,Oral exam,OSCE, SP1e, 2a, 2b,3b, 4a

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 19: isoimmunizationRationale: The problem of fetal hemolysis from maternal Disoimmunization has decreased in the past few decades. Awarenessof the red cell antigen-antibody system is important to help furtherreduce the morbidity and mortality from isoimmunization.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Describe the pathophysiologyof isoimmunization, including:1. the role of red blood cellantigens2. the clinical circumstancesunder which D isoimmunizationis likely to occurB. Discuss the use ofimmunoglobulin prophylaxisduring pregnancy for theprevention of isoimmunizationKKHMCQ, KF,Oral examMCQ, KF,Oral exam,OSCE2a, 2b1c, 2a, 2b,3b, 6cC. Discuss the methods used toidentify maternal isoimmunizationand the severity of fetalinvolvementKMCQ, KF,Oral exam,OSCE1c, 1f, 2a,2b40

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 20: multifetalgestationRationale: When there is more than one fetus, antepartum,intrapartum, and postpartum management must be modifiedin order to optimize outcome for the mother and fetuses.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Discuss the etiology ofmonozygotic, dizygotic andmultizygotic gestationB. Describe the altered physiologicstate with multifetal gestationC. Discuss the symptoms,physical findings and diagnosisof multifetal gestationKKHKHMCQ, KF,Oral examMCQ, KF,Oral examMCQ, KF,Oral exam,OSCE2a, 2b2a, 2b1b, 1f, 2a,2bD. Discuss the approach toantepartum, intrapartum andpostpartum management formultifetal gestationKHMCQ, KF,Oral exam,OSCE,Checklist1c, 1d, 2a,2bE. Describe the potentialcomplications (maternal andfetal) associated with multifetalgestationKMCQ, KF,Oral exam,OSCE1c, 2a, 2b42

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 21:fetal deathThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Describe the common causesof fetal death in each trimesterKMCQ, KF,Oral exam1a, 1b, 2b,2cRationale: Early and accurate diagnosis and management will helpthe patient with emotional adjustments surrounding fetal deathand may prevent associated obstetric complications.B. Describe the symptoms,physical findings and diagnosticmethods to confirm the diagnosisof fetal deathKMCQ, KF,Oral exam1a, 1b, 2b,2cC. Describe the maternalcomplications of fetal death,including disseminatedintravascular coagulopathyKMCQ, KF,Oral exam1a, 1b, 2b,2cD. Counsel the patientexperiencing death of the fetusKHOral exam,OSCE, SP,Checklist3a, 3b, 4a,4b, 5c, 6b,6c44

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 22: abnormal laborRationale: Labor is expected to progress in an orderly andpredictable manner. Careful observation of the mother and fetusduring labor will allow early detection of abnormalities so thatmanagement can be directed to optimize outcome.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. List abnormal labor patternsB. Describe methods of fetalsurveillanceC. Discuss fetal and maternalcomplications of abnormal laborKKKMCQ,Oral exam,KFMCQ,Oral exam,KFMCQ,Oral exam,KF2b2b2bD. List indications andcontraindications for oxytocinadministrationKMCQ,Oral exam,KF2bE. List indications for VBACKMCQ,Oral exam,KF2bF. Discuss strategies for emergencymanagement of breech, shoulderdystocia and cord prolapseKMCQ,Oral exam,KF2b46

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 23: third trimesterbleedingThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. List the causes of thirdtrimester bleedingKMCQ,Oral exam2bRationale: Bleeding in the third trimester requires immediate patientevaluation. Thoughtful, prompt evaluation and management isnecessary to reduce the threat to the lives of the mother and fetus.B. Describe the initial evaluationof a patient with third trimesterbleedingKHMCQ,Oral exam2bC. Differentiate the signs andsymptoms of third trimesterbleedingKHMCQ,Oral exam,OSCE1b, 1f, 2bD. State the maternal and fetalcomplications of third trimesterbleedingKMCQ,Oral exam2bE. Describe the initialmanangement plan for shocksecondary to acute blood lossKHMCQ,Oral exam1d, 2bF. List the indications andpotential complications ofblood productsKHMCQ,Oral exam,KF1a, 1c, 1e,2b48

UNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsUNIT TWOThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyEducational Topic 24: preterm laborA. Cite the risk factors forpreterm laborKMCQ,Oral exam,KF2bRationale: Prematurity is the most common cause of neonatalmortality and morbidity. The reduction of preterm births remainsan important goal in obstetric care. Understanding the causes andrecognizing the symptoms of preterm labor provides the basis formanagement decisions.B. Distinguish preterm labor fromBraxton Hicks contractionsC. Identify the causes of pretermlaborKHKMCQ,Oral exam,KFMCQ,Oral exam,KF2b2bD. Counsel the patient regardingthe signs and symptoms ofpreterm laborSHChecklist,OSCE, SP1a, 1b, 1d,1f, 2b, 3b,4a, 4b, 5a,5cE. Describe the initialmanagement of preterm laborKHMCQ,Oral exam,KF1a, 1b, 1d,1f, 2bF. List indications and contraindicationsof medications usedto treat preterm laborKMCQ,Oral examKF2bG. Describe the adverse eventsassociated with the managementof preterm laborKHChecklist,OSCE, SP1a, 1b, 1c,1e, 2bH. Counsel the patient who hasexperienced prior preterm birthKMCQ,Oral exam,KF1a, 1b, 1e,1g, 2b, 3b,4a, 4b, 5a,6c50I.Describe cervical incompetenceKMCQ,Oral exam,KF2b

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 25: prematurerupture of membranesRationale: Rupture of the membranes prior to labor is a problemfor both term and preterm pregnancies. Careful evaluation ofthis condition may improve fetal and maternal outcome.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Summarize the history,physical findings and diagnosticmethods to confirm rupture ofthe membranesB. Cite the factors predisposingto premature rupture ofmembranesKHKMCQ,Oral exam,KFMCQ,Oral exam,KF1a, 1b, 1f2bC. List the risks and benefits ofexpectant management versusimmediate deliveryKMCQ,Oral exam,KF1a, 1c, 1d,2b, 3b, 3cD. Describe the methods tomonitor maternal and fetalstatus during expectantmanagementKHMCQ,Oral exam,Checklist1f, 2bE. Counsel the patient with,preterm premature rupture ofmembranesKHMCQ,Oral exam,KF1e, 2b, 3a,3b, 4a, 4b,5a, 5b, 6c52

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 26: intrapartum fetalsurveillanceRationale: Intrapartum fetal evaluation allows detection of aspectsof labor that may affect the fetus.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Perform fetal auscultationB. Interpret electronic fetalmonitoringDKHDirectobservation,SPMCQ, KF,OSCE1b, 1f, 1g,5c2a, 2b54

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 27: postpartumhemorrhageThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. List the risk factors forpostpartum hemorrhageKMCQ, SP,KF1d, 1f, 2a,2bRationale: Postpartum hemorrhage continues to be a major,although often preventable, cause of maternal morbidity andmortality.B. Formulate a differentialdiagnosis of postpartumhemorrhageC. Describe the immediatemanagement of the patient withpostpartum hemorrhageKKHMCQ, SP,KFMCQ, SP,KF1c, 1d, 1f,2a, 2b1c, 1d, 1f,1h, 2a, 2b,6a56

