Obs n Gobs Flashcards
(225 cards)
1
Q
What is the nerve supply to the bladder and urethra?
A
Parasympathetic: S2-4, promotes urination (detrusor contraction)
Sympathetic: T12-L2, stops urination (detrusor relaxation)
Somatic: (voluntary nervous system) Pudendal nerve allows voluntary urination
2
Q
What is the pressure balance in urination?
A
Bladder pressure (detrusor and intra-abdominal pressure) VS Urethral pressure ( urethral muscle tone and pelvic floor)
3
Q
What are the components of the pelvic floor?
A
Pelvic bones, ligaments (cardinal and uterosacral), pelvic floor muscles (levator ani and coccygeus), pudendal nerve
4
Q
What are the risk factors of a prolapse:
A
Age (decreased oestrogen, poor tone) Multiparity Obesity Retroverted uterus Chronic cough Pelvic masses
50% parous women have a prolapse
5
Q
What are the symptoms of a prolapse?
A
“Something coming down”
Urinary incontinence or frequency (stress incontinence due to altered urethrovesical angle)
UTI (due to incomplete bladder emptying)
Constipation of difficulty defecating
6
Q
What are the types of prolapse?
What are the grades of prolapse?
A
Posterior:
- Rectocoele = rectum
- Enterocoele= small intestine
Anterior
- Cystocoele= bladder
- Vault = vagina in on itself (hysterectomy)
Uterine= uterus
1-3 with 2 at the introitus
7
Q
Investigations for a prolapse:
A
Examination
+ any examinations for urinary symptoms (e.g. urine dip)
8
Q
Management of a prolapse:
A
1st line: Lifestyle modification: weight loss, smoking cessation and physiotherapy– pelvic floor exercises
2nd line: Pessaries (ring or shelf) + topical oestrogen to prevent vaginal ulceration
3rd line: Surgical repair or hysterectomy
9
Q
Types of incontinence
A
Urge: Detrusor overactivity Stress: Sphincter weakness Overflow: Retention Fistula Neurological: MS or nerve damage Functional
10
Q
What is the aetiology of urinary incontinence?
A
Previous surgery Childbirth (stress) Diabetes- neuropathy, renal impairment, polyuria/dipsia, reduced immunity and increased infection Recurrent UTI Idiopathic (urge)
11
Q
What are the risk factors of urinary incontinence?
A
Age Parity Obesity Smoking Previous surgery
12
Q
What is the clinical presentation of an overactive bladder?
A
Urgency Urge incontinence Frequency Nocturia At orgasm Key in the door/ handwash triggers
13
Q
What is the clinical presentation of a sphincter weakness incontinence?
A
Involuntary leakage with increased intraabdominal pressure- coughing, laughing, lifting, straining, exercise
14
Q
What are the investigations for incontinence?
A
- HISTORY AND EXAMINATION (prolapse)!!
Frequency volume chart (bladder diary)
MSU urinalysis (infection, stones, diabetes, renal disease, carcinoma)
Residual urine measurement (in and out catheter, USS bladder)
ePAQ questionnaire (lifestyle and symptom questionnaire)
Urodynamics
Cystoscopy/ cystogram with contrast
15
Q
What is the management for stress incontinence?
A
1st line: weight loss, smoking cessation, pelvic floor exercises (physiotherapy), modify fluid intake, adjunctive pads or toileting aids
2nd Line: Surgery- slings, tension free vaginal tapes
3rd Line: Duloxetine if surgery denied
16
Q
What is the management for urge incontinence?
A
1st line: weight loss, smoking cessation, stop caffeine, modify fluid intake, adjunctive pads or toileting aids, bladder retraining
2nd line: medication-
anticholinergics (blocks Ach, blocks parasympathetic NS, blocks detrusor contraction)- oxybutynin, tolterodine
Mirabegron- beta 3 adrenergic receptor agonist, relaxes smooth muscle (detrusor)
3rd line: botox injections
Further: cystoplasty , catheters, bypass (urostomy)
17
Q
What is the normal duration of a menstrual cycle?
A
21-38 days (mean 28), 60-80ml blood loss
18
Q
What is primary vs secondary amenorrhoea?
A
Primary: menstruation not started
If no secondary sexual characteristics: 14
Otherwise: 16
Secondary: previously normal menstruation caesed for >6 months
19
Q
What is Kallman’s syndrome?
A
Hypogonadotropic Hypogonadism
GnRH secreting cells did not migrate to forebrain,
have absence in puberty and anosmia (can’t smell)
craniofacial defects
20
Q
What are the causes of PRIMARY amenorrheoa?
A
Constitutional variances/ delays, iatrogenic (drug use- dopamine antagonists)
Anorexia, depression, high exercise levels
Kallman’s, Hypothalamic Hypogonadism, Hyperprolactinaemia (causing reduced GnRH), space occupying lesions, pituitary adenoma, sarcoidosis etc.
Hypo/hyperthyroidism (reduced GnRH) Congenital adrenal hyperplasia (CAH) (deficient in sex steroids)
Turner’s syndrome/ other gonadal dysgenesis, Androgen insensitivity (defective androgen receptor, XY but failure to develop male characteristics), PCOS
Imperforate hymen, tranverse vaginal septum
21
Q
What are the causes of SECONDARY amenorrheoa?
A
Menopause, pregnancy, lactation, iatrogenic (drug use- dopamine antagonists)
Anorexia, depression, high exercise levels
Sheehan’s, Hypothalamic Hypogonadism, Hyperprolactinaemia (causing reduced GnRH), space occupying lesions, pituitary adenoma, sarcoidosis etc.
Hypo/hyperthyroidism, Cushing’s (reduced GnRH)
PCOS, adrenal tumours, POF, Asherman’s syndrome, cervical stenosis
22
Q
What is Sheehan’s syndrome?
