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phase 3a mine > womens health > Flashcards

womens health Flashcards

1
Q

gravity and parity definitions

A

Gravity = how many pregnancies, regardless of outcome
Parity = how many pregnancies delivered after 24 weeks (live and still births)

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2
Q

what is added into a obs/gynae history

A

PMH
- pregnancies (how many, outcomes, types of delivery, complications, miscarriages and terminations)
- cervical cancers and treatment
- STIs
-recent sexual history (last time when, who, condom, oral/penetrative; how many in last 3/6/12 months; paid for sex; non-UK partner)

Drug history
- harmful to baby eg sodium valporate
- contraception (how long, what type)

Menstrual - When was the first day of your last period and What is cycle normally like - regularity, pain, heaviness (how often changing, are you flooding, any blood clots passed) , bleeding between periods, bleeding after sex

breastfeeding

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3
Q

inauterine fetal death

A

aka still birth

death of a baby before or during birth , after 24 w of gestation

before 24 w - miscarriage

(WHO defines as 28w)

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4
Q

neonatal death

A

a baby that is born at any point of gestation that show signs of life but dies within 28 days of life

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5
Q

Parity 2^-1 means what

A

2 births, one of which was a still birth

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6
Q

ectropion

A

Tough squamous cells on outside exocervix
Squamous on inside endocervix . These sometimes come out like a sock - then keratinise and become squamous due to sensitisation

Not harmful
Caused by hormonal changes

can cause bleeding
- not usually in pregnancy but more likely if STI

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7
Q

female asymptomatic GUM screening

A

Self taken Vulvo-vaginal swab. Sent for Gonorrhoea/Chlamydia NAAT (Nucleic Acid Amplification Test)

Blood for STS (syphilis) + HIV

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8
Q

heterosexual men asymptomatic GUM screening

A

First void urine sent for for Chlamydia/Gonorrhoea NAAT

Blood test for STS + HIV

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9
Q

MSM asymptomatic GUM screening

A

First void urine for Chlamydia/Gonorrhoea NAAT
Pharyngeal swab for Chlamydia/Gonorrhoea NAAT (may be self taken)
Rectal swab for Chlamydia/Gonorrhoea NAAT (may be self taken)
Blood for STS, HIV, Hep B (& Hep C if indicated)

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10
Q

sexual history - enquire in what period of time

A

sex in last 3-12 months

antibiotics in last month

last period

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11
Q

heterosexual men symptomatic GUM screening

A

Urethral swab for slide + Gonorrhoea culture
First void urine for Gonorrhoea + Chlamydia NAAT
Dipstick urinalysis (If has dysuria)
Blood for STS + HIV

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12
Q

MSM symptomatic GUM screening

A

Urethral swab for slide + Gonorrhoea culture
First void urine for Gonorrhoea + Chlamydia NAAT
Dipstick urinalysis (If has dysuria)
Blood for STS + HIV
urethral and rectal slides
urethral, rectal, pharyngeal culture plates

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13
Q

female symptomatic GUM screening

A

Vulvo-vaginal swab for Gonorrhoea + Chlamydia NAAT
High vaginal swab (wet & dry slides) for
Bacterial Vaginosis (BV)
Trichomonas Vaginalis (TV)
Candida
Cervical swab for slide + Gonorrhoea culture
Dipstick urinalysis (If has dysuria)
Blood for STS + HIV

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14
Q

who is screened for Hep B

A

MSM
Sex workers
Anyone who has sex with sex workers
IVDU current and past - and their sexual partners
People from high risk areas - and their sexual partners (Africa, asia, E europe)

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15
Q

incontinence causes and the charactheristics of these syndromes

A

overactive bladder

Stress incontinence

Other causes
- Fistula
- Neurological
- Functional
- Overflow , retention

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16
Q

mixed urinary incontinence =

A

a combination of overactive bladder and stress incontinence
often one is predominant

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17
Q

incontinence assessments (4/5)

A

Urinalysis
- MSU, dipstick
- Nitrates- Infection
- Leucocyte- Infection
- Microscopic haematuria- Glomerulonephritis, nephropathy, neoplasia, infection
- Proteinuria- Renal or cardiac disease
- Glycosuria- DM, nephropathy

Frequency volume charts
- FVC, bladder diary
- Quantity and frequency of leakage, diurnal variation, fluid intake

Residual urine measurements

Questionnaire
- Eg does urine leak with exercise, how much of a problem is this for you
- In 4 domains - sexual, bowel, urinary (LUTS), vaginal

specialist investigation- urodynamics – Measure bladder pressure response to an event eg washing hand, cough, and measure when urge comes on

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18
Q

overactive bladder charecteristics

A
  • Involuntary detrusor contractions
  • characterized by urgency
  • Urgency incontinence
  • Frequency
  • Nocturia
  • Nocturnal enuresis
  • ‘Key in the door’ - urge associated with actions
  • ‘Handwash’
  • Intercourse
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19
Q

stress incontinence characteristics

A
  • Sphincted weakness
  • Raised pressure in abdomen
  • Coughing, vomiting, straining, lifting, movement, exercise, sex
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20
Q

incontience management

A

self management
- weight loss
- smoking cessation
- reduced caffeine intake
- avoidance of straining and constipation

Indwelling catheter - urethral or suprapubic
Barriers- Pads, absorbent pants
Pessaries
Skin care - to protect skin as the urine can be damaging
HRT - oestrogen

Overactive bladder
- Bladder drill - retraining
- Drugs
—-Anticholinergic - oxybutin
- Botox injections around bladder - paralyse bladder a bit
- Bypass - catheter

Stress incontinence
- Physiotherapy
- Surgery
— Sling
—Suspension

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21
Q

oxybutin
- class
- effect
- s/e
- contraindication

A

anticholinergic, antimuscarinic, atropine-like

for overactive bladder urinary incontinnce

Dry mouth
Constipation
Blurred vision
Cognitive impairment
Tachycardia

careful in elderly patients due to the above s/es being more serious in the elderly

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22
Q

uterovaginal prolapse
- symptoms
- risk factors
- examination
- investigations
- treatment
- grading severity

A

Symptoms
- Lump
- Protrusion
- Discomfort, dragging “heavy” sensation
- Sometimes - pelvic floor and sexual dysfunction
- Obstruction
- Dyspareunia (pain during or post sex)
- urinary incontience

risk factors
- Menopause
- Multiparity
- Vaginal delivery, forceps, tear
- Obesity
- Chronic cough
- Pelvic surgery

Examination
- Bimanual & Sims speculum

Investigations
- Usually none

Treatment
- Reassurance & advice
- weight loss
- pelvic floor exercises
- Treat pelvic floor symptoms
- Pessary (Various shapes)
- Surgery - if severe (outside vagina, ulcerated, failed conservative measures) or symptomatic - repair of protrusions/ hysterectomy

Severity = level of protrusion
eg: - Severe / 3rd = protrusion outside vagina
- complete/ 4th = out and stays out

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23
Q

cause of endometrial cancer

A

Lack of progesterone, unopposed oestrogen/ increased oestorgen:

Obesity
T2DM
Nulliparity
Late menopause / post menopause
PCOS
Ovarian cancer - make extra oestrogen
Oestrogen only HRT
Pelvic irradiation
Tamoxifen
Lynch syndrome

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24
Q

red flag symptom of endometrial cancer

A

post menopausal bleeding

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25
Q

endometrial cancer
- type of cancer
- investigations
- treatment

A

adenocarcinoma (glandular cells)

Transvaginal ultrasound
Endometrial biopsy
Hysteroscopy (camera)

Surgery - hysterectomy +/- pelvic lymph nodes
Radiotherapy adjuvant to surgery
Progesterone therapy (hormone treatment) - if unable to be operated on

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26
Q

cervical cancer aetiology

A

High risk, persistent HPV infection

  • Missed vaccination
  • Immunosuppression- body less able to clear high risk HPV
  • Early age intercourse, multiple sexual partners
  • Smoking cigarettes - body less able to clear high risk HPV
  • Pill
  • STDs
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27
Q

cervical cancer
- what type of cancer
- prevention
- treatment

A

squamous

Vaccination programme in young girls
Screening with HPV testing

Surgery - hysterectomy for stage 1
Stage 2+
Radiotherapy
Chemotherapy
palliative care inc pain relief

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28
Q

vulvar cancer
- what type of cancer
- aetiology
- risk factor
- treatment

A

squamous

High risk HPV
Lichen sclerosis

Past history of VIN or Lichen Sclerosis

Surgical excision
Radiotherapy
Chemotherapy

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29
Q

ovarian cancer presentation

A

Often asymptomatic
Bloating, IBS-like
abdominal pain/ discomfort
Change in bowel habit
Urinary frequency
Bowel obstruction - abdominal distention
‘pelvic heaviness’

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30
Q

vulvar cancer presentation

A

Vulval itching
Vulval soreness
Persistent ‘lump’
Bleeding
Pain on passing urine

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31
Q

ovarian cancer aetiology and risk factors and most common type of person to get it

A

Post menopausal women normally present

more times you’ve ovulated, the greater the risks
- Early first period
- Late menopause
- No parity
- No ovulation suppressing contraception

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32
Q

ovarian cancer
- type of cancer
- treatment
- investigations
- prognosis

A

epithelial

surgery and chemotherapy

ultrasound
Calculate risk of malignancy index

poor due to late presentation

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33
Q

SCT sickle cell thalassemia screening

(+ type of inhertance)

A

Offered to all - 8-10 weeks ideally inc testing biological parents in adoption situations
Positive result → counselling and prenatal diagnosis. Offered termination of the baby or can wait till newborn screening
Family origin questionnaire - origins of biological parents, assists the lab interpret the results

recessive
pre natal

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34
Q

infectious diseases screening

A

Recommended to all in early pregnancy (Early aids prevention of transmission mum to baby)
Reoffered by 20w if initially declines
Assessment, treatment and vaccination plans if positive, as per guidance

HIV, Hep B, syphilis

prenatal

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35
Q

syphilis
- pathogen
- when transmitted in pregnancy
- potential effects in pregnancy

A
  • treponema pallidium
  • Can be transmitted at any stage of pregnancy
  • May results in miscarriage, pre-term labour, still birth and congenital syphilis
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36
Q

hep B in pregnancy potential effects

A

Can result in acute or chronic HBV infection for the baby (Dependant on when transmitted, and viral mode of mum)

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37
Q

Downs, edwards and patau’s screening
- when
- what tests are involved
- options if it comes back positive

A

Offered to all between 11+2 to 14+1 weeks

Combined test for T21, T18, T13 (first trimester)
- Nuchal translucency ultrasound scan - increased level of fluid behind neck
- Crown rump length
- Maternal age
- Able to assess risk for each baby if twins (identical will be equal chance though)
- part of fetal anomaly scan

Quadruple test (second trimester) - (used if NT fails x2, or if too late for this)
- Blood test - Alpha FetoProtein, total Beta HCG, Oestriol & Inhibin A
- For downs only
- Less accurate for fraternal twins

If +
- Can wait, do nothing
- Non invasive prenatal testing (private)
—–Examines fragments of fetal DNA in maternal blood for all trisomies and baby sex
—–Not diagnostic but highly accurate
-Invasive prenatal testing - CVS or amniocentesis

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38
Q

downs syndrome
- whats happening geneticaly
- effect on baby

A

Trisomy of chromosome 21
Learning disability, facial features, good quality of life
Increased incidence of physical health conditions such as epilepsy, leukaemia, thyroid and heart conditions, hearing and vision loss

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39
Q

edwards syndrome
- whats happening geneticaly
- effect on baby

A

Trisomy of chromosome 18
Low survival rates
Severe learning disability and serious physical problems eg heart/ respiratory/ renal / intestinal defects

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40
Q

pataus syndrome
- whats happening geneticaly
- effect on baby

A

Trisomy of chromosome 13
Low survival rates
Severe physical abnormalities - congenital heart defects, urogenital, Holoprosencephaly (brain doesn’t divide into 2 halves), microcephaly, neural tube defects, deafness, severe learning disability

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41
Q

fetal anomaly scan
- what is offered and what are they looking for

A

Offer minimum 2 ultrasounds

10-14 w
- Confirm viability
- Singleton vs multiple pregnancy
- Estimate gestational age
- This forms part of the trisomy screening - crown rump length and nuchal translucency

18-20+6 w
- Detect major structural abnormalities. Identify if any require treatment before birth and to create delivery plans including post natal treatment. Provide information and option to terminate

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42
Q

diabetic eye screening during pregnancy

A

For mum if diabetic before pregnancy
Tested at least twice

prenatal

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43
Q

Newborn infant physical examination (NIPE)
- when
- looking for what

A

72h and 6-8w
Looking for congenital defects / concerns including eyes (cataracts), heart, hips (dysplasia) and testes (Descension). Prompt referral if required

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44
Q

risk factors for hip dysplasia

A

Breech presentation pre or at birth
First degree family history of hip problems in early life
If your twin had breech birth

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45
Q

newborn hearing scan
- what tests are involved
- why important
- if results not normal

A

hearing aid fitted soon after birth (80 days on average) to aid development. referral to specialist .

