O&G Flashcards

Question

Causes of obstructed labour

Answer 1

Fetal * Malpresentation * malposition * Macrosomia * Congneital anomalies Maternal * Bony or soft tissue masses in maternal pelvis * small pelvis

Answer 2

Maternal * Oedematous vulva * High temperature * Frequent uterine contractions Fetus * high presenting part, not engaged; ruptured membranes * moulding (extent of overlap of the foetal skull bones; excessive during obstructed labour) * Caput succedaneum - scalp swelling

Answer 3

* Gender, Age * Previous Breast carcinoma and other benign proliferative breast disease * Family Hx * Radiation * Dense Breasts * Oestrogen exposure * Early menarche, late menopause * Nulliparity, did not breastfeed * HRT, COCP * obesity

Answer 4

* Inflammatory conditions * fibrocystic change * fibroadenoma * PASH (Pseudoangiomatous stromal hyperplasia) * Sclerosing Adenosis

Answer 5

* Epithelial hyperplasia * Columnar cell change * Complex Sclerosing Lesion/ radial scar * Intraductal papilloma Note: the magnitude of risk is related to degree of histological atypia

Answer 6

* Target group 50-74yo women * involves 2 yearly mammograms If 2000 women are offered mammography over 10 years * 1 woman would have her life prolonged * 10 women would be treated unnecessarily (biopsy) * 200 women would undergo psychological distress of additional testing (false positive)

Answer 7

1. Medical History and Clinical Breast Examination 2. Imaging \> 35 --\> Mammogram +/- U/S \<35 --\> U/S 3. FNA biopsy or core biopsy

Answer 8

1. Ductal CIS BC cells confined to ductal space. Management is surgical Excision with clear margins +/- radiotherapy. 2. Lobular CIS BC cells confined within lobular space. RISK OF SUBSEQUENT BC IS BILATERAL. Management involves surgical excision + INCREASED SURVEILLANCE, consider anti-oestrogen medication.

Answer 9

* Discrete mass/ lumpiness * Pain * Nipple changes (inversion)/ discharge * Skin changes (tethering, peau d-orange, ulceration etc.)

Answer 10

Hormone receptor status (Oestrogen and Progesteroen Receptors) * 80% of BC are ER +ve * 65% of BC are PR +ve * ER+/PR+ have 80% response rate, compared to 10% for ER-/PR- * Assessed by immunohistochemistry HER2 * Assessed by immunohistochemistry or silver in situ hybridisation * Prognostically HER2 + BC has poorer survival than HER2 -ve BC

Answer 11

* Surgical excision with clear margins – mastectomy or wide local excision (WLE) * +/- axillary surgery – SLN biopsy, with axillary clearance if SLN positive * +/- radiotherapy * to the chest wall – if WLE, locally advanced disease or positive margins on mastecotomy * to the axilla or supraclavicular nodes – if nodal burden \> 4 * +/- chemotherapy – if high risk clinopathological features **Adjuct therapy** 1. _Selective Estrogen Receptor Modulators (SERMs) for ER+ve BC_ * Compounds that exhibit tissue-specific ER agonists or antagonist activity: molecularly diverse, non-steroidal (except fulvestrant), varying effects in different tissue but often anti-oestrogenic effect on breast epithelium, oestrogenic effect on bone * Tamofixen – antagonistic effect on E2 * Used in prevention and treating ER+ve BC in premenopausal women 1. _Aromatase Inhibitors (Anastrozole, letrozole, exemastane) For ER+ve BC_ * Blocks conversion of androgen to oestrogen * Used to treate ER positive invasice BC * Post-menopausal women (contraindicated in premenopausal women) * Survival benefit \> tamoxifen * Side effects include: * Hot flushes * Arthralgia * Accelerated OP * But no increase in DVT or EC 1. _Herceptin (Trastusumab) for HER2 +ve BC_ A monoclonal antibody that fits the shape of the HER2 binding site to prevent gorwth factor molecules from binding and causing unwanted cell growth

Answer 12

1. Frequent breast feeding with both breasts (every 2-3 hours) 2. Analgesia (ibuprofen) 3. Cold compresses 4. Antibiotics (Pathogen usually Staphylococcus aureus) --\> flucloxacillin or dicloxacillin May need drainage of abscess if no response to initial treatment

Answer 13

Primary dysmenorrhoea is a diagnosis of exclusion, must rule out secondary causes. Treatment * NSAIDs, topical application of heat * hormonal contraceptives (COCP, IUD)

Answer 14

* Endometriosis * PID * Intrauterine device * Uterine leiomyoma * Adenomyosis * Psychological

Answer 15

1. Patients with normal puberty * Anatomic anomalies: hymenal atresia, vaginal septum, Mayer-Rokitansky-Kuster-Hauser syndrome * Competitive athlete 1. Patients with growth delay and developmental retardation * Hypogonadism * Hypergonadotropic hypogonadism (primary hypogonadism) Insufficiency sex steroid production in the gonads * Primary gonadal insufficiency – Turner syndrome, androgen insensitivity syndrome, anorchia * Secondary gonadal insufficiency – chemotherapy, pelvic irradiation, trauma/ surgery, autoimmune disease, infections (mumps, TB) * Hypogonadotropic hypogonadism Insufficient GnRH from HPA axis * Genetic – Kallmann syndrome, Prader-Willi syndrome * Hypothalamic/ pituitary lesion – tumour, trauma, surgery, infection * Easting disorders 1. Patients with virilisation (male secondary characteristics) * Congenital adrenal hyperplasia * Polycystic ovary syndrome

Answer 16

1. Pregnancy - most common cause of secondary amenorrhoea 2. Ovarian disorders (e.g. polycystic ovary syndrome) 3. Hypogonadism * Hypergonadotropic hypogonadism * Hypogonatotropic hypogonadism e.g. functional hypothalamic amenorrhoea * Excessive exercise, reduced calorie intake, stess * Treat with lifestyle changes e.g. improve nutrition, increase BMI or offer pulsatile GnRH therapy iv. Hypothyroidism (Decrease T3/4, Increase TRH à increase prolastin - decrease GnRH - decrease oestrogens)

Answer 17

* Onset of symptoms 5 days before menstruation; symptoms end within 4 days of start of menstruation * Pain - dyspareunia, breast tenderness, headache, back pain, abdominal pain * GI - Nausea, diarrhoea, changes in appetite * Tendency to oedema formation * Neurological - migraine, increased sensitivity to stimuli * Psychiatric - mood swings, drowsiness, lethargy, exhaustion, depression, anxiety, aggressiveness \*Premenstrual dysphoric disorder (PMDD) - severe form of affective symptoms that interferes with daily life, including abnormal disagreements with family and friends

Answer 18

* Lifestyle changes e.g. exercise, healthy diet, avoiding triggers like alcohol and smoking * NSAIDs * Oral Contraceptive * If PMDD à SSRIs (Fluoxetine)

Answer 19

**Gravidity -** the number of times a woman has been pregnant **Parity** - number of times a women has given birth

Answer 20

* Amenorrhoea * Nausea and vomiting * Breast enlargement and tenderness * Hyperpigmentation or the areola and formation of linea nigra * Increased urinary frequency * Fatigue * Cravings or aversions for certain foods * Abdominal bloating and constipation

Answer 21

1. Pregnancy test * Urine beta-hCG (home pregnancy test) - beta-hCG may be detected in urine 14 days after fertilization * Serum beta-hCG (higher sensitivity) - detectable 6-9 days after fertilization. Beta-hCG doubles every 2.5 days in early pregnancy, peaks at 10 weeks gestation and then declines * Low value may indicate ectopic pregnancy or abortion, high value may indicated beta-hCG secreting tumour or twins 1. U/S (abdominal or transvaginal) * At 5-6 weeks - detection of embryo * 10-12 weeks - detection of fetal heart beat with Doppler U/S * 18-20 weeks - fetal movements

Answer 22

1. **Gestational age** à the age (in weeks and days) of the fetus calculated from the first day of the last menstrual period 1. **Embryonic age** à the age of the fetus calculated from the day of conception (fertilization) 1. **Naegele’s rule** à used to calculate the delivery date * First day of the last menstrual period + 7days + 1 year – 3 months * Inaccurate if: * The date of the last menstrual period is uncertain or unknown * The patient has irregular menstrual cycles * The patient conceived while taking contraceptive pills 1. **Ultrasound** à more accurate than Naegele’s rule * Measurement of the crown-rump length in the first trimester * Measurement of biparietal diameter, femur length, and abdominal circumference (starting at 14 weeks) 1. **Fundal height during pregnancy** à correlated with gestational age

