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OBGYN Flashcards

1
Q

What is adenomyosis?

A

Benign disease characterised by the occurrence of endometrial tissue within the myometrium (muscle layer of the uterus) due to the hyperplasia of the endometrial basal layer.

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2
Q

Risk factors for adenomyosis?

A

Later reproductive years (peak incidence is 35-50 yo)
Multiparous
Endometriosis
Uterine fibroids

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3
Q

Presentation of adenomyosis

A

1/3rd asymptomatic
Dysmenorrhoea
Menorrhagia
Dyspareunia
Abnormal uterine bleeding
Chronic pelvic pain, aggravated during menses
Infertility/pregnancy related complications

Globular, uniformly enlarged uterus that is soft but tender on palpation

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4
Q

Ix for adenomyosis

A

Transvaginal US
MRI is transvaginal US not suitable
Histology after hysterectomy confirms diagnosis

On imaging = myometrial wall thickening and myometrial cysts

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5
Q

Mx for adenomyosis

A

No contraception wanted:

  • Tranexamic acid (antifibrinolytic to reduce bleeding but not pain)
  • Mefenamic acid (NSAID to reduce pain and bleeding)

Contraception wanted:

  • 1st line: Mirena coil
  • COCP
  • Cyclic oral progesterones

More definitive options:

  • GnRH analogues (cause less FSH/LH secretion) to induce menopause like state
  • Endometrial ablation
  • Uterine artery embolisation
  • Hysterectomy
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6
Q

What are the pregnancy related associations with adenomyosis?

A 
1 Infertility
2 Miscarriage
3 Preterm birth
4 Small for gestational age
5 Preterm premature rupture of membranes
6 Malpresentation
7 Need for c section
8 Postpartum haemorrhage
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7
Q

What is androgen insensitivity syndrome?

A

Condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors.

Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics.

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8
Q

What is the inheritance pattern for androgen insensitivity syndrome?

A

X linked recessive

Mutation in the androgen receptor gene on X chromosome.

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9
Q

What is the genetic sex of a person with androgen insensitivity syndrome and what is their genetic phenotype?

A

Genetically male with XY sex chromosomes.

46XY

The absent response to testosterone and conversion of additional androgens to oestrogen = female phenotype externally (normal female external genitalia and great tissue)

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10
Q

What internal reproductive organs does a person have who has androgen insensitivity syndrome?

A
  • Testes in abdomen or inguinal canal
  • Absent uterus, upper vagina, cervix, Fallopian tubes, ovaries

Testes produce anti-Mullerian hormone which prevents them from developing female internal reproductive organs

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11
Q

What is partial androgen insensitivity syndrome and give some examples of how it could present?

A

The cells have a partial response to androgens.

Example presentations:

  • Ambiguous signs and symptoms
  • Micropenis / clitoromegaly
  • Bifid scrotum
  • Hypospadias
  • Diminished male characteristics
  • Failure of one or both testes to descend into the scrotum
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12
Q

Presentation of androgen insensitivity syndrome

A
  • Female external genitalia and physique
  • Blind ended vaginal pouch
  • Lack of pubic and facial hair
  • Taller than female average
  • Infertility
  • Increased risk of testicular cancer unless testes are removed
  • Inguinal hernia in infancy containing testes
  • Primary amenorrhoea at puberty
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13
Q

When is the diagnosis of partial androgen insensitivity and androgen insensitivity syndrome made?

A
  1. Partial androgen insensitivity is diagnosed at birth due to ambiguous genitalia
  2. Complete androgen insensitivity usually diagnosed at puberty as girls don’t get periods.
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14
Q

Ix for androgen insensitivity syndrome

A

Hormone tests:

  • Raised LH
  • Normal/raised FSH
  • Normal/raised testosterone levels (for a male)
  • Raised oestrogen (for a male)

Genetic testing - buccal smear for 46XY genotype
Pelvic US

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15
Q

Mx of androgen insensitivity syndrome

A

Options are:

  • Bilateral orchidectomy (removal of testes to reduce cancer risk)
  • Oestrogen therapy
  • Vaginal dilators or vaginal surgery to create adequate vagina length

Psychological support

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16
Q

What is Asherman’s syndrome

A

Adhesions (sometimes called synechiae) form within the uterus following damage to the uterus

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17
Q

Risk factors for Asherman’s syndrome

A

Following pregnancy
Dilation and curettage procedure (e.g., for tx of retained products of conception)
Uterine surgery
Pelvic infections

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18
Q

Presentation of Asherman’s syndrome

A

Following recent dilation and curettage, uterine surgery or endometritis:

  • Secondary amenorrhoea
  • Significantly lighter periods
  • Dysmenorrhoea
  • Infertility
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19
Q

Ix for Asherman’s syndrome

A
  • Hysteroscopy - gold standard. Can dissect and treat the adhesions
  • Hysterosalpingography - inject contrast into the uterus and do x-ray = HONEYCOMB APPEARANCE of uterus
  • Sonohysterography - uterus filled with fluid and pelvic US performed
  • MRI scan
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20
Q

Treatment for Asherman’s syndrome

A

Hysteroscopic dissection of adhesions

Recurrence of adhesions after dissection is common.

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21
Q

What is atrophic vaginitis?

A

Dryness and atrophy of the vaginal mucosa related to a lack of oestrogen.

Also called:
- Genitourinary syndrome of menopause

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22
Q

what is the pathology of atrophic vaginitis?

A

Oestrogen makes the epithelial lining of the vagina and urinary tract thicker, more elastic and produce secretions.
After menopause, low oestrogen levels result in thinner, less elastic and dry mucosa.
Tissue prone to inflammation
Changes in vagina pH and microbial flora = localised infections

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23
Q

Symptoms of atrophic vaginitis

A
  • Itching
  • Dryness
  • Dyspareunia
  • Bleeding due to localised inflammation
  • Recurrent UTIs
  • Stress incontinence
  • Pelvic organ prolapse
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24
Q

Signs of atrophic vaginitis on examination

A
  • Pale mucosa
  • Thin skin
  • Reduced skin folds
  • Erythema and inflammation
  • Dryness
  • Sparse pubic hair
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25
Q

Mx for atrophic vaginitis

A
  1. Vaginal lubricants
  2. Topical oestrogen - estriol cream, estriol pessaries, estradiol tablets, estradiol ring
  3. HRT if menopausal
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26
Q

CIs for topical oestrogens

A
  • Breast cancer
  • Angina
  • VTE
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27
Q

Diagnosis of atrophic vaginitis

A

Clinical on examination

Can do a pH test but this is non-specific

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28
Q

What is bacterial vaginosis?

A

An overgrowth of anaerobic bacteria in the vagina caused by a loss of lactobacilli (friendly bacteria that produce lactic acid to keep the pH of the vagina low, preventing other bacteria from overgrowing).

Not an STI but increases to risk of developing an STI.

