Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

O&G > Acute Gynae > Flashcards

Acute Gynae Flashcards

1
Q

How would you take a gynaecology history and what are the key questions to ask?

A

Gynae Hx:

PC (ODP, recurrence? etc)
HPC
MS COURS
–> Menstrual cycles - when was LMP, are your cycles regular+how long do you bleed for, any pain during this, heavy bleeding?/how many pads do you use, any abnormal bleeding in between cycles (PCB, IMB), age of menarche/menopause?
–> Sexual - do you have a regular sexual partner, have you had a recent STI check, pain during sex (start vs end = superficial vs deep), discharge changes?
–> Contraception - do you take regular contraception + which one, does your partner, any SE if on OCP
–> Obstetric - any chance you could be pregnant, previous pregnancies and their outcome, if birth then modes of birth, any complications from these pregnancies?
–> Urinary + Rectal sx - changes in waterworks, changes in bowel habit (freq, bleeding, dragging sensation = prolapse), Hx of UTIs
–> Smears (ONLY IF >25y) - when was your last cervical smear, what was the result of that?

PMH - include previous surgeries including hysterectomy if apt, medical admissions etc + conditions e.g. for RFs etc

DH - medicines, allergies

FH - family history of complications in pregnancy?*, risk factors - cancers/strokes

SH - support system, smoking, drinking

ICE!!! - always needed

SR - exclude other symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What questions are important to ask when a patient comes in with a suspected gynae infection?

A

Hx questions:

  • Discharge (colour, smell, consistency and amount)
  • Blood (inter-menstrual, post-coital)
  • Pain, itching
  • Urinary Sx - burning, frequency, urgency
  • FLAWS
  • Chance of pregnancy
  • Sexual Hx (regular partner, male or female, last different partner, recent STI check, contraception/barriers)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What investigations are key for infections within gynaecology? What pH changes may you see?

A

(NOTE - do speculum before bimanual as the lubrication ruins the speculum swabs)

Ix:
-> pH - sensitive but not specific; normally 3.5-4.5 due to lactobacilli in vagina but may be:
LOW pH = candida
NORMAL pH = normal, candida
HIGH pH = bacterial infections i.e. TV, BV, contamination (blood, semen, lube)

  • > Swabs - (1st = endocervical NAAT testing for N.G and Ch, 2nd = high vaginal charcoal swab for TV, BV, candida and GBS; may have a 3 where the second is an endocervical charcoal swab for gonorrhoea)
  • > Bloods - for HIV and Syphillis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is BV and its cause? What are some risk factors and protective factors?

A

BV = Bacterial Vaginosis

  • > Commonest cause of abnormal vaginal discharge
  • > Sexually associated but not sexually transmitted
  • > Occurs and remits spontaneously due to overgrowth of anaerobic bacteria [e.g. Gardnerella vaginalis] and loss of lactobacilli –> increased pH –> increased chance of BV

RFs:

  • > New sexual partner
  • > Sexual activity
  • > Copper IUD
  • > Bubble bathing, douching
  • > Other STIs
  • > Smoking

Protective Factors:

  • COCP
  • Circumcised partner
  • Condoms
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How would the patient present with BV and what Ix would you consider?

*Amsel + Hay-Ison criteria?

A

Sx:

  • > “Fishy’ odorous discharge
  • > NO other symptoms; 50% Asymptomatic

Ix:

  • > Dx is clinical + microscopy
  • > HVS [wet mount] microscopy shows CLUE cells which are vaginal epithelium cells coated with lots of bacilli + High pH

Amsel’s criteria [requires 3/4 of]:

  • Thin white, homogenous discharge
  • Clue cells on microscopy
  • Vaginal pH >4.5
  • Fishy odour on adding 10% KOH

Hay-Ison criteria is applied to gram staining (Grade 3 = BV)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How would you manage a patient with BV? [+2nd line?] What are complications of BV?

A

Mx:

  • > 1st line = Metronidazole 400mg BD PO for 7 days or intravaginal preparation for 5d
  • > 2nd line = intravaginal clindamycinn PV cream 5g 2% for 7 days
  • > Advice = avoid vaginal douching, shower gel, use of shampoo in bath, no alcohol on these Abs

Complications:

  • > Late miscarriage
  • > Pre-term birth, PROM
  • > Post-partum endometritis
  • > Increases risk of acquiring and transmitting STIs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is TV infection and how does it present? (Sx + O/E)

A

TV = Trichomonas vaginalis
-> Sexually transmitted

Sx:

  • > GREEN/yellow frothy discharge + offensive odour
  • > Vulval itching or vaginal soreness
  • > Dyspareunia
  • > Lower abdominal pain and dysuria

O/E:

  • > Strawberry cervix
  • > Discharge ^
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How would you Ix + manage a patient with suspected TV?

A

Ix:

  • HVS microscopy/wet mount shows flagellated organism
  • pH > 4.5
  • Endocervical swabs for other STIs
  • Culture and gram stain

Mx:

  • > Metronidazole [or Tinidazole] 7d
  • > No sexual intercourse for 7 days or at least use condoms, contact tracing + STI check up for previous partners, follow-up to retest after 3m, no alcohol on these Abs

Similar complications as BV:

  • > Pregnancy: PROM, Pre-term labour + LBW
  • > Enhances HIV/STI transmission
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is Thrush and what are some risk factors for it?

A

Candidiasis/Thrush

  • > 90% caused by Candida albicans, 5% by candida glabrata
  • > Can be spontaneous or secondary to disruption to normal vaginal flora (2nd most common infection after BV)

RFs:

  • > DM, Immunosuppression (poorly controlled)
  • > Intercourse
  • > Recent Abx e.g. for UTI
  • > Oestrogen exposure (more common in pregnancy, reproductive years)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How would someone with thrush present and how would you investigate them?

