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Phase 3A Flashcards > Obstetrics + Gynaecology > Flashcards

Obstetrics + Gynaecology Flashcards

1
Q

what are the main two urinary tract disorders in pregnant women?

A
  1. overactive bladder

2. stress incontinence

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2
Q

what is the pathophysiological cause of stress incontinence?

A

weakness of the urethral sphincter combined with increased intra-abdominal pressure

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3
Q

what % of pregnant women have stress incontinence?

A

> 10%

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4
Q

what are 4 causes of stress incontinence?

A
  1. pregnancy
  2. prolonged labour
    forceps delivery
  3. obesity
  4. age
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5
Q

what are 3 urinary symptoms that may present with stress incontinence?

A
  1. frequency
  2. urgency
  3. urge incontinence
    (faecal incontinence may co-exist)
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6
Q

what is a cystocoele?

A

where the bladder prolapses into the vagina?

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7
Q

what is a urethrocoele?

A

bulging of the urethra into the vaginal wall

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8
Q

what 3 ways can you test for urethrocoeles and cystocoeles?

A
  1. Sims speculum examination
  2. urine dipstick
  3. cystoscopy
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9
Q

how do you treat stress incontinence?

A
  1. 1st line is pelvic floor muscle training
  2. vaginal cones/ sponges
  3. duloxetine
  4. surgery
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10
Q

what type of drug is duloxetine?

A

an antidepressant (SS+NRI) that can treat urinary incontinence

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11
Q

what surgery can be done for stress incontinence?

A

tension-free vaginal tape

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12
Q

what is the clinical presentation of an overactive bladder?

A
  1. urinary urgency without incontinence
  2. usually occurs with frequency or nocturia
  3. can lead to incontinence
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13
Q

what are 3 causes of an overactive bladder?

A
  1. detrusor overactivity
  2. multiple sclerosis
  3. spinal cord injury
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14
Q

what are 6 ways you can treat an overactive bladder non-medically?

A
  1. reduce fluid intake
  2. avoid caffeine
  3. bladder training
  4. education
  5. timed voiding
  6. positive reinforcement
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15
Q

what are 4 ways you can treat an overactive bladder medically?

A
  1. anticholinergics
  2. oestrogen treatment
  3. botulinum toxin A
  4. neuromodulation
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16
Q

what are 6 causes of acute urinary retention?

A
  1. childbirth
  2. surgery
  3. anticholinergics
  4. retroverted gravid uterus
  5. pelvic masses
  6. neurological disease
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17
Q

how do you treat acute urinary retention?

A

catheter insertion

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18
Q

how do you diagnose acute urinary retention?

A

ultrasound or catheterisation after micturition

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19
Q

what is painful bladder syndrome?

A

where someone experiences suprapubic pain related to bladder filling. can also manifest with urinary frequency

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20
Q

what is interstitial cystitis?

A

inflammation of the bladder that can cause suprapubic pain?

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21
Q

how do you diagnose interstitial cystitis?

A

cystoscopy and histology

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22
Q

what are 6 ways to treat interstitial cystitis?

A
  1. dietary changes
  2. bladder training
  3. tricyclic antidepressants
  4. analgesics
  5. intravesicular drug infusion
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23
Q

how do you treat vesicovaginal and urethrovaginal fistulae?

A

surgery

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24
Q

how do you define a uterine or vaginal prolapse?

A

descent of the uterus or vagina beyond anatomical confines due to weakness of surrounding structures

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25
Q

what are 5 types of vaginal prolapse?

A
  1. urethrocele
  2. cystocoele
  3. rectocoele
  4. enterocoele
  5. apical prolapse
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26
Q

what is a rectocoele?

A

prolapse of the lower posterior wall of the vagina involving anterior wall of rectum

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27
Q

what is an enterocoele?

A

prolapse of the upper posterior wall of the vagina involving loops of small bowel

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28
Q

what is an apical vaginal prolapse?

A

a vaginal prolapse of the uterus, cervix and upper vagina

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29
Q

what % of parous women (women who have given birth) have some degree of prolapse?

A

50%

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30
Q

what are the symptoms of a vaginal prolapse?

A

dragging sensation or a lump. severe prolapse can interfere with sex, ulcerate and bleed. cystourethrocoele can cause urinary frequency

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31
Q

how do you diagnose prolapse?

A
  1. abdominal and bimanual exam
  2. ultrasound
  3. urodynamic testing for cystourethrocoele
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32
Q

what are 2 ways to avoid vaginal prolapse?

A
  1. pelvic floor exercises

2. avoidance of excessively long 2nd stage of pregnancy

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33
Q

how do you treat vaginal/ uterine prolapse?

A
  1. surgery
  2. pessaries if unfit for surgery
  3. physiotherapy
    vaginal hysterectomy for uterovaginal prolapse
  4. hysteropexy (suspension of prolapsed uterus) for uterine prolapse
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34
Q

what are 3 possible side effects of using a pessary?

A
  1. pain
  2. urinary retention
  3. infection
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35
Q

what is endometriosis?

A

presence and growth of tissue similar to endometrium outside the uterus that causes inflammation and progressive fibrosis and adhesions

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36
Q

what causes endometriosis in the pelvis?

A

retrograde menstruation

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37
Q

what are 2 factors that make a woman more likely to have endometriosis?

A
  1. age 30-45

2. nulliparous (never given birth) women

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38
Q

what is the clinical presentation of endometriosis?

A
  1. often symptomless
  2. dysmenorrhoea (painful menstruation)
  3. deep dyspareunia (difficult or painful intercourse)
  4. sub-fertility
  5. pain on passing stool
  6. menstrual problems
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39
Q

what are some common findings on observation and examination?

A

tenderness or thickening behind the uterus, with the pelvis feeling normal if mild disease

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40
Q

how do you diagnose endometriosis?

A

visualisation and biopsy at laparoscopy

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41
Q

what does an active endometriosis lesion look like

A

red vesicles on the peritoneum

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42
Q

what does a less active endometriosis lesion look like?

A

white scars or brown spots on the peritoneum

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43
Q

what additional pathophysiological features are present in severe endometriosis?

A

extensive adhesions and ovarian endometriomas (endometrial cyst)

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44
Q

what investigations are recommended for endometriosis?

A
  1. transvaginal ultrasound
  2. laparoscopy
  3. MRI to exclude adenomyosis
  4. MRI with IV pyelogram (kidneys, ureters and bladder) for deep penetrating disease
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45
Q

how do you treat endometriosis?

A
  1. pain management- progestagens or mirena good for pain (mimic pregnancy)
  2. combined oral contraceptive pill (tricyclic regimen)
  3. GnRH analogue- danazol (mimic menopause)
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46
Q

what hormone does a GnRH analogue inhibit the synthesis of to treat endometriosis, and what physiological state does this induce?

A

oestrogen (they induce temporary menopause)

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47
Q

what condition can be caused by taking GnRH analogues over a long period of time, and what is the therapy duration as a result?

A

reversible bone demineralisation so therapy is <6 months

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48
Q

how do you laparoscopically destroy endometriosis lesions?

A

scissors, laser or bipolar diathermy

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49
Q

what is the last resort surgery for endometriosis?

A

hysterectomy

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50
Q

how are progestogens and mirena good for pain management in endometriosis?

A

they create a pseudo-pregnant state that prevent endometrial sloughing and pain

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51
Q

what is mirena?

A

an implantable uterine device that secretes progestagens

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52
Q

what is adenomyosis?

A

presence of endometrium within myometrium (deeper muscular layer of the uterine wall)

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53
Q

what are 3 risk factors for adenomyosis?

A
  1. 40-ish years old
  2. endometriosis
  3. fibroids
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54
Q

what are the differences in occurence between endometriosis and adenomyosis regarding age and pregnancies?

A

endometriosis- young and nulliparous

adenomyosis- older and multiparous

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55
Q

what is the clinical presentation of adenomyosis?

A
  1. symptomless

2. painful, regular heavy menstruation

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56
Q

what can be seen on observation and examination of adenomyosis?

A

mildly enlarged and tender uterus

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57
Q

how do you diagnose adenomyosis?

A

MRI and clinical picture

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58
Q

how do you treat adenomyosis?

A
  1. progesteron IUD

2. combined OC pill

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59
Q

what are fibroids?

A

benign tumours of the myometrium (middle layer of uterine wall)

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60
Q

what % of women have fibroids?

A

25%

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61
Q

what three names are given to fibroids in different locations within the uterine wall and what are these locations?

A
  1. intramural (between muscles)
  2. subserosal (outside of uterus)
  3. submucosal (under the uterine lining)
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62
Q

what hormone is the growth of fibroids dependent on?

A

oestrogen

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63
Q

what is the clinical presentation of fibroids?

A
  1. 50% asymptomatic
  2. 30% menorrhagia
  3. dysmenorrhoea
  4. sub-fertility
  5. frequency and retention with large fibroids pressing on bladder
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64
Q

what two types of degeneration can fibroids undergo and what are the associated symptoms?

A
  1. red degeneration- occurs in pregnancy, causes pain, tenderness, haemorrhage and necrosis
  2. hyaline/ cystic degeneration- fibroid soft and partly liquefied
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65
Q

how can fibroids affect pregnancy?

A

can cause severe pain, premature labour, malpresentations and obstructed labour

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66
Q

how do you diagnose fibroids?

A
  1. MRI, but ultrasound is useful

2. hysteroscopy or hysterosalpinogram can assess distortion of the uterine cavity

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67
Q

what might cause a low haemoglobin in a patient with fibroids?

A

bleeding

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68
Q

what might cause a high haemoglobin in a patient with fibroids?

A

excess EPO secretion

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69
Q

how do you treat fibroids?

A
  1. asymp patients do not need treatment
  2. GnRH agonists cause temporary amenorrhoea and fibroid shrinkage but use <6 months
  3. small fibroid resection with surgery
  4. hysterectomy
  5. uterine artery embolisation to reduce volume of fibroids (but can cause more pain)
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70
Q

what are intrauterine polyps?

A

small benign tumours that grow in the uterine cavity, most endometrial and some are submucosal

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71
Q

what age are intrauterine polyps common?

A

40-50 year old women

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72
Q

what drug can cause intrauterine polyps in post-menopausal women?

A

tamoxifen (breast cancer hormone therapy)

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73
Q

how do you diagnose intrauterine polyps?

A

ultrasound or hysteroscopy

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74
Q

what is the clinical presentation of intrauterine polyps?

A

menorrhagia and inter-menstrual bleeding

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75
Q

how do you treat intrauterine polyps?

A

resection of polyps with cutting diathermy

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76
Q

what is subfertility?

A

pregnancy has not occurred after 1 year of regular unprotected intercourse

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77
Q

what is the difference between primary and secondary failure of conception?

A
  1. primary- never conceived

2. secondary- previous termination/ miscarriage

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78
Q

what are 4 general causes of subfertility?