A
Damaged pituitary gland following labour (pituitary necrosis), often caused by hypoxia- PPH or low BP
Presents with hypothyroidism, amenorrhoea,
23
Q
What is Asherman’s syndrome?
A
Uterine adhesions
24
Q
How do you investigate/ manage amenorrhoea?
A
Investigate: Bloods: LH, FSH, Testosterone, SHBG (low in PCOS), prolactin, TFT
Karyotyping
MRI (head and neck)
Pelvic USS
Treat underlying conditions!
25
What are the three arms of PCOS? (Rotterdam Criteria)
2/3 needed for clinical diagnosis
Hyperandrogenism
((((Oligomenorrhoea)))) Anovulation- marked by low day 21 progesterone
Polycystic ovaries on USS (12 or more follicles)
26
What is the clinical presentation of PCOS?
```
Oligomenorrhoea
Hirsutism
Infertility
Obesity
Metabolic syndrome (htn, t2dm)
```
27
What are some long term consequences of PCOS?
```
Infertility
T2DM
Gestational DM
CVD
Endometrial cancer
```
28
What is the management of PCOS?
WEIGHT LOSS!!!!!!
Smoking cessation
Manage t2dm (metformin), htn, dyslipidaemia, sleep apnoea
COCP (reduced risk of unopposed oestrogen on endometrium (ca risk))
Fertility:
Clomifene
Ovarian drilling
Metformin for fertility
29
What are the appropriate investigations for PCOS?
- LH:FSH ratio (elevated)
- Testosterone (elevated)
- Day 21 progesterone (reduced)
- SHBG (reduced)
- Fasting or random glucose
- Prolactin (would indicate hyperprolactinaemia as a cause of amenorrhoea)
- BMI + clinical exam
30
What is menorrhagia?
Heavy periods
31
What are the causes of pathological menorrhagia?
```
thyroid disease
haemostatic disorders- e.g. VWD
Anticoagulant therapies (e.g. warfarin, heparin)
```
fibroids
uterine or cervical polyps
adenomyosis, endometriosis
32
Investigations for menorrhagia?
Bloods: Hb, clotting profile, anaemia, TFT, beta HCG
TV USS: fibroids, ovarian mass, polyps
Endometrial biopsy
33
What is the management of menorrhagia?
Symptomatic.
1. Mirena coil
2. Antifibrinolytics; Tranexamic acid
NSAIDs: Mefenamic acid
COCP
POP (tricyclic)
Norethisterone
GnRH agonists
Polypectomy, Fibroidectomy, endometrial resection/ablation, Hysterectomy
34
What is dysmenorrhoea?
Painful periods
35
What are the causes of dysmenorrhoea?
Primary:
Idiopathic
Excess prostaglandins
```
Secondary:
Adenomyosis
Endometriosis
Polyps
Fibroids
PID
```
36
Management of Dysmenorrhoea?
Investigate with USS
NSAIDs (inhibit prostaglandins): Paracetamol, cocodamol, mefenamic acid
COCP
Mirena coil
Manage any secondary causes
37
What are the causes of intra-menstrual bleeding (IMB)?
Normal: mid cycle fall in oestrogen (spotting)
```
Polyps
Carcinoma- cervical, uterine
OCP
Infection- cervicitis, vaginitis, chlamydia
IUCD
```
38
What are the causes of post-coital bleeding (PCB)?
!!!!!!! CERVICAL CANCER !!!!!!!
Cervical trauma
Cervicitis, vaginitis, chlamydia
39
What is an ectropion?
Soft glandular columnar epithelium from inside cervical os is seen on surface of cervix
Normal- caused by hormonal changes, pill
Causes vaginal discharge or PCB
40
What are the causes of post-menopausal bleeding (PMB)?
!!!!!!!! ENDOMETRIAL CANCER !!!!!!!!!
Oestrogen withdrawal (HRT)
Endometrial or cervical polyps
Vaginitis (atrophic
SE of pessaries
41
What is normal menopause?
Cessation of menstruation after the age of 45 years old as a result of ovarian exhaustion
42
Describe progression of menopause
Climacteric phase: transition from reproductive to non reproductive states.
Erratic ovulation and menstruation starts, as ovaries become irregularly responsive to pituitary hormone stimulation, and number of follicles decline.
Once menopause is reached, ovaries "fail" and no longer respond, and there is diminished oestrogen production.
Low oestrogen--> reduced negative feedback to pituitary--> increased LH and FSH.
43
What are the symptoms of menopause?
EARLY:
Hot flushes, insomnia, irritability, mood swings, lethargy, anxiety, depression, reduced libido, dyspareunia, and failure to achieve orgasm
LONG TERM:
Loss of collagen from skin (drier and wrinkled), hair loss, breast tissue loss (replaced with fatty tissue, and breasts shrink).
Vaginal dryness, thin vaginal walls (increased infection risk), prolapse
Incontinence
Osteoporosis (decreased oestrogen causes calcium loss, raised fracture risk), fractures
CVD- strokes and heart attacks
44
What investigations can you do in ?Menopause?
LH and FSH (risen)
Mammography
DEXA
Investigate as IMB or PMB (endometrial biopsy)
45
What is the management of menopause?
HRT- combined oestrogen and progesterone (omit prog. if post hyterectomy as no risk of endometrial cancer as a result of unopposed oestrogen) e.g. tibolone (oral), patches, implant
Testosterone for libido
46
What are the causes and diagnosis and management of premature menopause/ POI/ POF?
Iatrogenic: chemo/radiotherapy, oophrectomy, hysterectomy
Idiopathic
Infection- mumps, pelvic TB
Autoimmune conditions
Raised FSH + LH, low oestrogen
Managed with HRT until 51y/o (+testosterone for libido)
+ care with CV and osteoporosis risk
Manage fertility- donor egg
47
What are the benefits of HRT?
Improved symptoms- hot flushes, psych symptoms, loss of libido
Lower risk of fracture and osteoporosis, bowel ca
Slows collagen loss
48
What are the disadvantages of HRT?
