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Gynaecology Flashcards

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1
Q

What is fragile X syndrome

A

fragile area on the FMR1 gene on the X chromosome

causes a problem with brain development

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2
Q

What is being tested in the 3 gene prenatal screening panel

A

cystic fibrosis
spinal muscular atrophy
fragile x syndrome

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3
Q

Pros and cons of adding in pre conception screening to pre conception care

A

pros: easy to assess risk prenatally, potentially avoid children suffering

Cons: difficult for parents to understand, extra time for counselling, can’t change genetics, may get results after becoming pregnant, expensive

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4
Q

What is cystic fibrosis

A

mutation in CFTR gene

autosomal recessive

affects secretions in lungs and GIT

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5
Q

What is spinal muscular atrophy

  • recessive or dominant
  • lower or upper motor neurone
  • what part of the spinal cord
A

autosomal recessive

lower motor neurone disease

affects cells in the anterior horn of the spinal cord creating atrophy in skeletal muscles, including those for breathing

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6
Q

Vaccinations recommended for pregnant women (prior to pregnancy)

A

MMRV
DTPa
Hep B

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7
Q

When should folic acid be taken in terms of pregnancy and what dose

A

1 month prior to conception
first 3 months of pregnancy
0.4mg daily

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8
Q

What is the nuchal translucency scan and what information does it provide

A

nuchal area of baby from 11 - 13 weeks +6 days there is fluid caught between developing skin

the thicker this fluid measurement is, the greater chance of a problem i.e. problem with placentation, anatomy, heart, GIT

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9
Q

Boundaries of the pelvic inlet

A

anterior - superior surface of pubic bones

poster - superior sacrum

Lateral - arcuate line of inner surface of the ilium

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10
Q

Boundaries of the pelvic outlet

A

anterior - pubic symphysis

posterior - tip of coccyx

lateral - ischial tuberosity

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11
Q

Layers of the urogenital triangle (anterior perineum)

A
  1. skin
  2. perineal fascia
  3. superior perineal pouch
  4. perineal membrane
  5. deep perineal pouch

simplified:

  • urogenital triangle muscles
  • urogenital diaphragm / triangular ligament
  • levator ani
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12
Q

Contents of the anal triangle (posterior perineum)

A

anus, external anal sphincter, ischioanal fossa

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13
Q

Levator ani muscles

A

puborectalis
pubococcygeus
iliococcygeus

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14
Q

Superficial perineal muscles

A

bulbospongiosus
superficial transverse perineal muscle
ischiocavernosus

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15
Q

Blood supply for perineum, vagina, uterus and ovaries

A

perineum - internal pudendal off internal iliac
vagina - vaginal a off internal iliac
uterus - uterine off internal iliac
fallopian tubes - ovarian and uterine arteries
ovaries - ovarian off abdominal aorta

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16
Q

Nerve supply to perineum, posterior vulva and anterior vulva

A

perineum - pudendal nerve (S2-4)

anterior vulva - ilioinguinal and genitofemoral

posterior vulva - pudendal

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17
Q

Location of Bartholin’s and Skene’s glands

A

Skene’s - periurethral

Bartholin’s - either side of vaginal opening

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18
Q

Ligaments supporting the uterus and their location

A

Round - anterior uterus, through inguinal canal to labia majora
Uterosacral - posterior inferior uterus to sacral fascia
Cardinal - lateral cervix and vagina to lateral pelvic walls
Broad - reflected folds of peritoneum from lateral uterus to lateral pelvic wall

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19
Q

Contents of the broad ligament

A 
fallopian tube
round ligaments 
ovarian ligaments 
nerves 
BV
lymphatics
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20
Q

Ligaments of the ovary

A

suspensory - attaches to lateral pelvic wall, contains ovarian artery and vein, ovarian nerve plexus, lymphatics

ovarian ligament - connects to body of uterus

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21
Q

Location ovarian veins drain into

A

L ovarian vein –> L renal vein

R ovarian vein –> IVC

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22
Q

Describe hormonal control of ovulation

A
  • Increased pulsatile secretion of GnRH
  • GnRH –> increased FSH and LH
  • LH –> theca cells –> androgens
  • FSH –> granulose cells –> androgens to oestrogen, inhibin
  • increased oestrogen –> FSH and LH surge
  • oestrogen + inhibin –> less FSH
  • less FSH –> dominant follicle with most FSH receptors survives
  • LH causes follicle rupture (ovulation)
  • corpus luteum is formed –> progesterone
  • LH and oestrogen decreases
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23
Q

4 stages of endometrial cycle

A

Regenerative phase

  • during menstruation –> 2-3 days after
  • 2mm
  • cuboid epithelium, neovascularisation, glands regenerate

Proliferative

  • oestrogen builds endometrium
  • 3-4mm
  • columnar epithelium, BV spiral, tubular glands

Secretory
- progesterone stimulated
6-8mm
- ciliated columnar epithelium, increased gland size, BV markedly spiral