A
  1. anovulation
  2. inadequate sperm
  3. fallopian tube damage
  4. defective implantation
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79
Q

what shows that ovulation has happened in the menstrual cycle?

A

elevated serum progesterone in the mid-luteal phase

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80
Q

what condition causes >80% of anovulatory infertility?

A

polycystic ovary syndrome

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81
Q

what is polycystic ovary syndrome?

A

a syndrome describing an enlarged ovary with multiple small follicles

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82
Q

how do you diagnose polycystic ovary syndrome?

A
  1. PCO on ultrasound
  2. irregular periods
  3. hirsutism
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83
Q

what causes increased androgen production in polycystic ovary syndrome?

A

disordered LH and peripheral insulin resistance

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84
Q

what is important to check for in the family history of polycystic ovary syndrome?

A

diabetes mellitus type 2

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85
Q

what is the typical clinical presentation of polycystic ovary syndrome?

A
  1. obesity
  2. acne
  3. hirsutism
  4. oligo/amenorrhoea
    female of reproductive age
  5. sometimes hypertension and scalp hair loss
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86
Q

what investigations should be done for polycystic ovary syndrome?

A
  1. FSH- normal in PCOS, raised in ovarian failure, lowered in hypothalamic
  2. prolactin and TSH
  3. serum testosterone
  4. LH
  5. screening for diabetes and abnormal lipids
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87
Q

what type of cancer is more common in polycystic ovary syndrome?

A

endometrial cancer

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88
Q

how do you treat polycystic ovary syndrome?

A
  1. 1st line weight loss plus oral contraceptive pill
  2. metformin
  3. mechanical hair removal
  4. cytoproterone acetate for hirsutism
  5. 2nd line anti-androgen
  6. clomiphene for fertility
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89
Q

what is hypothalamic hypogonadism?

A

reduction in GnRH release from the anterior pituitary gland leading to amenorrhoea

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90
Q

what are 4 risk factors for hypothalamic hypogonadism?

A
  1. anorexia nervosa
  2. dieting
  3. athletes
  4. stress
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91
Q

how do you treat hypothalamic hypogonadism?

A
  1. increase weight

2. OC or HRT for bone protection

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92
Q

the excessive release of which hormone can reduce GnRH release?

A

prolactin

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93
Q

what 3 things is excessive prolactin release associated with?

A
  1. PCOS
  2. hypothyroidism
  3. psychotropic drugs

(and tumours)

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94
Q

how does clomiphene (for inducing ovulation) work?

A

blocks oestrogen receptors on the hypothalamus and pituitary

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95
Q

what is 2nd line to clomiphene for infertility treatment?

A

gonadotrophin (FSH and LH)

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96
Q

what is ovarian hyper-stimulation syndrome?

A

a condition where gonadotrophins overstimulate follicles that get large and painful

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97
Q

what are 3 risk factors for ovarian hyper-stimulation syndrome?

A
  1. gonadotrophin stimulation
  2. age <35
  3. previous polycystic ovaries
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98
Q

what are 2 serious complications of severe ovarian hyper-stimulation syndrome?

A

thromboembolism and ascites

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99
Q

what are 10 causes of male subfertility?

A
  1. idiopathic oligospermia (no causative factor for reduced sperm count)
  2. asthenozoospermia (reduced sperm motility)
  3. alcohol
  4. smoking
  5. varicocele
  6. exposure to industrial chemicals
  7. mumps
  8. testicular abnormalities
  9. retrograde ejaculation
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100
Q

what hormone levels would suggest primary testicular failure?

A

high FSH and LH with low testosterone

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101
Q

what should men with azoospermia and an absent vas deferens be tested for?

A

cystic fibrosis

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102
Q

that investigations should be done for male subfertility?

A
  1. semen analysis

2. FSH, LH, testosterone, prolactin, TSH

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103
Q

how do you treat male subfertility?

A
  1. advice on loose clothing and testicular cooling
  2. lifestyle changed and drug exposures
  3. hormonal treatments
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104
Q

what is the most common cause of fallopian tube damage?

A

pelvic inflammatory disease

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105
Q

what is the clinical presentation for pelvic inflammatory disease?

A
  1. pelvic pain
  2. vaginal discharge
  3. abnormal menstruation
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106
Q

how do you assess the patency of the fallopian tubes?

A

laparoscopy and dye testing

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107
Q

what are 3 forms of assisted conception?

A
  1. intrauterine insemination
  2. IVF
  3. intracytoplasmic sperm injection
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108
Q

what is intrauterine insemination?

A

washed sperm is injected directly into the uterine cavity following gonadotrophin ovulation induction

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109
Q

what conditions make intrauterine insemination suitable?

A
  1. unexplained subfertility

2. cervical, sexual and male factors

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110
Q

what is in-vitro fertilisation?

A
  1. multiple follicular development with FSH+LH
  2. Egg collection
  3. embryo culturing
  4. implantation of embryos
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111
Q

what is intracytoplasmic sperm injection?

A

injection of sperm into the oocyte cytoplasm

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112
Q

what are the conditions that are screened for antenatally?

A
  1. sickle cell and thalassaemia
  2. infectious diseases (HIV, Hep B, Syphilis)
  3. down’s, edward’s and patau’s
  4. diabetic eye screening (for mother)
  5. fetal anomaly scan
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113
Q

what is edward’s syndrome?

A
  1. trisomy 18
  2. low survival rates and only 10% live past first birthday
  3. severe learning disabilities and organ defects
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114
Q

what is patau’s syndrome?

A
  1. trisomy 13
  2. most babies die before or shortly after birth
  3. major defects include heart, midline facial, abdo wall and urogenital defects
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115
Q

what are the 11 fetal abnormalities that are screened for in the fetal abnormality scan?

A
  1. anencephaly
  2. open spina bifida
  3. cleft lip
  4. diaphragmatic hernia
  5. gastroschisis
  6. exomphalos
  7. serious cardiac abnormalities
  8. bilateral renal agenesis
  9. lethal skeletal dysplasia
  10. trisomy 18 (edward’s)
  11. trisomy 13 (patau’s)
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116
Q

what are the things examined in the newborn infant physical examination?

A
  1. eyes
  2. heart
  3. hips
  4. testes

hearing is tested separately

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117
Q

what are the 9 conditions tested for in the newborn blood spot test?

A
  1. cystic fibrosis
  2. sickle cell disease
  3. congenital hypothyroid
  4. phenylketonuria
  5. MCAD deficiency
  6. maple syrup urine disease
  7. isovaleric acidaemia
  8. glutaric aciduria type
  9. homocystinuria
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118
Q

what are 5 pregnancy specific conditions that can affect someone during pregnancy?

A
  1. pre-eclampsia
  2. thromboembolism
  3. gestational diabetes mellitus
  4. obstetric cholestasis
  5. acute fatty liver
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119
Q

what are 8 pre-existing conditions that are important to remember during pregnancy?

A
  1. asthma
  2. epilepsy
  3. hypertension
  4. diabetes
  5. thyroid problems
  6. renal problems
  7. cardiac problems
  8. SLE/ RA
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120
Q

what should be done before pregnancy with regards to pre-existing medical conditions?

A
  1. optimise disease control and ensure medical condition is stable before pregnancy (contraception until ready to conceive)
  2. rationalise drug therapy to minimise effects on the baby
  3. advise on risks
  4. agree a care plan
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121
Q

what are 2 important things to consider about pre-existing medical conditions during pregnancy?

A
  1. the effect pregnancy has on the condition

2. the effect the condition may have on the baby

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122
Q

what is a condition that improves during pregnancy?

A

rheumatoid arthritis

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123
Q

what pre-existing medical condition increases the risk of pre-eclampsia?

A

essential hypertension

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124
Q

what are some factors to consider during delivery and postpartum care?

A
  1. safest mode of delivery
  2. neonatal support
  3. anaesthetic expertise
  4. ITU/HDU facilities
  5. ongoing post-partum care
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125
Q

what changes in the manifestation and management of anaemia during pregnancy?

A
  1. 2-3 fold increase in iron requirements

2. 10-20 fold increase in folate requirements

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126
Q

what effects can maternal anaemia have on the baby?

A

iron deficiency is associated with low birthweight and pre-term delivery

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127
Q

what changes in the manifestation and management of asthma during pregnancy?

A
  1. risk of exacerbation particularly in the 3rd trimester

2. all medications normally used in asthma can be used during pregnancy

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128
Q

what effects can maternal asthma have on the baby?

A
  1. risk of fetal growth restriction due to inadequate perfusion of the placenta
  2. premature delivery with deterioration of the mother’s condition
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129
Q

what are 4 low cardiac conditions during pregnancy?

A
  1. mitral incompetence
  2. aortic incompetence
  3. atrio-septal defect
  4. ventriculo-septal defect
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130
Q

what are 4 high risk cardiac conditions during pregnancy?

A
  1. aortic stenosis
  2. coarctation of the aorta
  3. prosthetic valves
  4. cyanosed patients
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131
Q

what are some management issues relating to cardiac problems during pregnancy?

A
  1. anti-coagulation for mechanical heart valves
  2. need to alter and add medications
  3. consistently monitor fetal growth and wellbeing- consider timing and mode of delivery of the scane
  4. post-partum cardiac failure
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132
Q

what is the most common liver disease during pregnancy?

A

obstetric cholestasis

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133
Q

what is the presentation of obstetric cholestasis?

A

itching with no rash, usually resolving after delivery

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134
Q

what is raised during obstetric cholestasis?

A

AST, ALT and bile acids

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135
Q

what is the recurrence risk for obstetric cholestasis?

A

> 80%

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136
Q

what effects can obstetric cholestasis have on the baby?

A
  1. risk of stillbirth and premature labour
  2. treatment with ursodeoxycolic acid does not seem to reduce fetal complications but is associated with improved biochem abnormalities
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137
Q

what changes in the manifestation and management of hyperthyroidism during pregnancy?

A
  1. often improves in pregnancy after 1st trimester
  2. maternal risk of thyroid crisis with cardiac failure
  3. carbimazole and propylthiouracil can cause maternal liver failure and fetal abnormalities
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138
Q

what effects can maternal hyperthyroidism have on the baby?

A

thyrotoxicosis due to transfer of thyroid stimulating antibodies

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139
Q

what effects can maternal hypothyroidism have on the baby?

A

early fetal loss and impaired neurodevelopment if untreated, aim for thyroxine replacement during pregnancy

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140
Q

what complications can diabetes cause to the mother during pregnancy?

A
  1. diabetic ketoacidosis
  2. hypoglycaemia
  3. retinopathy progression
  4. pre-eclampsia
  5. premature labour
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141
Q

what complications can diabetes cause to the baby during pregnancy?