Bleeding (regular or irregular)
Headaches, fluid retention, breast tenderness, PMS
!!!! 2-4x increased risk of thromboembolic disease!!!!
Slight increase of breast cancer (not in POI)
Risks of unopposed oestrogen (endometrial ca)
49
What is the difference between OCP and HRT?
```
Supraphysiological (OCP) dose
VS
Physiological (HRT) dose
```
OCP therefore causes FSH and LH suppression, and HRT does not (therefore not contraceptive)
50
What is the presentation and how do you diagnose POF?
Clinical presentation: secondary amenorrhoea, infertility
Diagnosis: <40y/o, 4 months amenorrhoea + FSH > 25 in 2 separate samples over 1 month
51
Explain the Hypothalamic-Pituitary-Gonadal Axis
Hypothalamus (GnRH)--+++-> Pituitary (FSH or lh)--+++-> Ovary (Oestrogen)--+++---> Pituitary (LH, and suppresses FSH) ((((ovulation)))--++-> Ovary (CL Progesterone) ---> Hypothalamus less GnRH
https://www.researchgate.net/figure/Representation-of-the-hypothalamus-pituitary-gonadal-axis-positive-and-negatives_fig4_258056691
52
Explain the relationship between oestrogen and LH in the menstrual cycle
Oestrogen (produced by GCs) stimulates LH after it reaches a certain threshold, after ovulation, no GC, no oestrogen, no LH.
53
What is the action of Progesterone in the menstrual cycle?
Progesterone, produced by CL after ovulation, maintains endometrial lining and supports implantation and early pregnancy
54
What is the action of FSH in the menstrual cycle?
FSH, produced in the pituitary, stimulated by GnRH, causes follicle development.
Stimulates oestrogen production from GCs
Oestrogen negatively feeds back to pituitary to reduce FSH to prevent multiple follicle development
55
What is the action of oestrogen in the menstrual cycle?
Oestrogen, produced in GCs, stimulated by FSH.
Causes endometrial prolferation.
Stimulates LH production from pituitary after a certain threshold
56
What is the action of LH in the menstrual cycle?
LH, produced by pituitary, stimulated by GnRH and rising oestrogen levels
Causes follicle rupture (ovulation), maintains corpus luteum
57
What is the action of progesterone in the menstrual cycle?
Progesterone, produced by the corpus luteum (following ovulation)
Maintains endometrial lining and primes it for implantation of an embryo
Negatively feeds back to the hypothalamus, reducing GnRH production and FSH and LH (which maintain the corpus luteum), therefore CL regression and progesterone decrease--> menstruation
58
How does hCG effect the menstrual cycle?
Produced by implanted embryo, hCG maintains CL, and therefore progesterone, stopping uterine shedding.
59
What is the definition of a miscarriage?
Pregnancy loss before 24 weeks
60
What are common causes of miscarriage?
- chromosomal abnormalities causing incompatibility with life (e.g. aneuploidy)
- abnormal foetal development
- maternal illness (e.g. APS, infection, thrombophilia)
- trauma
61
What is a threatened miscarriage?
bleeding, with closed os and foetal heartbeat present
| 25% miscarry
62
What is an inevitable miscarriage?
bleeding (++) with open os
63
What is an incomplete miscarriage?
some, but not all product of conception have passed
64
What is a missed miscarriage?
Foetus dies but still inside, close to asymptomatic
Closed os, no foetal heart
confirmed with USS
65
How do you manage a miscarriage?
Conservative: watch and wait, analgaesia.
Misoprostol
Surgical evacuation
66
How do you manage medical TOP?
Mifepristone (+ misoprostol)
or surgical evacuation
67
What are the risk factors for an ectoptic pregnancy?
- previous ectopic
- structural/ tubal damage (eg. PID/ previous surgery)
- endometriosis
- IUCD
- Progesterone only pill
- subfertility
- IVF
- Adhesions (Asherman's)
- Infection (current or previous)
- Unsuccessful/ reversed tubal ligation
68
What is the presentation of an ectopic pregnancy?
Severe abdominal pain (usually unilateral- due to tubal distention or rupture)
PV bleeding
Amenorrhoea
Cervical excitation
69
What investigations should you conduct for a suspected ectopic pregnancy?
TV USS
beta hCG/ urine pregnancy test
Assess haemodynamic stability: FBC, blood pressure, O2 sats
serum progesterone (identifies failing pregnancy)
70
What is the management for an ectopic pregnancy?
Conservative: only if woman is stable and has bHCG <1500
Surgical: Salpingotomy, Salpingectomy (if tubal)
Medical: Methotrexate (teratogenic so should have effective contraception afterwards)
71
What is gestational trophoblastic disease?
Abnormal cells arising from trophoblastic tissue, greater proliferation and hCG secretion.
Non-malignant: Hydatidiform mole
Malignant: Invasive mole (only in uterus), choriocarcinoma (metastatic)
72
What are the risk factors of gestational trophoblastic disease?
previous GTD
| extremes of age
73
Explain the pathophysiology of gestational trophoblastic disease
Molar pregnancy:
- Complete mole (no foetal tissue, increased risk of choriocarcinoma, 46 chromosomes), 2 sperm + empty ovum, or duplicated single sperm + empty ovum
- Partial mole (contains foetal tissue, 69 chromosomes), 2 sperm + 1 ovum
Choriocarcinoma:
- Choriocarcinoma, malignant trophoblastic tissue, can arise from molar pregnancy or germ cells.
74
What is the presentation of gestational trophoblastic disease?
```
irregular vaginal bleeding
hyperemesis
hyperthyroidism (as hCG mimics TSH)
LARGE FOR DATES
early pregnancy failure
Blood--> raised hCG
USS--> snowstorm appearance, grape like clusters
```
75
What is the management of gestational trophoblastic disease?