A

Sx:

  • > vulva itching, soreness, irritation
  • > “cottage-cheese” like discharge

Ix:

  • Clinical Dx, no Ix usually required
  • Diagnostic = HVS; microscopy, culture and gram stain (speckled gram+ spores, pseudo-hyphae in c.albicans)
  • Others: HbA1c in DM, MSU for UTIs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How would you treat someone with thrush? What if they were pregnant?

A

Mx:
EITHER topical clotrimazole pessary/cream [Canesten] AND/OR oral anti-fungal e.g. fluconazole or itraconazole

Advice:
+ avoid tight fitting clothing, local irritants like perfume, scented soaps/gels
+ don’t wash female area with soap/gels, no douching
+ If recurrent (>/=4 symptomatic episodes) then check adherence and use induction and maintenance fluconazole [every3d x3 then 6m 1/w]
+ If pregnant only use topical treatment***

Complications:

  • Hepatotoxicity with systemic antifungals (monitor LFTs)
  • Immunocompromised may get oesophageal or disseminated candidiasis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are cutaneous warts also known as and how do they present in a patient?

A

Condylomata acuminate = caused by HPV 6 and 11 infection

  • > Most are sexually transmitted
  • > HPV vaccine [Gardasil] prevents against subtypes 6, 11, 16 and 18

Sx:

  • Often asymptomatic
  • Genital warts on vulva, vagina, cervix and anus which are generally painless but may itch/bleed/get inflamed
  • Vaginal discharge
  • PCB/IMB from local trauma and pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

How would you manage (Ix+Mx) genital warts? What are some risks?

A

Ix:

  • Often clinical diagnosis
  • STI screen (triple swab, HIV, syphilis, HBV)

Mx:

  • Often no treatment required but might refer to GUM if STI risk factors
  • Medical (NOT for pregnant women) = imiquimod cream for keratinised warts and podophyllin/tri-chloro-acetic acid for non-keratinised warts
  • Surgical = cryotherapy, laser, electrocautery

Complications

  • > If high risk HPV virus then could lead to increased risk of anogenital cancers
  • > Distress/psychosexual dysfunction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is chlamydia caused by and how does it present?

A

Chlamydia = infection by the obligate intracellular gram- bacteria called chlamydia trachomatis [can’t be seen under microscope]

  • > Most common bacterial STI in the UK
  • > Affects the endocervix +/- urethra in women, and in men the urethra

Sx:

  • Asymptomatic in ~70-80% women
  • Symptoms (30%) = purulent PV discharge, dyspareunia, IMB/PCB, abdominal pain, dysuria

RFs = multiple sexual partners, no barriers, Hx of STIs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What investigations would you consider for someone with suspected chlamydia?

A

Ix:

  • > IF symptoms, then can treat on suspicion alone
  • > NAAT via vulvovaginal swab or first catch urine (men=urethral swab/FCU) = direct microscopy will show non=gonococcal urethritis, no organisms just neutrophils

-> [2nd line = culture + sensitivities but NAAT is main]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How would you manage a patient with chlamydia and what are some complications of chlamydia?

A

Mx:

  • 1st line = 100mg doxycycline 2x/daily for 7d [CI in pregnancy and breast feeding so instead use 2nd line = azithromycin 1g single dose]
  • Contact tracing (last 6m)
  • STI screening recommended
  • Avoid sex until Tx completed
  • F/u by 5w

Complications:

  • PID, sub/infertility, ectopic
  • Fitz-Hugh-Curtis (perihepatitis)
  • Reactive arthritis (conjunctivitis, urethritis, arthritis)
  • Pregnancy issues (PROM, PTL, postpartum endometritis)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is gonorrhoea caused by and how does it present?

A

Caused by the gram- intracellular diplococci neisseria gonorrhoea

  • > 2nd most STI after chlamydia
  • > RF = unprotected sex/no barriers, multiple partners, other STIs, HIV, MSM

Sx:

  • Asymptomatic in 50% patients
  • Symptoms = PV discharge, IMB/PCB, dysuria, dyspareunia, lower abdominal pain

O/E:

  • Speculum = mucopurulent endocervical discharge, easily induced endocervical bleeding
  • Bimanual = cervical motion/adnexal tenderness, uterine tenderness
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

How would you investigate suspected gonorrhoea?

A

note: empirical treatment only if recent sexual contact with confirmed gonococcal infection

Ix:
-> NAAT (men= FCU, women= vulvovaginal swab)
-> Direct microscopy (neutrophils, gram- diplococci)
[2nd line = Culture + Sensitivities]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

How would you manage a patient with gonorrhoea and what are some complications if left untreated?

A

Mx [post-confirmation of gonorrhoea by NAAT/microscopy/culture]:

  • > 1g IM Ceftriaxone
  • > Screen for other STIs
  • > Contact tracing
  • > F/u 1w later and avoid sex for 1w

Complications:

  • PID, infertility, ectopic
  • Conjunctivitis
  • Fitz-Hugh-Curtiz (perihepatitis - PID due to liver to abdominal wall adhesions)
  • Vertical transmission to baby (giving conjunctivitis)
  • Disseminated disease in 1% (fever, rash, meningitis, septic arthritis)
  • Increased HIV susceptibility
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is syphilis and what are some RFs for it?

A

Syphilis = systemic infection by gram- spirochete called Treponema pallidum
-> Can be transmitted sexually, blood bourne or vertical

RF = young age (<29y), African American, drug use, other STI infections, sex workers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

How may syphilis present?