A
  1. miscarriage
  2. macrosomia, shoulder dystocia
  3. fetal abnormality
  4. stillbirth
  5. neonatal hypoglycaemia, respiratory distress, hypocalcaemia and polycycaemia
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142
Q

what drugs are used for diabetes during pregnancy?

A
  1. insulin- basal bolus regime
  2. metformin
  3. glibenclamide (all of hypoglycemics contraindicated)
  4. statins and ACE-i contraindicated
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143
Q

what complications can chronic renal disease cause to the mother during pregnancy?

A
  1. severe hypertension
  2. deterioration in renal function
  3. pre-eclampsia
  4. caesarean section
  5. premature delivery
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144
Q

what complications can chronic renal disease cause to the baby during pregnancy?

A
  1. growth restriction
  2. stillbirth
  3. abnormalities due to maternal drug therapy
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145
Q

what are 4 physiological factors that determine the outcome in pregnancy of chronic renal disease?

A
  1. renal dysfunction
  2. maternal blood pressure
  3. creatinine levels
  4. proteinuria
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146
Q

how should you treat renal disease during pregnancy?

A
  1. pre-pregnancy risk assessment
  2. multidisciplinary care
  3. close renal function and blood pressure monitoring
  4. regular fetal growth and wellbeing assessment
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147
Q

what is the risk to the mother of having epilepsy during pregnancy?

A
  1. 25-33% increase in seizure frequency
  2. sudden unexpected death in epilepsy, which is more common in patients who do not take their prescribed anti-convulsants (EG mothers scared of harming babies)
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148
Q

what are the risks to the baby of the mother having epilepsy during pregnancy?

A
  1. risk of fetal abnormality, mainly due to anti-convulsant medication but possibly also epilepsy itself
  2. inheritance of epilepsy
  3. fetal hypoxia during seizures
  4. spina bifida may be related to maternal epilepsy
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149
Q

what is the risk of a congenital malformation during pregnancy if a woman is using sodium valproate, and what are some of these malformations?

A

10.7%

spina bifida, cleft palate, hypospadias, polydactyly
4.4% risk of autism spectrum disorder

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150
Q

what are 4 risk factors for thromboembolism during pregnancy?

A
  1. maternal age
  2. BMI
  3. operative delivery
  4. haematological changes during pregnancy
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151
Q

what should be done if thromboembolism is suspected during pregnancy?

A
  1. investigate with doppler ultrasound for DVT or VQ scan (ventilation-perfusion scan)/ CT pulmonary angiogram for PE
  2. LMWH is the treatment of choice for VTE in pregnancy
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152
Q

what is a normal cycle of menstruation?

A

loss for 2-8 days

cycle for 21-35 days

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153
Q

what is the normal volume of blood loss per menstrual cycle?

A

60-80ml

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154
Q

what is the definition of abnormal uterine bleeding?

A

any menstrual bleeding from the uterus that is either abnormal in volume, regularity, timing, or is non-menstrual

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155
Q

what is the definition of heavy menstrual bleeding?

A

menstrual blood loss that is subjectively considered to be excessive by the woman that interferes with her quality of life

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156
Q

what are the three most common broad causes of heavy menstrual bleeding?

A
  1. coagulopathy
  2. ovulatory
  3. endometrial dysfunction
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157
Q

what are the four most common pathological causes of heavy menstrual bleeding?

A
  1. uterine fibroids
  2. uterine polyps
  3. adenomyosis
  4. endometriosis
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158
Q

what % of women with heavy menstrual bleeding have no uterine, endocrine, haematological or infective pathology on investigations?

A

40-60%

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159
Q

what are the four main causes of abnormal menstruation?

A
  1. uterine fibroids
  2. uterine polyps
  3. endometriosis
  4. adenomyosis
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160
Q

what is a uterine fibroid made up of?

A

smooth muscle cells with collagen

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161
Q

what is a uterine polyp made up of?

A

benign growth of the endometrium, fibrous core covered by columnar epithelium

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162
Q

what is an adenomyosis deposit?

A

ectopic endometrial tissue in the myometrium

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163
Q

what 3 things should be covered in a menses history?

A
  1. duration
  2. cycle
  3. index of heaviness (clots, protection, flooding)
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164
Q

what associated concerns should be covered in a menses history?

A
  1. pain- duration and relation to cycle
  2. premenstrual tension
  3. infertility worries
  4. cancer phobia
  5. interference with life
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165
Q

what associated symptoms should be covered in a menses history?

A
  1. thyroid disease- cold/ heat intolerance, consistency of hair, lethargy
  2. clotting disorder- bruising, family history
  3. drug therapy- warfarin, heparin
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166
Q

what should be included in the general bodily examination for a history of irregular menstruation?

A
  1. sclera, palms, gingiva
  2. thyroid gland
  3. abdomen
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167
Q

what should be included in a pelvic examination for a history of irregular menstruation and why?

A
  1. vulva and vagina- malignancy
  2. cervix
  3. uterus- fibroids, adenomyosis
  4. adnexae- ovaries and fallopian tubes (adnexae- appendages)
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168
Q

what investigations should be done with a history of menorrhagia?

A
  1. FBC
  2. transvaginal ultrasound
  3. endometrial biopsy if older than 45 years and unresponsive to treatment
  4. hysteroscopy if there is an abnormal scan, no treatment response or a diagnosis of polyps or fibroids
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169
Q

what are 7 treatments for abnormal menstruation

A
  1. antifibrinolytics
  2. NSAIDs
  3. progestagens
  4. danazol
  5. COCP
  6. mirena coil
  7. endometrial ablation
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170
Q

what is the % reduction in menstrual blood loss for antifibrinolytics and how do they work?

A
  1. inhibit tissue plasminogen activator (stop the breakdown of blood clots)
  2. 50%
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171
Q

what is the % reduction in menstrual blood loss for NSAIDs and how do they work?

A
  1. inhibit cyclooxygenase and blog PGE2 receptors (reduce the concentration of prostaglandins which are associated with heavy menstrual bleeding)
  2. 25%
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172
Q

what is the % reduction in blood loss for danazol and how does it work?

A
  1. inhibits the production of sex steroids

2. 86%

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173
Q

what is the % reduction in blood loss for COCP and how does it work?

A
  1. inhibits ovarian function

2. 43%

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174
Q

what is the % reduction in blood loss for the mirena coil and how does it work?

A
  1. local release of progestagens

2. 85% after 3 months

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175
Q

what are 4 indications for endometrial ablation?

A
  1. heavy menstrual loss
  2. normal endometrium
  3. completed family
  4. not expecting amenorrhoea
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176
Q

what are 3 contraindications for endometrial ablation?

A
  1. malignancy
  2. acute pelvic inflammatory disease
  3. desire for future pregnancy
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177
Q

what is the largest cause of post-natal death in normal fetuses?

A

prematurity

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178
Q

what 4 conditions is prematurity a major contributor to?

A
  1. developmental delay
  2. visual impairment
  3. chronic lung disease
  4. cerebral palsy
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179
Q

what are 5 factors in neonatal intensive care that improve survival rates in premature infants?

A
  1. antenatal steroids
  2. artificial surfactant
  3. ventilation
  4. nutrition
  5. antibiotics
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180
Q

what are 6 risk factors for premature birth?

A
  1. antepartum haemorrhage and vaginal bleeding
  2. multiple pregnancies
  3. race
  4. previous pre-term births
  5. cervical weakness
  6. genital infection
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181
Q

what are 4 primary prevention strategies for preterm birth?

A
  1. smoking and STD prevention
  2. prevention of multiple pregnancy
  3. planned pregnancy
  4. physical and sexual advice
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182
Q

what are 4 tertiary prevention strategies for preterm birth?

A
  1. prompt diagnosis
  2. antibiotics
  3. corticosteroid
  4. tocolysis (drugs to prevent contractions)
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183
Q

define the diagnosis of preterm labour

A

persistent uterine activity and change in cervical dilation and/ or effacement before week 37

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184
Q

what is a secondary prevention strategy for preterm birth?

A

select those at increased risk for surveillance and prophylaxis

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185
Q

what are 2 screening methods for preterm labour?

A
  1. transvaginal cervical ultrasound

2. qualitative fetal fibronectin test

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186
Q

what is fetal fibronectin and what range of weeks will it start breaking down in for preterm delivery?

A

a glycoprotein that holds the fetal membranes to the uterine membrances and if it starts to break down between 22 and 35 weeks it indicated preterm delivery

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187
Q

what is a cervical risk factor for preterm delivery?

A

shortened cervix (<3cm)

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188
Q

what hormonal treatment can help women who are at risk of preterm delivery?

A

progesterone

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189
Q

what is pre-eclampsia?

A

pregnancy induced hypertension with proteinuria +/- oedema

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190
Q

what is the pathophysiological cause of pre-eclampsia?

A

failure of trophoblasts to invade spiral uterine arteries leaving them vasoactive (meaning they are still able to shrink in response to vasoconstrictors). increased blood pressure is an attempt to compensate

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191
Q

what 3 other systems can pre-eclampsia affect?

A
  1. hepatic
  2. renal
  3. coagulation
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192
Q

what are 3 high risk factors for pre-eclampsia?

A
  1. chronic hypertension
  2. chronic kidney disease
  3. diabetes mellitus
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193
Q

what are 3 moderate risk factors for pre-eclampsia?

A
  1. first pregnancy
  2. aged over 40
  3. family hx
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194
Q

what does proteinuria in pre-eclampsia indicate?

A

it is a late stage sign indicating renal involvement

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195
Q

what is the clinical presentation of symptomatic pre-eclampsia?

A

may mimic flu, can include-

  1. headache
  2. chest or epigastric pain
  3. vomiting
  4. increased pulse
  5. visual disturbance
  6. shaking
  7. irritability
  8. hyperreflexia
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196
Q

prophylaxis of which drug can reduce the risk of pre-eclampsia?

A

magnesium sulfate halves the risk of pre-eclampsia

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197
Q

how do you manage pre-eclampsia?

A
  1. regular BP measurements
  2. admittance is BP raises 30/20 since booking or is 160/100 total or 140/90 with proteinuria
  3. monitor fluid balance, U+E, LFT and platelets regularly
  4. cardiotocography (fetal heartbeat recording)
  5. ultrasound scanning
  6. labetalol or hydralazine to reduce blood pressure (pretreatments before the real treatment which is delivery)
  7. magnesium sulfate can be used to treat the first seizure caused by pre-eclampsia

the only cure for pre-eclampsia is delivery!!!! anti-hypertensives do not stop it

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198
Q

what are some indication for delivery in pre-eclampsia?

A
  1. severe fetal growth restriction
  2. oligohydramnios- deficient volume of amniotic fluid
  3. non-reassuring fetal testing results
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199
Q

what is the difference between pre-eclampsia and hypertension in pregnancy and how do you treat hypertension in pregnancy?

