O&G Flashcards
(121 cards)
1
Q
sites for ectopic preganancy
A
fallopian tubes (97%) ovaries abdomen C-section scar
2
Q
risk factor for ectopic pregnancy
A
previous ectopic
pelvic surgery - (C-section, appendectomy, sterilisation)
endometriosis
clamydia
3
Q
presentation of ectopic preganancy
A
typically at 6-8 weeks after LMP vaginal bleeding pelvic discomfort pain when opening bowels hypovolaemic shock - hypotension, tachycardia
4
Q
investigations for ectopic pregnancy
A
urine/serum beta HCG
transvaginal US
serial serum-hCG
5
Q
explain serial beta-hCG use is ectopic pregnancy
A
use if US can’t find ectopic but it is suspected
increase > 60% sugest intrauterine pregnancy
<66% increase or <15% decrease suggest ectopic
>15% decrease suggests failing PUL
6
Q
management of ectopic pregnancy
A
expectant management (conservative - wait for spontaneous resolution) medical management (Methotrexate) surgical management (salpingostomy or salpingectomy)
7
Q
define miscarriage
A
any pregnancy loss before 24 weeks gestation
8
Q
risk factors for miscarriage
A
old maternal age
PCO
smoking and alcohol
uterine malformations ( ascending UTIs, bicornuate)
9
Q
cause of miscairrage
A
cervical incompetence/weakness
transplacental foetal infection - syphilis, rubella
rhesus isoimmunisation
10
Q
explain rhesus isoimmunisation
A
Antibodies in the mothers blood attacks RBC in the foetus
Due to rhesus D antigen (RhD) on RBCs
Can only occur when all 3 apply
1) Mother is RhD negative
2) Foetus is RhD positive
3) Mother has previously been exposed to RhD+ blood and has become sensitised (previous pregnancy, miscarriage, ectopic, c-cestion)
11
Q
what are the types of miscarriage
A
threatened inevitable incomplete complete delayed/missed septic recurrent
12
Q
presentation of miscarriage
A
vaginal bleeding +/- clots
suprapubic pain
postcoital bleeding
13
Q
investigations for miscarriage
A
serum beta hCG (drop of >50% in 48hrs suggests failing pregnancy
transvaginal US
A gestational sac, mean diameter >25, with a visible yolk sac
Crown-rump length of embryo > 7mm and no obvious foetal heart beat
Empty uterus (if ectopic is ruled out) = complete miscarriage
Retained tissue = incomplete miscarriage
rhesus blood group
cytogenetic of products of conception (in recurrent miscarriages)
14
Q
Management of miscarriage
A
threatened or complete - analgesia + counselling + anti D
inevitable/incomplete/missed - above + manual evacuation, misoprostol (for bleeding), can consider conservative with antibiotics
15
Q
examples of gestational trophoblastic disease
A
partial hydatidiform mole complete hydatidiform mole invasive mole choriocarcinoma placental site trophoblastic tumour
16
Q
management of trophoblastic gestational disease
A
desired fertility - dilation and evacuation with mechanical suction with 12 month follow up and strict adherence to contraception
not desiring fertility: hysterectomy
17
Q
management of viable twins in gestational trophoblastic disease
A
elective termination via dilation and evacuation
if termination not desired manage as a high risk pregnancy with close observation specifically for eclampsia and thyrotoxicosis
18
Q
define hyperemesis gravidarum
A
persistent vomiting during pregnancy resulting in weight loss, ketosis, electrolyte disturbances and volume depletion
19
Q
investigations for hyperemesis gravidarum
A
urine ketones
check for UTIs
U&Es, LFTs
USS - multiple pregnancies, molar pregnancies
20
Q
management of hyperemesis gravidarum
A
IV fluids (avoid dextrose)
IV anti-emetics (ondansetron)
omeprazole
replace electrolytes/vitamins as required
21
Q
define infertility
A
