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Flashcards in O&G Deck (37):
1

A 30-year old-female, gravida 3 and para 3, presents with a three month history of incontinence which is exacerbated by an physical effort. Urometry confirms stress incontinence.

The lady with genuine stress incontinence at her age would definitely benefit from pelvic floor exercises as the first step before embarking on any surgical correction.

2

A 35-year-old female presents with a long history of incontinence. This tends to occur at any time and she has increasingly noticed some slight trickling of urine during ordinary daily activity. She has two children and has otherwise been well. She is found to have a cystocele and mild rectocele.

Cystocoele is descent or bulging of the bladder into the upper two thirds of the anterior vaginal wall. It denotes weakness in the investing fascia of the vagina.

Referral for surgery would be appropriate as pelvic floor repair in the lady with cysto-rectocele may restore continence by correcting the deranged anatomy.

3

A 22-year old lady presents to the Emergency department with sudden onset severe left-sided pelvic pain associated with nausea and vomiting. She has had four bouts of similar pain in the last 24 hours.

Adnexal torsion
This lady has adnexal torsion. By twisting on its vascular pedicle, any adnexal mass (for example, ovarian dermoid) can cause acute, severe pain by suddenly compromising its blood supply.

4

A 35-year old lady is referred to a gynaecologist with a four year history of mild generalised pelvic pain. PV examination reveals an enlarged boggy uterus that is mildly tender on palpation.

Adenomyosis
The examination finding of a boggy uterus suggests adenomyosis, which is caused by the presence of endometrial glands and stroma within the myometrium.

5

A 32-year old lady is referred to an infertility clinic after two years of trying for a baby. A detailed history reveals cyclical pelvic pain, secondary dysmenorrhoea, deep dyspareunia and sacral backache.

Endometriosis
This lady has a typical history of endometriosis, caused by the presence of functional endometrial glands and stroma outside the uterine cavity.

6

A 24-year-old lady presents to her GP complaining of a two day history of right upper quadrant (RUQ) pain, fever and a white vaginal discharge. She has seen the GP twice in three months complaining of pelvic pain and dyspareunia.

This lady has PID due to Neisseria gonorrhoeae Chlamydia infection which is responsible for the vaginal discharge. The RUQ pain is due to perihepatitic adhesions, which is a complication of PID (Fitz-Hugh-Curtis syndrome).

7

A 17-year-old girl presents to the Emergency department with sudden onset sharp, tearing pelvic pain associated with vaginal bleeding. She also complains of shoulder tip pain. On examination she is hypotensive, tachycardic and cervical motion tenderness is elicited.

This history is highly suggestive of an ectopic pregnancy. She has shoulder tip pain due to diaphragmatic irritation (referred) from intraperitoneal blood.

8

A 33-year-old lady presents to the Emergency department with abdominal pain. Her last menstrual period started two days ago. The pain started three days ago and now has an intensity of 8 out of 10. On further questioning, she always has very painful periods. She also has pain with defecation during her periods. A review of her notes reveals that this lady has had several laparoscopies.

Endometriosis

Symptoms of endometriosis are usually worse with onset of menstruation and include:

abdominal pain
dymenorrhoea, and
dyschezia
Management is by resecting endometriosis and preventing regrowth with continuous COCP or GnRH analogues.

9

A 50-year-old female presents with concerns related to reduced libido.
This has been causing problems with her husband as she does not feel like sex at all and she feels rather down.
In her past history she has had ovarian failure associated with a hysterectomy three years ago and is being treated with oestradiol 2 mg daily.
Which of the following would be the most appropriate treatment for this patient?

Testesterone patch
Hypoactive sexual desire disorder is well recognised in post-menopausal females as well as in patients following ovarian failure.

This may not improve despite adequate oestrogen replacement therapy as in this case and testosterone patches have been demonstrated to improve desire, activity and reduce distress.

Progestogens are not required in hysterectomised subjects and may cause a deterioration in symptoms.

10

A 28-year-old pregnant lady has a difficult instrumented vaginal delivery. Following delivery she is noted to have faecal incontinence and lax anal tone.

The pudendal nerve supplies the external anal sphincter, which is responsible for continence.