Answer 23

1. Cardiovascular - progesterone decreases peripheral vascular resistance --\> Increases CO, SV, CO 2. Resp - Increase oxygen consumption, diaphragm displaced up so decreased TLC, RV 3. Renal - Increased GFR so decreased creatinine, increase glucose in urine 4. Endocrine - increase insulin, triglycerides and cholesterol 5. Haem - haematocrit decreases (dilutional anaemia), increase RBC, platelets and WBC 6. GI - constipation, increase salivation 7. Skin - hyperpigmentation, striae gravidarum, palmar erythema, spider angioma

Answer 24

Occurs in 90% of pregnancies, onset at 5-6 weeks gestation, peaking at 9 weeks, usually abating by 16-20 weeks. Caused by surge in b-hCG Clinical diagnosis 1. Urinalysis – look for ketonuria or signs of infection 2. Blood glucose 3. Blood tests: FBC, UEC’s, LFTs, TFTs 4. U/S scan – arrange if this has not already been performed to exclude molar pregnancies which precipitate hyperemesis 5. In sever vomiting or electrolyte abnormality: * Serum magnesium, phosphate and calcium * Bicarbonate level * Blood gases if required \*Women with diabetes should be monitored carefully as dehydration increases risk of diabetic ketoacidosis

Answer 25

1. Diet and lifestyle changes * Stay hydrated and try have small meals regularly * Avoid fatty and spicy foods * Referral to dietitian if severe 1. IV Fluid therapy * 0.9% sodium chloride 1000mL * IV multivitamins if needed 1. First line pharmacotherapy 1. Ginger – 250mg orally four times per day to reduce nausea 2. Pyridoxine (Vitamin B6) - 25mg OD at night to reduce nausea 3. Doxylamine 25mg OD night (start with 12.5mg) – Sedating antihistamine 1. Second line pharmacotherapy If nausea and vomiting persists then a second sedating antihistamine should be added. H1 antagonists safe in pregnancy 1. Promethazine (H1 antagonist and weak dopamine agonist effect) 10-25mg tabled TD 1. Third line therapy 1. Metoclopramide 5-10mg orally TD (dopamine agonist) 2. Prochloroperazine (sedating antihistamine for short term use only) 5-10mg TD 1. Fourth line therapy 1. Odansetron (5HT3 antagonist) 4-8mg tablet orally (max 16mg in 24 hours) 1. Fifth line If all else fails… 1. Hydrocortisone 100mg IV BD or prednisolone 50mg orally faily for 3 days with ranitidine 300mg

Answer 26

Definition: amount of amniotic fluid \< 500mL in the third trimester Aetiology: * Fetal anomalies * Urethral obstruction * Bilateral renal agenesis * Autosomal recessive polycystic kidney disease * Chromosomal aberrations e.g. trisomy 18 * Intrauterine infections e.g. TORCH * Maternal conditions * Late or post-term pregnancies (\>42 weeks) * Placental insufficiency * Preeclampsia * Premature rupture of membranes Treatment * Amnioinfusion: infusion of fluid into the amniotic cavity through amniocentesis * Treat underlying cause * Delivery is advised if fetus is close to term

Answer 27

Labour is the process by which regular, painful contractions bring about effacement and dilation of the cervix and descent of the presenting part ultimately leading to expulsion of the foetus and the placenta from the mother. * _Cervical effacement_ refers to the gradual inclusion of the cervix into the lower uterine segment. The muscle fibres surrounding the internal os are drawn upwards and the cervix merges into the lower segment. * _Cervical dilatation_ is the opening of the cervix from closed to full dilatation. Cervical dilatation is measured in cm from 1-10cm

Answer 28

Definition: excessive amniotic fluid (\>2000mL in the third trimester) that results in uterine distention and is associated with an increased risk of fetal complications Aetiology: * Fetal anomalies * Gastrointestinal anomalies (Tracheo-oesophageal fistula, oesophageal atresia, duodenal atresia and stenosis) * CNS anomalies e.g. anencephaly, meningomyelocele * Chromosomal aberrations * Intrauterine infections e.g. TORCH * Maternal conditions * Diabetes mellitus * Rhesus incompatibility Treatment * Amnioreduction – drain excess amniotic fluid * Treat underlying cause

Answer 29

1. _First Stage_ * Time of onset of labour - full dilatation of the cervix (10cm) 1. _Latent Labour_ – is the time between the onset of labour to 4cm dilatation * No time frame 1. _Active labour_ – describes the time from 4cm to 10cm dilatation (full dilatation). * 1cm/hour * Average duration – 12-14hours in a nullipara and 8 hours in a multipara (6 hours active) 1. _Second Stage_ * Full dilatation of the cervix until expulsion of the foetus from the birth canal (delivery of the baby) * Average duration – 1-2 hours in nulliparae and \< 1 hour in multipara 1. _Third Stage_ * Begins after the delivery of the foetus and ends expulsion of the placenta and membranes * Average duration – no more than 50 minutes, often 5 minutes depending on management employed

Answer 30

Glucocorticoids produced by foetus * --\> Decreases progesterone --\> Increase uterine stretching * --\> Increases oestrogen –\> increasing uterine contractions, softening the cervix and increased uterine sensitivity to oxytocin

Answer 31

* Pelvis - size and shape of maternal pelvis * Passanger - size and position of infant * Lie - long axis of fetus to long axis of mother * Presentation - cephalic or breech * Attitude of head - should be flexed * Station - relationship of bony presenting part to maternal ischial spines (if passed ischial spines by 2 cms --\> +2) * Power - stregnth and frequency of contractions

Answer 32

_First stage_ * Analgesia as requested * Epidural, heat backs, hypnotherapy. nitrous oxide and oxygen administration * Fetal heart rate monitoring * Determine fetal position with abdominal and pelvic examination * Regular assessment of cervical dilation and descent of the fetal head * Amniotomy may be performed during the active phase if the fetal head is well applied _Second stage_ * Warm compresses and perineal massage * Assist the mother to find any comfortable and safe position * Episiotomy * Usually a midline incision of the perineum to enlarge the vaginal opening during delivery * Indications - shoulder dystocia, forceps or vacuum-assisted delivery, or vaginal breech delivery * Delay cord clamping for 1 minute _Third stage_ * Oxytocin – administered after cutting the umbilical cord (reduces blood loss by inducing stronger uterine contractions) * Controlled traction while allowing the placenta to separate spontaneously (Brandt-Andrews manouvre) * Examine the placenta to confirm completeness (regular surface with complete cotyledons), which should consist of the umbilical, complete amniotic membranes, and 3 blood vessels (one vein, two arteries)

Answer 33

1. Before engagement 2. Engagement, flexion, descent 3. Further descent, internal rotation 4. Complete rotation, beginning extension 5. Complete extension 6. Restitution/ external rotation 7. Delivery of anterior shoulder 8. Delivery of posterior shoulder

Answer 34

* Post-term pregnancy (\>= 42 weeks) * Preterm premature rupture of membranes after 34 weeks * Repature rupture of membranes at term * Hypertension during prengnancy, pre-eclampsia, eclampsia, HELLP syndrome * Maternal diabetes to avoid post-term pregnancy * Maternat request at term * Intrauterine death * Reduced fetal movements, changes in heart rate, not growing well * Multiple pregnancies

Answer 35

* Used to assess the cervix and the likelihood of a successful induction * Interpretation * Bishop score \>= 8 - favourable cervix for vaginal delivery * Bishop score \<= 6 - unripe or unfavourable cervix; not ready for vaginal delivery

Answer 36

1. Artificial rupture of membranes (shortens time to onset of labour) * Amniotomy hook 1. If the cervix is still unfavourable: cervical ripening with prostaglandin E1 or E2 (e.g. misoprostol) * Cervidil (Dinoprostone PGE2 10mg) continuous release vaginal pessary * Foleys Catheter (balloon catheter) * Prostin (PGE2) vaginal gel * Membrane sweeping (stretch and sweep) - best used in multipara. Examining finger passes through cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua. Placenta previa is absolute contraindication, not recommended if GBS carriage. 1. Maternal oxytocin infusion (syntocinin) * Exogenous oxytocin can be used to induce labor, strengthen uterine contractions during labor, contract uterine muscle after delivery of the placenta, and control postpartum hemorrhage. 1. Consider amniotomy (only if cervix is partially dilated and completely affaced, and the fetal head is well applied) 2. Administer under fetal heart rate monitoring