A

Primary [3-4w]

  • Painless chancres [genital ulcers]
  • Local lymphadenopathy
  • Resolves in 3-8w

Secondary [4-8w after chancres]

  • Only 25% get symptoms
  • Rough papulonodular rash on hands, feet, trunk
  • Condylomata lata (warts)
  • Snail track oral ulcer
  • Lymphadenopathy + systemic symptoms
  • Uveitis
  • Resolves in 2-12w

Latent:

  • No Sx, detected on routine tests
  • Early latent = <2y after infection i.e. exposure to/symptoms, Late latent = >2y after infection

Tertiary [1-20y]

  • Affects 1/3 of untreated illness
  • Gummatous syphilis [15%] = erosive skin and bone lesions
  • Cardiovascular syphillis [10%] = aortitis, aortic regurgitation (early diastolic decrescendo), HF
  • Neurosyphilis:
  • -> Tabes dorsalis (15-20y) - affects dorsal column so get sensory problems, lightning pains, absent reflexes
  • -> General paresis (10-25y) - dementia
  • -> Meningovascular (5-10y) - ischaemia, insomnia, emotionally labile
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What investigations would you consider for suspected syphilis?

A

Ix:

  • Microbiology Swabs –> dark field microscopy shows spirochete
  • Serology - can be treponema tests (rapid plasmin reagin, VDRL) or non-treponema tests (EIA, TPHA, FTA-ABS)
  • Neurosyphilis - CT/MRI head, LP (raised WCC and protein)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

How would you manage syphilis? [depending on stage]

A

Mx:
-> Early (primary, secondary and early latent) = IM Benzathine benzylpenicillin* 1.8g single dose

-> Late (tertiary non-neuro and late latent) = IM Benzathine benzypenicillin 1.8g (once weekly for 3w)

  • > Neurosyphilis =
  • IV Benzylpenicillin sodium 4-hourly for 10-14 days
  • Prednisolone for 3d started 24h before IV Abx to prevent Jarish-Herxheimer reaction which is the release of pro-inflammatory cytokines in response to dying organisms
  • If pregnant mother >22w then admit them when treating e.g. risk of febrile myalgia

AND FOR ALL:

  • > F/u and repeat bloods at 3m (4 fold drop in RPR)
  • > Notify partner/s

*in penicillin allergy (+non-pregnant), give 2 or 4w doxycycline 100mg 2x daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What are some complications of syphilis?

A

Complications:
- Risks in pregnancy (FGR, hydrous, congenital syphilis causing life-long disability - rash on hands and feet and bone lesions, stillbirth, neonatal death and pre-term birth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What is an ovarian cyst and what are some types[3]? What are some RFs for getting ovarian cysts? What are rokitansky protuberances?

A

Fluid filled sac in ovarian tissue

  • > 90% ovarian tumours are benign
  • > 8% premenopausal women have large cysts

RFs = PCOS, endometriosis (also pregnancy* i.e. luteal cysts seen in early pregnancy)

Types of ovarian cyst (benign):
- Physiological: Follicular cyst (commonest, lined by granulosa cells) and Corpus luteal cyst* (lined by luteal cells)

  • Benign germ cell: Dermoid cyst/mature cystic teratoma
  • -> lined by epithelial cells
  • -> most common benign tumour in those <30
  • -> often asymptomatic but most likely to TORT!
  • -> May see ‘rokitansky protuberances on USS’ which are white shiny masses that protrude out
  • Benign epithelial: serous cystadenoma and mucinous cystadenoma (usually very LARGE)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What is a key differentiator of benign ovarian tumours/cysts?

A

Most benign ovarian tumours are cystic - finding solid elements increases likelihood of malignancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Why is age important when considering ovarian cysts? What is the prevalence of them?

A

Ovarian cysts are very common in premenopausal women, due to fluctuations in hormones of the menstrual cycle

Cysts in post-menopausal women should make you consider malignancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

How may women present with an ovarian cyst?

A

Sx:

  • > Lower abdominal pain
  • > Distension/swelling with pressure symptoms (frequency, urgency)
  • > Deep dyspareunia
  • > Acute abdomen if rupture/ haemorrhagic/torsion!!

Rule out red flags/cancer Sx = early satiety, reduced appetite, weight loss, ascites

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

How would you Ix a woman with a suspected ovarian cyst?

A

Ix:

  • > If acutely unwell, A-E approach
  • > Pregnancy test
  • > TVUSS
  • —> outcome dependent on menopause status:
  • –> PRE-menopausal: if simple cyst, manage depending on size but if complex and <40y then request LDH, aFP and b-HCG levels
  • –> POST-menopausal: both simple and complex cysts require a Ca125 done and RMI calculated
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

How would you manage ovarian cysts in pre-menopausal and post-menopausal women?

A

Mx:

Pre-menopausal women

  • Simple cyst/unilobular:
  • -> <5cm = no f/u required
  • -> 5-7cm = repeat USS yearly
  • -> >7cm = further imaging e.g. MRI +/- surgery

Indications for watchful waiting = unilateral, normal Ca125, no free fluid, if pre/post-menstrual period, no solid parts (unilocular)

  • IF recurrent or unresolved, then can give COCP as preventing ovulation will prevent recurring cysts
  • IF recurrent, sustained >5cm or suspicious/multiloculated then surgical management (laparoscopic cystectomy) is usually curative

Post-menopausal women:

  • RMI <200:
  • -> if all 3 of: asymptomatic, simple cyst, <5cm, unilocular and unilateral then = repeat USS and Ca125 in 4-6m (by then it will have either resolved, repeat if unchanged BUT if changed by then, laparoscopic cystectomy)
  • -> BSO = indicated in those with any of: symptomatic, non-simple features, >5cm, multilocular and bilateral
  • RMI >200:
  • -> CT-AP and MDT management
  • -> TAH + BSO +/- omentectomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What are some complications of ovarian cysts?

A
  • Cyst rupture
  • -> Common in functional cysts
  • -> Conservatively managed with pain relief and watchful waiting
  • -> IF evidence of active bleeding, laparoscopy (+/- cautery) may be indicated
  • Ovarian torsion
  • -> if >5cm
  • -> Commonly in dermoid cysts
  • Subfertility
  • Malignant change
  • Oopherectomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What is ovarian torsion? What are some RFs for it?