The genitofemoral nerve is the cutaneous supply to the upper thigh and mons pubis and labia majora.

The iliohypogastric nerve is the sensory supply to the suprapubic skin.

The inferior gluteal nerve supplies the gluteus maximus muscle.

The obturator nerve supplies the medial thigh muscles.

11

Disease inheritance

There is no specific mode of inheritance associated with diabetes mellitus, except in a few rare disorders where it is associated with mitochondrial inheritance such as diabetes insipidus, diabetes mellitus, optic atrophy and deafness (DIDMOAD) syndrome/Refsum's disease.

The inheritance is therefore considered polygenic - many genes contributing rather than one single gene defect.

The 18-year-old female with a bleeding tendency following dental procedures together with menorrhagia suggests von Willebrand disease which is due to a deficiency of von Willebrand factor and is usually inherited in an autosomal dominant pattern.

Von Willebrand's disease is the most common hereditary bleeding disorder. It affects both sexes approximately equally. Most cases are mild, and bleeding may occur after a surgical procedure/ tooth extraction and it is also associated with menorrhagia.

The second case has haemophilia type A, which is due to an X-linked recessive inheritance of reduced factor VIII activity. The presentation is therefore in male children with bleeding tendency and often haemarthrosis is the presenting feature.

12

Vasectomy

Vasectomy is the most popular form of permanent surgical birth control for men. The 'no scalpel' vasectomy exposes the vas deferens with fewer surgical complications and shortened operative time.

In the no scalpel technique the vas is manipulated to an area below the median raphe of the scrotum. 1% lidocaine is injected to raise a wheal. The vas is delivered onto the scrotal skin by the insertion of sharp dissecting forceps. The vas is transected and ligated. Forceps are then used to pull the fascia over the end of the prostatic vas. The fascia is secured with a single medium steel handle clip.

Fascial interpositioning between the cut vas ends further reduces recannulisation rates and sterilisation failures. The testicular end is not cauterised or ligated but is simply allowed to retract into the scrotum.

The benefit in this technique is that the open end method has fewer symptoms of epididymal congestion and low instance of sperm granuloma.

Clips have a high failure rate and should not be used.

Irrigation of the vas does not reduce failure rates. Failure rates are 1 in 1000 which is about 10 times less than female sterilisation.

13

Toxoplasma gondii

Is a cause of congenital hydrocephalus

Toxoplasma gondii is an obligate intracellular parasite of the Apicomplexa family.

The life cycle of the T. gondii parasite has three stages:

Cyst
Oocyst
Tachyzoite
The latter can proliferate in the central nervous systemforming cysts.

This is particularly the case in the immunocompromised host, and infection is a serious problem in pregnancy, with fetal infection associated with:

stillbirth
prematurity
intrauterine growth retardation (IUGR), and
neurological and ophthalmological abnormalities.
The organism is identified with the Giemsa stain.

It is usually transmitted through faecal contamination (most often cats) but can be acquired through consuming uncooked meats (this is how the cats get the disease).

14

Uterine artery

Anastomoses with the tubal branch of the ovarian artery

The uterine artery is a branch of the anterior trunk of the internal iliac artery and provides the main blood supply to the uterus. It first runs downwards on the lateral wall of the pelvis in the same direction as the ureter; then turns inwards and forwards, lying in the base of the broad ligament.

By this change of direction it crosses above the ureter, at a distance of about 2 cm from the uterus, at the level of the internal os. On reaching the wall of the uterus it turns upwards to run tortuously to the upper part of the uterus where it anastomoses with the ovarian artery.

In this part of its course it sends many branches into the substance of the uterus. The artery supplies a branch to the ureter as it crosses it and shortly afterwards another branch is given off to supply the cervix and upper vagina.

15

Which of the following is suggestive of genuine stress incontinence (GSI)

Prolapse

With genuine stress incontinence the patient often reports loss of urine with physical activity. These activities include coughing, sneezing, climbing stairs, laughing, bouncing, and intercourse. Urine loss is instantaneous and is often described as a 'squirt' of urine.

In detrusor dyssynergia (DD) urgency follows physical activity or occurs while at rest. The urge is then followed by a large loss of urine.