Menstrual

  • less progesterone
  • degeneration and sloughing
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24
Q

Stages of cervical cycle

A

Follicular - internal os open, thin and watery mucus, increased elasticity, glycoproteins facilitate sperm penetration

Luteal - internal os tightly closed, mucus thick and viscous, decreased elasticity, glycoproteins prevent sperm penetration

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25
Points to mention to patient post CST
After effects: spotting up to 48 hours, any discharge or heavy flow need to return CST F/U: 7-10 days arrange a follow up to discuss results Register: results automatically go to a database Repeat: every 5 years from 25 Refer colposcopy: symptomatic or abnormal findings
26
Ddx AUB
PALM - structural Polyps, adenomyosis, leiomyosis, malignancy COINE - non structural Coagulopathy, ovulatory dysfunction, iatrogenic, not yet classified, endometrial (endometriosis, hyperplasia)
27
Causes of 1st and 2nd trimester bleeding
``` Implantation of placenta Ectopic Spontaneous abortion Molar Genital lesion (fibroid, polyp, cancer) ```
28
Gynae ddx for acute pelvic pain
Adnexal: ectopic, torsion, ruptured ovarian cyst Uterine: PID, torsion of pedunculate fibroid Pregnancy related: ectopic, labour, spontaneous abortion, placental abruption
29
Gynae ddx for chronic pelvic pain
``` primary dysmenorrhoea endometriosis and adenomyosis ovarian neoplasms fibroid chronic PID uterine prolapse ovarian remnant syndrome ```
30
Vulval pruritus ddx
infectious: candidiasis, BV dermatological: dermatitis, psoriasis, lichen sclerosis, lichen planus neoplastic: skin cancer inflammatory: irritants, atrophic vaginitis
31
Ddx for superficial and deep dyspareunia
superficial: inadequate lubrication, STI, lichen sclerosis, bartholin gland abscess deep: endometriosis and adenomyosis, PID, tubo-ovarian abscesses, ovarian cyst, fibroids and polyps
32
Diagnostic criteria for PCOS
2/3 of oligo/anovulation - >35 day cycles or short cycle <21 days hyperandrogenism - biochemical (increased free testosterone, FAI, DHES) OR clinical (acne, hirsutism, virilisation) polycystic ovaries on USS (>12 each side)
33
Complications of PCOS
``` infertility T2DM CVD endometrial hyperplasia and cancer miscarriage GDM anxiety and depression ```
34
Ddx PCOS
``` cushing's syndrome hyper or hypothyroid hyperprolactinaemia congenital adrenal hyperplasia androgen secreting tumours pituitary adenomas and adrenal tumours ```
35
Infertility definition
inability to conceive after frequent unprotected intercourse over a 12 month period and less than 35yo or 6 months if 35+ primary - never been pregnant secondary - been pregnant before, regardless of outcome
36
Female causes of infertility
Age Pre-ovarian failure: - hypothalamus - anorexia, Kallman syndrome, tumour, surgery - pituitary - adenoma, Sheehan's - high prolactin - systemic - thyroid, cushing's, CKD, liver failure Ovarian: - PCOS - POI Post ovarian: - tubal obstruction - PID, adhesions, ligation - uterine - endometriosis, adenomyosis, fibroids, congenital abnormalities, Asherman's - cervix - cervicitis, thick or acidic mucus, stenosis
37
Ddx for primary amenorrhoea
no sexual characteristics: - high FSH and LH --> USS gonads --> streak gonads (Turner's, Fragile X) - low FSH and LH --> MRI brain --> hypothalamic and pituitary causes sexual characteristics: - bHCG, TSH, USS uterus (mullarian abnormality)
38
Ddx for secondary amenorrhoea
Test: bHCG, TSH, PRL - pregnant - hypothyroid - prolactinoma, adenoma, apoplexy, Sheehan's All negative --> FSH, LH, oestrogen high FSH and LH --> ovarian USS (POI, menopause, resistant ovaries, ?PCOS) low FSH and LH --> MRI, test HPO axis hormones (physiological stress, Cushing's, increased exercise, decreased caloric intake) All normal --> uterine issue (IUD, ablation, hysterectomy, pregnant, Asherman's)
39
Colposcopy - types of staining and what each colour change means
Acetic acid - white = abnormal - more nuclear activity = whiter note: normal ectropion (simple columnar) stains white Iodine - dark brown = normal - stains glycogen rich tissue dark brown (normal mature squamous epithelium) - columnar, immature squamous epithelium and dysplastic tissue do not stain
40
Two main treatment options for CIN2 and 3
Large loop excision of the transformation zone (LLETZ) - loop electrosurgical excision procedure (LEEP) Cone biopsy - larger chunk of the tissue using a scalpel
41
Indications for colposcopy
HPV 16 or 18 HSIL LSIL <30yo & still present at 12 month re-test OR >30yo with no history of negative test in past 2 years Typical cervical cancer sx (AUB, discharge, dyspareunia)
42
LSIL vs HSIL