A

Twisting of the ovaries - a complication of ovarian cysts or tumours

  • > Dermoid cysts are the MOST likely, whereas endometriomas are the least likely
  • > Ovarian cysts >5cm are at risk of torsion

RFs:

  • > Ovarian cysts or tumours
  • > More likely in pregnancy
  • > Tubal ligation
  • > Long ovarian ligaments (i.e. younger girls before menarche have longer infundibuloligaments)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

How would a woman present with ovarian torsion?

A

Sx:

  • Sudden onset severe RIF or LIF pain (unlikely to radiate to shoulder tip like ectopic)
  • N+Vomiting
  • Localised tenderness and palpable pelvic mass
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

How would you Ix and Mx someone with suspected ovarian torsion?

A

Ix:

  • > A to E approach if acutely unwell
  • > Pregnancy test !!
  • > Bimanual may show an adnexal mass
  • > Speculum if suspecting PID
  • > Urinalysis - to rule out uterteric colic
  • > Bloods - FBC may show high WCC + surgery bloods
  • > USS with Dopplers is KEY (TVUSS>Abdo, unless children) - shows ovary oedema and free fluid in pelvis, and ‘whirlpool sign’. Doppler may show reduced blood flow (ischaemia)

Mx:

  • > Laparoscopy is the only way to definitively diagnose
  • > Decision is made in surgery to either untwist + fix ovary (detorsion) or also remove the affected ovary (oophorectomy)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What are some complications of ovarian torsion?

A

Risks:

  • > Ischaemia and necrosis of the ovary
  • > Abscess formation and sepsis
  • > Sub/infertility and menopause if no existing ovary left
  • > If not removed, may rupture causing peritonitis and adhesions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What is FGM and what are the 4 types? Who is usually at risk and affected?

A

FGM = female genital mutilation where there is partial or total removal of the external female genitalia

Type 1 = removing part/all of the clitoris
Type 2 = excision of the clitoris and labia minora +/- labia majora
Type 3 = infibulation where there is narrowing of the vaginal opening but cutting and repositioning the labia and creating a seal
Other: cutting, scraping, burning, pricking and piercing

2% women in London, 100,000 women and girls in England + Wales
- Often in younger girls, pre-puberty ~15y

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

How may women who have had FGM present?

A

Sx:

  • Constant pain
  • Dyspareunia
  • Incontinence
  • Recurrent infections
  • Psychological effects e.g. depression, flashbacks and SH
  • Bleeding, cysts and abscesses
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

How are women with FGM managed? What are some complications of FGM?

A

Mx:

  • Deinfibulation –> offered to those who are unable to have sex, pass urine or pregnant women at risk during recovery + analgesia
  • Must be recorded in notes
  • If <18yo, then must report to police and social services (via 101)
  • If 18+ then no obligatory duty to report (aside from notes) and may offer deinfibulation

Complications:

  • Repeated infections –> infertility
  • Life-threatening complications during labour and childbirth
  • Haemorrhage, urinary retention, menstrual difficulties, HIV, HBV

Note: REINFIBULATION e.g. after childbirth is illegal in the UK!

39
Q

What is Asherman’s syndrome? What is its aetiology and some RFs?

A

Presence of intrauterine adhesions within the uterus which occlude the uterine cavity
Due to adhesions/scar tissue which may be secondary to surgery, trauma (birth) or severe infection (endometritis)

Occurs in 5-40% of dilation and curettage i.e. after miscarriages/RPC

RFs:

  • Endometrial resection
  • D&C for miscarriage or TOP
  • Surgery - myomectomy , C section
  • Endometriosis
40
Q

How may women with Asherman’s syndrome present?

A

Sx:

  • Secondary amenorrhoea
  • Cyclical abdominal pain/dysmenorrhoea
  • Significantly lighter periods
  • Subfertility/infertility
41
Q

How would you Ix and Mx women with Asherman’s syndrome?

A

Ix:

  • Hysteroscopy [gold standard - may involve dissection and Tx of adhesions]
  • Sonohysterography - uterus filled with fluid + pelvic USS
  • Hysterosalpingography (contrast in uterus + XR)
  • MRI
Mx:
-> Hysteroscopic ablation
[-> Post-op copper IUD 
then:
-> PO oestrogens to induce endometrial proliferation (2-3m) and reassess cavity
42
Q

What is atrophic vaginitis? What is the aetiology? How many women does it affect?

A

Dryness and atrophy of the vagina due to lack of oestrogen

  • > AKA genitourinary syndrome of menopause
  • > Oestrogen acts on the vaginal epithelium and urinary track to ensure elasticity, secretions and thickening
  • > Post-menopause, women therefore can become dry, thin and less elastic [+changes in flora and pH which may predispose to infection]

10-40% of post-menopausal women

43
Q

How may women present with atrophic vaginitis? In who is it important to consider also?

A

Sx:

  • > Vaginal dryness
  • > Dyspareunia
  • > Itching
  • > Bleeding due to local inflammation
  • > O/E: pale, thin vaginal walls with loss of skin folds, dryness and erythema, sparse pubic hair

CONSIDER AV in women presenting with recurrent UTIs, stress incontinence or prolapses as oestrogen required to ensure connective tissue support

44
Q

How would you Ix and Mx atrophic vaginitis?

A

Ix:

  • > Mainly clinical based on Hx and O/E findings
  • > Swabs + urine dip/MC+S to rule out infection
  • > Biopsy if considering potential malignancy/ulcers

Mx:

  • > Vaginal lubricants for dryness [Sylk, Replens, YES]
  • > Topical oestrogen [creams, pessaries, tablets or rings]
  • —> However, ensure no CI e.g. VTE, angina or breast cancer! SE’s same as systemic HRT [endometrial cancer etc] so ensure on lowest dos and not for too long// f/u at least annually with view to stopping when possible
45
Q

What is PID? What are some common causative organisms?