A

pre-eclampsia always involved an element of proteinuria

if bp is above 160/100-

  1. parenteral hydralazine and labetalol
  2. oral nifedipine used with caution
  3. sodium nitroprusside (vasodilator)
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200
Q

what are the 5 important basic components of a sexual health history?

A
  1. history of presenting complaints
  2. past GU history
  3. past general medical/ surgical history
  4. drug history- any recent antibiotics?
  5. sexual history
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201
Q

what are 4 important components of the sexual history section of a sexual health history?

A
  1. last sexual intercourse
  2. regular/ casual partner
  3. male/ female
  4. condom use
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202
Q

what are 4 female specific components of a focused sexual health history?

A
  1. menstrual history
  2. pregnancy history
  3. contraceptive history
  4. cervical cytology history
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203
Q

what is 1 male specific component of a focused sexual health history?

A
  1. when last voided urine
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204
Q

what are the 6 stages of a genital examination in a woman?

A
  1. vulva
  2. perineum
  3. vagina
  4. cervix
  5. bimanual pelvic examination
  6. possibly anus and oropharynx if indicated
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205
Q

what are the 4 stages of a genital examination in a man?

A
  1. penis
  2. scrotum
  3. urethral meatus
  4. anus and oropharynx in msm or if indicated
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206
Q

what screening tests should be done on an asymptomatic woman for their sexual health?

A
  1. self taken vulvo-vaginal swab for gonorrhoea/ chlamydia

1. Bld test for STS and HIV

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207
Q

what screening tests should be done on an asymptomatic man for their sexual health?

A
  1. first void urine for gonorrhoea/ chlamydia

2. Bld test for STS and HIV

208
Q

what are 8 symptomatic presentations of a woman regarding sexual health?

A
  1. vaginal discharge
  2. vulval discomfort/ soreness/ itching/ pain
  3. superficial dyspareunia
  4. pelvic pain/ deep dyspareunia
  5. vulval lumps
  6. vulval ulcers
  7. intermenstrual bleeding
  8. post-coital bleeding
209
Q

what are 7 symptomatic presentation of a man regarding sexual health?

A
  1. pain/burning during micturition
  2. pain/ discomfort in the urethra
  3. urethral discharge
  4. genital ulcers, sores, or blisters
  5. genital lumps
  6. rash on penis or genital area
  7. testicular pain or swelling
210
Q

what symptomatic screening is necessary for a woman regarding sexual health?

A
  1. vulvo-vaginal gonorrhoea and chlamydia swab
  2. high vaginal swab
  3. cervical swab for gonorrhoea
  4. dipstick urinalysis
  5. bld for STS and HIV
211
Q

what STI’s does a high vaginal swab test for?

A
  1. bacterial vaginosis
  2. trichomonas vaginalis
  3. candida
212
Q

what symptomatic screening is necessary for a man regarding sexual health?

A
  1. urethral swab for gonorrohoea
  2. first void urine for gonorrhoea and chlamydia
  3. dipstick urinalysis
  4. bld for STS and HIV
  5. MSM also has urethral and rectal slides and urethral and rectal and pharyngeal cultures
213
Q

what are 4 at risk groups of people for hepatitis B?

A
  1. MSM
  2. commercial sex workers
  3. IVDU
  4. people from africa, asia and eastern europe and their partners
214
Q

what is the most common type of cancer in the UK and the second biggest cancer killer of women?

A

breast cancer

215
Q

what are the 1 year and five year survival rates for breast cancer?

A

1 year- 96%

5 years- 85%

216
Q

what is the lifetime risk of breast cancer for a woman?

A

1:9

217
Q

what are 6 risk factors for breast cancer?

A
  1. radiotherapy treatment below 35 years old
  2. BRCA1 and BRCA2 gene carriers
  3. HRT
  4. moderate-high alcohol consumption
  5. not breast feeding
  6. nulliparous
218
Q

what are the 4 stages of the screening program for breast cancer?

A
  1. invitation
  2. screening mammography
  3. assessment- about 5% recalled
  4. results, surgery and further treatment
219
Q

what are 5 reasons seen on a mammogram that warrant recalling of the patient?

A
  1. mass
  2. microcalcificaiton
  3. parenchymal deformity/ distortion
  4. asymmetrical density
  5. enlarged axillary lymph nodes
220
Q

what are 4 steps after recall in breast cancer screening to confirm a diagnosis?

A
  1. ultrasound
  2. biopsy
  3. marker insertion
  4. MDT discussion
221
Q

what is the most common type of breast cancer?

A

invasive ductal carcinoma

222
Q

what is the surgical treatment for invasive ductal carcinoma?

A
  1. wire localisation

2. wide local excision

223
Q

what ages are routinely invited for mammograms?

A

50-70 years old, often younger high risk women (previous radiotherapy or familial predisposition)

224
Q

what are 3 important descriptors of the 1st stage of labour and what are the spinal cord locations of the nerves involved with the pain?

A
  1. uterine contraction, cervical effacement and dilatation

2. T10-L1 and S2-4

225
Q

what is an important descriptor of the 2nd stage of labour and what are the spinal cord locations of the nerves involved with the pain?

A
  1. stretching of the vagina, peritoneum and extrauterine pelvic structures
  2. S2-4 pudendal and L5-S1
226
Q

what are 4 non-pharmacological pain management options for labour?

A
  1. acupuncture
  2. hypnotherapy
  3. massage
  4. hydrotherapy
227
Q

what are 4 pharmacological pain management options for labour?

A
  1. entonox
  2. oral analgesia
  3. parenteral opioids
  4. PCA opioids (self-administered by pushing a button)
228
Q

what is entonox comprised of and why is it a good way to manage pain in labour?

A
  1. 50% N2O and 50% O2

2. rapid onset, minimal side effects, self limiting

229
Q

what are some simple options for systemic analgesia during labour?

A

paracetamol or codeine

230
Q

what are 3 options for single shot opioid pain relief during labour and why are they good?

A
  1. morphine, diamorphine and pethidine

2. they cross placenta rapidly due to being lipid soluble

231
Q

what are some adverse effects of using opioid pain relief during labour?

A
  1. pethidine can cause seizures in epileptic patients

2. all cause sedation, respiratory depression, nausea and vomiting and pruritis

232
Q

what are 3 options for PCA opioids during labour?

A
  1. fentanyl
  2. alfentanil
  3. remifentanil
233
Q

what are 3 options for regional pain relief during labour?

A
  1. epidural
  2. spinal
  3. combined spinal and epidural
234
Q

at what spinal level should epidural analgesia be inserted and what anatomical landmark overlies this area?

A

L3/4 at tuffiers line (the top point of both iliac crests connected by a line)

235
Q

what are 5 indications for epidural anaesthesia in labour?

A
  1. maternal request
  2. cardiac and other medical diseases
  3. augmented labour
  4. multiple births
  5. instrumental/ operative delivery likely
236
Q

what are 6 contraindications for epidural/ regional anaesthesia in labour?

A
  1. maternal refusal
  2. local infection
  3. allergy
  4. coagulopathy
  5. hypovolaemia
  6. abnormal anatomy
237
Q

what are 5 broad adverse effects of regional anaesthesia in labour?

A
  1. cardiovascular- hypotension and bradycardia
  2. respiratory- poor cough
  3. neurological- rare related to haematoma or abscess
  4. drug-related- allergy, anaphylaxis
  5. headache
238
Q

what type of delivery might regional anaesthesia increase the likelihood of?

A

instrumental delivery

239
Q

what are 4 indications for general anaesthesia in labour?

A
  1. imminent threat to mother or fetus
  2. regional anaesthesia contraindicated
  3. maternal preference
  4. failed regional techniques
240
Q

what are 4 issues with general anaesthesia in labour?

A
  1. increased risk associated with altered physiology
  2. aspiration
  3. failed intubation
  4. awareness
241
Q

what are 4 advantages to regional anaesthesia compared to general anaesthesia during labour?

A
  1. safer
  2. can see baby immediately
  3. partner present
  4. improved post op analgesia
242
Q

what are 4 disadvantages to regional anaesthesia compared to general anaesthesia during labour?

A
  1. hypotension
  2. headache
  3. discomfort associated with pressure sensations
  4. failure
243
Q

what are 4 obstetric emergencies related to the mother?

A
  1. antepartum haemorrhage
  2. postpartum haemorrhage
  3. venous thromboembolism
  4. preeclampsia
244
Q

what are 3 obstetric emergencies related to the baby?

A
  1. shoulder dystocia
  2. cord prolapse
  3. fetal distress
245
Q

what is an antepartum haemorrhage?

A

bleeding from anywhere in the genital tract (uterus, cervix, vagina, vulva) after 24th week of pregnancy

246
Q

what % of pregnancies does antepartum haemorrhage occur in?

A

3-5%

247
Q

what % of antepartum haemorrhage does not have an identifiable cause?

A

40%

248
Q

what are 5 identifiable causes of antepartum haemorrhage?

A
  1. low lying placenta/ placenta praevia
  2. placenta accreta
  3. vasa praevia
  4. minor/ major abruption
  5. infection
249
Q

what is placenta accreta?

A

a condition in which the placenta grows too deeply into the uterine wall and remains attached after delivery, leading to major blood loss

250
Q

what is placenta praevia?

A

a condition in which the placenta partially or totally covers the opening of the cervix which can cause major bleeding during delivery

251
Q

what is vasa praevia?

A

a conditions in which fetal blood vessels cross near the cervix and are at risk of rupture when the supporting membranes rupture

252
Q

what is placental abruption?

A

a condition in which the placenta partially or fully seperates from the uterine wall before delivery, causing major blood loss during delivery

253
Q

how do you diagnose a low lying placenta/ placenta praevia?

A
  1. 20 week anomaly scan
  2. abnormal lie or painless bleed
  3. repeat scan for praevia
  4. placenta must be 20mms from the cervical os or C-section needed
254
Q

how do you manage a low lying placenta/ placenta praevia?

A
  1. advise symptoms to watch out for
  2. outpatient management
  3. may need admission with repeated bleeds
  4. anti-D is rhesus negative baby
  5. elective caesarean section at 38-39 weeks or before if bleeding doesn’t settle
255
Q

how do you manage bleeding during low lying placenta/ placenta praevia?

A
  1. ABCDE- if major bleed two cannulas, IV fluids, crossmatch 6 units, inform senior team and paeds
  2. examination- general and abdominal, vaginal, USS
  3. fetal CTG monitoring +/- delivery
  4. steroids if less than 34 weeks gestation
256
Q

how do you manage placenta accreta?

A
  1. 20 week scan
  2. loss of definition between wall of uterus and abnormal vasculature
  3. MRI scan
  4. elective c-section at 36-37 weeks
  5. discussion and consent
  6. ensure blood and blood products and a level 2 critical care bed are available
257
Q

if the mother has vasa praevia, is the mother or the fetus in more danger, and what is the mortality?