Dysuria indicates either an infection of the bladder and urethra, or of the vulval and perineal epithelium which is irritated by the dribbling of urine.

GSI is often associated with other pelvic relaxation problems, for example, cystocele, rectocele, and uterine prolapse.

16

Incontinence investigation

Urography (intravenous/CT/ultrasound) may show an ectopic ureter.

The cystometry is a fundamental test of bladder function and measures changes in bladder pressure with changes in bladder volume.

Urodynamic investigation of bladder function means an investigation of bladder movements and tensions during different levels of filling, and involves measurement of bladder activity (cystometry) and urethral flow (uroflowmetry).

17

Menstrual cycle

The menstrual cycle can be divided into three phases:

The follicular phase (proliferative)
Ovulation
The luteal phase.
Plasma oestradiol levels rise steadily in the first half of the cycle. There is a rapid rise between day 12 and 13 with the peak on day 13. This causes the hypothalamus to release lutenising hormone releasing hormone (LHRH) followed by the pituitary releasing lutenising hormone (LH). The peak of LH causes ovulation.

The levels of progesterone remain low up to day 12 then rise gradually up to ovulation. There is then a rapid rise in the luteal phase with a peak around day 19.

After ovulation the follicle turns into the corpus luteum which mainly produces progesterone.

There is a rise in body temperature of between 0.5 and 1°C at the time of ovulation. The temperature remains elevated throughout the luteal phase as a marker of progesterone activity, until a few days before the next period.

The average blood loss is between 40 to 80 mls.

18

Pudendal nerve

The pudendal nerve is the nerve of the pelvic floor and perineum.

It arises from the second, third and fourth sacral nerves. In the pelvis it runs on piriformis and then passes laterally through the greater sciatic foramen to enter the gluteal region. Here it curls around the sacrospinous ligament and passes through the lesser sciatic foramen to enter the ischiorectal fossa medial to the pudendal vessels. This sheath of fascia in the lateral ischiorectal fossa containing the vessels and nerve is the pudendal canal.

Branches:

Inferior rectal nerve - supplies external anal sphincter, anal canal and perianal skin
Perineal nerve - supplies scrotum/labium majus
Dorsal nerve of the penis/clitoris.
Levator ani (iliococcygeus and pubococcygeus) and coccygeus are supplied by branches of S3, 4 from the sacral plexus.

19

Vasectomy II

Male sterilisation by vasectomy is a safe, simple outpatient procedure. It can usually be performed under local anaesthetic. There are many different techniques of vasectomy.

Separate, small (3-4 mm) incisions allow the vas to be separated from its blood vessels. A centimetre of it is excised. The ends are tied with absorbable ligatures and separated. The ends may also be folded and tied, cauterised with bipolar diathermy and tissue interposed between the ends.

A no-scalpel method, developed in China, is gaining popularity.

Complications are

Bleeding (1-2%)
Wound infection/epididymo-orchitis (1-2%)
Granuloma formation (2%)
Chronic pain, occasionally severe (1-3%).
It is essential to check the operation has been successful and no early reconnection has taken place. Most surgeons require two consecutive sperm-free semen samples before the patient is told it is safe to discontinue alternative contraception methods. These are usually taken 10-12 weeks after the operation to give time to clear sperm remaining above the site of ligation. Once the samples are clear the late reconnection rate is less than 1 in 1000.

There is no effect on hormone levels.

There is no evidence of an increased risk of prostate or testicular cancer.

20

Ectopic pregnancy

Ectopic pregnancy causes up to 10% of pregnancy-related deaths and is the leading cause of maternal death in the first trimester.

The incidence of ectopic pregnancy is estimated at 20 in 1,000 pregnancies. Over 95% occur in the fallopian tube.

Rare sites include:

Interstitial (proximal tube within the muscular wall of the uterus)
Cervical
Hysterotomy scar (caesarean section scar)
Ovarian
Abdominal.
Predisposing factors involve any condition that may damage the fallopian tubes, including pelvic inflammatory disease (PID), which is the commonest predisposing factor.