A

Inflammation and infection of the pelvic organs, resulting from ascending infection of the genital tract [e.g. endometritis, oophoritis, salpingitis etc]

Most common cause = Chlamydia Trachomatis

Other common causes:
[STIs]
-> Neisseria gonorrhoea - tends to produce more severe PID
-> Mycoplasma genitalium
[Non-STIs]
-> Gardnerella - associated with BV
-> H. influenzae
-> E. coli
46
Q

What are some RFs for PID? How may they present?

A

RFs:

  • > Multiple sexual partners
  • > Early age of first coitus
  • > Not using barrier contraception and/or use of IUD/IUS
  • > Young age e.g. <25yo
  • > Existing STI
  • > Previous PID

Sx:

  • May be asymptomatic
  • Infertility
  • Chronic pelvic pain/lower abdominal [>bilateral]
  • Abnormal discharge
  • Abnormal bleeding i.e. IMB/PCB [both C+G cause bloody discharge but C more common]
  • Fever
  • Dyspareunia
  • O/E - cervical motion tenderness, pelvic tenderness, purulent discharge, fever, signs of sepsis
47
Q

What Ix would you consider in a woman with suspected PID?

A

Ix:

  • Abdominal examination
  • Bimanual (cervical excitation, check for adnexal assess such as tubo-ovarian abscesses)
  • Speculum (signs of inflammation or discharge) + triple swabs [2x endocervical NAAT and 1x HVS]
  • Urinary pregnancy test to rule out ectopic pregnancy
  • If febrile, bloods (FBC, CRP, ESR)
48
Q

How would you manage a woman with PID?

A

Mx:

  • > Assess patient for admission i.e. if septic, pyrexial >38 degrees; otherwise treated in the community as OP –> see within 2-3d to see Abx response –> f/u in 2-4w
  • > Start Abx before swabs come back if you suspect PID
  • > OP Abx include [an example from BASSH guidelines]:
  • –> 500mg IM Ceftriaxone single dose [covers Gonorrhoea]
  • –> 100mg BD PO Doxycycline for 14d [covers Chlamydia and Mycoplasma]
  • –> 400mg Metronidazole BD PO for 14d [covers anaerobes]

Inpatient - if pyrexial OR 2-3d later no response to Abx:

  • > 1st line = IV cefotixin + doxycycline
  • > 2nd line = IV clindamycin or gentamycin

-> Other: STI screening, contact tracing, discuss contraception, removal of any IUD! and avoid sex until treated

Note: consider referral to GUM clinic

49
Q

What are some complications of PID?

A

Complications:

  • Sepsis, abscess
  • Infertility
  • Ectopic pregnancies (paralyse cilia in Fallopian tubes)
  • Fitz-Hugh-Curtis syndrome
50
Q

What is Fitz-Hugh-Curtis syndrome?

A

FHC syndrome is inflammation and infection of the liver capsule [Glisson’s capsule] –> adhesions between the liver and peritoneum –>

  • Complication of PID
  • Results in RUQ pain
  • Laparoscopy and adhesion removal may be used as management
51
Q

What do endocervical and high vaginal swabs test for respectively?

A

Endocervical:
- NAAT for Chlaymdia, Gonorrhoea (sometimes Mycoplasma if available)

HVS:

  • BV
  • Trichomonas V
  • Candida
52
Q

What is Bartholin’s cyst? What are Bartholin’s glands and how does a cyst occur?

A

Cyst or abscess of Bartholin’s gland (greater vestibular glands)

Physiology:

  • > Bartholins glands are a pair of glands, placed either side of the posterior vaginal introitus, inferiorly
  • > They normally secrete mucus to help with vaginal lubrication. They are usually pea sized and NOT palpable
  • > The ducts may get blocked within the gland, causing a cyst (1-4cm), usually unilateral
  • > These cysts may get infected, forming a Bartholin’s abscess which are usually red, hot and potentially draining pus
53
Q

How may women present with Bartholin’s cyst and abscess? How would you Ix and Dx them?

A

Sx:

  • > Unilateral labial swelling, often asymptomatic or painless
  • > If infected, you may see the abscess with signs of infection, fever, dyspareunia, pain on sitting or walking

Ix/Dx:

  • Clinical Dx
  • If >40yo, consider vulval biopsy
  • If infected, MC+S from abscess [most are sterile but may help organism differentiation]
54
Q

What are some RFs for Bartholin’s cysts?

A

RFs:

  • Nulliparous
  • Previous Bartholin’s cyst
  • Sexually active
55
Q

How would you manage Bartholin’s cyst/abscesses? What are complications of it?

A

Mx:
-> Conservative, if the patient is well: good hygiene, warm compress and analgesia and they usually resolve
[Usually want to avoid incision due to often recurrence]
-> Flucloxacillin OD if infected abscess/systemically unwell

Surgical:
1st line if symptomatic = marsupialisation or word catheter:
-> Consider incision and draining + ‘Word catheter’ [where tissue heals around the balloon, which is in the cyst cavity post-drainage, and then taken out at a later date]
-> Marsupialisation = forming an open pouch to stop the cyst from reforming by incising and draining the cyst, the suturing the sides open

Complications:

  • Rupture
  • Recurrence
  • Sepsis/Abscess
56
Q

What is the normal epithelium within the cervix?

A

Endocervix = columnar epithelium
–> Transformational Zone –>
Ectocervix = squamous epithelium

57
Q

What is cervical ectropion? How may it present and why? What are some RFs for it? How is it Mx?