A

there is a major fetal risk, mortality is 60%

258
Q

how do you manage placental abruption?

A

small abruptions can be managed conservatively, large abruptions require resuscitations and delivery

  1. make sure blood is available
  2. ABCDE
  3. monitor fetal heart beat
  4. stabilisation of mother
  5. delivery if necessary
259
Q

what are 5 complications that can occur after antepartum haemorrhage?

A
  1. premature labour
  2. blood transfusion
  3. acute tubular necrosis
  4. disseminated intravascular coagulation
  5. fetal morbidity and mortality
260
Q

what are the categories of postpartum haemorrhage?

A
  1. primary- within 24 hours of delivery with less than 500mls of blood
  2. secondary- between 24hrs- 12 weeks after delivery
  3. minor- 500-1000mls
  4. major- >1000mls
261
Q

what are the ‘four T’s’ causes of postpartum haemorrhage?

A
  1. tissue- ensure placenta is complete
  2. tone- ensure uterus contracted
  3. trauma- look for tears
  4. thrombin- check clotting
262
Q

what are 5 risk factors for postpartum haemorrhage?

A
  1. big baby
  2. nulliparity and grand multiparity
  3. multiple pregnancy
  4. shoulder dystocia
  5. operative delivery
263
Q

what are 7 risk factors for maternal sepsis?

A
  1. obesity
  2. diabetes
  3. immunosuppression
  4. anaemia
  5. history of pelvic infection
  6. prolonged SROM
  7. vaginal discharge
264
Q

what are 9 signs and symptoms of maternal sepsis?

A
  1. pyrexia
  2. hypothermia
  3. tachycardia
  4. tachypnoea
  5. hypoxia
  6. hypotension
  7. oliguria
  8. impaired consciousness
  9. failure to respond to treatment
265
Q

what is the sepsis six?

A
  1. O2 as required to achieve SpO2 over 94%
  2. blood cultures
  3. IV antibiotics
  4. IV fluids
  5. bloods for Hb, lactate and glucose
  6. hourly urine output
266
Q

what are 5 signs of severe pre-eclampsia?

A
  1. severe headache
  2. visual disturbance
  3. papilloedema
  4. clonus
  5. liver tenderness
267
Q

what is the treatment for severe pre-eclampsia?

A
  1. stabilise BP with labetalol and nifedipine
  2. check bloods include platelets, renal and liver function
  3. magnesium sulphate if hyperreflexic (stops seizures developing)
  4. monitor urine output
  5. treat coagulation defects
  6. fetal wellbeing
  7. delivery
268
Q

what is eclampsia?

A

onset of seizures in a woman with pre-eclampsia (seizures in pregnant woman always eclampsia until proven otherwise)

269
Q

how do you treat eclampsia?

A
  1. IV magnesium sulphate for 24 hours
  2. recurrent seizures may require further doses
  3. treat hypertension with labetalol and nifedipine and hydralazine
  4. stabilise mother then deliver baby
270
Q

what factors make you suspicious of fetal compromise?

A

prolonged fetal bradycardia and fetal acidosis on the scalp

271
Q

what is cord prolapse?

A

when the cord presents before the baby in delivery after SROM, this can lead to vasospasm and hypoxia

272
Q

what are 5 risk factors for cord prolapse?

A
  1. premature rupture of membranes
  2. polyhydramnios (large volume of amniotic fluid)
  3. long umbilical cord
  4. fetal malpresentation (EG breech)
  5. multiple pregnancy
273
Q

how do you manage cord prolapse?

A
  1. call emergency buzzer
  2. infuse fluid into bladder via catheter if at home
  3. trendelenburg position with feet higher than head
  4. constant fetal monitoring
  5. alleviate pressure on cord
  6. transfer to theatre and prepare for delivery
274
Q

what is shoulder dystocia?

A

failure of the anterior shoulders to pass under the symphysis pubis after delivery of the fetal head, there is a high risk for maternal morbidity and fetal mortality and morbidity

275
Q

what are 3 maternal complications after shoulder dystocia

A
  1. postpartum haemorrhage
  2. 3rd and 4th degree vaginal tear
  3. psychological
276
Q

what are 4 neonatal complications after shoulder dystocia?

A
  1. hypoxia
  2. fits
  3. cerebral palsy
  4. brachial plexus injury
277
Q

what are 5 risk factors for shoulder dystocia?

A
  1. macrosomia (although most cases occur in normally grown babies)
  2. maternal diabetes
  3. previous episodes
  4. disproportion between mother and fetus
  5. post-maturity and induction of labour
278
Q

what is the HELPERRR mnemonic for shoulder dystocia

A 
H- call for help
E- evaluate for episiotomy
L- legs in mcroberts
P- suprapubic pressure
E- enter pelvis
R- rotational manoeuvres
R- remove posterior arm
R- replace head and deliver by c-section
279
Q

what is menopause and how do you diagnose it?

A

cessation of menstruation, diagnosable after 12 months of amenorrhoea or onset of symptoms if hysterectomy

280
Q

what is perimenopause and what are some of the symptoms?

A

the period leading up to menopause characterised by irregular periods, hot flushes, mood swings and urogenital atrophy

281
Q

what are some short term symptoms of menopause?

A

vasomotor symptoms (flushing and sweats), mood change, memory loss, headaches, dry skin, joint pain, lack of energy

282
Q

what are some medium term symptoms of menopause?

A
  1. dyspareunia
  2. recurrent UTI
  3. post-menopausal bleeding
  4. urinary incontinence and prolapse
283
Q

what are some long term impacts of menopause?

A
  1. osteoporosis due to low oestrogen
  2. cardiovascular disease due to adverse changes in lipids
  3. dementia has increased prevalence with early menopause
284
Q

how do you manage menopause?

A
  1. holistic approach with lifestyle approach and modification of risk factors
  2. inform about options such as HRT, vaginal oestrogen, clonidine or CBT
285
Q

what are 3 risks and 3 benefits of HRT during menopause?

A

risks-

  1. breast cancer (risk is most increased with oestrogen and progesterone, with little to no increase with just oestrogen)
  2. VTE
  3. cardiovascular disease

benefits-

  1. relief of symptoms of menopause
  2. bone mineral density protection
  3. might prevent long term morbidity
286
Q

how do you manage HRT with regards to breast cancer?

A
  1. discontinue HRT in diagnosed women
  2. do not routinely offer HRT to women with menopausal symptoms and a history of breast cancer
  3. can be offered in exceptional cases with severe menopausal symptoms after discussion
287
Q

which type of HRT increases the risk of venous thromboembolism- oral or transdermal?

A

oral

288
Q

what ages do you have start women on HRT by to ensure there is no increased risk of cardiovascular disease?

A

less than 60 years old

289
Q

which type of HRT increases the risk of stroke- oral or transdermal?

A

oral (only slightly)

290
Q

which regimen of HRT is recommended for perimenopausal women?

A

sequential/ cyclical- progesterone added to oestrogen 12-14 days every 4 weeks

291
Q

which regimen of HRT is recommended for menopausal women?

A

continuous combined HRT

292
Q

which regimen of HRT is recommended for women who have had a hysterectomy or have a MIRENA coil in situ?

A

oral or transdermal estradiol

293
Q

what are 5 groups of people who should have transdermal rather than oral HRT?

A
  1. gastric upset EG crohn’s disease
  2. need for steady absorption EG epilepsy
  3. increased risk of VTE
  4. medical conditions like hypertension
  5. patient choice
294
Q

what is premature ovarian insufficiency?

A

menopause, either natural or iatrogenic, primary or secondary that comes on before the age of 40

295
Q

what are 4 natural causes of premature ovarian insufficiency?

A
  1. chromosome abnormalities
  2. autoimmune disease
  3. enzyme deficiencies
  4. inhibin B mutations
296
Q

what are 3 iatrogenic causes of premature ovarian insufficiency?

A
  1. surgery
  2. chemotherapy
  3. radiotherapy
297
Q

how do you diagnose premature ovarian insufficiency?

A

FSH> 25 Iu/L in 2 samples greater than 4 weeks apart with 4 months of amenorrhoea

298
Q

how do you manage premature ovarian insufficiency?

A
  1. hormone replacement therapy at-least until average age of menopause (51)
  2. psychological support
299
Q

what are 4 non-hormonal alternative to HRT?

A
  1. alpha adrenergic receptor agonist- clonidine
  2. SSRI- fluoxetine, citalopram, sertraline
  3. SNRI/SSRI- venlafaxine
  4. anti-epileptic- gabapentin
300
Q

what are 3 contraindications for HRT?

A
  1. undiagnosed abnormal PV bleeding
  2. breast lump
  3. acute liver disease
301
Q

what are 4 cautions for HRT?

A
  1. fibroids, uncontrolled BP, migraine, epilepsy
302
Q

what are 8 causes of endometrial cancer?

A
  1. obesity
  2. diabetes
  3. nulliparity
  4. late menopause
  5. ovarian tumours
  6. HRT
  7. pelvic irradiation
  8. tamoxifen
303
Q

what investigations should be done if a patient presents with postmenopausal bleeding?

A
  1. transvaginal ultrasound
  2. endometrial biopsy
  3. hysteroscopy
304
Q

what is the most common type of endometrial cancer?

A

adenocarcinoma of columnar endometrial gland cells

305
Q

what is a type of endometrial cancer with a worse prognosis than adenocarcinoma?

A

adenosquamous

306
Q

what hormone ratio is a risk factors for endometrial cancer?

A

a high oestrogen: progesterone ratio

307
Q

what medication is protective against endometrial cancer?

A

the combined oral contraceptive pill

308
Q

how does oestrogen cause endometrial cancer?

A

oestrogen causes cystic hyperplasia which can lead to dysplasia

309
Q

what is the treatment for endometrial cancer if the uterus is preserved?

A

progestogens with 6 monthly biopsy

310
Q

what is the treatment for endometrial cancer if the uterus is not preserved?

A
  1. hysterectomy and adjuvant radiotherapy. 2. salpingo-oopherectomy if necessary.
  2. progesterone therapy can be helpful
311
Q

what is a common clinical presentation of endometrial cancer?

A
  1. post-menopausal bleeding
  2. pre-menstrual women have irregular or intermenstrual bleeding
  3. can coexist with atrophic vaginitis
312
Q

what investigations should be done for someone with endometrial cancer?

A
  1. FBC, renal function, ECG glucose
  2. transvaginal ultrasound
  3. endometrial biopsy
  4. hysteroscopy
313
Q

what are the 4 stages of endometrial cancer?

A

1- body of the uterus
2- body of the uterus and the cervix
3- beyond the uterus, but not beyond the pelvis
4- beyond the pelvis, EG bowel or bladder

314
Q

what are 7 risk factors of cervical carcinoma?

