Gynaecology Flashcards by Fiona Chatterton

Follicular phase = FSH stimulates follicular development
Oestrogen and inhibin produced by dominant follicle inhibits FSH production
Due to declining FSH levels, only the dominant follicle survives

LH surge occurs 36 hours before ovulation
Dominant follicle ruptures, releasing oocyte

In the luteal phase the corpus luteum is formed and progesterone is released
Luteolysis occurs 14 days post-ovulation

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What is metrorrhagia?

Regular IMB

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Duration of a normal menstrual cycle

21 - 35 days

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What is oligomenorrhoea?

Menses at duration >35 days

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What is adenomyosis?

A cause of painful/ heavy periods
It is similar to endometriosis but the endometrium breaks through the normal myometrium

An important cause of chronic pelvic pain

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List some causes of menorrgahia?

Local:

fibroids
polyps (endometrial )
endometriosis
adenomyosis
endometrial hyperplasia
PID

Systemic;

DM
Thyroid
Clotting disorder e.g. VWD

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Dysfunctional uterine bleeding is a diagnosis of exclusion. It is more common in obese women and at the extremes of reproductive age. What investigations should be done prior to this diagnosis?

FBC
smear
Clotting
TFT
TVUS
Endometrial biopsy

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Define menorrhagia?

Menstrual loss >80ml/ cycle

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1st line for a lady wanting contraception who has menorrhagia?

Mirena

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What is androgen insensitivity syndrome?

Also call testicular feminisation
X-linked recessive - patients have male karyoptype (46XY)

Testes develop but do not descend - androgen response does not occur so patients have undescended testes with female genitalia
Presents at puberty with amenorrhoea and lack of pubic hair

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An adult is found to have an undescended testes. What should be considered?

Orchidopexy = cancer risk is x6

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What secretes testosterone?

Leydig cells

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What do Sertoli cells do?

Loads of actions:

blood-testes barrier
provide nutrients
phagocytosis
release androgen binding globulin
secrete seminiferous tubule fluid

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LH acts on Leydig cells to regulate testosterone secretion

FSH acts on Sertoli cells to enhance spermatogenesis

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Don’t forget to ask about steroid abuse in male patients with infertility

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What is the normal scrotal volume?

12-25ml

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In male ?infertility what examinations would you perform?

1) Look for secondary sexual characteristics e.g. body hair, gynaecomastia
2) Scrotal and penile exam e.g. vas deferense, urethral orifice

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What investigations would you like to do for ?male infertility

1) Bloods: LH, FSH, TSH, PRL, testosterone
2) Chromosomal analysis
3) semen analysis - 6 weeks apart
4) ? Biopsy/ US

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What are the endocrine features of Klinefelters?

Low testosterone

High LH and FSH

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In a standard 28 day cycle - which are the most fertile days?

Days 8 to 18

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Lactational amenorrhoea is 98% effective. What are the 3 criteria?

1) Exclusive breastfeeding
2) Less the 6/12 post-natal
3) Amenorrhoea

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What is the mode of action of combined hormonal contraception?

1) Mainly inhibits ovulation

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What is the mode of action of the POP?

Primarily inhibits ovulation

E.g. desogestrel

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What is the mode of action of the implant?

Primary inhibits ovulation

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What is the mode of action of the depo provera?

Primarily inhibit ovulation for 14 weeks (given every 12)

What is the mode of action of the mirena?

It effects implantation by making the endometrium unfavourable (failure rate is 1 in 500)

What is the mode of action of the IUD?

Prevents fertilisation due to inflammatory response

BP and BMI measures before giving depo, CHC or POP

Do a PV to check uterine position/ size before IUD

Don’t forget to ask about FH of breast cancer if you are prescribing the pill

If yes, enquire about BRACA gene - this may make it too high risk

Which cancers does the pil protect against?

1) Protect = ovarian and endometrial | 2) Increase risk = cervical and breast

What is the main risk factor of the depo provera?

Low bone mineral density e.g. smoking, very low BMI etc

Give some absolute CI to using the COC?

- Smoking >15/day if >35 - migraine with aura - personal history of VTE - BP > 160/95 etc

When does the pill become effective

1) Day 1-5 of cycle/ day of TOP = immediately | 2) After day 5 = condoms for 1 week

What are missed pills rules/

1) 2 or more pills missed = take next pill and use condoms for 7 days 2) 2 pills of 1st 7 days missed = emergency contraception

POP missed pills rule

If 1 or more pill missed or late (>12 hours if cerazette) then need emergency contraception if UPSI has occurred in 2 days after this

If someone is anxious about having an STI screen done. What could you say to reassure them about the confidentiality?

GP does not have to be told | Samples are given a number not a name

What STIs are partner notification not required?

BV Thrush Herpes Warts

Which vaccines are given to protect people against STIs?

Hep B | HPV

A MSM is at risk of contracting HIV after UPSI with a high risk partner. What can you tell him about PEPSE?

1) has to be taken within 72 hours 2) 28 days total 3) reduces risk of hIV by 80% Could also consider the Hep B vaccine, must be given within 72 hours

What are the 2 situations in which an emergency abortion can be performed?