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 28: postpartuminfectionRationale: Early recognition and treatment of postpartum infectionwill decrease maternal morbidity and mortality.The student will be able to:A. List the risk factors forpostpartum infectionObjective Level of Evaluation ACGMECompetence Method CompetencyB. Describe the pathophysiologyof postpartum infectionKHKMCQ,Oral exam,KFMCQ,Oral exam,KF2b, 3b, 6c2bC. Identify the organismsinvolved in postpartum infectionKMCQ,Oral exam,KF2bD. Describe the evaluation andmanagement of the patient withpostpartum infectionSHChecklist,SP, OSCE1a, 1b, 1c,1d, 1e, 1f,2b, 4a, 4b,5a, 5b, 5c58

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 29: anxiety anddepressionRationale: Pregnancy, as any significant life event, may beaccompanied by anxiety and depression. Recognition ofpsychological disturbance is essential for early intervention.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Identify risk factors and,diagnose postpartum “blues,”postpartum depression andpostpartum psychosisB. Describe treatment options forpostpartum “blues,” postpartumdepression and postpartumpsychosisSHKHOSCE, SP,ChecklistMCQ,Oral exam,KF1a, 1b, 1d,1e, 2b, 4a,4b, 5a, 5c2b, 6cC. Identify appropriatetreatment options for depressionin pregnancyKMCQ,Oral exam,KF2a60

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 30: posttermpregnancyThe student will be able to:A. Identify the normalperiod of gestationObjective Level of Evaluation ACGMECompetence Method CompetencyKMCQ,Oral exam2bRationale: Perinatal mortality and morbidity may be increasedsignificantly in a prolonged pregnancy. Prevention of complicationsassociated with postterm pregnancy is one of the goals of antepartumand intrapartum management.B. Discuss the complicationsof post-maturityKMCQ,Oral exam2b, 3b62

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection b: abnormal obstetricsEducational Topic 31: fetal growthabnormalitiesThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Define macrosomia and fetalgrowth restrictionKMCQ,Oral exam2bRationale: Abnormalities of fetal growth carry increased risksfor morbidity and mortality. Monitoring fetal growth is animportant aspect of prenatal care and is performed on a regularbasis throughout the antepartum period.B. Describe etiologies of abnormalgrowthC. Cite methods of detection offetal growth abnormalitiesKKMCQ,Oral examMCQ,Oral exam2b1f, 2bD. Cite associated morbidity andmortalityKMCQ,Oral exam2b64

UNIT TWOUNIT TWOUNIT TWO: OBSTETRICSsection c: proceduresEducational Topic 32: obstetricproceduresObjective Level of Evaluation ACGMECompetence Method Competency3. Amniocentesis and cordocentesisKHMCQ,OSCE1f, 2b, 3b,6cRationale: Knowledge of obstetric procedures is basic to managementand counseling of the pregnant patient.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Describe the key components of pre-operative evaluation and planning,including complete medical histories, the informed consent process andworking with consultants.B. Describe the common peri-operative prophylactic measures, includingsteps taken to reduce infection and deep venous thrombosis.4. Antepartum fetal assessment5. Intrapartum fetal surveillance6. Induction and augmentation oflabor7. Episiotomy8. Spontaneous vaginal deliveryKHKHKKSHMCQ,OSCE, SPMCQ,OSCE, SPMCQ, SPMCQ,OSCEOSCE1f, 2b, 3b,6c1f, 2b, 3b,6c1f, 2b, 3b,6c1f, 2b, 3b,6c1a, 1d, 1e,1f, 1h, 2b,3b, 4a, 4b,5a, 5cC. Describe the components of routine post-operative care.D. List common post-operative complications.E. Descsribe each procedure and list the indications and complications ofeach of the following:1. Ultrasound2. Chorionic villous sampling66KKMCQ,OSCEMCQ,OSCE1f, 2b, 3b,6c1f, 2b, 3b,6c9. Vacuum-assisted delivery10. Forceps delivery11. Breech delivery12. Cesarean delivery13. Vaginal birth after cesareandeliveryKKKKKMCQ,OSCEMCQ,OSCEMCQ,OSCEMCQ,OSCEMCQ,OSCE1f, 2b, 3b,6c1f, 2b, 3b,6c1f, 2b, 3b,6c1f, 2b, 3b,6c1f, 2b, 3b,6c

NOTESUNIT THREEGYNECYNECOLOLOGOGY68

UNIT THREEUNIT THREEUNIT THREE: GYNECOLOGYsection a: general gynecologyEducational Topic 33: contraceptionand sterilizationRationale: An understanding of the medical and personal issuesinvolved in decisions regarding contraceptive methods is necessary toadequately advise patients requesting contraception. In the processof deciding whether to have a sterilization procedure, men andwomen often seek the advice of their physicians. Providing accurateinformation will allow patients to make an informed decisionregarding this elective surgery.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Describe the physiologic basisof contraception (OCPs, emergencycontraception, patches, rings, IUD,sterilization, etc.)B. Describe the effectiveness ofeach form of contraceptionC. Counsel the patient regardingthe benefits and risks for eachform of contraceptionKKHSHMCQ, KF,Oral examMCQ, KF,Oral examChecklist,OSCE, SP2b2b1a, 1b, 1c,1d, 1e, 1g,1h, 2b, 4a,4b, 5a, 5cD. Cite the financialconsiderations of the variousforms of contraceptionKMCQ, KF,Oral exam2bE. Describe the methods of maleand female surgical sterilizationKHMCQ, KF,Oral exam2bF. List the risks and benefits ofprocedures, including:1. Potential surgical complications2. Failure rates3. Reversibility (lack of)KMCQ, KF,Oral exam2b70

UNIT THREEUNIT THREEUNIT THREE: GYNECOLOGYsection a: general gynecologyEducational Topic 34: abortionRationale: Induced abortion is a reproductive option considered bysome patients. Regardless of one’s personal views, the practitionershould be aware of the techniques, management and complicationsof induced abortions.The student will be able to:A. Explain surgical andnon-surgical methods ofpregnancy terminationObjective Level of Evaluation ACGMECompetence Method CompetencyB. Identify potentialcomplications of induced abortionC. Provide non-directivecounseling to patientssurrounding pregnancy optionsKKHSHMCQ,Oral exam,KFMCQ,Oral exam,KFChecklist,OSCE, SP1c, 1g, 2b,3b, 6c1c, 1g, 2a,3a1a, 1b, 4a,4b, 5a, 5b,5c, 6d7272

UNIT THREEUNIT THREEUNIT THREE: GYNECOLOGYsection a: general gynecologyEducational Topic 35: vulvar andvaginal diseaseRationale: Vaginal and vulvar symptoms are frequent patientconcerns. In order to provide appropriate care, the physician mustunderstand the common etiologies of these problems, as well asappropriate diagnostic and management options.The student will be able to:A. Diagnose and manage a patientwith vaginitisB. Interpret a wet mountmicroscopic examinationObjective Level of Evaluation ACGMECompetence Method CompetencyC. Describe dermatologic disordersof the vulvaSHSHKChecklist,OSCE, SPChecklist,OSCE, SPOral exam1a, 1b, 1c,1d, 1e, 1f,2b, 4a, 4b,5c1f2a, 2bD. Evaluate a patient with vulvarsymptomsSHChecklist,OSCE, SP1a, 1b, 1c,1d, 1e, 1f,2b, 4a, 4b,5c74 74