Molar pregnancy:
- remove tissue via suction
- monitor hCG levels
Choriocarcinoma:
- methotrexate based chemotherapy
76
Explain the background and presentation of Lichen Sclerosus
Potentially autoimmune conditions (often seen with vitiligo and thyroid disease)
Mostly in post-menopausal women
Thin vulval epithelium with loss of collagen
Presents with pruritis and soreness, pink-white papules with come together to form white patches with fissures.
figure of 8 presentation (around vulva and anus)
increased risk of vulval cancer
77
What is the management of lichen sclerosus?
Observe as it can be premalignant
| Ultra-potent topical steroids: Clobetasol Propionate cream
78
Explain the cervical screening programme
Smears every 3 years from 25-50,
| Every 5 years from 50-64
79
What is Cervical Intra-epithelial Neoplasia (CIN)?
inc. pathophys, grading, risks and management
Pre-invasive phase of cervical cancer
Atypical cells in the squamous epithelium of the cervix (dyskaryotic, increased mitosis and large nuclei)
Graded I-III depending on extent of neoplasia
1/3 women with CIN will develop cervical cancer
Commonly caused by HPV inserting viral DNA into cells, smoking, HIV, OCP/ multiple sexual partners without barrier contraception
Managed by LLETZ (large loop excision of the transformation zone)
80
What is the clinical presentation of cervical cancer?
Most common cancer in women <35
Often picked up at screening
POST COITAL BLEEDING
watery discharge
weight loss, post-menopausal bleeding, bowel distrubance, fatigue, loss of appetite, general malaise etc.
81
What investigations are carried out for a ?cervical cancer?
```
Smear
Colposcopy
Chlamydia screening
Punch biopsy
CT for staging
```
82
What is a triple swab?
Vaginal swabs- screening for chlamydia, gonorrhoea, bacterial and fungal infections
2 x endocervical (chlamydia + gonorrhoea)
1 x high vaginal (bacterial + fungal)
83
What is the management for cervical cancer?
LLETZ (large loop excision of the transformation zone)
Cone excision (remove cervix)
Hysterectomy (simple or total +- pelvic lymph nodes)
Chemo/radiotherapy
84
What cells are involved in cervical cancer?
| + what staging
squamous cell carcinoma
| FIGO staging- dependant on extent of spread (only in primary organ, adjacent organs, lymph nodes, other organs)
85
What cells are involved in endometrial cancer?
| + what staging
```
glandular/ secretory epithelium- adenocarcinoma
FIGO staging (only in primary organ, adjacent organs, lymph nodes, other organs)
```
86
What are the risk factors and pathophysiology for endometrial cancer?
+ protective factors?
- UNOPPOSED OESTROGEN
- Obesity (adipose tissue is oestrogenic)
- Nulliparity
- HRT
- Tamoxifen
- PCOS
Protective:
COCP
Smoking
87
What is the clinical presentation of endometrial cancer?
- post menopausal women
- post menopausal bleeding
(heavy periods in pre-menopausal women)
88
How do you investigate ?endometrial cancer?
Transvaginal USS to assess endometrial thickness (<4mm is okay)
Endometrial biopsy
Hysteroscopy
89
What is the management of endometrial cancer?
Hysterectomy± pelvic lymph nodes removal
Radiotherapy
progesterone
90
What cells are involved in vulval cancer?
Squamous epithelial
91
What is the aetiology + presentation + management of vulval cancer?
HPV or lichen sclerosus
can present as VIN initially (Vulval Intra-epithlial Neoplasia)
Itching, soreness, bleeding, lump, pain on urination
manage with surgery ± radiotherapy
92
What cells are involved in ovarian cancer?
Epithelial (serosal)
93
What is the aetiology and risk factors/protective factors of ovarian cancer?
Epithelial cell tumours (mostly), some stromal/granulosa, germ cell tumours
Aetiology: increased exposure to oestrogen,
!!!!!!! more ovulation !!!!!!!
Risk Factors:
- Early menarche
- Late menopause
- Nulliparity
- IVF
- Family history (BRCA genes)
Protective Factors:
- OCP
- Multiple pregnancies
- Breast feeding
- Hyterectomy ± bilateral salpingoophrectomy
- Tubal ligation
94
What is the clinical presentation of ovarian cancer?
Older women: approx 75-85 y/o
Often very late presenting
General symptoms:
- IBS like bloating
- Abdominal pain/ discomfort
- Bowel obstruction
95
What investigations should be done in ?ovarian cancer?
- CA125 (50% positive predictive value) (normal value 35, value above 250 is a referral)
- USS
96
What is the management for ovarian cancer?
- Surgery (oophrectomy, bowel resection)
- Chemotherapy
- Palliative care
97
What is endometriosis?
uterine tissue outside the uterus
driven by oestrogen, and therefore is hormonally effected
found commonly:
- pouch of douglas (retrograde menstruation)
- ovaries
- tubal
- bowel
- peritoneum
- points of scar tissue
98
What are the pathophys theories of endometriosis?
```
Retrograde menstruation
Endometrial metoplasia (cells change into endometrial cells)
```
99
What is the presentation of endometriosis?
In women of reproductive age, cyclical presentation of pain, pain is worst a few days before period
- Dysmenorrhoea
- Menorrhagia
- Deep dyspareunia
- Sub-fertility (can damage reproductive structures)
- Dyschezia (pain on defecation)
- Pain improves during pregnancy
100
How do you diagnose endometriosis?
- Laparoscopy
- Elevated Ca125 (nonspecific, caused by irritation of peritoneum)
- Trialled management works
101
What is the management of endometriosis?
Analgaesics (NSAIDs: ibuprofen, naproxen, mefenamic acid)
Tranexamic acid for bleeding
Two Pharmacological Approaches:
1. Abolish cycles
- Monophasic and then triphasic COCP/ POP (3 months
back to back with 1 week break)
- Also consider Depot Provera, Implant, Mirena/ Copper
- Medroxyprogesterone/ Norethisterone
2. Invoke glandular atrophy
- GnRH analogues + HRT add back (tibolone)
Surgical
- endometrial ablation
- hysterectomy
102
What is adenomyosis?