LSIL - upper 1/3 of epithelium is dysplastic, most spontaneously clear HSIL (CIN II or III) - majority or full thickness of epithelium is dysplastic, needs treatment
43
HSIL and affect on fertility / pregnancy
Need treatment prior to becoming pregnant LLETZ and ablation - slightly increased risk of miscarriage and PTL in future Cone biopsy - higher risk due to cervical incompetency or stenosis
44
Stages of cervical cancer
``` 0 - CIN 1 - limited to cervix 2 - upper 1/3 of vagina involved 3 - pelvic wall or lower 1/3 of vagina 4 - beyond pelvis (bladder, rectum, distant) ```
45
Management of cervical cancer
1A - cervical excision for women wanting to preserve fertility Beyond 1A - radical hysterectomy with resection of pelvic LN, ovaries can be preserved
46
Causes of cervical ectropion
normal response to high oestrogen - OCP, pregnancy, adolescence early cervical cancer
47
Male causes of infertility
Congenital - Kallman, Klinefelter, CF, Kartagener's Pre testicular: - hypothalamus - Kallmann - pituitary - tumours, hyperprolactinaemia (prolactinoma, antiDA drugs) Testicular: - teratospermia, asthenospermia, oligospermia, azoospermia - varicocele - cryptorchidism - past torsion, epididymo-orchitis, trauma - tumour Post testicular: - congenital - absence of vas deferent, CF, kartagener's - post surgery - vasectomy, retrograde ejaculation
48
Types of molar pregnancies
complete: no foetal parts, benign and non invasive, diploid, no female genetic material, 46XX partial: +/- foetal parts, triploid, 69XXY invasive/persistent: malignant, locally destructive, +/- haemorrhage choriocarcinoma: malignant
49
Level 1 prolapse - organ and support failure
uterus and cervix, vault uterosacral ligament and cardinal ligament
50
Level 2 prolapse - organ and support failure
bladder and rectum arcus tendineous fasciae pelvis (ATFP) arcus tendinous rectovaginalis levator ani fascia
51
Level 3 prolapse - organ and support failure
urethra and anus pubourethral ligaments, perineal body, urogenital diaphragm
52
Grading of pelvic organ prolapse
0 - no descent during straining 1 - distal portion of prolapse >1cm above hymen 2 - <1cm above hymen 3 - >1cm below hymen 4 - complete eversion of total length of genital tract
53
Medical management of ectopic, miscarriage and abortion
ectopic - methotrexate (inhibit DNA synthesis) miscarriage - misoprostol (vaginal) medical termination of pregnancy (MToP) - mifepristone (anti progesterone) then misoprostol (myometrial contractions and cervical ripening) 36-48hrs later
54
5 types of miscarriage
Threatened - bleeding, +/- pain, closed cervical os, viable IUP on USS Incomplete/inevitable - bleeding, pain, open cervical os, products have passed through but not all, USS shows foetal parts Complete - bleeding and pain subsided, USS shows no products of conception Septic - pain, bleeding (+/- purulent), fever, malaise, needs surgical evacuation Missed - no symptoms, picked up on routine USS
55
Criteria for non viable IUP aka USS findings of a missed miscarriage
MSD >/=25mm but no foetal pole or yolk sac CRL >/=7mm but no foetal heart beat Gestational sac present but 2 weeks later there is no yolk sac or heart beat Yolk sac and heart beat present but 11 days later there is no heart beat
56
Benefits and limitations of female vs male sterilisation
Both: don't need to worry about contraception, but difficult to reverse Female Benefits - easier to reverse than male Risks - permanent, ectopic, higher failure rate Male Benefits - lower failure rate, more simple, less risks associated (LA not GA) Risks - difficult to reverse, contraception required a few weeks post surgery until ejaculate shows no sperm
57
Risk factors for endometrial cancer
Unopposed oestrogen - late menopause, early menarche - nulliparous - HRT - tamoxifen lifestyles - obesity, DM, PCOS Fam Hx
58
Post menopausal bleeding work up
Labs - routine bloods and coagulation TVUS - post menopausal >/=5mm is abnormal Endometrial sampling - pipelle biopsy or diagnostic hysteroscopy with biopsy
59
Clinical features of ovarian mass - when they are symptomatic - complications
asymptomatic until large (>10cm) or complication mass effect - distension, bloating, nausea, constipation complications - cyst rupture, adnexal torsion, haemorrhage
60
Ddx pelvic mass
6Fs - fat, foetus, fluid, faeces, flatus, filthy big tumour uterine - pregnancy, fibroids, adenomyosis ovarian - cyst, neoplasm bowel - constipation, tumour bladder - retention, tumour fallopian - PID causing pyosalpinx
61
Workup for ovarian mass
Bloods - FBC, UEC, CA125, bHCG | Imaging - TVUS and abdominal USS
62
When to excise ovarian cyst
``` suspicious on USS >7cm symptomatic complex cyst risk of malignancy index (RMI) >25 ```

RNH (9 decks)

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