UNIT THREEUNIT THREE: GYNECOLOGYsection a: general gynecologyEducational Topic 36: sexuallytransmitted infections (STIs) andurinary tract infections (UTIs)Rationale: To prevent sexually transmitted infections and urinarytract infections, the physician should understand their basicepidemiology, diagnosis and management. The potential impactof acute or chronic salpingitis is significant. Early recognitionand optimal management may help prevent the long-term sequelaeof tubal disease.The student will be able to:76Objective Level of Evaluation ACGMECompetence Method CompetencyA. Differentiate the signs andsymptoms of the following STIs:Gonorrhea, Chlamydia, Herpessimplex virus, Syphilis, Humanpapillomavirus infection, Humanimmunodeficiency virus (HIV)infection, Hepatitis B virusinfectionB. List the physical and clinicalfindings in the following STIs:Gonorrhea, Chlamydia, Herpessimplex virus, Syphilis, Humanpapillomavirus infection, Humanimmunodeficiency virus (HIV)infection, Hepatitis B virusinfectionKHKHMCQ,Oral exam,KFMCQ,Oral exam,KF2b1f, 2bUNIT THREEObjective Level of Evaluation ACGMECompetence Method CompetencyC. Describe the methods ofevaluation for the following STIs:Gonorrhea, Chlamydia, Herpessimplex virus, Syphilis, Humanpapillomavirus infection, Humanimmunodeficiency virus (HIV)infection, Hepatitis B virusinfectionD. Describe the management ofthe following STIs: Gonorrhea,Chlamydia, Herpes simplex virus,Syphilis, Human papillomavirusinfection, Human immunodeficiencyvirus (HIV) infection, Hepatitis Bvirus infectionE. Describe the pathogenesis ofsalpingitisF. List the signs and symptoms ofsalpingitisG. Describe the management ofsalpingitisH. Identify the long-term sequelaeof salpingitis, including: tuboovarianabscess, chronic salpingitis,ectopic pregnancy, infertilityI. Counsel the patient about thepublic health concerns for STIs,including screening programs, costs,prevention and immunizations, andpartner evaluation and treatmentJ. Describe the diagnosis andmanagement of UTIsKHKHKHKHKHKKKHMCQ,Oral exam,KFMCQ,Oral exam,KFMCQ, Oralexam, KFMCQ, Oralexam, KFMCQ, Oralexam, KFMCQ, Oralexam, KFChecklist,OSCE, SPMCQ, Oralexam, KF1f, 2b1a, 1b, 1c,1d, 2b2b2b1a, 1b, 1c,1d, 2b2b1e, 4a, 4b,5c, 6b, 6c2b

UNIT THREEUNIT THREEUNIT THREE: GYNECOLOGYsection a: general gynecologyEducational Topic 37: pelvic relaxationand urinary incontinenceRationale: Patients with conditions of pelvic relaxation and urinaryincontinence present in a variety of ways. The physician should befamiliar with the types of pelvic relaxation and incontinence, and theapproach to management of these patients.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Incorporate screening questionsfor urinary incontinence wheneliciting a patient historyB. Discuss the difference betweenstress, urge and overflowincontinenceC. Obtain pertinent historycomponents to differentiatebetween incontinence typesSHKSHOSCE, SPOral exam,OSCE, SPChecklist,OSCE, SP1a, 1b, 1c,1d, 1e, 1f,2b2a, 2b1a, 1b, 1c,1d, 1e, 1f,2b, 4a, 4b,5cD. Identify the following elementson physical exam: cystocele,rectocele, vaginal vault/uterineprolapseSHChecklist,OSCE, SP1f, 2bE. List behavioral, medical andsurgical methods to appropriatelytreat incontinence and pelvic organprolapseKHOSCE,MCQ, SP2a, 2b78

UNIT THREEUNIT THREEUNIT THREE: GYNECOLOGYsection a: general gynecologyEducational Topic 38: endometriosisThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Describe the theories of thepathogenesis of endometriosisKMCQ,Oral exam2bRationale: Endometriosis is a common problem in women ofreproductive age, which may result in pelvic pain, infertility andmenstrual dysfunction.B. List the common sites ofendometriosis implantsC. List the chief complaintsa patient with endometriosismay presentKKMCQ,Oral examMCQ,Oral examKF2b1d, 2bD. Identify the symptoms ofendometriosis in a female patientpresenting with abdominal painKMCQ,Oral exam,KF1d, 1fE. List the physical exam findingsa patient with endometriosis mayhaveKChecklist,MCQ,Oral exam,KF1d, 1fF. Describe how endometriosis isdiagnosedKMCQ,Oral exam,KF1d, 1f, 2bG. Outline a plan for managingendometriosisKChecklist,Oral exam,MCQ1d, 1e, 1f80

UNIT THREEUNIT THREEUNIT THREE: GYNECOLOGYsection a: general gynecologyEducational Topic 39: chronic pelvicpain (CPP)Rationale: Every physician should understand that chronic pelvicpain might be the manifestation of a variety of problems.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Define chronic pelvic painB. Cite the incidence and etiologiesKKMCQ,Oral exam,KFMCQ,Oral exam,KF2a, 2b2a, 2bC. Describe clinical manifestationsKMCQ,Oral exam,KF2a, 2bD. List diagnostic proceduresKMCQ,Oral exam,KF2a, 2bE. List management optionsKMCQ,Oral exam,KF1d, 1e, 2aF. Cite the psychosocial issuesassociated with chronic pelvicpainKMCQ,Oral exam,KF1a, 1c, 1d,1e, 1f, 4a,4b, 5a, 5b,5c82

UNIT THREEUNIT THREEUNIT THREE: GYNECOLOGYsection b: breastsEducational Topic 40: disorders of thebreastThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Demonstrate the performanceof a comprehensive breast examSHChecklist,OSCE, SP1a, 1b, 1c,1d, 1e, 1f,Rationale: Every physician should understand the basic approach toevaluating the common symptoms associated with the breast.B. Discuss diagnostic approach toa woman with the chief complaintof breast mass, nipple discharge orbreast painSHChecklist,OSCE, SP1a, 1b, 1c,1d, 1e, 1f,4a, 4b, 5cC. List history and physicalfindings that may suggest:1. Mastitis2. Carcinoma3. Fibrocystic changes4. Intraductal papilloma5. FibromaKMCQ, KF2b84

UNIT THREEUNIT THREEUNIT THREE: GYNECOLOGYsection c: proceduresEducational Topic 41: gynecologicproceduresRationale: Evaluation and management of gynecologic problemsfrequently requires performing diagnostic and therapeutic surgicalprocedures. Understanding the risks and benefits of such proceduresis important in counseling patients about their treatment optionsand reasons for having the procedures performed.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Describe the key components of pre-operative evaluation and planning,including complete medical histories, the informed consent process andworking with consultantsB. Describe the common peri-operative prophylactic measures, includingsteps taken to reduce infection and deep venous thrombosisC. Describe the components of routine post-operative careD. List common post-operative complicationsE. Descsribe each procedure and list the indications and complications ofeach of the following:1. Colposcopy and cervical biopsy2. Cone biopsy3. Cryotherapy4. Dilation and curettage5. Electrosurgical excision of cervix6. Endometrial biopsy7. Hysterectomy8. Hysterosalpingography9. Hysteroscopy10. Laparoscopy11. Laser vaporization12. Mammography13. Needle aspiration of breast mass14. Pelvic ultrasonography15. Pregnancy termination16. Vulvar biopsyKHMCQ, KF,Oral exam2b86

NOTESUNIT FOURrepreproductivoductiveendocrinologyinology,inferertility (rei)andrelatelated ed topics88

UNIT FOURUNIT THREEUNIT FOUR: REI AND RELATED TOPICSEducational Topic 42: pubertyRationale: The maturation of the reproductive system at the time ofpuberty is accompanied by physical and emotional changes that arepart of this normal transition. In order to provide appropriate careand counseling, the physician must have an understanding of thenormal sequence of puberty, and recognize deviation from the norm.The student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Normal puberty, including:1. Describe the physiologicalevents that take place in thehypothalamic-pituitary-ovarianaxis and their target organs atpuberty2. Describe the normalsequence of pubertal stagesand expected ages at whichthese changes occurKKHMCQ, KF,Oral examMCQ, KF,Oral exam2b2b3. Describe the psychologicalaspects of pubertyKMCQ, KF,Oral exam2bB. Abnormal puberty, including:1. Define abnormal puberty2. Describe the causes of earlyor late puberty3. Describe the diagnosticapproach to early or delayedpubertal onsetKMCQ, KF,Oral exam2b90