Others include:

Previous ectopic pregnancy (high risk)
Fallopian tube surgery including sterilisation (high risk)
Endometriosis
Infertility
Smoking
Age over 35
Congenital fallopian tube abnormalities (rare).
While all contraceptive measures reduce the rate of pregnancy, the relative risk of ectopic pregnancy (odds ratio) is increased. These include all intrauterine contraceptive devices, the combined oral contraceptive pill and the progesterone only pill.

21

Warfarin therapy

Produces skin necrosis in patients with activated protein C (APC) resistance (factor V Leiden)


An international normalised ratio (INR) greater than 1.5 is a contraindication as there is a high risk of a spinal haematoma.

Subjects with APC resistance, protein S or protein C deficiency appear to be particularly prone to skin necrosis.

There is no evidence to establish its use in the treatment of symptomatic carotid stenosis. If a patient has a stenosis of more than 70% on the affected side a carotid endarterectomy is indicated.

Six weeks of therapy is sufficient for the treatment of a distal (below knee) deep vein thrombosis (DVT).

Warfarin is teratogenic and is therefore contraindicated in the first trimester of pregnancy.

22

Regarding the ovary

The ovarian vessels are contained within the mesovarium
The ovaries lie close to the lateral pelvic walls suspended from the posterior surfaces of the broad ligaments. Each ovary is attached to the broad ligament by a sleeve of peritoneum, the mesovarium, which conveys the ovarian vessels. However, most of the ovarian surface is devoid of peritoneum.

The ovary often lies in a hollow, the ovarian fossa, on the lateral pelvic wall between the external and internal iliac vessels.

The ureter descends in the posterior boundary of the fossa while the obturator nerve and vessels cross its floor. Therefore, ovarian disease which involves the parietal peritoneum at this site may produce pain referred via the nerve to the medial side of the thigh.

The ovary is supplied by the ovarian artery, a direct branch of the abdominal aorta. After crossing the pelvic brim this vessel enters the broad ligament and divides into terminal branches within the mesovarium.

23

Vasectomy III

Does not inhibit spermatozoa production in the postoperative period

There is short term morbidity of infection and discomfort associated with vasectomy.

The vast majority of procedures can be undertaken under local anaesthesia as a day case.

Reversal is practical. Up to 90% will achieve motile sperm in the ejaculate within one year. The achievement of pregnancy is lower but still excellent, with figures quoting up to 70% success rate if reversal is within 3 years of the vasectomy. The pregnancy rate decreases with increasing time since the vasectomy, down to around 25% after ten years.

24

Vasectomy IV

s usually performed under local anaesthesia
Most vasectomies are now done under local anaesthesia.

A vasectomy involves occlusion of the vas deferens and has a failure rate less than 4 per 1,000. This compares well with quoted failure rates for female sterilisation of ~5 per 1,000.

There should be two 'blank' specimens following the procedure over the next three to six months before the man can be deemed safe!

Reversal will see up to 90% of men with sperm in evidence, but only about 30% of their partners will conceive.

Anti-sperm antibodies are not uncommon.

25

HELLP syndrome

'HELLP' syndrome is a severe life-threatening condition that occurs in pregnancy.

It is a mnemonic which stands for: Haemolysis, Elevated Liver enzymes and Low Platelet count.

It is related to pre-eclampsia but the patient may be normotensive.

Right upper quadrant pain is a characteristic finding (not lower abdominal pain).

Variations exist and the diagnosis does not require all the manifestations.

26

not a recognised complication of a lower segment caesarean section (LSCS) performed under regional anaesthesia?

Ischaemic lower limb

The addition of opioids to local anaesthetic solutions used in regional anaesthesia is associated with delayed respiratory depression, and this is more likely to occur with hydrophilic opioids than with lipophilic opioids.

The risk of aspiration of gastric contents is reduced under regional anaesthesia but it can still occur, especially with a high block or total spinal.

The incidence of electrocardiograph (ECG) ischaemic changes demonstrated in ASA 1 females undergoing LSCS is about 35%. This is believed to be due to the increase in myocardial work and oxygen demand that occurs secondary to the hypotension induced by the sympathetic blockade. Acute ischaemic limb is not a complication associated with LSCS.

A postural headache usually suggests that there is a cerebrospinal fluid leak close to the level of insertion of the regional block. This may be an indication for an epidural blood patch in order to seal the puncture.