Primary = inability to achieve pregnancy after 12 months of regular unprotected sex Secondary = infertility after previously been pregnant
22
Q
causes of male infertility
A
obstructive azoospermia - normal sperm production but not present in ejaculate (blockage of vas or epididymis, CF causing congenital absence of vas)
non-obstructive azoospermia - testicular failure (high FSH, low Testosterone) e.g. due to obesity, endocrinopathies, chemotherapy
XXY Klinefelter’s, Y microdeletions
unstimulated spermatogenesis - hypogonadotropic hypogonadism
23
Q
causes of female infertility
A
anovulation due to
group 2 =hypothalamic pituitary ovarian axis dysfunction (PCOS, adrenal dysfunction, thyroid dysfunction)
group 1 = hypothalamic pituitary failure (weight, stress, exercise, kallmans, pituitary tumour, sheehans)
group 3 = ovarian failure (chemo/radiotherapy, turner’s)
tubal causes
scarring, obstruction, adhesions (STIs, ectopic pregnancies)
PID, endometriosis, fibroids, polyps
24
Q
investigations for male infertility
A
FSH, testosterone karyotype (CF carrier, Y deletions) semen analysis (concentration, motility, morphology)
oligospermia = low sperm asthenospermia = immotile sperm teratospermia = abnormal morphology
25
investigations for female infertility
TV USS
cervical sear, chlamydia, gonorrhoea,
ovarian function (luteal phase progesterone, LH, FSH, anti mullerian hormone
hystero-salpingo-gram, hysteroscopy
26
management of infertility
lifestyle (smoking, alcohol, weight)
folic acid
group 2 - clomifene, letrozole, FSH injection
group 1 - gonadotrophin releasing hormone injections
ART (IUI, IVF, ICSI)
tubal catheterisation
surgical correction of epididymis blockage
27
types of epithelial ovarian cancers
High grad serous
Resembles fallopian tube mucosa
P53 and BRAC1 mututions
Those that arise from ovarian surface epithelium and Mullerian inclusion cysts
Endometrioid and clear cell – likely due to ovarian endometriosis, associated with PTEN loss
low grade serous – KRAS and BRAF mutations
28
risk factors for ovarian cancers
BRCA 1, 2, Lynch syndrome II
nulliparity, early menarche, late menopause
never on OCP
29
presentation of ovarian cancer
```
pelvic mass
altered bowel habits
abdominal pain
early satiety
urinary urgency
```
30
investigations for ovarian cancer
```
USS, CT
CA125 >35
RMI
cytology of plural or ascitic fluid
biopsy, histology
FIGO staging
```
31
management of ovarian cancer
surgery
chemotherapy - carboplatin, VEGF inhibitor, aromatase inhibitor
prophylactic bilateral Salpingo-oophrectomy
32
types of endometrial cancers
most commonly adenocarcinomas - 2 types - oestrogen excess (endometrial adenocarcinoma), non oestrogen excess (papillary serous, clear cell)
others = leiomyosarcomas, uterine carcinomas
33
risk factors for endometrial cancer
```
lynch syndrome
obesity
nulliparity
HRT
PCOS
tamoxifen use
```
34
presentation of endometrial cancer
post menopausal bleeding
post coital bleeding
altered menstrual pattern
persistent vaginal discharge
35
investigations for endometrial cancer
Pelvic and transvaginal US - endometrial thickening >5mm
hysteroscopy and biopsy
CT CAP
36
management of endometrial cancer
total hysterectomy + bilateral salpingo-oopherectomy + lymphadenectomy
adjuvant vaginal brachytherapy or pelvic external beam radiotherapy
chemo for late stages, serous or clear cell
37
types of cervical cancer
80% squamous cell carcinoma
15% adenocarcinoma
4-5% Adenosquamous
<1% endometroid, clear cell, serous, neuroendocrine
38
risk factors for cervical cancer
```
HPV - strains 16, 18 highest risk
smoking
immunosuppression
multiple sexual partners
early onset sexual activity
```
39
describe the HPV vaccination program
against strains 6, 11, 16, 18