Answer 37

1. **Obstetric forceps delivery** * A forcep is a metal device that enables gentle rotation and/ or traction of the fetal head during vaginal delivery * Instrument of choice when: can effect more rapid delivery, can be used in malpresentations, can be used for rotation 1. **Vacuum extractor** * A vacuum extractor is a metal or plastic cup, attached to the fetal head with a suction device, that enables traction of the fetal head during vaginal delivery * Instrument of choice: easier to apply, follows pelvic curve automatically, less force applied to fetal head, fewer cervical and vaginal lacerations

Answer 38

_Maternal_ * Maternal exhaustion * Drug-induced analgesia * Soft tissue resistance with failure to descend * Maternal illness – haemorrhage _Materno-fetal indications_ * Relative cephalopelvic disproportion * Melposition – e.g. occiput posterior * Malpresentation – e.g. presentation * Non-reassuring FHR tracing

Answer 39

Vacuum * Scalp emphysema * Caput formation, cephalohaematoma * Hyperbilirubinaemia * Subgleal haematoma Forceps * Fractured clavicle * Caphalohaematoma * Lacerations – abrasions * Facial nerve palsy * Forceps marks normal and benign

Answer 40

1. **Umbilical cord compression** * Part of the umbilical cord lies between the antecendent part of the fetus and the pelvic wall; the amniotic sac is intact 1. **Umbilical cord prolapse** * Acute, life-threatening emergency for the fetus, in which a part of the umbilical cord lies between the antecendent part of the fetus and the pelvic wall, causing rupture of membranes **iii. Knotting of umbilical cord**

Answer 41

1. First degree - cutaneous and subcutaneous skin tear 2. Second degree --\> + perineal muscles 3. Third degree --\> + involvement of external anal sphincter 4. fourth degree --\> + anterior wall of anal canal

Answer 42

**Gestational hypertension**: pregnancy-induced hypertension with onset after 20 weeks’ gestations. Defined as a SBP \>= 140mmHg or DBP \>=90 on 2 separate measurements at least 4 hours apart **Chronic hypertension**: Diagnosed \< 20 weeks’ gestation or before pregnancy **Pre-eclampsia**: Gestational hypertension with proteinuria, renal insufficiency, thrombocytopenia, evidence of liver damage (e.g. elevated liver enzymes, epigastric pain), pulmonary oedema, and/ or cerebral oedema (headache, visual blurring, vomiting, an altered mental status) * **Superimposed pre-eclampsia**: pre-eclampsia that occurs in a patient with chronic hypertension * **HELLP syndrome**: a life-threatening form of pre-eclampsia * (H = haemolysis, EL = elevated liver enzymes, LP = low platelets) **Eclampsia**: Severe form of pre-eclampsia with convulsive seizures and/ or coma

Answer 43

Moderate risk * Age 40 years or more * First pregnancy * Multiple pregnancy * Interval since last pregnancy of more than 10 years * BMI \> 35 * Family history of pre-eclampsia High risk * Chronic hypertension * Chronic kidney disease * Hypertensive disease during a previous pregnancy * Diabetes * Autoimmune disease

Answer 44

90% occur after 34 weeks’ gestation 1. Without severe features * Usually asymptomatic * Non-specific symptoms – headaches, visual disturbances, RUQ/ epigastric pain, rapid development of oedema * Hypertension * Proteinuria 1. With severe symptoms * Severe hypertension (Systolic \>=160mmHg or Diastolic \>=110mmHg) * Proteinuria, oliguria * Headache * Visual disturbances (e.g. blurred vision, scotoma) * RUQ or epigastric pain * Cerebral symptoms (altered mental state, nausea, vomiting, hyperreflexia, clonus)

Answer 45

* Onset - the majority of cases occur in the intrapartum and postpartum period * Most often associated with severe preeclampsia (but can be associated with mild preeclampsia) * Eclampsia seizure - generalized tonic-clonic seizure

Answer 46

Maternal Investigations * Assess for signs and symptoms of pre-eclampsia - sever hypertension, headache, epigastric pain, oliguria, N+V, oedema * FBC * UEC * LFTs * Urinalysis - proteinuria * IF evidence of thrombocytopenia or falling haemoglobin * Peripheral smear (haemolysis) * Coagulation studies (HELLP syndrome) Fetal investigaitons * U/S + AFI * Doppler U/S * CTG

Answer 47

Gestational hypertension and pre-eclampsia without severe symptoms * Delivery if \> 37 weeks * Maternal monitoring (1-2x week BP, urine dipstick, blood tests) * Fetal monitoring (U/S 3 weekly) * Educate patients about symptoms (vaginal bleeding, RFM) * Antihypertensives * Labetalol 20-80mg * Hydralazine 5-10mg * Nifedipine 10mg Severe Pre-eclampsia * Delivery if \> 34 weeks * If before 34 weeks need to stabilise and give corticosteroids * Oral Antihypertensives - Labetalol, Hydralazine, Nifedipine * Magnesium Sulfate for prophylaxis of eclampsia Only use diuretics if have pulmonary oedema Eclampsia * Stabilise - Airway management, supplemental oxygen * Midazolam (0.1-0.2mg/kg IV or IM if long seizure) * Magnesium sulfate to prevent further seizures * Deliver once stable HELLP syndrom * IV fluids * Blood trnasfusion * Antihypertensive agents * Magnesium sulfate * Delivery if \> 34 weeks

Answer 48

1. Complete miscarriage - all tissue passed 2. Incomplete miscarriage - confirmed non-viable pregnancy on U/S with some product of conception passes, some remain in uterus 3. Missed miscarriage - confirmed non-viable pregnancy on U/S with intact gestational sac. the cervix is closed an no products of conception have been passed 4. Recurrent miscarriage - 3 or more successive pregnancies ended in spontaneous miscarriage 5. Threatened miscarriage - the continuation of pregnancy is in doubt (vaginal bleeding with mild abdominal cramps and closed cervix) 6. Inevitable miscarriage - it is inevitable that this pregnancy will end before viability (Vaginal bleeding, cervical dilation) 7. septic miscarriage - products of conception become infected

Answer 49

Absence of fetal movement and cardiac activity at greater than 20 weeks gestation

Answer 50

Maternal * Uterine abnormalities - fibroids, uterine adhesions, septate uterus, cervical incompitence * systemic disease - DM, hyperthyroidism, infections, hypercoaguability Feto-placental * Chromosomal abrnoamlaities (account for 50%) * congenital anomalites Misc * Trauma * iatrogenic (amniocentesis or chorionic villus sampling) * Environmental - alcohol, smoking, drugs

Answer 51

Maternal * Fetal-maternal haemorrhage * Diabtes mellitus * Hypertensive pregnancy disorders * Uterine rupture * Advanced age * Heavy smoking Feto-placental * Intrauterine growth restriction * Placental abruption * Infection * Chromosomal abnormalities * Congenital malformations * Umbilical cord complications * Placental abnormalities * Fetal hydrops

Answer 52

1. Dooppler U/S - abscence of fetal cardiac activity 2. Pelvic examination - visualisation that bleeding from cervix 3. Transvaginal U/S - do if cant find heart of transabdominal scan 4. Downtrending b-hCG

Answer 53

Threatened miscarriage * Avoid strong physical activity * weekly pelvic U/S * rule out tratable causes for vaginal bleeding * Rh(D) negative women need Rh9D) immunoglobulin Inevitable, incomplete, missed misscariage 1. Conservative - allow nature to take its course and review in 7-14 days 2. Medical - misoprostol 800mg PV, review in 14 days 3. Surgical - Dilation and Curretage Stillbirth * do not such delivery unless maternal health risk * spontaneous labour usually begins within 2 weeks of intrauterine fetal death * vaginal delivery is safer than C/S but most opt for C/S * patients should be offered a fetal autopsy

Answer 54

PID is bacterial infection that spreads beyond the cervix to infect the upper female reproductive tract, including the uterus, fallopian tubes, ovaries and surrounding tissue Pathogens * Chlamydia trachomatis * Neisseria gonorrhoea * E.coli, ureaplasma and other anaerobes

Answer 55

* Lower abdominal pain, which may progress to acute abdomen * Nausea and vomiting * fever * dysuria, urinary urgency * menorrhagia and metorrhagia * dyspareunia * abnormal vaginal discharge

Answer 56

Abdominal Palpation * rebound tenderness if peritoneal irritation Pelvic Examination * cervical motion tenderness * uterine and/ or adnexal tendesness * purulent, blood cervical and/or vaginal discharge Investigations * FBC - leukocytosis * CRP - elevated * Pregnancy test - rule out ectopic * cervical, rectal and urethral swab --\> gonococcal and chalmydial DNA (PCR) and culture * U/S --\> free fluid, abscess, pyosalpinx/ hydrosalpinx * exloratory laparoscopy