All: automated otoacoustic emission (AOAE) test
Small device placed in ear that emits clicking noise and ear response is measured by screening equipment

Some babies also need a second test, the automated auditory brainstem response (AABR) test
3 sensors on baby’s head and headphones play baby clicking noise

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46
Q

newborn blood spot
- when
- looking for what

A

Offered and recommended
Parents can decline them individually or all
Day 5

Screens for 9 conditions
- Sickle cell disease (SCD)
- Cystic fibrosis (CF)
- Congenital hypothyroidism (CHT)
and 6 inherited metabolic disorders (IMDs)
- Phenylketonuria (PKU)
- Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
- Maple syrup urine disease (MSUD)
- Isovaleric acidaemia (IVA)
- Glutaric aciduria type 1 (GA1)
- Homocystinuria (HCU)

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47
Q

endometriosis
- =?
- charachteristics
- type of person to get it
- investigations

A

= patches of endometrial tissue outside of the endometrial cavity

Chronic
Pain
- Cyclical endometrial patches respond like the endometrium does during periods ie bleeds
- Dysmenorrhea
- Dyspareunia - pain during or post sex
- May also have pain during sex, bowel movements, heavy periods
Infertility

young and nulliparous
oestrogen dependant

TVS (transvaginal ultrasound)
Gold standard = diagnostic laparoscopy
bloods/CT help but not enough alone

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48
Q

endometriosis treatment

A

conservative
- laxatives
- NSAIDs
- tranexamic acid

(Abolish cyclicity )
- Oral contraceptive pill
—- Cheap
—- Effective
—- Minimal side effects
- GnRH antagonists
—- Long duration
—- HRT may be necessary

(Glandular atrophy)
- Oral prostagens
- Depot provera (form of progesterone)
- Mirena (hormonal IUD intrauterine device - coil) - releases progesterone

Surgery
- Ablation
- Excision
- Oopherectomy (bye bye fertility)
- Pelvic clearance (bye bye fertility)

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49
Q

adenomyosis
=?
what type of person gets it
symptoms
adenomyosis vs adenomyoma

A

ectopic Endometrial tissue within the myometrium - Thickened wall of uterus

Often old and multiparous
oestrogen dependant

pain! -similar symptoms and management to endometriosis

Localised = adenomyoma
Diffuse = adenomyosis

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50
Q

uterine fibroids
- aka
- =?
- risk factors/aetiology
- charachteristics
- treatment

A

leiomyoma

Benign myometrium uterine tumours
Smooth muscle tumours
Variable size and number
well circumscribed

Prevalence: 30% of women above 30. more common in A-C

Oestrogen dependant
- Risk factors dependant on contraception, pregnancies, menopause, HRT etc

Symptoms
- Depend on location and size
-often asymptomatic
- Pain in pelvis
- Heavy periods
- Anaemia
- Infertility
- Miscarriage
- urgency, frequency, retention

Myomectomy = removes fibroids . good for fertility preservation
NSAIDS, tranexamic acid
Coil, COCP
Hysterectomy

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51
Q

endometrial polyps
- common?
-characteristics
-what is it

A

common

Bleeding
Infertility

Fibrous tissue covered in columnar epithelium

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52
Q

maternal dealth definition

A

death of mother within 42 days of birth irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

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53
Q

urinary retention in the puerperium
- symptoms
- treatment
- risk factors

A

Abrupt onset of aching
Inability to urinate

Urgent catheterization i think

Epidural analgesia
Prolonged second stage of labour
Forceps or ventouse delivery
Extensive perineal lacerations
Poor labour bladder care

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54
Q

secondary PPH
- =?
- causes
- investigations

A

post partum haemorrhage after 24h from birth. primary = before 24h

Causes
-Endometritis
- Retained products of conception (RPOC)
- Subinvolution of the placental implantation site
- Pseudoaneurysms
- Arteriovenous malformations

Investigations
- Assess blood loss
- Assess haemodynamic status
- Bacteriological testing (HVS and endocervical swab)
- Possibly Pelvic ultrasound

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55
Q

minor and major post natal problems

A

‘Minor’
- Infection
- Postpartum haemorrhage (PPH)
- Fatigue
- Anaemia
- Backache
- Breast engorgement / mastitis
- Urinary stress incontinence
- Hemorrhoids/Constipation
- The ‘blues’

‘Major’
- Sepsis
- Severe PPH
- Pre-Eclampsia/eclampsia
- Thrombosis
- Uterine prolapse
- Incontinence (urinary or faecal)
- Post dural puncture headache
- Breast abscess
- Depression / psychosis / PTSD

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56
Q

post dural puncture headache
- what is it
- symptoms
- treatment

A

Accidental dural puncture → CSF leakage so reduced pressure around brain

Symptoms
- Headache
-worse on sitting or standing
-Starts 1-7 days after spinal/epidural sited
- Neck stiffness
- Dislike of bright lights

Treatment
- Lying flat!
- Simple analgesia
- Fluids and caffeine
- Epidural blood patch - seals hole in dura to stop leak so blood injected near the site

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57
Q

VTE prophylaxis post partum : medium and high risk factors and response

A

If high risk, give prophylactic LMW heparin for 6w
- Previous VTE
- Antenatal LMW heparin
- High risk thrombophilia
- Low risk thrombophilia + family history

If medium risk, give prophylactic LMW heparin for 10 days
- C section
- BMI above 40 (Severely obese)
- Long admission/ readmission
- Any surgery other than perineum repair
- Cancer
- IBD
- SLE
- T1DM
- IVDU
- Nephrotic syndrome
- Sickle cell
2 or more from
- Obese (30+BMI)
- 35y+
- Parity 3+
- Smoker
- VTE Fx
- Elective cesarean
- Gross varicose veins
- Pre-eclampsia
- Systemic infection
- Immobility
- Prolonged pregnancy
- Stillbirth
- PPH
- Preterm delivery

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58
Q

eclampsia puerperium symptoms

A

Headaches accompanied by one or more of the following symptoms within first 72hrs after birth: Visual disturbances, Nausea or vomiting

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59
Q

mild vs severe PPH

symptoms

A

Sudden and profuse blood loss or persistent increased blood loss
Faintness, dizziness or palpitations/tachycardia

post partum haemorrhage
mild= less than 1500mls blood loss (estimated)
severe = more than 1500mls and continuing OR in shock

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60
Q

puerperium sepsis
- indicators
- action

A

Infection plus systemic manifestations - low BP, high HR (90+), high glucose(7.7+), high RR(20+), high or low WBC, temperature above 38 or below 36, low O2 saturation,… leading to organ hypoperfusion and dysfunction

Action = sepsis 6 BUFALO in 1st hour
- Bloods cultures (and standard bloods)
- Urine output - catheter to measure hourly
- Fluid Resuscitation eg saline
- Antibiotics - broad spectrum initially
- Lactate, Hb, glucose
- Oxygen given - to get over 94%
- PLUS:
- Consider delivery - Evacuation of Retained Products of Conception (ERPC)
- VTE prophylaxis

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61
Q

the blues puerperium
- when, length
- what

A

3-10 days after birth
Emotional and tearful
Short lasting

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62
Q

prolactin and oxytocin physiology

A

Lactogenesis

Prolactin – milk production
- When baby sucks, nipple sensors cause the anterior pituitary to secrete more prolactin, stocking up for the next feed

Oxytocin aka Milk ejection reflex (MER)
- When baby sucks, nipple sensors cause the posterior pituitary to secrete oxytocin causing the myoepithelial cells to contract so that milk is released from the breasts

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63
Q

colostrum
- what
- when
- ingredients

A

initial secretion from breasts after birth, form of milk?

Colostrum = rich in proteins, vitamin A, sodium chloride, growth factors, antimicrobials, antibodies but contains lower amounts of carbohydrates, lipids, and potassium than mature milk.

Higher amounts of lactoferrin
- Regulates iron absorption in intestines and delivery of iron to the cells
- Protection against bacterial infection, some viruses and fungi – antimicrobial
- Involved in regulation of bone marrow function
- Boosts immune system

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64
Q

physiological changes post partum

A
  • Profound decrease in serum levels of placental hormones (human placental lactogen, hcg, oestrogen and progesterone) to pre pregnant levels
  • Increase of prolactin
  • Muscle returns to normal thickness (decreases) - ischaemia, autolysis and phagocytosis
  • Decidua is shed as lochia: rubra(Red) , serosa (pink) and alba (white) – secretions
  • Uterus descends inferiorly
  • Endometrium regenerates
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65
Q

puerperium =

A

from the delivery of the placenta, to 6w after the birth

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66
Q

when is lactation suppression

A

dont know what this means but 7-10 days

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67
Q

heavy menstrual bleeding HMB amount

A

> 80ml per cycle

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68
Q

what are pressure symptoms

A

Difficulty emptying bladder/ bowels - may need to lean forward or only certain times of day
Heavy feeling

ask about this with heavy menstrual bleeding

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69
Q

HMB investigations

A

Self- questionnaire on NHS website
Vaginal examination not always indicated
Bloods- FBC
- For anaemia symptoms
Transvaginal ultrasound
- For pressure symptoms
Diagnostic hysteroscopy
- For persistent bleeding between periods
- For significant risk factors - POS, unopposed oestrogen, obesity, cancer history etc

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70
Q

HMB causes

A

PALM COEIN
Polyps
Adenomyosis
Leiomyoma
Malignancy - hyperplasia
Coagulopathy
Ovulatory dysfunction
– PCOS
– Perimenopausal
Endometrial disorders
Iatrogenic
– Hormonal therapies
Not yet classified
– Chronic endometriosis
– AV malformations
Diagnosis then becomes HMB-C if that is the cause identified

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71
Q

HMB first line treatment and its pros and cons

A

1st line = Mirena coil (LNG-IUS)
Progesterone delivered locally
Effective , might take a while to work, long term in there (5 years)
But need to check for risk of STI / unprotected sex
Risks PID
No lag of fertility on removal
Small risk of perforation

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72
Q

HMB non surgical treatment options

A

1st line = Mirena coil (LNG-IUS)
____?? to reduce size of fibroids
Tranexamic acid
– Reduce bleed
– Not contraceptive
NSAID
– Reduce bleed
– Not contraceptive
Combined pill
Oral progesterones - mydroxy….
– Not contraceptive
– Reduce bleeding
– No affect on infertility
Progesterone contraceptive
Implant

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73
Q

HMB surgical options

A

Myomectomy = removal of fibroids
- For big or troublesome fibroids
- Keyhole / open surgery
- Maintains fertility
- Major surgery which carries risk - bleeding, infections, adhesions. Return of fibroids is not protected against.