A
  1. early age of intercourse (<16)
  2. multiple sexual partners
  3. STDs
  4. cigarette smoking
  5. other genital tract neoplasia
  6. OCP use
  7. multiparity
315
Q

what is the main causative factor for cervical carcinoma?

A

presence of HPV

316
Q

what % of the population will have HPV at some point of their life?

A

75%

317
Q

what are the two main oncogenic types of HPV?

A

16 and 18

318
Q

what is the most common histological type of cervical cancer?

A

squamous

319
Q

what is the stage 1 prognosis of cervical cancer?

A

> 90% 5 year survival

320
Q

how do you diagnose and stage cervical cancer?

A
  1. smear test can come back irregular
  2. cervical biopsy
  3. staging with vaginal and rectal examination and CT/MRI
321
Q

how do you treat cervical cancer?

A
  1. early stage cancers can be cured by excision of the cancerous region via cone excision, laser or cryotherapy
  2. extrafascial hysterectomy
  3. radical hysterectomy
  4. lymphadenectomy
  5. cisplatin chemotherapy
  6. radiotherapy
322
Q

what are the 6 (two ‘b’ denominations) stages of cervical cancer?

A 
1- tumour confined to cervix
2- tumour in cervix and upper 2/3 of vagina
3- tumour in lower 1/3 of vagina
3b- pelvic wall
4- bladder or rectum
4b- distant organs
323
Q

what are 2 causes of vulval cancer?

A
  1. VIN HPV

2. lichen sclerosis

324
Q

what is the most common histological type of vulval cancer?

A

squamous

325
Q

what is the clinical presentation of vulval cancer?

A
  1. vulval itching
  2. vulval soreness
  3. persistent lump
  4. bleeding
  5. dysuria
  6. past history of VIN HPV or lichen sclerosis
326
Q

what are the 4 stages of vulval cancer?

A

1- <2cm
2- >2cm
3- adjacent organs or unilateral nodes
4- bilateral nodes or distant mets

327
Q

how do you treat vulval cancer?

A
  1. conservative or radical surgery
  2. radiotherapy
  3. chemotherapy
328
Q

what is the clinical presentation of ovarian cancer?

A
  1. bloating/ IBS symptoms
  2. abdominal pain
  3. change in bowel habit
  4. urinary frequency
  5. bowel obstruction
  6. symptomless
329
Q

what are 2 causes of ovarian cancer?

A
  1. ovulation

2. gene mutation (BRCA 1/2)

330
Q

what % of ovarian cancer patients present with advanced disease, and what is the prognosis?

A

50%, and a 40% 5 year survival rate

331
Q

what is the most common histological type of ovarian cancer?

A

epithelial

332
Q

what investigations should be done for ovarian cancer?

A
  1. CA125 testing
  2. ultrasound
  3. symptoms and age index
  4. referral based on risk of malignancy index
333
Q

how do you treat ovarian cancer?

A
  1. surgery

2. chemotherapy

334
Q

what are 2 less common gynaecological cancers?

A
  1. vaginal

2. fallopian tube

335
Q

what is the puerperium?

A

a period of time from the delivery of the placenta to six weeks follow the birth where a woman’s organs return to their pre-pregnancy state

336
Q

what are 3 important features of puerperium?

A
  1. return to pre-pregnant state
  2. initiation or suppression of lactation
  3. transition to parenthood
337
Q

what are 2 endocrine changes in the puerperal period?

A
  1. profound decrease in placental hormones- lactogen, hcg, oestrogen and progesterone
  2. increase in prolactin
338
Q

what happens to the uterus and the genital tract during the puerperal peroid?

A

involution (shrinkage) back to original size, with the decidua (thickened uterus lining during pregnancy) being shed as lochia rubra, serosa and alba

339
Q

what is shed in the locha rubra, and what time period does it occur over?

A

day 1-4 post-birth-

  1. blood
  2. cervical discharge
  3. decidua
  4. fetal membrane
340
Q

what is shed in the lochia serosa, and what time period does it occur over?

A

day 4-10 post-birth-

  1. cervical mucus
  2. exudate
  3. fetal membrane
  4. while blood cells
341
Q

what is shed in the locha alba, and what time period does it occur over?

A

day 10-28 post-birth-

  1. cholesterol
  2. epithelial cells
  3. fat
  4. micro-organisms
342
Q

what two hormones are responsible for lactogenesis?

A
  1. prolactin- milk production (anterior pituitary)

2. oxytocin- milk ejection reflex (posterior pituitary)

343
Q

what are 8 minor postnatal problems?

A
  1. infection
  2. mild post-partum haemorrhage
  3. fatigue
  4. anaemia
  5. backache
  6. breast engorgement/ mastitis
  7. urinary stress incontinence
  8. haemorrhoids
344
Q

what are 9 major postnatal problems?

A
  1. sepsis
  2. severe post-partum haemorrhage
  3. pre-eclampsia/ eclampsia
  4. thrombosis
  5. uterine prolapse
  6. incontinence (urinary or fecal)
  7. post dural puncture headache
  8. breast abscess
  9. depression/ psychosis
345
Q

what are 6 signs and symptoms postnatally that women should report to health professionals?

A
  1. sudden and profuse blood loss
  2. fever
  3. abdominal pain
  4. offensive vaginal loss
  5. headaches accompanied by visual disturbance or nausea or vomiting
  6. unilateral calf pain, redness or swelling
  7. shortness of breath/ chest pain
346
Q

what early warning score can be used to assess women postnatally?

A

modified early obstetric warning score

347
Q

define sepsis

A

infection plus systemic manifestation of infection

348
Q

define severe sepsis?

A

sepsis plus sepsis-induced organ dysfunction and tissue hypoperfusion

349
Q

define septic shock?

A

persistent hypoperfusion of organs despite adequate fluid replacement therapy

350
Q

what are 5 risk factors for post-natal sepsis?

A
  1. obesity
  2. diabetes
  3. anaemia
  4. amniocentesis
  5. prolonged spontaneous rupture of membranes
351
Q

what are 5 likely causes of post-natal sepsis?

A
  1. endometriosis
  2. skin and soft tissue infection
  3. UTI
  4. mastitis
  5. epidural infection
352
Q

how do you differentiate minor and major post-partum haemorrhage?

A

minor- <1500mls blood loss and no clinical signs of shock

major- >1500mls blood loss and clinical signs of shock or continuing bleeding

353
Q

what is secondary post-partum haemorrhage?

A

abnormal or excessive bleeding from birth canal between 24hrs-12 weeks postnatally

354
Q

what are 4 causes of post-partum haemorrhage?

A
  1. endometriosis
  2. retained products of contraception
  3. pseudo-aneurysms
  4. arteriovenous malformations
355
Q

what 4 investigations should be done with post-partum haemorrhage?

A
  1. assessment of blood loss
  2. haemodynamic status
  3. bacteriological testing (HVS and endocervical swab)
  4. pelvic ultrasound
356
Q

what % of eclamptic seizures occur after the birth?

A

50%

357
Q

when is there maximum risk of venous thomboembolism relating to pregnancy?

A

post-partum, five fold higher than antepartum, 22 fold increase in first 3 weeks and persists relatively up to 6 weeks post partum

358
Q

what are 4 high risk factors for venous thromboembolism in the puerperal period?

A
  1. previous VTE
  2. antenatal LMWH requirements
  3. high risk thrombophilia
  4. low risk thrombophilia and FHx
359
Q

what are four lower risk factors for venous thromboembolism in the puerperal period?

A
  1. age over 35 years
  2. obesity
  3. smoker
  4. elective c-section
360
Q

what is the cause of a post-dural puncture headache?

A

leakage of cerebrospinal fluid and reduce pressure in fluid around the brain

361
Q

what is the clinical presentation of post-dural puncture headache?

A
  1. headache worse on sitting or standing and starts 1-7 days after spinal or epidural
  2. neck stiffness
  3. photophobia
362
Q

how do you treat post-dural puncture headache

A
  1. lying flat
  2. simple analgesia
  3. epidural blood patch
  4. fluids and caffeine
363
Q

what is post-natal urinary retention?

A

abrupt onset of achine or acheless inability to completely micturate, requiring catheterisation, over 12h after birth, or inability to spontaneously micturate within 6h of vaginal delivery

364
Q

what are 5 risk factors for post-natal urinary retention?

A
  1. epidural analgesia
  2. prolonged 2nd stage of labour
  3. forceps or ventouse deliver
  4. extensive perineal laceration
  5. poor labour bladder care
365
Q

how do you treat and minimise risk for post-natal urinary retention?

A
  1. maintain bladder function
  2. minimise risk of urethra/ bladder damage
  3. appropriate management such as catheterisation
366
Q

what is ‘the baby blues’

A

feeling emotional or tearful around 3-10 days after birth

367
Q

what are three red flag signs of mental health disorders in the puerperal period?

A
  1. recent significant change in mental state
  2. new thoughts of violence or self harm
  3. new and persistent expression of incompetency as mother or estrangement from infant
368
Q

what are 5 symptoms of post-natal depression?

A
  1. depressed
  2. irritable
  3. tired
  4. appetite changes
  5. negative thoughts
369
Q

what are 5 symptoms of post-partum psychosis?

A
  1. depression
  2. mania
  3. psychosis
  4. rapid cycling mood
  5. confusion
370
Q

what are 5 symptoms of post-natal ptsd and 4 consequences of this?

A
  1. anger, low mood, flashbacks, suicidal ideation, isolation
  2. delay or avoid future pregnancy, request c-section to avoid vaginal delivery, avoidance of physical or intimate relationships, impact on breastfeeding
371
Q

define maternal death?

A

the death of a woman while pregnant or within 42 days of termination of a pregnancy, irrespective of duration and site of pregnancy, and from any cause related to or aggravated by the pregnancy

372
Q

what are the 3 most common causes of maternal mortality?

A
  1. cardiac disease
  2. thromboembolism
  3. neurological
373
Q

what are the three main methods of fetal heart rate monitoring?

A
  1. intermittent auscultation
  2. pinard stethoscope
  3. hand-held doppler device (cardiotocography)
374
Q

what are some advantages and disadvantages of intermittent auscultation?

A

adv- inexpensive, non-invasive, can be done at home

disadv- variability and decelerations not detected, cannot monitor long tern, affected my movement and maternal HR

375
Q

what are some advantages and disadvantages of cardiotocography?

A

adv- provides info about FHR and contractions, long term monitoring possible, variability can be determined

disadv- no morphological assessment, no true beat to beat data, exposure to ultrasound insonation, no improvement in perinatal outcome in low risk pregnancies

376
Q

what is the mnemonic DR C Bravadao relating to cardiotocography?

A 
Dr- define risk
C- contractions
Bra- baseline rate
V- variability
A- accelerations
D- decelerations 
O- overall assessment
377
Q

what is a direct method of measuring a fetal heart rate? and what are some advantages and disadvantages?