Answer 57

1. One single dose of IM ceftriaxone 250mg and oral therapy with doxycycline 100mg orally BD for 14 days 2. If signs of vaginitis or recent gynaecological instrumentation - add oral metronidazole 500mg orally BD for 14 days 3. Treatment of sexual contacts and avoid intercourse until treatment finished 4. Consider removing IUD if symptoms have not resolved in 72 hours

Answer 58

**Short term** * Pelvic peritonitis * Fitz-Hugh-Curtis syndrome * Rare complication of PID involving liver capsule inflammation leading to the creation of adhesions. **Long term** * Tubo-ovarian abscess * Infertility: cause by adnexitis, adhesion of the fallopian tubes and ovaries, and tubal scarring (resulting in loss of ciliary action and tubal occlusion) * Ectopic pregnancy * Chronic salpingitis and hydrosalpinx

Answer 59

* Bacterial Vaginosis (45%) * Candidiasis * Trichomoniasis * Gonorrhoea * Chlamydia and more

Answer 60

Lower concentrations of Lactobacilli in vagina leads to overgrowth of anaerobes such as Gardnerella Vaginalis Clinical features * Increased vaginal discharge, usually grey or milky with fishy odour * pruritis and pain uncommon

Answer 61

Criteria to diagnose bacterial vaginosis 3 of 4 must apply to confirm diagnosis 1. Whiff test: add 1-2 drops of 10% KOH to vaginal fluid - intensification of the fishy odour 2. Vaginal pH \> 4.5 3. No leukocytes visible on microscopy 4. Clue cells; vaginal epithelial cells covered with bacteria identifies on wet mount preparation

Answer 62

Metronidazole 500mg orally BD for 7 days

Answer 63

* White, crumbly and sticky vaginal discharge that may appear like cottage cheese and is odourless * Erythematous vulva and vagina * vaginal burning sensation, strong pruritis, dysuria, dyspareunia Risk factors * immunodeficiency * pregnancy * topical corticosteroids * systemic antibiotic treatments

Answer 64

* pseudohyphae on wet mount with KOH * vaginal pH between 4-4.8 treat with topical azole (miconazole 2% cream insert 5g)

Answer 65

Clinical features * foul smelling, frothy, yellow-green, purulent discharge * vulvovaginal pruritis, burning sensation, dyspareunia, dysuria, straberry cervix Diagnosis * saline wet mount --\> protozoa with multiple flagella * culture if wet mount inconclusive * pH of vaginal discharge \> 4.5 treatment with oral metronidazole

Answer 66

* Typical onset during adolescence * menstrual irregularities - primary or secondary amenorrhoea, oligomenorrhoea * Obesity and possibly other signs of metabolic syndrome * Hirtuism * Androgenic alopecia * acne vulgaris and oily skin * Acanthosis nigricans * Subfertility

Answer 67

Two of the following 3 must be present, and other disorders must be excluded: 1. Hyper-androgenism and/ or hyper-androgenaemia * Increased testosterone 9total and free), increased LH (LH:FH ratio \> 2:1). Oestrogen is normal or slightly elevated. 1. Oligo- or anovulation 2. Polycystic ovaries on U/S Also evaluation for metabolic disease * test for hypertension * monitor BMI * assess for insulin resistance or T2DM * assess for hyperlipidaemia

Answer 68

_If treatment for infertility is not sought:_ Therapy is aimed at controlling menstrual, metabolic and hormonal irregularities 1. First line: if BMI \>25 - Weight loss 2. Second line: Combined oral contraceptive therapy _If seeking treatment for infertility_ 1. Weight loss 2. Metformin 500mg orally (immediate release) TD or 850-1000mg orally (immediate release) BD, or 1500-200mg orally (extended release) OD * Metformin can restore ovulation/ menses to the point where conception is possible * 6-9 months may be needed to take full effect * meta-analysis shows that continuing metformin throughout pregnancy may decrease rates of early pregnancy loss and premature birth 1. Clomifene * First-line in normal-weight women with PCOS. It is a non-steroidal anti-oestrogen that inhibits oestrogen negative feedback on the hypothalamus/ pituitary, which in turn leads to increasing FSH secretion that may allow follicular maturation and ovulation * If three treatments of clomifene have failed it is reasonable to add metformin * When clomifene fails to result n pregnancy, adding dexamethasone may be considered if patient has evidence of adrenal androgen excess

Answer 69

Postpartum haemorrhage is an obstetric emergency and is defined as a blood loss \> 500mL following vaginal birth or \> 1000mL after caesarean section delivery at any time, either before, during, or after placental delivery. Causes * Tone (most common) * Uterine tone (uterine atony) à soft, spongy, boggy uterus results in slow and steady loss of blood * Trauma * Incision from caesarean * Medical instruments à forceps, vacuum extraction, episiotomy * From baby coming through vaginal canal * Tissue * Abnormal placental separation (e.g. retention or incomplete placental detachment) * Thrombin * Bleeding diathesis – often due to hypocoaguability à can lead to DIC * Genetic – Von Willebrand Disease * Obstetric – Eclampsia, Placental abruption

Answer 70

1. Placenta accrete (80%) * Chorionic villi attach to the myometrium (but do not invade or penetrate the myometrium) rather than decidua baalis * Leads to uterine atony 1. Placenta increta (15%) * Chorionic villi invade or penetrate into the myometrium 1. Placenta percreta (5%) * Chorionic villi penetrate through the myometrium, penetrate the serosa, and in some cases, adjacent organs

Answer 71

* bloody show associated with labour * stillbirth * placental previa * placental abruption * uterine rupture * cervical trauma

Answer 72

The partial or complete seperation of the placenta from the uterus prior to delivery. Clinical features * **Continuous, dark, vaginal bleeding** * In 20% of cases, the haemorrhage is mainly retro-placental, vaginal bleeding does not occur * Abdominal pain or back pain, uterine tenderness * As the uterus tenses up to reduce bleeding * Hypertonic contractions, premature labour * Fetal distress - decelerations

Answer 73

\*Vaginal exam contraindicated à may worsen bleeding 1. U/S – rule out placenta previa, U/S can show retroplacental collection of blood 2. Fetal heart rate monitoring 3. Lab tests – FBC, coagulation factors

Answer 74

Presence of the placenta in lower uterine segment, which might lead to partial or full obstruction of the neck of the uterus with high risk of haemorrhage (rupture of placental vessels) and birth complications Clinical features * Sudden, painless, bright red vaginal bleeding * Usually occurs during the 3^rd trimester, stops spontaneously after 1-2 hours, and recurs during birth * Often causes preterm delivery (45%) * Soft, non-tender uterus * Usually no fetal distress NOTE: digital vaginal examination CONTRAINDICATED

Answer 75

Anatomic alteration of the fallopian tubes is the main cause, may be due to: * History of PID * Previous ectopic pregnancy * Past surgeries involving the fallopian tubes * Endometriosis * Bicornate uterus Non-anatomical risk factors * IUD * History of infertility * Hormone therapy

Answer 76

Patients usually present with signs and symptoms 4-6 weeks after their last menstrual period * Lower abdominal pain and guarding * Vaginal bleeding * Signs of pregnancy - amenorrhoea, nausea, breast tenderness, frequent urination * Tenderness in the area of the ectopic pregnancy * Cervical motion tenderness (extreme pain on bimanual examination), closed cervix * Enlarged uterus * Intestinal pregnancies tend to present late, at 7-12 weeks of gestation _Tubal rupture_ * Acute course with sudden and severe lower abdominal pain (acute abdomen) * Signs of haemorrhagic shock e.g. tachycardia, hypotension, syncope * More common in intestinal pregnancy

Answer 77

1. Positive pregnancy test: Increased beta-hcG * Follow up measurements are required to monitor the increase of beta-hCG over time (usually stay constant and don’t rise) 1. Transvaginal U/S * Best initial imaging test for determining the localization of the pregnancy and finding a heartbeat * U/S findings in an ectopic pregnancy * Empty uterine cavity in combination with a thickened endometrial lining * Tubal ring sign: echogenic ring that surrounds an unreuptured ectopic pregnancy * Possibly free fluid in the pouch of douglas 1. Endometrial biopsy * Shows decidualization of the endometrium with chorionic villi or fetal parts

Answer 78

1. Methotrexate - should have a decrease in bhCG in a week 2. Surgery - salpingostomy (tube conserving), salpingectomy (if does not desire future pregnancies + Anti D immunoglobulin for Rh(D) negative mothers