Presence of endometrial tissue in the myometrium
103
What is the presentation of adenomyosis?
- dysmenorrhoea
- menorrhagia
More commonly in older women of reproductive age after childbirth, RF is multiparity
Cyclical pain- worst during cycle
104
What is the management of adenomyosis?
Tranexamic acid, NSAIDs/ COX inhibs (ibuprofen, naproxen, mefenamic acid, paracetamol)
COCP POP IUD
Surgical
- ablation
- hysterectomy
105
What are uterine fibroids?
Uterine Leiomyomas
Benign smooth muscle tumours of the uterus (of the myometrium)
Oestrogen dependant- don't occur and shrink after menopause
106
What are the risk factors of fibroids?
- Afro-Caribbean
- COCP (gives oestrogen)
- Family history
107
What is the clinical presentation of fibroids?
- Menorrhagia ± anaemia
- Sub fertility
- Miscarriage
- Pain (torsion of pedunculated fibroid)
- Abdominal mass
108
What investigations are carried out in ?fibroids or ?polyps?
USS
Hysteroscopy
Endometrial biopsy
109
What is the management of uterine fibroids?
GnRH analogues (shrinks fibroids and induced amenorrhoea) not long term due to demineralisation and fracture risk
Myomectomy
Uterine artery embolisation
Hysterectomy
110
What are endometrial polyps?
endometrial growths into uterine cavity, usually benign
(can be precancerous)
Thought to be oestrogen sensitive, grow in high levels of circulating oestrogen
Fibrous tissue core surrounded by columnar epithelium
Occurs due to dysregulated apoptosis and growth
111
What are the risk factors for endometrial polyps?
Peri- or post-menopausal
hypertension
obesity
tamoxifen
112
What is the presentation of endometrial polyps?
peri/postmenopausal women
- irregular bleeding
- intramenstrual bleeding
- excessively heavy periods
- post menopausal bleeding
- infertility/ miscarriages
113
What is the management of endometrial polyps?
GnRH analogues
| Polypectomy + histology
114
What are ovarian cysts + how do you assess risk?
common, usually follicular or CL cysts
mostly benign <5cm
Risk assessment using RMI (risk of malignancy index):
Ca125 x USS score x Menopausal status
USS score: 1-3 based on findings
Menopausal Status: 1-3, 1=pre, 3=post
115
What are the types of ovarian cyst?
Functional: CL or follicular, can cause pain or bleeding if
rupture/ failure to rupture during ovulation
Endometrioma: chocolate cyst, cyst filled with old blood
Serous cystadenoma: most common in 30-40y/o, 30%
malignant
Mucinous cystadenoma: most common 30-50y/o, 5%
malignant, filled with mucus
Fibroma: benign small fibroid, sometimes presents with
pleural effusion, and ascites (Meig's)
Teratoma (Dermoid cyst): arise from primitive germ cells
116
What is the clinical presentation of ovarian cysts?
chronic pain, dull ache, cyclical
dyspareunia
abdominal mass
```
Rupture/ torsion (Ovarian or cyst):
- acute pain (unilateral)
- vomiting
- rupture: tenderness, guarding, peritonism,
discharge/bleeding
```
117
What investigations should be done in ?cyst rupture/torsion?
FBC (WCC, CRP)
Ca125
TVUSS/ MRI
118
What is the management for ovarian cyst torsion/ rupture?
conservative, analgaesia
surgical laparoscopic correction- resection, oophrectomy, ovary fixation
Preserve fertility
Send to histology
119
What is Pelvic Inflammatory Disease (PID)?
Infection of the upper reproductive tract
120
What is the aetiology of PID?
Acending infection from endocervix from endogenous vaginal bacteria (anaerobes), STIs (25% are chlamydia or gonorrhoea), uterine instruments (e.g. hysteroscopy etc.) , postpartum
121
What are the risk factors and protective factors of PID?
rf: STIs, multiple new sexual partners, recent birth, recent use of uterine instruments
protective: barrier method contraception, Mirena, COCP
122
What is the clinical presentation of PID?
CERVICAL EXCITATION, ADNEXAL TENDERNESS
```
Lower abdominal pain
Deep dyspareunia
Vaginal discharge
IMB/ PCB
Fever/ malaise
Subfertility
Ectopic pregnancy/ miscarriage
Abscess
```
123
What investigations should you carry out in ?PID?
Triple swabs
Examination for cervical excitation and adnexal tenderness
FBC, CRP, Blood cultures, beta hCG
124
What is the management of PID?
analgaesia
remove IUD
Ab: Ceftriaxone, Doxycycline, Metronidazole, Azithromycin
125
What investigations are carried out for ?subfertility?
Male: Semen analysis: motility, morphology
126
What is the definition of subfertility ?
Inability to conceive after 2 years of regular unprotected sexual intercourse
127
How long is it until the IUD is an effective mechanism of contraception?
Immediate
128
How long is it until the Progesterone Only Pill (POP) is an effective mechanism of contraception?
2 days
129
How long is it until the COCP, IUS, implant, Depot is an effective mechanism of contraception?
7 days
130
What is the management of varicella zoster exposure in pregnancy?
Check previous maternal exposure
If unsure or no; test for VZ immunoglobulins
Give VZ vaccine (an give within 10 days of exposure) (infectious 2 days before rash, until vesicular rash crusts over)
131
How do you manage Group B Strep in pregnancy?
- risk factors
- investigations
- management
Risk Factors of vertical GBS transmission:
- Previous GBS+ve
- Intrapartum fever >38
- Current preterm labour
- Prolonged rupture of membranes
Investigations:
- Vaginal and rectal swab at 35-37 week IF previous GBS+ve
Management: If +ve cultures or risk factors present
- IV penicillin
132
What is the management of a missed miscarriage?
vaginal misoprostol
133
What is assessed at the booking visit?
| + when is it?