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29
Q

Examples of anaerobic bacteria associated with bacterial vaginosis

A

Gardnerella vaginalisis (most common )
Mycoplasma hominis
Prevotella species

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30
Q

Risk factors for bacterial vaginosis

A
  • Multiple sex partners
  • Excessive vaginal cleaning e.g. soaps, douching
  • Recent abx
  • Smoking
  • Copper coil
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31
Q

Presentation of bacterial vaginosis

A

Fishy smelling watery grey/white vaginal discharge

1/2 of women are asymptomatic

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32
Q

Ix for bacterial vaginosis

A

Speculum examination - to look for discharge
High vaginal swab - to rule out other causes
Vaginal pH - >4.5

CLUE CELLS on microscopy (epithelial cells from the cervix with bacteria stuck inside them - usually gardnerella vaginalis)

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33
Q

Mx for bacterial vaginosis

A

Asymptomatic = no tx

Symptomatic =
- Metronidazole oral/vaginal gel 5-7 days (targets anaerobic bacteria)
No alcohol while taking metronidazole (disulfaram like reaction = nausea, vomiting, shock, angioedema)

Advice about reducing risk of future episodes

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34
Q

Complications of bacterial vaginosis

A

Increased risk of catching STI

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35
Q

Pregnancy related complications of bacterial vaginosis

A
  • Miscarriage
  • Preterm delivery
  • Premature rupture of membranes
  • Chorioamnionitis
  • Low birth weight
  • Postpartum endometritis

Use metronidazole in pregnancy to treat BV

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36
Q

What criteria is used for the diagnosis of bacterial vaginosis?

A 
Amsel's criteria
(need 3 /4)
1. Clue cells on microscopy 
2. Vaginal ph >4.5
3. +ve Whiff test - fishy smell on addition of potassium hydroxide
4. Thin white homogenous discharge
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37
Q

What is cervical cancer and what type of cancer is it usually?

A

A human papilloma virus related malignancy of the cervical mucosa.

Usually is SQUAMOUS CELL CARCINOMA
2nd most common type = adenocarcinoma

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38
Q

Risk factors for cervical cancer

A 
Sex
Human papilloma virus types 16, 18 and 31
Sexual intercourse at an early age
Multiple sex partners
High risk male partners
Immunosuppression (HIV/AIDS)
Smoking 
COCP use
Non engagement with cervical screening 
High parity
Low socioeconomic income
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39
Q

What is HPV?

A

Human Papilloma virus

Most common cause of cervical cancer
Also associated with anal, vulval, vagina, penis, mouth and throat cancers.

Is a STI

Types 16 and 18 are responsible for 70% of cervical cancers

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40
Q

Symptoms and signs of cervical cancer

A

Asymptomatic

Early symptoms:

  • Offensive and watery vaginal discharge
  • Intermenstrual bleeding
  • Post coital bleeding
  • Contact bleeding
  • Post menopausal bleeding

Advanced cases:

  • Pelvic and back pain
  • Symptoms of uraemia
  • Dyspareunia
  • Leg oedema
  • Obstructive uropathy and hydronephrosis
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41
Q

Appearance of the cervix in advanced cervical cancer

A

Ulceration
Inflammation
Bleeding
Visible tumour

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42
Q

What are premalignant lesions in the cervix called?

A

cervical intraepithelial neoplasia (CIN)

CIN = the abnormal growth of cells in the transformation zone of the cervix. Is a grading system for the level of dysplasia (premalignant change) diagnosed at colposcopy.

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43
Q

How is CIN detected?

A

Biopsy

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44
Q

What are the 3 types of CIN and how likely is each type to progress?

A

CIN 1 = mild dysplasia (few progress to CIN2, likely to return to normal without tx)

CIN 2 = moderate dysplasia (20-25% progress to CIN3)

CIN 3 = severe dysplasia or carcinoma in situ (cancer precursor, 30-70% develop cervical cancer over 10 years)

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45
Q

What is the screening programme for cervical cancer in the UK?

A

Smear test to collect cells from the cervix with a small brush, then transported to lab via liquid based cytology for detection of dyskaryosib (precancerous changes).

Every 3 years for women 25-49 yo
Every 5 yrs for women 50-64 yo

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46
Q

What is done with a smear sample?

A

Initially tested for high risk HPV.

-ve for high risk HPV = normal smear, and women returned to normal screening programme

+ve for high risk HPV = do cytology (cytology looks for dyskaryosis)

Cytology results:

  • Normal = repeat in 12 months
  • Abnormal = colposcopy
  • Inadequate = repeat in 3 months
  • 2 inadequate samples = colposcopy
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47
Q

Biopsy methods used to detect CIN

A

Smear test - cytology (only done after found to be high risk HPV +ve)

Colposcopy: large loop excision of the transformation zone (LLETZ)

Cone biopsy

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48
Q

What happens during colposcopy?

A

A speculum is inserted and a colposcope used to magnify the cervix.

Acetic acid and iodine solutions are used to stain and differentiate abnormal areas.

Do punch biopsy or large loop excision of transformation zone to get a sample for histology

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49
Q

Why is acetic acid used in colposcopy?

A

Causes abnormal cells to appear white (acetowhite).

Occurs in cells with increased nuclear material = cervical intraepithelial neoplasia and cervical cancer cells

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50
Q

Why is iodine staining used in colposcopy? and what is this test called?

A

Schiller’s iodine test

Iodine solution used to stain cells, healthy cells go a brown colour.

Abnormal areas don’t stain

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51
Q

What happens during a large loop excision of the transformation zone and what should you tell the patient for afterwards?

A

Performed during colposcopy, using local anaesthetic. Diathermy is used to remove abnormal epithelial tissue.

  • Bleeding/abnormal discharge for several weeks
  • Intercourse and tampons avoided after procedure (risk of infection)
  • Risk of preterm labour depending on depth of tissue removed
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52
Q

What is a cone biopsy and what are the main risks?

A

Used for treatment of CIN and very early stage cervical cancer.

Under GA

Remove a cone shaped piece of cervix with scalpel

Main risks:

  • Pain
  • Bleeding
  • Infection
  • Scar formation = stenosis of cervix
  • Increased risk of miscarriage/premature labour
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53
Q

Staging of cervical cancer

A

Stage O – carcinoma in situ: intraepithelial carcinoma

Stage I – confined to the cervix

Stage II – extends beyond the cervix onto either the vagina or parametrium but not to the lower 1/3rd of the vagina & not to the pelvic wall

Stage III – extension either to the lower 1/3rd of the vagina or pelvic wall.
Hydronephrosis or non-functioning kidney with no apparent cause warrants allocation to stage IIIb.

Stage IV – Extension beyond the true pelvis or involvement of mucosa of bladder or rectum

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54
Q

Mx of cervical cancer

A

CIN / early stage I = LLETZ pr cone biopsy

Stage I- II = radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy

Stage II-IV = chemotherapy and radiotherapy

Stage IV b = palliative care, chemo/radiotherapy

Pelvic exenteration = removal of all pelvic organs in very advanced disease
Bevacizumab - monoclonal antibody used to target VEGF

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55
Q

Prevention of cervical cancer

A

HPV vaccine

  • Given to boys and girls before they become sexually active to prevent them from contracting HPV
  • Current vaccine = Gardasil
  • Vaccine protects against strains 6, 11, 16 and 18

6& 11 = genital warts
16 & 18 = cervical cancer

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56
Q

Complications of cervical cancer

A 
Uraemia (due to ureteral obstruction)
Severe bleeding 
Sepsis 
PE
Infiltration of the ureter = urinary obstruction, hydronephrosis, kidney failure 
Fistula formation
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57
Q

What is cervical show and the mucus plug?