A

When the columnar epithelium of the endocervix extends out to the ectocervix
Therefore, this area is more fragile and prone to trauma hence why they may present with PCB (+ increased vaginal discharge, bleeding, dyspareunia)

RFs: linked to raised oestrogen levels

  • > Younger women
  • > COCP use
  • > Pregnancy

You will be able to see ectropion on speculum examination

Mx - reassurance; if asymptomatic, no treatment required. If bleeding is problematic, then may be treated with cauterisation using AgNO3 or cold coagulation during colposcopy + stop oestrogen-based contraceptives

58
Q

What are cervical and endometrial polyps? How are they investigated and managed?

A

Cervical polyp: overgrowth of endocervical columnar epithelium [benign, solitary, may be linked to oestrogen]

  • > Ix: speculum
  • > Mx: reassurance, removal and send to histology

Endometrial polyp: overgrowth of endometrial tissue

  • > Ix: TVUSS; outpatient hysterectomy and saline infusion sonography are most accurate
  • > Mx: may resolve spontaneously if small; polypectomy to alleviate symptoms/exclude EH or cancer
59
Q

What is miscarriage defined as and what is early vs late? What would be the term after the stated time period?

A

Spontaneous loss of a pregnancy before 24w

Early = <12w
Late = 12-24w

After 24, the loss/PV bleeding is an APH

60
Q

How common are miscarriages? What are the main causes?

A

Affects up to 25% (1/4) pregnancies so v common

Causes:

  • > Usually 1st trimester miscarriages are due to chromosomal abnormalities
  • > Medical/endocrine disorders e.g. APS, thrombophillia
  • > Uterine abnormalities (bicornuate or septate)
  • > Causes of late miscarriages may include cervical incompetence (e.g. post-LLETZ or cone biopsy)
  • > Infections
  • > Drugs
  • > Increasing risk with age
61
Q

What are the 5 types of miscarriages? When is the term ‘recurrent miscarriage’ used?

A
  1. Complete
    - PV bleeding
    - Cervical os = closed
    - Expelled all products of conception
  2. Incomplete
    - PV bleeding and cramping
    - Cervical os = dilated
    - Some products expelled
  3. Threatened
    - PV bleeding
    - FHR activity
    - Cervical os = closed but soft
  4. Inevitable
    - PV bleeding and cramping
    - ROM
    - Cervical os = dilated
    - May feel some products of conception in cervix
  5. Missed
    - No vaginal bleeding
    - No FHR on USS or empty sac
    - Cervical os = closed

[6] - Recurrent
= 3 or more consecutive spontaneous miscarriages occurring in the 1st trimester with the same biological father, which may/may not follow a successful birth
-> no cause found in 50%; prognosis for future successful pregnancy is 60% after 3 miscarriages

62
Q

How would a women with a miscarriage present?

A

Sx:

  • > PV bleeding
  • > Crampy abdominal pain, fever
  • > O/E Speculum - active bleeding, os open or closed or see any products
  • > Assess if any signs of shock
63
Q

How would you Ix suspected miscarriage?

A

Ix:

  • Pregnancy test
  • Speculum - Os, bleeding
  • Bloods - FBC, G&S, Rhesus status
  • TVUSS - look for FH –> CRL (>7mm) –> MSD (>25mm)

Usually, you require a second sonographer opinion but otherwise rescan in 1/2w if unsure

64
Q

What is a PUV?

A

Pregnancy of unknown viability

  • > A definite intrauterine gestation sac without evidence of a viable foetus when:
  • > CRL <7mm and no FH
  • > MSD <25mm in an empty sac
    i. e. we know where the pregnancy is but not if it will continue
65
Q

What Ix (+Mx) would you consider in someone with recurrent miscarriages?

A

Ix:

  • > Pelvic USS for structural abnormalities
  • > APS antibodies, (anticardiolipin antibodies)
  • > Cytogenetic analysis of products of conception
  • > Peripheral blood karyotyping of both parents

Tx

  • > APS = Aspirin/LMWH (Warfarin is used in non-pregnant individuals)
  • > Surgical Tx of uterine abnormalities
  • > Gamete donation/PGD for chromosomal translocation

However, cause is often never found

66
Q

What are the 3 forms of management for miscarriage?

A

Mx:
Note: G-ER or EPAU referral if >6w pregnant
+ ensure to rule out ectopic

  1. Expectant
    - -> Highly effective in women with an incomplete miscarriage, however may be less effective if sac is intact
    - > Wait 7-14d to await the events
    - > Repeat pregnancy test in 3w to see if it is passed; return if positive
    - > Repeat USS after 2w to ensure complete miscarriage
    - > Safety net (pain is like severe period pain, can take ibuprofen/para to help but if really bad, come back in, also if heavy bleeding i.e. >3 heavy sanitary pads soaked within 1h OR passing a clot larger than your hand)
  2. Medical
    - > 800mcg Misoprostol PV for missed mc
    - > 600mcg Misoprostol PV for incomplete mc
    - > Started within 24h
    - > Accompany with analgesia
    - > Counsel women on what to expect + safety net
    - > Pregnancy test after 3w
  3. Surgical
    -> Surgical management of miscarriage (SMM) which is performed under GA and involves suction an curettage, sent for histology
    OR
    -> Manual vacuum aspiration (MVA) done under LA in OP setting

++++ ANTI-D for Rh- women (as if <12w and have had uterine evacuation either medically or surgically or ectopic pregnancies)
-> Given within first 72h following surgery

++++ Psychological support

  • > Counsel about options
  • > Miscarriage association website and support groups
  • > Safety netting is key
67
Q

What safety netting advice is important to women being managed for miscarriages?

A
  • > If pain becomes more severe, uncontrolled with ibuprofen/paracetamol
  • > If experiencing heavy bleeding i.e. >3 heavy sanitary pads soaked within 1h OR passing a clot larger than your hand then seek medical help immediately
  • > Regardless
68
Q

What are the important strains of HPV to remember? How is it transmitted? RFs for HPV?