UNIT FOURUNIT FOURUNIT FOUR: REI AND RELATED TOPICSEducational Topic 43: amenorrheaThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Define amenorrhea andoligomenorrheaKMCQ, KF,Oral exam2bRationale: The absence of normal menstrual bleeding may representan anatomic or endocrine problem. A systematic approach to theevaluation of amenorrhea will aid in the diagnosis and treatment ofits cause.B. Describe the etiologies ofamenorrhea and oligomenorrheaC. Describe the evaluationmethods for amenorrhea andoligomenorrheaKHKHMCQ, KF,Oral examMCQ, KF,Oral exam2b2bD. Describe treatment options foramenorrhea and oligomenorrheaKHMCQ, KF,Oral exam2bE. Counsel patients who declinetherapySHChecklist,OSCE, SP1a, 1b, 1c,1d, 1e, 1f,1g, 1h, 2b,4a, 4b, 5a,5c92

UNIT FOURUNIT FOURUNIT FOUR: REI AND RELATED TOPICSEducational Topic 44: hirsutism andvirilizationThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Cite normal variations insecondary sexual characteristicsKMCQ, KF,Oral exam2bRationale: The signs and symptoms of androgen excess in a womanmay cause anxiety and may represent serious underlying disease.B. List definitions of hirsutismand virilizationC. List causes, including ovarian,adrenal, pituitary andpharmacologicalKKMCQ, KF,Oral examMCQ, KF,Oral exam2b2bD. Evaluate the patient withhirsutism or virilizationSHChecklist,OSCE, SP1a, 1b, 1c,1d, 1e, 1f,1h, 2a, 2b,4a, 4b, 5a,5b, 5c94

UNIT FOURUNIT FOURUNIT FOUR: REI AND RELATED TOPICSEducational Topic 45: normal andabnormal uterine bleedingThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Describe the normal menstrualcycleKHMCQ, KF,Oral exam2bRationale: The occurrence of bleeding at times other than expectedmenses is a common event. Accurate diagnosis of abnormal uterinebleeding is necessary for appropriate management.B. Define abnormal uterinebleedingC. Describe the etiologies ofabnormal uterine bleedingKHKHMCQ, KF,Oral examMCQ, KF,Oral exam2b2bD. Describe the evaluationmethods of abnormal uterinebleedingKHMCQ, KF,Oral exam2bE. Describe the therapeuticoptions of abnormal uterinebleedingKMCQ, KF,Oral exam2bF. Counsel patients about eachtherapeutic option andsequelaeSHChecklist,OSCE, SP1a, 1b, 1c,1d, 1e, 1f,1g, 1h, 2a,2b, 4a, 4b,5a, 5b, 5c96

UNIT FOURUNIT FOURUNIT FOUR: REI AND RELATED TOPICSEducational Topic 46: dysmenorrheaThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Define primary and secondarydysmenorrheaKMCQ,Oral exam,KF2a, 2bRationale: Dysmenorrhea is often the impetus for women to seekhealth care. Accurate diagnosis guides effective treatment.B. Identify the etiologies ofdysmenorrheaKMCQ,Oral exam,KF2a, 2bC. Describe the evaluation andmanagement of dysmenorrheaKMCQ,Oral exam,KF1d, 1f98

UNIT FOURUNIT FOURUNIT FOUR: REI AND RELATED TOPICSEducational Topic 47: menopauseThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyRationale: Women spend as much as one-third of their lives inthe postmenopausal years. It is important for all physicians whoprovide health care to women to understand the physical andemotional changes caused by estrogen depletion.A. Describe physiologic changes inthe hypothalamic-pituitary-ovarianaxis associated withperimenopause/menopauseB. Perform an assessment of thesymptoms and physical findingsassociated with hypoestrogenismKSHMCQ,Oral examChecklist,OSCE, SP2b1a, 1b, 1c,1d, 1e, 1f,5cC. Describe appropriatemanagement of menopausal/perimenopausal symptomsSHChecklist,OSCE, SP1a, 1b, 1c,1d, 1e, 1f,4a, 4b, 5a,5b, 5cD. Counsel patients regardingmenopausal issuesKMCQ,Oral exam2bE. List long term changesassociated with menopause,including osteoporosisKMCQ,Oral exam2b100

UNIT FOURUNIT FOURUNIT FOUR: REI AND RELATED TOPICSEducational Topic 48: infertilityThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Define infertilityKMCQ,Oral exam,KF2aRationale: The evaluation and management of an infertile couplerequires an understanding of the processes of conception andembryogenesis, as well as sensitivity to the emotional stress thatcan result from the inability to conceive.B. Describe the causes of maleand female infertilityC. Describe the evaluation andmanagement of infertilityKKMCQ,Oral exam,KFMCQ,Oral exam,KF2a, 2b1d, 1fD. List the psychosocial issuesassociated with infertilityKMCQ,Oral exam,KF1a, 1c, 1d,1e, 1f, 4a,4b, 5a, 5b,5c102

UNIT FOURUNIT FOURUNIT FOUR: REI AND RELATED TOPICSThe student will be able to:Educational Topic 49: PREMENSTRUALSYNDRTOME (PMS) and PREMENSTRUALDYSPHORIA DISORDER (PMDD)Rationale: Premenstrual syndrome involves physical and emotionaldiscomfort and may affect interpersonal relationships. Effectivemanagement of this condition requires an understanding ofsymptoms and diagnostic methods.Objective Level of Evaluation ACGMECompetence Method CompetencyA. Identify criteria for making thediagnosis of PMS, PMDD,depressionB. Describe treatment options forPMS, PMDD and depressionKHKOral exam,SPKF, MCQ,Oral exam1b, 1f, 2a,2b2a, 2b104

NOTESUNIT FIVEneoplasia106

UNIT FIVEUNIT FIVEUNIT FIVE: NEOPLASIAThe student will be able to:Educational Topic 50: gestationaltrophoblastic neoplasia (GTD)Rationale: Gestational trophoblastic neoplasia is important becauseof its malignant potential and the associated risks of morbidity andmortality.Objective Level of Evaluation ACGMECompetence Method CompetencyA. List the symptoms and physicalfindings of a patient with GTDB. Describe the diagnostic methodsutilized for a patient with GTDKKMCQ,Oral exam,KFMCQ,Oral exam,KF2b2b108

UNIT FIVEUNIT FIVEUNIT FIVE: NEOPLASIAEducational Topic 51: vulvar neoplasmsThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyRationale: Proper evaluation of vulvar symptoms allows for earlyrecognition and diagnosis of neoplasia, which can improve outcomeand may avoid the need for extensive surgery.A. Describe the risk factors forvulvar neoplasmsB. List the indications for vulvarbiopsyKKMCQ,Oral exam,KFMCQ,Oral exam,KF2b2b110

UNIT FIVEUNIT FIVEUNIT FIVE: NEOPLASIAThe student will be able to:Educational Topic 52: cervical diseaseand neoplasiaRationale: Detection and treatment of pre-invasive lesion reduces themedical and social costs of, as well as the mortality associated with,carcinoma of the cervix.Objective Level of Evaluation ACGMECompetence Method CompetencyA. Descsribe the pathogenesis ofcervical cancerB. Identify the risk factors forcervical neoplasia and cancerC. Perform an adequate Pap smearKKDMCQ,Oral examMCQ,Oral examChecklist2b, 3b2b, 3b1fD. Describe the appropriateutilization of new technologiesfor evaluating cervical neoplasiaKHMCQ,Oral exam2b, 3b, 6cE. Describe the initial managementof a patient with an abnormalPap smearKHMCQ,Oral exam2b, 3b, 6c112