A

When the mucus plug comes free and is discharged towards the end of pregnancy. Can happen several days before labour starts or at the start of labour when the cervix dilates.

Mucus plug = mucus accumulates in the cervix during pregnancy to form a plug hat seals the entrance to the uterus and protects it from infection.

Bloody show = discharge is tinged pink or brown/streaks of blood

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58
Q

What causes chlamydia?

A

Chlamydia trachomatis

Gram negative bacteria

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59
Q

symptoms of chlamydia in women

A 
Asymptomatic
Dysuria
Abnormal vaginal discharge 
Intermenstrual / post coital bleeding 
Deep dyspareunia 
Lower abdominal pain 
Cervical excitation
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60
Q

symptoms of chlamydia in men

A 
Urethritis (dysuria, urethral discharge)
Epididymo-orchitis - testicular pain 
Epididymal tenderness
Mucopurulent 
Reactive arthritis
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61
Q

Diagnosis of chlamydia in women

A

Nucleic acid amplification test (NAAT), from one of the following samples (in order of preference):

  1. endocervical swab
  2. vulvo-vaginal swab (self taken lower vaginal swab)
  3. First catch urine sample
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62
Q

Diagnosis of chlamydia in men

A

Nucleic acid amplification test (NAAT), from one of the following samples (in order of preference):

  1. First catch urine smaple
  2. Urethral swab
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63
Q

Apart from genital swabs/first catch urine, what other samples should you consider taking for chlamydia?

A

Rectal and pharyngeal NAAT swabs for chlamydia in the rectum or throat.

Do gonorrhoea testing (endocarvical charcoal swab)

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64
Q

Mx of chlamydia

A

Doxycycline 100mg BD 7 days

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65
Q

Mx of chlamydia in pregnancy

A

Doxycycline is CI in pregnancy and breastfeeding.

Give:
Azithromycin 1g stat then 500mg OD 2 days
or
Erythromycin 500mg QDS 7 days

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66
Q

When should you test for a cure of chlamydia?

A

Rectal chlamydia
Pregnancy
When symptoms persist

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67
Q

Patient information when diagnosed with chlamydia

A

Abstain from sex for 7 days
Treatment of all partners to reduce re-infection
Refer to GUM for contact tracing and notification of sexual partners (trace back 4 weeks for symptomatic men and 6 months for women/asymptomatic men)
Provide advice about preventing future infections
Consider safeguarding

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68
Q

Complications of chlamydia

A 
PID
Chronic pelvic pain
Infertility 
Ectopic pregnancy 
Epididymo-orchitis 
Conjunctivitis 
Lymphogranuloma venereum
Reactive arthritis
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69
Q

Pregnancy related complications of chlamydia

A 
Preterm delivery 
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis & pneumonia)
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70
Q

What is lymphogranuloma venereum

A

Condition affecting the typhoid tissue around the site of infection with chlamydia.
Most commonly seen in MSM.

Primary stage = painless ulcer on penis/vagina/rectum
Second stage = lymphadenitis in inguinal/femoral lymph nodes
Tertiary stage = proctitis (inflammation of rectum) = anal pain, change in bowel habit. tenesmus and discharge

Give doxycycline 100mg BD for 21 days

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71
Q

What screening is available for chlamydia?

A

National screening programme for people aged 15-24

Opportunistic screening of sexually active

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72
Q

What is cord prolapse?

A

the umbilical cord descends below the presenting part of the foetus and through the cervix into the vagina, after the rupture of the fetal membranes.

Significant danger of the presenting part compressing the cord = fetal hypoxia

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73
Q

Risk factors for cord prolapse

A 
Abnormal lie after 37 weeks gestation 
Prematurity
Multiparity
Polyhydramnios
Twin pregnancy 
Cephalopelvic disproportion
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74
Q

Diagnosis of cord prolapse

A

50% occur at artificial rupture of membranes
Fetal distress on CTG
Vaginal examination
Speculum exam to confirm diagnosis

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75
Q

Mx cord prolapse

A

Emergency C-section

Do not push the cord back in/touch the cord = vasospasm
Keep the cord warm and wet

If baby is compressing the cord - push the presenting part upwards while the women lies in left lateral position with a pillow under the hip or in knee chest position (all 4s) - using gravity to draw the foetus away from the pelvis

Retrofitting of the bladder via a catheter (500mls saline)

Terbutaline (tocolytic medication) - minimise contractions

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76
Q

What is gestational diabetes?

A

Diabetes triggered by pregnancy as pregnancy causes a reduced insulin sensitivity (placenta secretes substances that have an anti-insulin property).

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77
Q

Risk factors for gestational diabetes

A 
Previous gestational diabetes
Previous macrosomic baby >4.5kg
BMI >30
Ethnic origin 
Family hx of diabetes 
Maternal age >40
PCOS
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78
Q

Symptoms of gestational diabetes

A

Elevated BMI
Fetal macrosomia
Polyuria
Polydipsia

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79
Q

Ix for gestational diabetes

A

Oral glucose tolerance test

  • Screening test
  • Performed after overnight fast of at least 8 hours
  • Drink 75g glucose drink at the start of the test, BM measured before drink and 2 hours later
  • If previous GDM - test ASAP & again at 24-28 weeks
  • Risk factors/symptoms - test at 24-28 weeks

Normal result =

  • fasting <5.6
  • at 2 hours <7.8

(think 5 - 6 - 7 - 8)

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80
Q

Mx of gestational diabetes

A
  1. Women must monitor their BMs
  2. 4 weekly USS to monitor fetal growth and amniotic fluid vol (28-36 weeks)
  3. Fasting glucose <7 = trial diet and exercise 1-2 wks, metformin then insulin
  4. Fasting glucose >7 = insulin +/- metformin
  5. Fasting glucose >6 + macrosomia = insulin +/- metformin

Use short acting insulin in GDM
Can’t tolerate metformin or refuse insulin = glibenclamide (a sulfonylurea)

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81
Q

What should women with pre-existing diabetes do before conception?

A

Good glucose control

5mg folic acid from preconception until 12 weeks gestation

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82
Q

What medications should women with pre-existing diabetes be taking?

A

stop oral hypoglycaemic agents apart from metformin

Start insulin if needed

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83
Q

Management for pregnant women with pre-existing diabetes

A
  • Metformin + insulin
  • Weight loss if BMI >27
  • Detailed anomaly scan at 20 weeks
  • Retinopathy screening
  • Planned delivery at 37-38 + 6 weeks
  • Sliding scale insulin regime during labour (dextrose & insulin infusion titrated to blood sugar levels)
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84
Q

Postnatal care required for women with gestational diabetes

A

Diabetes improves immediately after birth
GDM = stop meds immediately after birth
Follow up of fasting glucose 6 weeks after birth

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85
Q

Postnatal care required for women with pre-existing diabetes

A

Lower insulin and be aware of hypoglycaemia in postnatal period - insulin sensitivity will increase after birth and with breastfeeding

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86
Q

What are babies at risk of if their mother is diabetic?