given to all females aged 11-13
2 s/c injections 6 months apart
40
describe the screening program for cervical cancer
pap smear
offered to women aged 25 - 65 (25-49 = every 3 years. 50-65 = every 5 years)
looks for precancerous lesions/cancerous cells at the transformation zone
includes HPV testing
41
presentation of cervical cancer
```
abnormal vaginal bleeding
post coital bleeding
mucoid/purulent discharge
dyspareunia
pelvic pain
obstructive renal failure
```
42
investigations for cervical cancer
VE and speculum - masses, bleeding
colposcopy, biopsy, histology
HPV testing
CT/MRI/PET
43
FIGO staging for cervical cancer
I – confined to cervix
II – invades beyond uterus but not lower third of the vagina
III – involves lower third or extends to pelvic wall
IV – extends beyond the pelvis
44
management of cervical cancer
LLETZ/cone biopsy/trachelectomy + pelvic lymphadenectomy
radical hysterectomy
chemo and radiotherapy
45
types of vulval cancers
90% squamous cell carcinomas
| others = adenocarcinomas, melanomas, BCC, sarcomas
46
describe VIN
vulval intraepithelial neoplasia (Classes I, II, III)
| precursor to squamous carcinoma
47
Management of VIN
I = symptomatic relief after excluding invasive disease, eradiated HPV
II/III - surgical excision/laser ablation/chemical ablation (imiquimod)
plastic and reconstruction input
48
types of vulval squamous cell carcinoma
SSC associated with VIN
usually <60 y.o.
associated with cervical cancer and HPV 16/18
SSC associated with dermatoses
>60 y.o.
keratinised and well differentiated
49
presentation of VIN
```
pruritus
pain
ulceration
leucoplakia
lump
```
50
presentation of vulval SSC
pain, mass, bleeding, discharge
skin changes - elevations, ulcerations
inguinal lymphadenopathy
51
investigations for vulval cancer
incisional biopsy
lymph node assessment: US, CT, MRI
FIGO staging
52
management of vulval cancer
vulvectomy + inguinal lymphadenectomy + skin grafts/flaps
| Chemotherapy (reduce size before surgery, with radiotherapy in late stage or adjuvant post surgery)
53
define menopause
when menstruation permanently ceases due to loss of ovarian follicular activity
diagnosed after 1 year of amenorrhoea
54
causes of heavy menstrual bleeding
uterine: fibroids, endometrial polyps, PID, endometrial cancer
absence of uterine pathology: PCOS, hyperprolactinaemia, thyroid dysfunction
secondary to: von williebrand disease, anticoagulation use
55
Assessment of HMB
History – menarche, cycle, SHx ?preg, DHx ?contraceptives, cervical screening, ?migraines, smoking/alcohol/drugs, FHx
Examination – abdominal, bimanual, speculum
Bloods – FBC, coag screen, ferritin, TFTs
Swabs -?STI
Imaging – USS ?structural abnormalities ?pelvic mass, hysteroscopy
Pathology – biopsy to exclude endometrial cancer in women >45 with ineffective treatment
56
management of HMB
first line
fertility desired = tranexamnic and mefinamic
not desired = merina coil
```
other options
systemic hormonal (COCP, GnRH analogues, ulipristal acetate - progesterone receptor modulator)
surgical - endometrial ablation. hysterectomy
```
57
causes of primary amenorrhoea
genito-urinary malformations: imperforate hymen. absenct vaginal/uterus
Turner's
hypothalamic: low BMI, stress, illness
58
causes of secondary amenorrhoea
PCOS
pituitary: prolactinoma, pituitary adenoma
thyroid dysfunction
59
Define dysmenorrhoea
primary - pain in the absence of underlying pelvic pathology
| secondary - pain caused by pelvic pathology (endometriosis, PID, fibroids) or IUD insertion
60
investigations for dysmenorrhoea
pregnancy test
TV US - fibroids, adnexal pathology, endometriosis
hysteroscopy, pipelle biopsy
endocervix/vaginal swabs: STIs
61