UNIT FIVEUNIT FIVEUNIT FIVE: NEOPLASIAEducational Topic 53: uterineleiomyomasThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyRationale: Uterine leiomyomas represent the most commongynecologic neoplasm and are often asymptomatic.A. Discuss the prevalence ofuterine leiomyomasB. Describe the symptoms andphysical findings in patients withuterine leiomyomasKKMCQ,Oral exam,KFMCQ,Oral exam,KF2b2bC. Apply diagnostic methods toconfirm uterine leiomyomasSHOSCE, SP,Chartrecall2a, 2bD. List the indications formedical and surgical treatmentof uterine leiomyomasKMCQ,Oral exam,KF2b114

UNIT FIVEUNIT FIVEUNIT FIVE: NEOPLASIAThe student will be able to:Educational Topic 54: endometrialcarcinomaRationale: Endometrial carcinoma is the most commongynecologic malignancy.Objective Level of Evaluation ACGMECompetence Method CompetencyA. List the risk factors forendometrial carcinomaB. Describe the symptoms andphysical findings of a patient withendometrial cancerKKMCQ,Oral exam,KFMCQ,Oral exam,KF2b2bC. Outline the appropriatemanagement of the patient withpostmenopausal bleedingKHMCQ,Oral exam,KF, OSCE2a, 2bD. Discuss the use of diagnosticmethods for a patient withendometrial carcinomaKMCQ,Oral exam,KF2b116

UNIT FIVEUNIT FIVEUNIT FIVE: NEOPLASIAEducational Topic 55: ovarianneoplasmsThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyRationale: Adnexal masses are a common finding in bothsymptomatic and asymptomatic patients. Management isbased on determining the origin and character of these masses.A. Outline the approach to apatient with an adnexal massB. Compare the characteristics offunctional cysts, benign ovarianneoplasm and ovarian malignanciesKKMCQ,Oral exam,KFMCQ,Oral exam,KF2b2bC. Describe the sumptoms andphysical findings of a patient withovarian malignancyKMCQ,Oral exam,KF2bD. List the risk factors for ovariancancerKMCQ,Oral exam,KF2bE. Describe the histoligicalclassification of ovarianneoplasmKMCQ,Oral exam,KF2bF. Counsel a woman with risk forovarian cancerSHOSCE, SP,Directobservation1g, 2a, 2b,4a, 4b, 5a,5b, 5c, 6c118

NOTESUNIT SIXhumansexuality120

UNIT SIXUNIT SIXUNIT SIX: HUMAN SEXUALITYEducational Topic 56: sexuality andmodes of sexual expressionThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyRationale: All physicians should be able to provide a preliminaryassessment of patients with sexual concerns and make referrals whenappropriate. Detection and management of a woman’s health careproblems may be affected by her modes of sexual expression.A. Obtain a basic sexual history,including sexual function andsexual orientationB. Describe the physiology offemale sexual responseSHKHSPOral exam,Keyfeatures1b, 4b, 5c2bC. Discuss female sexuality acrossthe lifespanKHOral exam,Keyfeatures2b, 5cD. Categorize common patterns offemale sexual dysfunctionKMCQ,Oral exam2bE. Identify physical, psychologicaland societal contributions to femalesexual dysfunctionSHSP2b, 4b122

NOTESUNIT SEVENVIOLENCEAGAINSAINSTWOMEN124

UNIT SEVENUNIT SEVENUNIT SEVEN: VIOLENCE AGAINST WOMENEducational Topic 57: sexual assaultThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyA. Identify patients at increasedrisk for sexual abuseKMCQ,Oral exam1a, 1e, 5c,6bRationale: Individuals who are the victims of sexual assault oftenhave significant physical and emotional sequelae.B. List the components of a historyon a sexual assault victim (child,adult and acquaintance rape)KMCQ,Oral exam1a, 1e, 5c,6bC. Describe an age-appropriateexamination on a sexual assaultvictim (child, adult andacquaintance rape)KMCQ,Oral exam1a, 1e, 5c,6bD. Describe age-appropriatecounseling on a sexual assaultvictim (child, adult andacquaintance rape)KOral exam,SP, OSCE1a, 1b, 1e,4a, 4b, 5a,5c126

UNIT SEVENUNIT SEVENUNIT SEVEN: VIOLENCE AGAINST WOMENEducational Topic 58: domestic violenceThe student will be able to:Objective Level of Evaluation ACGMECompetence Method CompetencyRationale: Domestic violence affects a significant proportion ofthe U.S. population in all economic classes and walks of life. Allphysicians should screen for the presence of domestic violence.A. Cite prevalence and incidence ofviolence against women, elderabuse, child abuseB. Assess the involvement of anypatient in domestic violencesituationsKKHMCQ,Oral examOral exam,SP, OSCE2b1a, 1b, 1e,2a, 4b, 5cC. Counsel patients for short-termsafetySHOral exam,SP, OSCE1a, 1b, 1c,4a, 4b, 5a,5cD. Counsel patients regarding localsupport for long-term managementand resourcesSHOral exam,SP, OSCE1a, 1b, 1e,4a, 4b, 5a,5cE. Counsel patients requiringresources for batterers andperpetrators of domestic violenceSHOral exam,SP, OSCE1a, 1b, 1e,4a, 4b, 5a,5c128

NOTESGLOSSOSSARARYAbortion:Induced: Termination of a pregnancy by medical or surgicalintervention.Spontaneous: Spontaneous termination of a pregnancy before the20 th week of gestation.Complete: Complete expulsion of the entire products of conception.Incomplete: Incomplete expulsion of the products of conception(Retained tissue in the uterus).Inevitable: Dilation of the internal cervical os but without yetpassage of the products of conception.Missed: Intrauterine retention of the non-viable products ofconception.Recurrent: Three or more consecutive first-trimester spontaneousabortions.Septic: A threatened, inevitable, incomplete, missed or completeabortion complicated by infection.Threatened: Vaginal bleeding in the presence of a closed cervix anda viable fetus. (Comment: Threatened abs may occur before fetal heartmotion is documented.)Abruptio placentae: Separation of the normally implanted placentafrom its uterine attachment after the 20 th week of pregnancy andbefore the birth of the infant. It occurs mainly in the third trimester.130Acromegaly: Overgrowth of the terminal parts of the skeletal systemafter epiphyseal fusion as a result of overproduction of growthhormone.