Answer 79

HPV 16, 18 Oncogenic HPV infection of the metaplastic epithelium at the transformation zone - most commonly Squamous Cell Carcinoma (80%), also adenocarcinoma (80%)

Answer 80

* Early onset of sexual activity; multiple sexual partners * High parity * Immunosuppression * History of STIs * Cigarette smoking and/ or exposure to second-hand smoke * Oral contraceptives * Low SES * Lack of regular screening * Age * Previous abnormality of cancer of cervix * Having many children * Diethylstilboestrol - if exposed in mother’s womb then at risk of clear cell carcinoma

Answer 81

* Abnormal vaginal bleeding * Post-coital spotting, menometorrhagia, irregular vaginal bleeding * Abnormal vaginal discharge * Blood-stained or purulent malodorous discharge * Cervical ulceration * Dyspareunia Late symptoms include: * Hydronephrosis – obstructive nephropathy caused by compression of the ureters * Compression of veins or lymphatic vessels in the pelvic area, leading to swelling of the lower extremities * Features of disseminated disease: lymphadenopathy, or, rarely abdominal, bone or chest abnormalities (pain)

Answer 82

HPV immunization preferably before first sexual intercourse * Women 9-26 years of age * Men 9-21 years of age 1. Tetravalent vaccine (Gardasil) protection against high-risk HPV types 16 and 18, as well as against low risk types 6 and 11 (most common cause of genital warts) 2. 9-valent vaccine (Gardasil9): protection against high-risk HPV types 16,18,31,33,45,52,58 as well as against low risk types 6 and 11

Answer 83

Cervical cancer has recognised precursor lesions which if treated, can prevent the development of cervical cancer. Organised screening programs are estimated to be able to prevent 90% of cancers. _The old screening test – The pap smear._ Was a 2 yearly screen for women 18-69 which looked at cell changes (cytology). _The new screening test – Cervical Screening (Introduced December 2017)_ 5 yearly cervical screening for ages 25-69, with exit testing at ages 70-74. Apart of a new national registry used to send invitations and reminders to women of appropriate age. It is more effective at preventing cervical cancers than the pap smear test. 99% of cervical cancers lesions contain HPV DNA.

Answer 84

1. _HPV negative_ à don’t need another cervical screening test for another 5 years. Sent a reminder from the National cervical screening program. 2. _HPV infection positive (not 16 or 18_) à 1/3^rd of women will have HPV. 50-80% of sexually active women will be infected with HPV at some stage in their life. 95% of women clear the infection. body will probably get rid of the HPV itself. If positive for HPV - sent for LBC. * If liquid based cytology is negative or LSIL à you will need another cervical screening test in 12 months. This assesses if you have cleared the infection. It takes 10-15 years for cervical cancer to develop, so waiting 12 months won’t be a problem. If the second test is clear, you won’t need another test for 5 years. If you still have the HPV infection after 12 months, you may need to see a specialist and have a colposcopy. * If LBC shows HSIL à refer for colposcopy and specialist input 1. _Certain type of HPV – 16 or 18_ à refer to specialist and do colposcopy 2. _You have an unsatisfactory test result_ à need a repeat test in 6-12 weeks

Answer 85

1. Cervical screening test 2. Liquid based cytology 3. Colposcopy - special microscope used to examine surface of cervix for abnormalities (cervical leukoplasia) 4. Conization - excision of a cone of cervical tissue that contains parts of the ectocervix and endocervix

Answer 86

**Non invasive** _CIN I_ _Preceded by LSIL_ * Follow up HPV and LBC after 12 months. If positive go for colposcopy. if negative go routine screening _Preceded by HSIL_ * Can manage observationally or treat _CIN II, III_ Prefer to treat - through excision or ablation, women can opt for observation if seeking pregnancy or pregnant **Invasive Disease** * Micro-invasive - cone biopsy or hysterectomy * Advanced disease - radical hysterectomy + Chemo + radiation **Also address fertility concerns and risk factors**

Answer 87

* Infection with HPV 16, 18, 31 and 33 (16 and 33 account for 55% of HPV-related cases of vulvar cancer) * Immunosuppression * Vulvar dystrophy and vulvar or cervical intraepithelial neoplasia (VIN/ CIN) * First VIN pathway à HPV related * Second VIN pathway à Lichen Sclerosus – differentiated VIN (older women, itchy) * Smoking * Smoking impaired HPV clearance along with immunosuppression * Precancerous lesions – Lichen sclerosus

Answer 88

* May initially be asymptomatic * Local pruritis, possibly with bruising sensation and pain * Reddish, blackish and or whitish patches of discoloration * Lumps or growth of various shapes, often wart-like lesions or ulcers * Dysuria, dyspareunia * Lymphadenopathy in the groin area

Answer 89

* Vaginal bleeding, vaginal ulceration with contact bleeding * Malodorous discharge * Possible urinary frequency * Leukoplakia, vaginal ulceration with contract bleeding

Answer 90

1. Squamous cell carcinoma (\>80%) 2. Basal cell carcinoma 3. Melanoma 4. Adenocarcinoma

Answer 91

1. Squamous cell carcinoma (most common) 2. Clear cell adenocarcinoma à seen in daughters of women who received diethylstilbestrol during pregnancy 3. Sarcoma botryoides – rare, highly malignant

Answer 92

1. Type I endometrial cancer: endometriod adenocarcinomas derived from atypical endometrial hyperplasia 2. Type II endometrial cancer: tumours of nonendometrial histology * Serous, clear cell, carcinosarcoma, mucinous * sarcomas - endometial stromal sarcoma, leiomyosarcoma

Answer 93

The development of type I endometrial cancers has been shown to be directly related to long-term exposure to increased oestrogen levels. Type II endometrial cancer is mostly oestrogen-independent and is strongly associated with a genetic predisposition. _Risk factors for oestrogen-dependent tumours_ Broken down to Exogenous and Endogenous Oestrogen and other * Nulliparity * Early menarche and late menopause * PCOS * Obesity * Unopposed oestrogen replacement therapy * Breast cancer - history of BC, tamoxifen treatment * Metabolic syndrome (obesity and T2DM) * Lynch syndrome (HNPCC) - 30% chance of endometrial cancer. Recommended to have hysterectomy after family completed.

Answer 94

_Tumour-related_ * Abnormal uterine bleeding is the main symptom * **Postmenopausal – any amount of vaginal bleeding, including spotting or staining** * **Perimenopausal/ premenopausal: metorrhagia, menometorrhagia** * Vaginal bleeding usually does not occur in type II cancer * Later stages may present with pelvic pain, palpable abdominal mass, and/ or weight loss * Pelvic exam often normal; possible findings include an abnormal cervix, enlarged uterus, or evidence of local metastases _Metastasis_ * Localised - spread to cervix, vagina, fallopian tubes, ovaries * Lymphogenic metastasis - seen in late stage cases – pelvic or para-aortic lymph nodes * Haematogenic metastasis - rare; occurs at a very late stage and usually in the lungs

Answer 95

* Endometrial biopsy with histology * Imaging * U/S transvaginal * U/S transabdominal and perhaps CXR, MRI, CT to exclude metastasis * Lab tests * FBC * Coagulation studies * b-hCG * TFTs

Answer 96

**Surgical management** * Indication - women with endometrial cancer who are postmenopausal, perimenopausal or do not intend to become pregnanct * Procedure - total hysterectomy with bilateral salpingo-oopherectomy with or without lymph node withdrawal **Medical management** * Progestins: indicated for women with early stage endometrial carcinoma (well-differentiated and progesterone and oestrogen receptor positive) who want to preserve fertility or as adjuvant * Radiotherapy and/ or chemotherapy (adjuvant or palliative)

Answer 97

increased oestrogen stimulation leads to excessive proliferation of the endometrium * Follicle persistence * PCOS * Oestrogen producing ovarian tumours * Hormone replacement therapy

Answer 98

1. U/S – endometrial thickening 2. Hysteroscopy with fractional curettage

Answer 99

1. Simple endometrial hyperplasia * Risk of carcinoma – 1% without atypica, 10% with atypia 1. Complex endometrial hyperplasia * Risk of carcinoma 3-10% without atypia, 30% with atypia

Answer 100

* Endometrial hyperplasia without atypia * Progestin therapy - COCP * Endometrial hyperplasia with atypia * total abdominal hysterectomy with/ without bilateral salpingo-oophorectomy * In women trying to conceive can go on progestin and close surveillence