management of dysmenorrhea
lifestyle - diet, exercise
NSAIDs
hormonal; - COCP, mirena coil
treat underlying cause
62
define endometriosis
an oestrogen dependent benign inflammatory disease characterised by ectopic endometrium
63
common sites for endometriosis
ovaries, fallopian tubes
pelvic peritoneum
uterosacral ligament
Less common: bladder, rectum, colon
64
explain the retrograde menstruation theory
Retrograde menstruation is the most commonly accepted theory
Endometrial debris flow backwards through fallopian tubes and into peritoneal surfaces
Fails to explain the low rate of disease in comparison to retrograde flow which is fairly common
A reason may be that retrograde menstruation relies of a deficient cell mediated response as many patients with endometriosis are found to have a reduced macrophage response in clearing menstrual effluent
65
aetiological theories for endometriosis
retrograde menstruation theory
Mullerian rest theory
vascular and lymphatic dissemination
66
presentation of endometriosis
```
dysmenorrhoea
cyclic pelvic pain
pelvic mass
alterend bowel habits
urinary symptoms
subfertility
```
67
complications of endometriosis
chronic pain
infertility
cyst formation and rupture
adhesions and scarring -> ureteric/bowel obstruction
68
investigations for endometriosis
VE/bimanual (mass, fixed retroverted uterus, uterosacral ligament nodules or tenderness)
TVUS
rectal endoscopic US
gold standard - diagnostic laparoscopy and biopsy
69
management of endometriosis
NSAIDS + COCP
progesterone - IM methypreogesterone, mirena coil
GnRH agonists (down regulates oestrogen)
cystectomy
ablative therapy of endometrial implants (electrosurgery/laser ablation/radical excision)
hysterectomy +/- BSO +/- peritoneal excisions
70
Define PCOS
a syndrome associated with set of symptoms as a result of elevated testosterone
Anovulatory symptoms (amenorrhoea, oligomenorrhoea)
symptoms of hyperandrogenism (hirsutism, acne, alopecia)
71
presentation of PCOS
amenorrhoea/oligomenorrhoea
hirsutism
severe acne
72
complications of PCOS
```
infertility
diabetes
hypertension
endometrial cancer
depression
```
73
Diagnosis of PCOS
rotterdam criteria: 2 of 3
1) clinical/biochemical evidence of hyperandrogenism
2) oligomenorrhoea/amenorrhoea
3) US features of PCO
74
investigations for PCOS
pelvic US
serum androgens (free testosterone, DHEAS, androstenedione)
serum LH and FSH
serum 17-hydroxyprogesterone
TFTs
serum prolactin
OGTT
lipid profile
75
Management of PCOS
weight loss
metformin
eflornithine (topical cream for hirsutism)
Fertility conserving
letrozole
clomifene
gonadotrophin injections (FSH)
```
non fertility conserving
COCP
spironolactone
corticosteroids
finasteride
```
76
common causative organisms of PID
chlamydia
gonorrhoea
mycoplasma
gardnerella
77
risk factors for PID
previous STIs, previous PID
unprotected sex, multiple partners, young onset of sexual activity
IUD
78
presentation of PID
```
history of prior STI
bilateral abdominal pain
abnormal vaginal bleeding, (post coital, inter-menstrual or menorrhagia)
purulent vaginal discharge
fever, nausea, vomiting
```
79
complications of PID
```
chronic PID
infertility
ectopic pregnancy
tubo-ovarian abscess
Fitz hugh curtis syndrome
```
80
clinical findings in PID
discharge, bleeding
cervical motion tenderness
uterine tenderness
adnexal tenderness
81
investigations for PID
```
swabs - vaginal, rectal, throat
vaginal secretions wet mount microscopy
vaginal secretions culture
WCC, CRP, ESR
pelvic CT
```
82
Management of PID
ceftriaxone, doxycycline, metronidazole
| consider removal of IUD
83
define menopause
LMP > 1 year ago
84
symptoms of menopause
```
hot flushes and sweats