<10 weeks
BMI
Blood pressure
Urinalysis (for proteinuria)
Blood test:
FBC + serum Ab (Rhesus status)
Infection: rubella immunisation, syphillis, HIV, Hep B
Haemoglobin electrophoresis (sickle cells)
Glucose tolerance test (if at risk of GD)
History:
Age (risks)
History of current pregnancy (LMP)
Past obstetric history
Past gynae history
Past medical history + drug history
Family history
Full social history (inc. domestic violence and FGM)
134
What is assessed at the dating scan?
| + When is it?
8-14 weeks
Dating + due date using crown-rump length
Multiple pregnancies
Nuchal translucency measurements
135
What is assessed at the abnormality scan?
| + When is it?
18-20 weeks
Structural abnormalities
Placental lie
136
What is the screening for Down's syndrome?
<14 weeks: 75% sensitivity
- USS nuchal translucency (raised indicated cardiac abnormality)
- PAPP-A (low indicated chromosomal abnormality)
- bHCG (raised in Down's)
>15 weeks:
- AFP (reduced)
- uE3 (unconjugated oestriol) (reduced)
- Inhibin A (raised)
- bHCG (raised)
If positive: CVS (quicker) or Amniocentesis (safer and more accurate)
137
What is assessed at 28 week antenatal check up?
Bloods: FBC, Rhesus status
Urine BP
* given Anti-D*
* offer pertussis vaccine*
138
What is the antenatal care from 34 weeks onwards?
Check ups every 2 weeks to assess:
- birth plan: vaginal or c-section, analgaesia etc.
- Urine and BP
- growth plotting (symphisiopubic height)
36w: check foetal presentation and placental lie
139
When is Anti-D prophylaxis given?
28 weeks and 34 weeks
140
What is assessed at a 41 week scan?
offered membrane sweep and induction of labour
141
When are the extra antenatal checks for nulliparous women?
25+31 weeks
- Urine and BP
- growth plotting (symphisiopubic height)
142
What are the risk factors for cord presentation?
```
Premature rupture of membranes
Long umbilical cord
Polyhydramnios
Multiple pregnancy
Abnormal foetal lie (e.g. breech)
Placenta praevia
Multiparity
CPD
```
143
What is cord prolapse and why is it worrying?
Umbilical cord descends ahead of the foetus
Causes cord compression or spasm--> foetal hypoxia and death
144
What is the management of cord prolapse?
Push presenting part of foetus back into uterus (to alleviate cord pressure)
Raise hips above head
Avoid handling cord
Tocolytics e.g. terbutaline
Emergency c-section
145
What is the diagnostic criteria for hyperemesis gravidarum?
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
146
What are risk factors for hyperemesis gravidarum?
```
Multiple pregnancies
Trophoblastic disease
Hyperthyroidism
Obesity
Nulliparity
```
147
What is the management of hyperemesis gravidarum?
Ginger
P6 Acupressure
Promethazine
Cyclizine
IV fluid correction
148
What are complications of hyperemesis gravidarum?
Wernicke's encephalopathy
IUGR or preterm birth
Mallory-Weiss tear
149
What are the side effects of Entonox in labour?
Maternal nausea and vomiting
150
What are the side effects of opioids in labour?
| + give examples of the drugs
Maternal: prolonged first/second stage of labour, feelings of unease, euphoria/dysphoria
Foetal: Respiratory depression, diminished breast-feeding behaviours
e.g. pethidine, morphine IM, PCA fentanyl
151
What level do you insert an epidural?
L3/4
152
Epidural;
- Indications
- Contraindications
```
Indications:
Maternal request
Multiple delivery
Instrumental deliveries
Maternal hypertension
```
Contraindications:
Maternal refusal
Allergy
Local infection
153
What nerves and levels cause pain in labour?
L5-S4
Especially pudendal nerve: S2-4
154
What are the 4 elements of a CTG?
Baseline foetal heart rate
Foetal heart rate variability
Accelerations
Decelerations
155
What are the causes of antepartum haemorrhage?
```
Placental abruption
Placenta praevia
Vasa praevia
Morbidly adherent placenta (accreta, increta, percreta)
Uterine
```
```
Polyps
Fibroids
Vulval varicosities
Vaginitis
Cervicitis
Carcinoma
```
156
How is an antepartum haemorrhage classified?
Bleeding >24 weeks
157
What are the risk factors and associations for placental abruption?
Pre-eclampsia/ hypertension
Smoking
Thrombophilia
Multiple pregnancy
Polyhydramnios
IUGR
PROM
Increasing maternal age
Abdominal trauma
IVF
158
What is the presentation of placental abruption?
```
Antepartum haemorrhage (could be hidden), blood dark red
PAIN
Tender, tense uterus- "woody"
Normal foetal lie
Foetal distress
```
159
What are the risk factors and associations with placenta praevia?
```
Multiparity
IVF
Dichorionic twins
Uterine fibroids
Endometriosis
Previous c-section
```
Maternal age
Previous uterine surgery (inc TOP)
160
What is the antenatal management of placenta praevia?
Detect in 20-week anomaly scan + repeat USS at 36 weeks
Anti D prophylaxis !!
Planned c-section if within 2cm of the os
Normal delivery if not
161
What is the management of an antenatal haemorrhage?
ABCDE and management
Steroids if <34 weeks
Arrange emergency c-section
162
What is the presentation and management of vasa praevia?
Antenatal diagnosis by USS
Elective c-section (or emergency if not detected)
163
What is the presentation of placenta praevia?
!! Bleeding- small bleeds before- bleeding is not concealed, bright red
NO PAIN/ tenderness/ uterine tenseness
Likely abnormal foetal lie
164
What is the management of morbidly adherent placenta?
Antenatal diagnosis via USS and MRI
Elective c-section at 36-37 weeks
±hysterectomy
165
What are the complications of an antepartum haemorrhage?