Answer 101

1. Intramural leiomyoma (most common) 2. Subserosal leiomyoma 3. Submucosal leiomyoma 4. Diffuse uterine leiomyomatosis

Answer 102

1. Abnormal menstruation * Hypermenorrhoea, menorrhagia, metorrhagia (anaemia?) * Dysmenorrhoea 1. Features of mass effect * Enlarged, firm and irregular uterus during bimanual pelvic examination * Back or pelvic pain syndrome * Urinary tract or bowel symptoms (urinary frequency/ retention, constipation, features of hydronephrosis) 1. Reproductive abnormalities * Infertility * Dyspareunia

Answer 103

**Symptomatic fibroids** _Medical therapy_ Preoperative medical therapy may help reduce tumour size and decrease tumour vasculization 1. Hormone therapy * GnRH agonist e.g. goserelin, leuprolide * Exogenous progestins 1. NSAIDs – for pain 2. Antifibrinolytics (tranexamic acid) à reduce bleeding 3. Androgenic agonist e.g. danazol à suppress growth of fibroids (may have side effects of acne, hair loss, oedema etc.) _Surgical therapy_ Indicated for rapidly growing fibroid, recurrent refractory bleeding secondary to medical therapy, severe symptoms 1. Myomectomy 2. Hysterectomy

Answer 104

Benign disease characterised by the occurence of endometrial tissue within the uterine wall * dysmenorrhoea * menorrhagia * chronic pelvic pain, aggravated during menses * uniformly enlarged uterus, tender on palpation

Answer 105

Conservative 1. Combined oral contraceptives 2. Progestin-only contraceptives + NSAIDs for pain relief Surgical * Hysterectomy

Answer 106

Epithelial tumours (70%) 1. Cystadenoma/ cystadenocarcinoma 2. Endometriod carcinoma 3. Clear cell carcinoma Germ Cell Tumours 1. Teratoma - mature or immature 2. Dysgerminoma 3. Yolk sac tumour of ovary 4. Non-gestational choriocarcinoma Sex cord-stromal tumour of the ovary 1. Granulosa cell tumours, theca cell tumours (secrete oestrogen) 2. Sertoli-Leydig cell tumour 3. ovarian fibroma

Answer 107

General Symptoms * Abdominal pain * Ascites/ bloating * Cancer cachexia/ satiety * Abdominal or pelvic mass * Urinary symptoms Granulosa cell tumours * Express aromatase (oestrogen synthesis occurs in 25%) * Menstrual irregularities such as postmenopausal bleeding or metorrhagia * Precocious puberty Sertoli-Leydig cell tumours - Can produce oestrogen or testosterone Struma ovarri - Symptoms of hyperthyroidism

Answer 108

1. Tumour markers * Epithelial ovarian tumour: CA-125 * Yolk sac tumour: alpha-fetoprotein * Non-gestational choriocarcinoma: beta-hCG * Granulosa cell tumour: inhibin B 1. Imaging * Transvaginal U/S is the gold standard, but abdominal or rectal U/S may also be conducted 1. Histology * Granulosa cell tumour: call-Exner bodies (granulosa cells arranged in clusters surrounding a central cavity with eosinophilic secretions, resembling primordial follicles) * Sertoli-Leydig cell tumour * Ovarian fibroma: clusters of spindle-shaped cells

Answer 109

GTD includes: * Hydatiform moles (both complete and partial) * Benign * Invasive moles * Malignant * choriocarcinoma * Malignant They typically arise from the abnormal fertilization of the ovum. Patients with GTD present with vaginal bleeding and pelvic tenderness

Answer 110

**Complete mole** * Does not contain any fetal or embryonic parts * Caused by fertilization of an empty egg that does not carry any chromosomes - the physiological haploid chromosome set contributed by the sperm is subsequently duplicated. * Fetal karyotypes - 46XX, 46XY **Partial mole** * Contains fetal or embryonic parts in addition to trophoblastic tissue * Caused by fertilization of an egg containing a haploid set of chromosomes with two sperm (each containing a haploid set of chromosomes as well) * Fetal karyotypes: 69XXX, 69XXY, 69XYY

Answer 111

**Complete mole** * Vaginal bleeding during the first trimester * Uterus size greater than normal for gestational age * Passage of vesicles that may resemble a bunch of grapes through the vagina * Endocrine symptoms * Pre-eclampsia * Hyperemesis gravidarum * Ovarian theca lutein cysts: bilateral, large, cystic, adnexal masses that are tender to the touch * Hyperthyroidism **Partial mole** * Less severe symptoms due to b-hCG levels that are lower than in complete moles * Vaginal bleeding * Pelvic tenderness

Answer 112

1. Dilation and suction curettage * Complete moles have a 20% risk of becoming invasive and a 25 risk of developing into choriocarcinoma 1. Monitor beta-hCG levels until roughly 12 weeks 2. Chemotherapy (usually methotrexate) if unresolved, as indicated by any of the following: * Beta-hCG values do not decrease * Histological features of malignant GTD are present * If metastases are present on CXR

Answer 113

Choriocarcinoma is a highly aggressive, malignant tumour which only develops after fertilization and implantation of an egg. Most cases of choriocarcinoma preceded by a hydatidiform mole: 1. 50% hydatidiform mole 2. 25% miscarriage or ectopic 3. 25% normal pregnancy

Answer 114

Diagnostics 1. Very high b-HCG 2. Pelvic ultrasound – mass of varying appearance 3. Uterine D&C 4. Staging – CXR, CT Treatment 1. Chemotherapy 2. Surgical treatment – hysterectomy – indicated maybe to stop bleeding 3. Monitor B-hCG for 12 months

Answer 115

The cervix usually keeps bacteria out of the uterus. However, when the cervix is open, bacteria can get into the womb. Both bacteria normally found in the vagina and abnormal bacteria can be the cause of endometritis. Possible risk factors for endometritis include: * Childbirth or miscarriage * Caesarean delivery * STIs and other bacteria * Pelvic procedures – D&C, endometrial biopsy, hysteroscopy, IUD insertion * PID (oftenassociated with, or the cause of endometritis)

Answer 116

* FBC, CRP * Cervical culture - chlamydia or gonorrhoea * Wet mount - discharge from cervix under microscope * Endometrial biopsy * Laparoscopy or hysteroscopy

Answer 117

1. Antibiotics – if bacteria causing the uterus lining inflammation 2. Removing retained products on conception if this is causing it 3. Drainage of any abscess’

Answer 118

Up to 1/3 of patients are asymptomatic * Chronic pelvic pain that worsens before the onset of menses * Dysmenorrhoea * Pre- or post-menstrual bleeding – premenstrual spotting, heavy periods, mid cycle bleeding * Dyspareunia – pain during or after sex * Infertility/ subfertility * Dyschezia – difficult or painful defecation (usually due to hard stools or constipation) * Urinary symptoms – blood, dysuria, Bowel symptoms – pain opening bowels * Tiredness \*Intensity of symptoms does not correlate with severity or amount of endometriosis

Answer 119

1. Examination * Rectovaginal tenderness * Adnexal masses * Fixed retroflexed uterus * Immobility of the pelvis 1. Transvaginal U/S * The uterus is generally not enlarged * Evidence of ovarian cysts, most do not detect endometriosis * Nodules in bladder or rectovaginal septum 1. Laparoscopy (**_confirmatory test_**) and biopsy of lesion * General anaesthesia, small incision at naval, telescope inserted at naval after abdomen inflated with CO2 1. MRI, colposcopy, cystoscopy, or other interventions

Answer 120

**Medical therapy – Analgesia and Aim to Induce No periods** * Mild to moderate pelvic pain without complications * Analgesia - NSAIDs, paracetamol * Inducing no periods * Continuous hormonal contraceptives (COCP) * Progestin’s – Depot Provera, Mirena, oral * However – significant side effects, not as effective in advanced disease, not useful in ovarian endometriomas, not useful for fertility, high rate of recurrence after therapy * NSAIDs alone if pregnancy desired * Severe symptoms * GnRH agonists (goserelin) and oestrogen-progestin OCPs (to avoid hypooestrogenic effects) **Surgical therapy** * First line - laparoscopic excision and ablation of endometrial implants * Confirms diagnosis and excludes malignancy * If there is a lack of response to medical therapy * Treat expanding endometriomas and complications, improves fertility in mild cases * Second line - open surgery with hysterectomy with or without bilateral salpingo-oophorectomy * Treatment-resistant symptoms * No desire to bear additional children * Least recurrence of symptoms but higher injury rate **Chronic pain management** * Pain specialist * Psychiatry * Stay at work, loose weight, yoga etc.