A

scalp ecg

adv- gold standard for direct, true beat to beat information

disadv- invasive, only monitors during labour, membranes must be absent and atleast 2cm dilatation, associated with scalp injury and perinatal infection

378
Q

what is an indirect method of measuring a fetal heart rate? and what are some advantages and disadvantages?

A

abdominal fetal ECG

adv- non-invasive, true beat to beat FHR and morphological analysis possible

disadv- research tool, signal is not guaranteed antenatally

379
Q

what is female genital mutilation?

A

any procedures involving partial or total removal of female external genitalia or injury to female organs with no medical reason. involves damaging and removing normal, healthy genital tissue.

380
Q

what is type 1 FGM?

A

clitoridectomy- partial or total removal of the clitoris

381
Q

what is type 2 FGM?

A

excision- partial or total removal of the clitoris and labia minora, with or without labia majora excision

382
Q

what is type 3 FGM?

A

infibulation- narrowing of vaginal orifice with creating of covering seal by cutting and appositioning the labia minora and or majora, with or without clitoral excision

383
Q

what is type 4 FGM?

A

all other harmful procedures involving pricking, piercing, incising, scraping and cauterising

384
Q

what are some societal reasons that make people think they need to participate in FGM?

A
  1. bringing status and respect
  2. protects virginity
  3. upholds family honour
  4. cleansing and purification
  5. perceived religious requirement
385
Q

which countries have the highest FGM prevalence?

A

most mid-african countries, 89% in mali, 97% in guinea, 90% in sierra leone, 88% in sudan

386
Q

how many women roughly are there in the uk living with FGM?

A

103,000

387
Q

is FGM legal?

A

FGM and any measures to assist FGM are illegal in the UK and can result in a fine and/or imprisonment for up to 14 years

388
Q

what are 8 gynaecological complications of FGM?

A
  1. dyspareunia
  2. sexual dysfunction and anorgasmia
  3. chronic pain
  4. keloid scar formation
  5. dysmenorrhoea with haematocolpos (blood filled dilated vagina due to obstruction)
  6. urinary outflow obstruction/ recurrent UTI
  7. PTSD
  8. difficulty in conceiving
389
Q

what are 8 obstetric complications of FGM?

A
  1. fear associated with childbirth
  2. increased chance of c-section
  3. increased likelihood of post-partum haemorrhage
  4. increased likelihood of episiotomy
  5. increased likelihood of severe vaginal lacerations
  6. extended hospital stay
  7. difficulty performing vaginal examinations during labour
  8. difficulty catheterising the bladder
390
Q

what is de-infibulation?

A

reversal of type 3 FGM

391
Q

what are 4 common complaints in paediatric gynaecology?

A
  1. amenorrhoea
  2. precocious puberty
  3. delayed puberty
  4. menstrual disorders
392
Q

what age is normal for menarche?

A

12-13 (95% 11-14.5)

393
Q

what counts as amenorrhoea in the paediatric population?

A

no menses by age 16 in the presence of secondary sexual characteristics, or in the absence of secondary sexual characteristics by 13, or menses more than 35 days apart

394
Q

what is secondary amenorrhoea in the paediatric population and what are some common causes?

A

cessation of menses after the onset of menses, often induced by weight loss, excessive exercise or PCOS

395
Q

what is precocious puberty in the paediatric population?

A

appearance of physical and hormonal signs of pubertal development before the age of 8 in girls and 9 in boys with secretion of high-amplitude pulses of GnRH by the hypothalamus

396
Q

what are 3 causes of central precocious puberty and is gonadotropin dependent or independent?

A

gonadotropin dependent

  1. trauma
  2. tumours
  3. hydrocephalus
397
Q

what are 3 causes of precocious pseudo-puberty and is it gonadotropin dependent or independent?

A

gonadotropin independent

  1. tumours of the adrenal glands
  2. ovarian tumours
  3. McCune Albright syndrome
398
Q

what is delayed puberty in the paediatric population?

A

lack of sexual development and pubertal onset in the normal time frame

399
Q

what investigations should be done in delayed puberty?

A
  1. FBC, CRP or ESR to exclude anaemia or hidden inflammatory disease
  2. U+E and LFT’s to exclude renal and liver disease
  3. bone profile- low for age alkaline phosphatase confirms slow growth
  4. coeliac antibodies for cryptic coeliac disease
  5. TSH and free T4 to exclude hypothyroidism
400
Q

what are 4 less common menstrual disorders in the paediatric population?

A
  1. irregular periods
  2. heavy periods
  3. dysmenorrhoea
  4. pre-menstrual tension
401
Q

what are 5 risk factors for ectopic pregnancy?

A
  1. increased maternal age
  2. lower socioeconomic class
  3. previous ectopic
  4. smoking
  5. assisted conception
402
Q

what are 4 locations that ectopic pregnancies can form?

A
  1. fallopian tube
  2. cervix
  3. cornu
  4. ovary
403
Q

what is the clinical presentation of an ectopic pregnancy?

A
  1. abdominal pain
  2. vaginal bleeding
  3. amenorrhoea
404
Q

what investigations and examinations should be performed in an ectopic pregnancy?

A
  1. pelvic examination
  2. pregnancy test
  3. ultrasound
  4. serum hCG if there is an empty uterus
  5. cross match blood
405
Q

how do you treat ectopic pregnancy?

A
  1. low risk- expectant management
  2. haemodynamically stable- surgery, methotrexate and RhD
  3. haemodynamically unstable- fluid resuscitation, surgery, RhD
406
Q

what surgery can be performed to treat ectopic pregnancy?

A
  1. salpingectomy

2. salpingostomy (removal of ectopic from tube)

407
Q

what is a spontaneous miscarriage?

A

where a fetus dies or is delivered dead before 24 completed weeks of pregnancy

408
Q

what is a threatened miscarriage and what % miscarry?

A

vaginal bleeding is present but foetus is still alive, 25% miscarry

409
Q

what is inevitable miscarriage?

A

vaginal bleeding is present and cervical os is open, despite foetus being alive

410
Q

what is an incomplete miscarriage?

A

where some foetal parts are passed and the cervical os is open

411
Q

what is complete miscarriage?

A

bleeding has diminished, uterus is not enlarged and os is closed

412
Q

what is septic miscarriage?

A

uterus contents are infected causing endometritis- presents with abdo pain and peritonism

413
Q

what is a missed miscarriage?

A

where the foetus has not developed but is not noticed until bleeding

414
Q

what accounts for 60% of miscarriages?

A

isolated non-recurring chromosomal abnormalities

415
Q

how do you diagnose a micarriage?

A
  1. serial beta hCG titers
  2. transvaginal ultrasound
  3. transabdominal ultrasound
  4. serum progesterone
416
Q

how, in general, do you manage a miscarriage?

A
  1. rhesus blood group, if negative give RhD
  2. venous access and monitoring of vital signs and fluid balance with heavy bleeding
  3. monitor urine output if hypotensive
  4. analgesia
417
Q

how do you manage a threatened miscarriage?

A
  1. conservative pain management

2. no specific treatment, reassurance and hope for good outcome

418
Q

how do you manage an inevitable/incomplete/missed miscarriage?

A
  1. surgical evacuation of early pregnancy tissue from the vagina and cervix (vacuum aspiration)
  2. natural evacuation
  3. analgesia
  4. misoprostol (a prostaglandin analogue)
  5. IM ergometrine can reduce bleeding
419
Q

how do you manage a complete miscarriage?

A
  1. analgesia

2. counselling

420
Q

what is recurrent miscarriage?

A

> 3 miscarriages occurring in succession

421
Q

what % of men aged 40-70 have erectile dysfunction?

A

52%

422
Q

what are 5 organic risk factors for male sexual dysfunction?

A
  1. diabetes mellitus
  2. smoking
  3. surgery
  4. trauma
  5. atherosclerosis
423
Q

what are 5 neurological risk factors for male sexual dysfunction?

A
  1. parkinson’s disease
  2. multiple sclerosis
  3. tumours
  4. stroke
  5. spinal cord injury
424
Q

what are 4 hormonal risk factors for male sexual dysfunction?

A
  1. hypogonadism
  2. hyperprolactinaemia
  3. thyroid disease
  4. cushing’s
425
Q

what are 5 drug related risk factors for male sexual dysfunction?

A
  1. antihypertensives
  2. beta blockers
  3. diuretics
  4. anti-depressants
  5. anti-psychotics
426
Q

what is the clinical presentation of psychogenic male sexual dysfunction?

A
  1. sudden onset
  2. early collapse of erection
  3. premature ejaculation
  4. major life events
427
Q

what is the standard presentation of male sexual dysfunction?

A
  1. gradual onset
  2. normal ejaculation
  3. normal libido
  4. poor lifestyle
428
Q

what should a physical exam for male sexual dysfunction include?

A
  1. genitals
  2. CVD assessment
  3. digital rectal examination in men over the age of 50
  4. neurological or endocrine examination or psych evaluation if necessary
429
Q

what investigations should be ordered for male sexual dysfunction?

A
  1. glucose
  2. lipid profile
  3. morning testosterone
  4. FSH, LH, prolactin
  5. vascular studies
430
Q

how do you treat testicular failure?

A
  1. holistic management

2. testosterone

431
Q

how do you treat erectile dysfunction?

A
  1. psychological support
  2. treat lifestyle factors
  3. sildenafil
  4. vacuum devices
  5. intracavernosal injection
  6. 3rd line is penile prosthetic
432
Q

what are 3 side effects of sildenafil?

A
  1. headache
  2. facial flushing
  3. dyspepsia
433
Q

what is premature ejaculation?

A

ejaculation within 1 minute of vaginal penetration or significant reduction in latency time that provides distress

434
Q

what are 6 risk factors for premature ejaculation?

A
  1. obesity
  2. genetics
  3. poor health
  4. emotional problems
  5. history of traumatic sex
  6. prostatitis
435
Q

what should you ask about when taking a history of someone with premature ejaculation?

A
  1. length of latency time
  2. context
  3. lifelong/ acquired
  4. impact on sexual function
  5. medication
436
Q

how do you treat premature ejaculation?

A
  1. more frequent masturbation
  2. woman on top
  3. condom
  4. squeeze technique
  5. stop and go technique
  6. SSRI
  7. dapoxetine
437
Q

what is peyronie’s disease?

A

the formation of fibrous plaques in the corpus cavernosa that causes an angled erection and causes erectile dysfunction and painful erections

438
Q

what are three conditions associated with peyronie’s disease?

A
  1. diabetes mellitus
  2. dupuytrens contractures
  3. lipid abnormalities
439
Q

how do you treat peyronie’s disease?

A
  1. measure penis
  2. vacuum devices
  3. oral para-aminobenzoate
  4. surgery after stable for 2 months with extracorporeal shock wave therapy
440
Q

what are 5 causes of menorrhagia?