The incidence of a venous air embolism (VAE) during lower segment caesarean section under regional is about 25% (using Doppler ultrasound and echocardiography). Thrombus and amniotic fluid emboli have also been reported.

27

Fetal alcohol syndrome

Have characterisitic facies

Maternal binge drinking is a major risk factor for fetal alcohol syndrome.

Microcephaly and mental retardation are both strongly associated with fetal alcohol syndrome.

The characteristic facies of fetal alcohol syndrome are

Short palpebral fissures
Flat philtrum
Thin upper lip.

28

UTI

Pseudomonas and Candida spp. are opportunistic infections, which affect immuno suppressed patients.

Chlamydia rarely causes UTIs but is associated with pelvic inflammatory disease.

Enterobacter and Klebsiella spp. tend to be hospital acquired infections.

Proteus spp. are often associated with urinary calculi.

Eschericha coli accounts for 80% of urinary tract infections.

29

Prostate cancer

PSA is a prostate specific marker but is not cancer specific and may be raised in other pathological process involving the prostate gland (for example, prostatitis, benign prostatic hyperplasia [BPH]).

Microscopic prostate cancer is found in 70-80% of men over the age of 80 at autopsy.

Prostate cancer is more common in black Americans.

Prostate cancer is the second most common cancer in men in the United Kingdom, Lung I is the most common.

Prostate cancer metastasises to bone producing osteosclerotic lesions usually in the axial skeleton.

30

Internal iliac artery

Branches of the internal iliac artery:

Anterior trunk:

Obturator artery
Superior vesicle (umbilical) artery
Uterine artery
Vaginal artery
Inferior vesical artery
Middle rectal artery
(Internal) pudendal artery - Inferior rectal artery
Posterior trunk:

Iliolumbar artery
Lateral sacral artery
Superior gluteal artery
End trunk:

Inferior gluteal artery
The superior rectal artery is the continuation of the inferior mesenteric artery and descends in the base of the pelvic mesocolon.

31

Pudendal nerve II

Sensory fibres from the perineum

As the pudendal nerve passes along the outer wall of the ischiorectal fossa it gives off an inferior rectal branch, and divides into the perineal nerve and the dorsal nerve of the clitoris. This nerve plus the inferior hypogastric plexus provides sensory innervation for the peritoneum in the Pouch of Douglas.

The inferior rectal nerve supplies the external anal sphincter and perianal skin. Anal canal sensation is also via the inferior rectal branch (parasympathetic) of the pudendal nerve.

The perineal nerve supplies

Ischiocavernosus
Bulbospongiosus
Superficial and deep transverse perinei
Sphincter urethrae
and skin over the posterior two-thirds of the labia majora and the mucous membrane of the labia minora.

The dorsal nerve of the clitoris supplies the clitoris.

32

Blood supply to the vulva

Deep external pudendal artery

The superficial external pudendal artery is one of three superficial branches of the femoral artery near the inguinal ligament. It supplies the skin and superficial fascia of the upper medial thigh, skin of the pubic region.

The deep external pudendal artery derives from the femoral artery and supplies the labium majus. It anastomoses with the internal pudendal artery.

The superior gluteal artery derives from the internal iliac artery. It passes the foramen supra-piriformis to the buttock, and divides into two branches:

The deep branch runs between the musculi gluteus medius and gluteus minimus, which supply the musculi gluteus medius, gluteus minimus and tensor fasciae latae
The superficial one runs under the musculi gluteus maximus, which supplies the musculi gluteus maximus.
The umbilical artery in turn gives off one or more superior vesical arteries to the bladder.

Beyond this point the umbilical artery is obliterated and continues to the umbilicus as the medial umbilical ligament.

The internal pudendal artery terminates in branches which supply the perineal and vulval structures, including the erectile tissue of the vestibular bulb and clitoris.

33

Internal iliac artery II

The branches of the internal iliac artery are as follows:

Anterior trunk:

Obturator artery
Superior vesicle (umbilical) artery
Uterine artery
Vaginal artery
Inferior vesical artery
Middle rectal artery
(Internal) pudendal artery - Inferior rectal artery
Posterior trunk:

Iliolumbar artery
Lateral sacral artery
Superior gluteal artery
End trunk:

Inferior gluteal artery.
The superior rectal artery is the continuation of the inferior mesenteric artery and descends in the base of the pelvic mesocolon.