GLOSSOSSARARYGLOSSOSSARARYAdenomyosis: Presence of endometrial tissue within the myometrium.Adnexae: The uterine appendages, including the fallopian tubes,ovaries and associated ligaments.Adrenal hyperplasia: A congenital or acquired increase in the numberof cells of the adrenal cortex, occurring bilaterally and resulting inexcessive secretion of 17-ketosteroids with signs of virilization.Amenorrhea: Absence or cessation of menstruation.Primary: Failure of menarche to occur by the 16 th year of life.Secondary: Absence of menses for three or more monthsafter menarche.Amniocentesis: Aspiration of amniotic fluid, usuallytransabdominally, for diagnostic or therapeutic purposes.Amniotic fluid: The fluid confined by the amnion.Anemia, megaloblastic: Anemia with an excessive number of megaloblastsin circulation, caused primarily by deficiency of folic acid,vitamin B12 or both.Anemia, iron deficiency: A deficiency of iron in the bloodstream, amore common cause of anemia in women.Anorexia nervosa: Eating disorder characterized by altered bodyimage and marked reduction in the intake of food, caused by psychogenicfactors and leading to malnutrition and amenorrhea.Anovulatory bleeding: Irregular uterine bleeding that occurs in theabsence of ovulation.Antepartum: Before labor or delivery.Apgar score: A physical assessment of the newborn, usually performedat 1 and 5 minutes after birth, used to determine the need forresuscitation.Ascites: An abnormal accumulation of fluid in the peritoneal cavity.Atony, uterine: Loss of uterine muscular tonicity, which may result infailure of labor to progress or in postpartum hemorrhage.Autonomy: In medicine, a patient’s right to determine what healthcare she will accept.Barr bodies: Sex chromatin masses on the nuclear membrane. Thenumber of Barr bodies is one fewer than the number of X chromosomesin that cell.Bartholin cyst: Cystic swelling of a Bartholin gland caused by obstructionof its duct.Bartholin glands: A pair of glands located at the 4 o’clock and 8o’clock positions on the vulvovaginal rim.Basal body temperature: The oral temperature at rest, used for detectionof ovulation.Benign cystic teratoma: The most common germ cell tumor, consistingof mature elements of all three germ layers (often called dermoidcyst).Biophysical profile: A physical assessment of the fetus, includingultrasound evaluation of fetal movement, breathing movements, fetaltone, amniotic fluid volume and electronic fetal heart monitoring.132

GLOSSOSSARARYGLOSSOSSARARYBiphasic temperature curve: A graph showing a basal body temperaturein the luteal phase that is 0.3-1 o F higher than that of the follicularphase, which indicates that ovulation has occurred.Blood flow, uteroplacental: The circulation by which the fetus exchangesnutrients and waste products with the mother.Breakthrough bleeding: Endometrial bleeding that occurs at inappropriatetimes during the use of hormonal contraceptives.Breech: The buttocks (often refers to a fetal presentation).Cancer staging: The clinical and pathological evaluation of the extentand severity of cancer.Carcinoma in situ: A neoplasm in which the tumor cells are confinedby the basement membrane of the epithelium of origin.Cesarean delivery: Birth of the fetus through incisions made in theabdomen and uterine wall.Chloasma (mask of pregnancy): Irregular brownish patches ofvarious sizes that may appear on the face during pregnancy or duringthe use of oral contraceptives.Chorioamnionitis: Inflammation of the fetal membranes.Choriocarcinoma: A malignant tumor composed of sheets of cellularand syncytial trophoblast.Chorionic villus sampling: The transcervical or transabdominalsampling of the chorionic villi for cytogenetic evaluation of the fetus.Climacteric: The period of life or the syndrome of endocrine, somaticand psychic changes that occur in a woman during the transitionfrom the reproductive to the nonreproductive state.134Clomiphene: A synthetic nonsteroidal compound that stimulates thematuration of follicles and thereby ovulation as a result of itsantiestrogenic effect on the hypothalamus.Coitus interruptus: Withdrawal of the penis during coitus beforeejaculation.Colporrhaphy:Anterior: A surgical procedure used to repair cystocele.Posterior: A surgical procedure used to repair rectocele.Colposcopy: Examination of the vagina and cervix by means of aninstrument that provides low magnification.Condyloma acuminatum: A benign, cauliflower-like growth on thegenitalia, thought to be caused by human papillomavirus.Cone biopsy: A cone of cervical tissue excised for histologic examination.Contraception: Prevention of conception.Cordocentesis (Percutaneous umbilical blood sampling, PUBS): A fetalassessment and therapeutic technique in which a needle is passed intoan umbilical vessel and blood is sampled or treatment is given.Corpus luteum: The cystic structure formed in the ovary at the site ofa ruptured ovarian follicle.Cul-de-sac: The pouch-like cavity (also called the Pouch of Douglas)between the rectum and the uterus, formed by a fold of peritoneum.Culdocentesis: Needle aspiration of intraperitoneal fluid or bloodthrough a puncture of the posterior vaginal fornix into the cul-desac.

GLOSSOSSARARYGLOSSOSSARARYCurettage: Scraping of the interior of a cavity or other surface with acurette.Fractional: Separate curettage of the endometrium and theendocervix for diagnostic evaluation. Specimens are submittedseparately for pathologic examination.Suction: Endometrial curettage using a suction catheter.Cushing syndrome: A symptom complex caused by hypersecretion ofglucocorticoids, mineralocorticoids and sex hormones of the adrenalcortex.Cystocele: Protrusion of the urinary bladder that creates a downwardbulging of the anterior vaginal wall as a result of weakening of thepubocervical fascia.Cystogram: A radiogram of the urinary bladder after the injection ofa contrast medium.Cystometry: Measurement of the function and capacity of theurinary bladder by pressure-volume studies, often used to diagnosehyperactive bladder.Cystoscopy: Direct endoscopic inspection of the interior of theurinary bladder.Decidua: Identifiable changes in the endometrium and other tissuesin response to the hormonal effects of progesterone.Dermoid cyst: See Benign cystic teratoma.Dilation: The physiologic or instrumental opening of the cervix.D immunoglobulin [RhO(D) immunoglobulin]: An immunoproteinthat prevents D sensitization.Disseminated intravascular coagulation (DIC, Consumptivecoagulopathy): An intravascular coagulation abnormality originallydescribed in the obstetric complications of abruptio placentae andintrauterine fetal demise.Double set-up: The simultaneous availability of two sterile set-upsfor either a vaginal or abdominal delivery.Dysgerminoma: A malignant solid germ cell tumor of the ovary.Dysmaturity: Intrauterine growth retardation leading to a small-fordatesbaby, associated with placental insufficiency.Dysmenorrhea: Painful menstruation.Dyspareunia: Difficult or painful intercourse.Dystocia: Abnormal or difficult labor.Dysuria: Painful urination.Eclampsia. The convulsive form of preeclampsia eclampsia syndrome.Ectopic pregnancy: A pregnancy located outside the uterine cavity.Ectropion: The growth of the columnar epithelium of the endocervixonto the ectocervix.Effacement: Thinning and shortening of the cervix.Embryo: The conceptus from the blastocyst stage to the end of the8 th week.Endometrial biopsy: The procedure of obtaining endometrial tissuefor diagnostic purposes.136

GLOSSOSSARARYGLOSSOSSARARYEndometriosis: The presence of endometrial implants outside theuterus.Endoscopy: Instrumental visualization of the interior of a hollowviscus.Enterocele: A herniation of the small intestine into the cul-de-sac,usually accompanied by (and sometimes confused with) rectocele.Episiotomy: An incision made into the perineum at the time ofvaginal delivery.Estrogen replacement: The exogenous administration of estrogen orestrogenic substances to overcome a deficiency or absence of thenatural hormone.Estrogen, unopposed: The continuous and prolonged effect of estrogenon the endometrium, resulting from a lack of progesterone.Eversion: See Ectropion.Exenteration, pelvic: The removal of all pelvic viscera, including theurinary bladder, the rectum or both, usually in the setting of advancedcervical malignancy.Fern (ferning): The microscopic pattern of sodium chloride crystalsas seen in estrogen stimulated cervical mucus or amniotic fluid.Fetal Testing (non-stress testing): Evaluation of the fetus by electronicfetal heart rate monitoring, when not in labor.Fetus: The conceptus from 8 weeks until birth.Fibrocystic changes (breast): Mammary changes characterized byfibrosis and formation of cysts in the fibrous stroma.Foreplay: The preliminary stages of sexual relations in which thepartners usually stimulate each other by kissing, touching andcaressing.Functional ovarian cyst: A physiologic cyst arising from the Graafianfollicle or the corpus luteum.Functioning ovarian tumor: A hormone-producing ovarian neoplasm.Galactorrhea: The spontaneous flow of breast milk in the absence of arecent pregnancy.Gender (sex) role: An individual’s understanding and feeling of theactivity and behavior appropriate to the male or female sex.Gonadal agenesis: The congenital absence of ovarian tissue or itspresence only as a rudimentary streak.Gonadal dysgenesis: The congenitally defective development of thegonads.Gonadotropin:Human chorionic (hCG): A glycoprotein hormone that is producedby the syncytiotrophoblast and is immunologically similar toluteinizing hormone (LH).Human menopausal (hMG): A preparation isolated from the urineof postmenopausal women, consisting primarily of follicle-stimulatinghormone (FSH) with variable amounts of LH, used forovulation induction.Pituitary: An endocrine organ composed of the anterior gonadotropinsecreting component and the posterior oxytocin secretingcomponent.138