Answer 121

IUGR – fetus with birth weight \< 10^th percentile for gestational age due to pathological process. Cuttoff at term is \< 2500g. Can be symmetric or asymmetric. 1. Symmetric (primary) growth restriction is characterized by all internal organs being reduced in size. * Due to intrinsic factors – chromosomal abnormalities, congenital anomalies, intrauterine infection 1. Asymmetric (secondary) growth restriction is characterized by the head and brain being normal in size, but the abdomen is smaller. Typically, this is not evident until the third trimester. * Due to extrinsic factors – utero-placental insufficiency, hypertension, multiple gestations, placental disease Macrosomia - Fetal weight of more than 4500g at term or fetal birth weight \> 90th percentile

Answer 122

_Maternal factors_ * Hypertension * CKD, CVD * Malnutrition, severe anaemia * Infection * Substance abuse (alcohol, drugs) * Cigarette smoking _Factors involving the uterus and placenta_ * Decreased blood flow in the uterus and placenta * Placental abruption (placenta detaches from the uterus) * Placenta previa * Infection in the tissue around the fetus * Chorioangioma _Factors related to the developing fetus_ * Multiple pregnancy * Infection * CMV, Rubella, toxoplasma gondii * Syphilis, Tuberculosis, Malaria, listeriosis * Herpes simplex, chicken pox * Congenital anomalies * Congenital Heart diseases * Anencephaly * Chromosomal abnormality * Trisomy 18, 13, 21, turner Syndrome

Answer 123

* Diabetes * Obesity, excessive weight gain in pregnance * Hydrops fetalis * Post-term pregnancy * Multiparity

Answer 124

* Hypoxia * Low Apgar score * meconium aspiration * hypoglycaemia * difficulty maintaining body temperature * polycythaemia

Answer 125

* Inter-observer variations * Obese patients * Transverse lie * Multiple gestation * Polyhydramnios/ oligohydramnios * Uterine fibroids

Answer 126

1. Physical examination - fundal Height 2. U/S + AFI 3. Doppler flow 4. Mothers weight gain 5. Non-stress testing 6. Foetal movement counting

Answer 127

Maternal complications * Genital tract lacerations * PPH * Uterine rupture Fetal complications * meconium aspiration * obstructed labour * shoulder dystocia Newborn complications * hypoglycaemia * childhood obesity * metabolic syndrome

Answer 128

Pathogens transmitted from mother to child during pregnancy. Toxoplasmosis gondii Other - Syphillis, Listeriosis, varicella, Parvovirus B19 Rubella CMV Herpes simplex Virus

Answer 129

1. First trimester 2. Increased risk of premature birth and miscarriage Newborn --\> chorioretinitis, intracranial calfiications, hydrocephalus Mother --\> asymptomatic, fever, malaise 3. Maternal - Serology (IgM, IgG) Fetus - PCR for T.gondii DNA in amniotic fluid 4. Mother - spiramycin Newborn - Pyrimethamine, sulfadiazine and folinic acid

Answer 130

* Any time - if syphillis is transmitted transplacentally * Early congenital syphilis (\<2yo) * Hepatomegaly and jaundice * Rhinorrhoea * Maculopapular rash on palms and soles * Skeletal abnormalities – metaphyseal dystrophy, periostitis * Late congenital syphilis (onset after 2 years of age) * Facial features – saddle nose, frontal bossing, short maxilla * Hutchinson teeth (notched, widely spaced) * Sensorineural hearing loss * Maternal screening in early pregnancy - RPR or VDRL Fetus --\> U/S - hepatomegaly, ascites, hydrops fetalis Newborn - RPR or VDRL then confirm with darkfield microscopy of lesion * Treat with IV penicillin

Answer 131

* 2nd or 3rd trimester - mortality is 40-50% for fetus * Fetus - Increase chance of miscarriage/ preterm birth, meningitis, respiratory distress syndrome Maternal - Diarrhoea, fever, myalgia * Blood culture of CSF culture (if meningitis) * Treat - IV ampicillin

Answer 132

* 1st or 2nd trimester --\> sever anaemia and hydrops fetalis --\> miscarriage/ stillbirth * Clinical * mother - rash and arthralgia * fetus - severe anaemia and hydrops fetalis * Investigations * Mother - Serology for IgG and IgM against parvovirus * fetus * PCR amniotic fluid * Doppler U/S * fetal blood sampling can confirm anaemia * Treatment - Intrauterine fetal blood transfusion

Answer 133

* First trimester * clinical * Fetal - congenital rubella syndrome * cataracts * cochlear defects - sensorineural hearing loss * cardiac defects - PDA, pulmonary artery stenosis * Mother - mild - macropapular rash, lymphadenopathy, arthralgia * Investigations * PCR (throat swab, CSF, urine) * serology * Treatment - termination if \< 16weeks, otherwise reassurance

Answer 134

* Most commonly gotten in third trimester, but can get whenever * clinical * 90% subclinical - most commonly get hearling loss * fetal - IUGR, periventricular calcifications, oligohydramnios, polyhydramnios * Newborn - periventricular calcification, chorioretinitis, sensorineural hearing loss, SGA, vision impairment * Investigations * Newborns, fetus and women * CMV IgM antibodies * Viral culture or PCR * Treatment * mother/ newborn - antivirals - ganciclovir and valganciclovir * fetus - intrauterine blood ant platelet transfusion

Answer 135

* Usually transmitted during vaginal birth * clinical features * skin, eye, mouth disease vesicular skin lesions, cataracts, chorioretinitis, meningoencephalitis * Investigations - clinical * treatment - acyclovir

Answer 136

* Self-obtained lower vaginal and rectal swab between 35 and 37 weeks gestation and sent off for culture Prophylactic antibiotics - Penicillin 5 million units IV initial dose, 2.5 mill every four hours OR ampicillin 2g IV initial dose * gestational age \< 37 * temperature \> 38 degs * rupture of amniotic membranes \> 18 hours * intrapartum NAAT positive for GBS * gbs bacteriuria in current pregnancy * delivery of an infant with early onset GBS disease in previous pregnancy

Answer 137

A new baby is no longer exposed to the medications and drugs taken by the mother during pregnancy and can result in the baby developing signs of withdrawal. features * CNS – terrors, irritability, sleep disturbances, seizures * Respiratory – tachypnoea, nasal flaring, chest recession * ANS – sneezing, yawning, fever, sweating * GI system – poor feeding, vomiting, diarrhoea

Answer 138

1. Morphine – drug of choice for opiate withdrawal 2. Phenobarbitone – for benzodiazepine and/ or alcohol withdrawal and as an adjunct to morphine Often need to be taken for months i.e. infants are being discharged home on morphine once stable and dose small enough

Answer 139

* Previous hyperglycaemia in pregnancy * Previously elevated BGL * Ethnicity: South and south-east Asian, aboriginal, Pacific Islander, Maori, Middle Eatern * Age \> 40 * Family history of diabetes mellitus * Obesity – BMI \> 35 * Hypertension prior to 20 weeks * PCOS * Medications: corticosteroids, antipsychotics * Recurrent pregnancy loss * At least one birth of a child diagnosed with fetal macrosomia (\>4500g or \> 90^th percentile)

Answer 140

**_Third trimester screening at 24-28 weeks recommended in all pregnancies_** Aim is to test as close to 28 weeks as possible as testing at 24-26 weeks may miss some women who develop abnormal glucose tolerance. One-step test option; 75g Oral Glucose Tolerance Test (OGTT) The OGTT should be performed in the morning after an overnight fast of at least 8 hours. * Glucose level: \>/ 5.1 mmol/L fasting * \>=10.0 mmol/L at 1 hour * \>=8.5 mmol/L at 2 hours

Answer 141

General management * weight loss and exercise (50% controlled this way) * Diabetes educator and dietician * bloog glucose monitoring and dietary intake Anti-hyperglycaemic medications 1. insulin - pre-prandial bolus and basal insulin at night may be required 2. metformin Other management consideration * Elevated BP - monitor * Psychosocial concerns * Obstetric considerations * Deliver at due date if well controlled on diet alone and no complications * Deliver at 39 weeks if on anti-hyperglycaemic drugs and no complications * 36-38 weeks if elevated BP/ sub-optimal control, failing insulin, macrosomia or IUGR

Answer 142

Antenatal * Maternal - hypertension, pre-eclampsia, UTI, insulin related hypoglycaemia * Fetal - macrosomia, polyhydramnios (fetal hyperglycaemia --\> fetal polyuria) Perinatal * maternal - increase risk of C/S * neonate - jaundice, polycythemia, hypoglycaemia, hypocalcaemia, shoulder dystocia, at risk of clavicle fracture Post-partum * Mother - 50% risk over 10 years of developing T2DM, 50% risk of GDM in subsequent pregnancies * Baby - increased risk of being overweight and devloping diabetes

Answer 143

all the same as GDM + _fetal embryopathy (first trimester)_ Hyperglycaemia -- inhibition of myoinositol uptake -- abnormalities in the arachidonic acid-prostaglandin pathway -- birth defects and spontaneous abortion * Effects: * Congenital heart disease – transposition of great vessels, VSD, PDA, dextrocardia, truncus arteriosis, tricuspid atresia * Neural tube defects * Duodenal atresia * Cleft palate, Flexion contracture of limbs * Renal agenesis

Answer 144

In a Rh-negative mother and Rh-positive child: Maternal exposure to fetal blood --\> production of maternal IgM antibodies against the Rh antigen --\> over time, seroconversion to Rh-IgG (able to cross the placenta) In a subsequent pregnancy with an Rh-positive child: rapid production of maternal IgG anti-D antibodies to fetal RhD antigens --\> Rh-IgG agglutination of fetal RBCs with haemolytic anaemia --\> risk of of haemolytic disease of the fetus and newborn with possible hydrops fetalis.

