Gynaecology

Question 1

What week is hyperemesis gravidum?

Answer 1

begins between 4–7th weeks, peaks between 9–16th weeks, and resolves by 16–20 weeks of pregnancy. NOTE IF ONSET STARTS AFTER 11 WEEKS THEN CONSIDER ALTERNATIVE CAUSE OF SYMPTOMS.

Question 2

What is the PUQE-24 scoring system?

Answer 2

Pregnancy Unique Quantification of Emesis (PUQE) 24 is a scoring system of nausea and vomiting in 24 hours. It is out of 15
mild <= 6; moderate 7–12; severe 13–15.

Question 3

What is hyperemesis gravidarum?

Answer 3

The term is used to describe the most severe spectrum of symptoms. It is a diagnosis of exclusion much like CFS, IBS and Behcets.

It is characterised by the TRIAD of
- Prolonged persistent and severe N+V
- Weight loss ≥5% of pre-pregnancy body weight
- Dehydration and electrolyte imbalance

Question 4

What are the causes of N+V in pregnancy?

Answer 4

• physiological morning sickness
• high HcG
• UTI
• multiple pregnancy
• Trophoblastic disease

Question 5

which antiemetic is associated with cleft palate if given in the first trimester

Answer 5

ondansetron

Question 6

which antiemetic cannot be given for >5 days?

Answer 6

metaclopramide

Question 7

What are the first line antiemetics for hyperemesis gravidarum?

Answer 7

Antihistamines- CYCLIZINE. PROMETHAZINE. PROCHLORPEZAMINE 2ND LINE as ondansetron and metaclopramide have more side effects and risks associated with them.

Question 8

Why give antacids and alignates for hyperemesis gravidarum?

Answer 8

Gaviscon (antacid)

CKS recommends using acid-suppressing drugs only as a last resort in severe cases in primary care as there is no evidence that they are safe
omeprazole and famitidine

Question 9

what is domperidone?

Answer 9

A dopamine receptor antagonist antiemetic

it should NOT BE USED FOR >7 DAYS BECAUSE THE RISK OF CARDIAC SIDE EFFECTS

Question 10

How is cervical cancer staged? How many stages are there and what do they mean?

Answer 10

using the FIGO system
1 A1 A2 B1 B2 B3 - Confined to cervix (varying size depending on the subdivision)
2 A1 A2 B - Spread from the cervix to the upper vagina, the uterus or parametrium (connective tissue around the uterus but NOT the pelvic walls (muscles or affecting the ureters)
3 A B C - Spread from the cervix to the lower vagina or to the pelvic walls. C- lymph nodes may also be involved. Cancer is any size.
4 A B - Spread to the bowel/bladder (A) or distant organs (B)

Question 11

What treatment is offered for stage 1 cervical cancer

Answer 11

1A Surgery - radical trachelectomy or hysterectomy
1B Chemo and radio

Question 12

What treatment is offered for stage 2 and 3 cervical cancer

Answer 12

combined chemoradiotherapy

Question 13

what treatment is offered for stage 4 cervical cancer?

Answer 13

4A - combined chemoradiotherapy
4B - palliative ie IVC filter, pain relief, stents/nephrostomy.

Question 14

How are high grade dysplasia treated?

Answer 14

CN1- Yearly survellance for 10 years
CN2- treated at colposcopy with LLETZ
CN3- treated at colposcopy with LLETZ

Question 15

What are the first signs of cervical cancer?

Answer 15

Starts with increased discharge that becomes smelly

Question 16

what are the symptoms of cervical cancer

Answer 16

• Vaginal discomfort
• DYSPARENURIA
• Cervical friability and ulcerations on examination
• If it spreads/later stage =
  
  • Back pain
  • Urinary retention
  • Constipation
  • Leg oedema
  • Hydronephrosis
  • Blood in urine

Question 17

what histology are the MAJORITY OF CERVICAL CANCERS?