34

Urogenital diaphragm

It lies inferior to the urogenital hiatus of the levator ani muscle and supports this potentially weak region of the pelvic floor.

The urogenital diaphragm is pierced by the urethra and vagina.

35

Levator ani muscles

Relax during micturition

The levator ani consists of a pair of broad, flat muscle, the fibres of which pass downwards and inwards. Together with its fellow on the opposite side, the two muscles constitute the pelvic diaphragm.

The periurethral levator ani is under voluntary control and actively contracts during abdominal straining.

As soon as the bladder fills to its functional capacity a signal from within the detrusor muscle receptors is sent to higher cortical centers in the brain to initiate the emptying phase.

Normal voiding occurs when urethral muscles relax before the detrusor muscle contracts. The voiding process begins with the inhibition of both sympathetic relaxation of the detrusor muscle and of sympathetic contraction of the proximal urethral sphincter. This is followed by the inhibition of the pudendal and sacral efferent nerves, resulting in the relaxation of the external urethral sphincter and levator ani muscles.

Finally, parasympathetic stimulation via the interaction of released acetylcholine and cholinergic receptors causes the detrusor muscle to contract, emptying bladder contents.

Rectal distention stimulates internal anal sphincter relaxation and the sampling reflex. If defecation is to be deferred voluntary contraction of the external anal sphincter and levator ani muscles occurs.

Accommodation refers to the relaxation of the rectal ampulla after an initial increase in pressure. At the appropriate time for defecation or when rectal pressure is high, the levator ani muscle, puborectalis muscle and external anal sphincter relax.

Pelvic floor relaxation, along with a squatting position, straightens the anorectal angle. An increase in abdominal pressure along with colonic and rectal contractions allows expulsion of a fecal bolus.

The main nerve supply of the levator ani muscles comes from the 3rd and 4th sacral nerves.

36

Pudendal nerve V

Leaves the pelvis through the greater sciatic foramen

The pudendal nerve arises from the second, third and fourth sacral nerves.

In the pelvis it runs on piriformis and then passes laterally through the greater sciatic foramen (foramen infra-piriformis) to enter the gluteal region. Here it lies inferior to piriformis as does the sciatic nerve, the inferior gluteal neurovascular bundle and the nerve to quadratus femoris.

The pudendal nerve curls around the spine of the ischium lying superficial to the sacrospinous ligament and then passes into the lessor sciatic foramen to enter the ischiorectal fossa.

The pudendal nerve, artery and vein and nerve to obturator internus cross the ischial spine as they leave the pelvis via the greater sciatic foramen and enter the lesser sciatic foramen. The pudendal nerve and vessels enter the perineum via the pudendal canal. The nerve to obturator internus is the most lateral of these structures, the pudendal nerve the most medial.

The inferior rectal nerve is the first branch of the pudendal nerve and along with the second branch, the perineal nerve, arises from the pudendal nerve in the pudendal canal (Alcock's canal). The remainder of the pudendal nerve continues as the dorsal nerve of the clitoris.

37

Ectopic pregnancy II

Ectopic pregnancy is a relatively rare condition presenting typically with severe lower abdominal pain plus/minus vaginal bleeding. It typically occurs six weeks after the last period.

Predisposing factors include any condition that may damage the fallopian tubes including pelvic inflammatory disease (PID) - being the commonest predisposing factor.

Others include:

Endometriosis
Congenital fallopian tube abnormalities
Previous fallopian tube surgery, or
Prior ectopic pregnancy.
The IUCD although protective against pregnancy per se, is frequently implicated in ectopic pregnancy. Although the incidence of pregnancy is low (less than 1% depending on type of IUCD) in those who do become pregnant the (relative) risk of an ectopic pregnancy is higher than in a pregnancy in a woman who does not have an IUCD.

The progesterone only pill is also associated with an increased rate of ectopic pregnancy if the patient does become pregnant whilst taking this preparation.