```
Maternal:
DIC
Hypovolaemic shock
Sheehan's syndrome (pituitary necrosis following hypovolaemic shock)
Post-partum haemorrhage
```
Foetal:
Hypoxia (+brain injury)
Demise
166
What is the classification of a postpartum haemorrhage?
Primary: haemorrhage within 24 hours of birth
Minor 500-1000ml
Major >1000ml
Secondary: haemorrhage from 24h-12 weeks of birth
167
What are the causes of PPH?
1. Tone: atony++++++++
2. Tissue: retained products (placenta)
3. Trauma: uterus (rupture, inversion), surgical trauma
4. Thrombin: DIC, haemophilia, sepsis, pre-eclampsia, ITP
168
What are the risk factors for PPH?
```
Previous PPH
Antepartum haemorrhage
Nulliparity
Multiparity
Clotting disorder (e.g. haemophilia)
```
Uterine malformations
Fibroids
Abnormal placentation
Polyhydramnios
Multiple pregnancy
```
During labour:
Prolonged labour
Macrosomia
Shoulder dystocia
Operative birth (c-section)
Instrumental delivery
Induction using oxytocin
Prolonged syntocinon administration
```
169
What are the red flag signs of severe pre-eclampsia?
Severe headaches
Flashing lights
Papilloedema
HELLP - RUQ pain, low platelets, raised LFTs
Clonus/ hyperreflexia (precursor to seizures)
170
How do you manage pre-eclampsia?
Labetolol
± nifedipine, hydralazine
±magnesium sulphate
Delivery!
Aspirin from week 10-36 in second pregnancy!
171
What is pre-eclampsia?
Hypertension and proteinuria in pregnancy >20 weeks
172
What is eclampsia?
Proteinuria, hypertension + seizures in pregnancy
173
How do you manage eclampsia?
Magnesium sulphate
| Delivery
174
What are the risks associated with pre-eclampsia and eclampsia?
Maternal:
- HELLP syndrome
- DIC
- Acute kidney injury
- ARDS (adult respiratory distress syndrome)
- Neurological complications
- Increased risk of htn/ CV disease in the future
Foetal:
- hypoxic brain injury
- Foetal growth retardation (IUGR)
- LBW
- Prematurity/ preterm birth
- SGA
175
What is the pathophysiology of pre-eclampsia?
Predisposition leads to poor vascularisation of the placenta
This causes placental ischaemia, and placenta releases thromboplastins (DIC) and renin (vasoconstriction)
This leads to hypertension (to preserve foetal nutrition), proteinuria and eventually seizures (+ foetal growth retardation)
176
What are symptoms in pre-eclampsia?
Headaches, visual disturbances
RUQ pain
Oedema
Rapid weight gain
177
What investigations would you do in ?pre-eclampsia?
```
Bloods:
FBCs (Hb, platelets)
U+Es (uric acid)
LFTs (HELLP)
Protein creatinine ratio (raised)
```
Urine dip
Blood pressure
Regular USS for foetal growth
178
What are differential diagnoses of pre-eclampsia?
Thrombotic thrombocytopenic purpura
Haemolytic uremic syndrome
Acute fatty liver
essential hypertension
179
What are the risk factors for pre-eclampsia?
```
Pre-existing hypertension
Previous pre-eclampsia
Family history of pre-eclampsia
Maternal renal disease
Obesity
Diabetes (gestational or T2DM)
Afrocaribbean
Nulliparity
Multiple pregnancy
```
180
What is cord prolapse and what are the risks?
When the cord is presenting and prolapses through the cervix
Causes vasospasm and foetal distress/ hypoxia
181
What are the risk factors of cord prolapse?
```
Obesity
Multiparity
Abnormal foetal lie
PROM
Long cord
Polyhydramnios
```
182
What is the management of cord prolapse?
Alleviate pressure on cord- push foetus back into uterus
Elevate hips over head (e.g. trendelenberg)
Emergency caesarean
183
What are the risk factors for shoulder dystocia?
```
Macrosomia
CPD
Maternal diabetes
Maternal obesity
Prolonged labour
```
184
What is the management of shoulder dystocia?
McRoberts
Suprapubic pressure
Delivery of posterior arm
C-section
185
What are the complications of shoulder dystocia?
Maternal:
Trauma- 3rd or 4th degree tear
Psychological distress, PTSD
PPH
Foetal:
Hypoxic brain injury and cerebral palsy
Brachial plexus injury- Erb's palsy
Clavicle fracture
186
Obstetric cholestasis:
- What is it
- Presentation
- Management
- Risks
Raised bile salts in blood
Presentation: Itching, mild jaundice, pale stools, dark urine, raised LFTs
Management: Ursodeoxycholic acid
Risks: Premature birth, foetal distress (meconium passage), and still birth
187
What are the risk factors for VTE in pregnancy?
```
Obesity
Smoking
Hypertension
Pre-eclampsia
Maternal age
Prolonged labour
Multiparity
Immobilisation
Cancer
Trauma
FH
IVF
```
188
What is the management of VTE in pregnancy?
Dalteparin (LMWH)
189
What is SGA, IUGR and LBW?
SGA- foetus with size below the 10th centile
IUGR- foetus unable to meet genetically predetermined size
LBW- Baby born <2500g
190
What are the precipitating factors to preterm birth?
Premature rupture of membranes
Cervical weakness
Amnionitis
Preterm labour
191
What are the risk factors for preterm birth?
Pregnancy related:
- multiple pregnancy
- APH
Non-modifiable
- maternal age (extremes)
- previous PTB
- weak and short cervix
Modifiable
- Maternal infection- BV, UTI, pyelonephritis, appendicitis
192
What are the complications associated with preterm birth?
Developmental delay
Respiratory distress syndrome + chronic lung disease + pulmonary hypoplasia
Cerebral palsy
Visual impairment
193
How do you manage premature rupture of membranes?