Answer 145

Give Anti-D immunoglobulin 1. Is administered at 28 weeks, and following the delivery of a Rh-positive infant or at 40 weeks (whichever occurs first) 2. If massive haemorrhage or vaginal bleeding 3. After amniocentesis or after chorionic villuc sampling

Answer 146

Short term * Hyperbilirubinaemia and kernicterus * Fetal and neonatal hydrops * Neonatal aneamia

Answer 147

_Functional cysts_ 1. Follicular cyst * Cysts lined with follicular epithelium; the most common form of ovarian cysts 1. Corpus luteum cyst * Corpus luteum cysts developed physiologically during the menstrual cycle or during pregnancy (corpus luteum gradiditatis). They produce progesterone, which may delay menses. _Benign pathological cysts_ Larger, complex symptomatic, do not resolve * E.g. dermoid, cystadenoma, endometrioma, fibroma * Chocolate cysts * Related to endometriosis _Neoplastic cysts_ * U/S, CA125, Menopausal status If multiply all of these and \> 200 --\> refer to gynaecological oncologist

Answer 148

1. Pelvic U/S * Functional à Smooth lining on all sides, single or multiple, hypoechoic to anechoic, fluid-level 1. Ca125 2. Laparotomy

Answer 149

1. Ovarian torsion 2. Ruptured ovarian cyst Both present with unilateral lower abdominal pain

Answer 150

* Classical C/S * Previous Uterine rupture * Some types of previous uterine surgery, such as removal of fibroids * Woman needs induction of labour and has unfavourable cervix * Woman has an anusual pelvic shape * Baby is in transvers position * Macrosomic baby * Any other contraindications to labour e.g. placenta previa

Answer 151

* Younger age * Normal BMI * Previous successful vaginal birth * OA position * \> 24 months since C/S * Spontaneous labour

Answer 152

* Group B streptococcus * E.coli * Listeria monocytogenes * Staph aureus

Answer 153

* Premature Rupture of Membranes, clinical chorioamnionitis and/or discoloured liquor * Prolonged rupture of membranes \> 18 hours * Pre-term labour or birth * Multiple gestation * Maternal peri-partum pyrexia (\>38) * Maternal GBS, UTI * Resuscitation required at birth * Invasive procedures – cannula, catheter, endotracheal tubes * Inadequate hand-washing * Parenteral nutrition * Ongoing respiratory disease

Answer 154

1. Blood culture 2. FBC 3. CRP 4. CXR 5. gastric aspirate and ear swab May include LP \*If late onset - add urine sample

Answer 155

1. _Antimicrobial therapy_ * EOS: Penicillin/ amoxicillin plus gentamicin * LOS: Vancomycin plus gentamicin * Always narrow therapy according to sensitivity 1. _Supportive_ * pink (respiratory support) * warm (temperature) * Sweet (watch for hypoglycaemia, provide glucose either through milk if able or IV) * BP, minimal handling

Answer 156

1. Transient tachypnoea of the newborn 2. Sepsis/ Pneumonia 3. Aspiration (meconeum) 4. Hyaline membrane disease (Most common in preterm) 5. Pneumonthorax

Answer 157

RDs is primarily a function of surfactant deficiency. Spontaneous or mechanical ventilation of the surfactant-deficient lung causes epithelial injury, protein leakage and pulmonary oedema which is prevented with exogenous surfactant treatment. Lack of surfactant results in collapse of alveoli and hence decreased lung compliance, increased resistance and decreased lung volume. Decreased alveolar ventilation impairs effective gas exchange. An increased mean airway pressure is required to open up the lung and to establish effective tidal volumes.

Answer 158

1. Blood culture 2. FBC 3. CRP 4. CXR 5. Oxygen saturation, ABG

Answer 159

1. Pink * Oxygen * CPAP * Invasive mechanisal ventilation * Chest drain (ICC) – pneumothorax * Antibiotics – pneumonia * Surfactant if hyaline membrane disease 1. Warm - euthermia, prone position 2. Sweet – monitor for hypoglycaemia - withhold neteran feeds, consider IV fluids

Answer 160

if jaundice presents before 24 hours ---\> its pathological If jaundice is present for \> 14 days --\> its pathological causes of early jaundice: 1. physiological jaundice 2. haemolysis - rhesus iso-immunisation, ABO incompatability 3. sepsis 4. polycythaemia (diabetes?) 5. bruising (birth trauma) 6. Rarer - G6PD def., red cell membrane defects (Hereditary spherocytosis) \*also breast milk jaundice

Answer 161

Acute bilirubin encephalopathy - hypotonia, poor feeding, high pitched cry, lethargy, siezures and very seriously... KERNICTERUS (Chronic bilirubin Encephalopathy) * developmetal delay * cerebral palsy * oculomotor dysfunction * sensori-neural deafness

Answer 162

* Serum bilirubin level * FBC * Direct anitbody test and blood group (haemolysis detection) * Septic screen? culture, cxr, fbc, crp?

Answer 163

1. Phototherapy is indicated in unconjugated hyperbilirubinaemia to prevent acute bilirubin encephalopathy and kernicterus arising as a consequence of bilirubin deposition in the basal ganglia and certain brainstem nuclei. * Phototherapy lowers the concentration of circulating unconjugated bilirubin to a level at which the risk of CNS deposition is minimised * The native form of unconjugated bilirubin is photo-reactive to photons with a wavelength of 450nm-510nm * Perform SBR day after cessating phototherapy 1. Intravenous Immunoglobulin and exchange transfusion * Used for aggressive haemolysis, most frequently occurring in response to Rhesus isoimmunisation * IVIG is unlikely to prevent the need for a first exchange transfusion, however the need for repeated transfusion is decreased

Answer 164

1. pruritis without rash 2. increased serum bile acids 3. abnormal LFTs + Bilirubin, FBC, coagulation profile Treat with Vit K (liver disease can increase risk of haemorrhage) and Urseodeoxycholic acid (protects hepatocytes from toxic effects of bile salts)

Answer 165

_Anterior vaginal wall prolapses_ 1. Cystocele (descent of the bladder) 2. Urethrocele (descent of the urethra) _Posterior vaginal wall prolapses_ 1. Rectocele (descent of the rectum) 2. Enterocele (herniated section of the intestines) Uterine prolapse – descent of the uterus Vaginal vault prolapse – descent of the apex of the vagina Uterine procidentia – protrusion of all vaginal walls or cervix beyond the vaginal introitus

Answer 166

Women with VTE should not get warfarin as crosses the placenta 1. LMWH (clexane 1mg/kg twice daily) * Proximal DVT or PE for at least 6 weeks postpartum * Distal DVT 6-8 weeks

Answer 167

1. fetal macrosomia 2. placental insufficiency 3. meconeum aspiration

Answer 168

**Conservative** * Insertion of a vaginal pessary (not long term and can lead to pressure ulcers) * Reduction of modifiable risk factors (smoking to prevent cough, weight loss, prevent constipation) * Kegel exercises – pelvic floor muscle training **Surgery** 1. Obliterative surgery – vagina is closed off or narrowed to provide more support for pelvic organs 2. Reconstructive surgery – restore original position of descended pelvic organs

Answer 169

1. lie 2. presentation 3. position 4. engagement 5. fundal-height 6. liquor volume 7. fetal heart rate

Answer 170

1. cervical position 2. cervical consistency 3. cervical effacement 4. cervical dilation 5. application 6. membranes 7. presentation 8. position 9. attitude 10. station 11. caput 12. moulding

O&G Flashcards

(197 cards)