loss of libido
mood changes
joint and muscle pain
urinary symptoms
```
85
diagnosis of menopause
```
clinical diagnosis (LMP>1year)
if <45 y.o. = FSH (2 results >30, 8 weeks apart)
if >50 and wants to stop hormonal contraception = 1 result >30 = can stop contraception in 12months
```
86
management of menopause
lifestyle (exercise, reduce alcohol, smoking and stress)
HRT (best for vasomotor symptoms)
CBT (mood and anxiety)
87
explain HRT
replaces E2
many types available (oral tablets, transdermal patch, vaginal ring, gel/cream)
given with progesterone (tablet, patch, IUS) to protect against endometrial cancer but increase risk of breast cancer
88
risks associated with HRT
endometrial, ovarian and breast cancer
VTE
cardiovascular disease
stroke
89
contraindications to HRT
```
history of breast cancer
untreated endometrial hyperplasia
current or recurrent VTE
thrombophilic disorders
liver disease with abnormal LFTs
```
90
describe the micturition cycle
```
bladder fills (low sympathetic sensory input from stretch receptors)
first sensation to void (onufs nucleus -> contracts EUS)
desire to void
micturition (inhibition of onufs and pelvic nerve to bladder -> detrusor contraction)
```
91
causes of stress incontinence
intrinsic sphincter deficiency/primary urethral weakness
insufficient suburethral support
defective striated or smooth muscle of the urethra and mucosal/submucosal cushions
92
investigations for urinary incontinence
urinalysis
bladder diary
cystoscopy and renal tract imaging
urodynamic testing (uroflowmetry, filling and voiding cystometry)
93
management for SUI
lifestyle - avoid caffeine and alcohol
first line = pelvic floor exercises
Duloxetine (SNRI)
surgical - midurethral sling, colposuspension, intramural bulking
94
causes of overactive bladder incontinence
bladder stones/tumours
diabetes
acute UTI
parkinson's, stroke, MS
95
management of OAB
```
avoidance of alcohol, caffeine
bladder retraining (scheduled voiding)
oxybutynin (anticholinergic) - if contraindicated then B3 adrenoreceptor agonist
```
detrusor muscle botox injections
percutaneous sacral nerve stimulation
augmented cystoplasty
96
describe the structural support of the pelvic floor
vaginal wall
transverse cervical ligaments
round and broad ligaments
uterosacral ligament
97
risk factors for prolapse
```
vaginal delivery (big baby, long time)
high parity
obesity, constipation
```
98
symptoms of prolapse
can be asymptomatic
vaginal
sensation of pressure, fullness, heaviness
sensation of "something coming down" - worse at end of day, better lying down
bleeding, discharge
dyspareunia
```
urinary symptoms
bowel symptoms (constipation, incontinence)
```
99
management of prolapse
lifestyle - smoking and weight loss
pelvic floor exercises
intra vaginal pessaries
surgery
100
physiological changes in pregnancy
RAAS stimulated -> increase BV
physiological anaemia, low platelets and low haematocrit
hypercoagulable state
increased circulating hormones -> headaches and migraines
relaxation of ligaments -> pelvic pain
increased PTH and Ca
relaxed smooth muscle -> constipation, reflux
101
what are some fetal complications of multiple pregnancies
miscarriage
congenital abnormalities
growth restriction
102
what are some maternal complications of multiple pregnancies
hyperemesis
pre-eclampsia
gestational diabetes
placenta previa
postpartum haemorrhage
postnatal depression/anxiety/poor relationship
103
complications associated with monochorionic twins
acute transfusion (Death of one twin in utero leads to increased risk of hypoxic-ischaemic injury in survivor due to acute transfusion from healthy to dying twin)