Polypectomy

Endometrial ablation
- Causes infertility
- Devascularized
- Minimally invasive
- Maybe some pain/bleeding
- Best surgical treatment for no fibroids

Uterine artery embolization
- Block blood supply to shrink fibroids

Hysterectomy
- Total / subtotal (leaves cervix behind)
- Should be considered if other management options have failed
- Causes infertility - contraception not needed
- Periods stop permanently and no more treatment required
- Major irreversible surgery - infection, urine issues
- Possible removal of ovaries - menopause symptoms, but may have this even if ovaries are left. Oestrogen has an impact on many other things. History of ovarian cancer may influence decision

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74
Q

chronic pelvic pain definition

A

non - cyclical (but can have cyclical elements, but not purely)
6 months +
In pelvis / lower abdomen
Not occurring exclusively with periods / sex / pregnancy

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75
Q

chronic pelvis pain causes

A

Endometriosis
Adenomyosis
Leiomyoma (fibroids)
Pelvic congestion syndrome
Pelvic inflammatory infection (PID)
Pelvic organ prolapse
IBS
Diverticular disease
Interstitial cystitis
Degenerative joint disease
Somatization
Nerve entrapmen

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76
Q

chronic pelvic pain history

A

normal history (socrates) plus…

MOSSCC
Menstrual
- Regularity, length, heaviness, change over time
Obstetric
Sexual
- partners, type of sex, deep dyspareunia, contraception, STIs
Surgical
- Abdominal surgery → adhesion
Cytology
- cervical smear history
Contraception

Urinary, bowel symptoms, MSK, bleeding along with pain

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77
Q

chronic pelvic pain examination

A

General demeanor
Vital signs
Abdominal examination – distension, masses, tenderness, guarding, rebound
Vaginal speculum + bimanual examination

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78
Q

chronic pelvic pain investigations

A

Urinalysis + MSU
Pregnancy test
FBC, CRP, TFT, LFTs
HVS (high-vaginal swab) - charcoal + ECS (endocervical swab) - green
TVS (transvaginal USS) for adnexal masses
MRI may be useful in adenomyosis
Diagnostic laparoscopy

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79
Q

pelvic congestions syndrome
- when
- symptoms
- what is it
- investigations
- treatment

A

Typically post-pregnancy

Constant dull ache
- Worse standing/ prolonged activity/ prior to periods/ during or post intercourse

Varicose veins-y
Problems with blood return

TVS
MRI venogram

Pain relief
Pressure stockings - return blood
Vascular surgery

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80
Q

pelvic inflammatory disease
- what is it
- symtoms
- investigations
- treatment

A

Infection of the upper genital tract (cervix, uterus, fallopian tubes)
Most commonly due to STI (chlamydia, gonorrhea). So risk factors - young, sexual partners, no protection
Rarely due to descending infection (e.g. appendicitis)

Bilateral lower abdominal pain, could be chronic
Deep dyspareunia
Abnormal vaginal bleeding (postcoital, intermenstrual or menorrhagia)
Vaginal or cervical discharge that is purulent
Tender abdomen
Fever

Bloods
HSV and endocervical swabs
Diagnostic laparoscopy

Contact tracing
Ceftriaxone 500 mg as a single intramuscular (IM) dose, followed by doxycycline 100 mg orally twice daily and metronidazole 400 mg twice daily for 14 days
Antibiotics

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81
Q

FGM definition

types

A

Partial or total remove of female external genitalia, or injury to the female organs for non-medical reasons.

1 - clitoridectomy
Partial or total removal of the clitoris

2 - excision
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora

3 - infibulation
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora/majora, with or without excision of the clitoris

4- other
All other harmful procedures for non-medical purposes, involving pricking, piercing, incising, scraping and cauterisation

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82
Q

law and FGM

A

illegal to perform or assist

compulsory to record and report FGM . police informed if under 18 (including piercing)

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83
Q

FGM health risks

A

Acute - not seen as FGM not done in UK
Haemotoma
Excessive bleeding

Later
Dyspareunia
Sexual dysfunction - anorgasmia
Chronic pain
Keloid scar
Dysmennorrhea
— Hematocolpos - menstrual blood unable to exit so builds up
Urinary outflow obstruction, recurrent UTI
PTSD
Difficulty getting pregnant

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84
Q

FGM obstetric complicantions

A

Fear of childbirth
Increased amounts of
- Cesarean
- Postpartum haemorrhage
- Episiotomy - cut to allow baby out
- Severe vaginal lacerations
- Fistula formation
- Longer hospital stay
Difficulty
- Examining vagina
- Applying fetal scalp electrodes
- Performing fetal blood sampling
- Catheterising the bladder

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85
Q

FGM defibullation

A

Reversal of infibulation is best preconceptionally. Can be done intra-partum, as the baby is crowning. Defibulation :
- Assess extent of scar
- Incise fused labia (using diathermy), extending to clitoral region
- Raw edges sutured

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86
Q

what is considered normal menarche

A

Onset between 12-13y (11-14.5)
Preceded by secondary sexual characteristics and peak height velocity
Initial cycles pain free and long gaps between. No ovulation
Bleeds duration 3-7 days
Interval 21-45 days
Thelarche (breast) → pubarche (genital hair) → menarche (periods)

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87
Q

common paediatric gynacology issues

A

Amenorrhea
Oligomenorrhea
Precocious puberty
Delayed puberty
Menstrual disorders
- Irregular
- Heavy
- Dysmenorrhea
- PMT(PMS)

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88
Q

ammennorhea
- types and causes

A

Primary - never had period
- no period by the age of 16 with the Presence of secondary sexual characteristics
— Hypothalamic
— Hypopituitary
— Ovarian tumours
— Anatomical
- No period by 13 in the absence of secondary sexual characteristics
— Underlying chromosomal abnormalities

Secondary - had a period but now none for at least 6 months - cessation
- Excessive exercise
- Weight loss , anorexia
- Polycystic ovaries (PCOS)

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89
Q

oligomenorhea definition

A

Menses more than 35 days apart

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90
Q

precocious puberty
- when
- types and causes

A

Puberty before 8 in girls or 9 in boys
Physical or hormonal signs
Types
- Central
— Gonadotropin-dependant
— HPG axis matures. Due to high amplitude secretion pulses GnRH by hypothalamus
— Can occur due to trauma, tumours and hydrocephalus
- Pseudopuberty
— Gonadotropin-independent
— Can occur due to adrenal or ovarian tumours

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91
Q

delayed puberty
- investigations

A

Runs in families
Investigations - FBC, CRP, ESR, U/E, LFT, bone profile, TSH and T4 - exclude malnutrition, anaemia, liver disease, iron deficiency, bowel disease, hypothyroidism

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92
Q

treatment of Menstrual disorders in adolescents
- Irregular
- Heavy
- Dysmenorrhea
- PMT(PMS)

A

often combined pill

(rule out migraines and DVT FH)

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93
Q

cervical screening
- when
- what
- why

A

All people with a cervix aged 25-64
If 65+ and one of your three last smears was abnormal

Screening for HPV
16 and 18 are high risk for cervical cancer

Aim is to find pre-cancerous change

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94
Q

results of cervical screening, what happens next….

A

No evidence of high risk HPV
- Rescreen in 3 years if 25-49
- Rescreen in 5 years if 50-64

Yes evidence of high risk HPV
- High risk HPV and normal cells → repeat in 1 year
- High risk HPV and abnormal cells → refer for colposcopy
- High risk HPV and normal cells, 2 years running → refer for colposcopy

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95
Q

colposcopy
- what is this
- what is done

A

if evidence of High risk HPV and precancerous cervical cancer…

Direct magnification of cervix
Acetic acid sprayed on
– Coagulates and clears mucus
– Triggers reversible precipitation of nuclear proteins. shows mitotic activity
Abnormal cells (dividing more than normal, reduced repair) go white
iodine stains glycogen in squamous cells - if not taken up, cells are abnormal/ not repairing as well

‘See and treat’

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96
Q

subfertile/infertile classification

A

not able to conceive in 1 year, having sex 2 times a week

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97
Q

LMP =
menstrual cycle length=

A

LMP = 1st day of last period
Menstrual cycle = interval between 1st day of last period and 1st day of next

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98
Q

length of menstrual phase, proliferative, secretory, follicular phase, luteal phase,
when is ovulation

A

menstrual day 1-5
proliferative 6-15
secretory 16-28
follicular -1-14
luteal 15-28
ovulation 14

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99
Q

when does progesterone peaK

A

DAY 21
corpus luteum produces progesterone

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100
Q

early cycle whats going on with hormones

A

Low oestrogen , low progesterone → stimulate GnRH pulses (hypothalamus)
GnRH → acts on hypothalamus to secrete LH and FSH
FSH and LH → ovarian follicles enlargen and produce oestrogen , so oestrogen rises

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101
Q

oestrogen effect

A

when low - inhibits LH/ FSH
when high - stimulates LH lots (and FSH a bit) causing spike mid cycle. this LH causes ovulation

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102
Q

LH high levels cause?

A

ovulation.

the folicle the egg came from becomes corpus luteum –> progesterone

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103
Q

corpus luteum
- what is it
- cause by what
- causes what

A

the follicle the egg was released from in ovulation

stimulated by LH surge, which was stimulated by rising oestrogen (GnRH stimulated by low prog/oes)

this secretes oestrogen

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104
Q

egg fertilised vs egg not fertilised (menstrual cycle)

A

Egg fertilised :
- Corpus luteum → beta HCG → acts like LH and keeps corpus luteum going
- Corpus luteum persists for 6 months
- Placenta takes over role 3 months in

Egg not fertilized:
- Progesterone peaks day 21
- Lowers LH, which is needed to fuel corpus luteum, so it breaks down (negative feedback)
- Lack of corpus luteum means progesterone and oestrogen levels drop, causing period

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105
Q

why does maternal age cause more miscarriage and less conception

A

mostly due to chromosomal abnormalities

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106
Q

initial advice for couple wanting to concieve including pre-conception advice

A

Most couples will get pregnant in 1st year. Half of remaining will conceive in second year
Give advice about age - if ready, go go go

Pre-conception advice
- Folic acid
— 3 months prior - first 3 months of pregnancy
— 0.4mg (5mg if high risk)
— to prevent neural tube defect
- Stop smoking for both
- Stop alcohol for women
- Weight loss/ gain
— More maternal risk if overweight
— Less fertilty if overweight
— BMI over 35 not treated for fertility issues
—BMI 30-35 need to self-fund
- Up to date cervical smears
- 2-3 x week sex
- Medication review
— No ACEi
— No recreational drugs
— No valporate
- Rubella advice- most vaccinated, booster shot available

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107
Q

criteria for early referral to fertility clinics
when is early referral

A

Criteria for early referral (6months of trying)
35y+
Known or suspected problem
Above causes
Abnormal examination

normally referral after 1 year i believe

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108
Q

fertility investigations for women

A

Ovulation
- At day 21, should be peak progesterone
- <16 - not ovulating, >30 - def ovulating. In between is maybe: so try next month or do series in case of long/irregular cycle

Ovarian reserve
- This is used to gauge response to fertility treatment, rather than predicting natural conception chances.
1. High FSH - brain needs more to stimulate eggs so high FSH (8.9+) , there is low ovarian reserve. <4 = high ovarian reserve.
2. Antral follicle count (AFC) - scan looking for follicles. 4 = low, 16 = high
3. Anti Mullerian hormone (AMH) - <5.4 = low, >25 = high, but this is age dependant

tubal patency
- Low risk of having issues (no STI problems, no surgeries):
— HSG (hysterosalpingogram) - dye scan
— HyCoSy
- High risk
— Laparoscopy and dye
— Screened for STI first- so as not to flush bugs higher

Smears up to date
Pelvic swabs for STIs
Hormone profile
- FSH
- Progesterone
- TFT
- Prolactin

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109
Q

fertility investigation for men
- measures
- if abnormal then?