```
Admit
Observe for signs of chorioamnionitis
Oral erythromycin
Steroids to mature foetal lungs
Magnesium sulphate
```
194
What investigations should be done in premature labour?
Sterile speculum- to assess cervical dilation
Bedside fibronectin (indicates upcoming labour)
TVUSS to assess cervical length
195
What investigations should be done in premature rupture of membranes?
Sterile speculum- to assess cervix
Nitralazine stick (testing that it is amniotic fluid)
High vaginal swab (for GBS)
Assess maternal and foetal well-being regularly
196
What is the management of preterm labour?
Maternal steroids
Tocolytics- B2 agonists, ritodrine
Abx
197
What is the management for women at high risk of preterm labour?
```
Regular scans
GBS testing
Foetal fibronectin
Cervical USS
Cervical cerclage
```
198
What is the pueperium?
Delivery--> 6 weeks
199
What is 'station'?
Level of the head in relation to the ischial spines
Above the spines (further in): -2 (2cm above)
At the spines: 0
Below the spines (further out): +2 (2cm below)
200
What are the characteristics of labour?
/
What is needed to "diagnose" labour?
Cervical effacement
Regular painful contractions
Mucus plug show or rupture of membranes
201
What is the first stage of labour?
From 4-10cm cervical dilation
202
How long should the first stage of labour take?
- How often contractions
Max 12 hrs.
Nulliparous: 1cm dilation per hour
Multiparous: 2cm dilation per hour
contractions every 3-5 min
lasting ~1 min
203
How long should the second stage of labour take?
- How often contractions?
Max 1hr. before intervention
Nulli: 40 min
Multi: 20 min
Every 30secs-2min
Lasts 90 seconds
204
What are the movements of the second stage of labour?
Head: flexed to extension
Rotation 90° from occipito-posterior to occipito-transverse
205
What is a partogram?
Assesses progression in labour
Monitors foetal: HR, head descent
Liquor colour
Cervical dilation
Maternal vital signs
206
What are the causes of failure to progress in labour?
Power;
- Inefficient uterine action-
Passage;
- Cephalo-pelvic Disproportion
Passenger;
- malpresentation
207
How do you manage malpresentation?
If breech: extracephalic version or c-section
If occipito-posterior: If prolonged first stage: c-section
If prolonged second stage: manual or ventouse rotation
If occipito-transverse: Usually with incomplete turning during decent- ventouse
If brow or face: c-section
208
What is the Bishop's score?
Prelabouring scoring system to establish whether induction is necessary or not
209
What is included in the Bishop's score?
Cervix texture: Soft (2), Medium (1), Firm (0)
Cervix length: <0.5 (3), <1 (2), <2 (1), >3 (0)
Cervix dilation: 5+ (3), 4-3 (2), 2-1 (1), <1 (0)
Foetal station: >0 (3), >-1 (2), >-2 (1), >-3 (0)
Foetal position: Anterior (2), Middle (1), Posterior (0)
210
How do you interpret the Bishop's score?
Total /13
211
How do you interpret the Bishop's score?
Total /13
<5: needs induction
5-9: Needs professional judgement
>9: spontaneous labour
212
What are the methods of induction?
Prostaglandin E2 gel in the posterior fornix
Cervical sweeping
ARM and oxytocin infusion
213
What are the indications of induction of labour?
Gestation: 40-40+14
PROM
Maternal health problems; e.g. hypertension, pre-eclampsia, diabetes, cholestasis
IUGR
Foetal distress
214
What are the contraindications of induction of labour?
```
CPD
Cord prolapse
Vasa praevia
Breech/transverse lie
Active genital herpes
2+ c-sections or 1 classical c section
Triplets +
```
215
What is polyhydramnios and how is it established?
Amniotic fluid index >95th percentile for gestational age
Calculated by measuring the vertical measurement of fluid pockets in 4 quadrants
216
What are the causes of polyhydramnios?
```
Idiopathic
Foetal oesophageal dysfunction; CNS, diaphragm hernia, atresia
Duodenal atresia (double bubble)
Twin-twin transfusion
Foetal hydrops
Foetal anaemia
Macrosomia
Maternial diabetes
Maternal lithium
Maternal infection
Foetal karyotype/ genetic abnormalities
```
217
What is foetal hydrops?
Oedema in 2 compartments of the foetus
| e.g. scalp, ascites etc.
218
What are the causes of foetal hydrops?
```
Twin-twin transfusion
Iron-deficiency anaemia
Immune; Rh disease
Congenital abnormality: e.g. Turners, Noonan's,
Alpha thalassaemia
```
219
What investigations should you do in polyhydramnios?
Fasting glucose
Karyotyping
TORCH screen
220
What is the management of polyhydramnios?
Nothing
Indomethacin
Amnioreduction
Paediatric assessment of baby after birth- NG tube passed through to check for abnormalities inc fistulas
221
What are the risks associated with polyhydramnios?
Maternal:
- PPH (increased uterine contraction needed)
- Malpresentation
Foetal:
- Preterm labour
- Increased risk of congenital abnormality
222
What is Oligohydramnios?
+ how is it established?
Amniotic fluid index (AFI) < 5th percentile for gestational age
Vertical measurement of fluid space in four quadrants
223
What are the causes of oligohydramnios?
```
Placental insufficiency!
Pre-eclampsia
Premature rupture of membranes
Renal agenesis
Genetic/ chromosomal abnormalities
Maternal infection
```
224
What are the risks of an amniocentesis?
1. Miscarriage
2. Infection
3. Rhesus disease
4. Club foot
225
What is the management of PPH as a result of atony?
Bimanual compression
Oxytocin infusion
Ergometrine slow IV/IM
Carboprost IM
Misoprostol rectal
```
Surgical:
Balloon tamponade
B-Lynch sutures
Bilateral artery ligation (uterine or internal iliac)
Hysterectomy
```