A

HPV 6 + 11 –> benign genital warts

HPV 16 + 18 –> CIN, VIN, cancer risks

Transmission is by physical or sexual contact, occasionally vertical

RFs = unprotected sexual intercourse, immunosuppression, multiple sexual partners, no barrier contraception

69
Q

How common is HPV? How does it present?

A

50% of sexually active adults have HPV

Sx:

  • Asymptomatic
  • Genital warts on vulva, vagina, cervix and anus (painless, may itch/bleed)
  • Pink/red/brown warty papules
  • Four types
  • -> Small popular
  • -> Cauliflower
  • -> Keratotic
  • -> Flat papule/plaques
70
Q

How would you Dx and treat HPV warts?

A

Dx

  • > Clinical Dx for warts (dermatoscope)
  • > Histology (biopsy) and cytology (smear)

Tx
Medical:
-> Imiquimod cream
*But CI in pregnancy

Surgical

  • > Electrocautery (/Plasmajet)
  • > Cryotherapy, laser

Prevention = HPV vaccine @ 12-13yo (Gardasil = 4 strains)

71
Q

What is Lichen Sclerosus? Who does it affect and what are some RFs?

A

Chronic inflammatory skin condition, usually affecting the vulva and perineum

  • > Those <10yo and >60yo
  • > Associated with autoimmunity and genetics
72
Q

How does lichen sclerosus present?

A

Sx:

  • Itching and discomfort, worse at night
  • Dyspareunia
  • Fragile, thin skin or thickened (+ blister formation)
  • O/E = white patches on the skin, may become cracked and sore
73
Q

How is lichen sclerosus treated? What is a complication of LS?

A

Tx:

  • > Steroid ointment cream Betamethasone/Dermovate (Clobetasol propionate 0.05%), 2nd line = tacrolimus (topical calcineurin inhibitor) and biopsy
  • > Also emollient use advised along with steroids and for maintenance + as soap sub
  • > F/u every 3-6m by dermatologist/experienced gynaecologist
  • > Cannot be completely cured but effectively managed

Risk of vulval cancer (SCC) - 1/20, therefore patients may undergo vulval mapping to monitor progression

74
Q

What is Lichen Planus?

A

Not strictly a gynaecological condition, but another skin condition where there are clusters of shiny, red-purple blotches which are sore, with white lines (Wickham’s striae) on the surface

  • > Dx is clinical
  • > Tx is same as LS; steroid ointment or tacrolimus
75
Q

What is mastitis? How common is it? What is the most common cause and what are 2 RF’s/associations?

A

Infection of the breast - usually caused S. aureus

  • > Affects 1/10 breastfeeding women due to backlog of milk within ducts
  • > Associated with nipple injury and smoking
76
Q

How may women present and be Dx with mastitis?

A

Sx:

  • Nipple discharge (white/bloody streaks)
  • Red, tender breast with possible abscess (burning pain)
  • Fever
  • Coryzal symptoms - aches, chills

Diagnosis = clinical

77
Q

How would you manage mastitis?

A

Mx:
-> Consider admission if signs of sepsis/HC, rapid progression or immunocompromised

Non-severe –> simple analgesia, supportive care (warm compress, massage breast), continue breastfeeding; if not improving after 24h (NHS) then see GP for Abx

Severe or non-lactational –>

  • > Infected nipple fissure, S/S not improved after 12-24h, milk culture positive
  • > Flucloxacillin 500mg QDS PO; if doesn’t improve after 48h with Abx then use Co-amoxiclav
  • > MRSA - use Trimethoprim
  • > Abscess is diagnosed with USS which is then incised and drained, and fluid is cultured
78
Q

What is PMS and who does it affect?

A

Pre-menstrual syndrome

  • Distressing symptoms occurring in the luteal phase of the menstrual cycle (in the absence of pathology)
  • Affects up to 90% women
  • RF’s = smoking, obesity, lack of exercise, FHx
79
Q

How may women present with PMS? How are women diagnosed?

A

Sx:

  • Mood swings
  • Poor concentration, anxiety
  • Lack of energy
  • Breast tenderness
  • Disturbed sleep
  • Bloating
  • Headache

Dx = requires a symptom diary over 2 cycles

80
Q

How would you manage PMS? [Conservative vs moderate vs severe]

A

Mx:
-> All patients receive conservative advice such as painkillers, stress reduction, smoking cessation and alcohol reduction, sleep hygiene and regular exercise

Moderate PMS - some impact on person, social and professional life

  • -> COCP - cyclical or continuous
  • -> +/- CBT Referral
  • -> + Paracetamol/NSAIDs

Severe PMS [Premenstrual dysphoric disorder] - withdrawal from social and professional activities, affects normal functioning

  • -> SSRI - trial for 3m
  • -> +/- CBT Referral
  • -> Alternatives include GnRH analogues, transdermal oestrogen and surgery
81
Q

What is TSS? What are some RF’s?

A

Toxic Shock Syndrome
-> Septicaemia from toxin TSST1 produced by Staph [and Strep bacteria - inflammatory cascade]

Caused by multi system inflammatory response to bacterial exotoxins
-> Tampons are a risk factor, overuse without changing BUT it is rare [40 per year; 17/100,000 users]

82
Q

How may patients with TSS present?

A

Sx:

  • > Fever, up to 39+
  • > D+V
  • > Diffuse red macular rash
  • > Shock, collapse
  • > Desquamation of palms and soles
  • > Myalgia, sore throat, headache
83
Q

How would you Ix and manage TSS? What is the prognosis and complications?