A
  1. fibroids
  2. endometriosis
  3. adenomyosis
  4. polyps
  5. PCOS
441
Q

what are 5 causes of amenorrhoea?

A
  1. hypothalamic hypogonadism
  2. PCOS
  3. being overweight
  4. excessive exercise/ weight loss
  5. contraceptive pill
442
Q

what are 5 causes of dysmenorrhoea?

A
  1. endometriosis
  2. fibroids
  3. adenomyosis
  4. polyps
  5. PCOS

(a lot of things that cause menorrhagia also cause dysmenorrhoea)

443
Q

what are 6 risk factors for pelvic inflammatory disease?

A
  1. low socioeconomic status
  2. frequent sex
  3. no barrier contraception
  4. younger women
  5. intrauterine devices
444
Q

what are 2 common bacteria that cause pelvic inflammatory disease?

A
  1. chlamydia

2. gonococcus

445
Q

what is shown on examination in severe cases of pelvic inflammatory disease?

A
  1. tachycardia
  2. high fever
  3. lower abdo peritonism
  4. bilateral adnexal tenderness
  5. cervical excitation
446
Q

what are 3 differential diagnoses for pelvic inflammatory disease?

A
  1. appendicits
  2. ovarian cyst accident
  3. ectopic pregnancy
447
Q

what investigations and examinations should be done for pelvic inflammatory disease?

A
  1. endocervical swabs
  2. WBC, CRP
  3. pelvic ultrasound
  4. laparoscopy with fimbral biopsy
448
Q

how do you treat pelvic inflammatory disease?

A
  1. analgesia
  2. IM ceftriaxone, then doxycycline and metronidazole
  3. drainage of pelvic abscess
449
Q

what are 4 complications of pelvic inflammatory disease?

A
  1. abscesses
  2. tubal obstruction
  3. subfertility
  4. chronic pelvic pain
450
Q

what is chronic pelvic inflammatory disease?

A

persisting pelvic infection with dense adhesions and obstructed fallopian tubes

451
Q

what is the clinical presentation of chronic pelvic inflammatory disease?

A
  1. chronic pelvic pain
  2. dysmenorrhoea
  3. deep dyspareunia
  4. heavy/irregular menstruation
  5. chronic vaginal discharge
  6. subfertility
452
Q

what are the 3 things categorised as ovarian cyst accidents?

A
  1. cyst haemorrhage
  2. cyst rupture
  3. cyst torsion
453
Q

how do you manage an ovarian cyst accident?

A
  1. laparoscopy or laparotomy (or other relevant surgery)
  2. resuscitation and haemodynamic support
  3. broad-spectrum antibiotics for peritonitis
454
Q

how do you manage a ruptured ectopic pregnancy?

A
  1. laparoscopy or laparotomy
  2. resuscitation and haemodynamic support
  3. broad spectrum antibiotics for peritonitis
455
Q

what are three risk factors for gynaecandidiasis?

A
  1. pregnancy
  2. diabetes
  3. use of antibiotics
456
Q

what is the clinical presentation of gynae candidiasis?

A
  1. discharge
  2. vulval irritation
  3. itching
  4. superficial dyspareunia
  5. dysuria
457
Q

how do you diagnose gynae candidiasis?

A

culture

458
Q

how do you treat gynae candidiasis?

A

imidazoles (clotrimazole) or oral fluconazole

459
Q

what is the bacterial vaginosis?

A

normal lactobacilli that are overgrown by anaerobes and gardnerella

460
Q

what is the clinical presentation of bacterial vaginosis?

A
  1. grey white discharge

2. fishy odour

461
Q

how do you diagnose bacterial vaginosis?

A
  1. raised pH

2. clue cells on microscopy

462
Q

how do you treat bacterial vaginosis?

A

metronidazole or clindamycin cream

463
Q

what is the a likely concerning explanation for infection and discharge in children?

A

foreign body, consider abuse

464
Q

what is the clinical presentation of chlamydia?

A

usually asymp but can occur with urethritis and vaginal discharge and complicate to pelvic infection

465
Q

what MSK condition can chlamydia cause?

A

reiter’s syndrome/ reactive arthritis

466
Q

how do you diagnose chlamydia?

A

nucleic acid amplification test

467
Q

how do you treat chlamydia?

A

azithromycin or doxicycline

468
Q

what is the clinical presentation of gonorrhoea?

A

often asymp but can occur with vaginal discharge, urethritis, cervicitis and bartholinitis (glands on either side of the vagina). may also present with bacteraemia and monoseptic arthritis

469
Q

how do you diagnose gonorrhoea?

A

culture and endocervical swabs

470
Q

how do you treat gonorrhoea?

A

usually IM ceftriaxone

471
Q

what is the cause of genital warts?

A

HPV

472
Q

how do you treat genital warts?

A

topical podophyllin or imiquimod cream, cryotherapy for resistant warts

473
Q

what is the cause of genital herpes?

A

herpes simplex virus 2

474
Q

what is the clinical presentation of genital herpes?

A

multiple small painful vesicles and ulcers around introitus (opening to vaginal canal), lymphadenopathy, dysuria and systemic symptoms common. attacks after dormancy are preceded by localised tingling

475
Q

where does the genital herpes virus lie dormant usually?

A

dorsal root ganglia

476
Q

how do you diagnose genital herpes?

A

examination and viral swabs

477
Q

how do you treat genital herpes?

A

acyclovir

478
Q

what bacteria causes syphilis?

A

treponema pallidum

479
Q

what is the clinical presentation of primary syphilis?

A

solitary painless vulval ulcer

480
Q

what is the clinical presentation of secondary syphilis?

A

weeks following primary with rash, flu symptoms and warty genital growths

481
Q

what is the clinical presentation of tertiary syphilis following a latent period?

A

dementia, tabes dorsalis- weakness, ataxia, loss of co-ordination, ataxia

482
Q

how do you treat syphilis?

A

parenteral penicillin

483
Q

what is the clinical presentation of trichomoniasis?

A

offensive grey/green discharge, vulval irritation and superficial dyspareunia

484
Q

how do you diagnose trichomoniasis?

A

wet film microscopy

485
Q

how do you treat trichomoniasis?

A

metronidazole

486
Q

what are 4 causes of endometritis?

A

pregnancy or instrumentation of the uterus, c-section or miscarriage can make it more common

487
Q

what organisms can cause endometritis?

A

chlamydia and gonococcus

488
Q

how do you diagnose endometritis?

A

swabs and full blood count

489
Q

how do you treat endometritis?

A

broad spectrum antibiotics

490
Q

describe normal physiological vaginal discharge

A

increases around ovulation, pregnancy and OC pill usage and is usually non-offensive

491
Q

what is bloody offensive discharge indicative of?

A

cervical carcinoma

492
Q

what is watery discharge in post-menopausal women indicative of?

A

rare fallopian tube carcinoma

493
Q

what is a hydatidiform mole?

A

a tumour consisting of chorionic villi that have swollen and degenerated

494
Q

what hormone is secreted by a hydatidiform mole?

A

human chorionic gonadotrophin (HCG)

495
Q

what is the clinical presentation of a hydatidiform mole?

A

exaggerated pregnancy symptoms- morning sickness, fatigue, headaches, may be heavy bleeding

496
Q

how do you diagnose a hydatidiform mole?

A

a strongly positive pregnancy test, and a snowstorm effect on ultrasound in a ‘large for date’ uterus

497
Q

what are 3 risk factors for hydatidiform moles?

A
  1. asian heritage
  2. extremes of child-bearing age
  3. previous mole
498
Q

what condition can HCG cause by mimicking a different hormone in a molar pregnancy?

A

hyperthyroidism by mimicking TSH, watch out for thyrotoxic storm during evacuation

499
Q

how do you treat a hydatidiform mole?

A
  1. suction removal of molar tissue
  2. give anti-D is rhesus-ve
  3. pregnancy avoided for a year with monitored levels of HCG
  4. oral contraceptives can be used if hcg levels drop rapidly after 6 months, if not, the mole was invasive or has given rise to choriocarcinoma
500
Q

where might an invasive hydatidiform mole metastasise?

A

lung, vagina, brain, skin, liver

501
Q

how do you treat an invasive hydatidiform mole?

A

chemotherapy

502
Q

what 2 types of cancer can a hydatidiform mole become and what are some characteristics of each?

A
  1. choriocarcinoma- post pregnancy pv bleeding, malaise, mets, responsive to methotrexate
  2. placental site trophoblastic tumour- slower growing, later presentation
503
Q

what is the criteria for a baby to be ‘small for gestational age’?

A

the baby must be < the 10th centile for their gestational age of weight

504
Q

what are 5 maternal risk factors that can lead to a baby being small for gestational age?

A
  1. multiple pregnancy
  2. malformation
  3. infection
  4. smoking
  5. diabetes
505
Q

what is asymmetrical growth restriction and what is the cause?

A

where placental insufficiency was the cause and the head circumference is relatively spared

506
Q

how do you measure the growth of a baby in utero?

A

measure the fundal height progress from the symphysis pubis

507
Q

what are 2 indications of placental insufficiency that can lead to a small for gestational age baby?

A
  1. oligohydramnios

2. poor fetal movements

508
Q

how should you monitor growth in utero in a baby that is suspected to be small for gestational age?

A

serial ultrasounds of head and abdominal circumference

509
Q

how can you examine fetal blood flow in a baby suspected of being small for gestational age?

A

umbilical cord doppler blood flow

510
Q

what are growth restricted babies more susceptible to in labour?

A

hypoxia

511
Q

what are 4 things that growth restricted babies are more susceptible to after being born?

A
  1. jaundice
  2. hypoglycaemia
  3. trouble with temperature regulation
  4. infection
512
Q

what growth markers can be used to distinguish premature babies from growth restricted babies?

A
  1. breast bud tissue development 34 wks

2. ear cartilage development at 35-39 wks

513
Q

what are 4 common problems for growth restricted babies in adult life?

A
  1. hypertension
  2. type 2 diabetes
  3. coronary arteries
  4. autoimmune thyroid disease
514
Q

what is the criteria for a baby to be ‘large for gestational age’ ?

A

baby is above the 90th centile in weight for gestation

515
Q

what are 4 causes of babies being large for gestational age?

A
  1. constitutionally large
  2. maternal diabetes
  3. hyperinsulinism
  4. beckwith-wiedemann syndrome
516
Q

what large for gestational age babies more susceptible to during labour?

A

shoulder dystocia

517
Q

what are 4 things that large for gestational age babies are more susceptible to after birth?

A
  1. immaturity of suckling and swallowing
  2. hypoglycaemia
  3. hypocalcaemia
  4. left colon syndrome (temporary bowel obstruction)

Phase 3A Flashcards (6 decks)

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