A

Semen quality
- Count should be >15million sperm / ml
- Motility should be > 40% (how many are going forwards rather than backwards or wiggling)
- Morphology should be >4% (head and tail and look normal)
- Total should be >39 million
- Repeat if abnormal after a month (time for spermatogenesis)

if not normal
- Ask about illness, drug use, steroids
- Clinical examination - secondary sexual characteristics and testicular size

If <5mill sperm/mil
- Endocrine - FSH, LH, testosterone, prolactin
- Karyotype eg klinefelters
- Cystic fibrosis

maybe:
Testicular biopsy (azoospermia)- cryopreservation
Imaging - vasogram, ultrasound, urology

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110
Q

fertility treatments for men

A

Mild →
Intrauterine insemination (IUI) = Ejaculate into sample, then sample injected into womb

Moderate →
IVF = Fertilise egg with lots of sperm in dish, then implant embryo

Severe →
Intracytoplasmic sperm injection (ICSI) = Single sperm injected into a single egg separately. Implant embryo

If no sperm →
- Surgical sperm recovery
- Donor insemination
- IUI or IVF (ICSI not needed as sperm good quality)

  • Reverse vasectomy
  • Hormonal treatment
    —- hypogonadotropic hypogonadism → gonadotropins given
    —- Hyperprolactinemia → suppress

Conservative measures
- Occupation
— Balls too near bodies for too long → heat eg truck drivers, cyclists
- Looser boxers (not definitely a cause but no harm trying)
- Stop smoking and drinking
- Folic acid, antioxidants
- Weight

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111
Q

WHO group 1 infertility
- characteristics
- causes
- treatment

A

Low FSH/LH causing anovulation

Cause:
- Weight loss
- Stress
- Extreme exercise

Treatment
- Normalise weight
- FSH and LH
- GnRH pump

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112
Q

WHO group 2 infertilty
- characteristics
- causes
- treatment

A

Normal FSH

Cause = PCOS
Need 2 of 3:
- Seen on scan - more than 12 on an ovary, or high volume
- Oligomenorrhea / amenorrhea / anovulation
- Raised androgens - clinical or biochemical

Treatment
- Normalise weight
- Ovulation induction - clomiphene or tamoxifen
- Metformin (adjuvant)

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113
Q

WHO group 3 infertility
- characteristics
- causes
- treatment

A

Cause = menopause
High FSH

Treatment- Donor egg

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114
Q

clomifene
- what does it do

A

Ovulation induction, (helps ovulation)
first line infertility treatment

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115
Q

fertility treatments for
- endometriosis
- surgical adhesions

A
  • remove patches surgically. more effective than medicine. could connect tube around damaged area (amastamosis)
  • undo adhesions surgically
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116
Q

IVF how many cycles offered

when offered

risks

A

<40 - 3 cycles
40-42 - 1 cycle

Treat after 2 years or 12 months insemination or if old mum

Multiple pregnancies (main risk)
ectopic pregnancy
Miscarriage
Possible fetal abnormalities
Ovarian hyperstimulation syndrome
Egg collection could cause - trauma, infection, bleeding
Ovarian cancer

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117
Q

anaesthesia vs analgesia

A

analgesia - no pain
anaesthesi - no sensation

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118
Q

describe labour pain

A

Intermittent intense periods of pain
Seconds-minutes
Continues for many hours

1st stage - uterine contractions, cervical dilation
2nd stage - descent of baby’s head, stretching of vagina and perineum
Pain moves therefore

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119
Q

types of labour anaesthesia and analgesia

A

Gas and air -
Oral analgesia - paracetamol, codeine
Parenteral opioids ‘ single shot’
IV opioids administered with patient button
Regional techniques —> Spinal / epidural / combined spinal epidural (CSE)

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120
Q

gas and air
- =?
- pros and cons

A

entonox 50% N20 nitrous oxide, 50% 02
Rapid onset
Low risk
Self-limiting
Green- house gas

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121
Q

parenteral opioids ‘single shot’
- egs
- pros and cons

A

Morphine, diamorphine
Sedation, respiratory distress, n/v
Could cross placenta - make baby sleepy too

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122
Q

IV opioids administered with patient button
- egs
- speed

A

Fentanyl, alfentanil, remifentanil
Rapid onset, rapid offset

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123
Q

regional techniques
- types
- advantages of each
- where
- what is injected in
- indications and contraindications
- complications

A

Spinal / epidural / combined spinal epidural (CSE)

Spinal - into CSF
- One off injection
- Feel pop/ give when going through dura
- Better anaesthetic block
- Shorter lasting- 2h

Epidural - into epidural space (superficial to the dura)
- Long lasting . patient can top up

Spinal cord terminates at L2 so perform at L3/4
L3/4 is where tuffier’s line is : join two iliac crests

What is injected in?
- Local anaesthetic
— Bupivacaine
- Opioids
— Fentanyl
— Diamorphine

Why?
- Maternal pain
- Cardiac condition - valve regurgitation
- Multiple births
- instrumental/ operative delivery likely
Why not?
- Mum doesnt want
- Local infection
- Allergy
- Coagulopathy
- Hypovolemia
- Systemic infection
- Abnormal anatomy

Complications
- CSF leak
- Headache
- allergy/ anaphylaxis
- Hyoptension
- Bradycardia
- Haematoma

124
Q

leading cause of maternal death durin preg

A

cardiac

125
Q

if a mum has a preexisting condition how should it be handled (general)

A

Preconception assessment
- Optimise disease control
- Defer pregnancy until condition is stable
- Effective contraception until ready to conceive

Medication review (start / stop)

Advise on risks

Effect of pregnancy on preexisting conditions
- Some worsen eg mitral stenosis
- Some improve eg rheumatoid arthritis

Effect on preexisting conditions on baby and pregnancy
- Risks of complications eg HTN → pre-eclampsia
- Drugs may cause abnormalities on baby

Plan delivery
- Safest mode
- Antenatal care

126
Q

anaemia in pregnancy
- most common 2 types
- complications
- treatment

A
  • iron def (micro), then folate def (macro) – due to increased number of rbc
  • low birth weight, prematurity
  • supplements
127
Q

asthma in pregnancy
- risks
- medication?

A

Risk of exacerbation of asthma is high if poorly controlled at time of conception
Risk of fetal growth restriction due to inadequate placental perfusion
Risk of premature delivery if mum deteriorates

all asthma medication can continue to be used safely

128
Q

Cardiac conditions in pregnancy
- high/low risk conditions
- treatment

A

Low risk
- ASD
- VSD
- aortic/ mitral incompetence
High risk
- Aortic stenosis
- Aortic coarctation
- Prosthetic valves

Should see specialist - echo
Alter medication to be safe for baby
Monitor fetal growth

larget cause of maternal death

129
Q

obstetric cholestasis
- symptoms / signs
- treatment
- risks
- epidemiology

A

Itching, no rash
Raised ALT/AST

Resolves after but likely to reoccur in further pregnancies

Treatment= Symptomatic
- Antihistamines
- Ursodeoxycholic acid

Risk still birth / prematurity

Common
More so scandinavia, chile

130
Q

hyperthryoidism in preg
- risks
- treatment

A

Thyroid crisis with cardiac failure = maternal risk
Thyrotoxicosis through to baby - transfer of antibodies through placenta
review medication - some not appropriate

131
Q

hypothyroidism in preg
- commonness
- treatment

A

May cause early fetal loss / impaired neurodevelopment
Needs to be treated early - thyroxine

132
Q

diabetes in preg
- treatment / prevention of complications
- risks

A

Retinal screening
Renal function
Folic acid higher dose - 5mg
Prevention of complications = glycaemic control

risks to mum
- diabetic ketoacidosis
- preeclampsia
- retinopathy progression
- hypoglycaemia

risks to baby
- shoulder dystocia (Related to macrosomia)
- macrosomia
- miscarrigae, still birth
- fetal abnormality
- prematurity
- respiratory distress
- neonatal hypoglycaemia, hypocalcaemia, polycythaemia

133
Q

chronic renal disease in preg
- risks

A

to mum
- HTN
- superimposed pre-eclampsia
- renal disease worsens

to baby
- intrauterine growth restriction
- prematurity
- still birth
- fetal abnormalities

more likely to get ascending infections due to dilated urinary tract

134
Q

epilepsy in pregnancy
- risks
- treatment/ prevention

A

Risk due to medication (anticonvulsants) mainly, but also the condition
for mum:
- more seizures
- SUDEP - sudden unexpected death in epilepsy - mainly for medication non compliance
for baby:
- epilepsy inheritance
- fetal abnormalities
- fetal hypoxia during seizures

Pre-pregnancy assessment, Monitoring to check for fetal growth
- Medications may need to be changed - sodium valproate and other anticonvulsants are teratogenic - neural tube defects, ASD, cleft palate, autism, learning difficulties, polydactyly
- High dose folic acid 5mg
- Plan delivery- avoid prolonged labour
- Control seizures
- Screen for abnormalities
- Postpartum support

135
Q

thromboembolism in pregnancy
- risk factors
- medication

A

Risk factors
- BMI
- Age
- Operative delivery

DVT prophylaxis if high risk
DVT found - LMW heparin
Warfarin teratogenic

136
Q

maternal fluid changes physiology
- plasma volume
- sodium and potassium and why
- osmolality and why

A

Plasma volume increases (1-2L)

  • Sodium and potassium retention (Rather than just one!)
  • Increase in natriuretic factors (get rid of salt)
  • Increase in anti natriuretic factors (retain salt) - this outweighs

Osmolality
- Reduction in osmolality, reduction in concentration of dissolved particles
- But no diuresis (trying to get rid of the water) - so the osmolality threshold must be reset in pregnancy
- Reduced threshold of thirst - drink at lower osmolalities
- Less oncotic pressure - less serum albumin

137
Q

kidneys physiological pregnancy
- size
- muscle tone
- ureters and effects
- blood flow
- GFR
- creatinine
- urine

A

Increase in size - dilation (+20%)
- Loss of muscle tone (due to progesterone)

Compression of ureters (esp in R kidney)
- Fluid backing up in kidney
- Hydronephrosis
- Urine stasis - increased risk of UTI

Increase in blood flow to kidneys (+50%)
Increase in GFR
Increase in creatinine clearance → reduced serum creatinine
Glucosuria and aminoaciduria- not reabsorbed as much as salt

138
Q

blood physiological pregnancy
- HR, SV, CO
- BP
- blood cells
- clotting

A

Increase in HR : from 5th week until term
Increase in stroke volume
Increase in cardiac output

Early :
- Reduced BP (both diastolic and systolic)
- Reduced peripheral resistance
Late:
- Increased BP (both diastolic and systolic)

Early phase - peripheral vasodilation

Dilution anaemia
- Big increase in red blood cells. But plasma increases even more. So concentration (of rbc and haemoglobin) is reduced
- Increase in demand for more rbc

Small increase in white blood cells

Blood become hypercoagulable → risk of thromboembolism (up to 6 months postpartum)
- Increase in fibrinogen levels
- So ESR increased
- Increase in clotting factors- 7, 9, 10
- Increase in plasminogen activator inhibitor

139
Q

heart changes in pregnancy and the effect

A

Heart goes up and left, Apex goes more lateral, more horizontal

So this means ECG changes occur
- Inverted T wave in lead 3
- Prominent Q wave in lead 3 and aVF
- QRS axis changes - left deviation

Altered heart sounds

140
Q

thoracic physiological changes
- pulmonary blood flow
- heart size

A

Increase in pulmonary blood flow
Increase in atria and ventricle size and ventricular muscle size