A 
Neonatal hypoglycaemia - requires close monitoring with regular Bus and frequent feeds. aim for BM >2, need IV dextrose/NG feeding if below.
Polycythemia (^Hb)
Jaundice 
Congenital heart disease
Cardiomyopathy 
Macrosomia
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87
Q

What is abnormal uterine bleeding

A

Irregularities in the menstrual cycle: frequency, duration, regularity of cycle length and volume of menses.
Irregular menstrual periods indicate anovulation or irregular ovulation.

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88
Q

Causes of abnormal uterine bleeding

A

PALM - COEIN
[Palm = structural causes, Coein = non-structural causes)

P = polyps
A = adenomyosis
L = leiomyomas 
M = malignancy / hyperplasia
C = coagulopathy 
O = ovulatory dysfunction 
E = endometrial
I = iatrogenic 
N = not yet classified

Extremes of reproductive age
PCOS
Physiological stress
Medication e.g. progesterone only contraception
Hormone imbalances - thyroid, Cushings, high prolactin

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89
Q

Causes of primary amenorrhoea

A

Hypogonadotrophic hypogonadism (abnormal functioning of the hypothalamus/pituitary gland)

Hypergonadotrophic hypogonadism (abnormal gonads)

Imperforate hymen

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90
Q

Causes of secondary amenorrhoea

A 
Pregnancy
Menopause
Physiological stress
PCOS
Medications e.g., contraceptives
Premature ovarian insufficiency 
Thyroid hormone abnormalities 
Excessive prolactin from a prolactinoma 
Cushing's syndrome
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91
Q

Causes of Intermenstrual bleeding

A 
Hormonal contraception 
Cervical ectropion, polyps or cancer
STI
Endometrial polyps or cancer
Vaginal pathology 
Pregnancy 
Ovulation
Medications - SSRIs and anticoagulants
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92
Q

causes of dysmenorrhoea

A 
Primary dysmenorrhoea 
Endometrosis
Adenomyosis 
Fibroids
PID
Copper coil
Cervical or ovarian cancer
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93
Q

causes of menorrhagia

A 
Dysfunctional uterine bleeding 
Extremes of reproductive age
Fibroids
Endometriosis/adenomyosis 
PID
Copper coil
Anticoagulant medications
Bleeding disorders e.g. VWD
Diabetes
Hypothyroidism 
Connectve tissue disorders
Endometrial hyperplasia or cancer
PCOS
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94
Q

causes of post coital bleeding

A 
Cervical cancer, ectropion, infection 
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer
95
Q

Causes of pelvic pain

A 
Urinary tract infection
Dysmenorrhoea (painful periods)
Irritable bowel syndrome (IBS)
Ovarian cysts
Endometriosis
PID (infection)
Ectopic pregnancy
Appendicitis
Mittelschmerz (cyclical pain during ovulation)
Pelvic adhesions
Ovarian torsion
Inflammatory bowel disease (IBD)
96
Q

Causes of vaginal discharge

A 
Bacterial vaginosis - clear fishy smelling 
Candidiasis (thrush) - creamy white and thick 
Chlamydia - yellow strong smelling 
Gonorrhoea - white or green discharge 
Trichomonas vaginalis - thin increased volume 
Foreign body
Cervical ectropion
Polyps
Malignancy
Pregnancy
Ovulation (cyclical)
Hormonal contraception
97
Q

causes of pruritus vulvae

A 
Irritants such as soaps, detergents and barrier contraception
Atrophic vaginitis
Infections such as candidiasis (thrush) and pubic lice
Skin conditions such as eczema
Vulval malignancy
Pregnancy-related vaginal discharge
Urinary or faecal incontinence
Stress
98
Q

what is an ectopic pregnancy?

A

A pregnancy that is implanted outside the uterus. The most common site is a Fallopian tube.
Can implant in the entrance to the Fallopian tube = corneal region, ovary, cervix or abdomen

99
Q

Risk factors for ectopic pregnancy

A 
Previous ectopic pregnancy
Previous pelvic inflammatory disease
Previous surgery to the fallopian tubes
Intrauterine devices (coils)
Older age
Smoking
100
Q

Presentation of ectopic pregnancy

A 
Presents around 6-8 weeks gestation.
Missed period
Constant lower abdominal pain in R or L iliac fossa
Vaginal bleeding 
Lower abdominal or pelvic tenderness 
Cervical motion tenderness

Ask about:

  • Unprotected sex
  • Dizziness/syncope (blood loss)
  • Shoulder tip pain (peritonitis)
101
Q

Ix for ectopic pregnancy

A

bHCG
Transvaginal USS - see gestational sac with yolk sac or fetal pole in Fallopian tube, empty uterus, fluid in the uterus (pseudogestional sac)

102
Q

What is a pregnancy of unknown location?

A

Positive pregnancy test with no evidence of pregnancy on the USS.
Can’t exclude an ectopic

103
Q

How do you manage a pregnancy of unknown origin?

A

Serial bHCG

  • Check after 48 hours
  • In an intrauterine pregnancy the bHCG will double every 48 hrs. Repeat USS in 1-2 weeks to confirm intrauterine.
  • In an ectopic pregnancy/miscarriage the bHCG will not double every 48 hours. Close monitoring.
  • Fall in bHCG of >50% over 48 hours = miscarriage. Do a urine pregnancy test 2 weeks later to ensure complete miscarriage
104
Q

Management of ectopic pregnancy

A

Pelvic pain/tenderness + positive pregnancy test = refer to early pregnancy assessment unit

All ectopic pregnancies need to be terminated.

3 options:

  1. expectant management (natural termination)
  2. Medical management (methotrexate)
  3. Surgical management (salpingectomy or salpingostomy)
105
Q

Criteria for expectant management of ectopic pregnancy

A
  • Follow up needs to be possible
  • Unruptured ectopic
  • Adnexal mass <35mm
  • No visible heartbeat
  • No significant pain
  • HCG <1500
106
Q

Criteria for medical management of ectopic pregnancy

A
  • Follow up needs to be possible
  • Unruptured ectopic
  • Adnexal mass <35mm
  • No visible heartbeat
  • No significant pain
  • HCG <5000

+confirmed absence of intrauterine pregnancy on US

107
Q

Side effects of medical management of ectopic pregnancy

A

Use of methotrexate:

  • IM injection into buttock
  • Halts the process of pregnancy + spontaneous termination

Cannot get pregnant for 3 months after treatment = harmful effects can last

Common SEs:

  • Vaginal bleeding
  • Nausea and vomiting
  • Abdominal pain
  • Stomatitis (inflammation of the mouth)
108
Q

Criteria for surgical management of ectopic pregnancy

A
  • Pain
  • Adnexal mass >35 mm
  • Visible heartbeat
  • HCG >5000
109
Q

Surgical options for management of ectopic pregnancy

A

Laparoscopic salpingectomy

  • GA
  • Removal of affected Fallopian tube

Laparoscopic salpingotomy

  • Done for women at increased risk of infertility due to damage to the other tube
  • Cut open the Fallopian tube, ectopic pregnancy removed, tube closed
  • Increased risk of failure to remove ectopic pregnancy

Give anti-rhesus d prophylaxis to rhesus negative women having surgical management

110
Q

What is endometrial cancer?

A

Cancer of the endometrium that lines the uterus

80% adenocarcinomas

Oestrogen dependent cancer e.g., oestrogen stimulates the growth of endometrial cancer cells

111
Q

What do you need to rule out for any woman presenting with postmenopausal bleeding?

A

Endometrial cancer

112
Q

Risk factors for endometrial cancer

A 
Age 55-65
Postmenopausal 
Unopposed oestrogen:
- Early menarche and delayed menopause
- Infertile, hx of repeated abortions 
- Nulliparity
- Obesity
- PCOS
- Oestrogen therapy without progesterones 
- Tamoxifen 
HTN
DM
Lynch syndrome - hereditary non-polyposis colorectal carcinoma  (HNPCC)
Endometrial hyperplasia 
Family hx
113
Q

Protective factors

A

COCP
Mirena coil
Increased pregnancies
Cigarette smoking

114
Q

What is a precancerous condition that can lead to endometrial cancer?

A

Endometrial hyperplasia

Most cases return to normal, 5% progress to endometrial cancer.

Mx: Mirena coil or continuous oral progestogens

115
Q

Presentation of endometrial cancer

A 
Postmenopausal bleeding 
Postcoital bleeding 
Intermenstrual bleeding 
Unusually heavy menstrual bleeding 
Abnormal vaginal discharge 
Haematuria 
Anaemia
Raised platelet count
116
Q

Referral criteria for endometrial cancer

A

2 week wait for:
- Post menopausal bleeding

Transvaginal USS for women 55yo+ if:

  • Unexplained vaginal discharge
  • Visible Haematuria + raised platelets, anaemia or elevated glucose levels
117
Q

Ix for endometrial cancer

A
  1. Transvaginal USS for endometrial thickness (normal <4mm post menopause)
  2. Pipelle biopsy (sensitive for endometrial ca)
  3. Hysteroscopy with endometrial biopsy
118
Q

Staging of endometrial cancer

A

Stage 1 = confined to uterus
Stage 2 = invades cervix
Stage 3 = invades ovaries, Fallopian tubes, vagina or lymph nodes
Stage 4 = invades bladder, rectum or beyond the pelvis

119
Q

Mx for endometrial cancer

A

Stage 1 and 2 = total abdominal hysterectomy with bilateral sapling-oophorectomy

Can have radiotherapy, chemotherapy, progesterone hormonal treatment to stop growth of cancer

120
Q

What is endometriosis?

A

Ectopic endometrial tissue is found outside of the uterus.

Endometrioma = a lump of endometrial tissue outside of the uterus

121
Q

what is a chocolate cyst?

A

Endometriomas in the ovaries

122
Q

Theories about the aetiology of endometriosis

A
  1. Retrograde menstruation through the Fallopian tubes into the pelvis and peritoneum where endometrial tissue seeds itself
  2. Uterine embryonic cells remain outside of the uterus
  3. Spread of endometrial cells via the lymphatic system
  4. Cells outside of the uterus go through metaplasia and become endometrial cells
123
Q

Risk factors for endometriosis

A

Reproductive age group
Positive family history
Nulliparity
Mullerian anomalies

124
Q

Symptoms of endometriosis

A
  • Dysmenorrhoea
  • Pre or post menstrual bleeding
  • Chronic or cyclic pelvic pain – worsens with onset of menses
  • Deep Dyspareunia
  • Sub-fertility
  • Uterosacral ligament nodularity
  • Pelvic mass
  • Fixed, retroverted uterus
  • Depression
  • Dysuria, flank pain and haematuria
  • Dyschezia (painful bowel movements), haematochezia (fresh blood in stool)
  • Infertility
125
Q

Ix for endometriosis

A

Pelvis USS - unremarkable or large endometriomas and chocolate cysts

Laparoscopic surgery - gold standard investigation. Biopsy lesions during laparoscopy and remove deposits of endometriosis to improve symptoms

126
Q

Examination findings in endometriosis

A

Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
Fixed cervix on bimanual examination
Tenderness in vagina, cervix and adnexa

127
Q

Mx of endometriosis

A

Initial management:

  • Establish a diagnosis
  • Provide clear explanation
  • Analgesia and NSAIDs

Hormonal management:

  • COCP
  • Progesterone only pill
  • Medroxyprogesterone acetate injections e.g., depo-provera
  • Nexplanon implant
  • Mirena coil
  • GnRH agonists (goserelin)3

Surgical management

  • Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions
  • Hysterectomy
128
Q

What are endometrial polyps

A

Focal overgrowth of localised benign endometrial tissue

129
Q

Risk factors for endometrial polyps

A 
HTN
Obesity
Tamoxifen / HRT
Hx of cervical polyps
Lynch syndrome (hereditary non-polyposis colorectal cancer)
130
Q

Characteristics of endometrial polyps

A
  • Localised within the uterine wall and extend into the uterine cavity
  • Can be pedunculated or sessile
  • Can be single or multiple
  • Can be up to many cm in size
  • May contain smooth muscle cells +/- blood vessels
  • Express both oestrogen and progesterone receptors (oestrogen stimulates growth)
131
Q

Symptoms of endometrial polyps

A

Usually asymptomatic

  • Irregular menstrual bleeding
  • Spotting
  • Menorrhagia
  • Postmenopausal bleeding
  • Infertility
132
Q

Ix for endometrial polyps

A

Transvaginal US
Hysteroscopy
Endometrial biopsy to rule out other conditions e.g. endometrial hyperplasia or carcinoma

133
Q

Mx for endometrial polyps

A

Asymptomatic women = observe and follow up

Symptomatic women= Surgical removal

134
Q

What epilepsy drugs are safe in pregnancy?

A

Levetiracetam
Lamotrigine
Carbamazepine

135
Q

What epilepsy drugs are not safe in pregnancy?

A 
Sodium valproate (neural tube defects)
Phenytoin (cleft lip/palate)
136
Q

Management of epilepsy in pregnancy

A
  • Folic acid 5mg before conception
  • Epilepsy controlled with a single anti-epileptic before conception
  • Seizure control can worsen in pregnancy due to stress, lack of sleep, hormonal changes and altered medications
137
Q

HTN medications unsafe in pregnancy

A

ACEi
ARBs
Thiazide like diuretics

[Can cause congenital abnormalities]

138
Q

HTN medications safe in pregnancy

A

Labetalol
CCB - nifedipine
A blocker - doxazosin

139
Q

management for women at high risk of pre-eclampsia in pregnancy

A

Aspirin 75mg OD from 12 weeks until birth

High risk groups:

  • HTN during previous pregnancy
  • CKD
  • SLE / antiphospholipid syndrome
  • T1DM / T2DM
140
Q

What happens to BP during normal pregnancy?

A

BP falls in the 1st trimester
Continues to fall until 20-24 weeks
After this BP increases to pre-pregnancy levels by term

141
Q

What is HTN in pregnancy defined as?

A

> 140/90
OR
increase above booking readings of >30/15

142
Q

3 categories of HTN in pregnancy

A
  1. Pre existing HTN (>140/90 before pregnancy, no proteinuria, no oedema )
  2. Pregnancy induced HTN (PIH) (HTN after 20 weeks, no proteinuria, no oedema - resolves after birth)
  3. Pre-eclampsia (HTN + proteinuria + oedema)
143
Q

what are fibroids?

A

Also called uterine leiomyoma

Benign smooth muscle tumours of the uterus

Oestrogen sensitive

144
Q

Types of uterine fibroids

A
  1. Intramural - within the myometrium, change the shape of the uterus as they grow
  2. Subserosal - below the outer layer of the uterus, grow outwards filling the abdominal cavity
  3. Submucosal - below endometrium
  4. Pedunculated - on a stalk
145
Q

Symptoms of fibroids

A 
asymptomatic
Menorrhagia
Prolonged menstruation 
Abdominal pain 
Bloating/feeling full
Urinary/bowel symptoms
Deep dyspareunia 
Reduced fertility
Polycythaemia (autonomous production of erythropoietin)
146
Q

Ix for fibroids

A

Hysteroscopy
Pelvic USS
MRI scan
Bimanual pelvic examination - irregularly enlarged firm uterus

147
Q

Mx for fibroids

A

Asymptomatic = no mx

<3cm & symptomatic:

  • Mirena
  • NSAIDs + tranexamic acid
  • COCP
  • Cyclic oral progestogens
  • Endometrial ablation
  • Resection during hysteroscopy
  • Hysterectomy

> 3cm & symptomatic

  • Same medical management as above
  • GnRH agonist before surgery to shrink fibroid (goserelin)
  • Uterine artery embolisation
  • Myomectomy
  • Hysterectomy
148
Q

Risk factors for fibroids

A

Early menace
Nulliparity
Reproductive years

149
Q

Complications of fibroids

A 
Menorrhagia - iron deficiency anaemia
Reduced fertility
Miscarriage/premature labour 
Constipation 
Urinary outflow obstruction & UTIs
Red degeneration of fibroid
Torsion of fibroid (pedunculated)
Malignant change to leiomyosarcoma
150
Q

What is red degeneration of fibroids

A

Ischaemia, infarction and necrosis of fibroid

Usually in pregnancy
Severe abdo pain + fever + pregnancy + hx of fibroids

mx = supportive, rest, fluids, analgesia

151
Q

What are genital warts caused by?

A

HPV types 6 and 11

152
Q

Symptoms of genital warts

A

small (2 - 5 mm) fleshy protuberances which are slightly pigmented
may bleed or itch
- Warts affecting penis, scrotum, vulva, inside vagina, cervix, perianal skin or inside anus
- Can be weeks, months or years after initial infection
- Painless fleshy growths

153
Q

Tx for genital warts

A

Topical treatments:

  • Podophyllotoxin
  • Imiquimod

Physical ablation

  • Excision
  • Cryotherapy
  • Electrosurgery
  • Laser surgery

Vaccination

154
Q

What causes gonorrhoea?

A

Neisseria gonorrhoeae

Gram negative diplococcus

155
Q

incubation period for gonorrhoea?

A

2-5 days

156
Q

What is gonorrhoea?

A

STI where neisseria gonorrhoeae infects mucous membranes with columnar epithelium (endocervix, urethra, rectum, conjunctiva, pharynx). Spreads via contact with mucous secretions from infected areas

157
Q

Symptoms of gonorrhoea

A 
Females:
-	Altered/increased vaginal discharge (commonly thin, watery, green/yellow)
-	Dysuria
-	Dyspareunia
-	Lower abdominal pain
-	Easily induced cervical bleeding
-	Pelvic tenderness
Men:
-	Mucopurulent / purulent urethral discharge
-	Dysuria

Can get anal and pharyngeal infection

158
Q

Diagnosis of gonorrhoea

A

NAAT to detect RNA or DNA of gonorrhoea on endocarvical, vulvovaginal or urethral swabs or first catch urine

MSM = rectal and pharyngeal swabs too

+ do charcoal swab for MC&S before using abx due to high rates of antibiotic resistance

159
Q

Mx for gonorrhoea

A

IM ceftriaxone single dose if sensitivies not known

Oral ciprofloxacin single dose 500mg if sensitivities known

  • Look at local resistances
  • Refer to GUM for contact tracing
  • Follow up test of cure with NAAT
  • Abstain from sex for 7 days of treatment
  • Provide advice about future reinfection
160
Q

Complications of gonorrhoea

A 
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Epididymo-orchitis (men)
Prostatitis (men)
Conjunctivitis - in neonates (ophthalmia neonatorum)
Urethral strictures
Disseminated gonococcal infection - untreated gonorrhoea, bacteria spreads to skin and joints causing skin lesions, polyarthralgia, tenosynovitis and systemic symptoms
Skin lesions
Fitz-Hugh-Curtis syndrome - inflammation of liver capsule
Septic arthritis
Endocarditis
161
Q

What is group B strep infection in newborns?

A

This is a common bacteria found in the vagina. It does not cause any problems for the mother, but can be transferred to the baby during labour and cause neonatal sepsis. Prophylactic antibiotics during labour are used to reduce the risk of transfer if the mother is found to have GBS in their vagina during pregnancy.

162
Q

Risk factors for GBS

A
  • Prematurity
  • Prolonged rupture of membranes
  • Previous sibling GBS infection
  • Maternal pyrexia e.g. secondary to chorioamnionitis (mum has fever >38)
163
Q

When to investigate and treat GBS

A
  • universal screening for GBS should not be offered to all women
  • a maternal request is not an indication for screening
  • women who’ve had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered maternal intravenous antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
  • if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
  • maternal intravenous antibiotic prophylaxis should be offered to women with a previous baby with early- or late-onset GBS disease
  • maternal intravenous antibiotic prophylaxis should be offered to women in preterm labour regardless of their GBS status
  • women with a pyrexia during labour (>38ºC) should also be given intravenous antibiotics
164
Q

Abx given for GBS

A

Benzylpenicllin

165
Q

What causes genital herpes?

A

Herpes simplex virus (HSV-1, HSV-2)

After an initial infection, the virus becomes latent in the associated sensory nerve ganglia. Typically this is the trigeminal nerve ganglion with cold sores and the sacral nerve ganglia with genital herpes.

166
Q

symptoms of herpes

A

Primary infection –

  • Small red blisters around the genitals that are painful
  • Vaginal or penile discharge
  • Flu like symptoms, fever, muscle aches
  • Itchy genitals

The virus lays dormant in the body & can be reactivated causing recurrent outbreaks

167
Q

Ix for herpes

A

viral PCR Swab of open sore

168
Q

mx for herpes

A

acyclovir

Paracetamol
Topical lidocaine 2% gel (e.g. Instillagel)
Cleaning with warm salt water
Topical vaseline
Additional oral fluids
Wear loose clothing
Avoid intercourse with symptoms
169
Q

What is a Hydatidiform mole?

A

Also known as a molar pregnancy

Can be a complete or partial mole.

Is a type of tumour that grows like a pregnancy inside the uterus.

170
Q

What is a complete mole?

A

A complete mole occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.

171
Q

What is a partial mole?

A

A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.

172
Q

3 types of gestational trophoblastic disease

A
  1. Hydatidiform moles (complete and incomplete)
  2. Invasive mole - malignant
  3. Choriocarcinoma - malignant, likely to metastasise to lungs
173
Q

Symptoms of hydatidiform mole

A

Behaves like a pregnancy - periods stop and hormonal changes of pregnancy occur

More severe morning sickness
Vaginal bleeding
Increased enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
174
Q

Ix for hydatidiform mole

A

US pelvis - snowstorm appearance of uterus

Confirm diagnosis with histology of mole after evacuation

175
Q

Mx of hydatidiform mole

A

Evacuation of the uterus (histology of the products of conception)
Refer to gestational trophoblastic disease centre
Monitor hCG levels until they return to normal
May require systemic chemotherapy if mets

effective contraception for 12 months to avoid pregnancy

176
Q

What is primary post partum haemorrhage

A

Loss of >500ml of blood vaginally within 24 hours of delivery

Minor PPH = 500-1000ml
Major PPH = >100ml

177
Q

What are the causes of primary PPH?

A 
4 Ts:
Tone = uterine atony 
Tissue = retention of placental tissues
Trauma = damage during delivery 
Thrombin = coagulopathies/vascular abnormalities
178
Q

Risk factors for primary PPH

A

Risk factors for uterine atony:

  • Older mum
  • Obese mum
  • Asian mum
  • Uterine over distention – multiple pregnancy, polyhydramnios, fetal macrosomia
  • Long labour (induction)
  • Placenta praevia, placental abruption, previous PPH
179
Q

Symptoms of uterine atony

A
  • Profuse vaginal bleeding

- Soft enlarged (increased fundal height), boggy ascending uterus

180
Q

Ix for primary PPH

A

Examination:

  • General examination for haemodynamic instability
  • Abdominal exam
  • Speculum exam – look for local trauma causing bleeding
  • Examine placenta – look to see the placenta is complete

Bloods:

  • FBC
  • Cross match blood
  • Coagulation profile
  • U&Es
  • LFTs
181
Q

Mx for primary PPH

A

1 Call for help

2 ABCDE

3 Definitive management:
- Uterine atony =
o Bimanual compression – inset gloved hand into vagina, form a fist inside the anterior fornix of the vagina, compress the anterior uterine wall, use the other hand to apply pressure on the abdomen behind the uterus
o Medical therapy – to increase uterine myometrial contraction
 Syntocinon (synthetic oxytocin)
 Ergometrine
 Carboprost (prostaglandin analogue)
 Misoprostol (prostaglandin analogue)
o Surgical
 Intrauterine balloon tamponade
 Haemostatic suture around uterus e.g. b-lynch
 Bilateral uterine or internal iliac artery ligation
 Hysterectomy

  • Trauma
    o Primary repair of laceration
    o If uterine rupture – laparotomy and repair or hysterectomy
-	Tissue
o	IV oxytocin 
o	Manual removal of placental with regional or general anaesthetic 
o	Prophylactic Abx
o	IV oxytocin infusion after removal
  • Thrombin
    o Correct coagulation abnormalities with blood products (need haematology help)
182
Q

Prevention of primary PPH

A

Active management of 3rd stage of labour routinely reduces PPH risk by 60%
- IM oxytocin given to women who have delivered vaginally/c-section

183
Q

What is secondary post partum haemorrhage?

A

= excessive vaginal bleeding in the period from 24 hours after delivery to 12 weeks postpartum

184
Q

Causes of secondary PPH?

A 
-	Uterine infection (endometritis) 
	RFs: c-section, PROM, long labour 
-	Retained placental fragments or tissue
-	Abnormal involution of the placental site 
-	Trophoblastic disease
185
Q

Ix for secondary PPH

A

US for retained products of conception

Endocervical or high vaginal swabs for infections

186
Q

Mx for secondary PPH

A

Surgical evacuation of retained products of conception

Abx for infection

187
Q

Indications for instrumental delivery

A

Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions

Increased risk of requiring instrumental delivery when epidurals are used

188
Q

Options for instrumental deliveries

A

Ventouse = suction cup on a cord

Forceps = large metal tongs used either side of the babies head and used to apply traction and pull the head

189
Q

Risks to mother during instrumental delivery

A 
Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Nerve injury:
- Obturator = weakness of hip adduction & rotation, numbness of medial thigh
- Femoral = weakness of knee extension, loss of patella reflex and numbness of anterior thigh & medial lower leg
190
Q

Risks to baby during instrumental delivery

A 
Ventouse = cephalohaematoma
Forceps = facial nerve palsy
  • Subgaleal haemorrhage
  • Intracranial haemorrhage
  • Skull fracture
  • Spinal cord injury
191
Q

What is lichen sclerosus?

A

Chronic inflammatory skin condition that presents with patches of shiny white skin, commonly affecting the labia, perineum and perianal skin

Autoimmune condition

192
Q

Lichen sclerosus symptoms

A

woman aged 45 – 60 years

‘porcelain’ white patches that may scar on vulva
itch is prominent
skin appears shiny, tight and thin
may result in pain during intercourse or urination

193
Q

Diagnosis of lichen sclerosus

A

Clinical

Can biopsy

194
Q

Mx of lichen sclerosus

A

Topical steroids and emollients

[clobetasol propionate]

195
Q

Complications of lichen sclerosus

A

Squamous cell carcinoma of the vulva
Bleeding
Narrowing of vaginal/urethral openings

196
Q

What is the ‘lie’ of a foetus?

A

The relationship between the long axis of the foetus and the mother - longitudinal, transverse or oblique

197
Q

what is the ‘presentation’ of a foetus?

A

The fetal part that enters the maternal pelvis first

  • cephalic vertex (normal)
  • breech
  • shoulder
  • face
  • brow
198
Q

What is the ‘position’ of a foetus?

A

The position of the fetal head as it exits the birth canal

  • occipito-anterior (normal)
  • Occipito-posterior
  • occipito-transverse
199
Q

Normal presentation of a foetus at birth

A

facing backwards, head first

= cephalic vertex presentation

200
Q

Risk factors for malpresentation

A
  • Prematurity
  • Multiple pregnancy
  • Uterine abnormalities e.g. fibroids, partial septate uterus
  • Fetal abnormalities
  • Placenta previa
  • Primiparity
201
Q

what is the definition of menopause?

A

No periods for 12 months
Is a permanent end to menstruation
On average - happens at 51 yo

202
Q

What is postmenopause?

A

the period from 12 months after the final menstrual period onwards

203
Q

What is perimenopause?

A

the time around menopause, where the woman experiences vasomotor symptoms and irregular periods.

Includes the time leading up to the last period and the 12 months after

204
Q

What is premature menopause

A

menopause before the age of 40

caused by premature ovarian insufficiency

205
Q

what are the changes in the sex hormones associated with menopause

A

oestrogen and progesterone low (lack of ovarian follicular function)
LH and FSH high - no negative feedback from oestrogen

206
Q

Perimenopausal symptoms

A 
Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
207
Q

Risks due to lack of oestrogen following the menopause

A

Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence

208
Q

diagnosis of menopause

A

clinical if >45 yo

FSH blood test if <45 yo with symptoms of menopause

-	Bloods:
o	Reduced oestrogen
o	Reduced progesterone
o	Reduced inhibin B
o	Very increased FSH
o	Testosterone and prolactin levels within normal ranges
-	Vaginal pH >4.5
-	Lipid profile = Increased total cholesterol, reduced HDL
209
Q

when to consider treating menopause symptoms

A

Treatment not warranted for all women as the menopause is a normal ageing process.

Treatment considered in the following cases:

  • Symptoms severe enough to infringe significantly on functional capacity
  • Premature menopause
  • Surgical menopause (e.g. post oophorectomy)
210
Q

Lifestyle modifications and local medical therapy for menopause symptoms

A
  • To help with hot flushes avoid bright lights and other predictable emotional triggers. Temp control e.g. fans
  • For atrophic vaginal symptoms = vaginal oestrogen creams, rings or tablets
  • Impaired sleep = exercise, acupuncture and relaxation techniques
  • Prevention of osteoporosis = smoking cessation, vitamin D, weight bearing exercises, bisphosphonates (alendronic acid)
211
Q

Ci for HRT

A

Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

212
Q

What HRT can be given for menopausal symptoms?

A
  • Is used for the short term treatment of menopausal symptoms
  • Types:
    o Oestrogen therapy (for women who have had a hysterectomy)
    o Oestrogen plus progesterone therapy (for women with a uterus)
  • Routes = oral or transdermal
213
Q

SEs of HRT

A

nausea, breast tenderness, fluid retention and weight gain

214
Q

Risks of HRT

A

o Cancer
 Unopposed oestrogen can result in endometrial hyperplasia = increased risk of endometrial cancer
 Oestrogen + progesterone therapy = increased risk of breast cancer
* Ovarian cancer
o Cardiovascular disease – CHD, DVT, PE, stroke
o Gallbladder disease
o Stress urinary incontinence

215
Q

Non-hormonal medication for menopausal symptoms

A
  • Used to treat menopausal women with vasomotor symptoms who don’t want to use hormonal replacement / have contraindications for HRT:
    o Selective oestrogen receptor modulators = tamoxifen, ospemifene and raloxifene
    o Paroxetine = for hot flushes
    o Clonidine +/- gabapentin
216
Q

Contraception for perimenopausal women

A

Need contraception for 2 years after last menstrual period in women <50 yo / 1 year after last menstrual period in women >50 yo

Use barrier method, Mirena, progesterone only pill, sterilisation or depot injection if <45yo
Can have COCP as long as there are no other CIs

217
Q

Side effects of the progesterone depot injection (depo-provera)

A

Weight gain

Reduced bone mineral density (can’t have depot >45yo)

218
Q

What is miscarriage (early and late)?

A

Miscarriage is the spontaneous termination of a pregnancy.

Early miscarriage is before 12 weeks gestation.
Late miscarriage is between 12 and 24 weeks gestation.

219
Q

what is a missed miscarriage?

A

The foetus is no longer alive but no symptoms have occurred

220
Q

what is a threatened miscarriage?

A

vaginal bleeding with a closed cervix and a foetus that is alive

221
Q

What is an inevitable miscarriage?

A

Vaginal bleeding with an open cervix

222
Q

What is an incomplete miscarriage

A

Retained products of conception remain in the uterus after the miscarriage

223
Q

what is a complete miscarriage?

A

a full miscarriage has occurred and there are no products on conception left in the uterus

224
Q

What is an anembryonic pregnancy?

A

a gestational sac is present but contains no embryo

225
Q

Ix for miscarriage

A

Transvaginal USS

Key features in early pregnancy to assess viability of pregnancy:

  • Mean gestational sac diameter
  • Fetal pole and crown rump length
  • Fetal heartbeat
226
Q

Mx of miscarriage

A

<6 weeks = expectant management

> 6 weeks:

  • Expectant
  • Medical (misoprostol)
  • Surgical

Rhesus negative mums need anti-D prophylaxis if there’s been any tx & >12 weeks or there’s surgical management at any gestation

227
Q

Risk factors for miscarriage

A
  • Older mum (increase in chromosomal abnormalities)
  • Previous miscarriage
  • Obesity
  • Chromosomal abnormalities (mum or dad)
  • Smoking
  • Uterine anomalies
  • Previous uterine surgery
  • Anti-phospholipid syndrome
  • Coagulopathy
228
Q

Symptoms of miscarriage

A 
VAGINAL BLEEDING 
-	Pass clots
-	Pass products of conception 
-	Haemodynamic instability w significant blood loss = pallor, tachycardia, tachypnoea, hypotension
-	Bleeding often accompanied by pain:
o	Cramping pain
o	Suprapubic
o	Tender on examination

Incidental finding on US

229
Q

What is expectant management of a miscarriage? what are the cons, follow up and CI

A
  • Allows the products of conception to pass naturally
  • Means women can stay at home, don’t require medications and no anaesthetic/surgical risk
  • Cons: unpredictable timing, heavy bleeding, pain, chance of it being unsuccessful & need further interventions
  • Need follow up – scan in 2 weeks / pregnancy test in 3 weeks
  • CI = infection, high risk of haemorrhage e.g., coagulopathy
230
Q

What is medical management of a miscarriage? What are the side effects of the medication used?

A
  • Vaginal misoprostol (prostaglandin analogue)
  • Works by stimulating cervical ripening and myometrial contractions
  • Usually give mifepristone 24-48hrs before misoprostol
  • Can be at home w access to gynae
  • Side effects of medication:
    o Vomiting / diarrhoea
    o Heavy bleeding + pain
    o Chance of requiring emergency surgical intervention
  • Pregnancy test 3 weeks later
231
Q

what is surgical management of miscarriage? and what are the risks involved?

A

12 weeks: Manual vacuum aspiration with local anaesthetic

  • Evacuation of retained products of pregnancy under general anaesthetic
  • Indication = haemodynamically unstable, infected tissue or gestational trophoblastic disease
  • Is a planned procedure
  • Risks: general anaesthetic, infections, uterine perforation, haemorrhage, Asherman’s syndrome (scar tissue in uterus), bowel and bladder damage, retained products of conception
232
Q

What is recurrent miscarriage defined as?

A

3 or more consecutive spontaneous abortions

occurs in around 1% of women

233
Q

causes of recurrent miscarriage

A 
antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking

Finals Revision (18 decks)

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