GLOSSOSSARARYGLOSSOSSARARYGranulosa cell tumor: A feminizing, estrogen-producing ovariantumor.Gravida: A pregnant woman.Gravidity: The pregnant state, or the total number of pregnancies awoman has had, including the current pregnancy.Hemoperitoneum: Blood in the peritoneal cavity.Hermaphrodite: A person who exhibits characteristics of both sexes.A true hermaphrodite is characterized by the presence of bothovarian and testicular tissue.Hirsutism: The development of various degrees of hair growth ofmale type and distribution in a woman.Hormone therapy (HT): Estrogen and progestin replacement therapy.Hot flushes (flashes): A vasomotor symptom characterized by transienthot sensations that involve chiefly the upper part of the thorax,neck and head, frequently followed by sweats, and associated withcessation or diminution in the ovarian secretion of estrogen.Hydatidiform mole: A pathologic condition of pregnancy characterizedby the hydropic degeneration of the chorionic villi and variabledegrees of trophoblastic proliferation.Hydramnios (polyhydramnios): Excessive amounts (more than 2liters) of amniotic fluid at term.Hyperplasia, endometrial: The abnormal proliferation of the endometriumwith a marked increase in the number of glands or cysticdilation of glands. These changes may be related to prolonged unopposedestrogen stimulation.140Hypoestrogenism: A condition of subnormal estrogen production withresultant atrophy or failure of development of estrogen-dependenttissues.Hypofibrinogenemia: A deficiency (usually < 100 mg%) of circulatingfibrinogen that may be seen in conditions such as abruptio placentae,amniotic fluid embolism and fetal death in which the fibrinogen isconsumed by disseminated intravascular coagulation.Hypogonadism: The subnormal production of hormones by thegonads.Hysterectomy:Abdominal: The removal of the uterine corpus and cervix throughan incision made in the abdominal wall.Radical: The removal of the uterine corpus, cervix andparametrium, with dissection of the ureters; usually combinedwith pelvic lymphadenectomy.Laparoscopic Assisted Vaginal Hysterectomy (LAVH): The combinationof laparoscopy (pelviscopy) with vaginal surgery techniquesto remove the uterus and, frequently, the adnexa.Subtotal (supracervical): The removal of the uterine corpus,leaving the cervix in situ.Total: The removal of the uterine corpus and cervix (withoutregard to tubes or ovaries).Vaginal: The removal of the uterus through the vagina.Hysterosalpingography: Roentgenography of the uterus and tubesafter injection of radiopaque contrast medium through the cervix. Itis useful in ascertaining irregularities of the uterine cavity andpatency of the fallopian tubes.

GLOSSOSSARARYGLOSSOSSARARYHysteroscopy: The transcervical endoscopic visualization of theendometrial cavity.Hysterotomy: Surgical incision of the wall of the uterus.Imperforate hymen: Failure of a lumen to develop at a point wherethe budding vagina arises from the urogenital sinus.Impotence: The inability to achieve or sustain penile erection.Infertility: The inability to achieve pregnancy with regular intercourseand no contraception within a stipulated period of time, oftenconsidered to be 1 year.Intervillous space: The space in the placenta in which maternal bloodbathes chorionic villi, allowing the exchange of materials between thefetal and maternal circulations.Intraductal papilloma: A benign mammary tumor, often multiple,occurring predominantly in parous women at or shortly beforemenopause. It is typically located beneath the areola and is oftenassociated with bleeding from the nipple.Intrauterine device (IUD): A device inserted into the uterine cavityfor contraception.Intrauterine fetal demise (IUFD, stillbirth): Intrauterine death of afetus. For purposes of vital statistics, a fetal death prior to 500 gramsis usually classified as an abortus.Intrauterine growth retardation (IUGR): See Dysmaturity.Intromission: Introduction of the penis into the vagina.Justice: Ensuring or maintaining what is considered to be just or fairaccording to predetermined criteria.Karyotype: A photographic reproduction of the chromosomes of a cellin metaphase, arranged accordingto a standard classification.Labor: The process of expulsion of the fetus from the uterus.Induced: Labor that is initiated artificially.Stimulated (augmented): Labor that is stimulated, usually withoxytocin.Lactogen, human placental (hPL): A polypeptide hormone that isproduced by the syncytiotrophoblast, is similar to prolactin andsomatotropin from the pituitary, and is involved in carbohydratemetabolism by the mother and fetus.Laparoscopy: The transabdominal endoscopic examination of theperitoneal cavity and its contents after inducing pneumoperitoneum.Leiomyoma (fibroid): A benign tumor derived from smooth muscle.Leiomyosarcoma: An uncommon malignant tumor of smooth muscle.Leukoplakia: An imprecise clinical term usually referring to whitelesions of the vulva.Levator muscle: The muscular sheet, consisting of the iliococcygeus,pubococcygeus and puborectalis muscles, which forms most of thepelvic floor (pelvic diaphragm) and supports the pelvic viscera.Libido: Sexual desire or urge.Lie: The relationship of the long axis of the fetus to the long axis ofthe mother. Examples are longitudinal, transverse and oblique.142

GLOSSOSSARARYGLOSSOSSARARYLigament:Cardinal: The dense connective tissue that represents the union ofthe base of the broad ligament to the supravaginal portion of thecervix and laterally to the sides of the pelvis. It is considered tobe the primary support of the uterus.Uterosacral: The peritoneal folds containing connective tissue,autonomic nerves and involuntary muscle arising on each side ofthe posterior wall of the uterus at about the level of the internalcervical os and passing backward toward the rectum, aroundwhich they extend to their insertion on the sacral wall. It isconsidered to play an important part in axial support of theuterus.Ligation, tubal: The surgical or mechanical interruption of thecontinuity of the fallopian tubes for the purpose of permanentcontraception.LMP: Last menstrual period.LNMP: Last normal menstrual period.Mastitis: Inflammation of the breast.Masturbation: Sexual stimulation by the manipulation of the genitals.Maturation index: The ratio of parabasal to intermediate to superficialvaginal epithelial cells (eg. 0/20/80), which is an indication ofestrogen effect.Maturity: The condition of a fetus weighing 2,500 grams or more.Membranes, premature rupture of (PROM): Rupture of the amnioticmembranes before the onset of labor.Menarche: The onset of the menses.Menopause: The permanent cessation of the menses caused by ovarianfailure or removal of the ovaries.Menorrhagia: Excessive or prolonged uterine bleeding occurring atregular intervals.Metaplasia: A reversible change in which one adult cell type is replacedby another cell type. The most common type of epithelialmetaplasia is the replacement of columnar cells by stratified epithelium(squamous metaplasia).Metrorrhagia: Uterine bleeding occurring at times other than theexpected menses; for example, intermenstrual bleeding.Mid pelvis: An imaginary plane that passes through the pelvis and isdefined by three points: the inferior margin of the symphysis pubisand the tips of the ischial spines on either side. This plane usuallyincludes the smallest dimensions of the pelvis.Mortality: A fatal outcome.Maternal: Death of the mother.Fetal: Death of the conceptus between >500 grams and birth.Stillbirth (intrauterine fetal demise): Death of a fetus before birth.For purposes of perinatal vital statistics, the fetus must be over 20weeks gestational age or over 500 grams in weight.Neonatal: Death of the infant in the first 28 days of life.Perinatal: Death of the fetus or neonate between 20 weeks ofgestation and 28 days after birth. It is the sum of stillbirths andneonatal deaths.144

GLOSSOSSARARYGLOSSOSSARARYMosaicism: The presence in an individual of cells of different chromosomalconstitutions.Mucus, cervical: The secretion of the cervical mucous glands; itsquality and quantity are influenced by estrogen and progesterone.Estrogen makes it abundant and clear (which is called spinnbarkeit)with a fern pattern on drying. Progesterone makes it scant, opaqueand cellular without a fern pattern upon microscopic examination.Neonatal: Referring to the first 28 days of life.Nonstress test (NST): Evaluation of the fetus by electronic fetal heartmonitoring, not in labor. Also known as fetal activity testing.Oligomenorrhea: Infrequent menstruation.Orgasm: The climax of sexual excitement.Osteoporosis: Atrophy of bone caused by demineralization.Ovulation, induction of: Stimulation of ovulation by artificial means.Oxytocin: An octapeptide formed in the hypothalamus and stored inthe posterior lobe of the pituitary. It has stimulant effects on thesmooth muscle of the uterus and the mammary glands.Papanicolaou smear (Pap smear): A cytologic smear of exfoliated cells(for example, from the cervix, endometrial cavity or vagina) used inthe early detection of cancer or for evaluation of a patient’s hormonalstatus.Parity: The number of pregnancies of a particular woman in whichthe fetus is over 20 weeks gestation prior to delivery.Pelvic floor: The floor or sling for the pelvic structures, located at thelevel of the pelvic outlet. The most important structures are thelevator ani muscle and fascial sheaths.146Pelvic inflammatory disease (PID): An infection of the pelvic viscera,usually by ascending routes. The likely etiologic pathogens include:Neisseria gonorrhoeae, Chlamydia trachomatis, and other anaerobicand aerobic organisms.Pelvic inlet: An imaginary plane passing through the pelvis thatrepresents the upper boundary of the true pelvis. It is boundedposteriorly by the promontory and alae of the sacrum, laterally bythe linea terminalis, and anteriorly by the horizontal rami of thepubic bones and the upper margin of the symphysis pubis.Pelviscopic Surgery: Laparoscopic surgery using multiple small incisions,specialized instruments and techniques.Percutaneous Umbilical Blood Sampling (PUBS): See cordocentesis.Perinatal: Pertaining to the combination of fetal and neonatal periods,considered to begin after 20 weeks of gestation and to end 28days after birth.Perineorrhaphy: Plastic repair of the perineum.Perineum: The pelvic floor and associated structures occupying thepelvic outlet.Pessary: A device placed in the vagina or uterus to support the uterus.Placenta previa: A condition in which the placenta is located in thelower portion of the uterus and covers part or all of the internal os.PMP: Previous menstrual period.Pneumoperitoneum: The presence of air in the peritoneal cavity.Polycystic ovary syndrome (Stein-Leventhal syndrome): A syndromeof secondary oligomenorrhea and infertility associated with multiplefollicle cysts of the ovary and failure to ovulate.

GLOSSOSSARARYGLOSSOSSARARYPolyhydramnios: See hydramnios.Polymenorrhea: Cyclical uterine bleeding that is normal in amount,but occurs

GLOSSOSSARARYGLOSSOSSARARYSalpingectomy: Surgical removal of fallopian tube.Salpingooophorectomy: Surgical removal of a fallopian tube andovary.Schiller test: The application of a solution of iodine to the cervix. Theiodine is taken up by the glycogen in normal vaginal epithelium,giving it a brown appearance. Areas lacking in glycogen are white orwhitish yellow, as in leukoplakia or cancer. Although nonstainingareas are not diagnostic of cancer, they aid in choosing the spot towhich a biopsy should be directed.Secondary sexual characteristics: The physical changes that haveoccurred in response to endocrine changes during puberty.Semen analysis: The evaluation of the components of semen, especiallyspermatozoa, as a means of evaluating male fertility.Sexual dysfunction: Sexual disinterest, unresponsiveness or aversion.Sexuality: The physiologic and psychologic expression of sexualbehavior. The periods of infancy, adolescence, adulthood and thepostclimacteric state each have characteristic manifestations ofsexuality.Sims-Huhner test (post coital test): A test for infertility in whichcervical mucus is aspirated after coitus and examined for quality andpresence or absence of infection. The motility, normality and numberof sperm are noted.Skene glands: The vestibular glands that open into and around theurethra.Somatomammotropin, chorionic: See Lactogen, human placental.Sonography (ultrasonography, ultrasound): In obstetrics and gynecology,a diagnostic aid in which high-frequency sound waves are used toimage pelvic structures in pregnant and non-pregnant patients.Spinnbarkeit: The ability of the cervical mucus to be drawn out into athread, characteristically greater in the preovulatory and ovulatoryphases of the menstrual cycle.Station: The location of the fetal presenting part (leading bony point)relative to the level of the ischial spines. Station +2 means thepresenting part is 2 cm below the ischial spines. Station -1 means thepresenting part is 1 cm above the ischial spines.Sterility: The absolute inability to procreate.Stress incontinence: The involuntary leakage of urine during anincrease in intraabdominal pressure as a result of weakness of thesupports of the internal vesical sphincter and bladder neck.Striae gravidarum: Streaks or lines seen on the abdominal skin of apregnant woman.Supine hypotensive syndrome: A hypotensive syndrome often characterizedby sweating, nausea and tachycardia. It occurs in somepregnant women in the supine position when the pregnant uterusobstructs venous return to the heart.Teratogen: An agent or factor that produces physical defects in thedeveloping embryo.Testicular feminization: A syndrome of androgen insensitivity characteristicsby primary amenorrhea, a female phenotype, testes (abdominalor inguinal) instead of ovaries, the absence of a uterus and a malegenotype.Thecoma: A functioning ovarian tumor composed of theca cells.150

GLOSSOSSARARYNOTESThelarche: The onset of development of breasts.Trimester: A period of three months. The period of gestation isdivided into three units of three calendar months each. Some importantobstetric events may be conveniently categorized by trimesters.Trophoblast: The epithelium of the chorion, including the covering ofthe placental villi. It comprises a cellular layer (cytotrophoblast) andsyncytium (syncytiotrophoblast).Tubercles, Montgomery: The enlarged sebaceous glands of the areolaeof the mammary glands during late pregnancy and lactation.Ultrasonography: See Sonography.Ultrasound: See Sonography.Urethrocele: Protrusion of the urethra through the supportingstructure of the anterior wall.Vacuum extraction: The use of a suction device placed on the infant’shead to assist vaginal delivery.Vasectomy: The surgical interruption of the ductus (vas) deferens forpermanent contraception.VBAC: Vaginal birth after cesarean delivery.Viability: The condition of a fetus weighing 500 grams or more; theability to live independently outside of the uterus.Virilization: The development of masculine traits in a female.Withdrawal bleeding: Uterine bleeding after the interruption ofhormonal support of the endometrium.152

NOTESNOTES154