141
Q

maternal oxygen consumption

mechanic
-volume - how so
- muscles
- lung volumes

biochem
- co2
- bicarb
- po2/hb saturation curves for mum and baby

A

Maternal oxygen consumption increases

Mechanic
- Greater thoracic volume
— Diaphragmatic elevation (+4cm)
— Subcostal angle increases - ribs more splayed
- Reduced thoracic compliance
- Better flow in and out - tracheo - bronchial smooth muscle relaxation (progesterone)
- Increase in tidal volume (so other volumes reduce)
- Reduce in overall lung volume

Biochemical
- Tidal volume increase → reduced CO2 partial pressure - blowing off CO2 (due to progesterone making central CO2 chemoreceptors more sensitive)
— Because fetal CO2 needs to diffuse to mum so mums should be lower to allow that steeper gradient allowing more rapid CO2 loss
— Risk of respiratory alkalosis - but kidney excretes excess bicarbonate HCO3- maintaining pH balance
— Lower HCO3- in blood - a state of compensated respiratory alkalosis
- PO2 oxygen concentration vs %Hb saturation curve
— Maternal: shift to the right - allowing oxygen to be released to the fetus at lower levels - Bohr effect (due to increased DPG affinity in rbc)
— Fetus: shifts to the left - favour O2 uptake - double Bohr effect (due to low DPG affinity)

142
Q

pregnancy stomach changes (3)

A

Delayed gastric emptying
Cardiac sphincter relaxation → risk of heartburn
Anesthetic risk - aspiration pneumonitis

143
Q

pregnancy liver changes (2) and risk

A

Reduced CCK secretion → Less inhibition of acid synthesis, lower pH in tummy → makes dyspepsia worse

Reduced gallbladder motility → risk of gallstones
Obstetric cholestasis

144
Q

bowel pregnancy change and its risk

A

Reduced gut transit time → More nutrient uptake in small bowel and more water uptake in large bowel
Risk of constipation

145
Q

neurological pregnancy changes (3)

A

Hyperemesis gravidarum - chronic pregnancy vomiting

Ptyalism - sialorrhea gravidarum Sensation of excess salvation

Altered appetite
- Cravings
- Pica - ingestion of non-nutritive substances (Eg mud, batteries, soap, coal, paper)

146
Q

metabolic pregnancy changes inc risks
- weight
- glucose
- insulin

A

Weight gain (mean 12.5kg)

Glucose
- Principle nutrient for fetus
- Hyperlipidaemia and glucosuria for mum
- No limit of glucose transport from mum to baby- high levels of glucose will go to baby and this can be harmful including baby growing too big and cleft palate

Insulin
- More insulin in response to glucose
- Decreased insulin sensitivity - more insulin resistance
- Risks gestational diabetes which is dangerous for mum and baby

147
Q

uterus pregnancy changes
- mass
- cells
- spiral arteries (what happens if these changes dont happen)

A

Mass increases - smooth muscle hyperplasia and hypertrophy
- Potential to compress aorta and inferior vena cava - aortocaval compression syndrome - lying lateral helps to take off the pressure

Uterine natural killer cells
- Control fetal evasion, immune protection

Spiral arteries remodelled - endovascular invasion
- Dilation→ wild bore, low resistance → greater supply of maternal blood
If this fails you are more likely to have
- Premature delivery
- Preeclampsia
- Recurrent miscariage
- Fetal growth restriction
- Placental abruption

148
Q

pregnancy cervix changes(3)

breast (3)

A

Increased softness
Increased vascularity
Blue-tinge (caused by oestrogen)
- Chadwicks sign
- Pooled blood

Increased volume
Fat deposition around gland tissue
Increased serum prolactin

149
Q

risk factors for HTN in pregnancy

A

Primigradivity
Black
Young female
Pre-existing renal diseasef
HTN
Collagen vascular disease
Multifetal pregnancies

150
Q

gestational diabetes definition

A

New HTN after 20w
Systolic >140
Diastolic>90
No /little proteinuria

25% develop pre-eclampsia

151
Q

pre-eclampsia definition

pathophysiology

A

New HTN after 20w
- Systolic >140
- Diastolic>90

Yes proteinuria
≥ 0.3g protein /24hr
≥ +2 on urine dip specimen

And possible the following
- Severe headache
- Visual disturbances e.g. blurring/flashing lights
- Papilloedema
- Clonus
- Liver tenderness
- Abnormal liver enzymes
- Platelet count falls to < 100 x 109/litre

Spiral arteries don’t dilate → inadequate blood delivery to placenta → baby growth is not correct

152
Q

eclampsia definition

A

features of preeclampsia plus generalised tonic-clonic seizures

153
Q

early/ late preeclampsia
what is the significance

A

Early - <34 week
Worse prognosis

Late >34 weeks

154
Q

signs and symptoms of pre-eclampsia

A

Symptoms
- Most asymptomatic
- Visual disturbance
- Headache
- Weight gain
- Epigastric pain
- Oedema

Signs
- Hyperreflexia
- Clonus

155
Q

preeclampsia investigations

A

Haemoglobin, platelets
Serum uric acid
Liver function tests
If 1+ protein by clean catch dip stick
Timed collection for protein and creatinine
Accurate dating and assessment of fetal growth

156
Q

preeclampsia treatment

A
  • Not much can be done
  • Restricted fluid - 80mls if severe
  • Delivery baby cures - good for mum, but may not be good for baby
  • Hospitalization for assessment
  • IV MgSO4 (anticonvulsant) if hyperreflexia
  • Antihypertensive - stabilise BP
    —Labetalol
    — Nifedipine
  • monitor baby, bloods, urine output, coagulation
157
Q

pre eclampsia - indications for delivery and management during

A

Maternal
- Gestational age 38 wks
- Platelet count < 100,000 cells/mm3
- Progressive deterioration in liver and renal function
- Suspected abruptio placentae
- Persistent severe headaches, visual changes, nausea, epigastric pain, or vomiting

Fetal
- Severe fetal growth restriction
- Nonreassuring fetal testing results
- Oligohydramnios

Deliver vaginally if poss
Induce labour
Epidural
Hydralazine or labetalol are pretreatments to reduce hypertension during delivery.

158
Q

chronic HTN in pregnancy definition

A

high BP prior to pregnancy
Before 20w, if BP not assessed before pregnancy
Not resolved post-partum

159
Q

prematurity and low birth weight definitions

A

Prematurity =Born before 37w
term = 37-42 w

Low birth weight = born less than 2.5kg
May be related or appropriate for their gestational age
VLBW <1500g
ELBW <1000

160
Q

complications of prematurity

A
  • developmental delay
  • visual impairment
  • chronic lung disease
  • cerebral palsy
161
Q

prematurity risk factors

A

50% have none
Non recurrent
- Antepartum haemorrhage and vaginal bleeding
- Multiple pregnancy (eg twin)
Recurrent
- Race
- Previous preterm birth
- Genital infection
— Increased prostaglandins → premature delivery
— BV
— UTI
— Appendicitis
— Pylonephritis
Cervical weakness

162
Q

prematurity prevention - 1/2/3

A

primary
- Smoking cessation
- STD prevention
- Prevent multiple pregnancy - fewer embryos transferred with IVF
- Advice on physical / sexual activity

Secondary
- Identify those at higher risk and follow up
- TV ultrasound
—- Cervical length - shorter with funner in uterus above it
- Qualitative fetal fibronectin test
- —Extracellular matrix protein – May indicate attachment (to decidua (uterus lining)) disruption
- Examination
- Exclude infection
- Treatments
— Progesterone IM/ pessary
— Cervical cerclage (Treatment for cervical shortness)

Tertiary
- Drugs to stop contractions - tocolysis
- Steroids to improve fetal lung maturity

163
Q

low lying placenta (LLP) / placenta previa
- what is it
- minor/ major
- diagnosis

A

Any part of placenta that implants onto lower segment

Major = reaching/ covering os
Minor = not

Diagnosis
Anomaly scan 20w
Repeat TV scans - minor at 36w, major at 32w

164
Q

where placenta for C section?

A

If placenta <20mm from os → c section 38-39w

165
Q

what do you do if placenta <20mm from os 38-39w

A

C section

166
Q

what to do if placenta previa / LLP bleeds

A

ABCDE
Examination - general, abdominal, vaginal
Fetal monitoring
Steroids if <34w

167
Q

placental attachment disorders
- what are they
- names for the severity
- management

A

placenta envades through myometrium

accreta –> increta –>percreta

Pick up on scan
Arrange caesarian (CS) at 36-37w
Discuss possible outcomes with parents
Discussion of hysterectomy at same time, or leave it but risk infection
Interventional radiology and ureter management
Arrange blood to be available as may be needed
Make a critical care bed available

168
Q

vasa previa
=?
risk

A

Vessels over cervical os, unprotected by placental tissue or umbilical cord. may rupture
Major risk to baby, not mum
Early delivery

169
Q

abruption
=?
effect
management

A

Premature separation of placenta from uterine wall
Can be concealed/revealed

effect
Fetal distress→ maternal shock
Large → resuscitation of mum

Management
Consider premature delivery
Blood transfusion
May need to go to intensive care

170
Q

post partum haemorrhage causes

A

(4 T’S)

Tissue retention
Surgery to remove remaining placenta
Tone : uterus not contracted
Trauma - tear → repair
Thrombin - blood clotting abnormality, so check clotting

171
Q

post partum haemorrhage risk factors

A

Big baby
Nulliparity and grand multiparity
Multiple pregnancy
Precipitate or prolonged labour
Maternal pyrexia
Operative delivery
Shoulder dystocia
Previous PPH

172
Q

maternal sepsis risk factors

A

Obesity
Diabetes
Impaired immunity/ immunosuppressant medication
Anaemia
Vaginal discharge
History of pelvic infection
History of group B Strep infection
Amniocentesis and other invasive procedures
Cervical cerclage
Prolonged spontaneous rupture of membranes
Group A Strep infection in close contacts / family members

173
Q

eclampsia
- =?
- treatment

A

Seizure in a woman with preeclampsia
Assume seizure in pregnancy is eclampsia until proven otherwise

IV MgSO4 4mgs over 5 mins
Treat HTN (labetalol, nifedipine)
Delivery
Stabilise mum first
Deliver if bradycardia

174
Q

seizure in pregnancy is ??? until proven otherwise

A

eclampsia

175
Q

cord prolapse
=?
risk
risk factors
management

A

Vasospasm
Baby isn’t getting any blood so risks fetal morbidity

Risk factors
- Membrane rupture
- Polyhydramnios (i.e. a large volume of amniotic fluid)
- Long cords
- Fetal malpresentation - breech, tummy down
- Multiparity
- Multiple pregnancy

Management
- Get mum on knees to take pressure off , feet higher than head
- Alleviate pressure on cord - with hand
- Go to theatre
- Monitor baby

176
Q

shoulder dystocia
- =?
- complications for mum/ baby
risk factors
management

A

= Failure for the anterior shoulder to pass under the symphysis pubis after delivery of the fetal head
Head comes out but not rest of body

Risky for mum and baby
Complications
Mum
- postpartum hemorrhage
- Vaginal tear
- Psychological impact on mum
Baby
- Hypoxia
- Cerebral palsy
- Fits
- Injury to brachial plexus (due to maneuvers done)
— Often resolves
— Physio review needed

Risk factors
- Macrosomia - big baby (related to diabetes)
- Maternal diabetes
- Previous shoulder dystocia
- Disproportion between mother and fetus
- Postmaturity and induction of labour
- Maternal obesity
- Prolonged 1st or 2nd stage of labour
- Instrumental delivery

Management - HELPER
H – Call for help (emergency buzzer)
E – Evaluate for episiotomy
L – Legs in McRoberts
Hold legs bent towards mums chest
P – Suprapubic pressure
Decompress anterior shoulder to pass under pubis
E – Enter pelvis
R – Rotational manoeuvres
Press on anterior shoulder or posterior arm moved
(R – Replace head and deliver by LSCS -Zavanelli)
Rare
— Risks skull fracture
— Difficult

177
Q

emergency contraception
- two types
- pros and cons

A

Hormonal
- One off high progesterone pill
- Inhibits ovulation
- Decreases viability
- Kills sperm
- May stop implantation
Pros
- Widely available
- One off
Cons
- Feels sick
- STI not protected
- No long term pregnancy protection

Non hormonal contraception
- Copper coil
- Needs professional fitting
Pros
- Most effective
- Can be used after 72 h
- Long term contraception as well
Cons
- Risk of PID
- Painful insertion

178
Q

male sterilisation pros and cons

A

Pros
- More effective than female
- Minor operation
- Permanent

Cons
- Not reversible (not NHS)
Complications:
- Infection
- Chronic scrotal pain
- Sperm antibodies
- Sperm granulomas

179
Q

female sterilisation
- when effective
- pros and cons

A

Wait til period to flush out eggs then all good

Pros:
Highly effective
Permanent
No hormones

Cons :
Surgery
Anaesthetic
bladder/ bowel injury
Not reversible (on nhs, hard privately, and risk ectopic pregnancies)

180
Q

Intrauterine contraceptive system
- what is it
- how does it work
- pros and cons

A

Progesterone coil
Mirena

Endometrial atrophy and may suppress ovulation

Pros
- Long term
- Effective
- May help with menstrual symptoms

Cons
- Need STI screen negative
- Risk PID
- Risk ectopic pregnancy
- Fitting may be painful - Esp if not pregnant before

181
Q

intrauterine device
- what is it
- how does it work
- pros and cons

A

Copper Coi

Non hormonal
Makes a foreign body reaction - preventing implantation and sperm transport

Pros
- Effective
- Long term
- Non hormonal
- Emergency contraception - effective immediately

Cons
- Menstrual symptoms- spotting
- Risk of PID
- Risk of ectopic preg
- Risk of perforation at time of insertion
- sti screen negative before insertion

182
Q

implants
- contain what
- pros and cons

A

Plastic releases progesterone slowly

Pros
- Most effective contraceptive
- Immediately reversible after taken out
- 3 years lasting
- Can help menstrual stuff
- No oestrogen effects

Cons
- Minor surgery for in and out
- Infection
- Occasionally uncomfortable

183
Q

injectable contraception
- egs
- pros and cons

A

High dose progesterone injected and slowly released
Depo provera IM
sayana pres SC= Self administered

Pros
- Reversible
- Effective
- Can help with symptoms menstrually
- Far apart - 12/13weeks

Cons
- Menstrual symptoms
- Delay of fertility after stopping
- Weight gain
- Lowers bone mineral density in younger age group

184
Q

lactational amennorhea
- when yes and when no
- recommened contracpetion?

A

If breastfeeding fully day and night, protected for 6 months
If hand pumped / bleed/ period restarts - no longer effective

Not recommended - should have other contraception in place

185
Q

natural cycle contracpetion pros and cons

A

Pros
If used well, very effective

Cons
Hard to use well
Need few cycles to get data
Not good if irregular cycles
Includes periods of abstinence

186
Q

diaphragm pros and cons

A

Pros
Sti protection
Can be inserted any point before intercourse (not during male erection)

Cons
Fitted by staff (one time)
Spermicide can be messy
Can be dislodged
Must remain in between 6-30h post intercourse

187
Q

progesteron only pill
- how does it work
- pros and cons

A

Thickens cervical mucus, maintains thin womb lining, decreases tubal motility, can stop ovulation
Taken continuously
2 types (3h window vs 12h)

Pros
- Prevents oestrogen side effects (breast tender, headaches)
- Can be used with oestrogen contraindications (migraine, smoker, BP)
- Can be used in morbidly obese

Cons
- Shorter window to take
- Less effective than COCP
- Increased risk of ectopic pregnancy - decreased tubal motility
- Ovarian cysts may develop

188
Q

nuvaring
- what is this
- pros and cons

A

Flexible soft vaginal ring . Emits low oestrogen dose
Insert for 3w, then 1w break then new one

Pros
Works well despite diar/vom
Ease PMS and bleeding

Cons
Side effects - headaches, vaginal discharge, breast tenderness - but normally temporary

189
Q

COCP
- how does it work
- pros and cons

A

Oestrogen and progesterone suppresses LH surge so prevents oestrogen
Thins womb and makes cervical mucus harder for sperm to penetrate
Can do 3w on, 1w off, or back to back until break through bleed

Pros
- Reversible
-Can help acne
- Can help periods lighten / less painful
- Protective against ovarian ad endometrial cancer
- 12h window

Cons
- Drugs interactions
- No STI protection
- Possible increase risk of breast and cervical cancer
- Increase risk of clot
- Reduced efficacy if taken late / post vomit

190
Q

UK-MEC contraception

A

staging system based on history contraindications
1- no restriction to using
2- advantages of contraception outweigh disadvantages
3- disadvantages generally outweigh advantages
Only sexual practitioner can green light
4- def no no

191
Q

contraception history/ examination key points

A
  • menstrual symptoms
  • parity (coil more sore)
  • previous success with contracpetion
  • smoking (no OCP)
  • migraine (no OCP)
  • medication review
  • liver problems
  • age (injectables not good for younger age group)
  • breastfeeding (no OCP)
  • clot history (no OCP)
192
Q

fraser competency
- =?
- criteria
- age
- gillicks

A

Must have sufficient maturity and intelligence to understand
Must persuade them to talk to their parents or allow doctor to
You think they will have sex regardless
You think their mental health will suffer if you do not
The advice/ treatment is in their best interest

to give advice/ contraception to under 16s (over 13s - 13 cant coonsent - safeguarding)

gillicks applies to under 16 medical and surgical treatment but does not include contraception, terminations or sexual health

193
Q

normal menstrual cycle length, blood loss, and loss length

A

Loss length : 2-8 days (mean 5 days)
Cycle: 21-35 (28)
Loss volume: 60-80mls

194
Q

menorrhagia definition

A

Heavy Menstrual Bleeding HMB that occurs at expected intervals of the menstrual cycle

195
Q

heavy menstrual bleeding definition

A

Menstrual blood loss that is subjectively considered to be excessive by the woman and interferes with her physical, emotional, social and material quality of life

196
Q

intermenstrual bleeding definition

A

Uterine bleeding that occurs between clearly defined cyclic and predictable menses

197
Q

Abnormal Uterine Bleeding definition

A

Any menstrual bleeding from the uterus that is either abnormal in volume (excessive duration and heavy), regularity, timing (delayed or frequent) or is non-menstrual (PCB, IMB, PMB)

198
Q

causes of heavy menstual bleeding

A

Coagulopathy
Ovulatory
Endometrial dysfunction
Uterine fibroids aka leiomyomas
Uterine polyps
Adenomyosis
Endometriosis

199
Q

gynecological malignancy presents how

A

Gynecological malignancy presents as intermenstrual bleeding (IMB), post menopausal bleeding (PMB) or postcoital bleeding (PCB) rather than HMB

200
Q

menorhhagia investigations
- when is endometrial biopsy indicated

A

FBC +/ haematinics
Coagulation
TFT
TVS
Hysteroscopy
- possible endometrial biopsy

Indicated if aged >45yrs and
- IMB
- Unresponsive to treatment
- New onset/change in menstrual pattern
Consider at any age if:
- Persistent IMB or irregular bleeding
- Infrequent heavy bleeding who are obese or have PCOS
- Women taking Tamoxifen
- Treatment for HMB has been unsuccessful
- New onset/change in menstrual pattern

201
Q

management of menorhhagia if

Women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis

A

LNG IUS - mirena progesterone coil
Antifibrinolytics (Tranexamic acid)
NSAIDs (Mefenamic acid)
Prostagens
COCP
POP
Danazol (steroid)
Reassurance

(primary care)

202
Q

management of menorhhagia if

Women with identified pathology, fibroids >3 cm in diameter, failed primary care management, requesting surgery

A

(secondary care)

Endometrial ablations
Hysterectomy
Uterine artery ablation
Myomectomy - resection of fibroids

203
Q

indications and contraindications of endometrial ablation in menorhhagia

A

Indications
Heavy menstrual loss
Not expecting amenorrhoea
Normal endometrium
Uterus less than 12 weeks size
Completed family

Contraindications
Malignancy
Acute PID
Desire for future pregnancy
Excessive cavity length

204
Q

gynae emergencies

A

Miscarriage
Ectopic pregnancy
Hyperemesis Gravidarum
Molar pregnancies - GTD (gestational trophoblastic disease)

205
Q

miscarriage
- common?
- types
- management

A

20% of pregnancies

Threatened = Any pregnancies with vaginal bleeding, with or without or abdominal pain (But 60% will remain viable )
Inevitable = The cervical os is open enough to admit one finger - body ready to (and will) expel embryo. bleeding happens
Delayed (aka missed/ silent)=Diagnosed with ultrasound scan (TV) -Gestational sac but no foetus within - maybe fetal pole but no fetal heart rate. foetus has died or not developed. often no bleeding, may be picked up
Complete = all pregnancy tissue has exited from uterus
Incomplete = Some of the matter has been expelled from the uterus, some has remained

Management
- Expectant = Wait and see. preg test after 3w, if positive, come back, if negative, all finished
—- (less so with missed, as it hasnt happened yet)
- Medical
— Usually complete within 24h if less than 12w, otherwise few more days
— Antiprogesterone then prostaglandin (misoprostol)
— pregnancy test after 3w as before
- Surgical
— Products of conception removed by suction, under anaesthetic
— Small risk of uterine perforation, infection, womb scarring, failure,
— pregnancy test after 3w as before

206
Q

what should serum beta HCG levels do?

A

The serum bhCG levels in a woman with a healthy, viable pregnancy during the first few weeks, can be expected to double in 36 to 48 hours.

207
Q

ectopic pregnancies
- common?
- where?
- investigations
- management

A

1% of pregnancies

Site
- Most common = fallopian tube (90%)
— Fimbrial (12%)
— Ampullary (50%)
— Isthmus (20%)
— Cornual/ interstitial (10%) - junction of fallopian tube and uterus
- Ovary
- Abdomen (a baby was born after growing in the liver!)
- Cervix

Presentation
Intermittent → persistent pain, normally low down on one side
Vaginal bleeding
Nausea
Full, off food
Pain pooing/weeing

Investigations
- An ectopic pregnancy must be considered a possibility when an empty uterus is found on ultrasound scan in a patient with a positive pregnancy test. Even with low beta HCG levels
- Slowly rising or static beta HCG levels

Management
- Rarely treated expectantly (watch and wait), not recommended (very very rare to deliver alive, and risky to leave – rupture!)
- Medical
— Methotrexate (chemo). And monitoring
- Surgical
— Fallopian tube removal
— or removal of ectopic pregnancy from the tube- Risk of incomplete removal so medical given too

208
Q

ectopic pregnancy rupture
- symptoms
- risk

A

a sharp, sudden and intense pain in your tummy
feeling very dizzy or fainting
feeling sick
looking very pale

209
Q

abdominal pain in young women next step

A

pregnancy test

210
Q

Hyperemesis Gravidarum
- presentation
- more common in ..
- treatment

A

Presentation
- severe Vomiting → dehydration +Ketosis
- Severe weight loss can cause but more rarely

More common in high levels of betaHCG (twins, molar pregnancies)

Treatment
- Regular small meals
- IV fluids
- Vitamin supplements
- Dalteparin to prevent clots
- Antiemetics

211
Q

molar pregnancies
- aka
- types : partial / complete
- more common in what race
- investigations
- treatment

A

Molar pregnancies - GTD (gestational trophoblastic disease) aka hydatidiform moles

Partial molar
- Some fetal tissue, some molar tissue
- Triploid = 2 sperm fertilise Ovum that contains genetic material

Complete molar
- No fetal tissue, all molar tissue
- Diploid =2 sperm fertilise ovum without any genetic material (empty ovum) (no maternal component)
- chance of turning into carcinoma

more common in Asian pregnancies

diagnosis:
characterized by presence of large fluid filled bubbles
“snowstorm” on TV ultrasound scan
Beta HCG levels extremely high

Treatment
- Empty uterus surgically preferred (less chance of material remaining)
- Methotrexate (chemo) offered if beta HCG does not fall satisfactorily (10%) - persistent trophoblastic disease

212
Q

high/ low risk pregnancies
- when and why is this assessed
- what qualifies as high risk

A

Classified as high or low risk at beginning of pregnancy. Continuous risk assessment throughout in case it changes. still birth avoidance

High risk
- Come to antenatal clinic appointments, extra scans, different monitoring
- Maternal factors : Geriatric, young, smoking, alcohol, drugs, safeguarding, BMI
- Previous pregnancy complications eg PPH, pre-eclampsia
- Current pregnancy complications eg Pre-eclampsia
- Medical condition - inc diabetes, kidney problems, HTN, epilepsy

Low risk
- Care provided in community - midwife

213
Q

antenatal (through preg) fetal monitoring
- looking for what (3)

A

Ultrasound
1. Growth
- Head and abdominal circumference and Femur length → estimated body weight
- Look for intrauterine growth restriction (higher risk of stillbirth)
- Asymmetrical 70%
— Normal head size, small body and limbs
— Smoking, preeclampsia
- Symmetrical 30%
— Both head and body small
— Infection, downs
2. umbilical cords - blood flow to baby – dopplers
3. Fluid around baby - liquor volume, fetal urine indicates kidneys are working

214
Q

antepartum (during preg) monitoring
- two options (based on what!)
- what is used to monitor these
- when they monitored
- pros and cons

A

Intermittent auscultation
- For low risk pregnancies!!
- Pinard stethoscope
- Hand-held doppler device
- 1st stage (4cm-9cm)- at least 1 min after a contraction, every 15 mins
- 2nd stage (fully dilated)- at least 1 min after a contraction, every 5 mins
Pros
- Non invasive
- Non expensive
- Can be used in home setting
Cons
- Not super sensitive
- Not able to monitor long term
- Affected by maternal movement and heart rate

continuous monitoring
- For high risk pregnancies!!
- Cardiotocography (CTG)
Pros
- Long term monitoring
- Identifies hypoxic babies
Cons
- Can’t move around as much
- Hospital based
- More expensive
- No improvement in outcomes in low-risk pregnancies

215
Q

fetal ECGs
- used how much
- types

A

very rare

Abdominal
- True beat-to-beat fetal HR
Scalp
- Invasive - on baby’s scalp
- Gold standard
- Risks scalp injury and perinatal infection

216
Q

fetal blood sampling
- how taken
- what does it measure

A

Speculum into vagina
Then little tube does blood prick
Measures pH

217
Q

menopause diagnosis/ definition
average age

perimenopause =

A

Cessation of menopause - 12 months ammenorhea for diagnosis
Average 51y

Perimenopause =Period leading up to menopause

218
Q

when can u get menopause symptoms

A

hysterectomy

219
Q

short medium and long term peri/menopause symptoms

A

SHORT
Hot flushes - impact sleep
Menstrual irregularities
Mood swings, irritability
Loss of memory, poor concentration
Loss of confidence
Lack of energy
Headaches
Dry and itchy skin
Joint pains

MEDIUM
Urogenital atrophy - recurrent UTIs, postmenopausal bleeding, dysparenuria, urinary incontience

LONG
Osteoporosis (no oestrogen)
CVD - increased prevalence with early menopause
Dementia - increased prevalence with early menopause

220
Q

menopause management

A

Lifestyle advice

CBT

Pharmacological
Hormonal
- HRT
- Vaginal oestrogen
Non-hormonal
- Clonidine (alpha adrenergic receptor agonist)
- SSRI (fluoxetine, paroxetine, citalopram, sertraline)
- SNRI (venlafaxine)
- Antiepileptics (gabapentin)

221
Q

HRT
- methods
- pros and cons

A

Oral / transdermal
TD for :
- GI issues eg crohns
- VTE/ stroke risk eg HTN
- epilepsy/ migraine require steady absorption
- Patients choice

Pros
- Protects bone mineral density
- Menopause symptoms relief

Cons
- Breast cancer (Esp if HRT is oestrogen and progesterone) … Contraindication if they get diagnosed or have history
- VTE … Only really for oral HRT, not transdermal
- CVD…Only if 60y+ … so Be careful starting in over 60s
- Stroke … Only really for oral HRT, not transdermal
- Risk irregular bleeding

222
Q

early menopause
- aka
- definition
- causes
- diagnosis

A

premature ovarian insufficiency POI

Menopause <40

Causes
- Idiopathic (most)
- Chromosome abnormalities
- Autoimmune disease
- Enzyme deficiency
- Surgery
- Chemo
- Radiotherapy

Diagnosis
FSH samples 4 w apart
4 months of amenorhea

223
Q

menopause and fertility

A

Still need contraception
Fertile for 2y if menopause <50 y
Fertile for 1y if menopause >50y

224
Q

breast cancer risk factors

A

BRCA1, BRCA2 gene (family history of breast cancer)
Radiotherapy below 35yrs (eg Hodgkin’s lymphoma)
HRT
Nulliparous
Not breastfeeding
Moderate- high alcohol consumption
Li fraunemi syndrome (genetic)- predisposed to lots of cancers
OCP
obesity, exercise
Early menarche, late menopause
Dense breast tissue

225
Q

breast cancer screening effect on incidence and mortality

A

increased incidence but reduced mortality

226
Q

who is invited for breast cancer screening and how often

A

50-70 invited (47-73 in trial now),
every 3 years

<50 breast tissue is denser (rather than fatty) so not likely to find anything

if high risk woman (BRCA1/2) - then you will be offered younger, but due to breast density, MRI with contrast is used instead
- From 30y, MRI
- From 40y MRI and mammograms
MRI also for breast implant patients

227
Q

grading of a lesion on mammogram

A

M1 Normal
M2 Benign
M3 Indeterminate
M4 Probably malignant
M5 Almost certainly malignant

228
Q

reasons to recall after a mammogram

A

Mass
Microcalcification
Parenchymal distortion/ deformity - breast tissue pulled in by cancer cells
Asymmetrical density
Large axillary lymph nodes
Clinical recall -if patient has a lump
Technical recall - unclear results

229
Q

if you are recalled after a mammogram, what do they do?

A

US, biopsy, further mammograms

230
Q

BRCA1
BRCA 2

Increase risk of what

A

BRCA1 - female breast cancer, ovarian cancer
BRCA2- female and male breast cancer, ovarian, prostate and pancreatic cancer

231
Q

breast cancer symptoms

A

Most appear normal
Skin tethering
Nipple discharge including bleeding
Palpable lump
- Most common painless. Pain is rare
- Irregular
- Hard
- Fixed
Nipple inversion
Locally advanced disease- coming through skin
Metastatic presentation

232
Q

breast cancer diagnosis

A
  • clinical
  • imaging
  • biopsy
    each graded 1-5
233
Q

breast cancer treatment
- and when to do which
- adjuvant treatments

A

Lumpectomy (/breast conservation/wide excision) + Radiotherapy (always given as adjuvant )
- Small tumour <25% or 25-50
- No previous radiotherapy
- Chemotherapy beforehand is possible

Mastectomy
- Large tumour
- Multiple cancers in same breast, esp if different quadrants
- May have reconstruction following this

Axilla surgery
1. Full axillary clearance
- All glands removed
- For axillary disease - Palpable or imaged node
- Can risk lymphoedema in arm - can be permanent and unpleasant
2. Sentinel node biopsy
- Remove 1-4 nodes that are most likely to have cancer (dye scan)
- For no axillary disease

after stuff is removed – pathology and staging -Then look to see if they need to clear more or not or do radiotherapy etc

gene analysis?

234
Q

breast cancer adjuvant treatments

A

Chemo
- Only for high risk of disease
- Young, Advanced disease, aggressive, oncotypes

Endocrine
- Tamoxifen inhibits oestrogen receptor on breast cells
— Poorly tolerated- menopause-like SE
— For premenopausal mainly
- Aromatase inhibitor - stop post-menopausal women producing oestrogen by converting from androgens, does not affect ovary oestrogen (only for oldies)

Radiotherapy
— For lumpectomy always
— For aggressive disease post-mastectomy sometimes
—Can change breast shape and texture

Bisphosphonates
- For high risk cancer, post menopausal women
- Reduce rate of bone metastases

Trastuzumab
- Alongside chemo
- For Her 2
- Small risk of cardiac failure

Reconstructive surgery

235
Q

malignant breast lump characteristics

A

Hard
Fixed
Painless
Irregular
Skin tethering
Nodal swelling
Older age

236
Q

breast lump causes

A

Benign breast change
Fibroadenoma
Cyst
Sebaceous cyst
Papilloma
Fat necrosis/haematoma
Mastitis/abscess
Cancer
Sarcoma, lymphoma, metastases
Implant related: (migration, capsule formation, rupture, edge or crease)

237
Q

fibroadenoma (breast lump)
- age
- characteristics inc size
- management

A

25-30y
Smooth, mobile, non tender, 1-3cm
Leave unless it is growing

238
Q

cyst (breast lump)
- age
- characteristics inc size
- management

A

35-55y
1mm-20cm
May be multiples
May feel cystic or hard and irregular
If symptomatic - aspirate
Will cease at menopause (unless on HRT)

239
Q

benign breast change
- age
-characteristics
- management
- aka

A

Tender, painful, rubbery nodularity
Cyclical variation
Any age, usually young
Reassure, no tx
Benign breast change / aka fibrocystic change

240
Q

mastitis
- age
- characteristics
- management
- aka
- dif diagonsis

A

Breast sepsis
Red, tender, swollen, painful, flu-like symptoms
May be lactational
may go on to abscess
Treatment = antibiotics, aspiration
<50y
Can look like inflammatory breast cancer - refer if antibiotics dont settle

241
Q

papilloma
- symptom
- treatment
- complications

A

(Blood) nipple discharge (needs imaging just in case)
Removed generally
Risk factor for breast cancer

242
Q

what is a ‘normal’ birth

A

Low risk at start and throughout pregnancy
Spontaneous onset of labour- No induction of labour
No spinal or epidural or general anaesthetic
Baby born in vertex position
No forceps, ventouse, C- section or episiotomy (perineum cut)
Born between 37-42w (‘term’)
After birth, mum and baby in good condition

243
Q

stages of labour

A

Latent stage
- Contractions (ir/regular)
- Mucoid plug (“show”) is lost
- Cervix begins to dilate :0-4cm
- Length 3-4days, long in first pregnancy

First stage
- Stronger contractions
- Cervix dilates up to 10cm
- 0.5cm/hour is acceptable in primiparus

Second stage
- From full dilation up to birth

Third stage
- After birth up to placenta expulsion

(Fourth stage)
- Early postnatal period - skin to skin → increased oxytocin production in mum and baby
— Regulates baby’s heart rate and breathing
— Contracts mums uterus
— bonding

244
Q

hormones of labour and their role (6)

A

Prostaglandins - cervical ripening

Oxytocin - surges at start of labour - causes uterus contractions
(Triggered by baby’s head pressing on bottom of uterus - positive feedback, so occiput anterior most stimulation as engages most receptors in this area due to angle)

Oestrogen - surges at start of labour - inhibits progesterone to prepare labour smooth muscle

Beta endorphins- natural pain relief

Adrenaline - released when birth is imminent - energy for labour (but can reduce oxytocin and slow contractions due to fight/flight)

Prolactin - to begin milk production in mammary glands

245
Q

different positions for baby to be in mum (3)

A

Cephalic = head down (most)
Breech = head up (most - C section)
Transverse lie = baby is horizontal (all C section)

246
Q

contractions
- start where
- how do they change along course of labour
- effect on fetus

A

Starts in fundus (pacemaker)
Shortens muscle fibres
Contractions increase in power as labour progresses
Fetus forced downwards - more pressure on cervix

247
Q

cervix effacement
- aka
- what is this
- what keeps cervix closed

A

cervical ripening

Cervix shortens shrinks in thickness from 4cm to very thin
Cervix is closed by mucus plug

248
Q

what is full dilatation

A

10cm

249
Q

fetal skull bones

A

prontal, temporal, parietal

250
Q

steps for baby to do in labour

A

Descent
- Fetus descends into pelvis from 37w to labour
- Encouraged by abdominal strength and longer, more powerful contractions

Flexion
- Due to contractions
- Occiput comes into contact with pelvic floor
- Fetal neck flexes - so circumference of head reduces, allowing easier passage

Internal rotation
- Due to contractions
- 90 degree turn

Extension
- Fetal occiput slip under suprapubic arch and neck extends once beyond this
- Head out of mum now, usually facing mums back

Restitution / External rotation
- Foetus aligns its head with its shoulders to face L/R

Delivery of body
- Gentle axial traction assists shoulder delivery

251
Q

amniotic fluid: SROM vs ARM

A

SROM = spontaneous rupture of membranes
Before or during labour

ARM = artificial rupture of membranes
Induce labour

rupture of sac (amnion) that holds amniotic fluid (liquor)

252
Q

delayed cord clamping
- =?
- why

A

at least 1 min after delivery

Beneficial for pre-term especially
Gives time for baby to transition
More cells and other stuff given - better for growth and development

253
Q

what drug encourages placenta to come out (actively) if it doesnt come out phsyiologically

A

IM oxytocic drug

then Examine - to check all complete

254
Q

misoprostol =

A

medical treatment for miscarriage - vaginal pill to encourage body to expel products (then 3w later a preg test to check it has worked)

255
Q

why do u need to watch out for increased bleeding and pain post-miscarriage

A

could be haemorrhage from placental attachment site (could be emergency blood loss)

256
Q

meconium =

what is its significance

A

earliest stool of unborn baby

meconium in liquor - baby can inhale this
MAS meconium aspiration syndrome
- airway obstruction
- surfactant dysfunction
- inflammation
- respiratory distress
- oedema
- pulmonary vaso and bronchoconstriction

257
Q

aspirin given in pregnancy why and when

A

to prevent pre-eclampsia development if high risk , from 12 w on

258
Q

pre-eclampsia treatment

A

aspiring for prevention (if high risk)
if def have it - monitoring, blood pressure control

259
Q

effects of mum being obese

A

higher risk of
- gestational DM
- gestationall HTN
- pre-eclampsia

surgery more complicated
- more adipose tissue - infections, slower healing
- hernias more likely
- if very time pressured, c section will take longer to get to baby

260
Q

which mental health FH is relevant in obstetric history

A

post-natal psychosis (not post-natal depression)

261
Q

HIV , previous group B strep in mum

A

HIV, even if undetectable, higher risk of stillbirth

group strep B can go to baby, so infection needs to be tested and treated

262
Q

contra/ indications for 5mg folic acid

A

purpose of folic acid = prevention of neural tube defect

indications
- either parent has neural tube defect or previous pregnancy with neural tube defect
- mum has coeliac or another malabsorption state
- mum has DM
- mum has sickle cell
- mum on anti-epileptic meds
- mum BMI 30+

contraindications
- allergy/sensitivity
- persistant hyperemesis
- cancer
- folate dependant tumours
- untreated B12 deficiency

263
Q

pelvic floor overactivity symptoms and treatment

A

tight muscles –> pain, stinging, itching

dilators
physio
CBT (vaginismus - psychological element)

264
Q

severe PMS treatment

A

first line = mirena coil
contraceptive pill
GnRH, HRT, oestrogen patch
CBT
hyster/oophrectomy

265
Q

typical GUM screen

what can be added, and why would you add it

A

swab - chlamidya, gonorrhea
blood - HIV, syphillis

hep B/C
hep C - drug use
hep B - MSM, certain countries..

266
Q

herpes

types
treatment options

A

1 (once a year, oral mainly)
2 (4x a year, oral or genital)
microbiology distinguishes

aciclovir
- continuous suppression
- episodic treatment - take when bump occurs

267
Q

when is the umbilical cord cut

A

after it stops pulsating- few mins (previously done straight away)

268
Q

synometrin =
purpose

A

synometrin = oxytocin and ergometrine
this induces placenta expulsion through contractions - the muscle tightenings clamp blood vessels shut

269
Q

CCT =

A

controlled cord traction
pressure on lower belly to straighten lower uterus and pull down on cord firmly but gently to deliver the placenta

270
Q

contraction rate for good/ hyperstimulated

A

good = 3 in 10mins
hyperstimulated = 5+

271
Q

cervix softness in labour changes

order of dilation/ effacement (on the whole)

A

nose to lips

primi - effacement then dilation
prev multiparous - same time

272
Q

show =
purpose
significance

A

= mucus plug lost (due to dilation)
it protects the uterus from ascending infection
not in itself a sign of labour, but usually in latent stage

273
Q

lie =
attitude =
position =
presentation =
station =

A

lie = baby’s axis (longitudinal, transverse, oblique)
attitude = flexion of baby’s neck (flexion better - smaller circumference)
position = where a position on baby’s body relates to birth canal (LOP, LOA..)
presentation = body part presenting itself first through the birth canal
station = how far descended fetal head is (-2 to +2 with 0 at iliac spines)

274
Q

fetal skull parts (useful for presentation)

A

face= face
bregma = anterior fontanelle (quadrilateral) at top of skull
occiput = back/base
sinciput = between bregma and face, front top part of skull
vertex = between two fontanelles - back top part of skull
posterior fontanelle (triangle) - seperater occiput and vertex

275
Q

crowning def

A

widest circumference of head through

276
Q

normal fetal HR

A

110-160
more if pre-term, less if post

277
Q

menopause
- age
- symptoms
- investigations
- treatment

A

Menopause at 51ish, final period,12 months with no bleed = certainty,
less responsive to LH/FSH → oes and prog falls

Menopause symptoms - stress incontinence, brittle hair/nails, erratic bleeding

Investigations - 2 readings from different points of cycle (2 or 6w later - should drop if no pathology) - LH/FSH/oes/prog. FH is key one - should rise (no inhibition of GnRH, trying to get the sex hormones to go big)

Treatments -
HRT (oestrogen + progesterone), SSRI, Topical oestrogens for reduced libido/ vaginal dryness, symptoms control eg lube, bladder training
Unopposed oestrogen only fine if hysterectomy (endometrial cancer risk)

278
Q

early menopause definitions

risk factors

A

<45 early menopause, <30 = premature ovarian insufficiency

FH
Oophorectomy
chemo/radiotherapy
?pituitary tumour

279
Q

PMB causes

A

endometrial/ ovarian cancer,
trauma,
polyps,
endometrial hyperplasia (HRT),
endometrial atrophy, atrophic vaginitis (both due to lower oestrogen)

280
Q

how thick does endometrium need to be for it to be endometrial hyperplasia

A

4mm+

281
Q

abdominal pain, positive pregnancy in 14-50y is WHAT until proven otherwise

A

ectopic

282
Q

PMB is what until proven otherwise

A

endometrial cancer

283
Q

post-coital bleeding is what until proven otherwise

A

cervical cancer (bleeds when hit)

284
Q

digital exam in pregnant ladays

A

only before 24w
fingers may go through cervix and disrupt baby/ placenta/ amniotic fluid

285
Q

when can fetal HR be heard

A

from 14w ish

286
Q

infertility causes/factors for both male and female

A
  • age
  • smoking, alcohol
  • how long trying together/ marriage status, how often trying
  • current relationship and previous relationship - miscarriage, stillbirth, ectopic, muller, live children, TOP
  • FH of fertility issues
  • cancer and treatment
  • PMH/PSH - esp gential/ pelvic/ thyroid/ pituitary/ STI
287
Q

exclusion reasons for NHS IVF

A

prev child (m/f, inc previous relationship, inc adopted)
previous sterilsation (m/f, even if reversed)
42y (f)
smoking (m/f)
BMI 30+ (f)

288
Q

infertility causes/ factors female only

A
  • previous assisted conception
  • menstrual (regulatity, heaviness, contracpetion, menarche..)
  • endocrine history (PCOS, thyroid, weight, hyperprolactinaemia)
    -BMI
  • bleeding in/post coital (endometriosis reduces fertility- if in tubes/ ovaries/ painful as reduces sex freq)
  • menopause
289
Q

contraception relevant to fertility

A

sterilisations (not 100% effective) - m +f
depo provera injections - can cause fertility issues for 12m afterwards

290
Q

infertility causes/ factors male only

A

cystic fibrosis (vas deferens not present) - ask about chest symptoms
ejaculation/ erection/ penetration issues

291
Q

infertility investigations

A
  • vaginal USS
  • semen analysis (density and mobility)
  • STI screen
  • hormone levels (LH, FSH, TFT, oes, prog, prolactin)
  • tubal patency (dye injected -hysterosalpingo (Scan) VS laproscopy/dye (look))
  • karyotyping
292
Q

infertility causes/ factors male only

A

cystic fibrosis (vas deferens not present) - ask about chest symptoms
ejaculation/ erection/ penetration issues

293
Q

colposcopy abnormal histology

A

increase in nucleus size / ratio to cytoplasm
chromosomal clumping
more nuclei
hyperchromatin

294
Q

colposcopy cell types / what is visualised (normal)

A

squamous (stratified) down to vagina
columnar (single cell) in entrance way - cervix . as it is single celled, you can see the vessels below

295
Q

painful defecation on periods suggests what

A

endometriosis

296
Q

chocolate cyst

A

endometriosis on ovary

297
Q

fluid in pelvis could mean what
what else would be useful for diagnosis

A

endometriosis.
symptoms complete picture. chocolate cyst/ laproscopy for diagnosis. certain diagnosis not needed for treatment though

298
Q

nifedepine =?

A

treats pre eclampsia and eclampsia
slows contractions in labour (maybe done to give more time)

299
Q

post birth contracpetion

A

ask immediately in post birth assessment to aid family planning
no oestrogen for a bit - clots

300
Q

medical termination of pregnancy

A

antiprogesterone PO (corpus luteum dies)

48h

prostaglandin PV (contraction, dilation, miscarriage

2w later - do pregnancy test

301
Q

neonatal jaunice causes

when bad/normal

A

in first 24h = bad
1-21d fine (fetal hb –> adult hb)

increased production
- hemolytic disease
— haemolytic anemia e.g SLE
— haematoma
— rhesus incompatibility
— congential infection e.g. rubella, CMV, herpes, syphillis, toxoplasmosis
- polycythaemia
- ventricular haemorrhage

decreased clearance
- prematurity
- metabolism errors e.g. gilberts
- hypothyroid/ hypopituitary

302
Q

neonatal jaundice investigations

A

look tan (not yellow)
billirubin monitored (transcutaneous, blood test)

303
Q

neonatal jaundice tx

A

observe for sepsis
- sleepy
- poor feeding
- floppy
- altered behaviour
- altered HR/RR/BP/temp

phototherapy (UV box)
IV immunoglob
exchange tranfusion via belly button (rarer)

304
Q

red baby causes

A

birth trauma (not an issue)
polycythaemia (could be due to delayed chord clamping)

305
Q

neonatal jaundice risk factors

A

group b strep
PROM >24h
preterm
mum or infant on antibiotics
twin
intubation

phase 3a mine (16 decks)

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