twin twin transfusion syndrome (chronic net shunting from one twin to the other: Donor twin = Growth restricted, oliguric, anhydramnios - Recipient twin = Polyuric, polyhydramnios, cardiac problems, hydrops
twin reversed arterial perfusion sequence (2 cords linked by a big arterio-arterial anastamosis, retrograde perfusion
One twin, called the acardiac twin or TRAP fetus, is severely malformed. The heart is missing or deformed, as are the upper structures of the body)
104
3 stages of labour
```
1 = reg contractions to cervix fully dilated
2 = full dilation to delivery of baby
3 = delivery of baby to delivery of placenta
```
105
what are the 8 cardinal movements of labour
```
engagement
descent
flexion
internal rotation
extension
external rotation
restitution
expulsion
```
106
indications for induction of labour
```
big baby
pre-eclampsia
post date
GDM
IUGR
```
107
methods of induction
sweep
foley's balloon
prostin (gel) or propess (slow release pessary)
oxytocin infusion
108
analgesia used in labour
entonox gas
opioids - IM diamorphine
regional blocks - epidural or spinal
109
when is labour diagnosed
regular painful contractions
at least 3cm dilated
cervix fully effaced
110
management of gestational diabetes
aim for glucose 4-7mmol/l
diet, metformin, insulin
stop all antiglycaemic medication post partum
111
define pre-eclampsia
new onset hypertension accompanied with proteinuria or other evidence of systemic involvement after 20 weeks gestation
112
risk factors for pre-eclampsia
primiparity
previous pre-eclampsia
BMI > 30
chronic hypertension
113
presentation of pre-eclampsia
```
headaches
scotoma, flashing lights
abdominal pain
oedema
seizure (indicates eclampsia)
```
114
investigations for pre-eclampsia
BP and urinalysis
FBC (thrombocytopenia)
LFTs (raised AST/ALT)
serum creatine (good indicator of disease progression)
umbilical artery doppler velocimetry and amniotic fluid assessment
foetal ultrasound, CTG
115
management of pre-eclampsia
frequent BP monitoring
aspirin at week 12 if high risk
IV labetalol
plan for delivery
116
management of eclampsia
```
magnesium sulphate (IM or IV)
monitor magnesium levels (toxicity can cause resp/cardiac failure)
urgent delivery of baby
```
117
management of pregnancy in WWE
folate - start at least 1 month prior to conception
adjust dose of AED (risk of teratogenicity) - preferably monotherapy
Vit K throughout pregnancy (Vit K for baby at birth)
seizure are usually self limiting but if not use rectal/IV diazepam
118
Causes of APH
```
placental abruption (part of the placenta covers the lower uterine wall - painless PV bleeding)
placental praevia (full or partial detachment of the placenta from uterine wall - painful PV bleeding, "woody" appearance)
uterine rupture (full thickness disruption of the uterine muscle - severe abdo pain between contractions, shoulder tip pain)
vasa praevia (foetal vessels rupture during active labour - triad of painless PV bleeding, foetal bradycardia, ruptured membranes)
local cause (polyps, cancer, ectropion, infection)
```
119
causes of PPH
tone - failure of the uterus to contract down
trauma - tears (usually 3rd/4th degree labial tear)
tissue - placenta praevia or abruption
thrombophilia
120
management if PPH
tone - bimanual compression, rusch catheter, B lynch sutures, uteritonic drugs (syntocinon, ergometrine), hysterectomy
trauma - suture the tears
tissue - remove the placenta
thrombophilia - give blood products
121
skin changes in pregnancy
```
atopic eruption in pregnancy (limbs and trunk, early onset - <3rd trimester)
polymorphic eruption in pregnancy (lower abdomen with umbilical sparring, striae)
pemphigoid gestinitis (urticarial wheals and bullae on abdomen)
```
