Obstetrics & Gynaecology

Question 1

Learning objectives

Answer 1

Answer

Question 2

Define candidiasis

Answer 2

• Infection caused by Candida.

Question 3

Explain the aetiology/risk factors of candidiasis

Answer 3

•	Caused by 15 different Candida species
•	Candida albicans is the MOST COMMON cause of candidiasis in humans 
•	Main types of candidiasis:
o	Oral candidiasis
o	Oesophageal candidiasis
o	Candidal vulvovaginitis 
o	Candidal skin infections 
o	Invasive candidal infections 
•	Risk Factors
o	Broad-spectrum antibiotics 
o	Immunocompromise (e.g. HIV, corticosteroids) 
o	Central venous lines 
o	Cushing's disease 
o	Diabetes mellitus 
o	GI tract surgery

Question 4

Summarise the epidemiology of candidiasis

Answer 4

• 60% of the healthy adult population are carriers
• Candidiasis occurs in over 80% of people with HIV
• Candida is one of the most common causes of invasive fungal infections in the Western world

Question 5

Recognise the presenting symptoms and signs of candidiasis

Answer 5

• Oral Candidiasis

o Oral Thrush (pseudomembranous oral candidiasis) - curd-like white patches in the mouth, which can be removed easily revealing an underlying red base. Most common in neonates
o There are lots of subtypes of oral candidiasis with slightly different features but the main features are: redness of the tongue and mouth, white plaques
• Oesophageal Candidiasis

o Dysphagia
o Pain on swallowing food or fluids
o It is an AIDS-defining illness
• Candidal Skin Infections

o Soreness and itching
o Skin appearance can be variable
o Red, moist skin area with ragged, peeling edge and possibly papules and pustules

Question 6

Identify appropriate investigations for candidiasis

Answer 6

• Oral Candidiasis - swabs and cultures are not particularly useful because a lot of normal people have candida in their mouth
• Swabs may be relevant to check for drug-resistance
• Therapeutic trials of antifungal (e.g. fluconazole) can help with diagnosis
• Oesophageal Candidiasis: definitive diagnosis is by endoscopy
• Invasive Candidiasis: blood cultures required if candidaemia is possible

Question 7

Define mastitis/breast abscesses

Answer 7

Define breast abscess
•	Abscess formation in breast tissues.
o	TWO main forms:
•	Lactational 
•	Non-Lactational

Question 8

Explain the aetiology / risk factors of mastitis/breast abscesses

Answer 8

•	Caused by INFECTION
•	Causative organisms defer based on whether the abscess is:
o	Lactational
•	Staphylococcus aureus
o	Non-Lactational
•	Staphylococcus aureus
•	Anaerobes
•	Risk Factors
o	Lactation
o	SMOKING
o	Mammary duct ectasia
o	Periductal mastitis 
o	Wound infections (e.g. from breast surgery)

Question 9

Summarise the epidemiology of mastitis/breast abscesses

Answer 9

• Lactational breast abscess are COMMON and tend to occur soon after starting breast feeding or weaning
• Non-lactational breast abscesses are more common in 30-60 yo smokers

Question 10

Recognise the presenting symptoms of mastitis/breast abscesses

Answer 10

• Breast discomfort
• Painful swelling
• Generally unwell and feverish
• Non-lactational - tend to present with a history of previous infections with less pronounced systemic upset

Question 11

Recognise the signs of mastitis/breast abscesses on physical examination

Answer 11

• Local
o Swollen, warm and tender area of the breast
o Overlying skin may be inflamed
o The nipple may be cracked
o Non-Lactational
• Scars or tissue distortion from previous episodes
• Signs of duct ectasia (e.g. nipple retraction)
• Systemic
o Pyrexia
o Tachycardia

Question 12

Identify appropriate investigations for mastitis/breast abscesses and interpret the results

Answer 12

• Ultrasound

* MC&S of pus samples

Question 13

Generate a management plan for mastitis/breast abscesses

Answer 13

• Medical
o Antibiotics
• Lactational: flucloxacillin
• Non-Lactational: flucloxacillin + metronidazole
• Surgical
o Lactational: Incision and drainage
o Non-Lactational: open drainage should be avoided. The involved duct system should be excised once the infection has settled

Question 14

Identify the possible complications of mastitis/breast abscesses and its management

Answer 14

• Mammary fistula

* Overlying skin may (rarely) undergo necrosis

Question 15

Summarise the prognosis for patients with mastitis/breast abscesses

Answer 15

• If untreated, a breast abscess may discharge onto the skin surface
• Non-lactational breast abscesses tend to recur

Question 16

Define polycystic ovarian syndrome

Answer 16

•	Characterised by oligomenorrhoea/amenorrhoea and hyperandrogenism (clinical or biochemical). Frequently associated with:
o	Obesity 
o	Insulin resistance 
o	Type 2 diabetes mellitus 
o	Dyslipidaemia

Question 17

Explain the aetiology/risk factors of polycystic ovarian syndrome

Answer 17

• Environmental factors
• Genetic variants
• Hyperinsulinaemia results in increased ovarian androgen synthesis and reduced hepatic sex hormone binding globulin (SHBG) synthesis
• This leads to an increase in free androgens (which gives rise to the symptoms)

Question 18

Summarise the epidemiology of polycystic ovarian syndrome

Answer 18

• PCOS is the MOST COMMON cause of infertility in women

* Affects 6-8% of women

Question 19

Recognise the presenting symptoms of polycystic ovarian syndrome

Answer 19

•	Menstrual irregularities 
•	Dysfunctional uterine bleeding 
•	Infertility 
•	Symptoms of hyperandrogenism:
o	Hirsuitism
o	Male-pattern hair loss 
o	Acne

Question 20

Recognise the signs of polycystic ovarian syndrome on physical examination

Answer 20

• Hirsuitism
• Male-pattern hair loss
• Acne
• Acanthosis nigricans (sign of severe insulin resistance) - velvety thickening and hyperpigmentation of the skin of the axillar or neck

Question 21

Identify appropriate investigations for polycystic ovarian syndrome

Answer 21

• Bloods
o High LH
o High LH: FSH ratio
o High testosterone, androstenedione and DHEA-S
o Low sex hormone binding globulin
• Other things to test for:
o Hyperprolactinaemia
o Hypo/hyperthyroidism
o Congenital adrenal hyperplasia (check 17OH-progesterone levels)
o Cushing’s syndrome
• Look for impaired glucose tolerance/T2DM:
o Fasting blood glucose
o HbA1c
• Fasting lipid profile
• Transvaginal USS: look for ovarian follicles and an increase in ovarian volume