Answer 17

SQUAMOUS

• Adenocarcinomas 5-20%
• Squamous cell 80-95%

Question 18

What mm thickness is suspicious of endometrial cancer?

Answer 18

> 4mm in post menopausal lady

Question 19

what are the risk factors for type 1 endometrial cancer?

Answer 19

type 1 is the most common - it is adenocarcinoma, oestrogen sensitive. type 2 is oestrogen insensitive.

risk factors include
- unopposed oestrogen (i.e. without progesterone)
- anything that stops the endometrial wall from shedding i.e., PCOS
- anything that increases the cycles of endometrial shedding i.e., nulliparity, early menarche or late menopause
- family history
- Older age >35 years
- Obesity
- BRCA or conditions like Lynch
- HRT
- Nulliparity
- Tamoxifen

Question 20

what is the cause of an enlarged tender but NOT TENSE uterus with no PV bleed

Answer 20

adenomyosis
a tense uterus or a mass may indicate fibroids
but an enlarged and soft/flaccid uterus is a sign of endometrial tissue invasion into the muscle –> flaccidity
It resolves in menopause

Question 21

What are the three types of fibroids? and how do they present?

Answer 21

Subserosal
Intramural
submucousal

• bleeding
• pain
• mass

treatment is focused on stopping bleeding, stopping pain and reducing the mass (GnRH agonsits) (reduce secretion of hormones but are used short term as not to increase risk of osteoporosis)

Question 22

What are the two types of physiological ovarian cysts? what is the management and what are the complications?

Answer 22

follicular
corpus luteum

Self resolving, no management needed.

Complications are haemorrhagic corpus luteum where when it degenerates it fills with blood –> scarring or rupture into the peritoneum.

Question 23

what are the main pathological ovarian cysts/tumours?

Answer 23

either classified by disease i.e., endometrioma which is a ruptured follicular cyst that has opened up the ovary allowing for endometrium to enter and grow alongside it.

Or classified by origin:
- endometrial
- germ
- sex cord stromal

Question 24

what are the most common ovarian cancers?

Answer 24

endometrial
- mucinous or serous
- found in >20

Question 25

Which endometrial cysts are most at risk of ovarian torsion / causing spinal cord compression?

Answer 25

dermatoid

Question 26

What is the name of the condition that presents with ascites, pelvic mass, and pleural effusion.

Answer 26

OHSS although this usually presents in a TETRAD (ascites, hypovolemic shock, AKI, Venous and Arterial thromboembolism, pleural effusion)
or
Meigg’s syndrome

Question 27

What should you ask in a Gynae history?

Answer 27

INITIAL QUESTIONS
- Gravity
- Parity
- LMP

PC
HPC
Gynae specific

Obstetric specific
Contraception specific
Systems review
PMH
DH
FH
SH

Question 28

What should you ask in a Gynae history?

Answer 28

INITIAL QUESTIONS
- Gravity
- Parity
- LMP

PC
HPC
Gynae specific
–> discharge, itching, bleeding (LMP, menorrhagia, oligomenorrhea, intramenstrual, post coital), menopause if appropriate, pain (abdo, urination, opening bowels), STI, smears, past gynae surgical history, + other symptoms i.e., bloating, shortness of breath, anaemia, weight loss.
Obstetric specific
–> Miscarriage, IVF, mode of delivery, any congenital effects, symptoms.
Contraception specific

Systems review
PMH
- Migraine with aura?
- Previous venous thromboembolism (VTE)
- Breast cancer (current or previous)
- Bleeding disorders(e.g. Von Willebrand’s)
DH
- that may be CI in pregnancy, breastfeeding or used to treat a gynae disease i.e., TXA or GnRH analogues - endometriosis or PCOS
FH
- Breast cancer
- Clots
SH
- If smoking more than 40 cigarettes a day, the COCP would be contraindicated.
- If over 35-years-old and smoking more than 15 cigarettes a day, the COCP would be contraindicated.

Question 29

What is the main cause of post coital bleeding?

Answer 29

cervical ectropion caused by COCP