1) Save the life of the women | 2) Prevent grave permanent harm to the physical or mental health of the women

Remember conscientious objection is not allowed if it is an emergency

Would have to abort if it was to save ladies life

In GP, patient wants a TOP. What actions do you take?

Refer to TOP clinic Nurse led Chat, scan and options Blood taken - FBC, G+S ? STI screen

What are the time cut offs for TOP in Tayside?

``` Surgical = up to 12 weeks Medical = up to 18 weeks, 6 days ``` (Elsewhere it is 24 weeks max and any if fetal abnormal)

An early medical abortion is at <9 weeks. How is it done?

1) Oral mifepristone 200mg (anti-progesterone) 2) vaginal or oral misoprostol (prostaglandin) - can be taken at home For later abortions, multiple doses of misoprostol will be needed

Surgical TOP is Scotland?

Vacuum aspiration from 6-12 weeks Done under GA as day case Vaginal prostaglandin used to ‘prime’ LARC fitted

Levonorgestrel and ulipristal acetate are emergency contraeption. How do they work?

Delay ovulation

Ulipristal acetate is more effective and can be taken up to 120 hours after UPSI. What is a major CI?

Severe asthma controlled by steroids

IUD is best EC as has pre- and post- implantation effects e.g. toxic to ovum

All women must be screened (+ treated) prior to insertion

When does an embryo implant?

Dat 8-10 post fertilisation

What is the incubation period for common STI?

Chlamydia/ Gonorrhoea = up to 1 weeks Hep B = 6 weeks HIV/ Hep C = up to 3 months

HIV targets CD4 cells. What is the normal level? What puts patients at risk of opportunistic infection?

Normal = 500-1600 cells/mm At risk = <200

What is the treatment for PCP?

High dose co-trimoxazole

Remember is anyone has HIV think - do they have TB too?

CMV presents in HIV with reduced visual acuity and floaters What CD4 level puts people at risk?

CD4 <50 Opthalmoplegia screening is offered to all patients with this CD4 level

Kaposi sarcoma is a vascular tumour seen in HIV. What causes it?

Human herpes virus 8 | EBV will also predispose to Burkitt’s lymphoma

What is the risk of mother to child transmission if viral load is undetectable?

<0.1%

Wha examination and investigations are done at the booking scan?

``` Height and weight BP, CVS and abdo exam US FBC - Hb, ABP, rhesus HIV, HBV, HCV, syphillus US Urinalysis - MSSU, C&S ```

What investigations/ examinations do you do in ALL pregnant women at every visit?

``` BP Urinalysis Symphysis-fundal heigh Lie Auscultation for heart ``` Ask about mood and anxiety

When you do an ultrasound at the booking scan - what are you looking for?

Intravascular-uterine pregnancy Obvious anomalies Placental site

When is the nuchal thickness measured?

Between 11 and 13+6 weeks (e.g. in the first trimester) Combined with HCG and PAPP-A (pregnancy associated plasma protein A) and maternal age

In the 2nd trimester, a blood sample can be taken at 15-20 weeks which measures HCG and AFP. UE3 and inhibin A What is the cut off for ‘high risk’ downs and therefore requires further investigation?

> 1 in 250

When is CVS performed?

After 12 weeks | Miscarriage rate = 2%

When is amniocentesis performed?

After 15 weeks | Miscarriage rate = 1%

What are the 2 main haematological disorders to be aware of in pregnancy?

Sickle cell Thalassaemia 60% of all women are anaemia in pregnancy

RF for gestational DM?

``` BMI >30 Previous macrosomic baby (>4.5 kg) Previous GDM FH of DM (1st degree) High risk ethnicity ```

Where should the bump be at what stage?

Pubic symphysis = 12 weeks Umbilicus = 20 weeks Xiphoid pricess = 36 weeks

If SFH measurement is <10th centile or growth is static/ slowing then...

Refer for US do fetal size

RF for ‘high risk’ pre-eclampsia

Chronic HT or previous gestational HT CKD Lupus or similar Type 1 or 2 DM

How do you treat primary, secondary and tertiary syphilis of duration <12 months?

Benzylpenicillin 2.4 mega units IM | doxycycline is used as the alternative in penicillin allergic

How do you treat latent syphilis e.g. 3 years previously?

Benzylpenicillin 2.4 units IM weekly for 3 weeks

Common cause of diarrhoea in HIV positive person?

Cryptosporidium

Patient with profuse watery diarrhoea +blood/ mucus and hypokalaemia?

Rectal villous adenoma | they secrete large amounts of mucus which can cause hypokalaemia - also risk of malignant transformation

Anchovy sauce pus in a liver abscess?

Infecting organism is most likely to be ameoibic causing an abscess

Papillary thyroid cancer derived from iodine rich cells

Medullary thryoid derived from C cells in the thyroid

Patient with small papule ulcer on genital region. This breaks down to form a painless ulcer. Lymph node involvement with matted inguinal lymph nodes, abscess and sinus formation

Lymphogranuloma venerum L1 -L3

Severe bleeding from placenta praevia necessitates resusucation and C-section

Vaginal delivery is CI if there has been major bleeding Normally placenta praevia is managed with a section from 38 weeks

Sudden onset SOB and pleuritic pain after amniocentesis?

Amniotic fluid embolism | this can be complicated by DIC as shown by development of a rash

Gynaecology Flashcards

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