A

A to E approach

  • > Bloods - FBC (low plt, high WCC), U&Es, LFTs, CRP, CK
  • > Blood cultures
  • > HVS, culture of tampon

Mx:

  • > ABC + remove tampon
  • > BS antibiotics IV

5-15% mortality
-> Complications include septic shock, DIC, ARDs and death

84
Q

What is pruritus vulvae? How does it present (hint: based on causes)

A

Pruritus vulvae - itchy vulva, which may be caused by a variety of things:

  • > Infection e.g. vulvovaginal candidiasis
  • > Atrophic vaginitis - 10-40% menopausal women
  • > Eczema
  • > Contact dermatitis
Presents:
VC = itching, burning, erythema and oedema of the vestibule and labia + thick, white curd-like discharge [if chronic, then may have lichenification and grey sheen of epithelial cells also]
AV = soreness, thin skin, itching, dyspareunia
Vulvar vestibulitis = may cause introital dyspareunia (on contact or after sex), soreness, burning
85
Q

What Ix would you consider in a women with pruritus vulvae?

A

Ix:
-> Vulvovaginal candidiasis = wet-mount test or KOH preparation

-> Atrophic vaginitis = vaginal pH and wet-mount test

Wet-mount is a sample of discharge which is observed for causes of vaginitis

86
Q

How would you manage pruritus vulvae?

A

Mx - depends on cause:

  • > VC = antifungals e.g. ketoconazole/ fluconazole, clotrimazole suppositories
  • > AV = topical oestrogen/HRT, lubricants
  • > Contact dermatitis = remove agent, 1% hydrocortisone cream or bethametasone if moderate
87
Q

What is sub fertility defined as? How common is it?

A

A woman of reproductive age who has not conceived after 1y of regular, unprotected sexual intercourse
-> Affects 1 in 6 couples, commoner with increased maternal age

85% of couples will conceive after 1y of unprotected sex (15% will not)

88
Q

When may patients be referred and investigated for infertility?

A

If couple has tried to conceive for ~12m without success

-> This can be reduced to 6m if woman is 35+

89
Q

What are the causes of sub/infertility and which are most common?

A

Women (uterine, tubal or ovulation) = ~50% (10, 15 + 25%)
Male, sperm problems = 30%
Unexplained = 20%

BUT ~40% of infertile couples have mix of female and male causes

Female causes:

  • > Ovarian = Hypothalamic amenorrhoea, PCOS, POI, primary hypothyroidism, prolactinoma
  • > Tubal = PID, adhesions, endometriosis
  • > Uterine = abnormalities, fibroids
  • > Genetic = chromosomal abnormalities e.g. Turners
  • > Lifestyle = smoking, method of sex

Male causes:

  • > Structural = VARICOCELE, cryptorchidism, CF and absence of vas deferens
  • > Hypothalamic
  • > Function = ED
  • > Lifestyle = smoking, BMI>30, EtOH
  • > Genetic = Klinefelter, Kallman’s
90
Q

What are some Ix to investigate sub fertility
i) mainly in primary care
ii) secondary care?
What would be some suggestive results/interpret them?

A

Ix:

  • > BMI (if low or high)
  • > Chlamydia screening for both
  • > Semen analysis (x2, 3m apart)
  • > Female hormone testing
  • > Rubella immunity in mother

Female hormone testing:

  • Serum LH and FSH on day 2-5 of cycle
  • Serum progesterone on day 21 [if 28d cycle] OR 7 days before next period
  • Anti-Mullerian hormone (produced by granulosa cells so isn’t altered by hormones)
  • TFTs, if suggestive Sx
  • Prolactin, if Sx of galactorrhea or amenorrhoea

Other tests [often in secondary care]

  • > USS
  • > Hysterosalpingogram - used to assess the shape of the uterus and potency of fallopian tubes
  • > Laparoscopy and dye test - observe any tubal obstruction + treat endometriosis/adhesions

Results:

  • -> High FSH = POI, poor ovarian reserve [pituitary producing more FSH to stimulate follicular development]
  • -> High LH = may be PCOS (esp raised LH:FSH)
  • -> Raised progesterone on day 21 indicates ovulation has occurred, the corpus lutetum has formed and has started secreting progesterone
  • -> AMH is an accurate measure of ovarian reserve so high level indicates good reserve
91
Q

How would you generally manage sub-fertility before 1y/general advice?

A

Mx advice:

  • > Generally wait for 12m (6m if 35+) before investigating as its quite common
  • > Difficulty is common, affects 1/6 for 1y
  • > Aim for healthy BMI (20-25)
  • > Avoid smoking and drinking excessive alcohol
  • > Reduce stress as may negatively affect libido and relationship - also avoid timing sex as this can place strain also and it isn’t necessary to time with ovulation anyway
  • > Aim for intercourse very 2-3d (let sperm count recover)
  • > Woman should be taking 400mcg folic acid daily
92
Q

How would you manage sub fertility?

A

Mx depends on the cause:

Ovulation issues

  • -> Weight loss i.e. PCOS
  • -> Clomifene, anti-oestrogen SERM, to stimulate ovulation (+/- metformin) - given on days 2-6 of the cycle
  • -> Letrozole may be used instead of clomiphene (aromatase inhibitor with anti-oestrogen effects)
  • > Other: gonadotrophins, ovarian drilling

Other:

  • > Tubal cannulation during a hysterosalpingogram
  • > Surgical options for tubal or uterine abnormalities
  • > IVF

Sperm:

  • -> Surgical sperm removal if due to blockage/surgical correction of obstruction
  • > Sperm motility issues/DM/ED/oligospermia = intracytoplasmic sperm injection (ICSI) - most common Tx for male infertility
  • -> Intra-uterine insemination (unclear if better than intercourse however)
  • > Donor insemination if male infertility (azoospermia)
93
Q

What is OHSS?

A

Ovarian hyperstimulation syndrome

  • > Ovaries become hyper stimulated e.g. w gonadotrophins or IVF
  • > Ovarian enlargement, increased vascular permeability, pro-thrombotic state
  • > Presents with abdominal pain, distension, N+V, SOB, oedema/ascites
  • > Mx is supportive, VTE prophylaxis and fluid replacement

O&G (7 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions