Obs & Gyn Flashcards
(33 cards)
Differential diagnosis for intermenstrual bleeding
- Cervical malignancy
- Cervical ectropion
- Endocervical polyp
- Atrophic vaginitis
- Pregnancy
- Irregular bleeding related to the contraceptive pill
Drugs associated with hyperprolactinaemia (due to dopamine antagonist effects)
- Metoclopramide
- Phenothiazines (e.g. chlorpromazine, prochlorperazine, thioridazine)
- Reserpine
- Methyldopa
- Omeprazole, ranitidine, bendrofluazide (rare associations)
If the woman fails to conceive after correction of hyperprolactinaemia, then a full fertility
investigation should be planned with what investigations?
- semen analysis
- tubal patency testing (laparoscopy
and dye test, hysterosalpingogram or hysterosalpingoconstrastsonography (hyCoSy))
Effects of premature menopause
Hypo-oestrogenic effects:
* vaginal dryness
* vasomotor symptoms (hot flushes, night sweats)
* osteoporosis
* increased cardiovascular risk
Psychological and social effects:
* infertility
* feeling of inadequacy as a woman
* feelings of premature ageing and need to take HRT
* impact on relationships
Causes
of oligospermia
pretesticular:
- pituitary tumours,
- smoking or
- medication
Testicular
- varicocoele,
- trauma,
- mumps or
- Y chromosome deletions
posttesticular
- prostatitis or cystic fibrosis causing vas deferens obstruction
Investigations for infertility
Woman:
* Day 3 FSH
* Day 3 LH
* Prolactin
* Testosterone
* Day 21 Progesterone
* Hysterosalpingogram report: the uterine cavity is of normal shape with a smooth regular outline. Contrast medium is seen to fill both uterine tubes symmetrically and free spill of dye is confirmed bilaterally.
* Transvaginal ultrasound scan report: the uterus is anteverted with no congenital abnormalities, uterine fibroids or polyps visualized. Both ovaries are of normal morphology, volume and mobility. No follicles are noted.
Men:
Semen analysis report: normal volume, count, normal forms and motility
Confirmation of the diagnosis and management of ovarian cancer
The surgical aphorism ‘there is no diagnosis without a surgical diagnosis’ means that tissue
needs to be obtained to confirm the diagnosis. Laparotomy should be performed with three objectives:
1. obtaining tissue for diagnosis
2. staging the disease according to the extent of tissue involvement
3. primary debulking – to perform a total abdominal hysterectomy and bilateral
salping-oophorectomy and to reduce all abdominal tumour deposits to a volume
of less than 2 cm. This allows optimal effect of chemotherapy following surgery.
Lymph node dissection and omental resection are usually part of the procedure.
Typical presentations of fibroids
- Menorrhagia
- Abdominal mass
- Pressure effect from pressure on the bladder, stomach or bowel
- Infertility
Management of fibroids
- Iron and folate for anemia
- conservative tranexamic acid and/or ponstan
- GNRH analogue to shrink fibroid
- Uterine artery embolisim
- Myemectomy
- Hysterectomy
Treatment and advice for cervical intraepithelial neoplasia
- The commonest treatment is large-loop excision of the transformation zone (LLETZ)
– removal of abnormal cervical tissue with a diathermy loop - Assuming that all of the abnormal cells are excised, with clear margins, at the time of LLETZ treatment, then six-month follow-up should be arranged where she should have a repeat smear and human papilloma virus (HPV) screening.
Advice after LLETZ procedure
- The patient may have light bleeding for several days.
* If heavy bleeding occurs she should return as secondary infection may occur and
need treatment.
* She should avoid sexual intercourse and tampon use for 4 weeks, to allow healing
of the cervix.
* Fertility is generally unaffected by the procedure, though cervical stenosis leading
to infertility has been reported, and midtrimester loss from cervical weakness is
rare.
Management of dysfunction uterine bleeding
- The anaemia should be treated with ferrous sulphate 200 mg twice daily until
- Tranexamic acid (an antifibrinolytic) should be given during menstruation to reduce the
amount of bleeding. - The levonorgestrel-releasing intrauterine device is used for its action on the endometrium to reduce menorrhagia,
- The combined oral contraceptive pill is effective for menorrhagia in young women (below 35 years).
If these first-line management options are ineffective then endometrial ablation should be considered, which destroys the endometrium down to the basal layer.
There are several approved minimally invasive endometrial ablation techniques with
broadly similar efficacy: these include use of radiofrequency waves, electrocautery, microwaves, heated saline, or a heated balloon.
Hysterectomy is considered a ‘last resort’ for DUB, due to the associated morbidity
Differential diagnosis of secondary amenorrhoea
Hypothalamic:
* chronic illness
* anorexia
* excessive exercise
* stress
Pituitary:
* hyperprolactinaemia (e.g. drugs, tumour)
* hypothyroidism
* breast-feeding
Ovarian:
* polycystic ovarian syndrome
* premature ovarian failure
* iatrogenic (chemotherapy, radiotherapy, oophorectomy)
* long-acting progesterone contraception
Uterine:
* pregnancy
* Asherman’s syndrome
* cervical stenosis
Causes of postmenopausal bleeding
- Endometrial cancer
- Endometrial/endocervical polyp
- Endometrial hyperplasia
- Atrophic vaginitis
- Iatrogenic (anticoagulants, intrauterine device, hormone-replacement therapy)
- Infective (vaginal candidiasis)
Causes of dysmenorrhoea
- Idiopathic
- Premenstrual syndrome
- Pelvic inflammatory disease
- Endometriosis
- Adenomyosis
- Submucosal pedunculated fibroids
- Iatrogenic (e.g. intrauterine contraceptive device (IUCD) or cervical stenosis after
large-loop excision of the transformation zone (LLETZ))
Differential diagnoses of postcoital bleeding in a young woman
- Cervical ectropion
- Chlamydia or other sexually transmitted infection (STI)
- Cervical malignancy
- Complication of the COCP
- Endocervical polyp
Treatment options for cervical ectropion
There are three options for treatment:
1. stop the COCP and use alternative contraception
2. cold coagulation of the cervix
3. diathermy ablation of the ectocervix
Diagnosis of antiphospholipid syndrome
The presence of one of the clinical features:
* three or more consecutive miscarriages
* midtrimester fetal loss
* severe early-onset pre-eclampsia, intrauterine growth restriction or abruption
* arterial or venous thrombosis
And haematological features:
* anticardiolipin antibody or lupus anticoagulant detected on two occasions
at least 6 weeks apart
Management of antiphospholipid syndrome in pregnancy
Oral low-dose aspirin and low-molecular-weight subcutaneous heparin from the time of a positive pregnancy test should be given in subsequent pregnancies to improve the likelihood of a successful live birth.
In the case of this woman, with such a strong family history of thrombosis and proven
antiphospholipid syndrome, she would also be recommended thromboprophylaxis throughout the pregnancy and postnatal period.
Causes of recurrent miscarriage
- Parental chromosome abnormality (3–5 per cent, e.g. balanced translocation)
- Antiphospholipid syndrome
- Other thrombophilia (e.g. activated protein C resistance)
- Uterine abnormality (intracavity fibroids, uterine septum)
- Uncontrolled diabetes or hypothyroidism
- Bacterial vaginosis (usually associated with second-trimester loss)
- Cervical weakness (‘incompetence’, second-trimester loss only)
Clinical features of endometriosis
- pelvic pain
- dysmenorrhoea
- dyspareunia
- infertility
Management of endometriosis
The mainstay of management for endometriosis is surgical, with ablation or excision of endometriotic deposits by laparoscopy.
Medical suppression of endometriosis is possible with the contraceptive pill or gonadotrophin-releasing hormone analogues, which inhibit ovulation and hence prevent stimulation of endometrial deposits by oestrogen. However these are ineffective for endometriomas. The levonorgestrel-releasing intrauterine device has also been used to suppress endometriosis and reduce symptoms.
Long-term complications of pelvic inflammatory disease
- Chronic pain.
- Infertility: tubal infertility is likely in this woman, and if she fails to conceive spontaneously then hysterosalpingogram should be performed with referral for assisted
conception if obstruction is confirmed. - Ectopic pregnancy: spontaneous and in vitro fertilization pregnancies are at
increased risk of implanting in the damaged tubes, and an early transvaginal scan
should be advised if she becomes pregnant. - The woman should also be advised that despite the likely subfertility, spontaneous
pregnancy may still occur so she should use effective contraception if she does
not want to conceive.
Causes of precocious puberty
- Constitutional (>90 per cent)
- Hypothyroidism
- CNS lesions (hydrocephaly, neurofibromatosis)
- Ovarian tumour
- Adrenal tumour
- Exogenous oestrogens
Complications of intrauterine contraceptive device (IUCD)/
intrauterine device insertion
- Uterine perforation
- Device migration through to peritoneal cavity
- Pelvic inflammatory disease
- Expulsion of device (commonly with the next period)
